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Eggs are a rich source of multiple nutrients that support child growth and development. Provision of eggs as a complementary food may improve dietary adequacy among young children at risk for undernutrition. Our objective was to test the impact of an egg intervention on the adequacy of total nutrient intakes and micronutrient density among 6‐ to 15‐month‐old Malawian children. Children 6 to 9 months old, living in Mangochi District, Malawi, were randomly assigned to the intervention group (n = 331) receiving an egg per day or a control group (n = 329) consuming their usual diet. Dietary intakes of macronutrients, vitamins and minerals were assessed using 24‐h recalls at baseline, 3‐month midline and 6‐month endline, with repeat recalls in a subsample. Usual nutrient intake and micronutrient density distributions were modelled to estimate group means and prevalence of inadequacy. Group differences at midline and endline were tested using unequal variance t tests with bootstrapped standard errors. The egg intervention resulted in higher intakes of fat and protein and lower intakes of carbohydrates. The egg group had lower prevalence of inadequacy for selenium, vitamin A, riboflavin, vitamin B5, vitamin B12 and choline. Micronutrient density inadequacy was lower in the egg group for vitamin A and choline at midline and endline, riboflavin at midline and vitamin B5 at endline. Inadequacy of nutrient intakes or density remained highly prevalent in both groups for multiple micronutrients. Though the egg intervention increased intakes of protein and several micronutrients, total intakes and micronutrient density of multiple micronutrients remained far below recommendations.

OBJECTIVES: The purpose of the study was to assess the safety of using eggs as a nutritional intervention for stunting in infants living in a rural indigenous community in Ecuador and to further understand the prevalence of egg allergy in this population. METHODS: The Lulun Project was a randomized controlled trial conducted in a rural indigenous population in Ecuador. Infants age 6–9 months were recruited and randomly assigned to the intervention (1 egg/day; n = 80) or control (no intervention, n = 83) group. At baseline and end line, enumerators collected anthropometric, dietary intake, morbidity, and sociodemographic data along with blood samples. Symptoms of allergies were assessed, including rash, congestion, coughing or wheezing, and diarrhea. Children in the intervention group were monitored by the study team for allergy symptoms during consumption of the first study egg. All children were monitored for illness and allergy symptoms throughout the study. We used ELISA assays to determine serum anti-ovomucoid and ovalbumin IgE levels, a validated approach to identify “risk of” egg allergy. RESULTS: 131 of the children had a sufficient serum sample to be analyzed for IgE levels. Ovomucoid levels were

Complementary feeding, when foods are introduced to complement a milk-based diet, generally occurs between 6 and 23 months of age. It is a critical period for both physical and cognitive development. During this period, the growth rate of the brain is one of the fastest during the life span and, consequently, the timing, dose, and duration of exposure to specific nutrients can result in both positive and negative effects. Complementary feeding is more than ensuring an adequate intake of nutrients; it also is about avoiding excess intakes of calories, salt, sugars, and unhealthy fats. Meals are cultural and social events where young children observe, imitate, learn about foods to like or dislike, and form lifelong eating habits and practices. Meals are also when a child learns to touch foods and connect food tastes to how foods look and feel. Ideally, complementary feeding is responsive and promotes child autonomy, but it can also be used to manage behavior problems or overly indulge a child, resulting in long-term consequences for nutrition and health. Therefore, in addition to what a child is fed, attention to how a child is fed is also important. In this review, 12 topics relevant for updating global guidance on complementary feeding were identified: age of introduction of complementary foods; continued breastfeeding; responsive feeding; safe preparation and storage of complementary foods; food textures, flavors, and acceptance; energy and meal and snack frequency; fats, protein, and carbohydrates; dietary diversity; milks other than breast milk; fluid needs; unhealthy foods and beverages; and use of vitamin and mineral supplements or supplementary foods.

Background In low- and middle-income countries (LMICs), low levels of formal maternal educational are positively associated with breastfeeding whereas the reverse is true among women with higher levels of formal education. As such, breastfeeding has helped to reduce health equity gaps between rich and poor children. Our paper examines trends in breastfeeding and formula consumption by maternal educational in LMICs over nearly two decades. Methods We used 319 nationally representative surveys from 81 countries. We used WHO definitions for breastfeeding indicators and categorized maternal education into three categories: none, primary, and secondary or higher. We grouped countries according to the World Bank income groups and UNICEF regions classifications. The trend analyses were performed through multilevel linear regression to obtain average absolute annual changes in percentage points. Results Significant increases in prevalence were observed for early initiation and exclusive breastfeeding across all education categories, but more prominently in women with no formal education for early breastfeeding and in higher level educated women for exclusive breastfeeding. Small decreases in prevalence were seen mostly for women with no formal education for continued breastfeeding at 1 and 2 years. Among formula indicators, only formula consumption between 6 and 23 months decreased significantly over the period for women with primary education. Analysis by world regions demonstrated that gains in early and exclusive breastfeeding were almost universally distributed among education categories, except in the Middle East and North Africa where they decreased throughout education categories. Continued breastfeeding at 1 and 2 years increased in South Asia, Latin America and the Caribbean, and Eastern Europe and Central Asia for primary or higher education categories. Declines occurred for the group of no formal education in South Asia and nearly all education categories in the Middle East and North Africa with a decline steeper for continued breastfeeding at 2 years. With a few exceptions, the use of formula is higher among children of women at the highest education level in all regions. Conclusions Over the course of our study, women with no formal education have worsening breastfeeding indicators compared to women with primary and secondary or higher education.

Author(s): Prado, Elizabeth L; Maleta, Kenneth; Caswell, Bess L; George, Matthews; Oakes, Lisa M; DeBolt, Michaela C; Bragg, Megan G; Arnold, Charles D; Iannotti, Lora L; Lutter, Chessa K; Stewart, Christine P | Abstract: BACKGROUND:Eggs are a rich source of nutrients important for brain development, including choline, riboflavin, vitamins B-6 and B-12, folate, zinc, protein, and DHA. OBJECTIVE:Our objective was to evaluate the effect of the consumption of 1 egg per day over a 6-mo period on child development. METHODS:In the Mazira Project randomized controlled trial, 660 children aged 6-9 mo were randomly allocated into an intervention or control group. Eggs were provided to intervention households during twice-weekly home visits for 6 mo. Control households were visited at the same frequency. At enrollment, blinded assessors administered the Malawi Developmental Assessment Tool (MDAT), and 2 eye-tracking tasks using a Tobii-Pro X2-60 eye tracker: a visual paired comparison memory task and an Infant Orienting with Attention task. At endline, 6-mo later, blinded assessors administered the MDAT and eye-tracking tasks plus an additional elicited imitation memory task. RESULTS:At endline, intervention and control groups did not significantly differ in any developmental score, with the exception that a smaller percentage of children were delayed in fine motor development in the intervention group (10.6%) compared with the control group (16.5%; prevalence ratio: 0.59, 95% CI: 0.38-0.91). Among 10 prespecified effect modifiers for the 8 primary developmental outcomes, we found 7 significant interactions demonstrating a consistent pattern that children who were less vulnerable, for example, those with higher household wealth and maternal education, showed positive effects of the intervention. Given multiple hypothesis testing, some findings may have been due to chance. CONCLUSION:The provision of 1 egg per day had no overall effect on child development in this population of children, however, some benefits may be seen among children in less vulnerable circumstances. This trial was registered at clinicaltrials.gov as NCT03385252.

