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Background/objectives: Plasma zinc concentration is the preferred biomarker of zinc status, but the time of day and time since previous meals can modify the results. Measuring fasting plasma zinc concentration is not feasible among young children, so adjustments need to be developed for interpreting results. Our objective is to develop correction factors to adjust for the effects of time of day and interval since the previous meal when measuring plasma zinc concentrations of young children., Subjects/methods: We measured plasma zinc concentrations among young Peruvian (n =297) and Ecuadorian (n=466) children, and constructed regression models adjusting for time of day, interval since previous meal and infections., Results: Plasma zinc concentrations were positively related to the number of hours since the previous meal in the Peru trial (r =0.22, P<0.0001) and negatively related to the time of day of blood sampling in both Peru (r = -0.24, P<0.0001) and Ecuador (r = -0.18, P<0.001). In multivariate models, plasma zinc concentrations were ~2 μg per 100 ml less for each hour later in the morning when blood samples were collected, in both populations, and concentrations were ~1.0 μg per 100 ml greater for every hour since previous meal consumption in Peru. The percentage of children with low plasma zinc concentrations varied according to both these factors., Conclusions: The time of day and the interval since the preceding meal should be recorded when measuring plasma zinc concentration and incorporated into the statistical analysis and interpretation when assessing population zinc status.

The exact mechanism whereby zinc influences growth is unknown, although it has been postulated that zinc may stimulate appetite and energy intake or enhance fat-free mass (FFM) accrual directly. We compared energy intake, reported appetite, and body composition of 6- to 8-mo-old Peruvian children with initial length-for-age Z-score (LAZ) < -0.5 SD who were randomly assigned to receive daily for 6 mo: 1) 3 mg/d zinc in a liquid supplement; 2) 3 mg/d zinc in a fortified porridge; or 3) no extra zinc in either the supplement or porridge. There were no group-wise differences in changes in dietary energy intakes or body composition or in the prevalence of reported poor appetite. However, among children with an initial LAZ less than the median (-1.1 SD), those who received zinc as a liquid supplement had a 0.41 kg greater increase in FFM than those who did not receive zinc (P < 0.05). We concluded that daily provision of 3 mg of supplemental zinc did not affect energy intake or reported appetite. Among children with initial mild-to-moderate stunting, those who received the zinc supplement had a greater increase in FFM than those who did not receive additional zinc. It is possible that the growth-restricted children were more likely to be zinc deficient and that FFM accrual may be an early growth response to supplemental zinc. Zinc supplements may be more efficacious than the same dose of zinc provided in fortified food; therefore, further research is needed on the optimal level of zinc fortification that will result in improved health outcomes in populations with high rates of zinc deficiency.

Background: Leptin, ghrelin, and insulin are hormonal regulators of energy balance and, therefore, may be related to growth during infancy. Zinc is essential for growth, and its growth effects may be mediated through these hormones., Objective: We examined the effects of supplemental zinc on plasma leptin, ghrelin, and insulin concentrations among young children at risk of zinc deficiency and examined the relations between these hormones and physical growth., Design: Children (n = 142) aged 6-8 mo were randomly assigned to receive 3 mg Zn/d as a supplement, in a fortified food, or as a placebo for 6 mo. Relations between hormones and anthropometric z scores, body composition, and growth rates were examined at baseline and 3 and 6 mo after the start of the intervention., Results: No treatment group-related differences were found in plasma leptin, ghrelin, or glucose concentrations or in anthropometric z scores at 3 or 6 mo after the start of the zinc intervention. Neither plasma leptin nor ghrelin concentrations at baseline or 3 mo were predictive of subsequent changes in growth. However, changes in weight-for-age z scores over the two 3-mo time intervals were positively associated with subsequent leptin concentrations and inversely associated with subsequent plasma ghrelin concentrations., Conclusions: Supplemental zinc did not affect the children's growth, anthropometric indexes, or plasma hormone concentrations in this study population. Our results suggest that plasma leptin and ghrelin concentrations in later infancy are a consequence of previous weight changes rather than predictors of short-term growth.

