Search

Micronutrient deficiencies are a public health concern among young children in low-income countries, and novel strategies are needed to improve the nutritional status of children at risk. One promising approach is the use of lipid-based nutrient supplements (LNS), which can be added to complementary food at the time of consumption. The optimal amount of zinc to include in LNS is uncertain, and concerns have been expressed about possible adverse effects of zinc on sensory characteristics of LNS. We conducted a series of acceptability studies of LNS containing either 0 or 10 mg of zinc per daily 20 g LNS dose among Burkinabe children 9-15 months old and their mothers. These acceptability studies included observations of children's consumption, maternal and child sensory reaction to the products using a 5-unit hedonic scale, a triangle test for detection of differences and a review of maternal reports of their child-feeding experiences during a 2-week home-feeding trial. The LNS products were well appreciated by the mothers and children during the sensory trials and the 2-week home-feeding trial. The addition of 10 mg zinc to LNS did not affect the consumed proportion of the offered porridge-LNS-mixture (P = 0.43). Results of the triangle test with mothers confirmed that there was no detectable difference between products containing 0 or 10 mg zinc per 20 g LNS dose. Most importantly, interviews and focus groups following the 2-week home-feeding trial indicated good acceptability of the products by mothers and their children., (© 2010 Blackwell Publishing Ltd.)

The United Nations Convention on the Rights of the Child holds governments responsible to ensure children's right to the highest attainable standard of health by providing breastfeeding support, and access to nutritious foods, appropriate health care, and clean drinking water. International experts have identified key child care practices and programmatic activities that are proven to be effective at reducing infant and young child undernutrition, morbidity, and mortality. Nevertheless, progress towards reducing the prevalence of undernutrition has been sporadic across countries of the Sahel sub-region of Sub-Saharan Africa. In view of this uneven progress, a working group of international agencies was convened to 'Reposition children's right to adequate nutrition in the Sahel.' The first step towards this goal was to organize a situational analysis of the legislative, research, and programmatic activities related to infant and young child nutrition (IYCN) in six countries of the sub-region: Burkina Faso, Chad, Mali, Mauritania, Niger, and Senegal. The purposes of this introductory paper are to review current information concerning the nutritional and health status of infants and young children in the Sahel and to summarize international guidelines on optimal IYCN practices. These guidelines were used in completing the above-mentioned situational analyses and encompass specific recommendations on: (i) breastfeeding (introduction within the first hour after birth, exclusivity to 6 months, continuation to at least 24 months); (ii) complementary feeding (introduction at 6 months, use of nutrient dense foods, adequate frequency and consistency, and responsive feeding); (iii) prevention and/or treatment of micronutrient deficiencies (vitamin A, zinc, iron and anaemia, and iodine); (iv) prevention and/or treatment of acute malnutrition; (v) feeding practices adapted to the maternal situation to reduce mother-to-child transmission of HIV; (vi) activities to ensure food security; and (vii) the promotion of hygienic practices concerning food preparation and storage and environmental sanitation. The following papers in this issue will present results of the situational analyses for the individual countries., (© 2011 Blackwell Publishing Ltd.)

We completed a series of studies to assess the acceptability of zinc-fortified, cereal-based complementary foods and zinc-fortified wheat breads. Young children and their caregivers completed acceptability tests with complementary foods fortified with iron only (60 mg iron as ferrous fumarate per kilogram cereal flour), or the same level of iron and zinc (240 mg zinc as zinc oxide per kilogram cereal flour), and the caregivers completed triangle taste tests to compare the same products. A separate group of adult participants completed acceptability tests with wheat breads fortified with iron and folic acid (15 mg iron as ferrous fumarate per kilogram flour and 1.5 mg folic acid per kilogram flour) or the same levels of iron-folic acid and 2 levels of zinc (63 mg zinc or 126 mg zinc as zinc oxide per kilogram flour). Finally, a threshold test was administered to another group of adult participants to compare nonfortified wheat bread to breads fortified with zinc in 80 mg increments ranging from 80 to 400 mg zinc as zinc oxide per kilogram flour. All products were acceptable when compared to non-zinc-fortified equivalents, and were well liked by the respective participants. For the triangle tests, caregivers were not able to detect significant differences between products. For threshold tests, adult participants detected differences in breads prepared from fortified wheat flour at 80 mg, 160 mg, and 320 mg zinc per kilogram flour, but not at 240 mg and 400 mg zinc per kilogram flour, respectively, when compared to nonfortified bread equivalents. Zinc fortification of cereal flours in the ranges of fortification that were tested does not adversely affect the acceptability of complementary foods and breads prepared from these flours. Practical Application: Fortification of staple food products is a low-cost approach to deliver additional micronutrients (including zinc) to large segments of a population. Determining the acceptability of products fortified with zinc is an important step in the development of zinc fortification programs.

Background: Information is needed on the minimum energy density and feeding frequency of complementary foods that can provide adequate energy intakes (EIs) for healthy breastfed children., Objectives: The objectives of the study were to evaluate the effects of various energy densities and feeding frequencies of complementary foods on EI from these foods, breast milk consumption, and total EI from both sources., Design: During 9 separate, randomly ordered dietary periods lasting 3-6 d each, we measured intakes of food and breast milk by 18 healthy breastfed children 8-11 mo of age who, 3, 4, or 5 times/d, were fed porridge with a coded energy density of 0.5, 1.0, or 1.5 kcal/g. Food intake was measured by weighing the feeding bowl before and after meals, and breast milk intake was measured by test weighing., Results: The mean amounts of complementary foods consumed were inversely related to their energy density and positively related to the number of meals/d (P < 0.001 for both); EIs from foods were positively related to both factors. Breast milk intake decreased slightly but progressively, with greater energy density and feeding frequency of complementary foods; total EIs (kcal/d) increased in relation to both factors (P < 0.001 for both)., Conclusions: The energy density and feeding frequency of complementary foods affect infants' total daily EI and breast milk consumption. Recommendations can be developed for the appropriate combinations of these dietary factors that are compatible with adequate EI, although longer-term effects of complementary feeding practices on breast milk intake and breastfeeding duration need further community-based studies.

