COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD ..^-^^^^ :rv SIrB' ] 1 J HX00044245 1 r^ V \ /nutrition J CLASS PJS.0^ CriumWa ®ntt)ers(ftp mtljeCttpofBrmgork COLLEGE OF PHYSICLANS AND SURGEONS LIBRARY Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/nutritionclassbyOOsmit The Nutrition Class By Charles Hendee Smith, M.D. "NUTRITION CLASSES ARE REALLY HEALTH CLASSES" Health in Education fl *-^M'.aJK. \ Education in Health *'No matter where the class is conducted, success or failure will depend upon the personality and insight of the class leader rather than upon the situation or equipment" CHILD HEALTH ORGANIZATION OF AMERICA Penn Terminal Building, 370 Seventh Avenue New York City CLARENCES. NATHAN, INC., CEs! n\?5an, inc.. Revised Edition or NEW YORK. How TO CONDUCT A NuTEIIION ClASS December 1921. — 10,000 The Nutrition Class HE study of large numbers of undernourished children during the past few years has made it plain that malnutrition is not a disease but merely a symptom, which may result from many different causes. Furthermore, the individual child is rarely underweight from a single cause, but there are many and complex factors in almost every case. These facts must be constantly remembered in considering methods of treatment. No single plan will reach all of these children. In organizing a Nutrition Class it is not sufficient to select a group of children who "look thin" and to lecture them on their diet and habits of life. In order to avoid serious errors it is necessary to undierstand something of the nature and causes of malnutrition. The state of a child's nutrition is, in general, a very good index of his health. A thin child is seldom a well child. A plump and rosy one is usually healthy. If a child has not grown normally and has not been able to store up fat and develop good muscles, it is safe to infer that he has not had uniformly good health. The solution of the malnutrition problem in the individual child must consist in seeking out the causes of ill health and in so far as possible in removing them or in counteracting them when they cannot be removed. In other words, a careful The Nutrition Class diagnosis must be made on every child who shows the effect of ill health in his defective nutrition, before any plan of treatment can be considered. A Nutrition Class is art Attractive School Ethical Culture School Children Supervised by Federation of Child Study DIAGNOSIS THE complete diagnosis must always remain a medical matter, for only a trained physician can discern the more obscure causes, some of which are very common. Teachers, social workers and dietitians can do the routine work of conducting a nutrition class, but unless they have some medical help, grave errors may easily be made. It is quite true that the medical profession is only just begin- ning to be aware of the importance of nutrition as a measure of health and that the physician, too, needs edu- cation in this whole matter. The Nutrition Class The diagnosis of malnutrition must consider two ques- tions : FIRST, Is the child undernourished? SECOND, What is the cause of the undernutrition? In order to answer the first question, the weight, height and age should be taken. The child should be measured without shoes, and weighed in his indoor clothes, without shoes or coat. The age in years and months (and the date of birth) should be noted. A table of standards should be at hand from which the average weight for height and age may be found. The amount and percentage of the child's underweight are then easily determined. The necessary equipment is simple — good scales, a measuring rod and a table of standards. Any child 10% or more under the standard for height and age may be considered as definitely undernourished . It is not sufficient to determine the weight deficit alone. One must consider the elements which, from the point of nutrition, make up the child's weight. These are chiefly fat and muscle, and either Mother and Johnny Anxiously Watching the Verdict of the Scales may be deficient. The weight of the bones differs somewhat in children of the same height but it is only occasionally a large factor in the weight vari- ation. Some children show a weight deficit due to poor muscles, but have an amount of fat which makes them look fairly nourished. Other child- ren are very muscular The Nutrition Class but have almost no fat. These are really less well nourished than is indicated by the height and weight ratio. There are two general types of undernourished children. The first is apathetic, Hstless and pale, with poor muscles and fat, round shoulders, bad posture and, usually, other defects. The second is the overactive child who is ner- vous, restless and never still. He generally has good muscular development but very little fat. The second step is to determine the causes of malnutri- tion. It is necessary to make a careful study of the entire history of the child's life, as well as of his present condition and daily routine. THE CAUSES MAT BE DIVIDED INTO FIFE MAIN GROUPS: I. — Inheritance. II. — Past Illness. Ill,- — Present Defects or Disease. IV. — ^Bad Hygiene and Improper Diet. V. — Social Factors and Environment. I. — INHERITANCE undoubtedly plays some part in the production of malnutrition. Small size and inherited feeble- ness of constitution may be transmitted from parents to children; but there is a dangerous tendency among the laity, and even among physicians, to give too great im- portance to this factor. It is a common observation that children who are well fed and carefully brought up are regularly larger and heavier than their parents. Heredity affects height much more than it does weight. It should not be considered as an important cause of malnutrition unless there are many small members in the families of both parents. Alcoholism and some diseases of the parents may permanently affect the child's nutrition, however. The Nutrition Class II.— PAST ILLNESS. Prematurity or small size at birth may give a child a bad start from which he never entirely recovers. Difficult Feeding in infancy or disorders of digestion, either acute or chronic, especially if prolonged or frequently repeated, prevent a normal growth and gain. Acute Illness, such as severe attacks of the contagious diseases, typhoid, pneumonia, surgical infections or even frequent colds or tonsilitis may cause a loss of weight which is recovered very slowly. While past causes can not be removed, it is a mistake to overlook them or to minimize their importance. III.— PRESENT DEFECTS OR DISEASE.— These can be detected only by a complete medical examination. A nurse or teacher can observe many of the gross defects such as decayed teeth, very large tonsils, skin lesions, bad posture or flat feet. She also may note certain symptoms, such as mouth breathing, cough, shortness of breath, palpitation, etc., but it is evident that medical training is necessary to go much beyond these. There- fore, it is essential that every nutrition class have some medical connection. A medical examination should include, in addition to the complete physical examination, an investigation of the blood, urine and stools when possible. A skin test for tuberculosis should be done on all cases, and a Wasser- man test, if there is any reason to suspect syphilis. The Defects most frequently found are: Carious Teeth — Chronic absorption from decayed or in- fected teeth certainly causes ill health. Quite as important is the imperfect mastication resulting from many tender or aching teeth. The Nutrition Class 8 Diseased Tonsils are also a cause of ill health, due to the the chronic absorption of pus and bacteria from their crypts. Chronic suppuration in the ears or elsewhere may be the cause of malnutrition. Obstructed Nasal Breathing, especially when due to adenoids, results in chronic oxygen starvation and is often associated with, frequently recurring colds. Other Defects such as eye strain or defective hearing affect a child's nervous system and indirectly his general health. Flat feet may give enough discomfort to prevent proper exercise and muscular development. Habitual bad posture may be quite as serious. Mental defect is often associated with poor physical condition; therefore mental tests should be made on every undernourished child. Present