Malnutrition in the second year of life and psychosocial care: a case-control study in an urban area of Southeast Brazil Desnutrição no segundo ano de vida e cuidado psicossocial: estudo caso-controle em área urbana do Sudeste brasileiro

The present study aimed to identify and measure the relationship between malnutrition and psychosocial care in the second year of life. A case-control study compared 101 malnourished 12-23-month-old children (weight-for-age < 5th percentile, WHO/NCHS) to 200 well-nourished children (weight-for-age > 25th percentile) for exposure to various maternal behaviors related to psychosocial care. A psychosocial care score was constructed, based on the number of desirable maternal behaviors that were absent (the higher the score, the worse the quality of childcare). The association was modified by per capita family income. After adjusting for possible confounders, children from higher-income households showed no association between psychosocial care and malnutrition. For children from lower-income households, worse psychosocial care doubled the risk of malnutrition (OR = 7.26; 95%CI: 2.42-21.82) compared to low income alone (OR = 3.08; 95%CI: 1.28-7.42). Child Malnutrition; Child Care; Child Nutrition Introduction Since the recognition of the importance of quality childcare as a determinant of infant nutritional status 1, considerable effort has been made by researchers and international agencies to find evidence for this relationship. One of the principal difficulties has been to construct childcare indicators that are valid and easy to measure for use in population-based studies. Food and health care indicators were proposed and tested in empirical studies, and results pointing to an association between them and malnutrition are available in the recent literature 2. The same is not true for the psychosocial dimension of childcare, one of the largest gaps in knowledge on the care and nutritional status of small children. Engle et al. 3 proposed that mother/child (or principal caregiver/child) interaction is an indicator of the quality of psychosocial care. According to these authors, positive mother/ child interaction, characterized by such behaviors as talking regularly with the child, telling stories, embracing the child frequently, providing a safe and attractive environment, and encouraging the child’s progressive independence, among other factors, can exert a protective effect on the child’s nutritional status. By promoting better development, responsiveness, and progressive independence in the child, adequate psychosocial care makes children themCarvalhaes MABL, Benício MHD 2312 Cad. Saúde Pública, Rio de Janeiro, 22(11):2311-2318, nov, 2006 selves more capable of obtaining adequate food and health care. In addition, through a positive feedback mechanism, a healthier and more active child makes the mother feel rewarded and stimulated to invest even more in positive care practices 4,5. Another possible positive effect of psychosocial care is its favorable impact on care practices related to eating and health 6. Solid empirical evidence of these effects has still not been produced, although since the early 1970s researchers have already pointed to inadequate psychosocial care for malnourished children as an important factor in malnutrition causality. A pioneering study in Mexico 7 identified an association between a non-responsive mother (or person in charge of caring) and a poor environment in terms of positive social/ affective interactions and the severity of malnutrition. Other research in both developed and developing countries has pointed to the presence of poor interaction between the mother and the malnourished child 8,9,10,11. Kerr et al. 8 investigated whether inadequate mother/child interaction could be a factor for child malnutrition in poor countries, similar to the results of some studies on the so-called “failure-tothrive” syndrome in developed countries. They compared 11 mothers of malnourished children with 11 mothers from a control group living in equally unfavorable socioeconomic conditions. Among mothers of malnourished children, symptoms such as apathy, dependence, and personal and family conflicts were more common 8. Subsequently, studying mother/child bonding in poor families in Santiago, Chile, Valenzuela 10 found that anxious or resistant attachment was seven times more frequent in the group consisting of mothers whose children displayed chronically delayed growth, as compare to the group of mothers/children with normal growth. According to the author, disorders in mother/child attachment can explain the poor quality of mother/malnourished child interaction. A study in the municipality of São Paulo, Brazil, reported numerous negative psychological symptoms in mothers of malnourished children: immaturity, isolation, low self-esteem, and feelings of inadequacy or inability to satisfy the child. The study identified a high prevalence of symptoms of weak mother/child attachment: unwanted pregnancy, emotional problems during gestation, sleep disorders, infant crying and intense colic, difficulties with breastfeeding, and maternal anxiety. According to the authors, these mothers showed difficulties in establishing interpersonal contacts and were depressed, unhappy, and self-focused, incapable of dealing with the child. The authors termed this situation “maternal deprivation” 7. However, the study only included malnourished children, so the results could not be conclusive. In a broad study on preschool children in Nepal, Gittelsohn et al. 11 detected an association between xerophtalmia and food care practices, health care, and psychosocial care. These same authors observed a strong relationship between the levels of quality in the three types of care. Although important for reinforcing the hypothesis ascribing a determinant role to inadequate psychosocial care in child malnutrition, the above-mentioned studies were unable to present solid empirical evidence for this effect, due to such limitations as the small number of children, lack of a control group, or failure to deal appropriately with possible confounders, including socioeconomic factors (family income, maternal work, family structure), maternal characteristics (schooling and mental health), and factors related to the children themselves, such as health status and conditions at birth. The objective of the current study was to identify and measure the association between psychosocial care and malnutrition. Specifically, we sought to identify a probable effect modification (statistical interaction) by socioeconomic status on this association, controlling for the effect of possible confounders.