Appropriate breastfeeding and complementary feeding practices are fundamental to children's nutrition, health, and survival during the first 2 years of life. The World Health Organization recommends exclusive breastfeeding until 6 months of age and continued breastfeeding for at least 2 years, along with the timely introduction of adequate amounts of complementary foods of suitable nutritional and microbiological quality. The amounts of energy and micronutrients required from complementary foods have been estimated as the difference between the total physiological requirements of these food components and the amounts transferred to the child in breast milk. Recommendations for the energy density of complementary foods and their frequency of feeding have also been proposed. Intakes of several micronutrients, including iron, zinc, calcium, selected B vitamins and (in some settings) vitamin A, remain problematic because commonly available, low-cost foods contain inadequate amounts of these nutrients to provide the shortfall in breast milk. Alternative strategies to provide these nutrients include adding animal source foods to the diet, providing fortified, processed complementary foods, administering micronutrient supplements, or offering some combination of these approaches. Advantages, disadvantages, and possible risks of these different strategies are discussed.

Background: Information is needed to design studies of the effects of complementary feeding regimens on children's intakes of complementary foods (CFs) and breast milk., Objective: We evaluated the effects of varied energy density of CFs on the time until stabilization of dietary intakes and on total daily energy intakes (EIs) and breast-milk intakes., Design: CFs with low [0.4 kcal/g (LD)] and high [1.5 kcal/g (HD)] energy density were fed 3 times/d to 10 children (aged 9-18 mo) during 2 randomly assigned sequences of three 8-d diet periods (HD-LD-HD or LD-HD-LD) along with ad libitum breastfeeding. CF and breast-milk intakes were measured., Results: Intakes of the HD diet and breast milk did not vary by day of period, but intake of the LD diet increased progressively. During days 5-7 of the last 2 diet periods in each sequence, more of the LD than of the HD diet was consumed (752 +/- 252 and 439 +/- 111 g/d, respectively; P < 0.001), but EIs from CFs were greater with the HD diet. Breast-milk consumption was slightly less (192 +/- 115 and 234 +/- 121 g/d, respectively; P = 0.03) but total daily EI was greater (774 +/- 175 and 441 +/- 85 kcal/d, respectively; P < 0.001) during the HD than during the LD diet period., Conclusions: New information on the effects of newly introduced diets on daily intakes of these diets and of breast milk can be used to design future studies. Total daily EIs were greater with the HD diet despite its negative effects on breast-milk intakes.

This study used simple rapid-assessment techniques to test the feasibility of increasing the consumption of complementary foods by infants by asking mothers to increase meal quantity or frequency or by altering the viscosity/energy density of the food. The feasibility of using micronutrient supplements either added directly to food or administered as liquid drops was also examined. The study was conducted in rural Bangladesh and involved four separate short-term behavioral change trials. Depending on the trial, fieldworkers recruited 30 to 45 infants 6 to 12 months of age. Following recommendations to increase the amount of food provided to infants, the mean intakes from single meals increased from 40 +/- 23 g on day 1 to 64 +/- 30 g on day 7 (p < 0.05). In a second trial, the mean meal frequency increased from 2.2 +/- 1.3 on day 1 to 4.1 +/- 1.3 on day 7 (p < 0.05). Provision of high-energy-density diets, prepared by decreasing viscosity with alpha-amylase or by hand-mashing rice and dhal into a paste before feeding, increased single-meal energy consumption from 54 +/- 35 kcal to 79 +/- 52 kcal or 75 +/- 37 kcal (p < 0.05), respectively. Both types of micronutrient supplements were well accepted and used according to recommendations. In conclusion, it was possible to change short-term child-feeding behaviors to promote increased food intake, mealfrequency, energy density, and micronutrient consumption. Because each of these interventions lasted for only about 1 week, however, the long-term sustainability of these changes is not known. Moreover, the effect of increased feeding of complementary foods on intakes of breastmilk and total daily consumption of energy and nutrients requires further study.

This paper provides an update to the 1998 WHO/UNICEF report on complementary feeding. New research findings are generally consistent with the guidelines in that report, but the adoption of new energy and micronutrient requirements for infants and young children will result in lower recommendations regarding minimum meal frequency and energy density of complementary foods, and will alter the list of "problem nutrients." Without fortification, the densities of iron, zinc, and vitamin B6 in complementary foods are often inadequate, and the intake of other nutrients may also be low in some populations. Strategies for obtaining the needed amounts of problem nutrients, as well as optimizing breastmilk intake when other foods are added to the diet, are discussed. The impact of complementary feeding interventions on child growth has been variable, which calls attention to the need for more comprehensive programs. A six-step approach to planning, implementing, and evaluating such programs is recommended.

