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U. S. DEPARTMENT OF LABOR
A Ç f ■jrj JAMIES J. DAVIS, Secretary
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Libmast
NUTRITION WORK FOR
PRESCHOOL CHILDREN
By
AGNES K. HANNA
Bureau Publication N o . 138
WASHINGTON
GOVERNMENT PRINTING OFFICE
1924
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CONTENTS.
Page.
Letter of transmittal_______________________________________ _ _ _______________
Introduction_______ __________ _____________¡__________ ___________________ 1
Nutrition work in the cities__________ _____ _______ \ ________________________
Organizations conducting nutrition w ork-______ ___ ___________________
Nutrition work in relation to general health supervision of preschool
children________________________________________________
General plan of work of organizations studied__________________
The problem of maintaining attendance in health centers___i___
Methods -used by organizations to attract mothers to centersMethods of holding interest of mothers_______________________
Standards of care for preschool children— _______________________
Children needing general supervision__________ _________ ____
Children needing corrective care____ ______________
Standards for selecting children for nutrition care_____ — _______.___
Methods o f conducting nutrition work___________________ ^___________ 7/
The nutrition class_________________ _________L________ 1________I __
Other group teaching— _____________ _________________ __ ___ \__ ___ 12
Individual teaching_____ _______________ ____ _._______ •__'___ _ _ j ___ 13
Factors entering into success of nutrition work— _____________
~~
Activities of nutrition workers________________________ _____ _______ 2 —
Weighing and measuring-__________________ ____________________
Recording habit histories— ____ ____________
Giving instructions to meet changes in child’scondition— ! _____ L
Food teaching_____________________
Budget work_________________________________ ’______ ______________ ~
Home visiting____________________________________
Arranging educational programs on nutrition w ork-_____________
Types of nutrition workers________________________
_____
Professional workers___________________________ ._____S___— ________
Volunteer workers___ ___________I_________________ ____ _ l ! ____ ______
Measuring results of nutrition work— _______ _____ ____ — _________Ü ___
Nutrition work in rural districts___ _____ ____ ___________ _________ ! ________
Counties having general health instruction— _________________ __ _ _ !
County doing special work for the undernourished__________________ I
Factors which hampered health work in rural districts_______________
Conclusions__________________________________________
Appendix— Organizations visited_____________________________________
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LETTER OF TRANSMITTAL,
U . S . D e p a r t m e n t of L abor,
,
C h il d r e n ’s B u r e a u ,
W ashington, January 10 192If..
There is transmitted herewith a report on Nutrition W ork for
Preschool Children, by Agnes K. Hanna.
The report is based upon a field study of the method o f conducting
nutrition work for preschool children in nine urban and three rural
communities in which some definite organized work in this field is
being done.
Respectfully submitted.
Sir :
G race A bbott,
Hon.
J am es
J.
D a v is ,
Secretary of Labor.
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Chief.
NUTRITION WORK FOR PRESCHOOL CHILDREN.
INTRODUCTION.
This report is an analysis o f the findings of a field study made by
the Children’s Bureau during January, February, and March, 1923,
o f the methods o f conducting nutrition work for preschool children
in nine middle-western and eastern cities (Kansas City, St. Louis,
Chicago, Detroit, Cleveland, Utica, Boston, New York, Philadelphia)
and in three rural districts (Macon County, Ala., Mississippi County,
Ark., Wayne County, Mich.). With the exception o f St. Louis, in
cluded in a preliminary study, the cities visited were selected be
cause in each o f them some definite and organized work for preschool
children had been undertaken. The rural districts were selected be
cause the work in each represented a different type of nutrition teach
ing, although in all of them the work for preschool children was the
outgrowth of the health teaching in the schools.
NUTRITION WORK IN THE CITIES.
ORGANIZATIONS CONDUCTING NUTRITION WORK.
The agencies undertaking nutrition work in the cities visited rep
resented a wide range of public and private activity in different
types of organizations. In some cities of the group well-child con
ferences and nutrition clinics in hospitals and dispensaries, health
centers of private organizations and of the city board of health, set
tlements, nursery schools, and day nurseries were all contributing to
the nutrition work for preschool children, whereas in five of the cities
practically all the wrork for preschool children was being done by
one or two organizations. The work of 30 organizations was studied,
and visits were made to 33 centers or clinics and to 3 nursery schools ;
in addition, home visits were made with 6 nutrition Workers.
Nutrition work as interpreted by organizations interested in the
care o f preschool children is any systematic.and concrete instruction
given under medical supervision to a child or to its parents that has
as its purpose the correction o f all the conditions that have interfered
with the normal growth and development o f the child. While prac
tically all the instruction as to food and health habits given in a
health center by physicians and nurses has a direct bearing upon the
nutrition of the children, it is only when this instruction is given
/ systematically and in relation to bringing the child up to a standard
' o f nutrition below which he has fallen that it is technically called
nutrition work.
The great variety o f activities designated as nutrition work by
the different agencies and the varying standards of care made it
1
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NUTRITION WORK ROE PRESCHÔOL CHILDREN.
impossible to attempt a statistical study of the extent and adequacy
of the nutrition work in each city. Although some of the agencies
visited had worked out the technique of nutrition work through
several years o f experience many had but recently started such
work, and a few of them frankly called the methods used experi
mental. Therefore it has seemed desirable to present in this report
a composite picture of the most effective work that was being done
rather than to discuss the experience and standards o f each indi
vidual city or organization.
N U T R IT IO N W O R K IN R E L A T IO N TO G E N E R A L H E A L T H S U P E R
V IS IO N O F P R E S C H O O L C H IL D R E N .
From the very beginning of this survey it was evident that it
would be impossible to study the nutrition work of any o f the or
ganizations except in relation to the problem of the general health
supervision o f all the preschool children being cared for by the
organization, because o f the different policies and interpretations of
the needs o f preschool children, the varying kinds and standards o f
care, and the different types of workers who gave instruction to the
child and its mother in the centers and in the home.
General plan of work of organizations studied.
The organizations caring for preschool children differed in gen
eral policy in the following respects: (1) Whether the organization
had any plans for providing medical supervision and care for all
the children within the district under its administration, or whether
only those children were being cared for who were brought volun
tarily by their mothers to the center or who were found by nutri
tion workers and nurses while visiting in the homes; (2) whether
the organization undertook to provide both medical examinations
and corrective care under medical supervision in corrective clinics
and in the home, or whether it merely undertook to provide through
child-welfare conferences for medical examinations without attempt
ing intensive follow-up care. The following tabular statement shows
the extent to which each o f these policies dominated the work in 25
agencies that were caring for preschool children in the 9 cities.
These agencies included 21 private organizations and the division of
child hygiene o f the board of health in 4 of the cities.
Policy of agency.
1.
To provide, on a city-wide plan, for periodic medical ex
amination but not for corrective care-------------------------- 2. To provide medical supervision and corrective or follow
up care for all children within a definite district—
__
3. To*provide medical supervision and corrective care for
children brought voluntarily to centers throughout
4.
Num
ber of
agen
cies.
i
4
Approximate
number of chil
dren cared for
by each agency
annually.
1 16, 000
200- 1 ,
200
8
1, 30 0 -5 , 000
12
20 -4 0 0
To provide, in a limited district, medical supervision
and corrective care for children brought voluntarily to
1 Including infants.
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NUTRITION WORK FOR PRESCHOOL CHILDREN.
3
Although the above outline presents only in a general way the ex
tent o f care given preschool children in these nine cities it indicates
that in the majority of agencies concerned with the care o f preschool
children the children attending centers, clinics, and classes are those
who are brought in for care by their parents. The effectiveness o f this
plan in any attempt to provide adequate care for all the preschool
children of a community is in direct proportion to the number of
health centers, the size o f the staff available for follow-up work, and
the extent to which the parents in the community are educated in re
gard to the necessity for periodic examinations and corrective care.