Disease. — Tuberculosis is one of the most fre- quent causes of malnutrition. This does not mean tuber- culosis of the lungs, the disease usually being in the "glands" of the neck, abdomen A Complete Medical Exam- ination is the first Step in Deiecting Defect and Disease 9^" ^^ Ethical Culture School Children Supervised by Federation of Child Study or chest. The last is by far the most frequent site. The tuberculin skin tests tell us whether a child has been infected and is of value at any age. Fever combined with malnutrition usu- ally means activity of the disease process. A careful examination for signs of bronchial node involvement (especially D'Espine's sign) and an X-Ray of the chest should be made if posi- The Nutrition Class tive skin test is found. The intradermal test is much more accurate than the usual Pirquet. Other Chronic Diseases must be ruled out before a child is considered as merely a case of malnutrition. It is obvious that diabetes or chronic kidney disease can not be properly treated in a nutrition class. Heart disease is better treated in a separate class, but in the milder degrees the treatment is so nearly identical that the cardiac condition need not bar a child from a nutrition class when no cardiac class is accessible. Intestinal parasites, malaria, blood diseases, etc., must be considered and ruled out. Syphilis also affects nutrition and the Wasserman reaction not infrequently sur- prises us with an answer to a difficult case in which no progress is made by the usual measures. IV.— BAD HYGIENE AND IMPROPER DIET. These are by no means confined to the poor and play a part in almost every case. It is necessary for the nutrition worker to be thoroughly familiar with the essentials which make up good "Health Habits" and also with the common errors, so that an intelligent study of the daily life may be made. Insufficient Food. — It will be found that a majority of the thin children take too little food. This may be be- cause there is not enough food available, due to poverty or bad buying. More often it is due to improper training by ignorant or careless parents, or spoiling by over-indulgent ones. Everyone who works with children is famihar with the child who eats no breakfast or lunch, with the one who simply *'picks" at his food, and with those who eat no cereals or bread or milk or vegetables. The result is that an insufficient amount of food is taken upon which proper growth is impossible. The Nutrition Class ^^ Improper Food. — This does harm in two ways, first by being substituted for the right kind of food; and second, by causing disorders of digestion. Tea and coffee stand at the head of the hst in frequency and importance, because they are used in place of milk, and because they are too stimulating for the sensitive nervous system of the child. Candy, soda water, cake, pies and pastry will upset the digestion when taken regularly or in large amount. Child- ren are certainly better off without them. If given at all, candy should be eaten after the main meal of the day and in small amount. Ripe fruits, such as apples, pears, peaches and bananas, are excellent for older children if taken with a meal in moderation, but if green or overripe, or if eaten shortly before a meal, or swallowed in large chunks, they may cause acute indigestion or diarrhoea. Pickles, nuts and sweet preserves tax the digestion more than their food value justifies. Improper cooking, especially frying, spoils much good food. Fried potatoes, fried meat, fried eggs form a large portion of the diet of many families. Too much meat is commonly eaten. Some children take too much bread and butter, and will eat nothing else if allowed their own way. Even milk may be drunk to excess, especially from the second to the fifth year A child who takes three or four pints of milk a day will sel- dom eat enough other food to balance his diet. Bad Eating Habits. — Eating too fast and chewing too little are almost universal habits and most children need constant admonition about them. Washing food down with water or milk is nearly as frequent. Eating too slowly, dawdling at the table is seen more often among children in better circumstances, and may become so exaggerated a habit as to cause a serious con- 11 The Nutrition Class dition on account of the small amount of food taken. This is a common habit of the only child of an anxious mother. Constipation. — Constipation or irregular bowels are habits of the majority of undernourished children. With- out a regular bowel movement, good health is of course impossible. The normal time is after breakfast and before school. A striking improvement in the health will fre- quently take place if the bowels are trained to move in the morning. Constipation results in poor appetite, indi- gestion, headache, anaemia and general ill health. In order to have time for a proper morning movement, a child must get up early enough to dress and eat breakfast without hurry, and then have 20 to 30 minutes free for the bowel action before starting for school. Children Amusing Each Other While Awaiting the Doctor Ethical Culture School Children Supervised hy Federation of Child Study Insufficient Sleep and Rest. — The child who seldom gets to bed before eleven or twelve o'clock nearly always must be wakened in the morning to be on time at school. He cannot get the ten or eleven hours of sleep which he needs and, next to food, sleep is the most important factor in a child's life. The Nutrition Class 12 The daily rest period is omitted too early by most children. It should be continued, after the noon meal, at least up to the school age and really is needed for several years later. Rest periods ought to be in the routine of every school day, as they are in open air and other special classes in which thought is given to health. Insufficient Fresh Air. — Most sleeping rooms have not enough ventilation especially in the winter. Since a child spends nearly half his time in bed, he can really get more fresh air by night than by day, if the windows are wide open. A small crack or opening is not enough. Both sashes should be wide open, top and bottom. If a child is well covered and screened from direct draught, the more air he gets, the better will be his health. By day there is scant time out of doors for the school child, but it is essential that he should go out after school whenever possible. In stormy weather, children may play in a room with open windows rather than sit in closed overheated rooms. Insufficient Exercise or Over Exertion. — The normal play impulse gives most children sufficient exercise. The under- nourished child frequently has such poor muscular develop- ment that he becomes exhausted by a normal amount of muscular work. This results either in chronic over fatigue or else in the gradual giving up of games. In other child- ren excessive exercise is a common fault and may be the chief cause of the failure to gain weight. Uncleanliness. — The tonic effect of bathing the entire body is an important factor in promoting good health. Dirty hands and faces increase the danger of taking bac- teria into the body. Dirty teeth predispose to early decay. 18 The Nutrition Class v.— SOCIAL FACTORS.