OBJECTIVES: Adequate protein quantity and quality are necessary for child health, growth and development, but may be lacking in complementary feeding diets with limited variety and few animal source foods. We assessed the impact of an egg feeding intervention on protein quality and quantity among rural Malawian children aged 9 to 15 months. METHODS: We enrolled 660 children into a 6-month trial to test the effect of eggs on child growth. Children were randomly assigned to the egg group (n = 331), who received one egg per day, or the control group (n = 329). Dietary intake data were collected at 3-month midline (9–12 months old) and 6-month endline visits (12–15 months old) by 24-hour recall interview with the primary caregiver. Repeat recalls were collected in a subsample at each timepoint. Crude protein intakes were calculated using local recipe and food composition tables. Breast milk intake was estimated as the difference between the estimated energy requirement and energy intake from complementary diet. Protein intakes were adjusted using the Digestible Indispensible Amino Acid Score (DIAAS), which weighs crude amino acid intakes against amino acid requirements. Treatment group differences in DIAAS were tested with ANCOVA. Group differences in adjusted total protein intakes from complementary diet and breastfeeding were tested using the National Cancer Institute method for estimating usual mean intakes with bootstrap standard errors. Adequacy was assessed using World Health Organization protein requirements. RESULTS: The egg intervention improved protein quality of the complementary feeding diet (DIAAS of 79 egg v 61 control at midline, 86 v 72 at endline, P 0.05). CONCLUSIONS: The egg intervention increased quantity and quality of protein intakes among young Malawian children, though protein inadequacy was uncommon. FUNDING SOURCES: The Bill and Melinda Gates Foundation.

The Lulun Project, a randomized controlled trial conducted in 2015, found that one egg per day for 6 months during early complementary feeding reduced stunting by 47% and increased linear growth by 0.63 length‐for‐age Z (LAZ). This follow‐up cohort study (Lulun Project II) aimed to test whether the growth effect remained in the egg intervention group compared with the control group after approximately 2 years. Mothers or caregivers from the Lulun Project were recontacted and recruited for this study. Enumerators collected data on socio‐economic and demographic factors, 24‐hr frequency of dietary intakes, morbidities, and anthropometric measures of height, weight, and head circumference using World Health Organization protocols. Statistical analyses followed the same analytical plan as Lulun Project, applying generalized linear models and regression modelling to test group differences in height‐for‐age z (HAZ) from LAZ at Lulun Project endline, and structural equation modelling for mediation. One hundred thirty‐five mother–child dyads were included in Lulun II, with 11% losses to follow‐up from endline Lulun Project. Growth faltering across all children was evident with HAZ −2.07 ± 0.91 and a stunting prevelance of 50%. Regression modelling showed no difference between egg and control groups for the HAZ outcome and other anthropometric outcomes, and significant declines in HAZ from endline Lulun Project in the egg intervention are compared with control groups. Current dietary egg intake, however, was associated with reduced growth faltering in HAZ from Lulun Project endline to Lulun Project II, independent of group assignment and through mediation, explaining 8.8% of the total effect. Findings suggest the need for a longer intervention period and ongoing nutrition support to young children during early childhood.

Background: Food-based interventions can reduce the prevalence of undernutrition and improve household food security, but nutritious and accessible foods may be underutilized. In Ecuador, eggs are inexpensive and widely available, but while they are a valuable source of essential nutrients for infants and young children, medical advice and community-based information have limited their inclusion in infants' diets. Objective: A qualitative component was conducted to understand local perceptions, knowledge, and practices to complement a randomized control trial that studied the effect of introducing eggs on nutritional status and growth in infants from 6 to 9 months in rural communities in the highland province of Cotopaxi, Ecuador. Methods: The qualitative inquiry consisted of key informant interviews, focus group discussions (FGDs), and structured observations in order to understand perceptions, knowledge, and practices related to household egg consumption and to the introduction of eggs in infants’ diets. Results: The two principal findings were that: (i) eggs are an available and culturally acceptable food source although they are not always a part of the diet; and (ii) perceptions and practices related to household consumption and the introduction of eggs into the diet of infants are shaped by local knowledge and practices, which are shaped by biomedical information and advice provided by public health professionals. Conclusion: Through an effective food-based intervention that includes qualitative research and a social marketing component, the behaviors of mothers and other caregivers can be modified, enabling children to realize the nutritional advantages of early introduction of eggs into their diet.

OBJECTIVES: Young children with complementary feeding diets that lack diversity and have low micronutrient density are at risk of iron deficiency anemia. Our objectives were to determine the impact of supplementing diets with 1 egg/day on: (1) plasma ferritin, soluble transferrin receptor (sTfR), and hemoglobin (Hb) concentrations; and (2) the prevalence of iron deficiency (ID), anemia, and iron deficiency anemia (IDA). METHODS: Children age 6–9mo in the Mangochi District of Malawi were individually randomized to receive 1 egg/day for 6mo (n = 331) or continue their usual diet (n = 329). Venous blood samples were collected at enrollment and a 6mo follow-up by assessors masked to group assignment. Plasma ferritin, sTfR, c-reactive protein (CRP), and α1-acid glycoprotein (AGP) were assessed using ELISA and hemoglobin was measured using Hemocue analyzers. Ferritin and sTfR were corrected for inflammation using CRP and AGP in linear regression models. Ferritin, sTfR, and hemoglobin concentrations were compared between groups using linear regression models, adjusting for baseline values. The prevalence ratios (PR) of ID (fer 8.3mg/L, or total body iron

Author(s): Stewart, Christine P; Caswell, Bess; Iannotti, Lora; Lutter, Chessa; Arnold, Charles D; Chipatala, Raphael; Prado, Elizabeth L; Maleta, Kenneth | Abstract: BackgroundStunted growth is a significant public health problem in many low-income countries.ObjectiveThe aim of this study was to evaluate the impact of 1 egg per day on child growth in rural Malawi.DesignWe conducted an individually randomized controlled trial in which 660 children aged 6-9 mo were equally allocated into an intervention (1 egg/d) or control group. Eggs were provided during twice-weekly home visits for 6 mo. Control households were visited at the same frequency. Assessors blinded to intervention group measured length, weight, head circumference, and midupper arm circumference at baseline and the 6-mo follow-up visit. To assess adherence, multipass 24-h dietary recalls were administered at baseline, 3-mo, and 6-mo visits.ResultsBetween February and July 2018, 660 children were randomly assigned into the intervention (n = 331) and control (n = 329) groups. Losses to follow-up totaled 10%. In the intervention group, egg consumption increased from 3.9% at baseline to 84.5% and 70.3% at the 3-mo and 6-mo visits, whereas in the control group, it remained below 8% at all study visits. The baseline prevalence of stunting was 14%, underweight was 8%, and wasting was 1% and did not differ by group. There was no intervention effect on length-for-age, weight-for-age, or weight-for-length z scores. There was a significantly higher head circumference for age z score of 0.18 (95% CI: 0.01, 0.34) in the egg group compared with the control group. There was a significant interaction with maternal education (P = 0.024), with an effect on length-for-age z score only among children whose mothers had higher education.ConclusionsThe provision of 1 egg per day to children in rural Malawi had no overall effect on linear growth. A background diet rich in animal source foods and low prevalence of stunting at baseline may have limited the potential impact. This trial was registered at clinicaltrials.gov as NCT03385252.

