J.biosoc.Sci. (1979) 11,411-424

HEALTH, GROWTH AND DEVELOPMENT OF PRESCHOOL CHILDREN IN NEWCASTLE UPON TYNE H. MARY FELLOWES, CATHERINE A. HYTTEN, W. Z. BILLEWICZ AND A. M. THOMSON MRC Reproduction and Growth Unit, Princess Mary Maternity Hospital, Newcastle upon Tyne Summary. One hundred and forty 'normal' children aged 0-5 years, selected from three large general medical practices to represent a wide socioeconomic range, were seen monthly for periods of at least one year. Average growth patterns, previously shown to be related to the energy value of diets, conformed to British standards. Height and weight were not significantly related to socioeconomic status, maternal 'efficiency', number of sibs nor place in family. About half the children aged 0-5 years or less changed growth 'channels', falling to 0-4% in children aged 2 years or more. Respiratory illnesses showed seasonal changes, but growth rates did not, and there was no evidence that illness of any kind or severity had more than a transient effect on growth rates. Developmental test scores were not found to be related to growth rates. Girls tended to have higher scores than boys. Children from non-manual families and those with sibs at least 5 years older scored more highly in tests of language than those in other types of family. Introduction

Social class differences and secular trends indicate that environmental influences on growth exert much of their effect during the earliest years of life. There is a considerable literature on the implications of fetal growth rate and size at birth, but much less on factors influencing patterns of growth and development during life between birth and age of entry to school. In developing countries, disease may be an important cause of impaired growth, especially in older infants and young toddlers (McGregor et ah, 1968, 1970) but evidence from affluent countries is scanty. Hewitt, Westropp & Acheson (1955) concluded from the data of the Oxford Child Health Survey that early growth may be impaired by illness, but Tanner (1962) commented that the question is 'beset with many complications and this study' (i.e. Hewitt et al.) 'cannot be regarded as more than suggestive for future work'. There is a large literature suggesting that acute or chronic malnutrition during early childhood may cause impaired functional as well as somatic development (see review by Birch & Gussow, 1970), from which it seems reasonable to believe that 411

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undersized or slow-growing children would show evidence of retarded performance in tests of development. Evidence of such an association is, however, scanty in children of pre-school age. The question is complicated by the effects on function and behaviour of the general family environment and of perinatal factors (Neligan, Prudham & Steiner, 1974). The present authors have previously reported, from the results of a semilongitudinal study of pre-school children in Newcastle upon Tyne during 1968-71, that intakes of dietary energy are positively correlated with weight-for-age and with rate of gain in weight between 6 months and 3 years of age (Black, Billewicz & Thomson, 1976). Those findings are consistent with those from a national sample of pre-school children (Department of Health and Social Security, 1975). This paper describes some findings on health and functional development in relation to somatic growth. Work of this nature involves many practical and theoretical complications, and the literature provides rather little guidance. A description of how the problems were tackled may therefore be helpful to others.

Material and methods Sampling The object was to examine differences between children being reared in a wide range of socioeconomic circumstances, not to describe those in a specific locality. It was decided to use samples drawn from the records of three large general medical practices; this was much less laborious and costly and yielded children not necessarily less representative than a sample drawn from the whole of a defined geographical area. One of the practices covered a mainly well-to-do surburban area, while the other two covered mainly Council-owned housing estates, parts of which included families rehoused from slums being demolished. The practice records were used to define all families containing an infant less than 6 months old; one-parent families and those of mixed race were excluded at this stage, the numbers being too small to be useful. The mothers were visited at home after being sent a letter of introduction from the family doctor. Nine families were then excluded because they were planning to leave the area soon. One family refused, but cooperation was obtained from 99 families which included 158 children aged 4 years or less at the time of enrolment. Eighteen of these children are not included in the data to be reported here: four suffered from congenital malformations likely to be associated with adverse effects on growth and development; eight left the area too soon for sufficient records to be obtained; and six because the mothers proved to be unwilling or unable to cooperate satisfactorily. The data therefore deal with 140 'normal' children under 5 years of age, each having been studied for at least 1 year between 1967 and 1971. The records of different children cover different age-spans; the overlapping cohort design has the advantage of avoiding the inherent limitations of a fully longitudinal approach (Billewicz, 1974).