— These act upon the child in his home. They are partly economic, depending not only upon the social status of the family, but also largely upon the personality and intelligence of the parents, and upon the atmosphere of the home. Insufficient Income must stand at the head of the list. It is the main cause of bad housing and crowding which mean insufficient air, light and rest for the child. When there is not enough money to buy food, it is evident that the children in the family will not gain adequately. Pov- erty is not the only cause of malnutrition, but it is a very definite one, and in many cases no improvement can be expected without financial relief in families where there is simply not enough to go around. Unintelligent Buying commonly adds to the difficulties of the insufficient income. The extravagances of the poor are well known to all who do social work. Mothers must be convinced that money spent on tea and coffee is wasted and should be used for milk; that bulk cereals, stale bread, dried fruits, and vegetables are the cheapest and best foods and should be bought before meat is thought about. The Personality of the Parents and the atmosphere of the home always have profound influence on the health of the child. The father's habits and earning capacity directly affect the income. His temper and intelligence must also be considered, for his unreasonable objections to any changes in the family routine may thwart a mother who would like to try to do better by her children. The mother is, of course, the center of the family, and her personality in- fluences the child's whole life. The irritation engendered by constant quarreling between the parents or children has an effect on the nervous system which may be reflected on the health and physique of the child. The Nutrition Class H ORGANIZATION OF THE CLASS 4 FTER the individual causes have been worked out for /-\ a group of children with malnutrition, it is evident that some form of class treatment is the most practicable manner of handling them. They all need the same care and much effort may be saved by class methods, but the individual and his problem must never be forgotten in the routine of the class. Classes may be held in various places. Dispensaries have long neglected the child with malnutrition, and every well-organized out-patient department should have a Nutrition Class. There is need for many more classes than can ever be conducted in dispensaries, however, and they have been organized in settlements, church houses, and most important of all, in the public schools. The school is the place where most of the classes should be conducted, for there are enough children in every large public school to fill several nutrition class groups. School classes should be held during school hours, as a part of the regular school work. When this is impossible the Nutri- tion Class may have to meet for half an hour after school once a week, but more than this should not be taken from the child's "free time." There should be some connection with a physician who can examine the children before admission to the class, and at intervals thereafter to check up on the original diagnosis. It is desirable that he should attend the class from time to time, though not absolutely essential that he be there at each meeting. The school physician is the natural person for this work. When he can not do it, the children may be sent to dispensaries or other physi- cians for examination and diagnosis, but this plan is not satisfactory and is not recommended. The school class has many advantages over all others. 15 The Nutrition Class Regular attendance can be secured, for the class should be made a required part of the school regime. The atmos- phere of education is a help, for the children go to school to learn, and, in general, believe what they are taught. Health lessons should carry more weight with many child- ren when coming from the teacher, who is trained in methods of instruction. The teaching must be graded appropriately for the children of different ages. The School Lunch Offers an Opportu- nity for Interesting Children in Good Foods Ethical Culture School Children Supervised by Federation of Child Study A properly conducted School Lunch offers exceptional opportunities for education about foods, cooking, eating habits and so forth. Each child can be given a health lesson with every meal at the school lunch. The hospital is better equipped to take care of the difficult cases, or those who have failed to gain in one of the classes held in school or settlement. While it is more difficult to obtain regular attendance in out-patient depart- ments, this can be overcome by a systematic follow-up system and such classes have the advantage of having physicians and an organized social service always avail- able. Also the laboratory, special clinics and other hos- The Nutrition Class ^ ^ pital facilities are extremely important in making difficult diagnoses and carrying out treatment. Size of Class.— There are two distinct types of Nutrition Classes according to size. 1st. Small classes restricted in number to 15 or 20 children. In a class of this size more thorough study and work is possible and the results are accordingly better. It is desirable to form such class groups for the especially diffi- cult cases, since they cannot get the individual ^attention which they need in a class of larger size. 2nd. Larger classes unlimited in number in which 60 to 80 children may be treated. These have the advantage of reaching and educating a larger number of families. The results are apt to be less perfect, since each child gets less attention and can be allowed to attend less regularly. Personnel. — No matter where the class is conducted the success or failure will depend upon the personality and in- sight of the class leader rather than upon equipment or situation. Certain general principles must be followed but the actual methods used will vary with the class of children, their age and the limitations of the staff and equipment. The person conducting the class (the "leader") should have some idea of class methods, of the essentials of hygiene and dietetics, and ought to know something of the important causes of malnutrition. In many classes as conducted at present the leader is a physician, in others, a social worker who may or may not be also a trained nurse. School classes are usually conducted by the teacher, social worker or school nurse. After some months of experience and some special training, an intelligent volunteer worker may qualify for the position of leadership. The leader must be the executive officer of the class, and see that a systematic routine is established so that no 17 The Nutrition Class important part of the work will be overlooked in the case of any child. She should supervise the general conduct of the class meetings, the keeping and filing of the records, the systematic weighing and measuring, the work of the social visitor and the class assistants. The leader can in- terpret the instructions and advice of the physician to the parents and children thus saving much of his time, and also can give much of the class instruction. Important qualifications for this position are a love for children and a knowledge of how to interest and stimulate them. This Teacher Has the Interest and Attention of Her Children as She Tells Them a Health Fairy Tale Ethical Culture School Children Supervised by Federation of Child Study In addition to the class leader, an ideal class organiza- tion should have several different types of workers: Physicians, one or more, depending on the number of children. The Nutrition Class 18 A social worker who visits the home and keeps the other workers informed of what happens outside the class room. A dietitian who is trained in teaching about foods, cook- ing and economic buying. She may teach mothers in classes or in the homes. Assistants, either paid or volunteer, who can do much of the routine clerical and class work. With a properly devised system it is possible to use assistants who have had no training before coming to work in the class. An intelligent volunteer will often become invaluable in a very few weeks. In most cases it is necessary for one person to fill two or more of these positions. The school class leader may have to take on all the work except the medical examination, even including the home visiting, and with excellent results provided the class is not too large. The teaching of health habits is not so difficult or complicated that any one with a love of children, imagination and initiative need fear to attempt it. Equipment. — The equipment needed is comparatively simple. The essentials are: A quiet room large enough to hold the class and workers, which must be set aside for this work alone during class hours. Desks or tables for the workers, accurate scales (not of the spring type), a measuring rod or tape, a chart showing weight and height standards, chairs or benches for the class, a file for the records. An examining table and screen are desirable. Printed matter — some of which is indispensable. Record forms for the history and examination upon which are printed the points to be noted. With these a worker with 19 The Nutrition Class very little training can learn to take an excellent history in a short time. The form given below is one modified slightly from that arranged for local Red Cross