WATCH NEW YORK'S CHILDREN GROW 5�99999999999999999�91 WS 115 R314w 1919 49410950R NLIi DSSSSfllM 1 NATIONAL LIBRARY OF MEDICINE ■x*r. "ft.. ^ '1r* .SO* m W *■* frifb---.. NLM052558141 WATCH NEW YORK'S CHILDREN GROW A REPORT OF NUTRITIONAL ACTIVITIES FOR CHILDREN IN NEW YORK COUNTY PREPARED BY THE HEALTH SERVICE, NEW YORK COUNTY CHAPTER, AMERICAN RED CROSS IN COOPERATION WITH THE CHILD HEALTH ORGANIZATION OF AMERICA ■115 R3I4-W cA ARMED FORCES MEDICAL LIBRARY WASHINGTON. D. C. WATCH NEW YORK'S CHILDREN GROW HE nutrition class or center is one of the most recent and promises to be one of the most effective health agencies in the field of child welfare. If rightly devel- oped, it bids fair to do for older children what the milk station has done for infants. It has seemed desirable to the New York County Chapter of the American Red Cross that fuller information regarding the growth, devel- opment and possibilities of this type of health agency should be made available to those spe- cially interested and to the public. To this end a survey has been made of the various types of nutritional work now in operation in New York. The following report has been prepared in co- operation with the Child Health Organization of America from the material collected in this survey. Nutrition classes of one form or other have been in existence in New York City for four years operating under a wide variety of condi- tions, few of them apparently knowing very definitely what the others were doing; also in very few have results been analyzed and studied so as to discover exactly what has been accom- plished in the different types of classes. There has been little or no conference or co-operation be- tween different organizations to improve and develop methods. It is really a matter of interest, and possibly of advantage that nutrition classes have been conducted under so many different conditions and have varied so widely in char- acter, for out of this diversity of experience there are bound to come ideas which will be of ad- vantage to all. 1 WATCH NEW YORK'S CHILDREN GROW The details of organization and method of operation will naturally vary according to the type of organization with which it is associated— whether a hospital, a general medical clinic, a school, a settlement house, a church, or whether it exists as an independent social agency. Al- though they must differ in detail, there are cer- tain essential features in personnel, in equipment, in operation which they must all have in com- mon if they are to accomplish the best results. WHEN A CHILD IS UNDER- NOURISHED THE "requirements for admission" to the nutrition class or center are much the same, regardless of the organization conducting the work. These evidences of mal- nutrition have been clearly stated by Dr. L. Emmett Holt in "Standards of Nutrition and Growth," published by the Child Health Organi- zation of America: Not every child who is below weight for height and age is to be considered under-nourished. There are con- siderable individual variations depending upon race, family inheritance, etc. How wide a variation from the average is to be considered within the normal range is somewhat of an arbitrary matter. It is pretty generally agreed that for practical pur- poses children between the ages of five and thirteen years who are 10 per cent or more below the normal average of weight for height and age should be considered under- nourished; such children will usually, on closer examin- ation, show other evidences of being physically below par. For children from thirteen to eighteen years a slightly wider variation from the average may be regarded as normal. Even more important than being below weight for height as evidence of malnutrition is failure to make progress in weight. This may be seen in various degrees: (1), some children gain but gain very slowly, their annual 2 WATCH NEW YORK'S CHILDREN GROW increase often being less than half the normal average; (2), others for prolonged periods, i.e., several months, make no gain at all; (3), still others show a steady loss in weight The last is naturally the most serious condition and should receive immediate attention. Class-RooWWeisWt 'RttorA Ten per cent below weight may assure you a place in the nutrition class It should be emphasized at the outset that the physician should be the person to determine whether a child is or is not in need of special nutritional attention. In addition to the data shown by weight, height and age charts, he may take into account muscular condition, color of the skin and mucous membranes, etc. He will discover some children who are less than 10 per cent under weight for height and age that are in need of special attention, and also a few chil- dren as much as 10 per cent under weight who do not present any special nutritional problem. 3 WATCH NEW YORK'S CHILDREN GROW NUTRITION GLASSES IN SCHOOLS The school, whether public, parochial or pri- vate, is the logical place for the operation of a nutrition class. However, the chief reason why it is not ideal for the purpose is because of the fact that so many nutritional disturbances have their origin in the pre-school period. This makes it necessary for the school to provide for the child of pre-school age, or for the community to develop elsewhere facilities for dealing with this group. It has been suggested that the nutritional work among the pre-school age group is a logical development of the municipal infant welfare work and should be continued by the same organ- ization which carries this on. If the nutrition class is in the school, the school physician can supervise the class; the school nurse can visit the homes; the dietitian can direct the class; and the Principal can give great im- petus to the work by personal interest. The chil- dren know one another; they are on a common ground; and it is much easier to secure attend- ance at a school nutrition class than at one of any other type. Private agencies also have carried on nutri- tional activities in several schools and it is prob- able that they will continue to turn to the school in their efforts to demonstrate how best to com- bat defective nutrition in children of this age period. In nutrition classes in public schools, as the children of pre-school age are not reached, it is advisable to begin with those in the first grade and continue the work up through the grades for older children. 