This study describes the factors associated with hemoglobin and plasma ferritin, zinc and retinol concentrations and erythrocyte riboflavin status among 208 Ghanaian infants who participated in a complementary feeding intervention trial from 6 to 12 mo of age. Anthropometric, morbidity and dietary data were collected regularly from 1 to 12 mo; blood samples were collected at 6 and 12 mo. The prevalence of low micronutrient status at 6 and 12 mo, respectively, was as follows: hemoglobin <100 g/L, 30 and 34%; plasma ferritin <12 microg/L, 17 and 43%; plasma zinc <10.7 micromol/L, 4 and 6%; plasma retinol <0.7 micromol/L, 26 and 26%; erythrocyte riboflavin <200 umol/L of packed red cells, 14 and 10%. Multiple regression was used to identify factors significantly associated with micronutrient status. From 6 to 12 mo, fever prevalence was associated with a decrease in hemoglobin, but an increase in erythrocyte riboflavin concentrations, and diarrhea prevalence was related to a decrease in plasma retinol. Seasonal differences were evident for most of the indicators of micronutrient status, and elevated C-reactive protein levels (indicative of recent infection) were related to lower hemoglobin, retinol and zinc concentrations but higher ferritin and erythrocyte riboflavin concentrations. Weight at birth or at 1 mo of age was positively related to iron, zinc and vitamin A status, but a more rapid weight gain was associated with depletion of iron stores. Socioeconomic status was related to higher hemoglobin, riboflavin and zinc concentrations. The feeding of a micronutrient-fortified food was positively associated with plasma ferritin and retinol concentrations at 12 mo. These results suggest that prenatal factors, socioeconomic status, dietary intake and morbidity all influence infant micronutrient status, and that fortification of complementary foods is one potential avenue for preventing deficiencies.

Objective: To examine factors associated with the physical growth of breast-fed Ghanaian infants during the first 18 months of life., Design: A community-based longitudinal study., Setting: The study was carried out in Techiman, a district capital and major food trading center in the Brong Ahafo region of Ghana., Subjects: One-month old infants (n=216) with birth weight >/= 2.5 kg were recruited from Maternal and Child Health Centers., Method: From 6 to 12 months, infants were provided with one of four types of nutritionally enhanced complementary foods. Anthropometric assessments were completed monthly from 1 to 12 months and every other month from 12 to 18 months. Information was collected on household characteristics, morbidity from common infections and dietary intakes. Blood samples were collected at 6 and 12 months to assess iron, zinc, riboflavin and vitamin A status. Multiple regression analysis was used to examine factors associated with growth during the age intervals of 1-6, 4-6, 6-12 and 12-18 months as well as size attained at 12 and 18 months., Results: Prevalence of diarrhea and fever were negatively associated with growth during the first year of life. No significant relationship was found between respiratory illness (defined as cough or purulent nasal discharge) and growth. With the exception of dietary zinc intake, dietary variables were generally not significantly associated with growth. Maternal education was positively associated with growth during most of the age intervals., Conclusion: These findings suggest that interventions to reduce morbidity and improve the education of girls may benefit children's growth in this population., Sponsorship: Nestle Foundation; Rockefeller Foundation African Dissertation Internship Award; Fulbright Scholarship. European Journal of Clinical Nutrition (2000) 54, 41-49

Background: Results of prior studies of the effect of viscosity reduction of high-energy-density, starch-containing diets on young children's energy intakes are inconsistent, possibly because of differences in the characteristics of the unmodified diets with which the low-viscosity diets were compared., Objective: Our objective was to determine the effects of dietary viscosity and energy density on total daily energy consumption by young, non-breast-fed children., Design: We measured the amount of food consumed and the duration of meals during 3 substudies, in each of which 3 study diets were offered for 4 consecutive days each in random sequence: high energy density, high viscosity (HD-HV); high energy density, low viscosity (HD-LV); and low energy density, low viscosity (LD-LV). The viscosity and energy density of the unmodified starch-containing HD-HV diet were varied across substudies to determine whether the effect of amylase liquefaction was related to the initial characteristics of the HD-HV diet. The viscosity of the HV diets ranged from 79000 to 568000 mPa s; energy density of the HD diets ranged from approximately 4.18 to 4.93 kJ (1.00-1.18 kcal)/g. Viscosity of the LV diets was approximately 3000 mPa s and the energy density of the LD diets was approximately 2.47 kJ (0.6 kcal)/g., Results: In each substudy, children consumed more of the LD-LV diet (g kg body wt(-)(1) d(-)(1)) than of the other diets and more of the HD-LV diet than of the HD-HV diet (P < 0.001). Energy consumption from the HD-LV diet was greater than from the other diets (P < 0.001), but the energy intakes from the latter diets were not significantly different., Conclusion: Amylase liquefaction of HD-HV porridges resulted in increased energy consumption by young children.

Microbial contamination of complementary foods is a major cause of childhood diarrhoea. In a community-based study in Ghana, we evaluated whether fermentation of maize porridge or storage of porridge in vacuum flasks reduces coliform contamination. The complementary food examined, Weanimix, consisted of, on a dry weight basis, toasted maize (75%), peanuts (10%), and soybeans (15%) milled into flour. The fermented food was Weanimix made with drum-dried, previously fermented maize. Fifty women with infants 6-18 months of age participated. A repeated measures cross-over design was used. Each mother participated in all four treatments (1 week per treatment, in random order): (a) non-fermented Weanimix (W), (b) fermented Weanimix (F), (c) non-fermented Weanimix stored in a vacuum flask (WV), and (d) fermented Weanimix stored in a vacuum flask (FV). Each week, mothers were supplied with the appropriate food, and asked to prepare a porridge each morning by boiling the dry mix in water. Samples were collected in the evenings and immediately plated onto 3 M Petrifilm. Contamination was defined as > or = 100 colony-forming units of coliforms per ml. Contamination rates (95% confidence intervals) were W = 48% (38-58%), F = 25% (17-34%), WV = 42% (32-52%), and FV = 13% (6-20%). All pairwise comparisons were significant (P < 0.05) except for W vs WV. Within the WV treatment, contamination rates were 85% when the sample temperature fell below 50 degrees C (N = 41) vs 12% when it remained > 50 degrees C (N = 59) (P < 0.001). These results indicate that contamination is reduced by fermentation, and further reduced by vacuum flask storage of fermented foods. For non-fermented foods, vacuum flask-storage was protective only when the temperature was maintained at > 50 degrees C; at < or = 50 degrees C vacuum flask storage increased the risk of contamination.