In a large number of the centers visited it was evident that practically
all the children had been brought in because they needed some defi
nite care, while in other centers the proportion of normal healthy
children brought in for general medical supervision was much higher.
Any agency undertaking to provide health supervision for all the
children in a district or a city must make a house-to-house survey
at definite intervals in order to keep in touch with every child in
the changing population o f the district and to educate the parents
as to the value o f this supervision; it must also provide centers, and
a medical staff o f sufficient size to insure periodic examinations of
all the children. If, in addition, it attempts to give adequate correc
tive or follow-up care for every child it must have a field staff exten
sive enough to do this work. Four agencies attempting to carry out
this comprehensive plan determined, in each instance, the size o f the
district to be supervised by the number o f field nurses and nutrition
workers on their staffs. Three districts had one nurse to about 1,800
or 2,000 inhabitants; in the fourth, the size of the district was based
on a city-districting unit rather than on a population unit. The one
agency following a city-wide plan for physical supervision o f all
preschool children gave physical examinations once a year to a large
majority o f these children and did a limited amount o f follow-up
work, but no actual corrective work, for children having physical
defects.
Although it seemed o f interest to include in the preceding tabular
statement the approximate number of children cared for by the four
types o f agencies the real significance o f such a statement can of
course be determined only when the quality and amount o f care given
are known.
The problem of maintaining attendance in health centers.
The records of the health centers show wide variations in their
supervision of the children during their preschool life. Frequently
the child has entered the clinic for the first time at the age o f 2, 3,
4, or 5 years; in a few instances he has a fairly complete record of
weekly or monthly attendance during the first year o f his life or
slightly longer, with occasional and irregular attendance at inter
vals of three to six months or one to two years throughout the prej school years. Most centers have a large number of records of chil
dren who have had fairly continuous supervision as infants but who
either have never returned to the center as preschool children or have
been brought in only once or twice for medical advice. Many chil
dren whose physical examinations show that they are in need of care
ful medical supervision and corrective care have been discharged
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NUTRITION WORK FOR PRESCHOOL CHILDREN.
because o f their failure to return to the clinic despite the fact that
visits had been made by the nurse, whereas others Jess in need of care
are returning at regular intervals.
The experience of most physicians and nurses in health centers
has been that, while it is not difficult to persuade a mother to return
to the center at regular intervals for supervision of the health and
care o f her baby, it is much more difficult to secure the same response
and cooperation in the care of her older children. There are several
reasons for this. These children are gradually outgrowing the
period when their food and their activities differ from those o f the
older members of the family, and as their expression o f feelings and
sensations can be more easily understood than the infant’s the
mother feels more confident of her own ability to judge of their
need of medical care. In a large family, also, household cares and
the more insistent needs of the new baby subordinate the problems
of the older children. The greater difficulty of controlling and
managing^ the preschool child is another element influencing attend
ance at clinics and conferences.
Although these and other conditions make it difficult to maintain
the attendance of preschool children at a center, nevertheless the
effectiveness o f any center is in direct proportion to its success in
the following types of w ork:
1. Educating the parents of the community as to the need of
periodic medical examinations of their preschool children
and stimulating the parents to bring their children to the
center.
2. Teaching the parents to understand the meaning o f the physical
condition of their children and the necessity of correcting
physical defects.
3. Providing instruction in the center that will hold the interest
of the mother and the child and maintain their cooperation
in correcting poor food and health habits.
The amount of effort that is necessary, the type of appeal or
publicity, and the kinds of workers needed in a center to “ put over ”
this instruction in any community will depend in a large measure
upon the character of the neighborhood in which the center is
located. Inability to understand English, limited understanding,
prejudices, national or racial customs or attitude of mind, all add
difficulties to the problem. . That any of these conditions are in
superable has been disproved by the experience of different centers—
practically all parents will respond, to the limits of their ability,
to a popular or persistent appeal to their interest in their children.
How far an agency should devote its energy and its funds to each
o f the three types o f instruction will depend upon its general policy.
Adequate care of a limited number of children, and the slow but
sure growth among the families of the community of a more intel
ligent attitude toward child care that will lead eventually to the
provision of adequate care for all children, is the ideal of most
public-health workers, rather than the creation of a popular interest
at various periods that is not sustained by a constructive after-care
plan. The evidence that a center or an organization is progressing
under the former plan is a steady growth in the number of pre
school children being cared for in the center and in the number of
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NUTRITION WORK FOR PRESCHOOL CHILDREN.
5
children brought in for general medical supervision as well as for
corrective care. ^Equally valuable evidence of progress in an or
ganization devoting its energy to popular education is an increased
demand for centers for corrective and follow-up care for children
and willingness of the. community to support such centers.
Methods used by organizations to attract mothers to centers.—
In most o f the centers visited no special effort was being made to
stimulate the attendance of preschool children who had not visited
the center before, since the organization usually was not equipped to
care for more new cases than would come to the center normally as a
result of effective work in the district. I f the work in a center must
be limited because of a small staff, it is extremely difficult to main
tain the best proportion between the amount of effort that should be
put on corrective work for a small number of children and that spent
° u* j 6 general supervision of a larger number o f more nearly normal
children. The center should be a preventive, as well as a correc
tive, agency; and it is as important for it to supervise the health
of the normal child and to prevent malnutrition and faulty habits as
to correct these after they have developed.
An important part of the work of agencies that undertake to care
for all the preschool children in a definite district is to make sure
that all the children come to the center. Personal interviews with
the mothers in a house-to-house survey are the means usually em
ployed for doing this. The four organizations caring for a certain
small district have this canvass made by the nurse or nutrition
worker who is responsible for each park o f the district, or by special
workers on the staff. Several advantages are to be gained from mak
ing the canvass o f her own district part of the work o f each nurse.
From the first contact with the mother the same person will have
charge of the child in clinics and in home visits; the experience and
training of a nurse should make her most effective in persuading
the mother that the child needs medical care; the interest and work
o f a nurse are understood and she is an accepted authority in the
community. In a center in an Italian district it was found that the
most effective person to stimulate mothers to bring their children to
the center was an Italian social-service worker. This worker’s lack
o f nursing training was completely offset by her greater knowledge
o f the point of view o f the Italian mothers and her ability to make
her points clear to them. Furthermore, her service as interpreter
in the center had given her fairly extensive clinical experience in the
needs o f the children.
That specially instructed volunteer workers can be used with ex
cellent results to stimulate mothers to bring their children to a
center for examination was proved by the experience of the one
agency providing child-health conferences for an entire city. In
this instance the attendance at the centers of 95 per cent of ail the
children found in the 1922 canvass 1 was attributed largely to the
individual efforts o f the volunteer workers, although their work was
supplemented by a general publicity campaign.
Without undertaking a house-to-house canvass it is possible to
reach most of the parents o f a community through clubs, churches,
1 Annual R eport fo r 1922.
84722°— 24------2
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NUTRITION WORK FOR PRESCHOOL CHILDREN.
and other organizations of men and women, and through the chil
dren in the schools; and all of these methods should he used in any
general publicity campaign.2 In all o f the rural communities visited
the schools were the center o f the health activities, and as a result
they were the main agencies for reaching the parents. In the cities,
although there was evidence of some cooperation between individual
teachers and principals and the workers in a center little attempt
was made to use the schools systematically as a means o f reaching
parents. One board o f health has undertaken to give examinations
each spring, in a few schools in the locality, to preschool children
who expect to enter school in the fall. This work is more closely
related to school problems than to the problems of agencies working
for preschool children.