Health, growth and development of young children

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General procedure It was out of the question to ask mothers to bring children repeatedly to a central clinic. An old ambulance was therefore fitted out as a mobile clinic and driven monthly to each home. This procedure was highly acceptable to mothers, but involved some difficulties where homes were situated on roads not level enough to permit weight and other measurements to be made with accuracy. The ambulance served well for interviews, clinical examinations and anthropometric measurements, despite problems with air temperature during the winter. For developmental tests, the child and its mother were brought to a central clinic in order to provide standard conditions, adequate space and freedom from interruption by sibs. Children were seen and measured and health histories were taken once each month, the shortest period of follow-up being 1 year and the longest 4 years. Developmental tests were made at 6, 9 and 12 months of age, then 6-monthly until 3 years and finally at 4 and 5 years. Families were classified according to the Registrar General's classification of paternal occupations. Maternal efficiency was scored as described by Thwaites & Sutherland (1952), omitting the item 'diet of child'. Scores of 1 (poor) to 3 (good) were given to state of child, attitude of mother to child, and state of home; the maximum total score was therefore 9 and the minimum 3. Anthropometry Accurate lever balances were used for weighing, one for babies and another for older children. These instruments were checked before each weighing session in the ambulance. Children were naked or wearing underclothes only. Linear measurements were made with equipment and methods described by Weiner & Lourie (1969). The measurements included weight, recumbent length (up to 2 years), height (2 years inclusive and older) and head circumference. Skinfold measurements were abandoned after initial trials showed that many children resented them. Even some of the simpler procedures often caused uproar among children too young to understand explanations, so patience was needed to secure reasonably accurate measurements. Two medically qualified observers used carefully standardized methods and checked each other at intervals. They were not shown previous measurements; the recording clerk asked them to repeat any measurements which she considered to be inconsistent (e.g. a decrease of height, or an unexpectedly large change in height or weight between one examination and the next). Health Children were seen and mothers interviewed at intervals of 1 month to keep periods of recall as short as possible. Mothers were asked to describe any illnesses occurring during the previous month, a special form being used which included a check-list of common signs, symptoms and treatments. Severity was assessed, and dates of onset and recovery noted. The records of family doctors were scrutinized following mothers' reports of illnesses, but this proved to be less useful than

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expected, since medical records were often brief and sometimes inconsistent with what mothers had told the observers. The survey health records covered a wide range of possible or firm diagnoses and classification was difficult. The data could not be easily reconciled with the diagnostic categories used by Spence et al. (1954) and Miller et al. (1960) in the Newcastle upon Tyne Thousand Families Study, nor with those of Dingle, Badger & Jordan (1964) in Cleveland, Ohio. Many illnesses were non-specific and could not be allocated with confidence to a prearranged diagnostic classification. The following ad hoc classification (reported here in a condensed form) was adopted: Categories: (a) respiratory tract infections, including minor and undifferentiated conditions without local signs; (b) diarrhoea and vomiting, together or separately, when not obviously secondary to some condition other than gastrointestinal infection; (c) other episodic illnesses, including skin diseases, trauma etc. As noted previously, four children with chronic or long-continued disabilities are excluded from the analyses. Duration of episodic illnesses was calculated in days, from the reported dates of onset and recovery. Dates were estimated if the mother could not be precise. Severity was classified into two grades, (a) Minor illnesses involved some disturbance of function, such as anorexia, lethargy, interrupted sleep. Trivial upsets without significant disturbance of function, e.g. fretfulness and dribbling associated with teething, were not included, (b) In severe illness the child was said or seen to be obviously ill; it was usually, but by no means always, put to bed and the family doctor consulted. A child was regarded as being at risk during a given month if the records covered at least two-thirds of the month included within a specified age-range. Developmental tests On advice from experienced workers, the screening inventory of Knobloch, Pasamanick & Sherard (1966) was used up to 12 months of age and the Denver Developmental Screening Test (Frankenberg & Dodds, 1967) at older ages. All tests were made by one of two observers, who standardized their procedures by testing children not otherwise involved in the survey, one observer dealing with the child while the other observed the procedure through a one-way screen and scored the results independently. The tests used had been devised to detect possible retardation of development in individual children, results usually being expressed along the lines of retarded, possibly retarded, or normal. We found it necessary to devise a scoring system which would permit comparisons to be made between groups, and which would allow for the ease or difficulty of passing test items which changed with age. Each item passed was given a score of 1. Failures were given a negative score weighted by the proportion of survey children passing at a given age. Thus, failure in an item passed by 80% of children of similar age was given a score of —0- 8, while failure in an item passed by 20% of children was scored —0-2. The items used at any given age encompassed the range from that failed by at least one child to that passed by at least one child. The sum of scores for individual items divided by the number of