nutrition classes by a com- mittee of nutrition workers. A weight chart is essential for every case, since the graphic weight curve carries more force than any row of figures. Large wall charts may be used which have the advantage of being easily seen by the entire class. In a large class there is rarely wall space for all the charts of this form and a smaller weight chart which fits into and files with the history may be used. These are large enough to show to small groups of children, and are more convenient to handle and file. The weight chart illustrated in the appendix has the advantage of being dated ready for use. It may be used for the weight curves for two or three years (since it covers 25 lbs.). In addition to the essential equipment, there is much use- ful material available if funds permit its purchase, especially printed matter such as diet lists, hygiene directions, health booklets and literature of all kinds These may be purchased of various organizations, or written by the class workers. A home record slip or book is of much value, either printed or made up by the child from a copy furnished. Wall charts help to drive home health lessons. They may be made as posters by the children or workers, and this variety is often better than those published in more pretentious form. A food exhibit, composed of models representing various articles of food, helps in teaching children exactly what they should eat. With them the day's ration of three meals may be shown at each meeting of the class. In place of food models, pictures may be cut from magazines and pasted on cardboard to show the same points. Each child The Nutrition Class may thus make his own "food exhibit," and the lessons learned in making it increase the depth of the impression. A Food Exhibit Graphically Shows the Children What to Eat The objects of the class method are: 1. To save the time and effort of the persons conduct- ing the class by group handling and teaching of children and parents. 2. To arouse the group spirit and to stimulate competi- tion among the children. It is much easier to get a child to correct his habits of life if all the other children in a class are doing the same thing. Children enjoy competition and this force is the most valuable ally in nutrition work. Emphasis should be placed on the idea that proper living and good health really are a game, the playing of which is great fun. The principles which must be borne constantly in mind in conducting all Nutrition Classes are, 1. The careful study and diagnosis of the individual case. 2. Correction of all remediable defects. 3. Education in health habits. 4. Correction of the social and economic factors in the home. 21 The Nutrition Class ROUTINE CLASS OPERATION I. Diagnosis. AT the first visit the History is taken by one of the /-%^ assistants, then revised and corrected by the head of the class. The first history will usually need subsequent additions and changes as the study of the family brings up new data. The physical examination and the routine tests are made and recorded. The social condition of the home is investigated and noted. The facts are gone over care- fully and additional questions put to the child and parent to complete the history, at subsequent visits. The Diagnosis must be made from the completed record and the probable causes of malnutrition recorded in the summary. All this can rarely be determined at the first visit. It may take weeks or even months to find the answer to a difficult case. At the first visit, the mother should always be present, and both parent and child must be impressed with the seriousness of bad health and poor nutrition. It is fairly easy to convince a mother that it is important for the child to grow up big and strong. It may be more difficult to make the child feel the desirability of making the effort necessary to do this. Boys may be appealed to on the basis of athletics, for they all know that size and strength help in sports and games. The same arguments will reach girls to some extent, but the better looks of a plump and rosy child may well be impressed upon them also. It is necessary to convince the parent that the Nutri- tion Class can help to make a healthy child out of an un- dernourished one. After the class has been under way for a time, it is easy to do this by showing the results with The Nutrition Class An Example of a Complete History NUTRITION RECORD »f l>r< Hi. NAME cJL.£,o>va,rt,6L '^CiT^^iA,/^^^.^_- Addrea • I 3 '2. Sct 12. vrs 5" m....S,> f A4o*.l1^1 - >.2.^ £.. 37 SCHOOL .St- VTiriA^ K^ Grade fe>^ Flour •/ Dale ot Birlh Oive 2,9 'oTReligi..!! CVi;rt£tf£cC- Referred b> 5c-^c>o-€ /J^-c^A-'S^,^ — Olhera mlerejlcd JEt^v,,o-vt. St/tfcffc»^-v/V'»-Ctr' ST :enby M-F. from •vi-^^'^TCm^ FliHir 2. Kr !«,. Ill kj ■• 3 - Lt Uale enrolled J^lfXI Date discharged SOCIAL HISTORY F «^-5|s;C^ - t — I '^ ~ 3"! i. /qoV^ b 'lot, 7 •■ Health or Cause uf Death /^i,q ^Xyu^t^ i^JLt HOME. Atmosphere V'"-^^*"***" Discipline &««-^ C£jJ2 ctf,^*^ AA^\•£»*«. 90»-«( Cooperation of Child ^ffv^~- Food supplied fl.**— o^^-t-^t / w ' * Cw 9-^v-^ PAST HISTORY. *«orn at ? rnoB. Latx.r y%l..vy„U^cJ! , -^-^-^^ Prenatal Ci !£6 S^ ^o s-f !^J f-o 1 -30 ' SU^o^ sue.faf,^^t-s *tr.. ■fo- 9X- Beds *^. '3-: moB. ReJJIii JVo ^«.v..»,*fo « ifott e Fed /imos. Hcsnl ""8 :^*- Swollen Glands O cf~^ .^.t^ ^L. Meat "C-A/*^^^ A* J , ^^^ -^ ^^ ^-uiuariita 0*^XJU C*.- -tvt*^- A/jJ-jfruit c{a^£^ ytAnXjq^*4.-£<*^^^ : A^O^ttU^ e*nA..J!fk£a^7( Move at .*<^-^l6 - **♦«— C«real8 'fl^A^^.t^ "7"^...-^~,_^^ " HABITS. Breakfast / i?a-uUJ t4o.j * J^^AX. T J^Ztfl^ , Cjr^^^i-»,u*a » . Typical Dinner ^»*wt.a^t", r^!a* ^ a-^'«.-«y , ^OtC a-<< Q.*i.Ct.>,_ Supper AA^t-t^ , -VuiciL V .^^tfitA.^^ Cv-tr-ht-e^ -i^^L-^^jb . "^tS^O— Eggs i- 3 o. wr^ 1,4-r Betw. meals X.£Cto A^.aL^^£^Cuc Cfcr - J>.-'-*~ -^ -K. /? - »4„_. ^^^ . - - .■ Appetite •*-ei'L^> ^ ttt^ 'wA«^ yl^i^^^^Jfiiy Digestion , ft.^wtC Bowela ■f'- -- ■ Sleep Rest or Nap , Outdoors 3:3c t-e 5" tw b o-pC.- ^c.^...^ 7-'<^indowl)j^>^, Bread »-Z -d^cA, {a<.&.>«.(^ I.S.C.C «. .-«./l-t4^ sily ^-t*^. Fats A-^^f-fc. , Sweets 'Cv^tt^ I cit. aj,y >j ion from Standard Size of Original is 8J^ x 11 23 The Nutrition Class The Reverse Side of the History Sheet JNMHB J-t-P-t^ a^-\^a . rfa^i~lie.^^^.t^x..^ corrections and „„,'-f,' t--^-^- IMPROVEMENTS OF ORIGINAL PHYS. EXAM. DEFECTS (Give Dates) PHYS. EXAM. ON DISCHARGE Doctor CL..£^. bate Ti-^^ 11 ")CLt WT. & (Av. lor Hi.) (>i,^ u. (73 »; ilT. & (Av. for Age) SH i. i,^ ( ,r r J He«d Me«j. Xi~ •• Chest Meas. i s- ■• AM. Meaa. X r •• tJEN. ApPEABANC£ Color SIdn XuTEino.s 3 joct-y^ F.t 3. ^■■ Mtucles X. /o^A^ Bones DpoBinnM A?/vw./ ?«7tc. (^, Poatore H l-Vw-, n.^-^ ^U.njU'ii^ Feet A< i.TKPB Nodes Cm^^co.-^ 'v^^nL -^«i/<.^t^ IIiiiBl^Size AT. a/oy •F-r/.^« %•!»:• -ho Q. Action ^tq . 'U.-^^, ^ncLg-Ct^ Murmurs a LUNOB D'Espioe rt Tr cUx^c^ .^i./>.i»*<_ £ Abdomen /vr 1 Liver f/- 3 Spleen 1^^ a; Genitals 1^ . ° MoDTH— Tongue V'- tXta-.^ M Teeth. Clean No. carious Ajtu-t. ^h. <)QrA Cou/^3^ 1 Occlusion > I'BABTMt 1 Tonsils, Size _3. ,vw«<. -60-51.1 Jl^«/ CJ/Sw-ir Jn<^>CiduJU. Character >Tt«,A:*ir.yvs «u<«4 Breathing A*C_ - (it*.*, rfc ci^u-.t^ Adenoids -W- Eabb Em ^EBVODB StsTIM MenUlity Von Firquet, Date NOTE ON DISCHARGE J^-tv»Xt^n.al T:,l.4ve-I.n ,1-. 57000, r/^o't ■ Mt^X. -M- <^ A1^«? Wssserman, Urinalysis. TitZ.»-l V'»i-*-i^-^, <{*^ /l-wf~ /Uto ^U*^ Symtolt: 1=E icellent, e=:(!on,l. 3=Poor. i=^Bad. x. xx, \x\= Enlarged. O—.lbnent. N^Normal. Underline defects. Size of Original is 8}^x 11 The Nutriticm Class H other children. The weight charts and the appearance of strikingly improved children offer good arguments. Best of all, the mothers of children who have gained are always most willing to testify as to the help their children have received. At the first visit a thorough explanation should be made to the mother concerning the causes of the child's condi- tion, and what first steps must be taken to improve it. The diet list and general hygiene instructions should be given out and discussed fully. II. Correction of Defects. DURING the preliminary study, steps can be taken to correct remediable defects. This is one positive means of making over the hand- icapped child who will not gain until relieved of certain defects. The dentist is our first ally who must be called upon to put the mouth into good condition. Decayed teeth must be removed or filled, even if first teeth. When it comes to tonsils or adenoids, the child must be considered as well as the throat. An operation always causes a loss of weight, and it is often best to build the child up somewhat by other means before sub- jecting him to it. All children should be kept in bed for five to eight days after the operation, until the throat has healed and the appetite and strength have returned. Defective vision should be corrected by proper glasses. Flat feet may be helped by tilting the sole of the shoe, exercises or proper braces. More serious defects must be referred to proper specialists. 