Consumption of food and nutrients by infants in Huascar (Lima), 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.

Validity and epidemiology of reported poor appetite among Peruvian infants from a low-income, periurban community.

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.

PIP: In Huascar (a low-income, periurban community in eastern Lima), Peru, a study followed 131 low birth infants (2.5 kg) for one year to compare mothers' reports of poor appetite with dietary intake (1621 days of observation). Infants consumed lower energy intakes during days mothers reported anorexia than during days mothers reported a normal appetite (1-6 month olds, 338 vs. 395 kJ/kg body weight; 6 month olds, 299 vs. 342 kJ/kg body weight) (p 0.001). In fact, when the researchers controlled for age, body weight, and the presence of specific symptoms of illness, intraindividual total energy intakes were almost 15% less on days of reported anorexia. Energy intake from non-breast milk sources was about 25-35% less in both age groups on days of reported anorexia (p 0.01). The researchers examined longitudinal data on 153 infants who were monitored during their first year of life to determine the epidemiology of poor appetite. As the age of the infant increased so did the prevalence of reported anorexia (22-317/1000 days of observation from 1 to 11 months of age). Mothers reported anorexia on about 15% of the 48,057 days of observation. A significant positive association between anorexia and fever, severe diarrhea, and respiratory illness existed. These findings suggest that poor appetite, instead of insufficient food, may partially account for the low energy intakes by infants in Huascar.

Effects of dietary viscosity and energy density on total daily energy consumption by young Peruvian children.

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.

Effects of common illnesses on infants' energy intakes from breast milk and other foods during longitudinal community-based studies in Huascar (Lima), Peru.

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.

Body composition of Peruvian children with short stature and high weight-for-height. II. Implications for the interpretation for weight-for-height as an indicator of nutritional status.

In some child populations, low height-for-age, suggesting chronic undernutrition, may paradoxically be accompanied by relatively high weight-for-height, suggesting obesity. This growth pattern was investigated with anthropometric assessment and body composition studies using H2(18)O stable isotope dilution in 139 preschool-age Peruvian children. Results suggested low height-for-age (15th percentile National Center for Health Statistics [NCHS]) and high weight-for-height (60th percentile NCHS). Skinfold thicknesses were lower whereas arm muscle areas were more similar to NCHS reference values. Total body water (as percent body weight) was greater than reference values, consistent with lower body fat. Differences in body proportions did not account adequately for the high weight-for-height. The data suggest that the high weight-for-height in these children is not obesity but is associated with lower body fat and greater lean tissue or lean tissue hydration that may reflect dietary, environmental, or genetic influences. Weight-for-height cutoffs for wasting or obesity may require different interpretations for different populations.

Growth patterns of breast-fed infants in affluent (United States) and poor (Peru) communities: implications for timing of complementary feeding.

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.

Body composition of Peruvian children with short stature and high weight-for-height. I. Total body-water measurements and their prediction from anthropometric values.

Total body water (TBW) was measured by 18O dilution in 139 undernourished, preschool Peruvian children with high weight-for-height. Values for TBW as a percent of body weight were relatively high, averaging 67.4 +/- 6.4%. Depending upon the method of calculation, mean values for the sample population for percent fat ranged from 9.4-18.5%. Regression of TBW on lean body mass suggested that hydration of the fat-free body was higher than for normally nourished children of comparable age. Thus, the increased weight-for-height in these children did not result from increased fat tissue, but from increased hydration of the fat-free body. TBW was most highly correlated with height and weight, both with r = 0.95. Equations predicting TBW from either height or weight were significantly different from those developed by other investigators to predict TBW for normal, well-nourished American children.

Infant-feeding practices and their relationship with diarrheal and other diseases in Huascar (Lima), Peru.

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.

Feeding practices and growth among low-income Peruvian infants: a comparison of internationally-recommended definitions.

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.

The relationship between infants' preceding appetite, illness, and growth performance and mothers' subsequent feeding practice decisions.

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.

Within- and between-individual variation in energy intakes by low-income Peruvian infants.

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.

PIP: Pueblo Joven Huascar, a low-income periurban community in Lima, Peru, was chosen 1) to examine the components of variation in infant energy intake, 2) to calculate the precision of estimates of energy intake from different sources, and 3) to estimate the number of dietary studies required to estimate true energy intake. The sample consisted of 1564 observations on 124 infants who were enrolled at birth and followed monthly. Total energy intake, and energy from breastmilk, nonhuman milk, or other liquids and solid food sources were calculated for each observation. Means, standard deviations and coefficients of variation for total energy and source-specific energy intakes were calculated for infancy (1-12 months), and for the successive 4-month periods. For months 1-12, the pooled ratio for total energy was 2.91. Pooled, age-specific coefficients of within-infant variation in total energy intake were 70% greater and between-infant coefficient of variation were 20-50% lower compared to a study of 48 breastfed British infants. For months 1-12, variance ratios for breastmilk and nonhuman milk were 0.75 and 1.15, compared to ratios of 3.72 and 3.69 for non-milk liquids and solid foods, respectively. For total energy, total energy per kg body weight, and breastmilk energy, the within-to-between infant variance ratios were larger during 1-4 months compared to later infancy. Ratios for energy from nonhuman milk, other liquids, and solid foods were somewhat greater from 9 to 12 months compared to 5-8 months. These data suggest that pooled monthly dietary studies will give estimates of infants' mean total and breastmilk energy intakes that are within 20-30% of their true mean intakes during each of the 4-month age periods examined. Monthly estimates of solid food energy intake by infants from 9-12 months will also be within 20% of the truth. At least 16 dietary studies are required, however, to estimate infants' average solid food energy intake when they are 5-8 month old, and be within 30% of their true intake for this period.