Methods o f holding interest o f mothers.—The center that does the
most effective work for preschool children is one in which all the
members of the staff—physicians, nurses, nutrition workers, and
volunteers—realize that their problem is primarily an educational
one and work steadily to improve their teaching technique. There
was wide divergence in the opinions o f the physicians in the centers
visited as to the limits of their activity. Some o f them undertook
only to diagnose the condition o f the child and to give general ad
vice to the mother and the nurse or nutrition worker, and others gave
a large part, if not all, o f the individualized instruction which the
mother received. The value o f having the physician spend time to
secure the cooperation o f both the mother and the child in his plan
for the child’s care should be more generally recognized. The es
tablishment of special conferences and clinics for preschool children
under the medical supervision of men or women especially interested
in their problems is of great assistance in securing this result.3
This plan was used in about one-half o f the agencies visited. Some
very effective teaching was being done in different organizations by
both nurses and nutrition workers, but there were many evidences of
poor teaching methods used by both'’ types of workers and o f failure
to recognize the fundamental educational problems in their work.
The use by one center o f the name “ health teacher ” for the youngwoman doing nutrition work has much to commend it, as it empha
sizes the educational character o f such work.
After children have been brought to a center for their first physical
examination their continued attendance at clinics and conferences is
dependent upon the quality o f the advice and instruction given in
the center and its adaptation to the problems o f each individual
mother so that she sees the value o f the effort and time that she
expends in clinic attendance and in carrying out the instructions
of physician, nurse, and nutrition worker.
Many o f the abnormalities in physical development and in reac
tions o f the preschool child which to a trained observer indicate a
definite physical or mental condition are accepted by the family
as individual habits or as personal or family peculiarities. As a
result, it is most difficult to persuade parents to undertake systematic
» How to Conduct a Children’ s Health Conference, by Frances Sage Bradley, M. D.
U. S. Chttdrett’s Bureau Publication No. 23. * W ashington, 1917.
3 Curtis, Robert D. : “ Standards and m ethods fo r health work among children o f pre- '
school age.” T ransactions o f the Eleventh Annual Meeting o f the American Child Hygiene
A ssociation, 1920.
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NUTRITION WORK FOR PRESCHOOL CHILDREN.
7
correction of these defects. Furthermore, the advice and instruc
tion given to a mother for the care o f her preschool child usually
either involves some surgical correction'of defects or else requires
some modification or change in the habits and activities o f the child
or o f the family. Inadequate food and bad food habits, unhygienic
habits o f living, lack of sleep, and lack o f parental control are all
factors that may cause undernourishment or the development of other
defects; yet to correct any o f these may require the overcoming of
prejudices, ignorance o f sanitation, hygiene, and food values, ana, in
many cases, indifference on the part of other members of the family,
especially the mother.
Unless the instruction given in the center is directly concerned
with the particular needs o f the individual family and is of a kind
to stimulate^ the interest and effort of both the child and the mother
the change in the child’s condition from week to week is usually so
slight that it is not a sufficient incentive for continued effort by the
mother. Is it reasonable to expect a mother to return to a center for
advice when she knows that she has not carried out the instructions
previously given because they seemed difficult or impractical and
only vaguely related to the child’s condition, which she looks upon as
“ nothing to worry about, anyway ” ?
In addition to the instruction adapted to the needs of her own
child which is given every mother, 11 out o f the 33 health centers
visited undertook a general educational program to help maintain
the interest o f the mothers and children coming to the center or to
demonstrate to the mothers standards o f child care. Such a pro
gram may include clubs and classes for mothers or for older children
in the families, motion-picture talks on health topics and other en
tertainments, and demonstrations and illustrated talks on child care,
health habits, and food selection and preparation, given as part of
the daily activity of the center. In one center this program was
extended to include a day nursery for infants and a nursery school
for preschool children, which were used to demonstrate to the
mothers the effect of adequate care for children not receiving such
care in their own homes.
One o f the greatest losses in effort observed in health centers is the
failure to provide interesting educational material as well as medical
advice in the conferences and clinics. Although it often takes great
effort and much time on the part o f the nurse or nutrition worker
to persuade a mother to bring her child to a center, nevertheless
when she does arrive no attempt is made to use her time while there
in the most profitable way. In all the centers where an effective
general program was planned as part of the regular work of a
clinic it was being carried out by a nutrition worker or nurse who
had no other responsibilities in the clinic.
Standards of care for preschool children,
In considering the standards of care given to preschool children in
health centers it is necessary to distinguish between the type and
amount of care given to the normal healthy child or to the one under
general medical supervision and that given to the child in need of
corrective work. These are not necessarily groups o f special chil
dren, for every child may sometimes fail to measure up to the normal
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N U T R IT IO N
W ORK
F O R P R E S C H O O L C H IL D R E N .
standard and consequently intensive care may be given him during
a certain period, although at other times he receives only general
supervision.
Children needing general supervision are brought to the center
for a thorough physical examination and advice from the physician.
Unfortunately the value o f medical supervision for the normal child
is not understood by most parents, and the actual number of normal
children returning systematically to health centers for physical ex
aminations is extremely small; in many centers there were prac
tically no such children. In most cases the children returning regu
larly for supervision were those border-line cases that can be kept
up to a minimum standard o f health only by constant care. In all
the centers the intervals at which children should return for exami
nations were determined largely by the children’s needs, but the
general policy o f a physician or an organization was also a factor
in the decision. The period most usually specified by the physician
was three months, although in a few cases it was advised that the
child be brought back in six months.
The method of keeping in contact with these children needing
periodic supervision varied greatly in different centers. In some
they were given the same monthly home supervision by the nurse
or nutrition worker as was given to children in need o f corrective
care. In five o f the dispensaries and health centers visited the date
for the return visit was. noted on the child’s record and the mother
was notified to return on this date by a postal or by a visit from the
nurse; in event of the mother’s not responding to the postal it was
followed up by a call from a nurse or social-service worker. I f an
agency is going to attempt to give general medical supervision
throughout the preschool years for as large a proportion as possible
o f the children in its district, it is essential that the amount of effort
and time given by the staff to. secure the return o f the children to the
center be reduced to the minimum. The very high percentage of re
turns shown in the records o f two agencies, which was secured by the
,
usfe of a return-visit file and notification by postals, indicates that this
method should probably be used more generally in health centers.
The willingness o f a mother to return periodically to a center is
influenced by her estimate o f the value of the medical advice given
and, as was noted before, her interest in the information that she ac
quires. The physical examinations at the different centers were very
similar, but the medical advice given varied widely. In five centers
the prevention of diphtheria was particularly emphasized and treat
ment at a dispensary was arranged for. The advice and information
given in different centers in regard to the food and health habits of
these children varied from the mere distribution of general printed
directions to individual and detailed advice by a nutrition worker.
Children needing corrective care—A. large majority o f the children ;
coming to health centers are in need o f corrective care. The reason \
for this is evident, since one o f the most marked characteristics of the \
preschool period is a gradual increase in the number of children hav^
ing defects and in the number of defects per child in each age period.4
From the standpoint o f care these children may be divided into two
*•Physical Status o f Preschool Children, Gary, Ind., by Anna E. Rude, M. D.
Children’ s Bureau Publication No. 111. W ashington, 1922.
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NUTRITION WORK FOR PRESCHOOL CHILDREN.
9
groups: Those needing correction of physical defects or treatment
for disease in a hospital, dispensary, or medical clinic; and those
needing correction o f habits and activities. As many o f the defects
needing medical correction are augmented by, or are the result of,
inadequate food and unhygienic habits, many children need both of
these types o f corrective care.
Practically all o f the centers adopted the same general policy in
regard to children having physical defects. In all cases in which the
family had a private physician the mother was referred to him for
recommendations as to treatment; in those in which the family had
no regular physician the physician at the center recommended a hos
pital or dispensary where the child could receive care.
The degree o f responsibility assumed by the different health cen
ters in securing the correction of physical defects varied considerably.