25 The Nutrition Class III. Education. THE education in health habits and diet offers the chief field for class instruction. In order not to dis- courage the children at the outset, it is best to gradually work each child into the routine of the class and not let him feel any lessening of the personal interest in him. It is highly desirable that parents attend classes with their children as often as possible. At each return visit the child is weighed. The height need only be taken at four-month intervals. The weight is noted on the child's record and on the weight chart. Weighed at Each Visit and Measured Every Four Months Much should be made of all this. The child (and parent) must know how much he weighs and how much he has gained as well as what he ought to weigh. They should watch the plotting of the weight curve, the meaning of which must be explained with great care. The next step is to question the parent and the child as to the general health since the last visit, as to the diet and daily regime, and as to how the instructions have been carried out. Tlie answers must be recorded on the chart. A printed form for the return visit simplifies this. The Nutrition Class 26 An Example of the Type of Printed Form Which is Useful IN Treating Malnutrition OUT OF BED at 7 BATH at ^vvj^ -6^ a- C<:^£«-^~f-. J?jf C4rt^L^a^=66^ cCt^ vt^ kSIicei 'f DESSERT 2WX^TabIespoonJ Cooked fruit, junket, custard MDtt 7?f. Have room dark and cool, windows open top and bottom, bed shielded from direct draueht Child should be in sleepinf baj or veil pinned in so that bedding can not be kicked off. NO tea, coffee, soda water, candy, jelly, sweet preserves, nuts, raisins. NO fried or greasy food. NOT too much milk (1 quart is enoueh. Every child needs at least 1 pint a day). NO food between meals unless ordered. WATER. 1 glass at each meal, 1 glass in mid morning and mid afternoon, none at bed time. Gooir Habfts and Proper Food are absolutely necessary for Good HeaIth and Proper Growth- The matter printed on this form comprises nearly all the facts which it is desirable to give to most of the patients, but it is necessary to write in the specific directions for the individual case. This gives elasticity to the form and makes the parent feel that the directions are for her child in particular. This type of form is distinctly for the parent but older children may also be interested in it. 21 The Nutrition Class The Return Visit Sheet NAME kjLa-V^CL^d , KccHUa-^ ADDRESS -*+3-i ^-d~&L,l^ X^'i t-SJ Date F\h, 1- "iUt Fi 1. It, Mt^ It AA»y i.5- Note by ;v\ . r M F iv\. F. M <-. Cornea ^j"?,* /vwtrt^t't— «Xv-i^u cU-r.^<. HEALTH g.^-< o Diet 7- <^-C-Ctru/»v' ^ *k»o7" 3. Cwe'-^,/«.»^W ^t ^yVtx-.-^ /UCCUH.*/ ?i< /Vi^.«c«.( 7^c*£&^T^ . (Sy.U.fO Lunches o ^•■rh.(3)ei>.k^. Appetite g^A •jl><^»^^ 3^ ^ Se^^^ EaU fast JVo ^K. vvs J^c Bowels Sleep Bed at, Up at r- n ?- 7 "i^"- 7 Rests 1 -^^1^ c*. ^Ccx.^ •Vi^..-ti::^v-t.«^f" '/^^.af^jti. Odt Doobs 3 - U o ' 3 - c j_- fe Exercise (.<-!« a-tfc/v c ^*vi- *>-^ vto-*^ ^T^iCo X 1 Teeth Brobheo 5 « a.A.Y ' ^ 3 jfeJl-cs id.JA. s SOCIAL SERVICE M.F. JYit^^A /^./q ^.r NOTE BY 2,, >/.« e/.... fcCtCi^ «^fl4Ain*^ /i^i e««^tii. jf/Ut^ -^ lif.:...,^ 1 A4^d-ii4ak. AtA*^ 7X^-M-^ "fc <6> '' /-. -^.»» ^UiuCf .^^-f- «^^ > .J AGE /J.-^ WT. & (AV.) feV" tfe" tot •" vt? C7^3 HEIGHT ^J- TEMP. Gi^ 'I 'I ^7? 9? '' ? Gen. Appearance g,„(- i.rfiu. LrirK-v ^»--i> .Smu 1^ My^k-at- ■^£ltZ44^0-\je^ 1^ M-^f^C-lp- Jc H^c^ O'^ny S-frJ^3^. ' ■^" """"" 1^ . 1 L. 3 - 2- S ^ 2-2 S~- 3 b . -^n. The Nutrition Class 28 The home record which has been filled out during the week may be also gone over. Much of the teaching in hygiene can be done at this time by the social worker or volunteer attendant. The children who have gained and who have done well since the last visit are now brought together in a general class. They may be arranged in a row in order of merit according to the greatest gain for the week and rivalry should be stimulated so that each child will try to be at the head of the class the following week. Class talks to parents and children save much time and have often a better psychological effect than individual advice. They need not be formal nor long but can be in- terspersed with the class routine whenever a text presents itself in the gain or loss of any child. Diet and hygiene offer an endless number of subjects — proper and improper foods, economic buying, methods of cooking, food values, the various kinds of food and their functions, habits of eating, sleep, rest, air, exercise, bathing, teeth, tonsils, etc. — in fact every aspect of the whole problem may be talked about to the class as a whole or in groups with much saving of time. The children who have not gained should be con- sidered separately and their charts must be gone over to find out the reason for the failure. It is necessary to demonstrate to the children that they cannot gain unless all the laws of health are obeyed all the days of the week. Re-examination of the child must be made at in- tervals to try to detect signs of disease which may have been overlooked. A good many children will not gain until they are taken out of school. Extra rest hours or a week or two of rest cure in bed may be necessary, especially when the appetite is poor. When a good rate of gain is established, school ^ The Nutrition Class may be resumed in the morning, and later on, for the day. If, after a considerable period, a child does not gain at home, he may be sent away to a country home or some similar place. Little will be accomplished by a short stay, for it takes two weeks for most children to become accustomed to the new routine. One or two months are frequently needed to produce a real gain. If a child stays away long enough to gain 5 to 10 pounds, he will get an impetus which will carry him on after the return home. But unless the parents and child have been educated to the necessity of proper mode of life, the weight gained will soon be lost after he comes home, because the real cause of the trouble has not been reached. Great patience is required in the treatment of the child- ren where the weight deficit is great and the chief cause cannot be removed. The result depends upon the removal or neutralizing of the causative factors and stimulating the children's interest so that they will make every effort to gain. The home record is perhaps the best means of finding out what the child is really doing in his daily life. Each child should be made to keep one for a week at a time every month or two. The record should show the time of rising, dressing, bathing, bowel movement, the time of each meal and the food taken, the hours in school, out of doors and of rest, the amount and kind of exercise, the bedtime and hours of sleep. The calories taken at each meal may be kept by the older and more intelligent children. This is undoubtedly a most valuable means of stimulating interest in the food taken, and will make some children eat properly when all else has failed. It is a simple matter to teach rough caloric values, for average portions of many foods fall into 100 calory portions. The Nutrition Class 30 .^ : H1^^ ^o ^ 1^ i4^ F I Si ^ n ^ n 1^ ^1 > ^^i..' •4 l^M < i i-5 s 7I ^i? ^ ^ t I 5^ ^ Size of Ohiginal is 8}4 x 11 The home record chart shown is compiled from those kept by four different children in order to show different types of record. Each day is copied accurately just as the child wrote it. Monday and Tuesday are from the chart of a very intelligent girl of 11 who kept accurate account of her entire day, as well as the calories she took. Wednesday and Thursday were written by a girl of 12, Fri- day and Saturday by a boy of 11, Sunday by a girl of 9. The last three days are distinctly poorer records than the first four. These home records give one an insight into what the child is actually doing each day, in a way which is not equalled by any other means. ^^ The Nutrition Class 100 Calory Portions Milk 5 ounces 1 glass — 150 cals. Egg 1 large 1 average — 75 cals. Meat . _. 