OBJECTIVES: Eggs are nutrient-rich and have the potential to improve maternal nutrition during pregnancy and birth outcomes, but cultural beliefs may inhibit consumption during pregnancy. This study sought to understand pregnant women's and key influencers’ knowledge, attitudes, beliefs, and practices as well as facilitators and barriers related to consuming eggs during pregnancy in Kenya. METHODS: The study was conducted in an urban (Nairobi) and rural (Kiambu) area, had 3 phases and primarily used mixed qualitative methods to triangulate data. Phase I included in-depth interviews, 24-hour dietary recall, and free-listing and pile-sorting exercises with pregnant women (n = 36), husbands (n = 12) and mothers-in-law (n = 12) of pregnant women, and health workers (n = 24). Phase II involved egg preparation exercises with pregnant women (n = 39). Phase III involved a week-long trial of egg consumption with pregnant women (n = 24). We used thematic content analysis methods to analyze qualitative data and tabulated quantitative data. RESULTS: All participants recognized eggs as nutritious for pregnant women and their unborn children, though only 25% of pregnant women consumed eggs the previous day. Participants believed eating too many eggs during pregnancy (1 or more eggs daily) leads to a large baby and complications during delivery. Unaffordability and unavailability of eggs also inhibit consumption. Health workers are the most trusted source of information on maternal nutrition, while other pregnant and nonpregnant women in the community were cited as those who most often discourage egg consumption. Fried and boiled eggs are the most common and preferred preparation methods due to ease and limited number of ingredients. Almost all women complied with the household trial, said they would continue eating eggs during pregnancy, and would recommend consuming eggs in moderation to other pregnant women. CONCLUSIONS: Although participants believed consuming eggs during pregnancy is beneficial, cultural norms, practices, and beliefs may prevent pregnant women from eating them daily. Interpersonal communication from health workers and agricultural policies to promote affordability could lead to increased consumption, which in turn could have potential positive impacts on maternal nutrition and birth outcomes. FUNDING SOURCES: RTI International.

Here, we analyzed four population-based demographic and health surveys conducted in Bolivia between 1998 and 2016 to understand trends in anemia in children from 6 to 59 months of age by selected sociodemographic characteristics and three categories of altitude: low, medium, and high. Over the 18-year period, the prevalence of anemia was virtually unchanged while that in children living at high altitude increased. Anemia in children living at all three altitude categories is more than 40% and a severe public health problem according to the World Health Organization. We did not identify a single consistent risk factor for anemia in children living at high altitude compared with those living at medium or low altitude. The most consistent characteristic associated with childhood anemia across the three altitude categories was diarrhea in the last 2 weeks. Low length/height for age, an adolescent or anemic mother, a mother with no or little education, and a mother who speaks Quechua or Aymara were also risk factors. We conclude that it is necessary to review anemia policies and programs and prioritize children who are at greatest risk of developing anemia, particularly those living at high altitude. As iron deficiency appears to explain only a small part of childhood anemia, there is also a need to better understand its other causes and develop appropriate interventions.

BACKGROUND: Adequate nutrients early in life promote cognitive development and are critical for proper growth and functioning. The effect of individual nutrients consumed through food is often not the same as consuming the same nutrients in supplementary form due to 'food synergy', the biological and chemical interrelations that occur between nutrients. Animal‐source foods, such as eggs, meat, fish, and dairy, are energy dense and contain multiple micronutrients and essential fatty acids with high bioavailability. The benefits of animal‐source foods may include higher food synergy relative to fortified foods as well as decreasing dependence on external suppliers of fortified foods. OBJECTIVES: To assess the effectiveness of animal‐source foods compared to any other feeding interventions or no intervention in improving growth and developmental outcomes in children aged 6 to 59 months. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, CINAHL, 18 other databases, and three trials registers up to August 2018. We also contacted authors and known experts in the field for assistance in identifying ongoing or unpublished data, and searched the reference lists of included studies and reviews, and websites of relevant organizations, for other studies that may not have been captured by our electronic searches. SELECTION CRITERIA: We included randomized controlled trials and quasi‐randomized controlled trials of any duration, where children between 5 months and 59 months (6 years) of age were provided with an animal‐source food (e.g. consumption of milk, meat, or eggs), prepared with any cooking method, compared with any intervention or no intervention. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trial eligibility using prespecified criteria, extracted data, assessed risk of bias, and graded the quality of the evidence using the GRADE approach. MAIN RESULTS: Study characteristics We included 6 studies that analyzed data from 3036 children aged 5 to 50 months. The studies were conducted in China, the Democratic Republic of Congo, Ecuador, Guatemala, Pakistan, the USA, and Zambia, and lasted between 5 and 12 months. Three studies were funded, in part, by government entities; one study was supported by a nonprofit organization. Two studies did not report a funding source. Three studies compared the effects of feeding an animal‐source food with a fortified (iron or iron and zinc), or unfortified cereal; two used a control group with no intervention; one compared a meat‐based diet to a dairy‐based diet. The types of animal‐source foods tested included yogurt, eggs, cheese, lyophilized (freeze‐dried) beef product, ground and frozen pork, puréed and jarred beef with gravy or pork, and powdered whey protein. We judged four studies to be at unclear risk of bias overall; three studies because they were funded by an industry with a plausible interest in the outcome of the intervention; and one study because there was insufficient information to assess five of the seven bias 'Risk of bias' domains. We judged two of the six studies to be at high risk of bias overall; one study because there was significant baseline imbalance in length‐for‐age z scores (LAZ) between groups and evidence of selective reporting; the other study because there there was both a significant baseline imbalance in LAZ and weight‐for‐age z scores (WAZ) between groups, and a large‐scale social media campaign that may have influenced care received at home in the control group. Key results Animal‐source foods versus cereal‐based foods or no intervention Five studies (2972 children) measured change in linear growth with either height‐for‐age z scores (HAZ) or LAZ. Three studies (592 children) reported a significant increase in HAZ and LAZ in the intervention group compared to the control group. Two studies (2380 children) reported a decline in LAZ in both groups. In one study (1062 children) there was no difference between the groups in the rate of decline; in the other (1318 children) the decrease in LAZ was significantly smaller in the intervention group. Five studies (2972 children) measured weight gain using WAZ. Three studies (592 children) reported a significant increase in WAZ in the intervention group compared to the control group. In two studies (2380 children), WAZ decreased in both groups. In one of these studies (1318 children), the decrease in the intervention group was significantly smaller than in the control group. In the other study (1062 children), there was no difference between the groups. Three studies (1612 children) reported impacts on all‐cause morbidity, but metrics were inconsistent between studies. One study with yogurt (402 children) reported a significant reduction in duration and incidence of diarrhea and upper respiratory infections in the intervention group. One study with eggs (148 children) reported a significant increase in the incidence of diarrhea in the intervention group, but this may have been due to cultural associations with eggs and gastrointestional problems. There were no other significant differences in fever, respiratory infections, or skin conditions between groups. The third study (1062 children) found no differences between intervention and control groups across morbidity measures. No studies reported data on anemia. Meat‐based diet versus dairy‐based diet One study (64 children) measured change in LAZ and WAZ in infants fed either a meat‐based diet or dairy‐based diet. There was a significant increase in LAZ among infants consuming the meat‐based diet and a significant decrease in LAZ among infants consuming a dairy‐based diet. WAZ increased in both groups, with no significant difference between groups. The study did not assess all‐cause morbidity or anemia. Quality of the evidence We rated the quality of the evidence as very low overall due to baseline imbalances between intervention and control groups, high heterogeneity in meta‐analysis, and imprecision due to wide confidence intervals and inconsistent direction of effects. We have little confidence in the results; further research is likely to change the estimate of magnitude and direction of treatment effect. AUTHORS' CONCLUSIONS: Given the limited quality of the evidence, we are uncertain of the effects of the provision of animal‐source food versus cereal products or no intervention on the growth or development of children. More adequately powered trials with deliberately selected animal‐source foods are needed.