Health, growth and development of young children

415

items gave the raw score for each child. Scores for groups of children were standardized to a group mean of 100 and a standard deviation of 15 points, overall and in the subdivisions of the tests. Results Anthropometry Table 1 shows that mean weights and heights agree fairly closely with the relevant standards for British children (Tanner, Whitehouse & Takaishi, 1966). Growth velocities (not reported here) also conform to the standards. It is of interest that from birth to 6 months, males gained 4-9 kg (SD 0-88, « = 42) and females 4-4 kg (SD 0-80, n = 31), the sex difference being significant (P < 0-05). Scanty evidence from babies weighed at 0-25 years suggests that the sex difference in growth rates arose during the first 3 months of life, no significant difference being present during the second 3 months. Mean heights (but not weights) were lower in the poorer social classes and in families with low maternal efficiency, but differences were not statistically Table 1. Mean weights and heights (±SD) of study children by sex and age, compared with standard median values* (±SD where available) Female

Male Age (years)

Study

Standard

Study

Standard

Weights (kg)

ot

0-5 1 1-5 2 3 4 5

3- 4 ± 0-5 (82)t 8- 2 ±0-8 (41) 10- 0 ± 1-1(39) 11- 5 ± 1-2(42) 12- 6 ± 1-4(41) 14- 7± 1-6(55) 17- 3 ± 2-0 (42) 19- 9 ± 2-7 (23)

Heights (cm)§ 68 • l ± 2 . 0 0-5 75 •9 ± 2.2 10 82 •3 ±2-6 1-5 86 •3 ±3-0 2 95 • 1 ± 3-6 3 4 103 •4 ±4-1 110 • 9 ±4-9 5

3-5 7-9

10-2 11-6 12-7 14-7 16-6 18-5 68-2 ±2- 3 76-3 ±2- 7 82-1 + 3.0 85-9 ± 3- 3 94-2 ±3- 8 101-6 ±4- 3 108-3 ± 4.7

3- 4 ± 0-5 (58)t 7- 9 ±0-9 (31) 9- 9 ± 1-2(29) 11- 0 + 1-2(34) 12- 2± 1-4(35) 14- 3 ± 1-8 (45) 16- 1 ± 2-1 (29) 17- 5 ±2-3 (13) 66 •0±2-2 74 • 2 ±2-4 80 •9 ±2-7 84 •9 ±3-4 93 •5 ±3-9 100 • l ± 4 - 5 105 •6 ±4-6

•Tanneryal. (1966). f Birth weights of all children, irrespective of age at enrolment. t Numbers of study children in parentheses. § Length up to 1 • 5 years of age.

