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U. S. DEPARTMENT OF LABOR
JAMES J. DAVIS, Secretary

CHILDREN'S BUREAU
GRACE ABBOTT, Chief

WHAT IS MALNUTRITION?
ASEIOULTUEAL & MECHANICS L ‘ :;
COLLEGE OF TEXA S L IB E A E I
By

LYDIA J. ROBERTS
5»

Bureau Publication No. 59
( Revised )

UNITED STATES
GOVERNMENT PRINTING OFFICE
WASHINGTON
1927

I c S S c.

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S IN G L E C O PIE S
OF THE PUBLICATION M AT BE OBTAINED UPON
APPLICATION TO THE CHILDREN’ S BUREAU
ADDITIONAL COPIES MAT BE PROCURED FROM
THE SUPERINTENDENT OF DOCUMENTS
GOVERNMENT PRINTING OFFICE
WASHINGTON, D. C.
AT

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CONTENTS
Page

Letter of transmittal___________________________________________________
Judging the nutrition of children______________________________________
Signs of good nutrition and of malnutrition__ ____ :________________
Judging nutrition by physical examination_________________________
Judging nutrition by height and weight standards_________________
Extent of malnutrition_________________________________________________,
Causes of malnutrition_______________________________
Specific causes_______ ___ _____ _____ ____________ j.______ _________
Underlying causes_______ ______^___ i_________ ______ ______ ______
Effects of malnutrition__________________ _________ j____________________
Physical effects_________________ ___________________________________
Mental effects_________ .__ ________ ___'_______ _______ ________ ___
Treatment of malnutrition_________ !__________________ L__I ____ Lu_____
School lunches_______________________ ______________ ¡_i__ ___._____ _
Nutrition clinics and classes__________ .________________ * ______ ___
Health education for all schoolchildren______ ______________________
Nutrition work for preschool children_________ ________________ I_ _
C onclusion__________ 1______________ _____________________________
List of references____________________________________________ __________

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LETTER OF TRANSMITTAL

n it e d

States D

epartm ent op

abor

h il d r e n ’s

ureau

Washington, February 1, 1927.
Si r : There is transmitted herewith a revision of a bulletin, “ What
is Malnutrition?,” which was published in 1919. Since then much
material has been made available by research on the standards of
height and weight for children of different ages and on other aspects
of the problem of the nutrition of children. The bureau has revised its
bulletin in the light of these later studies in an effort to assist persons
responsible for the welfare of children— parents, teachers, social
workers, and others— in recognizing and combating malnutrition.
Respectfully submitted.
G

Hon.

Jam es J. D

a v is ,

Secretary o f L abor .

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race

bbott,

Chief.

W H AT IS MALNUTRITION?
JUDGING THE NUTRITION OF CHILDREN

Malnutrition in children is widespread in the United States; in
some communities it is so common that it is scarcely recognized as
an abnormal condition. To combat malnutrition it is first necessary
to recognize it— to distinguish between the well-nourished child and
the malnourished one. It is, therefore, desirable to note the signs of
good nutrition and of malnutrition.
S IG N S OF G O O D N U T R IT IO N A N D O F M A L N U T R IT IO N

What is malnutrition? Is it an infectious disease like measles or
whooping cough, which runs its course and then is over? Unfortu
nately not; otherwise steps would have been taken long ago to
control it. Nor is it a disease like gout or rheumatism which causes
sufficient pain to demand attention and treatment. It is, in fact,
not a disease at all, but, as Sir George Newman, chief medical officer
of the board of education of England and Wales (27) ,* expresses it,
“ a low condition of health and body substance.” “ It is measur
able,” he says, “ not only by height, weight, and robustness, but by
many other signs and symptoms.” A description of these “ signs
and symptoms” in the malnourished child will furnish a better idea
of the meaning of malnutrition than any attempt at formal defini
tion. The picture will be even clearer if its opposite— a healthy,
well-nourished child— is described first.
A healthy, well-nourished child measures up to racial and family
standards for his age in height and weight. He has good color,
bright eyes— without blue circles or dark hollows under them, and
smooth, glossy hair. His posture is good, his step elastic, his flesh
firm, and his muscles well developed. He is usually happy and goodnatured, and he is full of life and animal spirits. His sleep is sound,
his appetite and digestion are good, and his bowels are regular. He
is, in short, what nature meant him to be before anything else— a
happy, healthy young animal.
A poorly nourished child lacks several of these characteristics of a
well-nourished child— or all of them— depending on the degree of
malnourishment. He is usually thin, but he may be fat and flabby.
His skin may have a pale, delicate, waxlike look or it may be sallow,
muddy, or even pasty or earthy. Usually blue circles or dark hollows
are under his eyes, and the mucous membrane inside his eyelids is
pale and colorless. His hair may be rough, like that of a poorly
cared for farm animal, his tongue coated, and his bowels constipated.
i The figures in parentheses used throughout this report refer to corresponding figures in the list of refer
ences on pp. 17-19.

