Human milk microbiome: associations with maternal diet and infant growth.

Introduction: Ingestion of human milk (HM) is identified as a significant factor associated with early infant gut microbial colonization, which has been associated with infant health and development. Maternal diet has been associated with the HM microbiome (HMM). However, a few studies have explored the associations among maternal diet, HMM, and infant growth during the first 6 months of lactation. Methods: For this cross-sectional study, Mam-Mayan mother-infant dyads (n = 64) were recruited from 8 rural communities in the Western Highlands of Guatemala at two stages of lactation: early (6-46 days postpartum, n = 29) or late (109-184 days postpartum, n = 35). Recruited mothers had vaginally delivered singleton births, had no subclinical mastitis or antibiotic treatments, and breastfed their infants. Data collected at both stages of lactation included two 24-h recalls, milk samples, and infant growth status indicators: head-circumference-for-age-z-score (HCAZ), length-for-age-z-score (LAZ), and weight-for-age-z-score (WAZ). Infants were divided into subgroups: normal weight (WAZ ≥ -1SD) and mildly underweight (WAZ < -1SD), non-stunted (LAZ ≥ -1.5SD) and mildly stunted (LAZ < -1.5SD), and normal head-circumference (HCAZ ≥ -1SD) and smaller head-circumference (HCAZ < -1SD). HMM was identified using 16S rRNA gene sequencing; amplicon analysis was performed with the high-resolution ANCHOR pipeline, and DESeq2 identified the differentially abundant (DA) HMM at the species-level between infant growth groups (FDR < 0.05) in both early and late lactation. Results: Using both cluster and univariate analyses, we identified (a) positive correlations between infant growth clusters and maternal dietary clusters, (b) both positive and negative associations among maternal macronutrient and micronutrient intakes with the HMM at the species level and (c) distinct correlations between HMM DA taxa with maternal nutrient intakes and infant z-scores that differed between breast-fed infants experiencing growth faltering and normal growth in early and late lactation. Conclusion: Collectively, these findings provide important evidence of the potential influence of maternal diet on the early-life growth of breastfed infants via modulation of the HMM.

A Nutrition Behavior Change Program Moderately Improves Minimum Diet Diversity and Handwashing Behaviors Among Tea Workers in Assam and Tamil Nadu, India.

Many workers in global supply chains remain nutritionally vulnerable despite the income they earn. The Seeds of Prosperity (SOP) program was implemented in Tamil Nadu and Assam, India, for tea supply chain workers (estate workers, small holder farmers, and farm workers). The aim was to enhance demand for diverse and nutritious foods and improve practices related to handwashing. The program used a behavior change communication approach wherein participants received weekly 1-hour group sessions with messaging on dietary diversity for 5 weeks and handwashing for 4 weeks. An impact evaluation was conducted to estimate changes in reported dietary and hygiene knowledge and behaviors among women. The study used a longitudinal quasi-experimental design in a subsample of program participants at baseline and post-intervention among both intervention and comparison. There was a small but significant increase in mean dietary diversity (DD) for all 4 worker groups (ranging from DD score changes of 0.3 to 0.7; P < .05) and in the proportion of women meeting the minimum dietary diversity in 2 of the 4 groups. Similarly, a significant increase in the mean number of handwashing moments was observed in 2 of the worker groups. An increase in home garden use was observed in 1 of the 4 worker groups. While the SOP program resulted in improvements in dietary diversity, most tea farming women still do not achieve minimum dietary diversity. Nutritious food access may be an important constraint to further improvement.

Nutrient Density as a Dimension of Dietary Quality: Findings of the Nutrient Density Approach in a Multi-Center Evaluation.