OBJECTIVES: Complementary feeding diets in low- and middle-income countries are usually inadequate to meet requirements for healthy growth and development. Food-based interventions may prevent nutrient inadequacies provided they do not replace other nutrient-rich foods. They may also be more sustainable than manufactured food supplements. We describe the contribution of daily egg supplementation to usual energy intake, usual energy intake by food group, and minimum dietary diversity of rural Malawian infants and young children. METHODS: We conducted a randomized controlled trial in rural Malawi in which 660 children aged 6 to 9 months were randomly allocated to receive an egg a day for 6 months or to a control group. Dietary intake of foods and drinks was assessed at baseline, 3-month midline, and 6-month endline visits using a tablet-based mulitpass 24-hour recall. Up to two repeat recalls were collected at each timepoint in a subsample of 100 children per intervention group. RESULTS: The intervention resulted in an increased usual energy intake in the intervention group of 30 kcal at midline (P = 0.128) and 36 kcal at endline (P = 0.087). It also resulted in a 7 kcal displacement of legumes and nuts in children at endline (P = 0.059). At midline and endline, usual energy intake from eggs was about 30 kcal higher in the egg group compared to controls (P

The Lulun Project incorporated a social marketing strategy that accompanied a randomized controlled trial (RCT) of a food-based intervention that introduced eggs into the complementary feeding diet of Ecuadorian infants. This strategy was designed to promote behaviour change, in this case, egg consumption, through voluntary prosocial behaviour, empowerment, and brand loyalty. A three-phase social marketing strategy (design, campaigns, and evaluation) contributed to our successful RTC by applying techniques drawn from marketing, publicity, design, and communications. To develop the strategy, we conducted (a) market research focused on culturally based norms, values, and local expectations; (b) a situational assessment based on the four Ps of social marketing (people, product, place, and price); and (c) fostered a creative process to develop the project's brand and communication plan. The strategy combined a communication plan, brand, and activities that were implemented in four campaigns: outreach, recruitment, promotion, and closing. Our evaluation showed that the social marketing strategy was instrumental in promoting the RCT's objectives and responding to unforeseen events and community concerns regarding the RCT. The strategy resulted in high compliance, low attrition, and infant feeding policy change, including Ecuador's Ministry of Public Health new complementary feeding guidelines for introducing eggs early in complementary feeding. Use of social marketing techniques, like those in our study, could be key for scaling up this food-based intervention-or others like it-in Ecuador and beyond.

Strategies to tackle stunting, obesity, and micronutrient deficiencies must take into account the inequities in which these diseases are rooted, argue Rafael Perez-Escamilla and colleagues

This study estimated the prevalence of violations of the International Code of Marketing of Breast-milk Substitutes (BMS) and subsequent resolutions of the World Health Assembly (Code) at health facilities, points of sale (POS), and on BMS labelling and media in Mexico. We carried out a cross-sectional survey among 693 mothers with children aged less than 24 months and 48 health providers at public and private health facilities in two states of Mexico. Observational assessment at 20 POS and the health facilities was conducted as well as an analysis of labels on BMS products for sale. Women attending public and private health facilities reported receiving free BMS samples in the previous 6 months (11.1%), and about 80% reported seeing BMS promotion in the mass media. Health providers reported contact with BMS manufacturer representatives in the previous 6 months (15.5%), and only 41.6% of the health providers had knowledge of the Code. BMS promotions were identified at nearly all POS. Analysis of 190 BMS labels showed that 30% included pictures/text idealizing the use of BMS, and all labels incorporated health and nutrition claims. Violations of the Code are prevalent within the health services, POS, and labelling of BMS products. The high percentage of health providers with no knowledge of the Code calls for action at national level to better disseminate and comply with the Code. A transparent, free from commercial influence, and continual monitoring system for Code compliance is needed, including a follow-up component on sanctions for contraventions of the Code.

Evidence is mounting about the benefits of eggs for child nutrition and potential benefits for women during pregnancy and birth outcomes. Maternal consumption of eggs during lactation may also enhance the breast-milk composition of certain nutrients, thus contributing to the nutrition and potentially also to the development of breastfed children. Relative to single nutrient supplements, eggs deliver nutrients and other hormone or immune factors in compounds that may be more readily absorbed and metabolized. In addition to macronutrients, eggs contain a number of micronutrients, such as choline, that are known to have brain health promoting effects. Among children less than 2 years of age, consumption nearly universally increases with age. Large regional differences exist; the prevalence of egg consumption among African children is less than half that of most other world regions and threefold less than in Latin America and the Caribbean. Among women of reproductive age, egg consumption is strongly related to socio-economic status in a dose-response fashion with women in the lowest wealth quintile eating the fewest eggs and those in the highest wealth quintile eating the most. Cultural factors likely play a role in around consumption of eggs during pregnancy, lactation, and early childhood, though most reports are anecdotal in nature and few high-quality data exist. Well-informed social marketing and behaviour change communication strategies have led to large increases in egg consumption among young children. Economic barriers that limit access are likely to be far more important than cultural ones in explaining low consumption.

