386 NUTRITION REVIEWS [November

MATERNAL NUTRITION AS RELATED TO PREGNANCY AND FETAL DEVELOPMENT

The effect of maternal nutrition on the course of pregnancy and labor has received considerable emphasis during recent months (iyutrition Reviews 1, 276 (19.49)). Atten- tion has been given to the relationship of cliet to the occurrence of polyneuritis, the frequency of anemia during pregnancy, and the character of labor. There has been less adequate analysis of the effects of maternal nutrition on the health of the fetus even though Hart, McCollum, Steenbock, and Humphrey (Res. Bull. no. 17, TVis. Agr. Exp. Sta. (1911)) many years ago pointed out that the diet of heifers seriously affected the viability and vigor of calves, and Warkany (Nutrition Reviews 1, 207 (1943)) more recently has demonstrated that the diet fed to breeding female rats influenced the incidence of congenital abnormalities in their offspring. Of great interest, therefore, is the report by Burke, Beal, Kirkwood, and Stuart (Am. J . Obst. Gyn. 46, 38 (1943)) of a long study of the effect of maternal nutrition on fetal development and infant health as well as on the complications of pregnancy.

The women selected for the investigation were patients in the prenatal clinics of the Boston Lying-in Hospital. They were ex- amined at frequent intervals throughout pregnancy and careful dietary analyses were made. Diets were called optimal if they provided daily 2600 to 2800 calories, 85 to 100 g. of protein, 1.5 g. calcium, 2.0 g. phos- phorus, 20 mg. iron, 8000 I.U. vitamin A, 2.0 mg. thiamine, 2.5 mg. riboflavin, 18 mg. niacin, 100 mg. ascorbic acid, and 400 to 800 I.U. vitamin D. A rating of “excellent” was assigned to those diets which contained these “optimal” amounts of foodstuff, “good” if they had 80 per cent or more, “fair” if they contained GO per cent to less than 80 per cent, “poor” if they provided less than 60 per cent, and “very poor” if they contained less than 50 per cent. The observations re- ported were obtained on 216 women and

their infants. The majority of the families represented had weekly incomes of $25 to $40. About 70 per cent of the women were under the age of 30 years.

A statistically significant relationship was found to exist between the adequacy of the maternal diet and the course of pregnancy. Of the women with “good” or “excellent” diets, 68 per cent had a normal prenatal course, while of the women with “poor” to “very poor” diets, only 42 per cent had a normal prenatal course. Furthermore, no instance of preeclampsia occurred in those women whose diets were “good” or “excel- lent,” but almost 50 per cent of the mothers whose diets were “poor” to “very poor” had toxemia. No statistically valid correlation could be made between the nutritional ade- quacy of diets consumed and length and char- acter of labor or the over-all complications of labor and delivery. Mothers whose diets were “poor” to “very poor” tended to have more difficult types of labor and more major complications a t deIivery despite the fact that they had, on the average, smaller in- fants than mere born to the women in the “good” or “excellent” diet group. There was a tendency for a relationship to exist between prenatal nutrition and major com- plications of the postpartum period, but the relationship was not definite or distinct.

The influence of maternal diet on the condition of the infants was striking. Mothers whose nutrition was “good” or “excellent” gave birt,h to children with pediatric ratings as follows: 42 per cent

superior,” 55 per cent with one or two minor physical defects, and 3 per cent with congenital defects. On the other hand, infants born of mothers on “poor” to “very poor” diets were rated: 2.5 per cent “su- perior,” 2.5 per cent with one minor physical defect, 28 per cent in fair or poor general condition, and 67 per cent in “poorest” condition. This latter group consisted of

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infants who n-ere stillborn, who died within a few hours or days, had marked congenital malformations a t birth, were premature (under 5 pounds a t birth), or were “func- tionally immature.” The size of the infants was equally striking. Those born of mothers with the best diets had an average weight of 8 pounds 8 ounces and an average length of 20.4 inches; those born of mothers with inadequate diets averaged only 5 pounds 13 ounces in weight and 18.6 inches in length. In only one instance did a mother whose nutrition was good give birth to an infant in poor physical condition.

This correlation was made on the basis of maternal nutrition as related to the condition of the infant. If the process is reversed and the condition of the infant a t birth is cor- related with the adequacy of the maternal diet, the results are equally convincing. The “superior” infants were produced by mothers whose diets had the following per- centage distribution: “good” or “excellent” 56, “fair” 35, and “poorf7 to “very poor” 9. In contrast, when the condition of the “poorest” infants was studied in relation to

the prenatal nutrition, it n-as found that 79 per cent of the mothers had diets which were rated as “poor” to “very poor,” 18 per cent had “fair, ”and only 3 per cent had ‘(good” or “excellent” diets.

From these results i t appears that poor nutrition during pregnancy affects the fetus more profoundly than it does the maternal organism. This is contrary to the usual obstetric teaching, and should certainly give both direction and impetus to the prenatal health program now spreading throughout the nation. The author\ state that the physical status of the women during preg- nancy was evaluated and, qince the study was painstakingly done, it is probably safe to assume that women selected for the investi- gation suffered no evident impairnient of health other than the conditions listed. The critical reader, hon-ever, would like to have had additional data in regard to the nutri- tional status of the women during pregnancy, namely hemoglobin and re11 blood cell counts, serum proteins, and plasma ascorbic acid, which might have added to the validity of the dietary histories.

HISTOPATHOLOGY OF SKIN IN AVITAMINOSIS A

Frazier and Hu (Arch. In2. Med. 48, 507 (1931)) described cutaneous lesions in pa- tients they observed in China which they attributed to vitamin A deficiency. Later Rao in India (Indian J . M e d . Res. 26,39 (1937)) recorded similar observations and conclusions. The most characteristic fea- ture of the lesions was the formation of keratotic plugs in Dhe hair follicles, with a rough dry skin resulting; hence such titles as phrynoderma, “toad skin” and “nutmeg grater skin.” However, i t has been dif- ficult to accept the conclusions which the authors drew because the diets of the sub- jects of these reports were deficient in more than one respect. Furthermore, little had been reported experimentally which could support these observations in man. Wol-

bach and Howe ( J . Exp. X e d . 42,753 (19.25)) reported slight, although demonstrable atrophy of hair follicles and sebaceous glands in association n-ith vitamin A deficiency, but they didnot observe distended keratinized follicles. Portmnn (Actn path. et microbiol. Xcandinuo. 4, 341 (1927)) described the loss of subcutaneous fatty tissue and a reduction in the total number of hair follicles present.

In what appears to be a cnreful systematic study in rats, A‘Ioult ( A y c l i . Dermat. Xyplz. 47, 768 (1943)) has presented experimental evidence which gives support to the obser- vations made in man. The rats, obtained at weaning, were fed a diet consisting of coconut cake meal, 30 per cent; flaked rice, 38 per cent; casein (ashless, estracted),