3 •4 7 •4 9 •7 11 • 1 12 •2 14 •3 16 •3 18 •3 65-5 ± 2 . 3 74-2 ±2- 7 80-5 ±3- 0 84-6 ±3- 3 93 0 ±3- 8 100-4 ±4- 3 107-2 ±4> 7

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significant. These two associations cannot be separated, since about 70% of children with fathers in non-manual occupations were given the maximum maternal efficiency score of 9, compared to 15% of children with fathers in manual occupations. Conversely, scores of 6 or less were found in 2% of non-manual families and 33% of manual families. Rates of growth in weight and height were not influenced by the presence of older or younger sibs, or by place in family, apart from the expected lower average birth weight of first children (3-34 kg) compared with later children (3-46 kg). There was no evidence of a seasonal influence on growth rates. It has been shown elsewhere (Black et ah, 1976) that weight-for-age was significantly correlated with dietary energy intakes; the same was true for gains in weight from 6 to 18 months and from 18 months to 3 years of age. Inspection of individual growth curves plotted against centile standards gives the impression that children cross more easily from one channel to another during early than during later life. There are two difficulties in deciding whether the growth of a given child should be regarded as having changed channels or not. The first is that a child above the 97th centile initially can only move down while one below the 3rd centile can only move up. This problem is not serious since the proportions at risk are small, and only some will change. The second difficulty is that for any child the chances of changing centile position depend on where it is located between the two centiles usually employed to define a channel. It is therefore necessary to determine upper and lower limiting values for rate of growth between specified ages in order to make the probability of changing channels independent of the child's initial location on the standard grid. Examination of the standards showed that at any given age, the percentage change required to move by the width of a channel is almost the same whether the child moves over 6 months from, say, the 3rd to the 10th centiles or from the 90th to the 97th, and similarly for downward movements. A child was therefore defined as having changed channels if the proportional change in height or weight exceeded or fell short of the two limiting values defined from the centile grid. The limiting values, of course, change with age. The percentages of children changing channels of weight during specific age intervals were: 0-0-5 years: 48-6% 0-5-1-0 years: 29-9% 1-0-1-5 years: 6-7% 1-5-2-0 years: 4-1% 2-0 years and later: 0-4% It seems, therefore, that growth in weight takes up to 2 years to settle down into a given channel, and that below that age it is difficult to predict the future channel. Height behaved in a similar way. It is of interest that of ten children who 'changed down' in weight during the first 6 months of life, eight were above the 75th centile of birth weight, whereas of 26 who 'changed up' 13 were below the 25th centile of birth weight. This is in agreement with previous observations that the initial weight gains of light babies tend to be greater than those of heavy babies. Examination of the records of babies who entered this study early enough to be weighed at 0-25 year suggests that the

Health, growth and development of young children

417

influence of birth weight on the early growth rate is mostly over by 3 months of age. At ages beyond 0-5 years, the association between initial weight and the direction of movement through centiles gradually disappears. Health Incidence of illnesses. Table 2 shows attack rates (illnesses that started in a given period) by clinical type, age of child and season. Respiratory illness accounted for about half of all episodes, regardless of age; the majority of cases involved the upper respiratory tract only. There was no obvious trend by age, but incidence was higher in the winter than the summer months. Gastro-intestinal illness occurred in about 7% of children per month, without trends by age or season; the high rate recorded for September-October is mainly due to 1 out of the 3 survey years, but the highest incidences did occur during these months in all years. The incidence of all other illnesses was usually intermediate between those of respiratory tract infections and diarrhoea and vomiting, and did not show any consistent trends by age or season. Table 2. Attack rates (% per month) of illnesses by type, age and season Type of illness At rick 1 lolL

r\.\,

Age (years) 0-5-1 1-2 2-5

Season Jan-Feb March-April May-June July-August Sept-Oct Nov-Dec All

Respiratory tract infection

Diarrhoea and vomiting

Other

All

25-6 22-4

61 8-6 6-4

11-9 13-2 11-5

43-6 44-3 39-4

3-1 6-2 6-7 7-4 121 6-5 6-9

7-7

12-6 15-0 14-3 10-2 12-1 11-9

33-7 38-3 43-0 34-8

21-5

23-0 19-4 21-2 131

29-8 26-7 22-1

520

45-3 40-9

(children x months) 344 696

2091 575 546 519 497 473 521

3131

More illnesses of all types were recorded in non-manual than in manual families, the averages per year per child being 5-8 and 4-1% respectively. The differences appeared consistently within age groups and for types of illness; it may be due to different standards of reporting by mothers in each class but no basis for an objective judgment exists. The proportion of illnesses for which a doctor was consulted was 52% in the non-manual and 75% in the manual group; and the proportions of illnesses for which an antibiotic was prescribed were 31% and 56%. These differences may reflect differences in maternal and medical reactions to illness, rather than differences in the types and severity of the illnesses themselves.