BACKGROUND: Eggs are a good source of nutrients for growth and development. We hypothesized that introducing eggs early during complementary feeding would improve child nutrition. METHODS: A randomized controlled trial was conducted in Cotopaxi Province, Ecuador, from March to December 2015. Children ages 6 to 9 months were randomly assigned to treatment (1 egg per day for 6 months [n = 83]) and control (no intervention [n = 80]) groups. Both arms received social marketing messages to encourage participation in the Lulun Project (lulun meaning “egg” in Kichwa). All households were visited once per week to monitor morbidity symptoms, distribute eggs, and monitor egg intakes (for egg group only). Baseline and end point outcome measures included anthropometry, dietary intake frequencies, and morbidity symptoms. RESULTS: Mothers or other caregivers reported no allergic reactions to the eggs. Generalized linear regression modeling showed the egg intervention increased length-for-age z score by 0.63 (95% confidence interval [CI], 0.38–0.88) and weight-for-age z score by 0.61 (95% CI, 0.45–0.77). Log-binomial models with robust Poisson indicated a reduced prevalence of stunting by 47% (prevalence ratio [PR], 0.53; 95% CI, 0.37–0.77) and underweight by 74% (PR, 0.26; 95% CI, 0.10–0.70). Children in the treatment group had higher dietary intakes of eggs (PR, 1.57; 95% CI, 1.28–1.92) and reduced intake of sugar-sweetened foods (PR, 0.71; 95% CI, 0.51–0.97) compared with control. CONCLUSIONS: The findings supported our hypothesis that early introduction of eggs significantly improved growth in young children. Generally accessible to vulnerable groups, eggs have the potential to contribute to global targets to reduce stunting.

Breastfeeding has benefits for women and children regardless of their socioeconomic status or country of residence. Although the World Health Organization (WHO) recommends that infants initiate breastfeeding within one hour of birth, are exclusively breastfed for six months and continue to breastfeed with complementary foods until two years of age or beyond, global practices are far from these recommendations. Breastfeeding improves both maternal and child health. It also promotes child cognitive development and helps them prepare for a bright future. Breastfeeding rates can be improved in a very short time through a package of evidence-based policies and programs to support women. Efforts to support breastfeeding for women who choose to do so include local, national and international policies and programs, implemented within healthcare systems, places of work, education and recreation and in communities. Breastfeeding is essential to achieving nine of the 17 Sustainable Development Goals as well as many other international health commitments.

Suboptimal complementary feeding practices contribute to a rapid increase in the prevalence of stunting in young children from age 6 months. The design of effective programmes to improve infant and young child feeding requires a sound understanding of the local situation and a systematic process for prioritizing interventions, integrating them into existing delivery platforms and monitoring their implementation and impact. The identification of adequate food-based feeding recommendations that respect locally available foods and address gaps in nutrient availability is particularly challenging. We describe two tools that are now available to strengthen infant and young child-feeding programming at national and subnational levels. ProPAN is a set of research tools that guide users through a step-by-step process for identifying problems related to young child nutrition; defining the context in which these problems occur; formulating, testing, and selecting behaviour-change recommendations and nutritional recipes; developing the interventions to promote them; and designing a monitoring and evaluation system to measure progress towards intervention goals. Optifood is a computer-based platform based on linear programming analysis to develop nutrient-adequate feeding recommendations at lowest cost, based on locally available foods with the addition of fortified products or supplements when needed, or best recommendations when the latter are not available. The tools complement each other and a case study from Peru illustrates how they have been used. The readiness of both instruments will enable partners to invest in capacity development for their use in countries and strengthen programmes to address infant and young child feeding and prevent malnutrition.

Although there are some examples of successful complementary feeding programmes to promote healthy growth and prevent stunting at the community level, to date there are few, if any, examples of successful programmes at scale. A lack of systematic process and impact evaluations on pilot projects to generate lessons learned has precluded scaling up of effective programmes. Programmes to effect positive change in nutrition rarely follow systematic planning, implementation, and evaluation (PIE) processes to enhance effectiveness over the long term. As a result a set of programme-oriented key principles to promote healthy growth remains elusive. The purpose of this paper is to fill this gap by proposing a set of principles to improve programmes and interventions to promote healthy growth and development. Identifying such principles for programme success has three requirements: rethinking traditional paradigms used to promote improved infant and young child feeding; ensuring better linkages to delivery platforms; and, improving programming. Following the PIE model for programmes and learning from experiences from four relatively large-scale programmes described in this paper, 10 key principles are identified in the areas of programme planning, programme implementation, programme evaluation, and dissemination, replication, and scaling up. Nonetheless, numerous operational research questions remain, some of which are highlighted in this paper.

The risk of stunted growth and development is affected by the context in which a child is born and grows. This includes such interdependent influences as the political economy, health and health care, education, society and culture, agriculture and food systems, water and sanitation, and the environment. Here, we briefly review how factors linked with the key sectors can contribute to healthy growth and reduced childhood stunting. Emphasis is placed on the role of agriculture/food security, especially family farming; education, particularly of girls and women; water, sanitation, and hygiene and their integration in stunting reduction strategies; social protection including cash transfers, bearing in mind that success in this regard is linked to reducing the gap between rich and poor; economic investment in stunting reduction including the work with the for-profit commercial sector balancing risks linked to marketing foods that can displace affordable and more sustainable alternatives; health with emphasis on implementing comprehensive and effective health care interventions and building the capacity of health care providers. We complete the review with examples of national and subnational multi-sectoral interventions that illustrate how critical it is for sectors to work together to reduce stunting.

A number of case studies have shown that promotion of breastfeeding (BF) coincides with improved BF and exclusive BF (EBF) practices. We quantify the relationship between BF promotion and changes in BF practices by analyzing the relationship between implementation of the WHO/UNICEF Global Strategy for Infant and Young Child Feeding as measured by the World Breastfeeding Trends Initiative (WBTi) and trends in EBF and BF duration over the past 20 y in 22 countries in Africa, Asia, the Middle East, and Latin America. The median annual increase in EBF was 1.0%/y in countries in the upper 50th percentile of WBTi scores, indicating national policies and programs most consistent with WHO/UNICEF recommendations, whereas the median increase in EBF was only 0.2%/y in countries with the lowest WBTi scores (P = 0.01). The median annual increase in BF duration in all countries was

Despite its established benefits, breastfeeding is no longer a norm in many communities. Multifactorial determinants of breastfeeding need supportive measures at many levels, from legal and policy directives to social attitudes and values, women's work and employment conditions, and health-care services to enable women to breastfeed. When relevant interventions are delivered adequately, breastfeeding practices are responsive and can improve rapidly. The best outcomes are achieved when interventions are implemented concurrently through several channels. The marketing of breastmilk substitutes negatively affects breastfeeding: global sales in 2014 of US$44·8 billion show the industry's large, competitive claim on infant feeding. Not breastfeeding is associated with lower intelligence and economic losses of about $302 billion annually or 0·49% of world gross national income. Breastfeeding provides short-term and long-term health and economic and environmental advantages to children, women, and society. To realise these gains, political support and financial investment are needed to protect, promote, and support breastfeeding.

