Search

Objective. To evaluate the adequacy of protein intakes now recommended as safe for infants and toddlers. Methods. Subjects were recovering malnourished infants, age 5.3 to 17.9 months, length age (LA) 2.5 to 6.4 months, weight age (WA) 1.5 to 5.2 months, weight/length (W/L) 78% to 100% of National Center for Health Statistics data; and toddlers age 11.4 to 31.6 months, LA 6.1 to 17.9 months, WA 3.9 to 12.0 months, W/L 79% to 99%. Infants were assigned at random to formulas with 5.5%, 6.7%, or 8.0% energy as 60:40 whey:casein protein. The 5.5% was based on FAO-WHO-UNU safe protein and average energy for ages 2.5 to 6.0 months. Toddlers received 4.7% (recommended for 6 to 18 months), 6.4%, or 8.0%. Identical concentrations (weight/kcal) of other nutrients were maintained; intakes were adjusted weekly to reach, in 90 days, the 50th percentile of weight for a LA 3 months greater than the initial one. Results. Infants consumed 125 ± 11 (SD), 116 ± 10, and 126 ± 14 kcal and 1.7 ± 0.1, 1.9 ± 0.2, and 2.5 ± 0.3 g protein Kg-1· d-1; gained 2.4 ± 0.7, 2.9 ± 0.7, and 2.6 ± 0.5 months in LA, and reached a W/L of 105 ± 5, 103 ± 6, and 105 ± 5% of reference. Sum of four fat-folds (Σ FF) grew 13.1 ± 6.9, 10.4 ± 4.8, and 11.7 ± 5.3 mm to 32.5 ± 5.2, 31.7 ± 4.7, and 30.5 ± 5.5 mm; arm muscle areas (AMA) 57%, 51%, 70% to 1004 ± 109, 1017 ± 110, and 1004 ± 116 mm2, still low; arm fat areas (AFA) 93%, 66%, and 93% to higher-than-normal 598 ± 105, 610 ± 101, and 541 ± 116 mm2. Regression of intake on weight gain estimated energy for maintenance + activity to be 81.0 ± 7.5 (SEM) kcal · kg-1· d-1, and cost of gain (storage + metabolic cost) as 7.6 ± 1.7 kcal/g, with no significant effect of % protein. Toddlers consumed 107 ± 9, 103 ± 12, and 105 ± 10 kcal and 1.3 ±0.1, 1.6 ± 0.2, and 2.1 ± 0.2 g protein kg-1 · d-1; gained 3.3 ± 0.7, 2.9 ± 0.6, and 3.3 ± 0.7 months in LA; to a W/L of 102 ± 1, 102 ± 3, and 101 ± 4%. Σ FF grew 9.2 ± 4.0, 7.4 ± 4.3, and 6.0 ± 3.8 to 28.9 ± 5.2, 30.5 ± 3.7, and 27.0 ± 2.7 mm; AMA 31%, 33%, and 34% to 1121 ± 115, 1124 ± 110, and 1117 ± 120 mm2; AFA 53%, 44%, and 45% to higher-than-normal 578 ± 106, 636 ± 99, and 569 ± 68 mm2. Cost of maintenance + activity was 70.8 ± 3.8 (SEM) kcal · kg-1 · d-1, that of weight gain 9.7 ± 1.35 kcal/g, with no effect of % protein. Conclusions. Within age groups, there were no significant protein-related differences in growth. In both infants and toddlers, high-energy intakes resulted in mild obesity, with lean body mass still deficient. Protein intakes two SD below the means in the lowest protein/energy cells, 1.5 g · kg-1 · d-1 for infants and 1.1 g · Kg-1 · d-1 for toddlers, should still be safe for nearly all children of comparable biological ages.

Fecal carbohydrate in human metabolic balance studies is normally determined using a calculation method where fecal energy (kcal) from protein and fat is subtracted from total fecal energy, and divided by 4.1 kcal/g, the heat of combustion of carbohydrate. This method, however, has not been validated. In this study fecal carbohydrate in 17 preschool children, consuming diets containing cassava, amaranth, maize, or a casein control diet, was determined analytically as fiber and starch. A correlation coefficient of r=0.856 (P