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His skin seems loose, his flesh is flabby, and his muscles are undevel
oped. Because of lack of muscular tone his shoulders are usually
rounded, the shoulder blades sometimes standing out to such an
extent as to produce the deformity, known as “ wings ” ; his chest is
flat and narrow; his abdomen protrudes. His teeth may be decayed,
and he may have enlarged or diseased tonsils and adenoids.
The animal spirits natural to all healthy young are likely to be
lacking in the malnourished child; he may be listless at play and
work, not caring to romp and play like other children; he is likely to
tire easily; and he may be regarded as lazy. He is likely to lack
mental vigor also— to have little power of concentration and atten
tion— and to lack the natural inquisitiveness and mental alertness of
a child. He may be nervous, restless, and fidgety; and he will
probably sleep lightly and be finicky about his food.
Such then are some of the signs that distinguish a malnourished
child from a well-nourished one. A malnourished child is an improp
erly nourished child. He may be undernourished, as is shown by
deficiency in weight and height and by other symptoms, or he may
be abnormally nourished, as is shown by overweight and other symp
toms. Malnutrition exists in all degrees— from severe cases in
which practically every symptom described in the foregoing para
graphs is present, to cases which, though they seem to lack^ defi
nite symptoms, still give the general impression that the child is not
quite normal in physical condition. The term malnutrition is usu
ally applied only to cases showing a definite degree of undernutrition,
especially those in which thinness of body and flabbiness of flesh and
muscle are marked; it will be used in this sense throughout this
report.
J U D G IN G N U T R IT IO N BY P H Y S IC A L E X A M IN A T IO N ( 7 ) (44) (46)

The only sure way to decide whether a child is malnourished is
to have bim examined by a physician who takes into consideration
all the signs that may point to malnutrition. According to one
widely used system of grading nutrition by physicians’ examinations,
the Dunfermline scale, “ the general appearance of the child, the con
dition of the skin and subcutaneous tissue, the muscular tone and
development, the state of the mucous membranes, the vigor or list
lessness which may appear in the child’s facial expression, carriage,
movements, voice, interest, attention— all contribute to our [the
examining physicians’] decision.” (7)
*v
,T
The Dunfermline scale, which was originated by Dr. Alister M ac
kenzie, of Dunfermline, Scotland, chief medical officer of the Car
negie Dunfermline Trust, divides children into four grades, as follows:
1, excellent (children of superior condition, such as the well-nour
ished child described on page 1); 2, good (children who fall just
short of grade 1); 3, requiring supervision (children whose nutrition
is on the border line of being seriously impaired); 4, requiring medi
cal treatment (children whose nutrition is seriously impaired). Chil
dren in grades 3 and 4 are usually considered malnourished.
In spite) of the definiteness of the grades in this scale its successful
application depends largely on the individual examiner that uses it.
All examiners can not be expected to agree in selecting children for
the different grades. However, in a test application of the scale m
New York City, in which nearly 300 children were graded by three

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physicians in succession, it was found that the physicians agreed in
judging the children with regard to nutrition as closely -as they did
in judging them with regard to defects of teeth or tonsils.
Errors may enter into the application of the scale. For example,
in certain sections of New York City physicians had become so accus
tomed to undernutrition that they considered it a racial or a local
characteristic, and as they found no children of the superior type
that belonged in grade 1, they used the scale merely to show four
degrees of undernutrition. To avoid such an error it would seem
wise for health authorities to be sure that examiners are familiar with
the superior type of child' and that they understand that the scale
is to be applied strictly according to the definitions.
Other scales are sometimes used: A three-grade scale— “ good,”
“ fair,” and “ poor” ; and a five-grade scale— “ excellent,” “ good,”
“ fair,” ,“ poor,” and “ very poor.” An advantage of the four-grade
scale is that it definitely classifies every child examined either as need
ing attention or as not needing attention. There is no middle ground,
as there is in three-grade or five-grade scales, by which the examiner
may grade a child as “ fair,” without stating definitely whether or not
the child needs attention. But it matters little what terms are used to
describe the grades if the standards for each grade are well defined
and if these standards are strictly adhered to. The advantage is
evident of grading all children instead of disregarding all but the
ones that are markedly underweight.
J U D G IN G N U T R IT IO N B Y H E IG H T A N D W E IG H T S T A N D A R D S

A thorough examination by a physician is not yet available to all
children. The custom has arisen, therefore, during the past few years,
of using increase in height and weight as a rough index of nutrition.
Emerson (25), who was one of the first to call popular attention to
the problem of malnutrition, regards the relation between a child’s
weight and his height as a reliable standard of nutrition. Most
authorities (25) (29) (37) (3) agree that the age of the child should
be considered in deciding what his normal weight should be for his
height. The Baldwin-Wood-Woodbury table, which is generally
regarded as the best available measuring stick for this purpose, gives
the average height and the average weight for children at different
ages (4). This table shows that the difference in weight for a given
height is small during the earlier years of childhood but that during
the adolescent years it is considerable, owing to the changes in the
form and composition of the body that take place during adolescence.
It is not claimed by the compilers of weight-height-age tables that
every normal child is of the weight given in the table as the average
weight for a child of his height and age. Some deviation from the
average is expected and allowed for. Workers in this field have
various opinions as to how far a child’s measurements may deviate
from the average without causing him to be placed outside the group
considered normal. Whether or not he is considered definitely mal
nourished depends on the'standard used by the examiner. Emerson
holds that any child habitually 7 per cent or more underweight for
his height is malnourished. Holt, Wood, and a large majority of
other workers in this field consider 10 per cent a safer limit to use in
routine examinations, and Clark (54) and others believe that instead

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W H A T IS M A L N U T R iT IO ii!