4 WATCH NEW YORK'S CHILDREN GROW A School Class A PPARENTLY the first nutrition class to be l_\ organized in New York in a public school X \ was the one at Public School No. 64, started in February, 1918, by the Bureau of Edu- cational Experiments, which is still continuing the work as a test of the feasibility of carrying on nutrition work in schools. This undertaking represents a pioneer attempt at transferring the work of the hospital nutrition clinic to the public school. The procedure resembles closely that found at such places as the Bellevue and Post Graduate Hospital nutrition classes and the ex- periment represents an attempt to discover how far the school machinery can serve to obviate the difficulties encountered by the hospital clinic, chief among these being the inability of the hospital to insure regular attendance of the chil- dren, and to reach all the under-nourished chil- dren of school age. The chief disadvantages of the school as compared to the hospital clinic are admitted to be the relative difficulty in enlisting the interest of parents, many of whom have no appreciation of the fact that the children are not in perfect health, and, of course,»the lack of official connections with outside clinics where physical defects may be remedied. Much effort has been directed toward the solu- tion of these two difficulties. After three years a growing confidence and interest is evident on the part of the parents in the neighborhood as a re- sult of careful follow-up work and home visits on the part of social workers. Mothers' meetings are conducted monthly. Wherever consent of the parents can be obtained the children are taken by the social worker to outside clinics for the % correction of physical defects, and there has been excellent co-operation at all times not only from 5 WATCH NEW YORK CHILDREN'S GROW the clinics on the one hand, but from the school authorities on the other. Classes are held once a week in the school. The staff comprises a physician and one or more social workers, according to the number of children under treatment. The number has varied during the different years of the experi- ment. A particular type of social worker is re- quired for the exacting work of the school nutri- tion class. The workers at Public School No. 64 are designated as nutrition workers. The work requires a certain experience in case work and home visiting, an ability to teach, and a certain knowledge of the principles of nutrition and hygiene. In securing workers for this experiment those with training in social work have been chosen, and the requisite additional training given them. At entrance a thorough physical examination is given and very complete records covering physical and social data are kept. As each child is weighed the figure is recorded on his graphic weight chart, and also on a slip of paper which he carries home. The treatment for these mal- nourished children is somewhat different from that observed at other places in that there has been comparatively little emphasis on diet. Sug- gestions as to what to eat are given, but as little interference as possible is made with the home table. An idea of what the child is actually eating at home is ascertained by study of a home diet record kept by the older children themselves, and by the mothers in cases of the younger children. The child is given careful instruction in health habits. Because under-nourished children need frequent rest, a half hour rest is advised, and in some cases arranged. A similar rest at home is part of the program. A mid-morning lunch of milk is provided at 10:30. 6 WATCH NEW YORK'S CHILDREN GROW A cup of milk a good recess lunch When children fail to gain the cause is searched for, and as this is frequently a failure to take rest periods, late hours, improper food, or rapid eating, it presents an excellent opportunity to stress those factors in the gain or loss of the child. With the younger children, interest in health habits has been awakened by story telling. For older ones instruction has been given in a regular physiology period. The details of the work have varied from year to year as different age groups have been handled and the necessary staff, equip- ment, and technique required have become evident. The development of an educational pro- gram that will carry over into individual habits and gradually modify existing home conditions has been at all times the goal toward which this experiment has been directed. In keeping with the general school tradition medical treatment and relief work are not the basis of the program but undertaken as incidental when found to be necessary. 