The nutrient adequacy of a diet is typically assessed by comparing estimated nutrient intakes with established average nutrient requirements; this approach does not consider total energy consumed. In this multinational survey investigation in Indonesia, Mexico, and South Africa, we explore the applications of the "critical nutrient-density approach"-which brings energy requirements into the equation-in the context of public health epidemiology. We conducted 24 h dietary recalls in convenience samples of normal-weight (BMI 18.5-25 kg/m2) or obese (BMI > 30 kg/m2), low-income women in three settings (n = 290). Dietary adequacy was assessed both in absolute terms and using the nutrient density approach. No significant differences in energy and nutrient intakes were observed between normal-weight and obese women within any of the three samples (p > 0.05). Both the cut-point method (% of EAR) and critical nutrient density approach revealed a high probability of inadequate intakes for several micronutrients but with poor concordance between the two methods. We conclude that it may often require some approximate estimate of the habitual energy intake from an empirical source to apply a true critical nutrient density reference for a population or subgroup. This will logically signify that there would be more "problem nutrients" in the diets examined with this nutrient density approach, and efforts toward improved food selection or food- or biofortification will frequently be indicated.

There's an App for That: Development of an Application to Operationalize the Global Diet Quality Score.

BACKGROUND: The global diet quality score (GDQS) is a simple, standardized metric appropriate for population-based measurement of diet quality globally. OBJECTIVES: We aimed to operationalize data collection by modifying the quantity of consumption cutoffs originally developed for the GDQS food groups and to statistically evaluate the performance of the operationalized GDQS relative to the original GDQS against nutrient adequacy and noncommunicable disease (NCD)-related outcomes. METHODS: The GDQS application uses a 24-h open-recall to collect a full list of all foods consumed during the previous day or night, and automatically classifies them into corresponding GDQS food group. Respondents use a set of 10 cubes in a range of predetermined sizes to determine if the quantity consumed per GDQS food group was below, or equal to or above food group-specific cutoffs established in grams. Because there is only a total of 10 cubes but as many as 54 cutoffs for the GDQS food groups, the operationalized cutoffs differ slightly from the original GDQS cutoffs. RESULTS: A secondary analysis using 5 cross-sectional datasets comparing the GDQS with the original and operationalized cutoffs showed that the operationalized GDQS remained strongly correlated with nutrient adequacy and was equally sensitive to anthropometric and other clinical measures of NCD risk. In a secondary analysis of a longitudinal cohort study of Mexican teachers, there were no differences between the 2 modalities with the beta coefficients per 1 SD change in the original and operationalized GDQS scores being nearly identical for weight gain (-0.37 and -0.36, respectively, P < 0.001 for linear trend for both models) and of the same clinical order of magnitude for waist circumference (-0.52 and -0.44, respectively, P < 0.001 for linear trend for both models). CONCLUSION: The operationalized GDQS cutoffs did not change the performance of the GDQS and therefore are recommended for use to collect GDQS data in the future.

Mixed methods evaluation explains bypassing of vouchers in micronutrient powder trial in Mozambique.

Micronutrient powders (MNP) are recommended by the World Health Organization as an effective intervention to address anaemia in children. A formative process evaluation was conducted to assess the viability of a model using free vouchers in two districts of Mozambique to deliver MNP and motivate adherence to recommendations regarding its use. The evaluation consisted of (a) an examination of programme outcomes using a cross-sectional survey among caregivers of children 6-23 months (n = 1,028) and (b) an ethnographic study to investigate delivery experiences and MNP use from caregiver perspectives (n = 59), programme managers (n = 17), and programme implementers (n = 168). Using a mixed methods approach allowed exploration of unexpected programme outcomes and triangulation of findings. The survey revealed that receiving a voucher was the main implementation bottleneck. Although few caregivers received vouchers (11.5%, CI [9.7, 13.6]), one-fourth received MNP by bypassing the voucher system (26.3%, CI [23.6, 29.0]). Caregivers' narratives indicated that caregivers were motivated to redeem vouchers but encountered obstacles, including not knowing where or how to redeem them or finding MNP were not available at the shop. Observing these challenges, many programme implementers redeemed vouchers and distributed MNP to caregivers. Virtually, all caregivers who received MNP reported ever feeding it to their child. This study's findings are consistent with other studies across a range of contexts suggesting that although programmes are generally effective in motivating initial use, more attention is required to improve access to MNP and support continued use.

Several problem nutrients are identified in the complementary diet of 6 to 11 month old breastfed children in Western Guatemala.