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The presence or absence of sibs appears to have had no effect on the incidence of illness. Medical advice was sought somewhat more frequently for illnesses in only children (72%) than in children with sibs (60%). Since there were more only children (one-child sibships) in the non-manual group, this difference is not due to social class. Duration of illnesses. Table 3 gives, by age, percentage distributions of durations of minor and severe illnesses together (excluding trivial complaints). About twothirds of the episodes lasted for less than 1 week, while 10% lasted for 2 weeks or more, and 2-3% for 4 weeks or more. Table 3. Distribution (%) of lengths of episodes of illness,* by age (trivial illnesses excluded) Length of episode (weeks) Age (years)

-1

1-

2-

3-

4-

5-

6+

No. of episodes

0-5-1 1-2 2AU

72-7 64-9 68-1 67-8

21-9 25-1 21-0 22-2

3-7 6-8 6-3 61

1-2 2-3 1-7

1-6 10 11 1-2

0-5 0-5 0-5

0-5 0-7 0-6

187 399 958 1544

* All episodes beginning within a given age range are included, even if the child is not regarded as being at risk for calculations of incidence (see text).

The average duration of minor plus severe illness (excluding trivial) was 6-6 days in manual families and 5-4 days in non-manual families. This may help to explain the greater frequency of medical visits and the greater use of antibiotics among the former. Inoculations. Table 4 gives percentages of children inoculated, by social class, and shows significant differences in the expected directions. Malaise attributed to smallpox vaccinations was reported in 24-6% of children (duration 2-5 days, on average); to triple vaccine in 2-7% (2-7 days); to measles in 35-8% (4-3 days); and to poliomyelitis in 0-9% (1 subject, 2 days). Table 4. Percentage of children inoculated, by social class Fathers' social class Type of inoculation Triple Poliomyelitis BCG Measles Smallpox

Non-manual {n = 62)

Manual {n = 78)

96-8 96-8 8-1 53-2 79-0

65-4 590 29-5 25-6 30-8

Illness and growth. Table 5 shows mean weight gains within different ageranges, according to the number of days of illness (per year) of all kinds. There are

2-20±0-44(8) 1-92 + 0-84(11) 1-79 10-30(6) 2-3010-69(4)

2-1110-53(22) 1-86 ±0-73 (21) 1-7210-40(12) 2-06 10-74(12)

Females 0-14 15-28 29-42 43 +

Both sexes 0-14 15-28 29-42 43 +

+ 0-37 (5) 10-65 (9) 1 1-30 (3) 10-41 (8)

(11) (6) (7) (9)

2-3810-67 (16) 2-2710-63 (15) 2-3110-66 (10) 2-26 + 0-44 (17) ,

2-18 2-25 2-35 2-33

2-4810-77 2-3010-67 2-2910-37 2-2010-48

10-2-0

10-42(10) 1 0-38 (7) 10-48(6) 10-60(9)

2-2610-36(16) 2-24 + 0-48(17) 2-04 1 0-53 (16) 2-14 10-51 (18)

2-17 2-49 2-22 2-32

2-4210-16(6) 2-06 1 0-49 (10) 1-94 10-55(10) 1-96 + 0-35(9)

2-0-3-0

Age (years)

2-06 1-95 1-93 1.93

1 0-48 (16) 10-39 (13) 10-57 (17) + 0-44 (10)

2-20 1 0-54 (7) 1-8010-43 (7) 1-99 10-77 (8) 2-15 10-25 (3)

1-96 10-43 (9) 2-11 + 0-27 (6) 1-8810.33 (9) 1-83 10-48 (7)

30-4-0

o no j- n IA

2-02 1 0-55 (16) 1-97 10-59 (10)

W

o i o -j- n "\$

1-52 + 0-33 (3) 1-81 +0-45 (4)

1 O C i d 1Q I -00 x « ~ " (4)

2-14 ±0-53 (13) 2-08 + 0-68 (6)

4-0-5-0

• Actual number of days of illness in the age group 0-5-1-0 years is half the number (per year) shown in this column.