Few advances would contribute more to the growth and well-being of infants and children in the developing world than the making available of acceptable staple foods that are easy to grow and process nutritionally complete enough to serve as the major weaning food and safe without refrigeration. High-fat quality-protein maize (QPM) grown in Mexico had > 10% of its energy as well-balanced protein and > 15% as fat. When it was fed to 6 recovering malnourished infants to provide 85 to 88% of dietary energy all of 9.8% protein calories and all of 13.5% fat calories it was easily consumed and tolerated. In comparison with a fiber-free casein-based diet fecal wet and dry weights of children consuming 2 varieties of high-fat QPM were 3 to 4 times greater and apparent digestibilities of energy were 86 +or- 3 and 86 +or- 4 vs. 97 +or- 1% of carbohydrate 88 +or- 3 and 89 +or- 5 vs. 100% and of nitrogen (N) 77 +or- 4 and 75 +or- 4 vs. 89 +or- 2% of intake. High "biological values" 43 +or- 10 and 46 +or- 13 vs. 43 +or- 10% of absorbed N led to comparable apparent N retentions: 33 +or- 8 and 35 +or- 9 vs. 38 +or- 9% of intake. Results were similar to those from earlier studies with Peruvian QPM with a typical fat content. Fat absorptions from QPMs were nearly complete equal to those from separated vegetable oils in the casein diet. Breath H2s were suggestive of significant colonic salvage of incompletely digested maize carbohydrates. (authors)

Summary: An infant formula based on high protein rice flour, with added lysine and threonine, was evaluated in recovering malnourished infants. Acceptability, tolerance, and the digestibility of most major nutrients (energy 93.9 ± 0.7%, fat 96.9 ± 0.3%, carbohydrate 96.8 ± 0.6% of intake) were excellent. Digestibility of protein, as with all rice products, was moderately low (80.1 ± 3.3%), but its high biological value made N retention equal to that from casein. Plasma-free amino acids were consistent with the low essential/total amino acids ratio found in cereals, with slower absorption, and with the possibility that leucine was the first-limiting amino acid. Absorptions of Ca, Mg, PO4, and Zn were considered satisfactory. Energy costs of weight gain and the estimated percentage N in the weight gained during 14 days were comparable to those attained with the highest quality cow's milk-derived formulas in children of similar ages and nutritional status.

Whole groat flour was consumed by nine infants and young children as 22.5, 45, or 67% of total diet energy (one half of 6.4%, all of 6.4%, or all of 9.6% protein energy). Isonitrogenous and isoenergetic casein control diets were given. Apparent absorption of oat nitrogen (N) was consistently around 75% of intake (casein, 87%), but absorptions of oat energy, carbohydrate, and fat, as percentages of intake, decreased disproportionately as oat flour intake was doubled and then tripled. Apparent retentions were 39 +/- 5% of mixed oat-casein protein intake in the 22.5% diet, the preceding and following casein controls being 38 +/- 8% (NS) and 44.4% (p less than 0.05) of the intakes; 32 +/- 6% from oats in the 45% diet, controls 38 +/- 5 and 46 +/- 5% (both p less than 0.05), and 33 +/- 11% from oats in the 67% diet, controls, 36 +/- 9% (NS). Fasting plasma free total essential amino acid (TEAA) levels of children consuming 45% oats were low (562 +/- 119 mumol of TEAA/L) and did not change significantly after meals. Fasting molar proportions of individual essentials (millimoles of EAA per mole of TEAA) were similar to those from milk protein diets and did not vary significantly 3 and 4 h after feeding, suggesting that no individual amino acid, but rather protein digestibility, was first limiting to N retention. Oats are a satisfactory source of energy, protein, and fat for very young children and many infants.

Nutritionists, including those involved in famine relief, have learned in the last 25 years that certain deficiency diseases arise from the high protein foods used to rehabilitate starving populations. Other, sometimes inappropriate relief foods starving populations. Other, sometimes inappropriate relief foods include unprocessed or inappropriate grains and unfortified dry skimmed milk. Yet, relief workers do not always receive the most appropriate food for distribution to certain populations. Millions of dollars are appropriated to protect relief supplies for starving people in Somalia, but money is not spent to develop and evaluate simple foods that might save the lives of starving people. There are several items relief agencies and governments should consider when deciding on the most appropriate foods to prevent starvation in famine situations. During kwashiorkor, intestinal mucous produce grossly defective cells, resulting in considerable lactose malabsorption. Thus, using milk to rehabilitate people, especially children, poses a considerable hazard. High carbohydrate diets to rehabilitate starving people can cause gross edema and fatal congestive heart failure. Generally, clinically apparent vitamin or mineral deficiencies do not occur during famines, because the amount of vitamins or minerals needed to small to maintain a very shrunken body. Yet, when the body demand increases as a result of a rehabilitation diet poor in vitamins and minerals but high in protein or calories, clinical deficiency symptoms emerge, e.g., pellagra in Mozambique. Common food combinations used in relief situations consists of corn, soy, and milk fortified with vitamins and minerals (Bal'ahar mixture, India). Both mixtures require the addition of vegetable oils to make it easier for infants and small children to digest the mixtures.

Metabolic balance studies were carried out in young children fed diets based on maize, amaranth, or cassava flours and in corresponding casein controls. Dietary fiber intakes were 22.2, 20.5, and 9.0 g/day for the maize, amaranth, and cassava groups, respectively. Fecal energy losses at least doubled in all test diets when compared with the corresponding controls and could generally be accounted for by recovered fiber in the feces. Fecal starch was also a significant contributor to fecal energy in the cassava group. All cassava fiber was recovered in the feces, whereas only 48.4 and 16.3% were recovered from ingested maize and amaranth. 2,6-Diaminopimelic acid (DAPA), an indicator of bacterial mass, was highest in the cassava group. Expired breath hydrogen was highest for those consuming maize or cassava. Resistant starch may have been responsible for the high DAPA and breath hydrogen values in the cassava group.