Background: Zinc supplements reduce childhood morbidity in populations in whom zinc deficiency is common. In such populations, deficiencies in other micronutrients may also occur., Objective: The objective was to determine whether the administration of other micronutrients with zinc modifies the effect of zinc supplementation on children's morbidity and physical growth., Design: Two hundred forty-six children aged 6-35 mo with persistent diarrhea were randomly assigned to 1 of 3 groups to receive a daily supplement of 10 mg Zn alone (Zn; n = 81), zinc plus vitamins and other minerals at 1-2 times recommended daily intakes (Zn+VM; n = 82), or placebo (n = 83) for approximately 6 mo after the diarrhea episode ended. Morbidity information was collected on weekdays. Weight, length, and other anthropometric indicators were measured monthly, and plasma zinc and other indicators of micronutrient status were measured at baseline and 6 mo., Results: Supplement consumption was high ( approximately 90%) in all groups, although slightly more vomiting was reported in the Zn+VM group (P < 0.0001, analysis of variance). The change in plasma zinc from baseline to 6 mo was greater in the 2 zinc groups (6.1, 27.3, and 16.2 micro g/dL in the placebo, Zn, and Zn+VM groups, respectively; P < 0.0001, analysis of variance). The Zn group had fewer episodes of diarrhea, dysentery, and respiratory illness and a lower prevalence of fever and cough than did the Zn+VM group and a lower prevalence of cough than did the placebo group (P = 0.05). No significant effects of supplementation on growth were observed., Conclusion: Morbidity was greater after supplementation with zinc plus multivitamins and minerals than it was after supplementation with zinc alone.

Background: The deuterated-retinol-dilution technique provides a quantitative estimate of total-body vitamin A (TBVA) stores in adults. To apply the technique to children, information on plasma retinol kinetics in this age group is needed., Objectives: We described the plasma retinol kinetics of an oral dose of [(2)H(4)]retinyl acetate in a population of Peruvian children (12-24 mo of age) in order to examine the relation between TBVA stores and individual plasma isotopic ratios 3 d after the dose and to estimate 1) the time required for the isotope dose to mix with endogenous vitamin A, 2) the fractional catabolic rate for retinol, and 3) TBVA stores., Design: An oral dose of [(2)H(4)]retinyl acetate (14 micromol retinol equivalents) was administered to children (n = 107) to construct a population-level kinetic curve of the plasma ratio of [(2)H(4)]retinol to retinol to estimate equilibration time and the fractional catabolic rate. TBVA stores were estimated by using a modification of the isotope dilution equation for adults., Results: The dose of [(2)H(4)]retinyl acetate fully mixed with endogenous vitamin A 8 d after the dose. The fractional catabolic rate was 0.022/d (95% CI: 0.014, 0.030/d). Mean (+/- SD) TBVA stores were estimated as 0.097 +/- 0.081 mmol (range: 0.016-0.392 mmol). Plasma ratios of [(2)H(4)]retinol to retinol 3 d after the dose were correlated with the inverse of estimated TBVA stores (r = -0.74, P < 0.0001)., Conclusions: Compared with previous results in adults, the equilibration time occurred earlier and the estimated system fractional catabolic rate was higher in this population of children. The modified isotope dilution equation provided estimates of hepatic vitamin A concentration that are similar to values reported in US children at autopsy.

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.