2 ounces about size of a chop Fish 3 " about 3 X 2 X 1 inches Pea or Bean Soup. ...4 " }/^ cup Bread 1 slice about 4x4 x% in ches Cereals (cooked) .... ^-1 cup Macaroni 1 cup Rice J^ cup Potato 1 medium Sugar 2 tablespoonf uls Butter, Oil 1 tablespoonful Green Vegetables 1 to 2 cups Prunes 4 average Apple, Orange 1 average This list is not long nor compHcated. It does not con- tain every possible article of food, but merely those which form the main part of the diet. Small prizes are very useful means of stimulating in- terest. Children will work for them at times when nothing else will make them gain. A. prize may be offered to an individual child if he will make his weight curve reach a certain spot at a certain time. Prizes for the greatest gain in a month or year are useful. It is better to separate the adolescent from the younger children in the prize offers, otherwise the older children will get all the prizes, as their normal rate of gain is nearly double that of the younger child. Prizes for attendance, for resting regularly, for cleanliness, for clean teeth and so forth will all obtain results. Prizes may also be offered for the best homo record and for the best poster which illustrates a health les- The Nutrition Class son. This makes the children think about the matter in a way which makes a lasting impression. Stars pasted on the weight chart stimulate younger children especially. Different colors may be used to indicate gains in weight, clean teeth, daily rests, drinking milk, etc. Honor rolls showing the children who have gained most each month or year are productive of effort from some children. They should be legible, preferably printed or written large and brought to the children's notice fre- quently as a great honor. The printed matter given out must be selected with care, especially with regard to the age and intelligence of the child. The material for older children should appeal to their reason and must offer them really desirable rewards for the effort they must make to change their mode of life. For younger children. The Child Health Alphabet, health fairy stories, rhymes, primers, plays, games, etc., have proven of great value in exciting interest in subjects other- wise hard to present to the young. It is a tactical mistake to give a child of twelve or fourteen a nursery rhyme. Lit- erature written over the heads of small children or unintel- ligent parents is equally useless. /' The work in the class can be of infinite variety. Every / effort must be made to keep it from becoming cut and dried. The children must be interested first of all, then amused and lectured, scolded and praised, bribed and brow- beaten by turns. No one method will reach them all, but the class leader who wishes to succeed must be prepared to ^ be teacher, friend preacher and even mountebank. Above all, he must study child nature and lack seK-consciousness in his dealings with children. Graduation. — Graduation from the class should be held up as a very great honor. Exercises can be held and diplo- ^^ The Nutrition Class mas awarded with some ceremony. The "alumni" of the class should be urged to attend. A short talk on the causes and dangers of malnutrition; on how to keep the health they have gained; an exhibition of the weight charts of the graduates and an explanation to all the child- ren and parents of the point shown on the charts will prove effective. An entertainment may well be added; patriotic songs may be sung and even simple refreshments served. It is necessary to have a definite standard which a child must reach before he is graduated. He must first approximate the average weight for his height and age, as determined by the table of standards. In addition, he should have all remediable defects corrected. His teeth must be in good condition, if necessary his tonsils must be removed and his defects of vision corrected. His posture must be good and his general appearance healthy. Finally, his daily habits and diet must conform to the teaching in the class as judged by his own reports and his parent's testimony. The 'purpose of the class should not merely he to make the child gain weight. This is hard enough to accomplish, but unless the class graduates a child who is free from de- fects and who has learned good health habits, it has failed in its complete duty. IV. Work in the Home HOME visits by a nurse or social worker are of great importance. Tact is, of course, the prime requisite in order to secure the co-operation of the whole family. The visitor should make a complete study of the home and all the social factors in the case, point out faults and help correct them. She should find out whether instructions given in the class are carried out and note all points which The Nutrition Class SJf. Diploma BELLEVUE HOSPITAL NUTRITION CLASS This is to certify ^hat has graduated from the NUTRITION CLASS by reaching normal weight for height and age. This was done by following the RULES OF HEALTH EATING THE RIGHT KIND AND RIGHT AMOUNT OF FOOD. EATING SLOWLY, CHEWING WELL. SLEEPING TEN HOURS WITH OPEN WINDOW RESTING ONE HOUR A DAY. KEEPING CLOTHES AND BODY CLEAN. BRUSHING TEETH AFTER MEALS. HAVING BOWELS MOVE BEFORE SCHOOL. Date Signed ^5 The Nutrition Class must be taken up at future meetings. If relief is needed, she should refer the family to the proper agencies. A great deal of educational work can be done in the home, particularly in regard to the preparation of proper food, cooking, regularity of meals and cleanliness. The correction of defects depends largely on the social worker for she must see that the child is taken to the spe- cial clinics or physician. In brief, it rests with the social worker to convert the advice given in the class into action. RESULTS THE results which may be expected will depend upon many factors. The size of the class, equip- ment, the number of workers, and most of all, the personality of the leader. In a small class nearly all of the children can be made to gain at a good rate, providing there is not serious disease. In a large class, fully two-thirds of the children may be expected to do well. The remaining third should be trans- ferred to smaller classes for more careful study. A result may be considered good if a child gains at better than the average rate for his age. One must not expect to graduate all children within a few weeks or months, since some of them will be 20 or 30 pounds underweight, and it may take several years for them to graduate. A study of the histories and weight charts of many children makes it evident that without attention the weight will often remain stationary for a year or two at a time. In the more severe cases it is a triumph to obtain even an average rate of gain. When the weight deficit is only five pounds or less, and where the cause is easily discovered and removed, a child may be graduated within a few months. The Nutrition Class 36 Nutrition Classes are really Health Classes. THE real place for the nutrition work is in the home and school. Parents must be taught that malnutrition may be prevented by proper feeding and training of children during the pre-school age as well as during school life. They must learn to watch weight and growth, to record it system- atically and most of all, to realize that a failure to gain regu- larly is a warning signal that the child is not in good health. Every school teacher must learn to teach health habits in a way to make them living, vital matters rather than dry axioms of "physiology" or TheABC of Health Made Vital "hygiene" as they have been in the past. When every school has proper health teaching, malnu- trition will be less pre- valent. Physical educa- tion as too often practiced is not health education and does not meet the children's greatest need. Nutrition Classes have already demonstrated what can be done with under- nourished children. The special Nutrition Class will probably always have