In Reply.—Discussions of WIC often ignore the original 1972 legislation and its extensions: there are three related but different programs. Prenatal supplementation is credited with prolonging gestation, increasing birth weights, and enhancing infants' cognitive skills. Although one third of all births are covered, these laudable goals have not been reached and our worst pediatric problem, very low birth weight and its consequences, causes ever more human suffering and enormous costs among the population groups that WIC is supposed to reach.1Either the program is poorly targeted or the problem is not nutritional, or both. Although it does no harm and may help a small minority of truly undernourished pregnant women, it continues to divert much attention and considerable resources away from the research needed and the preventive, mostly educational, programs that can do something effective.2 For children younger than age 5 years WIC provides a generous dietary supplement: few

Normal infants exhibited circadian rhythmicity of plasma F concentration. Infants from 2.1 to 3.2 months of age had CSR significantly higher than those of older infants. THF/THE urinary excretion ratios increased with age. The 17OHCS excretion was higher in the younger infants. Urinary excretions of free corticoids and cortisol were similar in all age groups. In marasmus, plasma F concentrations in the morning and evening were significantly elevated. Normal diurnal variation returned following therapy. CSR and 17OHCS excretions were not different from age controls, but were significantly lower than size controls. THF/THE ratios, urinary excretion of free corticoids and cortisol were normal. In marasmic kwashiorkor, plasma F concentrations were significantly elevated in the morning and evening. There was a suggestive decrease with therapy. CSR was low before and after treatment. THF/THE ratios, urinary 17OHCS excretion, and urinary free corticoids and cortisol were not significantly different from infants matched for size or patients with marasmus.

To determine whether increasing proportions of cassava could be consumed and satisfactorily digested, eight recovering malnourished children (20-38 mo old) received 25, 50 and 75% of their diet energy as freeze-dried cassava flour during 9-d periods, with intervening casein control diets. Enough casein was added to all cassava diets to bring protein energy to 8% of the total. When compared to the control diet, the 25% diet had no significant effect on consumption time or measures of protein and energy digestion. With the 50% diet, fecal wet and dry weights were moderately higher than with the 25% diet (196 +/- 44 and 24 +/- 4 vs. 121 +/- 36 and 16 +/- 3 g/d, respectively), as were fecal energy (89 +/- 16 vs. 63 +/- 16 kcal/d) and calculated carbohydrate (11 +/- 2 vs. 5 +/- 1 g/d); apparent nitrogen absorption (mostly from casein) was slightly lower (79 +/- 5 vs. 83 +/- 6%) and consumption time slightly higher (5-25, median 10, vs. 4-18, median 6 min/feeding). When energy from cassava was increased to 75%, fecal weights (240 +/- 49 and 31 +/- 5 g/d), energy (124 +/- 27 kcal/d) and carbohydrate (16 +/- 4 g/d) were all higher than when cassava provided 50 or 25% of energy. Consumption required 8-34, median 17 min/feeding and apparent nitrogen absorption was 76 +/- 6% of intake.(ABSTRACT TRUNCATED AT 250 WORDS)

The quality of the protein in a complete tube feeding formula intended for use in adults was evaluated in convalescent malnourished children. The casein-soy protein isolate blend was found to be similar to casein by comparative nitrogen balance studies carried out in five children, with protein providing 6.4% of calories. Three- and four-hour postprandial plasma free amino acid determinations at the same level of protein intake did not show the drop of plasma free methionine or of the methionine/total essential amino acid molar fraction characteristically seen when this amino acid is first limiting for protein synthesis. Three additional children were fed the formula, altered only by the addition of water, for periods of up to 3.6 months to test the tolerance to and completeness of the diet. No untoward effects nor signs of specific nutrient deficiency were encountered. Linear growth was appropriate for the stage of recuperation. The failure to achieve a normal (greater than 3.8 g/dl) serum albumin concentration in two of the three children may have been due to their rapid weight gain. Although it is intended for the adult, our results indicate that the formula could meet the nutritional requirements of infants and children.