It was influenced to a large extent by the type of community in which
the centers were located, those situated among non-English-speaking
groups taking, on the whole, more responsibility. Dental clinics were
in the same buildings as those occupied by several o f the centers
visited, and consequently a large percentage o f all the dental defects
o f the preschool children coming to these centers were corrected.
In a number o f other centers the nurses or nutrition workers
undertook to make appointments at some dental clinic for the chil
dren under their care, and often they personally took the children
to the clinics. In a few centers the staff took no responsibility for
dental care but constantly urged the parents to do this themselves.
The removal o f defective tonsils and adenoids was the type o f cor
rective work which was most often recommended for preschool chil
dren and for which the staff of many centers assumed responsibility.
Arrangements for hospital care were made for all children for whom
the consent of the parents was secured, and in addition the nurse or
nutrition worker made sure that the appointments were kept.
In all centers the children needing corrective medical attention
were given continuous follow-up care in the homes until the defects
were corrected, or as long as the parents needed instruction or would
cooperate by coming for supervision to the. center. A monthly visit
was the minimum standard for such follow-up care. It is a very
difficult problem to persuade parents to have defects corrected; and
where the need for such correction is very great the nurse and the
physician try to keep in contact with the parents at intervals of a
week or so through clinic attendance and home visits.
There are several types o f defects that may be overcome by change
in the habits or the activities o f the child. It is this type o f correc
tive work that is primarily the problem of the staff o f a health
center. The largest group o f children needing this care are the
undernourished children, and in all o f the 23 centers doing effective
work with this group provision was made for their care in special
nutrition clinics or by individual instruction from a nutrition worker
in conferences and in the homes. Poor posture and bad habits are
other defects for which special corrective work may be done in a
center. Posture classes or clinics for preschool children were found
in three centers. Only one o f the organizations visited had estab
lished habit clinics for the correction o f habits that are the result of
wrong mental attitudes; individual instruction o f the mother in all
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NUTRITION WORK FOR PRESCHOOL CHILDREN.
such, cases was included, however, as part of the work o f the three
nursery schools visited.
There are two points o f view in regard to the standards of care
that should be given to the children for whom corrective educational
work was being done in health centers: (1) Intensive instruction
should be given in a clinic and in the home at sufficiently close in
tervals to maintain the interest and cooperation o f the parents and
the child. This usually means weekly or semiweSkly visits either
in the center or in the home. This intensive care is maintained for
a definite period (three to nine months) or until an acceptable stand
ard o f improvement is attained. Following this intensive instruc
tion follow-up care is given at regular intervals. This type o f work
was being done in eight o f the centers. (2) Instruction should be
given to the mother for as long a time as she will cooperate in carrying out directions, each child being seen at least once a month.
When the mother assists by coming to the center regularly the in
struction is more intensive; also, in individual cases where there is
definite need but inability on the part of the mother to come to the
center, the nutrition worker should visit the home at more frequent
intervals than once a month.
There is much difference in the policy o f various organizations
as to how frequently these children receiving regular instruction
from the center should be examined by the physician. In most cen
ters the physician expected to see them every time that they came to
the center. The periods between their visits varied greatly, however,
since in a few centers most o f the instruction was given in a special
clinic and the children were expected to return weekly or biweekly,
whereas in other centers practically all of the instruction was given
in the home and the children came to the center only at intervals of
three to six months for medical examinations. O f three organiza
tions visited which had excellent clinic attendance one required only
a yearly examination by the physician, and the other two considered
a six-month interval more satisfactory.
S T A N D A R D S F O R S E L E C T IN G C H IL D R E N F O R N U T R IT IO N
CARE.
The standards for selecting the preschool children for whom nutri
tion work should be done varied in different agencies. In some cen
ters the only children given this care were those who did nor
measure up to a weight to height standard, and in other centers
any child showing evidence o f malnutrition or of poor food habits
was assigned to the nutrition worker for care. In several organiza
tions no attempt was made to care for all the border-line nutrition
cases because there were only one or two nutrition workers on the
staff, so that only the most seriously undernourished children were
included.
In very few centers was it possible to secure an accurate definition
o f the standards used in judging nutrition cases, as this varied with
the point o f view o f each examining physician. In using weight to
height as an index of undernourishment, some physicians used 7 per
cent and others 10 per cent underweight as a standard; this may
have been affected by slight differences in the tables of weights and
heights used in different centers. More emphasis was usually placed
upon the general condition o f the child than upon his weight. The
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wide variation in the percentages o f preschool children who are
under weight in the different age groups 6 may be one o f the reasons
why underweight is considered a minor factor in nutrition work for
these children. Individual opinions of physicians as to conditions,
other than weight, upon which standards o f nutrition are based, also
showed variability. Consequently it was impossible to secure com
parable figures as to the extent of undernourishment among the chil
dren attending different centers.
Twenty of the organizations visited were doing some definite nu
trition work for preschool children, and in 14 o f these the nu
trition worker was handling primarily nutrition cases. In 3 organi
zations the nutrition worker not only cared for the nutrition cases
but took charge o f the preschool clinics and did the home visiting
for all preschool children. (In one organization this plan was soon
to be replaced by more specialized nutrition work.)
There are both advantages and disadvantages in this plan. The •
main advantage is that any discussion o f the food o f preschool
children must be related to advice about the family diet if it is to
be at all effective, and this is a technical problem needing a specially
trained person. That there is need for instruction in food as well
as in health habits for many children who are not considered under
nourished is borne out by two studies of the adequacy o f the diets
of preschool children. In one study 72 per cent of the children
were found to have questionable or inadequate diets, though only
40 per cent o f them were graded as “ poor ” or “ very poor ” in
nutrition as judged by both weight and general condition.6 The
second study showed that 60.5 per cent had inadequate diets and
29.2 per cent had questionable diets, whereas only 9.7 per cent were
undernourished on a basis o f 10 per cent underweight for height.7
The chief disadvantage in having a nutrition worker care for all
preschool children is that few o f the women doing this work have
had sufficient training or clinical experience to recognize evidences
of disease or to give advice as to nursing care, yet situations
requiring such service are often met in home visiting.
M E T H O D S O F C O N D U C T IN G N U T R IT IO N W O R K .
Methods of conducting nutrition work for preschool children have
been influenced .by the difficulty o f maintaining in clinics or classes
meeting regularly a continuous attendance o f all the preschool chil
dren needing this type of care, and also by the fact that the instruc
tion of the mothers even more than of the children is necessary.
Although it is most desirable—in fact, often essential—in any plan
for the care of the preschool child to secure his cooperation it is
not possible to secure it as fully as that o f the older child.
BPhysical Status o f Preschool Children, Gary, Ind., by Anna E. Rude, M. D.
Children’s Bureau Publication No. 111. Washington, 1922.
8 The Nutrition and Care o f Children in a M ountain County o f Kentucky, by
Roberts, pp. 29 and 8. U. S. Children’ s Bureau Publication No. 110. W ashington,
7 Children o f Preschool Age in Gary, Ind. P art II, Diet of the Children, by
Roberts, pp. 57 and 102. U. S. Children’s Bureau Publication No. 122, W ashington,
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U. S.
Lydia
1922.
Lydia
1923.
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NUTRITION WORK FOR PRESCHOOL CHILDREN.
The nutrition class.
The class method 8 of conducting nutrition work, therefore, which
has been used with a considerable degree of success for many groups
of children of school age, has had but a limited use for preschool
children. In only four o f the centers visited was formal class work
in nutrition undertaken. In one of these the class was held in an
under-age kindergarten with full attendance of children but with
only about one-fifth of the mothers; in another the class had dropped
from 12 to 5 children; and in the third center the class had just been
discontinued because it had taken so much effort on the part of the
nurses to bring the children together each week. The class attend
ance in the fourth center was very irregular, averaging about 12
mothers each week out o f a group of 60.