OBJECTIVE: To estimate the global burden of malnutrition and highlight data on child feeding practices and coverage of key nutrition interventions. METHODS: Linear mixed-effects modeling was used to estimate prevalence rates and numbers of underweight and stunted children according to United Nations region from 1990 to 2010 by using surveys from 147 countries. Indicators of infant and young child feeding practices and intervention coverage were calculated from Demographic and Health Survey data from 46 developing countries between 2002 and 2008. RESULTS: In 2010, globally, an estimated 27% (171 million) of children younger than 5 years were stunted and 16% (104 million) were underweight. Africa and Asia have more severe burdens of undernutrition, but the problem persists in some Latin American countries. Few children in the developing world benefit from optimal breastfeeding and complementary feeding practices. Fewer than half of infants were put to the breast within 1 hour of birth, and 36% of infants younger than 6 months were exclusively breastfed. Fewer than one-third of 6- to 23-month-old children met the minimum criteria for dietary diversity, and only ∼50% received the minimum number of meals. Although effective health-sector–based interventions for tackling childhood undernutrition are known, intervention-coverage data are available for only a small proportion of them and reveal mostly low coverage. CONCLUSIONS: Undernutrition continues to be high and progress toward reaching Millennium Development Goal 1 has been slow. Previously unrecognized extremely poor breastfeeding and complementary feeding practices and lack of comprehensive data on intervention coverage require urgent action to improve child nutrition.

To understand the factors contributing to changes in breastfeeding duration, we analyzed data from seven countries in Latin America and from Haiti to document changes in breastfeeding duration between 1986 and 2005. We used a novel method that permits the overall change to be separated into the portion attributable to changing population characteristics (e.g., greater urban population or increased maternal employment) and the portion resulting from changing breastfeeding behaviors within population subgroups (e.g., more breastfeeding among urban women). Our results indicate that in the low-to-middle-income countries studied, which are experiencing socioeconomic and demographic changes, improvements in breastfeeding duration occurred. These improvements are explained almost entirely by changing breastfeeding behaviors, which were particularly evident in certain subgroups of women, such as those with higher levels of education, and very little by changing population characteristics. The socioeconomic and demographic changes we studied that were previously associated with less breastfeeding no longer appear to have a large negative effect. Our findings show that individual behaviors are amenable to change and that changes in individual behaviors collectively contribute to positive national trends in breastfeeding.

Anemia resulting from severe iron deficiency (ID) is the most prevalent and widespread nutrition-related health problem in infants and young children in low-income countries and has proven very resistant to prevention through public health interventions. Accumulative evidence from animal and human studies suggests that such deficiencies are associated with large adverse effects on child cognitive and motor development. Therefore, effective interventions to improve iron status will have large health benefits. Action to reduce young child ID would benefit from overarching policy and programmatic guidance that informs decision makers about what to do, when to do it, and how to do it. The impetus for new approaches to prevent ID in young children reflects growing recognition of the need to intervene early and often and for better vehicles to deliver iron. Prevention of ID requires strong delivery systems that enhance consumer demand and promote compliance. When this occurs, the prevalence of anemia is greatly reduced.

Linear growth retardation and anemia are the most prevalent nutritional problems in the world; effective interventions are urgently needed. We evaluated Ecuador's National Food Nutrition Program (PANN 2000) that included a micronutrient-fortified complementary food (FCF), Mi Papilla, in poor periurban and rural communities of Ecuador. The program is preventive and targeted to all infants and young children living in poor communities and receiving government health services. We compared dietary intake, micronutrient status, and growth over 11 mo in a cohort of children from the catchment areas of the PANN 2000 with same-age control children in nearby communities eligible to enter the program 1 y later. PANN 2000 children enrolled in the program when they were age 9-14 mo and were age 20-25 mo at the final survey. They consumed significantly more energy, protein, fat, iron, zinc, vitamin A, and calcium than control children because of their FCF consumption. Anemia, 76% in both groups at baseline, fell to 27% in PANN 2000 children but only to 44% in control children (P < 0.001). The odds of being anemic were 58% lower for PANN 2000 children (P = 0.003). The effects on linear growth and weight were limited to children who were older when the program began (12-14 mo) and were significant for weight (interaction with age, 0.38 kg; P = 0.029) and positive but not significant for length (0.66 cm; P = 0.08). An FCF, including ferrous sulfate, delivered through public health services, is highly effective in improving weight and hemoglobin and reducing anemia.

Adoption of the recommended breast-feeding and complementary feeding behaviors and access to the appropriate quality and quantity of foods are essential components of optimal nutrition for infants and young children between ages 6 and 24 mo. Iron, zinc and vitamin B-6 are deficient in complementary food diets in Bangladesh, Ghana, Guatemala, Mexico and Peru. Low intakes of iron are consistent with a high prevalence of anemia seen in this age group. The adequacy of observed intakes for calcium, vitamin A, thiamin, folate and vitamin C depends on the age range in question and the set of requirements used in the assessment. The lipid content of many complementary food diets is low. In addition to providing essential fatty acids, lipids are needed for the absorption of fat-soluble vitamins and also enhance the texture, flavor and aroma of foods, which may lead to increased intake. The relative roles of palatability, micronutrient deficiency and morbidity-induced anorexia in the appetite of infants and young children are not known. However, even among children who were growth retarded and had a total energy deficit compared with requirements, up to 25% of food offered was not consumed. This indicates that dietary quality rather than quantity is the key aspect of complementary food diets that needs to be improved. Targeted fortification or the production of complementary foods fortified with micronutrients and of an adequate macro- and micronutrient composition is one approach to help meet nutritional requirements during the vulnerable period of 6-24 mo.

Eggs have been consumed throughout human history, though the full potential of this nutritionally complete food has yet to be realized in many resource-poor settings around the world. Eggs provide essential fatty acids, proteins, choline, vitamins A and B12, selenium, and other critical nutrients at levels above or comparable to those found in other animal-source foods, but they are relatively more affordable. Cultural beliefs about the digestibility and cleanliness of eggs, as well as environmental concerns arising from hygiene practices and toxin exposures, remain as barriers to widespread egg consumption. There is also regional variability in egg intake levels. In Latin American countries, on average, greater proportions of young children consume eggs than in Asian or African countries. In China and Indonesia, nutrition education and social marketing have been associated with greater amounts of eggs in the diets of young children, though generally, evidence from interventions is minimal. Homestead chicken-and-egg production with appropriate vaccination, extension service, and other supports can simultaneously address poverty and nutrition in very poor rural households. With undernutrition remaining a significant problem in many parts of the world, eggs may be an uncracked part of the solution. © 2014 International Life Sciences Institute.

The objective of this commentary is to briefly review key issues related to i) the uses of energy balance vs. growth to determine the recommended length of extended breast feeding; ii) the merits as well as criticisms of the most recent scientific evidence on its recommended length; and iii) the conceptual and practical issues in using this information to make a public health recommendation. (excerpt)

The cost of feeding Latin America's children is high, when viewed in the context of public expenditures on food. The need to increase the cost-effectiveness of such expenditures, coupled with the growing interest in partnerships between the public and private sectors and increases in urbanization, female employment, and household food expenditures, suggests a potential role for processed complementary food in the prevention of malnutrition. The nutritional characteristics of the various foods currently used in nutrition and health programmes are variable, depending on the scientific information available when the food was formulated. A growing interest in the role of the private sector in public health interventions is evidenced by the number of programmes in which such a collaboration exists. The cost of production per 100 g of dry product varies from US$0.04 for World Food Programme blended foods to approximately US$0.20 for recently formulated foods with a significantly higher fat content for national programmes in Mexico and Peru. The constraints and challenges for harnessing the potential of processed complementary foods to improve infant and child nutritional status are numerous. However, the multifactorial causation of child malnutrition points to the importance not only of ensuring access to the appropriate mix of foods, but also of promoting optimal breastfeeding and complementary feeding practices and care.