2-06 ±0-58 (14) 1-8O±O-63(1O) 1-66 ±0-50 (6) 1-94 + 0-78(8)

0-5-1-0

Males 0-14 15-28 29-42 43+

Days of illness/year*

Table 5. Weight gains (kg) between given ages by number of days of illness (mean ± SD)

1

I3.

1

1

3-

gron

420

H. M. Fellowes et al.

no consistent patterns or significant differences. Inspection of the 12 children who showed unimpaired mean increase of weight between 0-5 and 1-0 years of age but had 43 or more days of illness per year failed to reveal any plausible reason for this apparent lack of effect of prolonged illness on growth. More detailed tabulations failed to show any evidence of a consistent relationship between duration and severity of illness and weight attained or increments of weight over 3- or 6-month intervals. In individual cases, there appeared to be fluctuations of weight associated with some episodes of illness, but these appear to have had no long-term effects on weight-for-age. No associations were found between illness and weight or height increments. Developmental tests Age. Scrutiny of percentage passes at any given age indicates that the Denver test seems to run out of 'difficult' items for survey children aged 5 and to some extent at age 4. For example, 11 out of 25 items were passed by more than 75% of children at age 4, and so were 10 out of 13 available items at age 5. Scores at ages 4 and 5 are therefore of dubious value and will not be described here. Correlations of total test scores for the same individuals at different ages decreased with the distance between pairs of ages, as would be expected. For example, coefficients of correlation between the score at 1-5 years and other ages were: at 0-5 years, 0-40; at 2 years, 0-61; and at 3 years, 0-31. For sectors of the tests, correlations were smaller, since the numbers of test items were small and their emphasis changed with age. For example, language items at early ages were concerned with the ability to produce and td some extent recognize sounds in association with everyday objects, while items at later ages were concerned with ability to recognize sounds with a definite meaning, comprehension and recognition and use of simple grammatical rules. Satisfactory development of early skills need not imply good development of the operational ability to use them later. There was, indeed, a striking lack of correlation between test results in the early and later periods which, taken in conjunction with social class differences (see below), may indicate differences of tuition and opportunity rather than intrinsic differences of ability. Sex. At all ages, girls scored more highly than boys (irrespective of social class); for example, the average scores for girls and boys, respectively, were 102-2 and 98-8 at 1 year and 104-0 and 96-7 at 3 years. It seems possible that sex differences, which have been noted previously (Bayley, 1970) are produced by the selection of test items available at a given age and by 'conditioning' rather than by true differences in ability. For example, the general sex difference noted above is reversed (but not significantly) for gross motor development at age 1-5-2-0 years, when the test items include 'throws a ball overhead', 'pedals a tricycle' and 'balances on one foot', while girls are significantly ahead of boys in personal/social items at ages 1-5-3-0 years when the test items included 'imitates housework' and 'helps in the house'. The two observers did not think that girls were more amenable to testing than boys. Social class. Table 6 gives scores for language items, items other than language and for total test results, for children of manual and non-manual social classes. For language, non-manual children were significantly superior to manual children at all

Health, growth and development of young children

421

Table 6. Comparisons of test scoresf by social class of families Test items Other than language

Language

All

Age at test (years)

NMt



NM$



NMt



0-5 10 1-5 20 30

— (34) 98-9 (33) 104-4 (37)** 106-9 (36)** 108-2 (42)**

— (33) 101-3 (34) 95-4 (36) 93-4 (37) 93-7(53)

97-3 101-4 100-3 102-9

102-5 98-5 99-7 97-7

98-5 97-6 102-8 103-6* 105-5**

101-4 102-4 97-0 96-6 95-7

•/»< 0-05; **P< 0-01. t SD = 15 throughout. t Non-manual. § Manual.