of S3tting up a fixed standard by which children of all ages are to be
judged statisticians should make an effort to arrive at standards for
different ages, as slight deviations from the standard are more sig
nificant in younger children than in older ones. Thus, for children
of preschool age, of the early school years, and of the adolescent
years, respectively, some such deviations as 7 per cent, 10 per cent,
and 15 per cent might be allowed for. The next few years undoubt
edly will see a movement in this direction.
But is weight for height and age alone an adequate index of
nutrition? Are all children that are 10 per cent below the average
weight for their height and age malnourished? And are all that are
not so much as 10 per cent underweight well nourished? These
questions are still debated. For a number of years the weight stand
ard was universally employed as the standard by which the nutrition
of children was judged. But as the work has progressed it has become
apparent to critical observers of the results that this standard alone
will not suffice.
Studies by Dublin and Gebhart (20), Clark (54), and the U. S.
Children’s Bureau (10) all reveal the inadequacy of this method.
In the Dublin-Gebhart study the nutrition of 4,047 children of Italian
parentage in New York City was judged in two ways; first by physi
cians who took into consideration a number of factors indicative of
nutrition, and second by the weight-height-age standards. Compari
son of the results of the two methods of judging showed that prac
tically all the children that were as much as 10 per cent underweight
by the weight-height-age standards were judged by the physicians to
be malnourished. The weight method did not fail to select the most
malnourished children, but it did not select all the children that the
physicians considered malnourished, as three-fourths of the children
considered by the physicians to be malnourished would have passed,
by the weight-height-age standard, as well nourished. In the Clark
study likewise nearly 10,000 native white children were examined by
physicians for evidences of malnutrition and judged as to their nutri
tion by the weight-height-age standard. Comparison of the results
of the two methods of judging showed that the selection of malnour
ished children by the weight-height-age standard agreed somewhat
more closely with the physicians’ selection in this study than in the
Dublin-Gebhart study. However, about half the children selected
by the physicians as malnourished would have been considered well
nourished if the weight standard only had been employed. The
results of other studies, as well as the observations of nutritionists in
their daily work with children confirm these findings, and the tend
ency of modern work in judging the nutrition of children is away
from the exclusive use of the weight-height-age standard.
This does not mean that the weight of children is unimportant as
a factor in judging their nutrition, but it does mean that weight must
be supplemented by other factors. It is generally agreed that all
children should be weighed at least once a month and that any con
tinued failure to gain weight— at least, tO\gain the normal amount
of weight in a year—should be considered abnormal. It is also widely
agreed that the large majority of children underweight as much as 10
per cent (or, if age is considered, as much as the percentages allowed
for their respective ages) can be regarded as malnourished. But
some children not underweight to this extent may be malnourished. It

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is desirable, therefore, that every child examined should be studied by
the signs of good nutrition previously outlined and that his diet and
method of living should be inquired into. All children that fail to
measure up to a high standard in all these respects should be consid
ered in need of attention, whatever their weight may be.
It is is a hopeful sign that emphasis is now put more and more on
attaining the “ optimum” development and nutritional conditions for
children, rather than merely average conditions.
EXTENT OF MALNUTRITION

What is the extent of malnutrition? There is no method of know
ing this for the country at large, but the results of typical investiga
tions are available. One such study was made in March, 1918, by
the bureau of child hygiene of the department of health, New York
City. When 171,661 school children in one borough had been graded
by the Dunfermline scale (see p. 2) the following results were
obtained: Grade 1 (excellent), 17.3 per cent; grade 2 (good), 61.1
per cent; grade 3 (requiring supervision), 18.5 per cent; grade 4
(requiring medical treatment), 3.1 per cent. If these figures were
applicable to the city children as a whole, and the bureau of child
hygiene believed that they were, New York’s 1,000,000 school chil
dren at that time would have been graded about as follows: Excellent,
173,000; good, 611,000; requiring supervision, 185,000; requiring
medical treatment, 31,000.
The results of numerous studies made in different parts of the
country since 1918 show similar and even more serious situations.
In a Children’s Bureau study in a rural county in Kentucky (13) 40
per cent of the children were classed by the physician as “ poor,” 35
per cent as “ fair/,’ 18 per cent as “ good,” and only 7 per cent as
“ excellent.” From extensive observations of thousands of children
in widely separated localities^ Emerson (25) concludes that at least
one-third of the children in the United States are malnourished.
Other studies tend to confirm these findings.
Although the results of such studies are not entirely comparable,
owing to the different methods of judging nutrition that have been
employed, they doubtless do give a fair picture of the national situa
tion. It is probably safe, to conclude that from one-fourth to onethird of the children in the United States are definitely malnourished;
and that the number of children of really superior nutrition is small.
Fortunately there is an increasing tendency in recent years for nutri
tion workers to center their attention more and more on the task of
bringing all children into the “ superior” group, rather than to be
concerned merely with the markedly malnourished children. This is
unquestionably a move in the right direction.
CAUSES OF MALNUTRITION

What causes malnutrition? Why are so few children in the “ excel
lent” group? And why are so many distinctly below par? Are a
certain few predestined by inheritance to be physically fit and others
doomed to be inferior?
There is no doubt that inheritance influences a child’s develop
ment. A child may be born with tendencies to tuberculosis or other
disease, or, as Davenport (19) (30) has shown recently, to slender31411°—27------ 2

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ness or stoutness. But slenderness must not be confused with mal
nutrition. A child of slender stock may be well nourished, for he
may eat the kind of food that will nourish adequately all parts of his
body, and, even though he puts on fat with greater difficulty than a
child of stout stock, he may have sufficient subcutaneous fat to cover
his bones and muscles.
The case histories of a large number of malnourished children show
that the majority of these children started life in normal physical
condition. Given this start, they should have developed into healthy,
well-nourished children. That they failed to do so indicates that
something was wrong with their diet and mode of living.
Lack of any one of a number of conditions necessary for normal
growth may be the cause of malnutrition. Only the most important
causes will be given here.
S PE C IFIC C AU SES

Improper diet.