The course of 61 infants admitted for treatment of chronic diarrhea and malnutrition was reviewed. 30 children had (M) marasmus, 18 (K) kwashiorkor, and 13 (MK) marasmic kwashiorkor. After initial rehydration, infants were managed with a predominantly oral nutrition regimen utilizing a formula based on whole protein (casein), vegetable oil, glucose, and sucrose. Intravenous fluids were required for 38 infants (62%) for a median duration of 6 days, principally for the delivery of antibiotics, although amino acids were added in many instances. Feedings were started at 25 kcal/kg/day and were increased 35 kcal/kg/day every other day until acceptable steady weight gain ensued, provided that stool ouput did not exceed 100-50 gm/day and stool character was improving. Infants with M and MK reached a maximum intake of 151 + or - 21 kcal/dg/day after 5 weeks of treatment. Weight gain had been occurring for 2 weeks prior to this time. Infants with K were purposely not advanced past 75 kcal/kg/day until edema had cleared; a maximum intake of 135 + or - 16 kcal/kg/day was reached at 5 weeks. Mean initial serum albumin concentration in these infants with K was 1.8 + or - 0.3 gm/day and required 20 + or - 13 and 53 + or - 24 days to exceed 2.0 and 3.6 gm/dl, respectively. 14 of the 61 infants were moribund on arrival and died within the first 3 days; the remaining 8 died of overwhelming infection (6 generalized and 2 pneumonia). Data suggest that once infection is controlled, infants with chronic diarrhea and malnutrition can usually be effectively managed by enteral feeding without resorting to parenteral alimentation.

Infants consumed 75% of calories as 82% extraction wheat flour with satisfactory short-term protein and energy digestion. Protein needs, repre sented by N retentions from casein, probably were not satisfied. Long-term (3+ months) studies in four infants showed that 50% calories and 80% protein from wheat (casein added to 8% protein calories) supported weight gain and linear growth more than expected. Prolonged feeding of 75%calories and 100%protein from wheat was attempted in three infants. In the oldest (15.5 months), digestibility and growth was satisfactory; in one, despite good digestion, weight gain and growth was inadequate and serum albumin fell until 0.2% lysine was added; and in another, weight gain was satisfactory but albumin fell to 3.25 g/dl and growth was inadequate. In six other infants, lysine addition during the 2nd of 3 months was associated with significant increase in N retention and weight gain and stabilization of albumin; lysine withdrawal resulted in significant decrease in weight gain with no effect on N retention or albumin; growth was barely adequate during 3-month study. Serum cholesterol fell only when dietary protein was inadequate. It is practically impossible for unsupplemented wheat to satisfy protein needs of infants and most small children. J. Nutr. Ill: 1917

Fasting and postprandial plasma free amino acids were studied in nine children on the 9th day of consumption of a diet in which potato protein provided all nitrogen at a marginal level of protein intake (5.03-5.10% protein-calories). The analysis of the potato utilized indicated that 49% of total amino acids (TAA) were free amino acids (AA) and 40% essential amino acids (EAA). Fasting values of TAA and total essential amino acids (TEAA) and the ratios of EAA/TEAA were similar to those obtained previously with milk or casein diets. The low percentage of protein-calories in the diet and relatively poor nitrogen absorption of the potato were reflected in a low (0.236) fasting TEAA/TAA ratio. Met/TEAA and Trp/TEAA ratios were significantly (P less than 0.05) but not markedly lower 3 hours postprandially compared to fasting values, returning to the initial levels 4 hours postprandially. Thr/TEAA ratio was significantly higher (p less than 0.05) at 3 hours but not so at 4 hours. The results suggest that potato protein has an adequate ratio of TEAA/TAA and the balance among individual EAA concentrations should be able to meet the EAA requirements of growing infants and small children if fed and absorbed in sufficient amounts to meet total nitrogen needs.

Energy intake is known to affect the efficiency of nitrogen (N) utilization. Less is known about the effect of protein intake on energy metabolism by the growing human. Initial observations were made on a single child consuming successive isoenergetic diets in which protein intake was varied in five levels between 1.0 and 2.0 g/kg per day. Rate of weight gain varied from 2.1 (low protein) to 8.4 (high protein) g/kg per day. The estimated percentage of N in the weight gained was relatively constant during all five dietary periods. Six children were subsequently studied while consuming diets in which protein provided 4, 5.3, 6.4 to 6.7, and 8% of energy intake during randomly assigned dietary periods. Mean rate of weight gain varied from 2.8 ± 2.4 (4% protein energy) to 6.7 ± 1.2 (6.4-6.7% protein energy) g/kg per day (P < 0.05). As protein intake increased from 6.4 to 6.7 to 8% of energy, no further increase in rate of weight gain appeared to occur. Assuming the cost of weight gain to be 5.6 kcal/g, a mean of 16.8 ± 7.9% of energy used for weight gain at the upper levels of protein intake was "wasted" at the lowest level of intake. Reanalysis of studies in which protein quality of wheat protein was improved by incremental supplements of lysine also demonstrated a similar effect of protein quality on weight gain. In addition, the estimated percentage of N in the weight gained did not differ significantly among dietary periods. The data suggest that energy utilization is remarkably sensitive to both the quantity and quality of protein in the diet. These findings have implications in a number of clinical settings in which there are attempts to improve weight gain by "pushing calories" without providing adequate protein. In addition the data raise questions concerning the current Food and Agriculture Organization/World Health Organization recommendations for protein and energy intakes by children in the 6-month to 3-year age groups. Am. J. Clin. Nuir. 32: 138 1-1387, 1979.

