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to be satisfactory unless there is excess of proteids and fats over the starchy food. Judged by this
standard most diets supplied by public funds are probably wanting in value for the children, however
useful they might be as a single meal for a normal individual.
Dr. L. Haden Guest in discussing the question of feeding of children found the same difficulties
of assessment. He suggests, in judging of whether a child requires to be specially fed at school, that
two standards (i.) the social circumstances of the parents, and (ii.) the physiological condition of the
child must both be used, but notes that in children in obvious need of feeding from their physiological
appearance the parents circumstances were often good and vice versa.
Malnutrition in school children may arise from a formidable list of causes, chief among which are :
1. Insufficient building up of the tissues due to deficiency of food either in quantity or in
quality (improper food); it may be due to want of assimilation from bad teeth, hurried meals,
indigestible food, or excess of liquid with meals, particularly alcoholic liquids or strong tea
or coffee. Smoking may come in. Or there may be defects in the lymphatic system, particularly
sub-acute or chronic tubercular conditions. There may be deficiency in oxidation,
from the quality of the air breathed (although probably the results of this are very indirect)
from actual deficiency of air entering the lungs owing to nasal obstruction or adenoids, or
to defects of the chest (rickets, bad postures, tight clothing) ; or there may be defective oxidation
from circulatory defect in the blood, from mechanical defect of the heart, from anaemia,
or of the lymph stagnating from want of exercise.
2. Excessive breaking down of the tissues may occur in many nervous conditions,
particularly in the irritable and neurotic children who fail to get sufficient sleep, or are constantly
irritated by vermin ; after febrile illnesses, or due to actual overwork and the effects of
chronic fatigue. Late hours are probably a very powerful factor.
3. There are also conditions of arrested or delayed development of a congenital nature.
When a child is handled in school many of these causes are suspected, and it is difficult to apportion
their effects. Enquiries are very difficult, as generally neither the children nor their parents seem capable
of giving accurate and definite statements about such matters as health or feeding. It seems quite
impossible to distinguish between bad feeding, improper feeding and bad home conditions, in the cases
where there is nothing organically wrong with the children. Removal for the greater part of the waking
hours to a fresh environment, as in the open-air schools has an undoubted benefit to most, but in the
children examined and classed as badly nourished the medical inspectors have always refrained from
assigning deficiency of food as the main cause. The girls seemed to show the effects of want most.
During the first half of June, 1908, over 10,000 children were medically examined in accordance
with the following scheme:—
To inspect the children in the schools named paying particular attention to their nutrition and the prevalence
of anaemia. It will be sufficient to return them for:—
Nutrition as— Anæmia as—
Excellent (1) Normal N.
Very good (2) Pale P.
Good (3) Very Pale V.P.
Fair (4)
Bad (5)
In cases of children who are marked (5) you might make an attempt to ascertain whether their want of nutrition
is due to underfeeding; other home conditions (e.g., want of sleep); or the results of ill-health from various
diseases.
Average samples should be taken from each department (boys, girls, and infants), preferably taking whole
classes.
These children were definitely classed as regards nutrition, and the presence or absence of anæmia.
There are no definite standards, and in the classification it was evident that the personal equation of
the examiner played considerable part, but at the same time the total result may be taken as representing
a fair average judgment.

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