a place in the school for the milder cases, and in the hospital for the more severe ones. Malnutrition may not be expected to disappear in a short time, but will undoubtedly diminish if we persevere in the education of children and parents in the proper habits of living which will do much to prevent its development. Ethical Culture School Children Supervised hy Federation of Child Study APPENDIX Illustrative Gases The Weight Chart THE form of the weight chart is of no small impor- tance. Those illustrated below have been in use at Bellevue Hospital for over five years and have proven entirely satisfactory. Each small square represents one week in the horizontal direction and haK a pound in the vertical — the chart cov- ering 1 year and 25 lbs. The dates are printed at the top so that they need not be written in, which saves much time. The horizontal lines are numbered in the margins from 1 to so that it is merely necessary to fill in the tens place with the numbers showing the range of weight which the chart covers {i.e., if a child weighs 15 lbs. the bottom line would be marked 70 and the next heavy zero Kne 80. It is not necessary to mark in all the figures opposite the other lines). Then find the date at the top on which the child was weighed and follow this vertical line downwards until you cross the horizontal line representing the exact weight and make a dot at this juncture. It is very easy to interpolate between the lines if the weight is taken on a day between those indicated, e.g., a child comes in weighing 72 lbs. on February 12, 1917 (see Chart A. H.). He is weighed next on February 22nd, and weighs 73}^. The date February 22nd does not come on a vertical line but is 2/7 of the distance between the lines for February 19th and February 26th. The fraction of a pound can be estimated in the same way between the horizontal lines. If the first weight is a multiple of 10 it is well to begin ten pounds from the bottom to allow for possible losses. It is best to write in the year in the left-hand margin, to show the year covered by each curve. Since the chart ^ The Nutrition Class covers 25 lbs. vertically, it may be used for more than one year if desired. If this is done, the average line cannot be shown. At subsequent visits the weight is plotted in the same way, and the dots connected by a line, thus giving a con- tinuous weight curve. If it is desired to plot the Average Weight Line, first determine from a table the average weight for the child's age and height, and mark this point on the chart. Since most children gain about five pounds a year before twelve years and ten pounds a year after twelve years, it is fair to assume that the average line should have a slant upward from left to right corresponding to these figures. Therefore, with a ruler, dot in a line which passes through the "average point" and which has a slant of five or ten pounds between the left and right margins. Another method of plotting the average line is as fol- lows: First determine from the table and plot the average weight point for the child's height and age. Note the amount which a child should gain each month as shown on the table. Then count the number of months be- tween the "average point" and the right-hand margin, and multiply by the number of ounces of average gain. This will show how many ounces the "average line" should cover between the "average point" and the right margin — or, in other words, gives the slant of the "average line." The advantage of the dated chart is its great saving of time and trouble. It may seem a disadvantage to some that the weight curve does not always start at the left- hand margin, but it is really not necessary that it should start there. What we want to show is the progress of the child's weight, and it matters little where the weight curve begins. If it is started late in the year it can easily be continued after January 1st starting at the left-hand side. The Nutrition Class 40 This chart when used for several years shows seasonal variations in the child's weight. It is desirable to write on the chart the cause of marked losses or gains. The facts to be noted should always be written below the weight line, not above it. If written above, they may use space needed for the next year's weight curve. M. C. Admitted Nov. 11, 1916. Age 9 years, 1^/^ months. Irish descent. Eldest of five children. Father, a bartender (misrepresented income to social worker). Mother has never cooperated and very rarely attends class. Home conditions very bad, 4 rooms, 2 dark. Cooking fair; food fairly abundant. Past History — Early history uneventful. Measles at 1)^ years. Pneumonia at 2 years. Colds, very frequent. Habits — Breakfast: Cereal, tea, roll. Dinner: Meat, potato, tea. Supper: Bread, tea. Nothing between meals. Appetite very poor. Bowels irregular. Sleeps well. Retires at 9, up at 7:30. Window open. Never rests. Wets bed every night. Out of doors after school, active. Present History — Brought on account of poor appetite, frequent colds, bed wetting. Physical Examination — Bright, alert child. Color pale. Posture fair. Wt. 45 lbs. Nutrition very poor, muscles poor, very Ht. 49 ins. little fat, bones slender. Av. Wt. 56 lbs. Nose obstructed by large adenoids, breathes through mouth. Tonsils very large and irregular; need removal. Teeth — two carious. Heart, lungs abdomen — normal. D'Espine's sign to III dorsal vertebra. Von Pirquet test strongly positive. u The Nutrition Class Summary — Home conditions unfavorable, mother unwilling to be bothered, careless. Diet insufficient, (tea), poor appetite. Nasal obstruction, hypertrophied tonsils, frequent colds. Tuberculous infection (probably latent). NAME M-C- SEPXF-MBP.Rp.1 1007.^ 1 MAY- 1 JUH' 1 JUL- AUG- 1 SKP- OC r J NOV- 1 DEC- I=II=II II , s« , -t — i I a 7 S ^ ■A ^ e L ^■^■J - z ^ -4 /. ^ ^^^ ^"-^^ ' ,-^ ^ ^ ^2 "^'^ ^u 15. ' > is f c ^^'' *nt\n ^ ^ _»" Q \ ^-^ ^1^ T 5 ~> 7 !^« -Z X ->^ K^'^ i 2- 7 ,-^^N ^^ ^\. -i S^ 1 i^.*^ s ^-^ 1 5 z , 5: % ^'^ . p '1 s;=::^ Q 5 -J Nr^^ 2 t S S 5 I 2, fi 1 .»s i £ * ift ^ J- 3 S^ iO mS S^ m 1 g : ^^--^ WIUEVV , ^52 Pw -^ -'a : c Hi 3 ' i s ^ 0-^ i ^-^^ , -_ = - = -_" ^?__ foo 2^j — -^_ d szf= _ _-__M . -,2S^^S,f5 ^v f 2 Sl 2 4.5 L 1919. ''C C J. S « 32 « « 8 ^ 7 - B s i ^ ^ eg ^ ^ "^ 6 i 5 -/ C e ir 2 I- '--'■ — ^? ^- = -__.^_^^^ -b-t'- — ni — ' i is * ^ ^ w ^ i S i ^ S S S >•■'" »itJE H,kEl> 1918' - p :_^2^^_5~ ■ 3a_,.<: ■^ sf-^ s it , 'jgS i- ^ """ ~~ — »- ^ 1 5 - = -'-*' 1917 -=*"--*■ ■^^ r -1^ """1 ""'"•'° The Nutrition Class 4^ Procedure — Instruction in hygiene and diet in class and at home by social worker. Little response from parent. Enuresis cured at once by correct regime. The weight curve showed the usual small initial gain, then a long stationary period until Sept., 1917, when the parents at last consented to a tonsillectomy. Fol- lowing this, there was a gain of 4 lbs. The loss in November was attributed to coffee being substituted for milk. In January, 1917, a prize was offered if the child would gain 5 pounds in three months, that is, if she could make her weight curve reach the point marked "A." An immediate gain began, but not quite to the re- quired point. She was then sent to a country home for five weeks and gained 2 pounds. The dotted line represents the time when no classes were held during the war. She had influenza in October, 1918. On her first visit to the class, November 12, 1918, she was again offered a prize if she could gain 5 pounds, reaching point "B" by March 1st. Her weight curve responded at once, and she would have reached "B" but for a cold. She was given the prize the next week. For the next four months there was practically no gain — since the incentive was lost. She gained fairly through the autumn and very well at Holiday Farm in December. The winter and spring of 1920 illus- trate well the effect of various factors on the weight curve. In every case where there was a loss it was possible to find some definite cause. This child was 11 pounds or 20% underweight on admis- sion at 9 years. She was still 16 pounds or 17% un- derweight at 133^2 years. She is not a brilliant suc- cess therefore, but her case is worth recording because it shows the effect on the weight curve of so many different factors. Although she has never graduated, yet the class has held