BLOOD GLUCOSE, INSULIN (IRI), growth hormone, and plasma free fatty acids (FFA) were determined in six children consuming a diet of uneven distribution of protein relative to energy (study period). Preprandial and postprandial samples surrounding the 8 AM protein-free feeding and the 3 PM feeding containing all the day's protein were compared with values obtained in the same children similarly sampled while consuming an isonitrogenous isoenergetic diet of even protein distribution (control period). After the 8 AM feeding during the study period there was a mean maximal rise of blood glucose at 30 min of 51 mg/dl compared with a rise of 16 mg/dl during the control period. Glucose remained significantly elevated above fasting values at 120 min during the study but not the control period. IRI response after the 8 AM feeding was significantly greater and suppression of FFA was more marked during the study than during the control period. Glucose concentration 30 min after the 3 PM feeding was significantly lower during the study period than during the control period. A peak value occurred at 60 min during the study period which was equal to the 30 min peak control value. Despite the slower elevation of blood glucose during the study period, IRI rose at 30 min, possibly related to a larger influx of amino acids from the protein-containing meal. FFA rose at 30 and 60 min and were then suppressed by the slowly rising blood glucose. Growth hormone after both meals while consuming both diets was variable but considered normal. The qualitative changes in glucose-IRI-FFA responses were for the most part attributable to differences in the test meals and suggested little long-term adaptation to the uneven protein distribution diet.

The ability of infants with protein-energy malnutrition to absorb iron was assessed using the serum iron response to a dose of ferrous sulfate providing 3 mg elemental iron per kg body weight. Responses were grouped as flat (delta serum Fe less than 30 microgram/dl), intermediate (30 to 100 microgram/dl), and normal (greater the 100 microgram/dl). Of 25 consecutively admitted children studied, seven had a flat, five an intermediate, and 13 a normal curve (mean delta serum Fe: 10 microgram/dl, 66 microgram/dl, and 175 microgram/dl, respectively). There were no differences among the three groups in hematocrit, fasting serum iron or transferrin saturation, severity of malnutrition, or evidence of other malabsorption sufficient to explain these differences. Although hematocrits, fasting serum iron, and transferrin saturations did not change appreciably during nutritional rehabilitation, all children with initially abnormal responses subsequently had normal tests.

Eighteen Peruvian children with protein-calorie malnutrition were studied to evaluate the usefulness of the limulus assay for endotoxin in detecting gram-negative sepsis. Nine of the children had at least one positive Limulus assay, and eight of this group had bacteriologic cultures indicative of gram-negative infection. Four of these nine children with positive Limulus assays died, whereas only one of the nine children with negative assays died. This preliminary study suggests the usefulness of the Limulus assay as an adjunct to bacteriologic cultures in the early detection of significant gram-negative infection in severely malnourished children.

A precooked, instantized mixture of brown and black beans, with and without 0.3% DL-methione added, served as the only source of protein in the diets of 10 recovered malnourished infants and children 10 to 42 months of age. At 6.4 to 5.7% dietary protein calories stool wet weights were twice as high, apparent N absorption significantly lower (65.6 +/- 5.9 versus 87.5 +/- 2.3% of intake), and apparent N retention much lower (9.8 +/- 6.1 versus 34.5 +/- 10.2% of intake) than during preceding and following isocaloric and isonitrogenous casein-based diets. The addition of methionine resulted in minimal improvement in N retention and a highly suggestive increase in fasting plasma free methionine. Prolonged feeding of the methionine-enriched beans at 8.0 to 10.9% protein calories supported satisfactory growth and serum albumin levels in two of three children, not so in the smallest one, in whom repeated balance studies demonstrated no decrease over time in stool wet weight and on marginal improvement in N absorption and retention. The poor digestibility of the protein in these beans is the first-limiting factor in its utilization by infants and small children.

The opaque-2 (o2) gene increases the lysine and tryptophan contents of maize and its protein quality; the sugary-2 (su2) gene improves vitreousness and density but decreases lysine; the double-mutant surgery-2 opaque-2 (su2o2) has the improved kernel characteristics and an even higher protein quality than opaque-2. Digestibility of energy and protein, and protein quality of normal, o2 and su2o2, both as endosperm (E) and whole kernel (WK) meals, were studied in eight convalescent malnourished children, 10--25 months of age. Diets provided 100--125 kcal/kg/day, 10% fat, with all of 6.4% protein calories from one of six maize meals or casein. Endosperm meals provided 83.2, 91.2 and 82.1% of energy, WK meals 73.2, 68.6 and 67.2% of energy in respective diets. Apparent N retention from E meals was lower than from WK meals, both lower than from casein. For each type of meal (E and WK) there was strong correlation between lysine "absorbed" and N retention, but this was higher from WK at equal lysine intakes. For 50% of children to match N retention from casein, presumably equal to requirement, they would have to consume 203.9, 148 or 122.5% of energy requirement as normal, o2 or su2o2 E meals, obviously impossible. For WK meals, they would have to consume 108.2, 90.3 or 84.2% of energy as normal, o2 or su2o2.