[Tolerance and digestibility of Peruvian "common foods" in malnourished infants]. / "Alimentos comunes" peruanos. Tolerancia y digestibilidad en infantes desnutridos.

Six diets were prepared based on commonly used Peruvian foods, mainly of vegetable origin, which were offered to eight infants (mean age: 12.8 +/- 8.2 months) recovering from malnutrition. The purpose of this study was to evaluate the acceptability, tolerance and digestibility of the diets in question. Five were prepared with a potato and wheat base (noodle) and the sixth with a quinua-oats base. The acceptability and tolerance was satisfacotry, allowing maintenance of an adequate calorie and protein intake in all patients except one. On the quinua-oats based diet, the mean apparent absorption of nitrogen and fat was significantly lower (P less than 0.05) than in the case of the other diets. The increase in height coefficient (height age/chronological age X 100) and weight/age proved to be adequate during the study, except in the three youngest patients. The authors consider that this type of diets (potato-wheat based) can be recommended for infant feeding after the first year of life, and that the quinua-oats based diet still needs a more thorough evaluation prior to recommending its use.

[Digestibility and protein quality of quinua: comparative study of quinua (Chenopodium Quinoa) seed and flour in children]. / Digestibilidad y calidad proteínica de la quinua: estudio comparativo, en niños, entre semilla y harina de quinua.

Based on the hypothesis that the digestibility of quinua seed is the limiting factor in the utilization of nutrients from this staple, two quinua-based diets were prepared using quinua seeds and quinua flour. Theses diets were offered to children recovering from malnutrition. The digestibility and protein quality of the quinua diets were compared to those of a casein control diet by analyzing the children's metabolic balance. Results showed that digestibility of the quinua diets were compared to those of a casein control diet by analyzing the children's metabolic balance. Results showed that digestibility of the quinua seed is the limiting factor in the protein and energy utilization, and that milling improves significantly the digestibility of fat and carbohydrates. Findings also confirmed that the protein quality of quinua seeds is adequate for human consumption.

Prolonged consumption by infants of wheat-based diets with and without casein or lysine supplementation.

Infants consumed 75% of calories as 82% extraction wheat flour with satisfactory short-term protein and energy digestion. Protein needs, represented 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 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.

Protein quality and digestibility of sorghum in preschool children: balance studies and plasma free amino acids.

The protein quality and digestibility of two high lysine (2.9-3.0 g/100 g protein) and tow conventional varieties (lysine content 2.1-2.2 g/100 g protein) of whole grain sorghum milled as flour were assessed through balance studies in 13 children 6-30 months of age. Sorghum protein provided 6.4 or 8.0% of dietary energy. Control diets contained 64% kcal protein as casein. Children consumed 100-150 kcal/kg body weight/day. Sorghum consumption was associated with weight loss or poor weight gain. We found no difference by variety in apparent nitrogen absorption or retention. Mean absorption and retention of nitrogen (+/- SD) from 26 six-day sorghum dietary periods were 46 +/- 17% and 14 +/- 10% of intake, respectively (corresponding preceding casein control values: 81 +/- 5% and 38 +/- 3%). Stool weight and energy losses during sorghum periods averaged 2.5 to 3 times control values. Plasma amino acids were determined in eleven children after 16 days of sorghum consumption. Fasting concentration of total amino acids (TAA) was similar to values previously obtained with wheat protein at similar levels of intake. Total concentration of essential amino acids (TEAA) was low as were concentrations of lysine (Lys) and threonine (Thr). Analysis of postprandial changes of the Lys/TEAA and Thr/TEAA molar ratios confirmed that Lys was the first limiting amino acid.

Utilization of the protein and energy of the white potato by human infants.

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.

Experience with a mixture of wheat-noodles and casein in the initial dietary therapy of infants and young children with protein-energy malnutrition or acute diarrhea.

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.

Nutritional management of chronic diarrhea and malnutrition: primary reliance on oral feeding.

PIP: 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.^ieng

Wheat-based diets: effect of short-term consumption on serum cholesterol and triglyceride levels in infants.

The effect of consumption of wheat-based diets on serum cholesterol and triglyceride levels was studied in eight previously malnourished children. While consuming a control diet of casein, soy-cottonseed oil blend, and a mixture of sucrose and starch, the serum cholesterol level was 169 +/- 42 mg/dl (mean +/- SD). This decreased significantly (P less than .001) to 108 +/- 30 mg/dl after nine days' consumption of an isoenergetic-isonitrogenous diet in which whole wheat or white flour provided all the protein and +/- 50% of carbohydrate, and remained at this level for the 27-day dietary period. On changing again to the casein-based diet, the serum cholesterol level rose within nine days to 154 +/- 42 mg/dl. There was no similar diet-related change in serum triglyceride values. None of the known mechanisms whereby diet affects serum cholesterol adequately explains these findings.