7 WATCH NEW YORK'S CHILDREN GROW In a number of other public schools in Man- hattan, health teaching is given to under-nour- ished children. No physician is connected with this instruction. It is conducted weekly by the domestic science teacher, often in co-operation with the school nurse. A real interest on the part of the children is awakened through competition, story telling, dramatization, etc. Hot School Lunches FOURTEEN of the one hundred and sixty- three public schools in Manhattan serve hot lunches at noon. The object of a lunch service and the educational campaign to be conducted therewith is not so much to feed children as to overcome malnutrition among them. They are felt to be a necessity particularly in sections where many mothers work outside of their homes during the day, or where children have to go some distance to school. The food is served from a central kitchen and is prepared by paid workers, under the supervision of a manager of school lunches. The Director of Cooking of the Department of Education has entire charge of all educational work in connec- tion with the school lunches, in addition to sup- plying menus, recipes, etc. Children are charged only with the actual cost of the food, each dish- hot soup, pudding, milk, etc., averaging 3c per portion, with the exception of the following: 1 slice of bread, lc; 2 crackers, lc; 1 piece of candy, lc. The domestic science teachers are usually present at the school lunches to direct the children and encourage them to select proper food. One of the best examples of a Public School midday lunch is seen at Public School No. 28. The lunch room, which is located in the base- 8 WATCH NEW YORK'S CHILDREN GROW ment of the building, is conducted on the cafe- teria plan. Just outside the door is a picture of a healthy looking family eating a meal. Below is the a la carte menu, giving the price of each article. The children select their food from that displayed on a long counter. To insure a properly balanced meal being selected and that not all will be spent on candy and sweets, it is required that each child take bread, butter and milk be- fore sweets are sold to them. This is arranged by having the cakes and candies last in order on the counter. An entire substantial meal is furnished for ten cents. Pupils of the school in neat white aprons and caps, assist a woman worker in giving service behind a counter. The hot lunch at school Approximately 100 children patronize the lunch room daily, and share in the responsibility by clearing the tables. The malnourished children are weighed regu- 9 WATCH NEW YORK'S CHILDREN GROW larly by the domestic science teacher and in- struction in health,habits is also given by her. Close co-operation exists between her, the principal and school nurse, and all are enthusias- tic about the nutritional work. The homes are visited by the school nurse and she takes the children to clinics for the correction of defects or for medical advice. Educational Work WITH the Department of Cooking, the school lunch in the nutritional educa- tion program is considered but a small factor. Much more importance is attached to the educational phase of nutrition. The domestic science teachers of the various schools deserve great credit for their originality and ability in presenting methods which have attracted and held the interest of the children. Some of the methods developed are: Food Plays, Making Food Posters, Meal Charts (children clip from magazines pictures of food and paste on cardboard, making a bal- anced meal); Honor Roll for Good Health Habits, Health Games (for example, contest in guessing American names for foods—by pupils of foreign parentage), Milk Parties (children buy milk in school, the bottles being brought clean from home daily. This is done to link home with the nutritional work. Also milk is brought from the homes of the children). Some domestic science teachers conduct mothers' meetings at which they demonstrate cooking or give talks on foods, illustrating these with charts. At least two or three times during a school term assembly periods are devoted to a "Nutritional entertainment," at which stereop- tican slides, "movie" films and health plays are 10 WATCH NEW YORK'S CHILDREN GROW presented. Frequently Cho-Cho, the Health Clown, the Picture Man or the Health Fairy of the Child Health Organization have given enter- tainments. A thrilling visit from Cho-Cho and the Health Fairy The following card is used to enlist the co- operation of parents in the efforts of the school to build up the under-nourished pupils: P. S. No......... Dear Parent: Do you know that............ ought to weigh .... lbs. more than he does? Do you want him to become well and strong? Will you come to school...... P. S. No.....Room___at___ to talk with us about his weight and health? •■•.•■...... Principal 11 WATCH NEW YORK'S CHILDREN GROW The Cooking Department of the Board of Education has a large collection of pamphlets and posters pertaining to nutrition which is regularly distributed to its domestic science teachers in the various schools. It is desirable that all who are interested in nutritional activi- ties should be better informed regarding the nutritional program of the New York Public Schools. NUTRITION GLASSES IN OUT- PATIENT DEPARTMENTS OF HOSPITALS NUTRITION classes in New York City have had their origin in out-patient departments of hospitals, beginning with the pioneer class which was star- ted at Bellevue Hospital in 1916. Today nutri- tional work is carried on at Bellevue, Mount Sinai, Post Graduate and New York Nursery and Child's Hospitals. It should be stated that the class at Mount Sinai Hospital Dispensary is always called a Health Class; that nutritional work is merely one phase of its efforts. The advantages of conducting a nutrition class in an out-patient department are many. Physicians are at hand; equipment is easily obtained, and the facilities for the correction of physical defects are readily available. Attendance THE problem of securing attendance at such a hospital class is a real one and not as at classes held in Public Schools where a class can be brought into session within a few minutes' notice. 