The particular value of the class method is the appeal to group
and social interests and the development of. a spirit o f competition,
all of which may be used to stimulate the effort of each individual
in the class. Although there is some difference of opinion as to the
value or necessity of competition as a means of stimulating children
to work for improvement in health habits,9 the value o f group pres
sure and the advantage of hearing the varying experiences of the d if
ferent members of the group are almost generally conceded.
Other group teaching.
The importance of group work is recognized by most nutrition
workers, and group teaching in various forms was used in different
centers. In many centers every effort is being made to get groups of
mothers together in classes or clubs, meeting weekly or monthly, for
general instruction about foods and about prenatal, infant, and child
care. These efforts, however, have been only fairly successful, as
the actual number of mothers coming to any center for regular
class work is very small. Four o f the centers visited have a definite
plan of group instruction for every nutrition-clinic meeting. This
usually consisted of demonstrations, talks, or cooking lessons, and it
often included some discussion o f the habits and activities of the
individual children, as the mothers discussed their own experiences
with the nutrition worker. This type of work does not necessitate
regular attendance nor the use of the formal technique employed in
a nutrition class.
Some very effective informal group teaching for the mothers who
happened to come at the same time to the clinic was seen in four
centers that had no definite group program. Although this method
of securing exchange of ideas and experiences among small groups
of mothers by discussing their problems together was used quite
spontaneously by thes6 four nutrition workers, its value was so
evident that it should be used more generally in nutrition clinics.
A ll these methods of group teaching were arranged for the benefit.
of the mothers rather than to secure the cooperation or interest o f the
children. The one point where group pressure was of great as
sistance in this last respect was its influence in teaching, the children
8 Emerson, W illiam R. P . : Nutrition and Growth in Children. D. Appleton & Co New
York, 1922.
>
»H ealth Education and the N utrition C lass; Report o f the Bureau o f Educational
Experiments, p. 225. E. P. Dutton & Co., New York, 1921.
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to like the foods that they should eat. The “ party ” served to the
children at a food demonstration in four of the centers, the midmorn
ing or midday lunch served in three nutrition clinics, and the meals
served in all the nursery schools illustrate the value and the ease
o f teaching children to eat the right things, if they are made to
feel that they are expected to take— and to like—everything served
to them. Another type o f group teaching planned to secure the in
terest and cooperation of the children was the telling o f stories that
emphasized health habits. This was seen in two centers: In one case
the story-telling was done in connection with informal group work
with the mothers, and in the second case it was given in a formal
nutrition class.
Individual teaching.
The usual method of nutrition teaching found in health centers
was individual instruction given to each mother, through which it
is possible to go more deeply into the problems of each child than in
group teaching, although it involves a loss in not creating a group
attitude among the mothers coming to a center. Some individual
teaching should always be done even with the most effective group
work.
Without the benefit o f the social interest of group work the
nutrition worker must depend upon her individual appeal to the
interest o f the mother and the child. This is a question both of
personality and of good teaching methods. In a few centers the
nutrition worker made an earnest effort to interest and teach the
children as well as the mother, providing small chairs and tables
and a few easily cleaned toys, or giving out colored stars or pictures
as a reward for their efforts.
The most marked difference in method in the centers doing indi
vidual work was the extent to which this teaching was done in the
center or in the home. Although clinic attendance is influenced to
a certain extent by the type of the group which the center serves,
this is not the only factor, as is shown by the experience o f various
centers placed among quite similar population units. The most im
portant factors are: The extent to which the community is educated to
come to the clinics and the preference o f the staff of the centers for
the home or for a nutrition clinic as the place to give instruction.10
The value and necessity o f home visiting is not questioned by any
nutrition worker. The difference in point o f view is in regard to
the amount o f individual teaching that should be done in the center.
Although nutrition work is similar to other types of public-health
teaching that may be done in the home, it has been developed to a
large extent for the undernourished and underweight child, and it
therefore offers a slightly different situation from that o f general
nursing instruction. In spite o f differences o f interpretation o f the
/significance o f weight to height as an index o f malnutrition, prac
tically all nutrition workers use the gain or loss of weight o f the
child to encourage the mother to continue or change her course of
procedure in regard to his food, habits, or activities. It is therefore
10 Nursing and Nursing Education in the United States, p. 50.
uf Nursing Education.. The M acmillan Co., New York, 1923.
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NUTRITION WORK FOR PRESCHOOL CHILDREN.
necessary to weigh the child at fairly regular intervals if any inten
sive corrective care is to be given. The nutrition workers o f two
organizations were provided with portable scales, so that this im
portant factor o f their teaching could be included in home instruc
tion. In all of the other centers the nutrition workers relied upon
the attendance of the child at the center for a record o f his weight,
and as a result many nutrition workers were attempting to do home
teaching without the benefit of definite knowledge of weight varia
tions.
As a place for instruction both the center and the home may be
most valuable. Certain types of instruction can be given as effec
tively in the center as in the home; others can be fully understood
only when all the conditions that affect the situation can be seen and
talked over. The experience of several centers has proved that some
o f the food instruction often given in the home can be given at much
less cost and quite as adequately in the center. An effective teacher,
for example, can make a cooking demonstration individually valu
able to 10 or 12 mothers, whereas it would take many hours of her
time to give the same demonstration in 10 or 12 homes. Further
more, the attention of the mothers as evidenced by the questions
asked in these centers was secured much more fully in the center
demonstrations that were seen than in the home demonstrations.
The mother in her home was usually distracted by the need of look
ing up supplies and cleaning dishes, the feeling o f being hostess, and
constant attention to the wants o f the children.
F A C T O R S E N T E R IN G IN T O S U C C E S S O F N U T R IT IO N W O R K .
The final measure o f success in nutrition work is the extent to
which faulty living habits have been overcome and more adequate
habits substituted for them. In any habit-forming program re
sults will be secured far more easily if stimulation and encourage
ment is given at fairly close intervals. The nutrition worker who
can see the mothers and children under her care at weekly or at
semiweekly intervals, especially in the beginning o f her work with a
family, has a great advantage over the worker who sees her families
at monthly intervals. There is some difference of opinion among
nutrition workers as to the length of the period during which this
intensive care should be given or as to the standard of success that
should be attained in each case before such work is reduced and
more general supervision given instead. The shortest period for
intensive work in any of the centers was three months; in some it
;was from six to nine months.
The number o f children cared for at one time by a nutrition
worker will necessarily depend upon the amount of care given each
child, and also upon the extent to which this instruction is given irlv
the home or in the center. Each nutrition worker, in centers where
intensive work is being done, usually has under her care from 40 to
70 children, the number that she cares for each year depending upon
the amount o f care given each child. Where nutrition work is less
intensive she may be responsible for I§0 to 250 children at a time,
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ACTIVITIES OF NUTRITION WORKERS.
Weighing and measuring.
As has been suggested, the child’s weight may be used in nutrition
work in two ways— as an index of his condition and as a means of
interpreting to the mother the adequacy of her care. This difference
in the use o f the record of a child’s weight is partly the cause of the
wide variation in the technique o f weight taking found in different
centers. In some the children were always stripped for weighing;
in others their weight was sometimes taken with their clothes on and
at other times without. The most satisfactory plan was the follow
ing, used by one organization: When a physical examination was
being given the child was weighed stripped and again in all his
indoor clothes with the exception of shoes and sweaters; when the
child returned periodically to the center his “ clothed weight” was
taken each time and compared with the clothed weight at the pre
ceding visit. As most of the standard tables11 o f height and
weight of children of 2 to 6 years are based on “ stripped weights,”
it seems desirable to take the child’s weight without clothing when
he is haying a physical examination, but there seems little reason
for requiring the complete undressing o f a child every time he is
weighed in the home or in the center for the benefit of the instruction
to the mother.