Objective: To determine whether supplemental zinc, with or without additional micronutrients, affects the severity and duration of persistent childhood diarrhea and the rate of nutritional recovery., Design: The study was a community-based, double-blind, randomized trial implemented in a shanty town in Lima, Peru. Children aged 6 to 36 months with persistent (>/=14 days) diarrhea received daily, for 2 weeks, a placebo (group P, n = 136) or a supplement of 20 mg of zinc, either with (group Z+VM, n = 137) or without (group Z, n = 139) additional vitamins and minerals. Symptoms of illness were recorded daily, and biochemical and anthropometric assessments were completed at baseline and on day 15., Results: The treatment groups were similar at baseline with regard to the characteristics of the presenting episode, anthropometric data, and plasma zinc concentration. The children consumed, on average, 95% (group P), 94% (group Z), or 88% (group Z+VM) of the supplement (P <.001). The plasma zinc concentration did not change significantly from baseline to day 15 in group P (4 microg/dL) but increased by 38 microg/dL in group Z and 14 microg/dL in group Z+VM. The median duration of diarrhea after starting treatment was 1 day; among children who continued to have diarrhea, there was a significant effect of treatment on diarrheal duration (P =.04, analysis of covariance). Specifically, the duration of illness was significantly reduced by 28% in children in group Z (P =.01) and by 33% in girls in group Z+VM (P =.04). There were no differences in the severity of the episode by treatment group., Conclusion: There was a significant reduction in the duration of persistent diarrhea in selected subgroups of zinc-supplemented ambulatory patients in this population.

Background: Data from a longitudinal study of 153 low-income Peruvian infants were used to assess the relationship between internationally-recommended definitions of feeding practices and infants' monthly weight gain and weight status at 12 months., Methods: Infants were classified into feeding categories using monthly reported data. Analysis of variance was used to assess the relationship between reported usual feeding practices and growth. Reported breastfeeding practices were compared to observed breastfeeding practices and to weighted breast milk intakes to determine the validity of recommended breastfeeding definitions., Results: Breastfed infants who consumed non-human milks during the first month of life gained less weight during that month (P < 0.002) than exclusively and predominantly breastfed infants. Reported daily nursing frequency was associated with observed nursing frequency and breast milk energy intake (P < 0.05) for infants < 9 months old. Patterns of growth varied according to early diets. Infants who consumed breast milk and non-human milks and those who were fully weaned by 4 months were more likely to be underweight at 12 months than other infants. Infants classified as token breastfeeders ( < or = 3 times/24 hours) from 0 to 120 days had monthly gains that were similar to those of fully weaned infants., Conclusions: Infants feeding definitions should 1) continue to differentiate exclusively breastfed infants from other infants who are almost exclusively or predominantly breastfed; 2) distinguish partially breastfed infants who consume only non-breastfeeding frequency or the % of their total daily energy that comes from breast milk.

To assess the validity of maternal reports of poor infant appetite, these histories were compared with measured energy consumption on 1621 d of observation of 131 Peruvian infants in a low-income community. Mean (+/- SD) total energy intakes on days with reported anorexia were 338 +/- 88 kJ/kg body wt in infants 1-6 mo of age and 299 +/- 92 kJ/kg body wt in infants aged > 6 mo compared with 395 +/- 92 and 342 +/- 88 kJ/kg body wt in the respective age groups when appetites were reportedly normal (P < 0.001). Energy intake from non-breast-milk sources was more affected than energy from breast milk. The epidemiology of poor appetite was assessed in 153 infants who were monitored longitudinally during their first year of life. The prevalence of reported anorexia increased progressively from 22 to 317/1000 d of observation from < 1 to 11 mo of age. Infant age and the presence of fever, diarrhea, and respiratory illnesses were each associated negatively with the presence of reduced appetite. Poor appetite, rather than lack of food, may explain in part the low energy intakes by infants in this community.

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.

Objectives: To determine appropriate indicators and age intervals for growth monitoring in this population, the relationship between monthly weight and length indicators and nutritional status at 12 months was evaluated among 102 low-income Peruvian infants., Methods: Cutoffs for defining adequate vs slow growth were obtained from published reference data, and sensitivities and specificities of each indicator were calculated., Results: Low weight gain in early infancy, especially from 1 to 2 months, is useful for predicting low weight at 1 year (sensitivity = 81%, specificity = 65%, 25th percentile cutoff). Use of actual weight at 2 months, however, produces comparable results (sensitivity = 86%, specificity = 57%, 50th percentile cutoff). Monthly length gains were weak predictors of low length for age. Neither weight nor length gains accurately predicted the opposite form of undernutrition. Nonhuman milk consumption before 4 months and poor appetite from 3 to 12 months were related to low early weight gain and subsequent undernutrition., Conclusions: Growth monitoring programs in this population should enroll infants at birth, monitor actual weight, promote exclusive breast-feeding and delayed introduction of nonhuman milk, and provide specific feeding advice to mothers of infants with frequently depressed appetite.