Background: The optimal age at which to introduce complementary foods is a topic of considerable debate., Objective: This study was designed to evaluate this issue in a nutritionally vulnerable population in Honduras., Design: Mothers of low-birth-weight (1500-2500 g) term (ie, small-for-gestational-age) infants were recruited in the hospital and assisted with exclusive breast-feeding during the first 4 mo. At 4 mo, mothers were randomly assigned to either continue exclusive breast-feeding to 6 mo (EBF; n = 59) or to feed complementary solid foods (jarred rice cereal, chicken, and fruit and vegetables) twice daily from 4 to 6 mo while continuing to breast-feed at their initial frequency (SF; n = 60). At 4 and 6 mo, breast milk and total energy intake were measured for a nonrandom subsample (those who could stay overnight in a central unit: 32 EBF and 31 SF)., Results: At 4 mo, breast milk intake in the subsample was not significantly different between groups (EBF: 729 +/- 135 g/d; SF: 683 +/- 151 g/d: P >0.2); from 4 to 6 mo it increased (by 28 g/d) in the EBF group but decreased (by 39 g/d) in the SF group (P < 0.005). Nonetheless, total energy intake (including solid foods) increased more from 4 to 6 mo in the SF than in the EBF group. However, there were no significant differences between groups in weight or length gain during the intervention or subsequently (6-12 mo)., Conclusion: There was no growth advantage of complementary feeding of small-for-gestational-age, breast-fed infants between 4 and 6 mo of age.

To evaluate the effect of introducing complementary foods before 6 mo of age, we randomly assigned 164 infants who had been exclusively breast-fed for 4 mo to continue being exclusively breast-fed until 6 mo (EBF group) or to receive iron-fortified foods in addition to breast milk from 4 to 6 mo (BF+SF group). At 6 mo, the BF+SF group had higher mean iron intake (4 mg/d compared with 0.2 mg/d in EBF infants) and higher hemoglobin, hematocrit, and ferritin values than the EBF group (P < 0.05). The percentage with low hemoglobin (< 103 g/L) did not differ significantly between groups, but fewer infants in the BF+SF group had a low hematocrit (< 0.33; 21.4% compared with 32.0%, respectively; P < 0.05). The percentage of infants with ferritin concentrations < 12 microg/L at 6 mo was lower than the percentage with low hemoglobin or hematocrit, raising questions about the validity of the cutoffs at this age. Infants at greatest risk for anemia and low ferritin were those with birth weights < 2500 g; no infant with a birth weight > 3000 g had a low ferritin value at 6 mo. We conclude that the risk of iron deficiency is low among infants with birth weights > 3000 g who are exclusively breast-fed for 6 mo. Iron drops are recommended for low-birth-weight infants; for breast-fed infants with birth weights between 2500 and 3000 g, further research is needed to determine whether iron drops are more effective than complementary foods for preventing iron deficiency before 6 mo.

Lactational amenorrhea (LA) is associated with postpartum infertility and is known to be related to breast-feeding frequency and duration, but the exact role of complementary feeding of the infant has not been clearly defined. Data on LA were collected during and after a 2-mo intervention trial in which low-income Honduran women who had breast-fed fully for 4 mo were randomly assigned to one of three groups: continued full breast-feeding until 6 mo (FBF, n = 50), introduction of complementary foods at 4 mo with ad libitum breast-feeding from 4 to 6 mo (SF, n = 47), or introduction of complementary foods at 4 mo with maintenance of baseline breast-feeding frequency from 4 to 6 mo (SF-M, n = 44). Women were followed up until the infant was 12 mo of age, or later if menses had not occurred by then. All but six of the women continued to breast-feed for > or = 12 mo. With the exclusion of those whose menses returned before 18 wk postpartum (which could not have been due to the intervention), the proportion of women who were amenorrheic at 6 mo was 64.5% in the SF group, 80.0% in the FBF group, and 85.7% in the SF-M group (chi-square test = 4.13, P = 0.02; one-tailed test with the latter two groups combined). The total duration of LA did not differ significantly among groups. The most significant determinant of LA was time spent breast-feeding (min/d), which was in turn negatively associated (P = 0.06) with the infant's energy intake from complementary foods in regression analyses. These results indicate that there is a significant effect of introducing foods at 4 mo on the likelihood of amenorrhea at 6 mo postpartum, but not thereafter, and that this effect is not seen in mothers who maintain breast-feeding frequency.