A diet insufficient or unsuitable is generally conceded to be the
most common cause of malnutrition. Food is the first requirement
of a growing child (18). Every movement his body makes and every
bit of work it does requires energy, and this energy must be furnished
by food.
If the food supply is insufficient the body itself will be consumed
to provide energy, and loss of weight will result. Therefore, the diet
of a growing child should be generous in amount. If a child eats
an insufficient breakfast, such as bread and coffee, he is practically
sure to eat too little total food for that day, even though he may eat
a good dinner and a good supper. If he indulges in sweets and highly
seasoned foods, or eats irregularly between meals, or keeps late hours,
or sleeps in a poorly ventilated room, or gets too little exercise, he will
have a finicky appetite, and this will result in his taking too little food.
Whenever the food eaten habitually by a child falls below his actual
need, no matter for what reason, malnutrition follows.
Besides being adequate in amount, a child’s diet must be adequate
in kind if malnutrition is to be avoided. To be well nourished, a
child must have every day some protein to help form his muscles,
his blood, his heart, his lungs, his brain, and all other parts of his
body. Certain proteins of animal origin, such as those in milk, eggs,
and meat, are especially valuable for growth, and a large proportion
of the protein in the child’s diet should be furnished by these foods.
Another need of the child is minerals. He must have calcium and
phosphorus to build sound bones and teeth, iron to make red blood,
and other minerals for uses just as definite. Since milk is about the
only food that is a liberal source of calcium and since vegetables,
fruits, whole cereals, egg yolks, and milk are the main food sources
of most of the other minerals, it is readily seen that malnutrition in
a child may be caused by not feeding him a sufficient quantity of
these foods.
In addition to proteins and minerals, a child’s diet must contain
some of the growth-regulating substances known as vitamins. One
of these, vitamin A, is provided in liberal amounts by the fat of milk,
by egg yolks, by glandular organs such as liver, and by the leaves of
plants; another, vitamin B, by whole-grain cereals, vegetables, fruits,
milk, and other natural foods; and a third, vitamin C, by succulent
fruits and vegetables, such as oranges and tomatoes. Vitamin D

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(the antirachitic vitamin) is provided by direct sunshine, by eod-livei
oil, and to a less extent by egg yolk (42). There is little danger that
an ordinary diet will be entirely lacking in vitamins unless it is made
up of foods that have been purified too much. However, children
that receive no leafy vegetables and practically no milk nor eggs
may fail to grow normally because they receive an insufficient
amount of vitamins, minerals, and adequate proteins, and the mal
nourished state of many children may be laid to the fact that they
receive too little of these foods and of fruits and whole cereals.
Wrong food habits.

Parents can do much to prevent malnutrition in their children by
providing a diet adequate in amount and quality. But to feed a
child ideally parents must take into account also the suitability of
the food, the hours of eating, and all other food habits, for indigest
ible foods and faulty habits of eating may help to cause malnutrition.
If the child’s body is unable to use the food eaten malnutrition is
as certain to follow as if the foods were inadequate in amount. The
child’s digestive tract is not fully grown and should not be expected to
deal with all foods suitable for an adult any more than his immature
muscles should be expected to do the work of an adult. To avoid
taxing the child’s digestive system, parents should provide simple,
well-cooked, easily digested foods; should exclude rich, highly sea
soned, indigestible foods; should introduce new foods gradually; and
should see that the child eats regular, unhurried meals and does not
eat indiscriminately between meals.
Insufficient sleep.

Insufficient sleep is another cause of malnutrition. Experiments
with malnourished children have shown that even after the diet has
been regulated children do not gain properly unless their hours of
sleep are sufficient and regular. Teachers and others dealing with
large groups of children testify to the fact that children who should
go to bed not later than 7 or 8 o ’clock go to bed at 9, 10,11, or even
later. Continued shortage of sleep is a serious cause of malnutrition
and general ill health in many children.
Chronic fatigue.

Chronic fatigue brought about by too strenuous or too long-con
tinued physical activity in work, in play, or in school athletics,
combined with too little sleep, may be the chief cause of malnutri
tion. Overexcitement, overstimulation, and too much energy put
into school work or extracurricular activities may add to this general
fatigue. With many children, in order to cure chronic fatigue and
thus bring about an improvement in their nutrition, it is necessary
to restrict physical activities, to reduce the school work, to see that
they give up outside lessons and go to bed earlier, and even to pro
vide extra rest periods during the day.
Lack of exercise.

On the other hand, too little outdoor play with its consequence of
too little fresh air, exercise, and sunshine may be responsible for poor
nutrition and poor physical development in many children.
Diseases and defects.