The bulkiness of cooked rice imposes limits on the quanti ties that can be consumed, especially by infants and small children. Rices of higher protein content should offer a nutritional advantage if protein quality does not suffer. Protein quality of a high protein rice (IR480-5-9, 11.4% protein) was compared isonitrogenously with that of a rice of lower protein content (IR32, 7.1% protein) and with casein by nitrogen balance studies in eight children 12 to 18 months of age. Diets provided 100 to 125 kcal and 240 to 300 mg N/kg body weight/day constant for each child. Non-protein energy was supplied by sucrose and a blend (80:20) of soy bean :cottonseed oil. Two 7-day rice dietary periods (alternating IR32 and IR480-5-9) were preceded and followed by 9-day casein control periods. Apparent N absorption from rice ( 65.7 ± 6.7% ) was significantly less than from casein ( 84.9 ± 4.27� ) • Apparent N retention from IR480-5-9 was 23.0 ± 2.5%, that from IR32 28.6 ± 9.4% (initial casein period: 35.2 ± 5.9%). Digestibility of these two non-glutinous rices was compared with that of a glutinous variety, IR29, in further studies in which equal quanti ties of rice (13.2 or 16.5 g/kg body weight/day) were consumed. Fecal wet weight tended to be lower during rice consumption than during con sumption of the control diet, significantly so only for IR29. Fecal dry weight, fecal energy and calculated fecal carbohydrate did not differ between rice and control periods. There were significant linear correlations of fecal wet and dry weight with fecal energy for both the rice and control diets. Al though several factors suggested that the protein quality of IR480-5-9 was inferior to that of IR32, this would more than be offset by the increased protein content of the former when equal quantities of rice were consumed. Overall digestibility of rice by children appeared to be excellent and should not limit consumption by this age group. J. Nutr. IOS: 1740-1747, 1978.

Fasting plasma free amino acids were determined in 54 convalescent malnourished infants: seven infants while consuming a diet based on isolated soybean protein, containing 4.0% to 5.3% of dietary metabolizable energy (calories) as protein (A), 20 at 6.4% to 6.7% protein calories (B), 23 at 6.4% to 6.7% protein calories with added DL-methionine (C), and four with 8.0% to 12.3% protein calories (D). There were no differences in total amino acid concentration (TAA) among the four groups; the molar fraction of essential amino acids (EAA:TAA) was lower for group A; there were no differences among the four groups in Lys:EAA or 1/2 cystine:EAA ratios or in Met concentration. Met:EAA was higher in C than B, with considerable overlap of individual values. In 10 of 13 infants who were represented in both B and C, Met concentration and Met:EAA ratio were higher in group C. Fasting plasma AA levels are not consistently reliable for field or clinical assessment of dietary Met adequacy. Fasting and postprandial (3- and 4-hour) plasma AA were determined in 29 infants: in 12 the preceding diet and the test meal were both Met-deficient with less than 6.7% protein calories (E), in five the preceding diet was milk-based but the test meal was Met-deficient at less than 6.7% (F), in five the preceding diet and test meal were based on isolated soybean protein at less than 6.7% with DL-Met added (G), and in seven the test meal was soy-based with greater than 9.0% protein calories (H). Plasma Met concentration and Met:EAA fell significantly at 3 and 4 hours in groups E and F, but not in groups G and H, suggesting that a postprandial fall in Met:EAA ratio can be used to identify dietary Met deficiency in field situations.

The nutritional quality of lupins (Lupinus mutabilis) for infants and children was evaluated in two sets of balance studies. In the first the digestibility and protein quality of diets based on lupin flour, with and without methionine supplementation, were compared with those of a control diet consisting of casein, sucrose and vegetable oil. Apparent nitrogen absorption from lupin flour (81.8 and 84.3% of intake) was slightly but significantly less than that during casein control periods (87.2 and 86.8% of intake, P less than 0.05 and less than 0.001). Apparent nitrogen retention from unsupplemented lupin (15.6 +/- 5.8% of intake) was significantly less than that from casein in the corresponding control periods (29.8 +/- 4.9%, P less than 0.001); a small but significant (P less than 0.05) increase in nitrogen retention was observed during the control period following the lupin diet when compared with that preceding it. Methionine supplementation of lupin produced a marked improvement in apparent nitrogen retention (to 22.2 +/- 6.9%, P less than 0.05). In the second set of studies the digestibility of lupin oil was compared with that of a blend of soybean and cottonseed oils (50:50). Excretion of fecal fat (9.8 +/- 3.0% of intake) and fecal energy (6.7 +/- 1.2% of intake) with the diet containing lupin oil were similar to those observed with the control diet. Both the protein quality and oil digestibility of Lupinus mutabilis are very similar to those from soybeans processed in a similar manner. For certain countries the lupin could be a valuable source of protein and edible oil for human consumption.