12 WATCH NEW YORK'S CHILDREN GROW The children who come to hospital classes are of pre-school age or school age. They are re- ferred by out-patient departments to which they have gone for treatment of all sorts of condi- tions. Others are often sent by the hospital physicians after their discharge from the wards. The school nurse, the teacher, or the social worker may send them and in some instances they are referred by relief agencies. At the Mount Sinai Class a number of children are referred from baby welfare stations and a considerable proportion are referred by mothers and fathers who bring their children to the class. The Staff IN the ideal class the staff should include a pediatrist, one or more nurses, a trained nutrition worker, a story-teller and a num- ber of social Avorkers. Mount Sinai has had the occasional use of a psychiatric social worker to make mental tests. Such a complete staff, how- ever, is not always available. In all of the above- named classes a pediatrist, a nurse and volun- teers are to be found on the staff; in only two of these a trained dietitian and in three, one or more social workers. The duties of the staff mem- bers vary in the different classes depending large- ly upon the size of the organization and conse- quently upon the subdivision of the work. The preliminary and subsequent physical examina- tions are made by the physician. At Bellevue and Mount Sinai Hospitals he participates, regulat- ing the child's diet and other health habits, though he does not do it all; in the other places this part of the work is done entirely by the dietitian. The duties of the nurse are to assist the physician in the clinic, to make investiga- tions of home conditions, to conduct children to 13 WATCH NEW YORK'S CHILDREN GROW other clinics when necessary, and to do follow- up work generally. The chief duty of the dieti- tian is to teach the principles of dietetics by conducting cooking classes, giving cooking dem- onstrations in the home, giving class talks to mothers and children, and explaining the diet lists used and the prescribed diets. Volunteer workers form an important part of the staff in all the nutrition classes. The greatest advance in utilizing their services and training them for this type of work has been developed at the Bellevue Hospital Class. The duties of these volunteers consist in taking histories, weights, heights, and temperatures, preparing the child for examination, filing charts, keeping the follow-up records and in many other ways assisting other members of the staff. Rather fun to share mother's lesson in cooking oatmeal By thus relieving physician, nurse, and dieti- tian of clerical work much time is saved which 14 WATCH NEW YORK'S CHILDREN GROW can be devoted to that work for which these individuals have been particularly trained. The volunteers have found this work very interesting and instructive and feel that it is something really worth while. Equipment IT is obvious that the nutrition class in its construction and equipment should be the embodiment of cleanliness, order and effi- ciency. The space required varies with the size of the group; but circumstances do not always permit of giving all the space needed. At Bellevue Hospital, in addition to the waiting room, the class proper is conducted in a room about 25 feet square; at the New York Nursery and Child's Hospital a room about 15 feet square is available, while the Mount Sinai Hospital class is fortunate in having five rooms varying in size from about 19 feet square to 12 by 30 feet, each Scales—a cot—cha irs—table—screen—and record equipment are the only essentials 15 WATCH NEW YORK'S CHILDREN GROW room being used for a different purpose. In all instances the equipment of the classes consists of an examining table, screens, a weighing scale, a measuring rod, desk, chairs or benches, wall exhibit charts and posters, wax food models, and in one instance a blackboard was provided. The printed matter consists of medical and social record cards, weight charts, home record sheets, diet lists, and other health literature. A valuable form of medical record card has been developed at the Bellevue Hospital Class which combines the history, physical examination, social history, and follow-up data all on one card. With such a form it has been found that much time can be saved and greater efficiency attained than by having each set of data on separate sheets and in different files. Conduct of the Class TREATMENT of malnutrition as con- ducted in all classes resolves itself first into a search for any disease or abnor- mal physical condition in the child and then any fault in his habits, hygiene or diet. On his first visit to the clinic the child's history is taken, he is weighed, measured, and given a complete physical examination. The parent is urged to be present so that the examination may partake of the nature of a conference between physician, parent and child, and it has been found that under such an arrangement the correction of physical defects will be obtained more frequent- ly. The examination to be of any value is made with the child stripped to the waist, and includes in most places as a minimum an examination of the teeth, tonsils, adenoids, heart and lungs. Wherever possible a complete physical examina- tion is more satisfactory. 16 WATCH NEW YORK'S CHILDREN GROW An examination—stripped at least to the waist —with mother present is an interesting event For any remediable physical defects which are discovered definite recommendations are offered and efforts are made to secure their correction. The close connection of the classes at Bellevue, Mount Sinai, Post Graduate and the New York Nursery and Child's Hospitals with hospitals, makes it easy for them to secure this hospital aid. At the other classes not directly a part of a hospital the children are referred or taken by nurse or social worker to the nearest clinic. At the Mount Sinai Hospital class the procedure after a defect is discovered differs somewhat from that followed elsewhere as the child is kept under observation in the class even though he goes to another department for the treatment of the defect. To insure the carrying out of the recommenda- tions made by the physician, a follow-up system has been instituted in all classes through the agency of a nurse or social worker. Experience 