Enlarged or diseased tonsils or adenoids, decayed teeth, tubercu
losis, and syphilis are also causes of malnutrition. Adenoids and

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defective tonsils may act in two ways. If these tissues are enlarged
they may obstruct the free passage of air to the lungs and may also
make swallowing difficult, so that the child eats too little and conse
quently is malnourished. If these tissues are diseased the germs from
the diseased areas find free access to the blood stream and are carried
to distant parts of the body, where they have harmful effects. In
addition, the bacterial toxins may circulate through the body, caus
ino- repression of growth and even destruction of body tissues. Many
severe cases of malnourishment may be cured merely by removing
these abnormal, or diseased growths.
Bad teeth may affect a child’s nutrition in two ways: 1, Painful or
seriously impaired chewing surfaces may interfere with thorough
mastication of food or with the child’s desire to eat proper foods; 2,
abscessed teeth, like abscessed tonsils, may become sources of infec
tion and in the same way cause tissue destruction.
To avoid these conditions, teeth should be inspected regularly
(every six months); and every cavity, however slight, should be
filled promptly.
.
J t
^ i * ' i* i \
Probably the most active agent m tearing down the body is tubercu
losis. It gradually destroys the parts of the body infected, and its
toxins are so pernicious that only the strongest, most robust body
can withstand them.
Many children with congenital syphilis show a marked degree of
malnutrition. In some of these children malnutrition may be the
outstanding symptom of the disease, and the malnutrition may
persist until antisyphilitic treatment is given.
When these physical defects— enlarged-or diseased tonsils or ade
noids, decayed teeth, tuberculosis, or congenital syphilis— are present,
they become even more important causes of malnutrition than im
proper feeding or sleeping habits. Even if a child eats plenty of
wholesome food he can not gain weight, nor even hold his own, if his
body is being torn down as fast as it can be built up. It will be seen
later that some of these defects may be results as well as causes of
malnutrition.
U N D E R LY IN G CAU SES

Before nutrition workers attempt to correct malnutrition it is nec
essary for them to inquire not only into thè' specific causes of it but
also into the underlying causes. Why are children improperly fed?
Why do they have too little sleep? Why are bad teeth and tonsils
not attended to? The answer seems to be that ignorance, lack of
parental control, and poverty— singly or' together— are the causes
underlying these bad conditions.
Abundant evidence has been found that ignorance and lack of
parental control are more important causes of malnutrition in children
than poverty. Studies have shown that many children are improp
erly fed because their parents do not know what are the proper foods
for children nor how to spend their money to get the best return in
food values (12) ; because they do not know that children should
have regular, unhurried meals— including especially a good breakfast;
and because they do not know that the habit of drinking tea and
coffee and the habit of eating indiscriminately between meals are
worse for children than for adults. Besides, some parents that do
know these things fail to’ put them into practice, allowing their chil-

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dren to eat whatever they like and whenever they wish, to live under
continual stimulation and excitement, and to choose their own time
for going to bed (50). The problem of malnutrition in children will
not be solved until parents have some fundamental instruction in
physical care (15) (16), and in the essentials of child management
and training (9). The new movement for parent education will be
one means of effecting this.2
At the beginning of the nutrition movement practically all the blame
for the prevalence of malnutrition was laid on poverty. Experience
soon showed the importance of ignorance and lack of parental control
as factors and a tendency arose to minimize the importance of poverty
as a factor in malnutrition. The extent to which poverty causes
malnutrition has not been determined, but it is undoubtedly true the
many children would be better nourished if their parents had an income
that would enable the family to have sufficient air and sunlight and
an adequate diet.3 An intelligent and well-trained housewife can
come much nearer to providing an adequate diet for her family on a
small income than an ignorant housewife with the same amount of
money— the former may succeed where the latter fails— but the fact
remains that however intelligently expended, there is a minimum
income which is necessary for the purchase of the food required for
an adequate diet. Poverty is sometimes the explanation of ignorance
Better location, better houses, better and more varied foods, and
opportunities for educational contacts require not only an intelligent
appreciation of their value but an income adequate to obtain them.
EFFECTS OF MALNUTRITION

Why worry about malnourished children? Many of them manage
to keep alive, to pass through school, and grow up to take their place
in the world as men and women. Does it make any difference if they
are undernourished now? It does, indeed, make a great difference.
“ Malnutrition/7said Sir George Newman (27) after many years of
observation of its effects, “ is one of the gravest evils in its [the child’s]
physique. The malnourished child tends to become disabled and
unemployable, incapable of resisting disease or withstanding its onset
and process” (27). Its evil effects are shown in both the physical
and the mental development of the child.
P H Y S IC A L E FFEC TS

Stunted growth, anemia, nervous instability, and diminished energy
have already been shown to be accompaniments of malnutrition.
From the point of view of appearance and of the comfort of living
these are important. A malnourished, irritable child is not only far
from pleasing in appearance but is a constant drain on the life of his
associates, and a lifeless, uninterested child is no joy to himself nor
to any one else.
2 In a recent study of child life in cities and rural districts of Scotland b y the M edical Research Coun
cil (29), the efficiency of the mother in caring for the children was the only factor that showed positive
correlation with greater growth and better nutrition among the children.
3In England, during the W orld War, when mothers were away from home working and children were
more or less neglected, the percentage of markedly undernourished children decreased instead of increasing.
This decrease was attributed b y English authorities to the high wages prevalent during the war, which
made It possible for families to have better and more abundant food and more desirable living conditions.