The importance given to weight taking and the accuracy with
which it was done varied in the different centers. In some a volun
teer worker without much supervision took the weight; in others
the nutrition worker always did so, discussing with the mother the
changes in the child’s weight while her interest was centered on
the subject.
Graphic weight charts were used in 12 of the centers. In the four
centers that used a formal class method large wall charts were used •
in the rest a small chart was kept for the benefit o f the nutrition
worker and the mother. I f the record of weight is to be used as
a means of showing the results of success or failure in carrying out
a satisfactory health program it is valuable to show changes in
weight as clearly as possible. Charting of weights is o f great benefit
in accomplishing this.
Recording habit histories.
In most centers a more or less complete record o f the daily
activities, habits, and food was taken wheh the child was first
brought to the center, but in only a few centers was a similar record
taken on return visits. This record was often taken by a clerk,
volunteer, or assisting nurse before the child was seen by the phy
sician, in order to give him a more complete picture of the factors
affecting the child’s condition. While this method may be of value
/in saying the physician’s time or in assisting him there is a .definite
loss in not having this history taken by the person—whether phy
sician or nutrition worker—who is to give the main instruction in
health habits to the mother. The taking of a record to be used by
11 Statures and W eights o f Children under Six Years o f Age, by Rob rt Morse W oodbury,
Ph, D. U. S. Children’ s Bureau Publication No. 87. W ashington, 1U21.
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NUTRITION WORK FOR PRESCHOOL CHILDREN.
someone else is usually rather a formal proceeding, and the result
in many cases is not an accurate picture o f the real activities and
habits o f a child. If, on the contrary, this record is taken by the
person giving the instruction, it becomes a means o f giving a most
valuable and individualized instruction in health habits. The most
effective nutrition workers in all the centers used the latter method.
Giving instructions to meet changes in child’s condition.
The discussion of the activities, habits, and food of the child in
relation to the physical findings o f the physician and to the changes
in the child’s weight or condition constitutes the main instruction
given in nutrition clinics, classes, and home visits. This discussion
should be based upon accurate knowledge o f the child’s daily
activities, the amount of rest taken, his living conditions, the nervous
stimulation he is under, and the adequacy o f food taken during a
typical 24 hours, in order that the causes which may have produced
the defect or underweight in the child may be understood. In
addition to .this information it is necessary to know in what respects
his daily program has been altered during the period following the
previous instruction, in order to interpret any changes in physical
condition or in weight. To secure this information the questioning
of the mother must be most skillful and sympathetic. In many cases
an adequate understanding of the problems involved can be secured
only after several clinic and home visits.
Food teaching.
The importance of food as a fundamental requirement of good
nutrition and the inadequacy of the diet and bad food habits found
in a large proportion of the homes have made instruction about foods
an important part of nutrition work. This has been the main reason
for employing as nutrition workers women with special food training.
Although the food of the preschool child is the immediate problem
o f the nutrition worker it is seldom possible to secure changes in his
food without discussing the family dietary.
To secure changes in this is a slow and difficult process, and the
successful nutrition worker approaches the problem gradually. She
begins by emphasizing the value o f such foods as milk, greens, oat
meal, and eggs, and encourages the mothers to use these foods and
to report the number of times they are used and the amount eaten
by the child. In many cases she has to contend with prejudices
against or apathy toward the use of any or all of the foods that she
advises. One o f the hiost effective methods o f overcoming the dis
couraging “ He no like,” which is the final and only answer given
to much of the advice about foods, is to give the child an opportunity
to taste the food properly cooked. This can be done by a “ party ”
at the clinic or by a demonstration in the home. The value o f this
type of work is not fully realized, for aside from the centers and
nursery schools where a meal was served only six of the nutrition^
workers interviewed made the preparation and serving of foods to
the children a definite and regular part of their work, although
several gave an occasional demonstration to teach a mother how to
cook a particular dish.
In a great deal of the food work observed the instruction given
to the mothers never went beyond continuous pressure to add more
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NUTRITION WORK FOR PRESCHOOL CHILDREN.
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milk, fruit, greens, and other vegetables to the dietary and to use
a hot cereal for breakfast. This general advice was always supple
mented by explanations as to the value of each of these foods and
advice as to their preparation and as to different dishes in which they
could be used. Whenever the mother, showed willingness to make
changes in the family dietary, however, she was given most helpful
information as to the relative cost and nutritive value o f different
foods and the desirability o f substituting other foods for some of
those that she had been using.
Budget work.
One o f the chief discouragements in nutrition work is the large
number o f homes in which the income is insufficient to buy adequate
food or, if sufficient, is so mismanaged that inadequate diet results.
The first condition is a relief problem and the second an educational
one. The relation of health centers to relief agencies varies accord
ing to the community. In some cities the nutrition worker may be
caring for the undernourished children in families receiving relief
from another agency, which is at the same time sending a dietitian
or visiting housekeeper into the home to plan the budget and regu
late the food purchases. In other instances the relief agency may
have no visiting housekeeper and may not take advantage o f the
budget supervision that might be given by the nutrition worker of
a health center. 'The most effective care of the children in families
receiving relief was found to result when the relief agency formally
transferred to the nutrition workers o f the health center the problem
o f making out a satisfactory budget for the family. Under these
circumstances the health of the family is related to its expenditure,
and the nutrition worker can exert pressure to have adequate food
bought. When there is no possibility o f influencing the expenditures
o f a family it is only by securing the confidence o f the mother and
by persistent effort that the family can be taught to obtain the best
results from its limited resources.
Home visiting.
Most o f the nutrition workers were paying from 30 to 60 home
visits a week to the children under their care. When the main in
struction was given in the center these visits were for the purpose
o f seeing whether or not the advice given was understood and being
carried out, of helping maintain or establish friendly relations with
the mother, o f securing a clearer idea of the living conditions and
special problems o f the family, and o f giving advice and help in
regard to these or o f persuading parents to have defects corrected.
)The importance given to home visiting by the different nutrition
workers and the effectiveness of their visits varied greatly. In some
o f the visits the only definite purpose and accomplishment o f the
nutrition worker seemed to be to develop cordial relations, and no
^advantage was taken o f any of the conditions that were encountered
to give any real help or advice. In most cases, however, the nutrition
worker made a point o f making some definite contribution to her
health teaching as well as giving incidental advice at each visit.
The requirement o f full notes on the home visits is o f great assist
ance in stimulating a nurse or nutrition worker really to accomplish
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N U T R IT IO N
W ORK
FO R P R E S C H O O L C H IL D R E N .
something during her visits. I f such notes may be dictated rather
than written it is a great saving of time.
Arranging educational programs on nutrition work.
The amount o f time spent by nutrition workers on general edu
cational work in clubs or classes, or in demonstrations or illus
trated talks for the benefit of all the mothers and children com
ing to a clinic, varied greatly in different organizations. In one
center where there is only one nutrition worker on a staff with several
nurses a large part of her time was devoted to a general educational
program and the remainder of it given as food consultant with the
nurses caring for preschool children. In another organization with
similar conditions the nutrition worker was giving less time to the
general educational program and had charge o f all nutrition cases
in which the food problem was a difficult one.
The value of providing in the center objective illustration o f good
standards o f food preparation and selection, hygienic habits, and
child care has not been fully realized by most child-health organiza
tions. I f such work is to be of the greatest value it must include
illustrative material that will “ put the ideas over ” to these mothers.
Pictures or models o f food are useful, but actual food materials are
much more so. Talking about how to prepare foods has little mean
ing to most people; they need actual demonstrations. When the
demonstrator who is explaining this illustrative material is a real
teacher she will use the experience of the women or children in her
audience to contribute to her explanations. Such a program is in
tended not to supplant the giving o f individual instruction but to
supplement it and help to create a desire for further instruction.