Objectives: (i) To examine the components of variation in infant energy intake. (ii) To calculate the precision of estimates of energy intake from different sources. (iii) To estimate the number of dietary studies required to estimate true energy intake with varying degrees of precision., Design: Energy intakes were determined from monthly 12-h observations with test-weighing of breastmilk and all foods consumed. Variance components were evaluated by pooling results of studies performed when infants were 1-4, 5-8 and 9-12 months old., Setting: Pueblo Joven Huáscar, a low-income, peri-urban community in Lima, Peru., Subjects: 124 infants who were enrolled at birth and followed monthly., Results: Within-to-between infant variance ratios were > 1.0 for total energy and energy from solid foods, and < 1.0 for energy from breast- and non-human milks during the 4-month periods examined. Total energy and energy from breastmilk were estimated to within 13-24% of infants' true intake. Non-breastmilk energy was estimated to within 19-143% of true intake. Four dietary studies per age period are required to estimate total energy and breastmilk energy consumption with 20-30% precision. At least 16 studies are required to estimate infants' average energy intake from solid foods from 5-8 months with 30% precision., Conclusions: The degree of precision achieved during assessment of infants' usual energy intake changes with age and composition of the diet. Thus, the number of dietary studies required to obtain a fixed level of precision differs according to these characteristics.

This study investigated the practices followed by physicians in the clinical, therapeutic, and dietary management of children under the age of 5 with diarrhea. A total of 148 physicians were observed while they provided outpatient services at various public and private health institutions in two areas of Peru. They were also interviewed to assess their theoretical knowledge about the proper management of diarrhea in children. The physicians treated 222 children under 5 with diarrhea. It was observed that in taking their clinical histories the physicians ascertained the duration of the problem, the number of bowel movements, their consistency, and the presence of fecal mucus or blood in 175 (79%), 158 (71%), 140 (63%), and 153 (69%) cases, respectively. Antibiotics were prescribed for 130 children (58%), and 102 (46%) were not given any oral rehydration therapy (ORT). The oral rehydration salts (ORS) were recommended to only 40 (18%) of the children. On the other hand, during the interviews only 38 physicians (26%) indicated that they prescribe drugs for diarrhea, while 110 (74%) said that they recommend ORT. Fewer than half the mothers received recommendations regarding the type of food that they should give their children during the diarrhea episode. The results reveal a sizable discrepancy between theory and practice in the medical management of childhood diarrhea, which means that it is necessary to instill in physicians the importance of assessing and treating children with diarrhea according to a uniform and systematic scheme that includes careful therapeutic and dietary guidance.

To examine the effects of concurrent infection on population-based assessment of trace element status, we collected data on clinical signs and laboratory indicators of infection when obtaining blood for serum zinc, copper, and ferritin analyses in 153 Peruvian children aged 11-19 mo. Fifty-two (34.7%) of the children had some reported sign of infection and 43 (28.3%) had elevated C-reactive protein concentrations or leukocytosis. Children with any evidence of infection had marginally lower mean (+/- SD) serum zinc concentrations (7.0 +/- 2.3 vs 7.5 +/- 2.0 mumol/L, P = 0.16) and significantly greater serum copper (24.7 +/- 4.7 vs 22.7 +/- 4.2 mumol/L, P = 0.006) and serum ferritin concentrations (10.0 +/- 12.9 vs 3.9 +/- 4.4 micrograms/L, P < 0.001) than did those without infections. Infection caused an underestimation in the rate of low copper status by 1 percentage point and low iron status by 12 percentage points. Thus, the effect of concurrent infections is of variable magnitude and may differ by nutrient, nutritional status of the population, and prevalence and severity of infections.

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.