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Long-continued malnutrition with its accompanying diminished
energy and lowered resistance to infection may leave a permanent im
print on a growing child. Evidence of this was shown at the time of
the Boer War, when England was shocked to learn that three out of
every five men who applied for army service were physically unfit for
it. A commission appointed to inquire into the cause of this condition
returned the verdict that malnutrition during childhood was one of the
most serious causes. In the United States at the beginning of the
World War practically the same situation was found. A very large
number of applicants had to be rejected because of physical unfitness,
and the consensus of medical opinion blamed malnutrition and remedi
able defects of infancy and early childhood as the chief factors respon
sible for this condition.
One of the most serious results of malnutrition is increased sus
ceptibility to disease and lack of resistance to it. If an infectious
disease such as measles, whooping cough, or scarlet fever attacks a
neighborhood, the difference between the well-nourished and the mal
nourished child at once appears. The child in good physical condi
tion may not escape the disease; but if he contracts it, he has more
vigor to withstand the attack, and his recovery is usually rapid. On
the other hand, if the malnourished child contracts the disease, espe
cially if he has bad teeth, or diseased tonsils, or adenoids, he probably
has a more serious case; and if he recovers, he does so with greater
difficulty. A large proportion of mortality among children is due
directly or indirectly to faulty nutrition. Scarlet fever, diphtheria,
measles, pneumonia, tuberculosis, and intestinal diseases claim most
of their victims from those who are too poorly nourished to resist
them.
The relation between malnutrition and tuberculosis needs special
emphasis. Tuberculosis may be an active cause of malnutrition, and
a malnourished body is the best soil for tuberculosis. Malnutrition
makes the child susceptible to tuberculosis, which, once started, tears
down the body and increases the degree of malnutrition. This makes
the progress of the disease still easier, and thus the process continues
until death. The way to withstand tuberculosis is to build strong
and well-nourished bodies by good food, fresh air, rest, and sunshine.
Then the disease can make no headway.
The chances for cure in organic diseases of childhood are also
dependent on the child’s nutrition to a greater degree than has been
generally recognized. Holt has shown that lesions even of the heart,
or the kidneys, or other vital organs, which under adverse conditions
of nutrition usually terminate fatally, may be outgrown provided
good nutrition is built up and maintained constantly (38).
Are the effects of malnutrition permanent, or may they be eradicated
completely in adult fife ? The results of experimentation on animals,
as well as observations on human beings, indicate that if malnutrition
has not been too severe nor too long continued its effects may be
overcome almost entirely when the nutritional state is restored to
normal (48). The sooner malnutrition is recognized and corrected,
therefore, the greater are the chances for the child’s complete recovery.
The effects of long-continued or severe malnutrition may never be
overcome completely.
If parents are impressed with these facts and if they are taught to
regard malnutrition as an abnormal condition likely to result in serious

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illness and possibly in death, they may be persuaded more easily to
put forth greater efforts to bring their children into a state of good
nutrition.
M E N T A L E FFEC TS

The effects of malnutrition on mental work have long been recog
nized. Early school-feeding experiments both in England and in the
United States showed that improvement in the nutrition of children
practically always resulted in improvement in their school work (5).
The teachers testified that after the children’s nutrition had been
improved they were easier to teach, showed better power of concen
tration and attention, and obtained better ratings in school work
than they did in the undernourished condition. This is not difficult
to understand, for a starved brain can not be expected to work effi
ciently any more than any other part of a starved body.
Studies of the weights and heights of school children also suggest
a relationship between physical and mental development. Many
studies showing the degree of correlation between the growth of school
children and their mental advancement as shown by progress in school,
intelligence tests, and class standing indicate that in general the bestdeveloped children physically are the farthest advanced mentally.
This correlation is not always evident, however, when individuals or
small groups are studied; malnourished children are not always dull
and backward in their school work, and mentally retarded children
can not always be made to do good school work merely by improving
their nutrition. The native mental endowment is the greatest determining factor. Although any child’s mental powers are lowered by
extreme malnutrition, a highly endowed child has a sufficient margin to
enable him to do creditable school work and to pass well in mental tests,
when tested for short periods of time. Such a child even though
malnourished and below his own maximum will still be superior men
tally to a better-nourished child of inferior mentality. With a child
of average intelligence malnutrition may be a sufficiently important
factor to put him into the mentally retarded group. Although com
parisons can not be made between individuals it is safe to conclude
that a child does the best mental work of which he is capable only
when he is at his “ optimum” state of nutrition and physical well
being. It is true also, as Baldwin has asserted many times, that
when large numbers of children are considered, the physically
superior children are also mentally superior.
It is, then, imperative from the point of view of the mental as
well as the physical welfare of the race that every effort should be
made to make and keep the rising generation well nourished.
TREATMENT OF MALNUTRITION

The first step in treating malnutrition is to find the cause or causes.
This requires a careful inquiry into the child’s method of living, as
well as a thorough physical examination. When the causes have
been discovered the next step, obviously, is to remove them. With
some children this is a comparatively simple matter, but with others
the whole program of life needs to be overhauled. Tonsils and ade
noids may need to be taken out, bad teeth cared for, the diet regulated,
and a new scheme of living instituted. It may be necessary for the

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nutritionist to urge the child’s parents to exercise a wiser, firmer con
trol of his way of living and to teach them the meaning of healthful
living and adequate food. To do this requires putting into practice
a program of health education and sometimes even the provision of
opportunities for obtaining proper food and other factors of normal
living. If poverty is the cause of the child’s having insufficient food
the help of relief agencies must be enlisted. Some of the agencies
that have been established to meet these needs are discussed in the
following sections.
SC H O O L LU N C H E S (6)