17 WATCH NEW YORK'S CHILDREN GROW everywhere furnishes striking evidence of the value of this part of the service. Methods of Attaining Correction of Faulty Diet and Habits A FTER the physical examination has been /\ made and physical defects corrected, at- ± jL. tention is ne,xt focussed upon the correc- tion of any faults which have been discovered in the child's diet and health habits. This is done either through an individual consultation or through group instruction of a class. Roth the class and the individual methods are better than either one alone. Advantages are claimed for both methods and the selection of one or the other depends chiefly upon local conditions. The class method of instruction is used at the Bellevue and Post Graduate Hospitals. At the former this method is used because the Director feels that if any impression is to be made upon the problem of malnutrition with a limited staff of trained workers, this method is necessary; though as good results as are obtained with the individual method are hardly to be expected. The in- dividual method is used at the Mount Sinai, New York Nursery and Child's Hospital classes, and more striking results are claimed for it. In the class method as used at Bellevue Hospi- tal, a group of children gather about the physi- cian's desk for the purpose of discussing the problem of each. Thus the children get the bene- fit of a general discussion relative to mistakes made by themselves and their classmates, and are frequently invited to suggest corrections. Another advantage claimed for this method is that it arouses in the children the spirit of emula- tion and competition which are perhaps the most potent influence in keeping up interest and effort. 18 WATCH NEW YORK'S CHILDREN GROW The exciting moment when we talk with doctor about last week's gain in weight At the Post Graduate Hospital the class method is featured as a club and the principles of dietetics and health are taught objectively by food models and also by discussion. Combina- tions suitable for different meals can be shown. The supervisor of this class has developed an interesting manner of presenting health lessons by the use of objects and symbols drawn on the blackboard, supplemented with appropriate explanations and questions. Technical terms are cleverly couched in catchy combinations such as "Captain Protein," "Lieutenant Car- bohydrate," "Good Fairy Vitamines." The children in the club are governed by rules which, while not based upon parliamentary proceedings, employ a knowledge of the prin- ciples of hygiene. The following are a few of these by-laws: (1), Cleanliness; (2), Fresh Air; (3), Wash hands before eating; (4), Open windows when sleeping; (5), Eat cereals, vege- 19 WATCH NEW YORK'S CHILDREN GROW tables, fruits, and milk. This club decides whether a member is doing creditably enough to remain within its circle. The meetings of these classes are held weekly for a period of two hours. Each child is expected to return weekly until a regular gain is established. Much supplementary home work is needed to get the results claimed for the class method. Later the visits are made less frequent if the numbers are so large as to cause crowding. Stimulating Interest THE attendance of the parents is insisted upon at the first visit and is encouraged at all times because the instruction is directed to them as well as to the children. For each child a weight chart is prepared showing the average weight line corresponding to his height and also his own weight line plotted as he is weighed at each return visit. At Bellevue Hos- pital, photographs of the children are taken on admission, and from time to time. These not only furnish valuable records of progress made, but also interest the children in trying to im- prove their appearance. This is done inexpen- sively by photographing children in groups and cutting up the finished prints. At the return visits the child presents his Home Record slip upon which appear certain facts concerning his daily diet and habits and these slips often enable physician or nurse to detect the cause of the failure to gain when a verbal report had given no clue. In case of a failure to gain, an individual conference is held with the child and when possible with his parent to discover the cause. Where no definite cause can be found, it has been noted that the with- drawal of the child from school for a short time 20 WATCH NEW YORK'S CHILDREN GROW is often followed by a definite gain, and in other cases a sojurn in the country for a few weeks is of great benefit. Various other methods are used to encourage good habits and to stimulate the children to gain. Thus, a red star attached to the weight chart means that no tea or coffee has been taken; a blue star, cereal eaten every morning; a silver star, clean teeth; and a gold star, the highest gain in the class for the week. Sometimes small prizes such as pencil boxes and boy scout suits areoffered as an extra inducement to effort and it is remark- able to note the efficacy of these methods and the results which they bring. It must be remembered, however, that the actual gain often does not represent the greatest or most honest effort and therefore a credit system should be devised which would give recognition to honest and sus- tained effort rather than to actual gain in weight and other objective signs. Maintaining Interest of Mother and Child BOTH parents and children readily come to clinics for the first time and perhaps for a second visit, but interest soon be- gins to lag; visits are likely to become less and less frequent until finally the patient fails to come at all. To get good results in a nutrition class it is obvious that regular attendance is essential. It then becomes a problem to devise ways for securing regular visits. Various methods of attaining this end are used. At Bellevue Hos- pital attendance