Low income, primiparous mothers who had exclusively breast-fed for 4 mo were randomly assigned to one of three groups: 1) continued exclusive breast-feeding to 6 mo (EBF), 2) introduction of complementary foods at 4 mo, with ad libitum nursing 4-6 mo (SF), and 3) introduction of complementary foods at 4 mo, with maintenance of base-line nursing frequency 4-6 mo (SF-M). After the intervention phase (4-6 mo; n= 141), home visits were conducted for a subsample at 9 (n = 60) and 12 (n = 123) mo. At each visit, an observer recorded infant food intake at the midday meal and interviewed the mother regarding usual feeding patterns and the infant's acceptance of 20 common food items. All but two infants (1.5%) were breast-fed to 9 mo and all but eight (6%) to 12 mo. There were no significant differences among groups in breast-feeding frequency, amount or number of foods consumed at the midday meal, percentage of food offered that was consumed, usual daily number of meals and snacks, number of food groups consumed, or overall food acceptance score. Frequency of consumption of foods from eight different food groups (dairy, meats, eggs, grains, beans, fruits, vegetables, tubers) was not significantly different among groups except that, at 9 mo only, the SF group (but not the SF-M group) consumed more vegetables than did the EBF group. These results indicate that delaying the introduction of complementary foods until 6 mo does not adversely affect appetite or food acceptance among breast-fed infants.

Objectives: To evaluate the impact of introducing complementary foods to exclusively breast-fed infants at 4 vs 6 months on growth from 6 to 12 months, and to compare growth patterns of Honduran infants with those of breast-fed infants in the United States., Design: Randomized intervention trial from 4 to 6 months and longitudinal study of infants from birth to 12 months., Setting: Low-income communities in San Pedro Sula, Honduras., Subjects: Primiparous, breast-feeding mothers and their infants (n = 141) recruited from public maternity hospitals., Intervention: Infants were randomly assigned to exclusive breast-feeding to 6 months, or exclusive breast-feeding with addition of hygienically prepared, nutritionally adequate complementary foods at 4 months, with or without maintenance of baseline breast-feeding frequency. After 6 months, mothers continued to breast-feed and also fed their infants home-prepared foods after receiving instruction in appropriate feeding practices., Outcome Measures: Infant weight was measured monthly during the first year of life and infant length monthly from 4 to 12 months., Statistical Analysis: Growth parameters were compared between the Honduran and US cohorts using multiple-regression and repeated-measures analysis of variance. Stepwise multiple regression was used to identify determinants of infant growth., Results: There were no differences in growth patterns by intervention group. Mean birth weight of the Honduran infants was significantly less than that of a cohort of breast-fed infants in an affluent US population (n = 46) (2889 +/- 482 vs 3611 +/- 509 g), but the Honduran infants exhibited rapid catch up in weight in the first few months of life, and the cohorts were similar in weight by 3 months. Mean weight and length gain were similar to those of the US cohort from 4 to 9 months but were lower from 9 to 12 months. Mean length for age was significantly less than that of the US cohort from 4 to 12 months; this was attributable to the difference in maternal height (12 cm shorter in Honduras on average). Within the Honduran cohort, growth velocity of low birth weight infants (< 2500 g; n = 28) was similar to that of their normal birth weight peers; thus, the former subgroup remained smaller than the latter throughout the first year of life., Conclusions: In poor populations, when breast-feeding is exclusive for the first 4 to 6 months, continues from 6 to 12 months, and is accompanied by generally adequate complementary foods, faltering in weight does not occur before 9 months among infants born with birth weights of more than 2500 g.

A randomized clinical trial was completed to compare the efficacy of a mixed diet composed of locally available foods versus a lactose-free, soy-based formula for the management of young Mexican children with acute diarrhea and dehydration. A total of 87 patients between 5 and 36 months of age received either a blended mixed diet containing rice, chicken, carrots, beans, and vegetable oil (group MD) or a soy formula (group SF) immediately after standard oral rehydration therapy. The initial clinical characteristics of the patients in each group were similar, as were their stool outputs during the first 6-hour period of rehydration before the diets were offered. There were six treatment failures, all of which were in group SF (p < 0.01). The stool outputs of children in group MD and in group SF were 82 +/- 55 versus 112 +/- 88 gm/kg per day, respectively, on day 1 (p = 0.037), and 48 +/- 33 versus 66 +/- 55 gm/kg per day on day 2 (p = 0.109). The duration of diarrhea among those in group MD was significantly reduced compared with those in group SF (29 vs 67 hours; p < 0.001). We conclude that the mixed diet resulted in improved clinical outcomes compared with the lactose-free, soy protein isolate formula.

Data from a longitudinal study of 153 low-income Peruvian infants were used to examine (i) whether infant characteristics such as appetite, illness and past growth performance are related to subsequent changes in their feeding practices (e.g. addition of non-human milks, solid foods, weaning), and (ii) whether this relationship depends on maternal characteristics such as feeding exposure and experience (MFEE). With one exception, infants were breastfed from birth. Feeding practices during the first month of life were related to practices throughout infancy. Most mothers changed their practices once (61%) or twice (34%) from birth to 6 months. Low weight gains from 1 to 2 (P < 0.003) and 2 to 3 (P < 0.04) months were identified as significant predictors of feeding changes during the following months, using logistic regression models that also adjusted for MFEE, infant gender, previous practice, and previous practice change. The interaction between past weight gain and MFEE (objective ii) was not statistically significant in the logistic regression models. However, when analyzed separately, the relationships between low weight gains and subsequent feeding changes were observed for high but not low MFEE mothers. The prevalences of anorexia and infection (diarrhea, respiratory, and/or fever), and poor length gain during the previous month were not related to subsequent changes in feeding practices. These results suggest that poor growth influences feeding practices from 2 to 4 months, when exclusive breastfeeding is recommended.