BACKGROUND AND OBJECTIVES: The failure of infants in developing countries to meet nutrient intake recommendations is well documented. The objective of this study was to assess the nutritional adequacy and identify problem nutrients of the diets of Guatemalan infants with continued breastfeeding. METHODS AND STUDY DESIGN: A single previous-day dietary recall was collected from a convenience sample of 94 mothers of infants aged 6-11 mo attending a public health clinic in the urban area of Quetzaltenango, Guatemala. Energy and nutrient content of complementary feeding (CF) and breastmilk, modelled by subtracting estimated energy intakes from CF from energy requirements, were calculated and nutrient adequacy of the diet was assessed. Nutrient densities and critical nutrient densities of CF were computed to identify "problem nutrients" and main food sources of these nutrients. RESULTS: Complementary diets were adequate for protein, but likely to be inadequate for pantothenic acid and vitamins C, A, D, E, and K, as well as calcium, iron and zinc. In the worst-case scenario, i.e. for small girls with limited energy allowances, riboflavin, niacin, vitamin B-6 and magnesium were identified as "problem nutrients" as well. Formula milk, cow milk and Incaparina® were main food sources of "problem nutrients". CONCLUSIONS: The intake of micronutrients during the first six months of the recommend CF period in Guatemala has a number of notable inadequacies, but the gaps are narrower than traditionally reported for this age group in low-income settings.

Improved Information and Educational Messages on Outer Packaging of Micronutrient Powders Distributed in Indonesia Increase Caregiver Knowledge and Adherence to Recommended Use.

The objective of this study was to examine the influence of improved information and educational messages on outer packaging of a micronutrient powder (MNP), locally known as “Taburia”, on knowledge and adherence to recommended use. A community-based cluster randomized controlled trial was conducted among 1149 caregivers and their children aged 6⁻36 months. Caregiver⁻child dyads were randomized by their villages to receive 30 sachets of Taburia with the: (i) original outer packaging; (ii) improved outer packaging; or (iii) improved outer packaging combined with cooking demonstrations. Adherence to Taburia use was assessed through caregiver interviews and observation of unused sachets during home visits; “high” adherence was defined as consuming 13⁻17 sachets in the previous month. Data collection included surveys and focus groups discussions. The majority of caregivers (>80%) preferred the improved packaging because it was more attractive and contained more comprehensive information. Caregivers who received the improved packaging had better knowledge regarding the recommended use of Taburia (p < 0.001) and higher adherence with the prescribed use of Taburia (43% with “high” adherence) (p < 0.001) than those who received the original packaging (29% with “high” adherence). Caregivers who participated in cooking demonstrations generally had better knowledge regarding the benefits of Taburia and recommended use, but this did not lead to higher adherence to recommended use. “Underconsumption” of Taburia (≤7 sachets) was much less prevalent than “overconsumption” (≥23 sachets), and original packaging users were more likely to consume Taburia daily instead of every two days as recommended. We conclude that the design of the outer packaging and comprehensiveness of information provided are important influencers of recommended MNP use by caregivers.

Large-Scale Food Fortification and Biofortification in Low- and Middle-Income Countries: A Review of Programs, Trends, Challenges, and Evidence Gaps.

BACKGROUND: Food fortification and biofortification are well-established strategies to address micronutrient deficiencies in vulnerable populations. However, the effectiveness of fortification programs is not only determined by the biological efficacy of the fortified foods but also by effective and sustainable implementation, which requires continual monitoring, quality assurance and control, and corrective measures to ensure high compliance. OBJECTIVE: To provide an overview of efficacy, effectiveness, economics of food fortification and biofortification, and status of and challenges faced by large-scale food fortification programs in low- and middle-income countries (LMIC). METHODS: A literature review of PubMed publications in English from 2000 to 2017, as well as gray literature, targeting nongovernmental organizations whose work focuses on this topic, complemented by national reports and a "snowball" process of citation searching. The article describes remaining technical challenges, barriers, and evidence gap and prioritizes recommendations and next steps to further accelerate progress and potential of impact. RESULTS: The review identifies and highlights essential components of successful programs. It also points out issues that determine poor program performance, including lack of adequate monitoring and enforcement and poor compliance with standards by industry. CONCLUSIONS: In the last 17 years, large-scale food fortification initiatives have been reaching increasingly larger segments of populations in LMIC. Large-scale food fortification and biofortification should be part of other nutrition-specific and nutrition-sensitive efforts to prevent and control micronutrient deficiencies. There are remaining technical and food system challenges, especially in relation to improving coverage and quality of delivery and measuring progress of national programs.