T Y P E S O F N U T R IT IO N W O R K E R S .
Professional workers.
In most o f the centers practically all the instruction was being
given by nutrition workers who had had home economics but no
nursing training. Because o f their knowledge o f food materials and
household problems these women were especially well equipped to
give the practical and detailed advice that is necessary in any plan
involving changes in household activities and in diet. Another ad
vantage o f having this group of workers is that they are primarily
teachers and they are trying to give each idea to the mothers in the
most effective way. Although instruction about foods is emphasized
by these Workers, they all realized the equal importance of lack of
personal hygiene, overactivity, and physical defects as factors in m ilnutrition and considered each of these in working out the derailed
corrective program for each child. This type of nutrition worker whs
sometimes called a dietitian, although the name “ health teacherd’
used in one center more adequately describes the character of the
work done in many centers. Although not adopted by any of the"
organizations visited, the name nutritionist is receiving increasing
recognition as a distinctive title for women doing this type of work.
In three of the centers a large part o f the instruction in the nutri
tion clinic was given by the physician although a food teacher or a
special nurse was assisting in each case. Some of the most effective
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teaching o f mothers that was observed was by two o f these physi
cians, both o f whom were using a nutrition-class method. In most
centers where the physician expects to see the child each time he re
turns to the clinic a certain amount o f general instruction is always
given by the physician, but the details o f the advice about foods and
o f the correction o f poor health habits are usually left to some
one else.
In two organizations nutrition work was being carried on by a
special group o f nurses, all o f whom had taken some special food
training. It was impossible to draw any conclusions as to the ad
vantages or disadvantages of this plan, as in one case the work was
just starting and in the second organization the nurses had been try
ing to give some very detailed food instruction without sufficient
supervision and individual assistance to make the plan really suc
cessful or to keep up the interest and enthusiasm o f the nurses.
Volunteer workers.
Volunteers were being used for different types o f work in a little
more than one-third o f the centers visited. Giving clerical assistance
to the physician, taking social histories, and weighing and measuring
children were the activities most often performed by these women.
In two centers volunteers were provided to tell stories to the children
so that the mothers would be free to get the benefit o f the instruction
given to them, and in another center the cooking demonstration given
for the nutrition class was by a volunteer. There is little question
of the value o f using intelligent volunteer service to extend or in
crease the activities o f a center.
M E A S U R IN G R E S U L T S O F N U T R I T IO N W O R K .
It is difficult to measure the results of nutrition work, for in the
fullest sense they should include an improvement not only in the
children under care but also in the living conditions of the family.
Unless an organization has done intensive nutrition work with a cer
tain number o f children through a definite period it is difficult to
measure accurately what has been achieved. Only two or three or
ganizations have attempted any statistical analysis of results, but the
following standards are used by different nutrition workers in meas
uring the value o f their work:
1. The proportion o f the children being given intensive care dur
ing a definite period of time who have attained a higher
I
standard o f nutrition.
&
i 2. The proportion o f the children under supervision during a
definite period who have gained weight in excess o f the
f
normal gain for their age and height.
I 3. The proportion o f children needing correction o f physical
defects who have such corrections made.
4. The extent of the children’s gain or improvement in individual
cases.
5. The proportion o f children maintaining good health habits dur
ing a definite follow-up period.
6. Improvement of living standards in the community (greater
use of special foods, particularly milk* more windows open at
night; more outdoor life and sunshine for children; etc.)
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20
NUTRITION WORK FOR PRESCHOOL CHILDREN.
. Unfortunately most o f the forms used by the different organiza
tions are not planned with the idea of recording the kind o f infor
mation that will show definite results of the care given. This is a
loss not only in the evaluation o f the effectiveness of the work, but
also m the failure to give the individual nutrition worker definite
standards toward which to direct her efforts and a definite reason
for making adequate records o f the information that she secures in
the nutrition clinic and in home visits.
NUTRITION WORK IN RURAL DISTRICTS.
. The nutrition work studied in the rural districts consisted prima
rily of health education for the children in the schools, though -as
the result o f this work interest in nutrition problems was shown by
many parents and a certain amount o f individual work for pre
school children was being done by the nutrition workers. The school
work was of two general types : (1) General health instruction with
emphasis on health habits and food selection given to all the chil
dren in the schools, but no special ivork undertaken for the under
nourished children; (2) similar health instruction for all the chil
dren and, in addition, special instruction to undernourished children
and some provision for a mid-morning lunch.
C O U N T IE S H A V IN G G E N E R A L H E A L T H IN S T R U C T IO N .
In one o f the counties where no special work for the undernour
ished children was undertaken in the schools the general health in
struction was given through periodical visits by a public-health
nurse, supplemented by some instruction from the teacher. The
cooperation o f the children was secured by the formation o f health
clubs. The degree to which the children were informed on health
problems and the record of their efforts to acquire good health
habits were evidence o f the interest aroused by this method in the
two schools that were visited. The nurse tried to visit each school
once a month. In addition to the club work with the children she
undertook to make a preliminary physical examination of the chil
dren in most of the schools and advised them of the desirability
o f having dental or medical care. At the same time she discussed
the possible needs of their small brothers and sisters and urged them
to ask their mothers to bring these children to the health center
located in the chief town of the county.
The response from the 65 schools of the county was not large
as only about 20 preschool children had been brought into the
center during the last year. Most of the actual work for preschool
children was done in the children’s weekly conference, since the
many duties of the nurse made it impossible for her to make many
home visits. The conference activities consisted o f a preliminary
physical examination by the nurse, including vision, hearing teeth
throat, posture, muscle tone, general appearance, height, and weight*
an examination by a physician from the local hospital for all cases
that showed need of more complete examination; and individual
instruction given to each mother in which emphasis was placed
on health habits and adequate food.
In the second county, where the health teaching was given as a
regular class problem without relation to the needs o f the under
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NUTRITION WORK FOR PRESCHOOL CHILDREN.
21
nourished children, the instruction was being given by grade teachers
under fairly regular supervision by a nutrition worker. The qual
ity of the instruction varied with the interest and ability of each
teacher; this was especially noticeable in these rural schools, in
which the supervision was more irregular. Although some of the
teaching was very good it was not coordinated with the actual
physical condition of the children; its purpose was to give general
information which would create interest in the formation o f good
. habits. As the principal activity o f the nutrition worker was
/ to supervise and instruct the teachers her only contact with the
/
parents was through general talks given at parent-teacher association
meetings. Although a mild interest in the preschool problem had
been expressed at these meetings no actual plan had been made
for the care o f these children.
COUNTY
D O IN G
S P E C IA L
WORK
FOR
THE
U N D E R N O U R IS H E D .
6 third county was the only one where the weight of all the
children was taken at regular intervals and special emphasis given
correcting underweight. Some actual teaching was done by
the nutrition worker in each school, but as she gave only part
time to this county all the instruction between her visits was given
by the teachers. Either because of the personality o f the nutrition
worker aud the quality o f her teaching or because the plan for
emphasizing the needs o f the undernourished children created greater
interest in the homes there were more requests from the mothers in
these schools than in any o f the others for information as to the
food needs o f their preschool children. Most o f the instruction to
the mothers was given in the homes, though group meetings were
occasionally arranged in the school buildings.
/
F A C T O R S W H IC H H A M P E R E D H E A L T H
D IS T R IC T S .
j
f
l
,
'
WORK
IN R U R A L
.In two o f these counties health teaching was being undertaken
without any attempt to take the children’s weight regularly or to
use their gain or loss in weight as a means of insisting upon the
acquisition o f improved health habits. The question of the value
o f this plan in school procedure should be more fully and com
pletely studied. From the standpoint o f securing the cooperation
and interest o f the mother not only for her child in the school but
also for the possible needs o f her preschool children, the value
of, emphasizing health teaching by showing its relation to the
actual condition of the children seems obvious. 'Wherever a nurse,
nutrition worker, or teacher gives every child avpreliminary exami
nation— whether this consists merely o f weight taking or includes
spme examination o f posture, vision, hearing, and throat— and at
the same time explains individually or in a class the relation o f
health habits to the child’s condition there is always greater interest
jSOh, the part of the child, which is apt to be reflected in the home.