In developing countries, the age at which breastfed infants are first given complementary foods is of public health importance because of the risk of diarrhoeal disease from contaminated weaning foods, and the potential risk of growth faltering if foods are inappropriately delayed. To evaluate whether there are any advantage of complementary feeding prior to 6 months, low-income primiparous mothers who had exclusively breastfed for 4 months were randomly assigned to one of 3 groups: continued exclusive breastfeeding to 6 months (EBF) (n = 50); introduction of complementary foods at 4 months with ad libitum nursing from 4-6 months (SF) (n = 47); and introduction of complementary foods at 4 months, with maintenance of baseline nursing frequency from 4-6 months (SF-M) (n = 44). Baby foods in jars were provided to the SF and SF-M groups from 4 to 6 months. Subjects were visited weekly and provided with lactation guidance; at 4, 5, and 6 months measurements were made of infant intake and breast milk composition. At 4 months, breast milk intake averaged 797 (139) g per day (no difference among groups). Between 4 and 6 months, breast milk intake was unchanged in EBF infants (+6) but decreased in the SF (-103), and SF-M (-62) groups (p < 0.001). Change in total energy intake (including solid foods) and infant weight and length gain did not differ significantly between groups. Weight and length gain from 4-6 months were comparable to those of breastfed infants in an affluent USA population. The results indicate that breastfed infants self-regulate their total energy intake when other foods are introduced. As a result, there is no advantage in introducing complementary foods before 6 months in this population, whereas there may be disadvantages if there is increased exposure to contaminated weaning foods.

This paper reports on the evaluation of a pilot intervention which used nutrition education techniques to introduce a fortified, home-prepared weaning food (eko ilera, or 'pap for health') in 12 communities in Kwara State, Nigeria, from June to August, 1988. The recipe added toasted cowpea flour, red palm oil, and sugar to increase the energy and protein density of the traditional maize or sorghum starch porridge used for weaning from 38 to 85 kcal and 0.8 to 2.0 g protein per 100 g. A stratified, random sample of participating (n = 295) and non-participating (n = 301) mothers from the same communities were interviewed from 2 to 8 weeks following the completion of the intervention, and their rates of knowledge, trail, and adoption of eko ilera were evaluated. Of the participating mothers, 57% (95% CI: 51%, 63%) knew the modified recipe, 48% (43%, 54%) tried it, and 17% (12%, 21%) adopted it with the intention of using it in the future. Only 2% (1%, 7%) of non-participating mothers knew about the recipe. Multivariate analyses indicated that the mothers' level of education and their perception of the cost and length of preparation time of the recipe were significantly associated with its adoption. The intervention was successful in using face-to-face nutrition education methods to introduce eko ilera to mothers in this region of Nigeria and to encourage its trial and adoption.

To determine the effect of dietary viscosity on energy consumption by young children, 56 Peruvian children 9-20 mo of age with acute diarrhea were randomly assigned to either a liquid or semisolid diet, with or without added amylase to reduce viscosity. Intakes of the study diet, breast milk, and other foods were measured for 2 consecutive d during and again after illness. Total 24-h energy intake (chi +/- SD) during diarrhea, 349.4 +/- 121.8 kJ/kg (83.6 +/- 29.1 kcal/kg) was 18% less than intake after recovery, 428.9 +/- 141.0 kJ/kg (102.6 +/- 33.7), P < 0.001. In the ANOVA breast-fed children consumed significantly less total energy (P = 0.008) and energy from the study diet (P = 0.02) than non-breast-fed children. Breast milk intake did not change with illness. There was no significant relationship between viscosity of the study diet and either total energy intake or intake of energy from the study diet. Energy intake by these children was primarily determined by health status and breast-feeding practice, not by dietary viscosity.

We compared growth, dietary intake, and morbidity of infants breast-fed for > or = 12 mo from two populations: Davis, CA (n = 46) and Huascar, Peru (n = 52). When compared against WHO reference data (based primarily on formula-fed infants), Huascar infants appeared to falter as early as 3-4 mo, but when compared with Davis breast-fed infants, the curves for weight and length were very similar in girls until 10-12 mo and in boys until 6-9 mo. Thereafter, Huascar infants grew less rapidly than did Davis infants. Breast milk intake was very similar between groups, but in Huascar the amount and nutrient density of complementary foods consumed after 6 mo were lower and morbidity rates were much higher than in Davis. These results indicate that growth faltering of Huascar infants, when judged against breast-fed infants in the United States, occurs primarily after the first 6 mo of life and is not due to poor lactation performance.

Clinical trials were conducted to measure the effect of dietary energy on total daily energy intakes by nine hospitalized young children recovering from protein-energy malnutrition. Semi-solid mixed diets containing either 50 or 100 kcal/100 g were offered at fixed intervals five times per day until the children refused further intake. Each diet was offered for seven consecutive days in alternate order. The mean +/- SD amount consumed with the low-density (LD) diet was significantly greater than with the high-density (HD) diet (220 +/- 35 vs 148 +/- 21 g/kg/d, P less than 0.001), but the amount of energy consumed with the HD diet was significantly greater than with the LD diet (148 +/- 21 vs 110 +/- 18 kcal/kg/d, P less than 0.001). There were no differences in total daily intake by day of diet period with the HD diet, but the intakes increased during the first 2-4 days with the LD diet. The maximum intakes at a single meal averaged between 40 and 66 g/kg/d for individual children receiving the LD diet, and were negatively related to the children's lengths and weight-for-length Z scores. We conclude that dietary energy density limited the amount of energy consumed from LD weaning diets offered at fixed frequencies, presumably because the volume of intake required to satisfy the children's energy needs exceeded their gastric capacity.