ages above 1 year (and this is also true of results at 4 and 5 years). It is of interest that comprehension and grammar start being incorporated into the language section of the test from 1-5 years. Although the numbers become very small the language score differences hold for boys and girls separately. There was no consistent or significant social class difference in results from test sections other than language. At the age of 0-5 years the total test results for girls in the manual group were higher, though not significantly, than those for non-manual girls; there was no such difference for boys. At 6 months the range of language items is too small to allow subdivision (see Table 6). Size of family. Only children and those with sibs at least 5 years older had significantly higher scores in language at all ages than children with sibs of nearer age. This difference is present within social classes, and is much more pronounced in the manual than the non-manual class. With items other than language, only children (having no sibs) scored more highly during the first year of life, but not later. This difference, too, appears within social classes, and appears to be greater in the manual class. Physical growth. The data, examined cross-sectionally and longitudinally, show no evidence of any associations between developmental test scores and growth in height, weight or head circumference.

Discussion One hundred and forty young children were followed monthly for periods of up to 4 years or until each child attained 5 years of age. The socioeconomic range of the families extended from affluence to moderately severe poverty. Good medical services were available to all and, with few exceptions, housing conditions were at least adequate.

422

H. M. Fellowes et al.

Average growth rates (previously shown to be related to the energy intakes from diets; Black et al., 1976) corresponded to relevant British standards. Height for age (but not weight) showed a gradient with socioeconomic status, but this was not statistically significant; nor was there evidence of any significant association of growth with maternal efficiency scores, number of sibs or place in family. There were no seasonal variations in growth increments. The monthly incidence of significant respiratory illness was about 22%, higher in winter than in summer. Gastro-intestinal illnesses affected about 7%, without seasonal variations. Illnesses of other types occurred in about 12% of children per month. Illness was reported more frequently in non-manual than in manual families, but the proportion in which a doctor was consulted, and the proportion in which antibiotics were prescribed, was higher in the manual group. No evidence was found of any consistent or significant association between duration and severity of illness and weight or height for age, or growth increments. This strengthens the view that differences of growth in groups of presumably similar genetic constitution were determined mainly by nutritional influences (Black et al., 1976). Such a conclusion agrees with that reached by Miller et al. (1960) in their report on Newcastle upon Tyne children born in 1947. Those children suffered from more varied and probably more severe illnesses than those born a generation later, and they certainly received less treatment with antibiotics. Miller et al. (1960) found a significant decrease in mean height at age 3 years in 27 (out of 614) children with severe respiratory diseases, but the latter were associated with particularly adverse environmental conditions. "Therefore... the most likely common factor is inadequate nutrition'. It has been shown elsewhere (Department of Health and Social Security, 1975; Black et al, 1976) that under more recent conditions the energy intake of pre-school children is correlated with weight-for-age and growth in weight. This may be interpreted as evidence that the growth of some children is impaired by inadequate food intake. If so, however, it is not due to poverty, since the data of Black et al. (1976), confirmed in a national sample by the Department of Health and Social Security (1975), show an inverse association between energy intake and socioeconomic status. Growth rates became stable after 1-5-2-0 years of age, so that most children then remained in the same growth channel. Between birth and 0-5 years of age, changes of channel were frequent. Our dietary data do not permit a detailed examination of possible nutritional causes of these phenomena. Bayley (1970) and Honzik (1976) have drawn attention to difficulties in testing the development of very young children. As already noted, the tests used in this study were devised for screening purposes and a continuous scale was imposed on the evaluation of results in order to compare them with growth and other variables. This may or may not be wholly justifiable. In developmental tests, girls tended to score more highly than boys, and nonmanual children were clearly superior to manual in tests of language at all ages. Superiority in language also appeared in children with sibs at least 5 years older. No evidence was found of any association between rates of growth and achievement in developmental tests. It seems likely that levels of achievement are determined mainly by social interactions and training within families, rather than

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Health, growth and development of pre-school children in Newcastle Upon Tyne.

J.biosoc.Sci. (1979) 11,411-424 HEALTH, GROWTH AND DEVELOPMENT OF PRESCHOOL CHILDREN IN NEWCASTLE UPON TYNE H. MARY FELLOWES, CATHERINE A. HYTTEN, W...
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