and Medical Care of Preschool Children in
NEVIN S. SCRIMSHAW AND MIGUEL A. GUZMÁN
In the 1950s there was only limited recognition of the fact that malnutrition is often precipitated by episodes of infection and that malnourished children were more susceptible to infection, a synergistic interaction. The Institute of Nutrition of Central America and Panama (INCAP) was established in 1949 and immediately began studying factors responsible for the high prevalence of protein-calorie malnutrition including kwashiorkor. It was observed that almost every case of kwashiorkor was precipitated by antecedent infections ( Béhar and Scrimshaw 1960), and that the more malnourished children had infections of greater frequency and severity.
As in most developing countries, the officially reported causes of the high mortality of infants and preschool children were incomplete and inexact. Deaths in which malnutrition is the direct or the underlying cause were almost entirely misinterpreted, and usually did not appear in the official statistics. For example, during 1956 and 1957 the cause of the 222 deaths among children 0-4 years of age in four Guatemalan villages, including one (Santa Catanria Barahona) selected for the current study, was reviewed by visiting the households immediately afterwards ( Béhar, Ascoli, and Scrimshaw 1958). Forty of the deaths occurred with clear signs of kwashiorkor, forty-two with respiratory infections, and thirty-seven with diarrhoeal disease. The official records indicated only one death from malnutrition, and the kwashiorkor deaths were all ascribed to ascariasis. However, it was also apparent that, without the impact of infections, there would have been few or no cases of kwashiorkor. Moreover, few children would have died from an episode of infection had they been nourished sufficiently to have had normal resistance to infectious disease ( Béhar, Ascoli, and Scrimshaw 1958).
Information on the frequency of infections and of malnutrition is even more unreliable. In general, however, their incidences are high in the preschool years, particularly during the first two years of life. In Guatemala, breastfeeding commonly extends to twenty-four months, but beyond six months it no longer provides the protein and calories needed for proper growth and development. In developing countries such as Guatemala, a weaning child is particularly vulnerable to acute diarrhoea because of exposure to an