Processed complementary foods have the potential to play an important role in the diets of infants and toddlers in Latin America. Both feeding frequency and nutrient density need to be considered when formulating recommendations on appropriate feeding practices and composition of processed foods. Unfortunately, empirical data are not yet available on the relationships among feeding practices, feeding frequency, energy density, energy intake, and intake from breastmilk that would permit appropriate public health recommendations to be made. Analyses of nutrient requirements and the nutrient contents of typical toddler foods show that it is virtually impossible to satisfy iron requirements without fortification unless there is a substantial intake of animal products. Zinc and calcium have also been identified as problem nutrients. The optimal characteristics of processed complementary foods include adequate energy density, appropriate micronutrient:energy ratios, suitably low renal solute load, appropriate viscosity for age, desirable sensory properties, resistance to microbial contamination, simple preparation techniques, and low cost.

OBJECTIVES: This study examined the effectiveness of a hospital program to promote exclusive breast-feeding in Santos, Brazil. METHODS: In a prospective design, women who delivered at a hospital with an active breast-feeding promotion program (n = 236) were compared with women who delivered at a nearby control hospital (n = 206). RESULTS: The two groups had similar demographic characteristics and previous breast-feeding histories. Exposure to breast-feeding activities, assessed by maternal recall prior to discharge, was universally high at the program hospital and universally low at the control hospital. Multivariate survival analysis showed that exclusive breast-feeding lasted 53 days longer among women who delivered at the program hospital. CONCLUSIONS: Hospital-based breast-feeding promotion programs may be effective in extending the duration of exclusive breast-feeding.

The objectives of these analyses are to identify in Mexico City recent: a) infant feeding policies in maternity wards, b) infant feeding patterns, and c) socio‐economic, cultural, behavioral and biomedical determinants of breastfeeding. Subjects (n = 518) were recruited in two large public hospitals and followed‐up in their homes at one and four months post‐partum (pp). Breastfeeding rates at four months ranged from 49% to 60%. The main reason given for stopping breastfeeding was insufficient milk. Multivariate survival analyses showed that delivery in a nursery (vs. rooming‐in) ward, maternal employment, having a refrigerator in the household, being a teenaged mother and low maternal motivation for breastfeeding were risk factors for shorter breastfeeding duration. These results may be useful for improving breastfeeding promotion policies in Mexico.

The WHO evidence-informed guidelines provide recommendations to Member States and their partners on interventions with vitamins and minerals. Evidence gathered and synthesized through systematic reviews contributes to the development of these guidelines, a process that is dependent on the availability and quality of evidence. Although the guideline development process is stringently governed and supervised to maintain clarity and transparency, the lack of adequacy and specificity of available evidence poses limitations to the formulation of recommendations that can be easily applied for policy and program decision making in diverse contexts. The symposium created a space for dialogue among scientists and public health practitioners to improve the understanding of how evidence fulfills the needs and reflect on mechanisms by which policy and program guidance and priorities for research could be better informed by policy and program needs. Ultimately, programmatic success depends not only on identifying efficacious agents but ensuring effective delivery to those with the potential to respond. To do this, we must understand the rationale for recommending interventions, the biological pathways by which interventions work, delivery systems required to make efficacious interventions work, and other contextual factors that might limit or facilitate successful implementation.

Child undernutrition is a major public health challenge, estimated to be responsible for 2.2 million annual deaths. Implementation of available interventions could prevent one-third of these deaths. Emerging evidence suggests that breast-feeding can lead to improvements in intelligence quotient in children and lower risks of noncommunicable diseases in mothers and children decades later. Nonetheless, breast-feeding and complementary feeding practices differ greatly from global recommendations. Although the World Health Organization recommends that infants receive solely breast milk for the first 6 months of life, only about one-third of infants in low-income countries meet this goal, just one-third of children 6 to 24 months old in low-income countries meet the minimum criteria for dietary diversity, and only one in five who are breast-fed receive a minimum acceptable diet. Although the potential effects of improved breast-feeding and complementary feeding appear large, funding for research and greater use of existing effective interventions seems low compared with other life-saving child health interventions.

Background and aims: To describe growth patterns of young children in Latin Amer- ica and the Caribbean, the types of nationally representative data available on complementary feeding practices and complementary feeding practices. Methods and results: Data on growth, timing of introduction of liquids and foods, and comple- mentary feeding practices were abstracted from nationally representative surveys. The high prevalence of stunting relative to the low prevalence of underweight is striking, with the "average" child in the region, with the exception of the Haitian child, short and chubby. The focus of the demographic and health surveys continues to be on undernutrition with only one question, intake of sugary foods, related foods that may have consequences for adult health. The United States has more comprehensive information; Mexico has information on beverage consumption and Brazil on soft drink and biscuit or snack consumption. In 14 of 19 countries, fewer than half of infants are exclusively breastfed for the first 6 months of life, indicating an early introduction of liquids and complementary foods. Among the 5 countries with data on the intake of sugary foods, intake in the previous 24 h among children 6e23 months of age ranged from 14% to 79%. Conclusions: The absence of data to characterize complementary feeding diets as they relate to risk of overweight and chronic diseases in the Region of the Americas calls attention to the need to improve data collection frameworks and methods to address this important gap in knowledge.

BACKGROUND: Breastfeeding has large benefits for mothers and infants. The short-term benefits for child survival and reduced morbidity differ by population subgroup because of differences in underlying risk factors. Although breastfeeding is more common among poor than well-off women how breastfeeding patterns change between these subgroups is important from a policy perspective as the poor will benefit more from increased duration of breastfeeding. METHODS: We use nationally representative data from eight countries in Latin America and the Caribbean to document changes in breastfeeding duration between 1986 and 2005 and separate the overall change into the portion attributable to changing population characteristics and the portion resulting from changing breastfeeding behaviour within population subgroups. RESULTS: Breastfeeding duration increased in six out of the eight countries and the changes observed are largely explained by changing behaviour within population subgroups rather than changing population characteristics. Changes in breastfeeding duration did not tend to be equitably distributed but in four countries (Bolivia Brazil Colombia and Peru) the population subgroups whose children are most at risk for mortality and increased morbidity from not being breastfed were least likely to show improvements in breastfeeding duration. Between 1986 and 2004 in Peru breastfeeding duration declined by 0.6 months among rural women while increasing by 9.7 months among urban women; it increased by 6.3 months among women with prenatal care but only by 3.7 months among women with no prenatal care. Changes in breastfeeding in Guatemala and Haiti tended to favour the well-off compared with the poor though not consistently. In Nicaragua changes in breastfeeding duration tended to favour the less well-off. DISCUSSION: While promoting breastfeeding is a must for all women to maximize its benefits for child survival and health additional efforts are needed to reach poorly educated and rural women with little access to health care.