Experiences and lessons learned for programme improvement of micronutrient powders interventions.

Continual course correction during implementation of nutrition programmes is critical to address factors that might limit coverage and potential for impact. Programme improvement requires rigorous scientific inquiry to identify and address implementation pathways and the factors that affect them. Under the auspices of "The Micronutrient Powders Consultation: Lessons Learned for Operational Guidance," 3 working groups were formed to summarize experiences and lessons across countries regarding micronutrient powder (MNP) interventions for young children. This paper focuses on how MNP interventions undertook key elements of programme improvement, specifically, the use of programme theory, monitoring, process evaluation, and supportive supervision. Methods included a review of published and grey literature, interviews with key informants, and deliberations throughout the consultation process. We found that although much has been written and published about the use of monitoring and process evaluation to inform MNP interventions at small scale, there has been little formal documentation of lessons for the transition from pilot to scaled implementation. Supervision processes and experiences are not documented, and to our knowledge, there is no evidence of whether they have been effective to improve implementation. Improving the efficiency and effectiveness of interventions requires identification of critical indicators for detecting implementation challenges and drivers of impact, integration with existing programmes and systems, strengthened technical capacity, and financing for implementation of effective monitoring systems. Our understanding of programme improvement for MNP interventions is still incomplete, especially outside of the pilot stage, and we propose a set of implementation research questions that require further investigation.

Sensory Evaluation of Foods with Added Micronutrient Powder (MNP) "Taburia" to Assess Acceptability among Children Aged 6-24 Months and Their Caregivers in Indonesia.

Although it is generally accepted that the addition of micronutrient powders (MNPs) to foods causes no or negligible changes to organoleptic properties, there are anecdotal reports of low acceptability of the MNP (locally known as "Taburia") distributed in Indonesia. We hypothesized that the organoleptic properties of Taburia do not reduce the acceptability of foods if used as recommended. Acceptability of Taburia and a comparison MNP (MixMe™) were evaluated among 232 children aged 6-24 months and their caregivers. Both caregivers' perceptions of child acceptance, and their own assessments of organoleptic qualities when added to rice porridge or meals commonly consumed by young children, were assessed. Changes to the organoleptic properties of foods mixed with Taburia and comparison MNP were reported by caregivers, even when following preparation instructions. Taburia was found to enhance texture, sweetness, saltiness, and umami taste, but was also perceived as slightly bitter. Ratings for overall appearance and taste did not differ between rice porridge, plain or with Taburia, but the overall taste of Taburia was preferred over comparison MNP (p = 0.012). Meals consumed by children were preferred without the addition of MNP (p < 0.001). We demonstrate that the addition of Taburia to foods, commonly consumed by Indonesian infants and young children, affects organoleptic properties of the foods, even when prepared according to recommendations. However, these changes are unlikely to be the cause of reported adherence problems in Indonesia. This needs to be taken into consideration for product development and communication strategies promoting adherence.

Context-specific complementary feeding recommendations developed using Optifood could improve the diets of breast-fed infants and young children from diverse livelihood groups in northern Kenya.