is aided by using a follow-up index, by which a postal card is sent or a visit is made to the home by the nurse or social worker when a child fails to attend. It is quite clear that the nutrition class has possibilities of a greater field of usefulness than 21 WATCH NEW YORK'S CHILDREN GROW the mere treatment of a case of malnutrition. Its benefits can be extended through its nurses, dietitians and social workers to the family as a whole, in educating its members not only in nutritional problems but also in the general principles of public health. The methods used consist of food exhibits, class talks, cooking classes, cooking demonstrations at home and the distribution of public health literature. Nutritional Problems the Basis for Wider Health Study CLASS talks are given frequently to groups of mothers and children for the purpose of conveying definite health messages. Cooking classes have proved to be very popular and it has been found desirable to have the mother actually participate in the preparation and cook- ing of the various foods. An interesting attempt has been made at Bellevue Hospital to create a desire to read carefully the health literature which is distributed. Literature is given out with great care and pains are taken to impress the mother with the fact that it has been written especially for her child, and for this reason the leaflet is ex- plained in detail, additions are made, or portions are erased if necessary in such a way as to make her feel that it means something, otherwise, as has often been noted, it is thrown away at the door. At the Mount Sinai Hospital class a certain competition has been developed among mothers by having different kinds of admission cards in- dicating different degrees of interest and success in carrying out the instructions given in co- operation toward a higher standard of health habits and methods of living. Those who do well are promoted and by their own efforts determine 22 WATCH NEW YORK'S CHILDREN GROW the rating given. At this class restlessness among the children awaiting their turn to see the physi- cian is prevented by providing reading and picture books, rocking horses and toys. Co-operation with the Home THE effect of parental sickness on the health of the children is more important than might at first sight appear. Illness of the father leads to poverty and domestic privation and maternal sickness often brings about definite neglect of the children. Hence, when the homes and the home-life of the chil- dren are known it is often easy to discover the causes which prevent the child from gaining. These visits to the home by the nurse, dietitian or social worker form a very important part of the activities of all the clinics, and are most important in securing results. The home visitors of the Mount Sinai and Post Graduate Hospital Classes not only direct their attention to the child but also help in the solution of other home problems which present themselves. NUTRITIONAL ACTIVITIES OF THE COMMUNITY HOUSE OF THE ASSOCIATION FOR IMPROV- ING THE CONDITION OF THE POOR A SOMEWHAT different method of at- tacking malnutrition is that of the Association for Improving the Condi- tion of the Poor. The nutrition work of this Association is an integral part of a larger, preventive health program which it is carrying out on an intensive basis in a congested district 23 WATCH NEW YORK'S CHILDREN GROW of 40,000 population, with headquarters in its Community House. The essential steps in this program are prenatal instruction for all expec- tant mothers in the district, suitable arrange- ments for the birth of the child, postnatal in- struction for the mother, the periodical weighing and complete physical examination of all the children and immediate attention to the re- moval of all the defects which the physician finds. This organization after some study of this problem has reached the conclusion that the nutrition class or clinic is only one feature of the program, that the problem involves essentially a readjustment of food habits of the family and that the emphasis should therefore be placed on the home. Not the least important feature of the examin- ation clinic is that of a feeder for the nutrition workers. It is in the Community House that de- fective nutrition is discovered in its earliest stages before its effects have become perman- ently fixed and before the habits leading to the condition are firmly established. All cases of defective nutrition discovered by the doctor are at once referred to the nutrition worker for correction. The children of school age are organized into nutrition classes which meet in the public schools of the neighborhood. The work in the nutrition class is accompanied by visits of the dietitian to the home to give practical instruction to the mother in the preparation of the right kinds of food and in demonstrating to her the benefits of conforming with the suggestions made by the nutrition worker. At first the visits are made once a week, but later every two weeks. One dietitian can take care of fifty children, weighing them weekly, meeting with them once a week in the nutrition class and visiting the homes. 