A randomized, double-masked clinical trial was completed to compare the effects of four dietary regimens for the nutritional management of 116 Peruvian children between 3 and 24 months of age with acute diarrhea. Diets consisted of a modified whole milk formula (group M), a lactose-hydrolyzed milk formula (HM), wheat noodles and whole milk (N-M), or wheat noodles and lactose-hydrolyzed whole milk (N-HM), all offered in amounts up to 55 kcal/kg body weight/day for the first 2 days of treatment and up to 110 kcal/kg/day for 4 days thereafter. The clinical characteristics of the patients in each group were similar initially. Treatment failure rates in the two milk groups combined (M = 14.3%, HM = 20.0%) were greater than in the two noodle-milk groups combined (N-M = 3.4%, N-HM = 3.4%), p = 0.03. The average stool outputs by children in both M groups (range 40-66 g/kg body weight per day on all study days) were consistently greater than those by children in both N-M groups (range 29-50 g/kg/day). The differences by dietary group were statistically significant on days 3 and 4 (p less than 0.04, analysis of variance). The estimated median durations of illness [and 95% confidence limits (CL)] in each milk group (M = 138 h, CL: 88-214; HM = 113 h, CL: 75-170) were significantly greater than in each noodle-milk group (N-M = 52 h, CL: 35-76; N-HM = 67 h, CL: 45-100), p less than 0.001-0.071. In this group of patients, noodle-milk mixtures produced fewer treatment failures, lower fecal outputs, and shorter durations of diarrhea than did milk alone, regardless of the lactose contents of the respective milks or mixed diets. Small differences in intestinal absorption and changes in body weight by dietary group that were identified were of minor clinical importance during the short duration of study. Thus, the noodle-milk diets employed during this study were safer than the milk diets for the dietary management of children with acute diarrhea.

A nutrition education program was undertaken in Kwara State, Nigeria to improve infant feeding practices and nutritional status of weaning-aged children. A series of ethnographic, market survey, epidemiological, dietary, clinical, and communications research studies were implemented to develop a culturally acceptable, yet nutritionally adequate, weaning food. A premise of the project was that the development and introduction of any new weaning food should be based upon ingredients available in the community and to households, at a low cost and with minimum preparation time, and that would be culturally acceptable by mothers for feeding young children. Initially, research was conducted to define the problem in both nutritional and anthropological terms. Data was collected to describe: (1) present patterns of infant feeding and their determinants; and (2) dietary intake and nutritional status of infants in the intervention area. This paper focuses on the process of defining the problem and developing an intervention from an interdisciplinary perspective. The development of the new weaning food, Eko-Ilera, a fortified pap based on the traditional weaning food, is described.

Consumption of breast milk, liquids, and foods by 131 poor Peruvian infants was measured on 1661 child-days of observation during their first year of life. Breast-milk intake was estimated by 12-h test-weighing; macronutrients were analyzed in samples of milk. Other foods and liquids were weighed at preparation and consumption; nutrient contents were estimated from food composition tables. Mean energy intakes increased with age but declined from 95% to 78% of recommended amounts during the year. Mean protein intakes were generally above recommended amounts but more than one-third of infants received less than 80% of the suggested safe intakes in the second (6-mo) semester. Breast milk was the major source of energy and protein during the first semester. Breast milk and cow milk together contributed more than half the energy and protein during the second 6 mo, when cereals were also an important source of energy and protein. Mean intakes of calcium, thiamin, and ascorbic acid were less than recommended at some ages but mean intakes of other selected micronutrients exceeded recommendations.

To assess the effects of common infections on dietary intake, 131 Peruvian infants were observed longitudinally. Home surveillance for illness symptoms was completed thrice weekly, and food and breast-milk consumption was measured during 1615 full-day observations. Mean (+/- SD) energy intakes on symptom-free days were 557 +/- 128 kcal/d (92.4 +/- 26.5 kcal.kg-1.d-1) for infants aged less than 181 d and 638 +/- 193 kcal/d (77.7 +/- 25.7 kcal.kg-1.d-1) for infants aged greater than 180 d. Statistical models controlling for infant age, season of the year, and individual showed significant 5-6% decreases in total energy intake during diarrhea or fever. There were no changes with illness in the frequency of breast-feeding, total suckling time, or amount of breast-milk energy consumed. By contrast, energy intake from non-breast-milk sources decreased by 20-30% during diarrhea and fever, and the small decrements in total energy consumption during illness were explained entirely by reduced consumption of non-breast-milk foods.

The usefulness of a mixture of wheat noodles and a casein-based formula in the early management of 11 children with second or third degree malnutrition and of ten better nourished children with acute diarrhea was studied. Response of the malnourished children, gauged by clinical course and balance studies, paralleled that previously documented using only casein-based formula diets. Children with acute diarrhea recovered well but had expectedly higher fecal energy losses than previously seen in healthy children consuming the same diet. Diets containing substantial amounts of wheat noodles, a low cost widely available staple, can be appropriately used in the refeeding of chronic malnutrition and acute infectious enteritis.