Delayed umbilical cord clamping, immediate skin-to-skin contact, and early initiation of breastfeeding have been shown to be simple, safe, and effective and should be implemented in all deliveries, with very few exceptions. Although these practices can also prevent death, their importance extends beyond survival and optimizes both short-and long-term neonatal and maternal health and nutrition. Their implementation requires that they be integrated with one another and included with other standard lifesaving care practices. Leveraging knowledge of efficacious interventions into high-quality programs with broad coverage is often the main obstacle to improving neonatal and maternal health in low-income countries. To achieve results at-scale, attention must be given to increasing access to scientific information supporting evidence-based practices and addressing the skills needed to implement the recommended practices; establishing and communicating global, national, and local policies and guidelines for implementation in conjunction with advocacy and synchronization with other maternal and neonatal care efforts; reorganizing delivery care services; and monitoring and evaluation. This will require international investments similar to those being made for other lifesaving neonatal interventions. Neonatal vitamin A supplementation, recommended for implementation in Asia, is controversial, and the evidence for and against this recommendation is reviewed.

The effects of both inadequate energy intake and diarrhoeal disease in the aetiology of childhood malnutrition are well established. Their relative importance is still debated, however, and the resultant uncertainty affects public health policies designed to improve child nutrition. This paper summarizes several earlier publications, and presents the results graphically to show that the same synergistic relationship holds across both urban and rural populations as well as across populations with differing levels of diarrhoea and malnutrition. The results show that the effect of inadequate energy intake on nutrition status depends on the level of diarrhoea, just as the negative effect of diarrhoea on nutrition status depends on the level of energy intake. The public health implications of these findings are threefold. First, an immediate strategy to improve child nutrition should focus on mechanisms to improve energy intake and dietary quality in general, and in and around the diarrhoeal episode in particular. Second, concurrently and as a long-term strategy, environmental conditions that put young children at risk for diarrhoea have to be improved. Finally, inasmuch as diarrhoea does not have a negative effect on growth among infants receiving the major part of their energy from breast milk, breast-feeding has a special and previously unrecognized role in the relationship between energy intake and diarrhoea as they affect nutrition status. Thus, efforts to promote increased energy intake and dietary quality among infants and young children should be coupled with efforts to promote breastfeeding exclusively through at least the first 4 months of life and partially through 24 months, when children are most at risk for diarrhoea.

Delayed umbilical cord clamping, early skin‐to‐skin contact and early initiation of exclusive breastfeeding are three simple and inexpensive delivery care practices which have the potential to improve short‐term and long‐term nutrition and health outcomes in mothers and infants. In preterm infants, delayed clamping prevents intraventricular haemorrhage and improves haematological status, and in full‐term infants, delayed clamping improves iron status through 6 months of age. Early skin‐to‐skin contact, in addition to regulating neonatal temperature, improves early breastfeeding behaviours, which has important implications for long‐term infant nutrition and health. Finally, early exclusive breastfeeding prevents neonatal mortality and morbidity and provides numerous health and nutritional benefits to the infant, throughout infancy and beyond, as well as to the mother. Though each practice has been the subject of controlled trials and systematic reviews, with evidence of benefit from their implementation, these practices are not common in many delivery settings, nor are their long‐term effects on infant and maternal nutrition and health status adequately recognized. We discuss the immediate and long‐term health and nutrition benefits of each practice, and identify the policy and programme changes needed for integration and implementation of these practices into standard delivery care.

Evaluation of the responsiveness of weight and length to supplementary feeding shows that the two periods of greatest response coincide with weaning (ages 3-6 mo) and peak incidence and duration of diarrheal disease (ages 9-12 mo). Analyses were done for seven consecutive nonoverlapping intervals comparing children randomly assigned to receive supplemental feeding from birth to age 36 mo or to serve as control subjects. Absolute responsiveness was greatest between ages 3-6 mo; supplemented infants grew 0.61 cm more and gained 162 g more than did unsupplemented infants (p less than 0.005). Relative to rates of growth, responsiveness was greatest between ages 9 and 12 mo (the period of peak diarrheal prevalence), followed by ages 3-6 mo (the period of weaning). Responsiveness to supplementation is thus directly related to age-dependent risk patterns for malnutrition. Targeting supplementation programs to coincide with periods of high nutritional risk should maximize their effectiveness in reducing malnutrition, though caution should be exercised to avoid disruption of breast-feeding.

Background Attributes that caregivers assign to complementary foods have been primarily described in the context of illness, but attributes assigned to foods in everyday circumstances must be understood to effectively promote good complementary feeding. Objective This study aimed to understand how mothers judge complementary foods to be appropriate by cross-cultural examination of food perceptions in four different Latin American and Caribbean countries. Methods We used semistructured interviews to assess attributes that mothers ascribed to a list of key foods, both home-made and manufactured, and reasons for feeding or not feeding them. We elicited attributes from 79 caregivers with children 6 to 24 months of age from two urban and periurban sites each in Brazil, Jamaica, Mexico, and Panama. Results Textual analysis based on six home foods common to the four countries and manufactured foods resulted in six attribute categories, five of which could be positive or negative (Nutrient Content, Effects on Child, Child's Response, Availability and Accessibility, and Other Food Attributes); one (Food Quality and Safety) was only negative. Analysis of attributes of home foods (chicken, eggs, beans, carrots, bananas or plantains, and oranges) revealed many beliefs that were common within and across countries, whereas analysis of the attributes of manufactured foods revealed that these foods were less known. Conclusions The consistency of the attribute categories across countries and across home and manufactured foods suggests their relevance to planning programs to improve complementary feeding in Latin America and the Caribbean and possibly other developing countries. These results can be used programmatically to assess the need for and the focus of food education programs, and to indicate which countries will be more receptive to certain foods as a means of improving complementary feeding.

In this paper evidence from trend data national evaluations and efficacy and effectiveness studies are used to critically analyze the plausible causal relationship between international and national initiatives to promote breast-feeding and changes in breast-feeding behavior in Latin America. An analysis is provided of the age-specific effect of breast-feeding on infant health in relation to age-specific maternal breast-feeding behaviors and response to specific interventions.

Large numbers of infants and young children suffer from the short- and long-term health effects of poor breastfeeding and complementary feeding practices. Strategies to improve the availability of and access to low-cost fortified complementary foods can play an important corresponding role to that of behavior change in improving nutritional status of young children. However, the nutritional quality of complementary foods used in publicly funded programs is not always optimal, and such programs are costly and reach only a tiny fraction of those who could benefit. To broadly reach the target population, such foods need to be commercially available at affordable prices and promoted in a way that generates demand for their purchase. A sensible long-term policy for the promotion of low-cost fortified complementary foods calls for attention to their nutritional formulations and cost, the economics of production, and the legislative, regulatory, and competitive framework in which marketing occurs. This paper provides information on how to improve the nutritional formulations of fortified complementary foods and outlines the necessary conditions for a market approach to their production and promotion.