24 WATCH NEW YORK'S CHILDREN GROW Baby as well as the "run arounds" being weighed at home With the children of pre-school age the class method is obviously impracticable and the work must be accomplished entirely through work with the mother in the home. Since it is impos- sible for most of the mothers to bring their little tots to the clinic every week to be weighed and to receive the necessary instruction, the nutri- tion workers go to them. A portable scale capable of weighing up to 125 pounds has been secured. This, the nutrition worker can take with her on her weekly visits to the home. The child is weighed in the presence of the mother. A failure to gain gives the worker an effective opening in persuading the mother to carry out the instruc- tions faithfully. For the most part children with whom the Association undertakes to do inten- sive work are continued for a period of sixteen weeks and longer if conditions warrant and if the physician decides it will be helpful. Children are dropped from intensive work when a satisfac- 25 WATCH NEW YORK'S CHILDREN GROW tory gain has been made for a period of sixteen weeks or longer and when the improvement in food and health habits and in the correction of physical defects has been sufficient to require no longer constant supervision. But the child is still kept under observation. The home is revisited about once a month and the child reweighed, and if the child has lost in weight and fallen back into his old habits intensive work is again resumed. Results Some preliminary results of this work are now available which are exceedingly interesting. In one group of 62 children who were observed for at least 16 weeks none lost weight; 24 per cent gained less than the average expected gain of children for their height and age, while 76 per cent gained more than the average expected gain. The median of actual gain for this group was 173 per cent (the median for normal children of that height and age being 100 per cent). In a second group of 54 children, 13 per cent gained weight, but less than the normal expected gain, while 87 per cent gained more than the average expected gain; the median for this group was 220 per cent. In the third group of children of pre-school age, 33 per cent gained but less than the normal weight, whereas 67 per cent gained more than the normal expected gain. The median for this group was 159 per cent. 26 WATCH NEW YORK'S CHILDREN GROW NUTRITION CLASSES IN CHURCH HOUSES AND SETTLEMENT HOUSES THAT a nutrition class can be success- fully conducted apart from a hospital or dispensary is also shown by the classes at St. George's Church, the Thirty- ninth Street Neighborhood Rooms and the Friendly Aid Society. Children of school age and of pre-school age are admitted to these classes. The staff at St. George's comprises a pediatrist, two nurses, a special worker and several volunteers. The class is conducted in the Deaconess house, for which two rooms, each about 20 feet square, have been set aside, one serving as a waiting room and the other as an examining room. In the latter a dental chair has been installed and arrangements are under way for securing a dentist. Individual Method of Treatment THE nutritional work is conducted by the individual method and the procedure consists in making a physical examina- tion, securing the correction of any physical defects at the neighboring hospitals with which this class has close co-operation, and then con- ferring with the child and parent with regard to a correct diet and good health habits. The class also has excellent co-operation with vari- ous relief agencies. The children's interest is maintained by affix- ing stars of various colors to the weight chart for gains in weight and for correct habits of health. A valuable method of attaining these ends is a bulletin board upon which names are posted of children making the highest gains as 27 WATCH NEW YORK'S CHILDREN GROW Having fun while we wait for the doctor—a health game devised for use in a Nutritional Class well as of those whose physical defects have been corrected. The health games developed by the special worker at this clinic constitute an un- usual form of entertaining and interesting the children. One such game constructed from a large paper box, has 20 holes, about the size of a golf ball, cut out of the cover. Each hole is labeled with the picture of some food (bottle of milk) or the name of some health habit (clean hands) or some incorrect food habit (rapid eat- ing) or faults in hygiene (flies on food), etc. The game is played by rolling the ball on the box and should it fall into the hole labeled "milk bottle" a score of 100 points is obtained; whereas if the ball falls into the hole marked "flies on food," 100 points are deducted from the score. Someone is placed in charge of these games so that the significance of each play may be dis- cussed. 28 WATCH NEW YORK'S CHILDREN GROW Both at this class and at the Thirty-ninth Street Neighborhood Rooms, the children's in- terest is also stimulated by a professional story- teller who tells stories bearing on health topics. Country outing trips are occasionally made. Once a month the children are invited to a food party, at this party an opportunity is provided for them to express their ideas about proper menus for different meals. Mothers are attracted to the St. George's clinic by cooking classes and by medical advice in minor matters which is given by the attending physician. OTHER TYPES OF NUTRITION CLASSES THE problem of malnutrition and the method of attacking it is not yet a closed chapter and it is fortunate that many different groups are still studying this pro- blem. Some interesting nutritional activities have been developed by private organizations which conduct schools—notably the Children's Aid Society. The Children's Restaurant An interesting experiment has been made by the Bowling Green Neighborhood Association by which a children's restaurant has been conducted to study the value of furnishing adequate meals to under-nourished children and incidentally to educate the parents in food values. The children selected for this test were given a careful physical examination and any physical defects discovered were corrected. At the restaurant three meals daily were served (at 8, 12 and 5:30) to a group of 25 children. Many more crowded around the 29 WATCH NEW YORK'S CHILDREN GROW street window to see the actual food placed there during each meal. The weekly weight of each child was recorded and progress indicated upon a chart which hung in the restaurant so that the children could see this for themselves. Instruction