“ School lunches” (that is, extra meals provided by school author
ities) were established in England almost immediately following the
discovery in 1900 of thè extent of malnutrition in that country, and
they have since been extensively used there. This extra meal is
sometimes a breakfast, sometimes a mid-morning lunch, and some
times only a cup of milk. The school lunch ministers largely, though
not entirely, to the children of the poor, and its use is based on the
belief that insufficient food is the chief cause of poor nutrition. The
results of school feeding in England have been so beneficial to the
children that the extra meal as a specific measure for dealing with
malnutrition has become firmly established.
In America the school lunch began, as in England, with supplemen
tary school feeding of children in the poorer sections of cities. New
York, Philadelphia, Chicago, and other cities early started lunches
of this kind to provide extra nourishment for children who' came to
school without breakfast, or who were otherwise underfed, largely
because of poverty. As nutrition work has developed, extra meals
have been provided in many cities for undernourished children in all
stations in life. This is in accord with the belief of Emerson and others
that an undernourished child gains better on five small meals than on
three larger ones. Not all nutritionists) however, agree that this is
necessarily true, and many prefer to keep the children to three regular
meals unless it is demonstrated in individual cases that the extra
feedings are conducive to better results. *
The type of school lunch which has developed most rapidly in this
country is the hot midday lunch for children who live too far from
school to go home at noon or who for other reasons would not have
an adequate lunch unless the school provided it. These lunches, which
are paid for by the children, have been introduced widely during the
last decade or more, and special impetus has been given to the move
ment for supplying a hot noon meal for children in rural schools.
It is obvious that such lunches afford rich opportunities for the
nutritional betterment of children (21). Through this one meal eaten
together by the children day after day, the school not only can in
sure that one of the day’s meals is what it should be but through
a proper use of its opportunities for education can do much in train
ing children in the formation of right food habits, in the cultivation
o f a liking for wholesome foods, and in wise selection of food. The
failure of the usual school lunch lies in the lack of educational super
vision. Even though good food is provided the children choose their
lunches unsupervised and thus too often have lunches inadequate in
amount and unsuitable in kind. Fortunately many schools are rec
ognizing the need for trained nutrition supervisors to plan the meals

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and to train and guide the children in the choice of food. Thus used,
the school lunch becomes one of the most effective means for health
education, and there is need that it should be employed far more
generally.
N U T R IT IO N CLINICS A N D C LASSES

One of the most effective methods of dealing with undemutrition
is the nutrition clinic or class. Doctor Emerson as long ago as 1910
conducted such classes in Boston (24) (26). Dr. Charles Hendee
Smith started a nutrition clinic at Bellevue Hospital in New York
City in 1916 (52), and in the four or five years following this their
spread was rapid (53) (41) (55) (45) (47) (50). The method of con
ducting a dispensary nutrition clinic is as follows:
Underweight children are examined by a physician to discover their
needs, and then groups of these children meet weekly to be weighed
-and to be given instruction in food values and in general hygiene.
A weight chart is kept for each child, and the children compete to see
which can gain most or be first to reach the normal rate of increase
in weight. Any physical defects, such as diseased tonsils or adenoids,
are always corrected first, as no gain can be expected until these
defects are removed. Visits to the homes to study home conditions
and to engage the interest of the parents in carrying out the classroom
instructions are a necessary part of the work. Mothers are urged to
come to the class, but the instruction is given primarily to the chil
dren. The cooperation of the child is, in fact, the biggest factor in
the success of the class. Once a child becomes interested in his own
improvement, he will drink milk, eat vegetables and oatmeal, go to
bed earlier, open his windows, and take the necessary rest periods—
things his parents may have been almost powerless to get him to do.
The repeated health instructions, together with the weekly check
ing up and the spirit of class competition, combine to p rod u ce^ 1'
excellent results.
The work that began in dispensaries spread rapidly. Soon nutri
tion classes were conducted in settlements in day nurseries, in schools—
any place where children were gathered together. It was early rec
ognized by all workers in this field that the school is the logical place
for the educational phases of nutrition work for children of school
age. Here all such children can be reached, regularity of attendance
can be obtained, and the educational facilities of the school— the ?
medical service, the hygiene classes, the physical-training exercises, j
the home-economics department, and the school lunch, as well as the I
general school activities— all can be utilized to insure that the chd- .1
dren learn hygienic living, and, during the school day at least, prac
tice it.
The first efforts to put a nutrition program into the school took the
form of nutrition classes for underweight children conducted by the
regular clinical methods that had been developed in the dispensaries.
In 1918 Doctor Emerson assisted the Bureau of Educational Experi
ments in starting nutrition classes in a public school in New York City
(26) (40), and since then he has been instrumental in developing this
type of work in the schools of numerous cities throughout the coun
try.
Other individuals and organizations have also begun similar
work in schools.

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H E A L T H E D U C A T IO N F O R ALL S C H O O L C H IL D R E N

As the work has progressed the emphasis has been shifting more
and more from the mere remedial aspects to the preventive ones.
Instead of being limited entirely to classes for the most underweight
children— as it was in the beginning— the work is rapidly developing
into an all-round health-education program for every school child.
In many schools all children— not merely the underweight ones—-are
weighed at least monthly, and medical examinations are given to as
many as possible. Instruction concerning diet, sleep, exercise, and
other matters of hygiene is given in all grades, and the work is
correlated with the regular school subjects and activities (31-38).
Teachers now put emphasis on the practice of healthy living instead
of following the old method of formal instruction without any appli
cation to the children’s own lives.
In some schools, in addition to the regular health-education pro
gram, special classes are still conducted for the most undernourished
children. In others, additional attention is given to such children
by special measures— such as extra rest periods or relief from some
of the school strains. In most schools nutrition work no longer
stands out as a separate unit, but it has been incorporated into the
health-education program and the whole fabric of school life. Not
all schools, by any means, have as yet any type of nutrition or healtheducation work; but the opinion of leaders appears to be that the
study of nutrition is gradually becoming a part of the regular healtheducation program in schools.
Introduction of nutrition work into a school system calls for trained
direction. In the elementary grades most of the health instruction
is given by the classroom teachers. For this work they should have
more training in hygiene and nutrition than the usual teacher has.
At least one specialist in nutrition should be employed to plan and
'direct the teaching and to develop the educational supervision of the
school lunch. Home-economics teachers may develop into such spe
cialists if they have the time and the training required, or extra
nutritionists may be employed. A nutritionist who has adequate
preparation in other phases of health education may become also the
health-education director for the entire school. All-round develop
ment of this program requires the services of a physician and, for
follow-up work, of a school nurse (22).
N U T R IT IO N W O R K F O R P R E S C H O O L C H IL D R E N