the child's interest and she has kept on trying. She ^3 The Nutrition Class has no help whatever at home. The bad nasal ob- struction and habit of mouth breathing which persisted after the operation and the tuberculous infection (even if latent), have been two serious handicaps. It seems fair to assume that under the circumstances a gain of 323/2 pounds in the 43^^ years is more than she would have gained without the Nutrition Class. S. W, 10 years 11 months. Jewish. Admitted to Class Aug. 11, 1920. Father in good health. Mother asthmatic. Eight children, all living and well, eldest 25, youngest 6. Home — 5 rooms, all light, fairly clean. Rent $25 a month, son pays half. Income — father $16.00; two children work. Mother fairly intelligent and very responsive, needs instruction. Early History — Normal. Measles at 9, colds and sore throats frequent. Operation on tonsils 2 years ago. Habits — Breakfast: coffee, eggs. Dinner: Potato, milk. Supper: Cereal, milk or tea, bread. Appetite good. Bowels move after breakfast. Bed at 10, up at 8. Window open. School 9-12, 1-3. Out rest of day. Very active child. Present History — Brought for undernutrition. Chief Complaints — Occasional dizziness, frequent colds, mouth breathing. Physical Examination — (Abstracted) . Aspect normal, bright child, school — grade 5A. Color, fair. Weight, 58.6 clothed. Nutrition poor, muscles fair. Height, 52. Cervical lymph nodes enlarged. Av. Wt. for Ht., 66. Tonsils: right out, left large, cryptic. 12% underweight. Breathes through mouth. Teeth — severa carious. Heart, lungs, abdomen — normal. Von Pirquet — negative. Intradermal tuberculin 1/100 mgm. — negative. The Nutrition Class u n..Mt 5AV MTT orsm: SEPT- 14 1909 A6E 11 Jl!.' 1 r£B- 1 MAE.- 1 APE- 1 MAIT- 1 JITH- 1 JUL T^X SiP- -^J HOV- DEC- 131.1 7? 6° / ■" / / / ■■ / / _i 7" " z , .2 1 . 1 -/■ \ iW^ [f ^' f^P A ' /* — — / [ ,' t t r ' n r / f» fl / m h 1 - ^ f 1 ^ • r - ^ ' 1 *, 1 r* ^ S _ _ 1 i _ ^ _ _ _ ^ _ _ -_ __ _ y _ i y^ -_ ^ pj_, r— — !— — - — -^ — — __ — 3^*- - — I ■ ^1 ff 1 ' ■■ M 1 u ^' \ ? f« ' ' ; ' 1 1 1 i s:/ ^ J i 1 1 1 1 1 h* J 1 u \ y* i^ c 1 1 '1- 11 =j "" ' M' " "1* - "■" ""1 1 " " " -- U If u Summary of ProhaUe Causes — Mother ignorant concerning proper care and feeding. Frequent colds and sore throats. Diet unbalanced. Sleep insufficient; no rests. Overactivity. Mouth breathing, diseased tonsil, carious teeth. Procedure — Preliminary instruction in diet and health habits, which was well received by both mother and child. Operation on adenoids and left tonsil. After one week's rest sent to country for three weeks. There was a net gain of three-quarters of a pound in eight weeks. (Child probably lost weight after operation and re- gained it in the country.) Teeth put in order and kept so by dentist. Jf5 The Nutrition- Class The child followed directions carefully except that she objected to green vegetables. She took one quart of milk daily, rested one hour a day and was in bed by 8 P.M. each night. She reached the normal weight line Nov. 24, was grad- uated and given a diploma. She returned two weeks later with a gain of nearly a pound more. April 26, 1921. Returned for observation. Looked like a different child. Weight 811^ lbs. overweight. Height 53M in.; 13 lbs. or 19% This child is an example of what can be done in a favorable case. The home conditions were good. The mother was ig- norant but anxious to learn and very eager to cooperate. There was no serious organic disease and the defects were correctable. The child followed directions and attended regularly. She was 12% underweight, graduated in 3)^ months, and in 4 months more became 19% overweight. 'once a Drinking as much milk as possible, but no coffee or tea. Eating some vegetables or fruit every day. Drinking at leail four glasses of vtratet a day. i A bowel movement every day. Playing part of every day cut of doors Sleeping long hours witKi " idows open The Nutrition Class J^6 v.,uz A-H- MTiorjremAUG-16-1904 igeIQ^ Jii:- J FEB 1 MAE.- 1 4PL- MAY 1 JUU' JUL- AUG- | 5Z.P- OCT- J NOV- | DEC- i " / i ,e Z ^ ' "^t ^ 1 z yo -__ y<- _______ 10 Lit %'^ A 7 t 7 ' f- 7 t : : ' _ „ 1 ' 2 ^^j U^^ L* _ '^ ~ . 1 ^« jsi^---' __ CS__ 1 fto- _ _____ _ J_ _8o 3 _____ j^_ 80 ° ?v 7 ' ' ' «a .„ / "^ ' . H -_^--^_ ^ ^^- ,11 , ' "^ ^ , 1 1 1 ^ ^'\ __-^^ ' / w.^--' * , t i 7 t\j*^ ^ ^ 1917' - -ir ' 1 -J- . . _...._.._...' ■'■ . Ui|J.„-| . = i| =.Jt. 1 1 -1 » == . .-. »„!=,» „ „».| .«|, „ ...'" A, H. — This Chart Shows the Importance of Drinking Milk, The dotted portions of the curve represent the time during which this child took no milk, the soHd portions the time during which she drank one quart of milk a day. Note that nearly all her gains were made while she was taking milk. The other factors remained about the same during these two years. The home conditions were fair, but the income and food insufficient. Her habits of living were good, but the diet was poor. She was a tall, slender girl with flat chest, poor muscles and fat, and retarded mentally. She had three carious teeth, buried, irregular tonsils, and a 4 plus Von Pirquet reaction. She was 16 pounds or 18% underweight. At the end of two years she was 13% underweight. Although the home conditions, mental retardation and other causes could not be removed, nevertheless this girl gained at somewhat better than the average rate. Child Health Organization OF AMERICA The Child Health Organization has undertaken a nation-wide campaign to raise the health standard of the school child. The Organization will be glad to know your community problems, make sug- gestions for local work, furnish a speaker if expenses are paid, and supply literature at cost. Health Clowns, and other Dramatic Characters, trained by this Organiza- tion are available for engagements throughout this Country and Canada. Single performances, $25; two performances in one day, $35, plus hving and traveling expenses. Literature Weight Cards — Tags — Posters. Health in Play- — My Health Book. Standards 0/ Nutrition and Growth. The Demonstration and Its Application. The Nutrition Class. Alphabet Cards, A to Z. (Reverse side blank, suitable for local notices or clinic instructions.) Cho-Cho's Health Game. Health Plays for School Children. Rosy Cheeks and Strong Heart. Rhymes of Cho-Cho's Grandma. Cho-Cho and the Health Fairy. Child Health Alphabet. Four Plays Dramatizing "Cho-Cho and Health Fairy" stories. Happy's Calendar. Milk, The Master Carpenter. Price List furnished upon application Order from the CHILD HEALTH ORGANIZATION OF America Penn Tekminal Building 370 Seventh Avenue New York City THE U. S. BUREAU OF EDUCATION has arranged for the sale of the following Reprints: Summer Health and Play School. Teaching Health. Further Steps in Teaching Health. The Lunch Hour at School. Health Training for Teachers. Your Opportunity in the Schools. Class-Room Wight Record. Right Height and Weight for Boys. Right Height and Weight for Girls. Wanted: Teachers to Enlist for Health Service. Diet for the School Child. Child Health Program for Parent-Teacher Suggestions for a Program for Health Associations and Women's Clubs. Teaching in the Elementary Schools. Orders for these should be sent to: The Superintendent of Documents, Government Printing Office, Washington, D. C. (Remittance must accompany aU orders.) CHILD HEALTH ORGANIZATION OF America BOARD OF TRUSTEES Dk. L. Emmett Holt, President Dr. Thomas D. Wood, Vice-President Dr. Frederick Peterson, Secretary James G. Berrien, Treasurer Mrs. John Collier Clinton H. Crane Dr. Samuel McC. Hamill Dr. Royal S. Hatnes Dr. Victor G. Heiser Owen R. Lovejot Mrs. Frederick Peterson Dr. Bernard Sachs Mrs. Frank A. Vanderlip Df. Philip Van Ingen Mr. Allan Wardwell Miss Florence Wardwell Dr. Herbert B. Wilcox Dr. C.-E. a. Winslow STAFF Sai-ly Lucas Jean, Director Associate Directors Marie L. Rose Anne L. Whitney Anne Raymond, Field Representative Assistants Margaret C. Carey Grace T. H.vllock Alice F. Loomis Advisory Directors J. Mace Andress Lucy Oppen COLUMBIA UNIVERSITY LIBRARIES' This book is due on the date indicated below, or at the expiration of a definite period after the date of borrowing, as provided by the rules of the Library or by special ar- rangement with the Librarian in charge. 1 DATE BORROWED DATE DUE DATE BORROWED DATE DUE ! C28(t 140) Ml 00