OBJECTIVE: To formulate age- and context-specific complementary feeding recommendations (CFR) for infants and young children (IYC) and to compare the potential of filling population-level nutrient gaps using common sets of CFR across age groups. DESIGN: Linear programming was used to develop CFR using locally available and acceptable foods based on livelihood- and age-group-specific dietary patterns observed through 24 h dietary recalls. Within each livelihood group, the nutrient potential of age-group-specific v. consolidated CFR across the three age groups was tested. SETTING: Three food-insecure counties in northern Kenya; namely, settled communities from Isiolo (n 300), pastoralist communities from Marsabit (n 283) and agro-pastoralist communities from Turkana (n 299). SUBJECTS: Breast-fed IYC aged 6-23 months (n 882). RESULTS: Age-specific CFR could achieve adequacy for seven to nine of eleven modelled micronutrients, except among 12-23-month-old children in agro-pastoralist communities. Contribution of Fe, Zn and niacin remained low for most groups, and thiamin, vitamin B6 and folate for some groups. Age-group-consolidated CFR could not reach the same level of nutrient adequacy as age-specific sets among the settled and pastoralist communities. CONCLUSIONS: Context- and age-specific CFR could ensure adequate levels of more modelled nutrients among settled and pastoralist IYC than among agro-pastoralist communities where use of nutrient-dense foods was limited. Adequacy of all eleven modelled micronutrients was not achievable and additional approaches to ensure adequate diets are required. Consolidated messages should be easier to implement as part of a behaviour change strategy; however, they would likely not achieve the same improvements in population-level dietary adequacy as age-specific CFR.

The stunted child with an overweight mother as a growing public health concern in resource-poor environments: a case study from Guatemala.

BACKGROUND: Overweight and obesity are emerging at alarming rates in low income women in many countries. Guatemala has the additional burden of a high prevalence of chronic under-nutrition (stunting) in children. AIM: The purpose of this paper is to explore the dual burden of infant and child (5-23 months) under-nutrition and maternal over-weight and obesity in the Western Highlands of Guatemala. SUBJECTS AND METHODS: Anthropometric measures were collected in 446 mother-infant dyads in a metropolitan population of mixed indigenous (Maya) and non-indigenous descent in the Western Highlands of Guatemala. Children were identified as stunted based on a height for age <-2 below the WHO reference median and maternal overweight/obesity defined as a BMI ≥25. Stunted children with an overweight/obese mother were compared to other children who were not stunted and/or who did not have an overweight/obese mother. RESULTS: The prevalences of stunting (38%) and maternal overweight/obesity (45%) were high, but just 17% of the mother and child pairs were dual burden. The socio-demographic characteristics of stunted children were not influenced by maternal overweight or obesity. CONCLUSION: Policies are needed to address under-nutrition as well as preventing obesity and obesity-related chronic disease risks of stunted children and their mothers.

Quantitative Methodologies Reveal a Diversity of Nutrition, Infection/Illness, and Psychosocial Stressors During Pregnancy and Lactation in Rural Mam-Mayan Mother-Infant Dyads From the Western Highlands of Guatemala.

BACKGROUND: The nature and severity of 3 categories of maternal stressors (nutritional, infectious, and psychosocial) that may impact maternal health and early infant growth are not often considered together. OBJECTIVES: To describe quantitative methodologies; assess construct validity of questionnaires; report variability in sociodemographic, obstetric, nutritional, infectious, and psychosocial characteristics; and compare characteristics between pregnancy and lactation and between study cohorts of Mam-Mayan mother-infant dyads. METHODS: Grounded in participatory action research and a socioecological framework, this observational study enrolled a longitudinal cohort of 155 women, followed during pregnancy (6-9 months), early (0-6 weeks), and later (4-6 months) postpartum, and 2 cross-sectional cohorts (60 early and 56 later postpartum). Household and social factors; obstetric history; nutritional, infectious, and psychosocial stressors; and infant characteristics were explored. RESULTS: Diet diversity (3.4 ± 1.3) and adult food security (38%) were low. Urinary and gastrointestinal infections were rare (<5%), whereas experience of local idioms of distress was frequent (20%-50%). Participants reported low maternal autonomy (81%), high paternal support (70%), small social support networks (2.7 ± 1.3 individuals), and high trust in family (88%) and community-based institutions (61%-65%) but low trust in government services (6%). Domestic violence was commonly reported (22%). Infant stunting was common (36% early postpartum and 43% later postpartum) despite frequent antenatal care visits (7.5 ± 3.8). Participant engagement with the research team did not influence study outcomes based on comparisons between longitudinal and cross-sectional cohorts. CONCLUSIONS: The variability in sociodemographic, nutritional, and psychosocial variables, will allow exploration of factors that promote resilience or increase vulnerability of the mother-infant dyad.