It is during the preschool years that malnutrition usually starts,
and yet activities for its prevention and correction in these years
have been much slower in developing than for the years of infancy
and school attendance. The Children’s Year campaign,4 however,
was instrumental in directing the public’s attention to this “ neglected
age.” As part of this campaign, hundreds of thousands of children
were weighed and measured by physicians. The most important
results of this work were the widespread realization of the needs of
infants and preschool children and the rapid development of welfare
* T he Children’s Year campaign was an effort to protect children from the effects of war, made b y the
U. S. Children’s Bureau and the child conservation section of the field division of the Council of N a
tional Defense, in cooperation. It was carried on during 1918, the second year of the participation of the
United States in the W orld War. In this campaign a program of child welfare was set forth, including
ublic protection of maternity and infancy, m other’s care for older children, enforcement of all child
ibor laws and full schooling for all children of school age, and recreation.

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work for these two groups of children by State and local publichealth agencies and by private organizations.
With the passage of the Sheppard-Towner Act November 23, 1921,
Federal aid was made available to the several States for developing
their work in the hygiene of maternity and infancy.5 Forty-three
States and the Territory of Hawaii have now accepted the terms of
the act and are doing some type of hygiene work for mothers and
infants. In addition to carrying on the program for prospective
mothers, all these States are working toward the establishment of
health centers for all children. Through these measures nutritional
care has been made available in many localities where it was formerly
lacking, especially in rural districts.
In the past a large part o i the work of most health agencies has
been done for infants rather than for children 2 to 6 years old. How
ever, the importance of careful supervision of the physical condition of
these older children has been demonstrated, and the number of chil
dren 2 to 6 years old cared for by health agencies is steadily increas
ing. Standards for conducting conferences in child-health centers
and methods of organizing and conducting nutrition work in these
centers have been presented in other Children’s Bureau .publications
(14) (17),
;
/
Other agencies besides the child-health center are contributing to
improvement in the nutrition of preschool children as well as older
children: Habit clinics, nursery schools, home demonstration work,
and the various aspects of the new movement for parent education.
Habit clinics were originated for the purpose of attacking mental
problems of childhood, including those of management and training.
The methods and successes of such clinics have been described by
Dr. D. A. Thom in a study of their organization and value (11).
Since the problem of correcting malnutrition is largely one of develop
ing wise parental control, the habit clinic, which attacks difficulties
of sleep, diet, and other physical habits from the point of view of
child management, is usually of great service in promoting the proper
nutrition of the child.
The nursery school likewise has proved to be a valuable health
agency to the children that it reaches. The children actually live
several hours of every day in the nursery school, and it thus becomes
possible for the school to see that these hours, at least, are lived
properly. The outdoor play, the daytime nap, and the noon meal
can be supervised, and training in right habit formation can be
directed by specialists in child management. In addition to these,
the weighing and measuring and the medical supervision of the chil
dren, and the training the parents receive either directly or indirectly
from their association with the school, are all conducive to the phys
ical betterment of the children. The home demonstration work
carried on by the United States Department of Agriculture in coop
eration with State colleges of agriculture is also helping to raise the
standard of nutrition in rural districts (1). The American Red Cross
through its nutrition service has developed nutrition work in many
rural communities (2).
The new movement for parent education, which is now receiving
popular recognition, also promises good results. Clubs of mothers—
‘ This act is administered b y the U. S. Children’s Bureau.

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and in the more progressive communities of fathers as well— are
being organized in ever-increasing numbers throughout the country
for the study of the problems of childhood. With a better under
standing of the requirements for the all-round development of chil
dren and of the newer methods of child training improvement in the
nutrition of children and in the whole quality of child life can not
fail to follow.
C O N C L U S IO N

Unfortunately not all these agencies have as yet been made avail
able to the large^mass of children. Many children do not receive the
advantages of such attention until they reach the preschool age,
many not until they enter school, and many not at all. Although
nutrition work in the country at large is progressing rapidly and in the
right directions it can not be considered adequate until it reaches a
higher percentage of children than at the present time and until it
covers every period of the child’s life. When all mothers have
adequate prenatal care; when all children have proper supervision up
to the age of 6 years by child-welfare agencies or by private physicians;
when all schools, through proper medical attention, health instruction,
school lunches, and healthful schoolroom conditions, insure suitable
nutritional and health care for every school child; when all parents
have some fundamental training in the care, feeding, and manage
ment of children; then the ideal— continuous conditions favorable to
normal nutrition and growth for all children from conception through
out the growing period— will come near being realized. Not till then
can we hope to solve the problem of the malnourished child and thus
to grow a healthy, well-nourished generation.

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17

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W H A T IS M A L N U T R IT IO N ?

21. Education, Bureau of, United States Department of the Interior: The
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- “ Health program in the public schools of Joliet, 111.” Ibid., no.
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48. Morgulis, Sergius: "Inanition.”
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