The digestibility and protein quality of the white potato were studied in 11 infants, ages 8-35 months, recovering from malnutrition. Seven 9-day dietary periods comprised the study. Digestibility was assessed by metabolic balance during the last 6 days of dietary periods in which potato provided 25%, 50% or 75% of dietary energy. Casein-based control dietary periods preceded and/or followed each potato dietary period. Fecal wet and dry weights, fecal energy, computed fecal carbohydrate and fecal fat during consumption of the 25% potato diet did not differ from control. Analysis of variance showed that consumption of increasing amounts of potatoes produced a significant linear increase in all parameters of digestibility except fecal fat. Fecal wet weight and energy content during the 75% potato period were more than double control values. Regression analysis of data from potato dietary periods showed fecal wet weight to be an excellent predictor of fecal dry weight (r = 0.904), energy content (r = 0.785) and computed fecal carbohydrate (r = 0.770). Protein quality of potato was assessed with N balance studies during the dietary periods in which potato provided all dietary protein (approximately 5% protein kcal). Apparent N retention was 78% of that from an isonitrogenous casein control diet. Decreased apparent N absorption was primarily responsible for the difference; the "biologic value" (percent of absorbed N that was retained) was similar for both diets.

Between 1966 and 1976, heights and weights were determined yearly on all available children from 163 families who had had at least one child successfully treated for malnutrition between 1961 and 1971 and from eight families who had adopted such a child. Between 1959 and 1976, a total of 72 fathers departed from these families: 12 died, 47 deserted, six were jailed, and seven left to look for work elsewhere. Heights and weights as Z scores and the weight age/height age ratios were analyzed, when available, during four periods around the date of the event: 6 to 18 months before (period 1B), 0 to 6 months before (period 2B), 0 to 6 months after (period 3A), and 6 to 18 months after (period 4A). Mean Z scores for all children measured in the period were already low (-0.26 ± 0.93 and -0.25 ± 0.95) during period 1B, were higher during period 2B, (-0.15 and 0.04), lower during period 3A (-0.39 and -0.46), and similar to original levels during period 4A (-0.37 and -0.27). Mean weight age/height age was low (0.93 ± 0.17) only during period 3A for children 2 to 18 years of age. In paired comparisons for children measured during any two periods there were significant increases in Z height and Z weight from periods lB to 2B and from periods lB to 4A in children < 2 years of age and a significant decrease in the weight age/height age ratio from periods lB to 3A in those 2 to 18 years of age. Loss of father had little or no further impact on the already poor growth of these children.

Two varieties of cassava, processed as Nigerian fermented flour (gari) or as Brazilian flour (farinha), were fed to two groups of eight infants and young children, each group receiving both forms of one variety, with preceding, intervening and following casein control diets. The flours provided 50% of diet energy, with casein added to make 8% energy as protein, vegetable oils to make 20% as fat and corn syrup solids and sugar to make 72% carbohydrate (CHO) energy. Fecal wet weight increased (P less than 0.05) from approximately 100 g/d (casein diets) to means (+/- SD) of 202 +/- 72, 171 +/- 58, 154 +/- 46 and 190 +/- 67 g/d; dry weights from means of 14.7-18.3 g/d to means of 22.9-24.4 g/d (P less than 0.05); fecal energy from means of 50-60 kcal/d to means of 89-94 kcal/d (P less than 0.01); fetal fat was generally not affected; and fecal CHO nearly tripled (P less than 0.01) from approximately 4 to 12 g/d. Apparent nitrogen absorptions and retentions from the cassava + casein diets were modestly lower than from casein diets. Rates of weight gain were very variable and not significantly different by diet; serum albumin levels were essentially unchanged. The results with these flours were indistinguishable from each other and from those previously found with freeze-dried cassava flour in otherwise identical diets. Variety and processing method had no effect on the digestibility of cassava starch and oligosaccharides and on the great resistance to digestion and the water-holding capacity of cassava fiber.

To test the hypothesis that nitrogen utilization is maximal if protein is ingested in parallel to calories, balance studies were carried out in nine children, 4 to 26 months old and weighing 6 to 8 kg, convalescing from protein-calorie malnutrition. Diets provided 2 gm of protein and 125 Kcal/kg of body weight per day in five feedings. During the control period (6 to 12 days) protein was evenly distributed. During the study period (6 to 15 days) one half the daily protein was given in a single meal to three children, all the daily protein being given in a single meal to the other six. Calories were evenly distributed throughout the day. Apparent nitrogen retentions, changes in serum proteins and fractional urine nitrogens were similar on both diets. Weight gain was significantly less while consuming the diet with uneven distribution of protein. The child appears able to retain nitrogen adequately while consuming all his protein in a single meal without regard to calorie distribution. Difference in rates of weight gain between the two diet periods may reflect a difference in composition of tissue laid down.