Regulatory Monitoring of Fortified Foods: Identifying Barriers and Good Practices.

While fortification of staple foods and condiments has gained enormous global traction, poor performance persists throughout many aspects of implementation, most notably around the critical element of regulatory monitoring, which is essential for ensuring foods meet national fortification standards. Where coverage of fortified foods is high, limited nutritional impact of fortification programs largely exists due to regulatory monitoring that insufficiently identifies and holds producers accountable for underfortified products. Based on quality assurance data from 20 national fortification programs in 12 countries, we estimate that less than half of the samples are adequately fortified against relevant national standards. In this paper, we outline key findings from a literature review, key informant interviews with 11 fortification experts, and semi-quantitative surveys with 39 individuals from regulatory agencies and the food fortification industry in 17 countries on the perceived effectiveness of regulatory monitoring systems and barriers to compliance against national fortification standards. Findings highlight that regulatory agencies and industry disagree on the value that enforcement mechanisms have in ensuring compliance against standards. Perceived political risk of enforcement and poorly resourced inspectorate capacity appear to adversely reinforce each other within an environment of unclear legislation to create a major hurdle for improving overall compliance of fortification programs against national standards. Budget constraints affect the ability of regulatory agencies to create a well-trained inspector cadre and improve the detection and enforcement of non-compliant and underfortified products. Recommendations to improve fortification compliance include improving technical capacity; ensuring sustained leadership, accountability, and funding in both the private and the public sectors; and removing political barriers to ensure consistent detection of underfortified products and enforcement of applicable fortification standards. Only by taking concrete steps to improve the entire regulatory system that is built on a cooperative working relationship between regulatory agencies and food producers will a nutrition strategy that uses fortification see its intended health effects.

The Nutritional Contribution of Foods and Beverages Provided by Government-Sponsored Day Care Centers in Guatemala.

BACKGROUND: Meals served at government-run day care centers must be nutritionally adequate to ensure good health and proper development of preschool-aged children. They can provide a controlled opportunity to complement the daily diet of children in vulnerable populations. OBJECTIVE: To determine the nutrient adequacy and leading food sources of nutrients provided by the diet served in government-sponsored day care centers. METHODS: Estimated daily energy and nutrient intakes of a theoretical 40-day day care center menu were calculated, and the nutrient adequacy was assessed. Nutrient densities and critical nutrient densities of the menu were computed to identify nutrient inadequacies. Furthermore, main sources of nutrients were identified, and energy and nutrient distributions were examined by meal time. RESULTS: The menu provides approximately 90% of daily energy requirement and more than 100% of Recommended Nutrient Intakes (RNIs), with the exception of vitamin D and calcium. Sugar was the first leading source of energy, whereas milk was the first leading contributor of vitamin D. CONCLUSION: Within an environment of budgetary constraints, the Guatemalan government developed and advocated an exemplary menu offering for children in the vulnerable preschool period. We have demonstrated that, if prepared and served as planned, the items from the official, standard menu would supply most of the nutrients needed. High vitamin A intake related to the mandated national fortification program is a potential problem. From the analysis, it was found that vitamin D emerges as the most prominent candidate for a problem nutrient of deficient intake.

Energy contribution from non-breastmilk items in low-income Guatemalan infants in their sixth month of life.

OBJECTIVE: To examine the nature and energy contribution of complementary feeding in breastfed infants in their sixth month of life, and the prevalence of the use of bottles as a delivery method. MATERIALS AND METHODS: We recruited 156 breastfeeding infants at a health clinic in metropolitan Quetzaltenango, Guatemala. A previous-day recall was performed. RESULTS: Sixty nine mothers (44%) reported offering items other than breastmilk. The median contribution of energy from complementary foods among infants with mixed feeding (n=66) was 197 kcal/day (interquartile range [IQR] 49-353). The median energy contribution of formula or cow's milk among consumers (n=39) was 212 kcal/day (IQR 84-394). Bottles were used on the previous day by 55 (80%) of the 69 mothers not offering exclusive breastfeeding. CONCLUSIONS: Premature introduction of non-breastmilk items is commonly practiced in feeding Guatemalan infants. Adherence to the internationally recognized guidelines for early infant feeding should be an intervention priority for this population.