Lack o f medical supervision was the great difficulty in all the
rural districts visited. While some very effective general-health
teaching was being done, corrective work was always hampered by
lack o f accurate knowledge o f the child’s real condition.
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22
NUTRITION WORK FOR PRESCHOOL CHILDREN.
CONCLUSIONS.
1. A health center that undertakes the care o f preschool children
has three primary responsibilities: Educational, to educate the
parents in the community to which it contributes as to the health
needs of their preschool children and as to the standards of physi
cal and mental development of the normal child; supervisory, to
provide general health supervision for as large a number of pre
school children as possible; corrective, to provide instruction in
clinics and in home visits that will help to overcome poor health
and living habits, and to give parents advice and assistance in
securing the correction of defects that need medical care.
2. The wide variation in the frequency and regularity of the at
tendance of mothers of preschool children in different centers in
dicates that there is need in many centers for a closer study of all
of the factors that influence nonattendance in their communities.
In some centers nonattendance is accepted as an unfortunate situation
without much effort to overcome it by changes in policies or publicity
or in plans for instruction.
3. Nutrition work is the type of corrective work most generally
provided for preschool children, although the correction of postural
defects and o f wrong mental attitudes and bad habits is receiving
an increasing amount of emphasis in some health centers.
4. The excellent results secured by centers that have undertaken
to give intensive care during a definite period to children needing
corrective work indicate the desirability of greater use of this
method. While one of its values is the stimulation of the interest
and effort of the mother through frequent contacts, it also provides a
spur to the staff worker who must measure the results of her work
within a definite period.
5. There is much variation in different localities as to the division
of responsibility between the nurses and nutrition workers of a
center in the care of preschool children. There are, however, three
main plans:
(a) All general supervision o f the children is the responsibility
of the nurses. All nutrition cases are under the care of a
nutrition worker for a definite length of time or until each
child attains a higher standard of nutrition.
(&) The nutrition worker is responsible for the general supervi
sion of all preschool children as well as for the correc
tive work in nutrition cases.
(c) General supervision of all preschool children is given by the
nurses, and the corrective work in nutrition cases is dohe
by the physicians and the nurses. The nutrition worker
serves as a* consultant and provides a general educational
program at all clinic meetings.
t
The use of a specialized worker for nutrition cases seems thd
most desirable of these plans. When there is only one nutrition1
worker on the staff of an organization the influence o f her work will
be more far-reaching if she cares for only a few special nutrition
cases and devotes most of her time to a general educational program.
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NUTRITION WORK FOR PRESCHOOL CHILDREN.
23
6. The nutrition worker is primarily a teacher, and her success
will be in proportion to her ability to interest the women with whom
she works and to stimulate the formation o f good food and health
habits. Special food training is an essential requirement for such a
worker, as she must be able to analyze and give advice as to the
family dietary.
7. There is much difference o f opinion among nutrition workers
as to the relative value o f the home or a clinic as the place in which
f nutrition work should be done. In a few centers practically all of
the instruction was given in the home, while in others great effort
was being made to bring the mothers to the center for both individual
and group instruction. There is need o f a demonstration as to the
comparative cost and effectiveness o f using the home or the center
as the place for each type o f activity undertaken by a nutrition
worker.
8. A formal class method of conducting nutrition work was seldom
used for preschool children. Advice was usually given to the
mothers individually, though group instruction was used in a few
centers. Group instruction of some kind should be made a definite
part of a nutrition program. Demonstrations of food preparation
and selection given in the center for groups o f mothers and preschool
children are of the greatest value in stimulating the interest of the
mothers and in initiating a liking for new foods.
"9. The standards for deciding which children are in need of nutri
tion care varied greatly in different health centers, as they depended
largely upon the interpretation o f the individual physicians. In the
majority o f centers, however, less emphasis was given to weight as
an index o f poor nutrition than is generally the case in nutrition
work for older children.
10. Carefully taken habit and food histories and a record o f the
variations in the child’s weight are the facts on which a nutrition
worker bases her advice and the encouragement that she gives to a
mother. It is important that all these facts about a child should be
secured and recorded at sufficiently close intervals to give an accurate
picture of his condition and to show his progress. Nutrition records
should be planned with both of these points in mind, and they
should be so arranged that important facts will always be recorded.
11. Nutrition work was one of the recent additions to the activi
ties of most health centers. I f this type o f work is to be of the
greatest benefit it is most important that some concrete measure of
the results accomplished should be made a definite objective o f the
nutrition worker. This should be made a part o f the record form
used.
jl2. In the rural districts visited nutrition teaching was centered
inv the schools. This school work was used as a means o f creating
ah interest in the needs of the preschool children as well as the
school children. There are definite limitations to the effectiveness
p i this plan. Even for school children, the nutrition teaching in a
/school must be related to the actual condition of the individual child
if the interest and cooperation o f the parents are to be enlisted, and
unless such cooperation is secured it is impossible to get in touch
with the preschool children. Although the school nutrition worker
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Federal Reserve Bank of St. Louis
24
NUTRITION
WORK FOR PRESCHOOL CHILDREN.
can give the mothers excellent advice in regard to the food, habits,
and activities of their preschool children, lack o f medical super
vision is a serious handicap to constructive nutrition work for these
children. Health teaching in the schools is an important factor in a
health program for rural communities. It should serve not only to
encourage the formation of good health habits among the school
children but also to create and maintain interest in a broader county
or State plan which would provide medical supervision for both
school and preschool children in rural districts.
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APPENDIX.— ORGANIZATIONS VISITED,
IN CITIES.
j
/B oston , M a ss.:
Boston Dispensary.
/
Brookline Food Center.1
Community Health Association.
Neighborhood Kitchen.1
Ruggles Street Nursery School.
Chicago, 111.:
/
Elizabeth McCormick Fund.
In f ant-Welfare Society.
K i Cleveland, O h io:
|
Babies’ Dispensary Hospital.
Cleveland Nutrition Clinics.1
Cuyahoga County Public-Health
/
Committee.1
Lakeside Dispensary.
Detroit, M ich .:
Child-Hygiene Division, Depart
ment of Health.
Merrill-Palmer Nursery School.
Kansas City, M o .:
Children’s Bureau.
New York, N. Y . :
American Red Cross, Bronx Chap
ter Health Center.
Babies’ W elfare Federation.1
Bellevue Hospital, Out-Patient De
partment.
J
New York, N. Y.— Continued.
Bureau of Educational Experi
ment— Nursery School.
Department of Child Hygiene,
Board o f Health.
Greenwich House Health Center.
Judson Memorial Health Centre.
Mulberry Health Center, Associa
tion for Improving the Condi
tion o f the Poor.
New York Diet Kitchen Associa
tion.
East Harlem Nursing and Health
Demonstration.
Philadelphia, Pa. :
Babies’ Hospital.
Children’s Hospital, Department
for the Prevention of Disease.
Division of Child Hygiene, Board
of Health.
Star Centre.
St. Louis, Mo. :
Municipal Health Clinics, Health
Department.
Utica, N. Y. :
Baby-W elfare Committee.
IN RURAL DISTRICTS.
j Macon County, Ala. :
J
Tuskegee Institute Health Center.
f!
Health work in rural schools.
Mississippi County, A r k .:
Nutrition work in the schools.
Wayne County, M ich .:
Health work in rural schools.
»N ot included in tabular statement on page 2.
25
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}
X
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