Dietary intake during diarrhea in children less than three years of age was estimated from information recorded on illustrated dietary forms used by children's caretakers during the first week of illness in a prospective community-based study of diarrheal diseases in Lima, Peru. The frequency of consumption and the amount consumed of food groups and selected commonly consumed foods were analyzed by the final duration of the diarrheal episode. Cereals were less frequently consumed during the acute phase of diarrheal episodes that ultimately became persistent (> 14 days' duration), apparently shortening the duration of the episode by one day (median duration of four days in children not consuming vs three days in children consuming cereals during diarrhea, p < 0.02 Kaplan-Meier log-rank test). Only roots and tubers (mainly potatoes) were consumed in greater quantity during episodes that became persistent. There was no evidence that consumption of breast milk or non-maternal milk was associated with an alteration in diarrheal duration. This study provides further evidence of the beneficial effects of continuing feeding during diarrhea using foods available at the home level, especially cereals, which are commonly used in the diet of young children.

The observed variances in monthly weight and length gains of 96 Peruvian infants were compared with predicted variances obtained by applying the reference curve-fitting methods to the same Peruvian data. Predicted variance estimates were significantly less (P less than 0.0001) than the observed variances from 2 to 12 mo of age. The extent of underestimation in total variance that occurred when 1-mo growth-increment reference data were generated by curve-fitting and interpolation was approximated. This underestimation, caused by not taking into account infants' random deviations from their own growth trajectories, ranged from 59% to 94% and resulted in misclassification of approximately 24-67% of infants as abnormal gainers (below the 5th percentile or above the 95th percentile with respect to existing reference data) in the intervals evaluated.

A double-masked clinical trial was conducted to assess the effects of inclusion of beans in a mixed diet for young Peruvian children with acute diarrhea. Dietary treatment consisted of either rice, beans, and vegetable oil (group RB, n = 25) or rice, soy-protein isolate, corn syrup solids, and vegetable oil (group RS, n = 21), each given in amounts up to 150 kcal/kg body weight per day immediately following rehydration therapy. The groups were generally similar at the time of admission, and there were no differences in the rates of treatment failure (8% in group RB, 14% in group RS; P = .65). Mean stool outputs were 83 +/- 46 (SD) g/kg body weight in group RB and 71 +/- 43 g/kg body weight in group RS on day 1, and these outputs consistently ranged from 25% to 40% greater in group RB than in group RS (P = .058). By contrast, the median duration of liquid stool excretion was substantially less in group RB than in group RS (60 vs 121 hours, P = .01). The fractional absorption of carbohydrate, fat, and total energy was significantly greater by children in group RS, but there were no differences in net apparent absorption of these nutrients because the children in group RB consumed significantly more of their assigned diet. Children in group RS gained significantly more weight during the whole period of observation (194 g vs 1 g, P = .047), but these differences could be entirely explained by the weight (and presumably fluid) changes on day 1. There were no consistent differences by dietary group in any of the other anthropometric indicators.(ABSTRACT TRUNCATED AT 250 WORDS)

This study assessed feeding practices in relation to diarrhoea among 2,599 children, aged 0-3 years, in the highlands of central Peru. A high prevalence of diarrhoea was observed, with 18% of the children ill with diarrhoea the preceding day. With few exceptions, the presence of diarrhoea did not alter the types of foods actually offered to young children. Caretakers, however, reported that children with diarrhoea should be given different foods. Appetite for breastmilk was reported by mothers to remain normal for children with diarrhoea; however, appetite for nonhuman milk and solid food was reported to decrease substantially. Since data on amounts of food consumed were not collected, whether the total nutrient intake was reduced due to decreases in amounts of food consumed can not be determined from this study. The major findings are that although mothers report reducing the types of foods offered to their sick infants, in actuality the types of foods offered vary little during illness. However, because mothers are quite concerned about the lack of appetite among young children, they may be particularly amenable to changing feeding practices following diarrhoea episodes. The promotion of improved complementary foods and feeding practices during and after diarrhoea may be an ideal method by which to improve weaning practices in Peru.

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.