Stunting at birth: recognition of early-life linear growth failure in the western highlands of Guatemala.

OBJECTIVE: Measurements of length at birth, or in the neonatal period, are challenging to obtain and often discounted for lack of validity. Hence, classical 'under-5' stunting rates have been derived from surveys on children from 6 to 59 months of age. Guatemala has a high prevalence of stunting (49.8%), but the age of onset of growth failure is not clearly defined. The objective of the study was to assess length-for-age within the first 1.5 months of life among Guatemalan infants. DESIGN: As part of a cross-sectional observational study, supine length was measured in young infants. Mothers' height was measured. Length-for-age Z-scores (HAZ) were generated and stunting was defined as HAZ <-2 using WHO growth standards. SETTING: Eight rural, indigenous Mam-Mayan villages (n 200, 100% of Mayan indigenous origin) and an urban clinic of Quetzaltenango (n 106, 27% of Mayan indigenous origin), Guatemala. SUBJECTS: Three hundred and six newborns with a median age of 19 d. RESULTS: The median rural HAZ was -1.56 and prevalence of stunting was 38%; the respective urban values were -1.41 and 25%. Linear regression revealed no relationship between infant age and HAZ (r = 0.101, r(2) = 0.010, P = 0.077). Maternal height explained 3% of the variability in HAZ (r = 0.171, r(2) = 0.029, P = 0.003). CONCLUSIONS: Stunting must be carried over from in utero growth retardation in short-stature Guatemalan mothers. As linear growth failure in this setting begins in utero, its prevention must be linked to maternal care strategies during gestation, or even before. A focus on maternal nutrition and health in an intergenerational dimension is needed to reduce its prevalence.

Energy contribution from non-breastmilk items in low-income Guatemalan infants in their sixth month of life / Contribución de energía de fuentes diferentes a la leche materna en infantes de seis meses de edad de bajos recursos en Guatemala

Objective. To examine the nature and energy contribution of complementary feeding in breastfed infants in their sixth month of life, and the prevalence of the use of bottles as a delivery method. Materials and methods. We recruited 156 breastfeeding infants at a health clinic in metropolitan Quetzaltenango, Guatemala. A previous-day recall was performed. Results. Sixty nine mothers (44%) reported offering items other than breastmilk. The median contribution of energy from complementary foods among infants with mixed feeding (n=66) was 197 kcal/day (interquartile range [IQR] 49-353). The median energy contribution of formula or cow's milk among consumers (n=39) was 212 kcal/day (IQR 84-394). Bottles were used on the previous day by 55 (80%) of the 69 mothers not offering exclusive breastfeeding. Conclusions. Premature introduction of non-breastmilk items is commonly practiced in feeding Guatemalan infants. Adherence to the internationally recognized guidelines for early infant feeding should be an intervention priority for this population.

Objetivos. Examinar la naturaleza y contribución energética de la alimentación complementaria en infantes lactantes en el sexto mes de vida y la prevalencia del uso de biberones como método de alimentación. Material y métodos. Se seleccionaron 156 infantes lactantes en un centro de salud en la ciudad de Quetzaltenango, Guatemala. Se solicitó una rememoración de la alimentación del día anterior. Resultados. Sesenta y nueve madres (44%) reportaron dar alimentos adicionales a la leche materna. La mediana de contribución energética de alimentos complementarios en infantes con alimentación mixta (n=66) fue 197 kcal/día (rango intercuartil [RIC] 43-353). La mediana de contribución energética de leche de vaca entre consumidores (n=39) fue 212 kcal/día (RIC 84-394). De 69 madres que ofrecían alimentación mixta, 55 (80%) proporcionaron biberones. Conclusiones. Las madres guatemaltecas practican comúnmente la introducción prematura de la alimentación complementaria. La adhesión a las guías internacionalmente reconocidas para alimentación de infantes debe ser una prioridad de intervención en esta población.