Longitudinal studies of the consumption of foods and nutrients by 70 children between 5 and 30 months of age have been completed, during 632 individual days of observation in rural village homes in Bangladesh. Foods and prepared menu items for each child were weighed before serving; leftover food was subtracted from portions served to determine the amounts consumed. Breast milk intakes were estimated by test-weighing of children before and after all feedings during 12-h daytime periods and were corrected to 24-h consumption. All children between 5 and 12 months of age and 85% of children between 24 and 30 months were breast-fed; the average amount of breast milk received by these age groups declined from 632 to 368 g/day. Concurrently, the rate of consumption of cereals increased from 54 to 100% of children, and the amount received increased from 35 to 94 g/day. The children received an average intake of energy between 63 to 71 kcal/kg body weight/day and an average intake of protein between 1.2 to 1.5 g protein/kg body weight/day in the various age and sex categories. The absolute consumption of energy and protein increased with age, but the amount of energy per kg of body weight and the percentage of energy requirement for the amount of energy per kg of body weight and the percentage of energy requirement for length-age remained constant or declined in older girls. Vitamin A consumption, mostly from breast milk, averaged between 152 and 249 micrograms retinol equivalents per day, with younger children receiving more than older ones and boys receiving more than girls. Breast milk was the major source of all nutrients for younger children. Cereals provided more protein and iron than mothers' milk in older boys, but breast milk remained an important source of nutrients for all children.

Longitudinal studies of the feeding practices and morbidity from infectious diseases of 153 Peruvian newborns from an underprivileged, periurban community were completed during their first year of life. Feeding practices were assessed by monthly questionnaires, and illnesses were identified by thrice-weekly, community-based surveillance. All infants were initially breast-fed, but only 12% were exclusively breast-fed at 1 month of age. At 12 months of age, 86% of children still received some breast milk. Incidence and prevalence rates of diarrhea in infants younger than 6 months of age were less among those who were exclusively breast-fed compared with those who received other liquids or artificial milks in addition to breast milk. The diarrheal prevalence rates doubled with the addition of these other fluids (15.2% v 7.1% of days ill, P less than .001). Infants for whom breast-feeding was discontinued during the first 6 months had 27.6% diarrheal prevalence. During the second 6 months of life, discontinuation of breast-feeding was also associated with an increased risk of diarrheal incidence and prevalence. Upper and lower respiratory tract infections occurred with lesser prevalence among exclusively breast-fed younger infants. The prevalences of skin infections by category of feeding practice were not as consistent, but exclusively breast-fed infants tended to have fewer skin infections during the initial months of life and older infants who continued to breast-feed had fewer infections than those who did not. None of the results could be explained by differences in the socioeconomic status of the infants' families.

In longitudinal studies of infectious diseases and nutrition in Bangladesh, we determined the degree of bacterial contamination of traditional weaning foods and evaluated the role of these foods in the transmission of diarrhoeal diseases. 41% of samples of food items fed to weaning aged children contained Escherichia coli; these organisms were used as indicators of faecal contamination. Milk and foods prepared particularly for infants were more frequently and heavily contaminated with E. coli than was boiled rice, and E. coli levels were found to be related to the storage of cooked foods at high environmental temperatures. 50% of drinking water specimens also contained E. coli, but colony counts were approximately 10-fold lower than in food specimens. The proportion of a child's food samples that contained E. coli was significantly related to the child's annual incidence of diarrhoea associated with enterotoxigenic E. coli. This observation underscores the importance of seeking locally available foods that are hygienic as well as nutritious to supplement the diets of breastfeeding children in developing countries.

In a double-blind prospective trial, 64 children, 3 to 36 months of age, who had diarrhea for at least 14 days were randomly assigned to receive either a milk-based diet containing 6 g/kg of body weight per day of lactose or the same diet in which the lactose was greater than 95% prehydrolyzed with beta-galactosidase. Clinical and nutritional outcomes were compared. The groups were similar at the start of the study. Four of 33 patients (12.1%) in the lactose group were considered to have treatment failure because of excessive purging with or without refusal to accept the diet, compared with 1 of 31 patients (3.2%) in the hydrolyzed lactose group (P = .20). Among successfully treated boys, fecal excretion was initially similar, but on days 3 to 5 of the trial the lactose group purged a mean 74.4 g/kg per day (95% confidence limits 17.8, 131.0) compared with 42.0 g/kg per day (95% confidence limits 11.4, 72.6) in the hydrolyzed lactose group (P less than .01). Diarrhea stopped within 30 hours of hospital admission in 11 children in the hydrolyzed lactose group (35.5%) compared with 1 child in the lactose group (3.3%) (P less than .001). Fecal excretion of carbohydrate, nitrogen, and energy was significantly greater in lactose group (P less than .01), but there were no significant differences in fat excretion or in incremental weight change during hospitalization. Feeding lactose-containing nonhuman milk as the sole nutrient source to children with persistent diarrhea resulted in substantially greater purging which was sufficiently severe to increase the risk of dehydration in these children.

The deuterium oxide elimination method for measuring average daily milk intake was validated against measured formula intake in 16 studies of 11 infants in a metabolic ward. Deuterium oxide (approximately 0.10 g/kg body wt) was given orally. Deuterium enrichment was measured in urine samples collected predose, as available for 6-h postdose for TBW determination, and at 24 h and 5-10 d postdose for HDO elimination calculated according to the two-point method. Urine samples were vacuum distilled, water was reduced to hydrogen gas, and deuterium enrichment was measured by isotope-ratio mass spectrometry. Milk intake was measured throughout the elimination period from prefeeding and postfeeding bottle weights (n = 12) or volumes (n = 4). Without corrections for atmospheric water influx, milk intake was overestimated by 76 g/d (6%). With corrections for estimated metabolic water production, isotopic fractionation, and atmospheric water influx, deuterium measured 98% +/- 3% or 1300 g milk intake/d compared with actual milk intake of 1329 +/- 206 g/d.