Although few episodes of diarrhea last longer than 14 days these episodes are particularly associated with growth faltering and malnutrition. We have examined the role of the duodenal microflora in prolonging diarrhea in Peruvian children ages 3 to 36 months by comparing the microflora in 89 children with persistent diarrhea, 38 children with acute diarrhea and 34 diarrhea-free controls from the same environment. Bacteria were retrieved from 93% of all aspirates, including 94% of those from controls. There were no significant differences among the 3 groups with respect to total bacterial count, to the proportion of children with duodenal Enterobacteriaceae and to the proportion with anaerobes, lending no support to the hypothesis that proliferation of bacteria in the small intestine during the acute illness prolongs diarrhea. When only children older than 18 months were compared, anaerobes were cultured more frequently from those with persistent diarrhea than from controls, but the presence of anaerobes was not associated with adverse clinical outcome. Although malabsorption, especially steatorrhea, was common, there was no association between elevated bacterial counts and fecal loss of nutrients in 69 children who received the same diet. In this population steatorrhea could not be attributed to bacterial overgrowth.

Longitudinal studies of morbidity from infectious diseases and physical growth were completed from July 1982-June 1984 for 153 Peruvian newborns during the first year of life. Admission to the cohort was restricted to infants with birth weights greater than 2,500 g. Surveillance workers inquired about symptoms of diarrheal, respiratory, and other illnesses during thrice-weekly home visits; anthropometrists measured weight and length each month to assess the infants' patterns of physical growth and relative nutritional status. During 48,209 child-days of observation, upper respiratory infections were present on 13,409 child-days (27.8% prevalence) and diarrhea on 7,466 child-days (15.5% prevalence). The diarrhea incidence rate averaged 9.8 episodes per child-year of observation; all children had at least one episode of diarrhea. Average weights approximated those of the National Center for Health Statistics reference population during the first five to six months, but declined thereafter in relation to reference data. Average lengths were less than the reference data at all ages. The average weights for age and lengths for age of girls were generally greater than those of boys relative to the reference population. Rates of stunting and wasting increased progressively during the first year of life.

Community-based studies of diarrhea etiology and epidemiology were carried out from July 1982-June 1984 in 153 infants residing in a poor peri-urban community near Lima, Peru. Study infants had nearly 10 episodes of diarrhea in their first year of life. Diarrhea episodes were associated with organisms such as Campylobacter jejuni, enterotoxigenic and enteropathogenic Escherichia coli, Shigella, rotavirus, and Cryptosporidium. These organisms appeared to be transmitted to infants in the home through animal feces, through contaminated water and food, and by direct person-to-person contact. A particularly important route of transmission may have been weaning foods, which were often contaminated because of improper preparation and inadequate cleaning of utensils. Improved feeding practices, along with avoidance of animal feces and improved personal and domestic hygiene, should be considered important interventions in reducing the high incidence of diarrhea in infants in developing countries.

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.

To assess the hydration status of 40 exclusively breast-fed Peruvian infants, their milk intake and urinary volume and concentration were measured during 8-hour daytime observations. Maximum home temperatures ranged between 26 degrees and 33 degrees C; environmental relative humidity ranged between 49% and 96%. The infants consumed between 105 and 528 gm milk during the observation period; the standardized intakes ranged between 4.0 and 12.1 gm/kg body weight per hour (mean +/- SD 7.5 +/- 1.7 gm). The infants voided between 0.9 and 6.3 ml urine per kilogram of body weight per hour (mean +/- SD 3.4 +/- 1.3 ml). The maximum urinary specific gravity in each infant ranged between 1.003 and 1.017. We conclude that healthy infants can maintain adequate hydration status while exclusively breast-fed under these environmental conditions.

This paper reports on a rapid ethnographic assessment methodology (REA) that was developed as an essential component of the dietary management of diarrhea (DMD) program. The DMD program is an interdisciplinary research project that has been developed to design intervention programs to reduce or eliminate the nutritional complications of diarrhea in Peru and Nigeria. Anthropological data gathering was an important component of the intervention design, but time and budgetary constraints required a rapid methodological approach. This paper outlines the REA methodology, describes the advantages and disadvantages of the approach, and discusses future applications for international primary health care interventions.