in food values and health habits was given at the same time. Supplementing the work at the restaurant, home visits were made by a nurse, food values were taught and home conditions so far as possible improved. The Health Play Schools A N experiment of wider scope is that of the /\ Summer Health Play Schools conducted X JL by the Federation for Child Study and the Women's Conference of the Society for Ethical Culture. These organizations realizing that many children instead of improving during the summer vacation actually run down physi- cally, have established five Summer Health Play Schools with a twofold purpose of improving nutrition and providing wholesome play in pleas- ant surroundings for city children. At the end of the school year a list of children suffering from malnutrition was obtained and a thousand such were selected. The children came to these Summer Health Play Schools at 8:30 and were dismissed at 4:30. Every child was given a physical examination and any physical defects discovered received attention. They were then organized into classes, and instruction in good health and food habits was given. One of the important features of this work was the pro- vision of a mid-day meal of approximately 1,000 calories and an afternoon lunch of crackers with milk. The mid-day meal was followed by a rest hour with sleep for the younger children and quiet games and reading for the older ones. 30 WATCH NEW YORK'S CHILDREN GROW The Morningside Nutrition Center A NOTHER variety of nutritional activity / \ is seen at the Morningside Nutrition and A. ^ Homemaking Center, organized primar- ily to study methods of making available to a community the services of home economics ex- perts and to train nutrition workers. This is a co-operative enterprise between Teachers Col- lege, Columbia University, and the Charity Organization Society. One of the most important lines of work has been the conduct of nutrition classes for children. The directors are members of the staff of Teachers College, and one of them is also Home Economics Secretary of the Charity Organization Society. Under their supervision, advanced (mostly graduate) students take charge of the classes. The functions of the nurse in other centers have been fulfilled here by public health nurses in training, from the Department of Nursing and Health of Teachers College. Physi- cal examinations of the children have been made by students from the Physical Education Depart- ment under the personal supervision of the pro- fessor in charge. The nutrition class exercises are conducted by students from the Department of Nutrition, they also do the home visiting which is considered an indispensable feature of the work, but one requiring close supervision by a trained social worker to be of much value. The children coming to the center have been gathered largely from Public School No. 43, by weighing and measuring certain grades system- atically, with a view to getting groups of differ- ent ages for comparative study, and to giving the students experience in methods suitable to each group. The teachers have given the heart- iest co-operation, helping to sustain attendance and interest and giving valuable suggestions with 31 WATCH NEW YORK'S CHILDREN GROW regard to home situations. The school visitor has been a particularly valuable ally. When physical defects are detected, these are brought to the attention of the parents either by the nurse attached to the class or by the nutrition student who regularly visits in that home, and if visits to a clinic are necessary, one of these workers usually takes the child. Instruction in regard to food and health habits is conducted by the class method, and careful attention has been given to developing system- atic educational programs for the different age groups. One of the students presents the lesson each time, and this is observed and criticised by the other members of the training class. The rooms are especially cozy and homelike, though furnished in the simplest manner. There is a very friendly atmosphere among the children, some of whom have been in regular attendance for nearly a year. It has been deemed advisable to keep the children under supervision for long periods, in this experimental stage of nutrition class work. The routine of keeping graphic weight charts for each child, of recording home conditions as revealed by social visiting, of stim- ulating interest by means of stars or other suit- able signs of progress is similar to that described for other centers. The home contact main- tained by home visiting is strengthened in this center by the other lines of work, such as classes for mothers and special case work not necessarily connected with malnutrition of children. 32 WATCH NEW YORK'S CHILDREN GROW SUMMARY IT is evident from the study of the foregoing report that the problem of malnutrition among children presents a variety of phases, each one of which needs special and separate measures for its solution. The different plans presented in this report, which are now being followed in New York County, have each of them some special features of value. One who contem- plates the formation of a nutrition class would do well to study carefully the types of classes here described, and by selecting the best points from each might be able to produce something better than any single one here mentioned. The type of class followed most closely will of necessity depend upon th,e organization with which it is connected, whether a school, a hospi- tal, a social agency or a church. In all types of classes it is the consensus of opinion that medical direction is desirable, and that the essential features are educational. In the educational side of the program both the children and the parents must participate. 33 »:*' k (■« WS 115 R314w 1919 NLM 05255614 1 NATIONAL LIBRARY OF MEDICINE £ t :> • viff!** '■^^P NLM052558141