In the underdeveloped world it is not difficult to establish cause-and-effect relationships between unemployment and underemployment, poverty, inadequate diets, chronic hunger, undernutrition and malnutrition, low birth weight, high infant and preschool child mortalities, and growth stunting among the survivors.1 Early in the 20th century, when millions of Europe's poor migrated to this country and crowded into inadequate and unsanitary urban settings, such relationships were clearly present.2 Whether the mass migrations, during World War II, of the South's rural poor into the industrial centers of the North created a similar problem is doubtful, as progress was being made simultaneously in the control of diarrheal diseases and other infections, and in assuring the quality, safety, and low cost of our food supply. Trends in infant and child mortality and in the growth of children revealed continued improvement in health and nutritional status.

Pregestimil ® , the control formula, and Nutramigen ® , a casein hydrolysate formula, further modified to reduce osmolality from 443 to 300 m0sm/kg water, were well accepted and tolerated while supporting adequate growth and maintaining normal serum albumin levels in six recovering malnourished infants. Stool characteristics were similar in both groups. An apparent nitrogen absorption of 88±4% of intake was observed for both products with apparent nitrogen retention rates of 39±8 and 43±6% for the control and test products, respectively. Mean fat absorptions exceeded 93% of intake for both products and carbohydrate absorption was practically complete as confirmed by the absence of significant peaks in the breath hydrogen determinations. Dry stool weights and fecal excretions of energy, fat and carbohydrate were modestly but significantly higher with reformulated Nutramigen ® than with Pregestimil ® , however, no clinical effects were noted in this infant population.

Fecal fat excretion was studied after a mild episode of diarrhea in eight infants for whom adequate control data were available. Mean age of onset of diarrhea was 28 days. Duration of the episode, defined as the number of days until the infant was again feeding and libitum, averaged 5.1 days. Balance studies were carried out 3 to 13 days later. Mean fecal fat excretion rose from a prediarrhea value of 2.9 +/- 1.4 gm/day to 8.7 +/- 3.1 gm/day following diarrhea (P less than 0.001). Restudy of five infants one month later showed persistent steatorrhea in one. Mild transient steatorrhea may follow mild diarrhea in infancy and should be considered in infants who are slow to gain weight subsequent to an episode of diarrhea.

A low-lactose product designed for use as a protein supplement for children who do not drink milk was tested under the more stringent conditions of treating convalescent and acutely malnourished children.

Six young children consumed a diet in which whole kernel maize meal supplied 81.6% of the energy (E) and 100% of protein (6.4% of E); vegetable oil completed 25% of E as fat. Apparent absorption (abs) of E was 89±2%, of nitrogen (N) 76±7% of intake; apparent N retention (ret) was 25±11% of intake. The same six plus four other children consumed diet M-A: maize supplied 40.8% of E and 50% of protein, toasted amaranth 24.0% of E and 50% of the 6.4% protein E, oil completed 25% fat E. Apparent abs of E was 89±3%, of N 68±9% (P

A case of chronic, severe diarrhea and maldigestion beginning in early infancy and possibly due to primary lactase deficiency is presented. By the age of 19 months, this had resulted in marked copper deficiency with anemia, neutropenia, osteoporosis, pathological fractures and probably aggravation of intestinal enzyme activity deficiency. At 6 4/12 years of age copper therapy produced a dramatic improvement in all manifestations, including the maldigestion, and there was a striking growth response.

In four severely malnourished infants who were rehabilitated on high-calorie, low-Cu diets, we have observed the appearance of severe anemia, marked neutropenia, scurvy-like bone changes, and hypocupremia. In 2 cases there was a prompt and dramatic response to Cu supplementation. In the other 2, slower but good responses were obtained with vitamin B12; supplemental Cu produced further responses. The Cu requirement of rapidly growing infants with poor stores is estimated at between 42 and 135 µg/kg/day.

Two thirds of the worlds children are undernourished; a significant cause of high mortality rates in children aged 1-5. Survivors of early malnutrition are prone to impairment of the central nervous system. No single measure of aid can be effective in preventing malnutrition unless we fully understand its causes. For some years the author has been involved in studying through yearly examinations the later growth of over 100 infants and children admitted with severe malnutrition to the British American Hospital in Lima Peru between January 1961 and December 1966. One of the basic findings was that there were large individual differences in terms of later growth. While the children who returned to the same poor environment became relatively more stunted in time the ones whose home environment improved (usually through adoption) showed remarkable improvement. Anthropometirc measures (such as head size height etc.) were correlated with income parental education number in family etc. as variables in the analysis. From this study one should be able to identify the income levels and housing conditions below which the growth of children are likely be stunted.