Breast milk consumption in rural Costa Rica.

Breast milk consumption was measured in 20 breast-feeding infants, aged two days to six months. This was achieved by test-weighing infants before and after every feeding over a 24-hour period. Infant length, weight, number of breast-feedings, and time spent sucking were also measured. The mean consumption among 10 full breast-feeders (no supplementation) was 639 +/- 214 ml/day at a mean age of 42 +/- 36 days, and 396 +/- 249 ml/day at a mean age of 95 +/- 53 days for ten breast-feeders receiving supplements (partial breast-feeders). Significant correlations were found between the number of feedings per day and breast milk consumption (ml/day) when examining all twenty infants (r = 0.788, p less than 0.01) and the ten partial breast-feeders (r = 0.903, p less than 0.01), but not the ten full breast-feeders (r = 0.431). Correlations between the time sucking per day (min/day), and breast milk consumption (ml/day), were again significant for all twenty infants (r = 0.576 p less than 0.01) and partial breast-feeders (r = 0.728, p less than 0.02), but not for full breast-feeders (r = 0.357). The weight-for-length ratio for full breast-feeders ranged from 94 to 135% of the 50th percentile of the National Center for Health Statistics (NCHS) curves, while for partial breast-feeders it ranged from 103 to 141%. Both groups show adequate growth in this poor, rural area of Costa Rica.

Hair zinc levels in rural Costa Rican infants and preschool children.

Correlations between hair zinc and age, sex, weight, and length were determined on 138 boys and girls aged 6 months to 4 years from a low socioeconomic region of rural Costa Rica. Zinc deficiency, as assessed by hair zinc concentrations of less than 70 microgram/g, was observed in only a few of these children. A negative correlation between hair zinc and growth parameters was obtained, which may reflect increased zinc needs during rapid growth. Females had significantly more zinc in hair than males of similar age. This study confirms previous findings that normally growing infants and preschool children have normal hair zinc levels.

Child malnutrition and deprivation--observations in Guatemala and Costa Rica.

Traditional populations consisting of small tribal groups living in close contact with nature may be virtually free from endemic malnutrition owing to the relative absence of infectious diseases. Transition toward modern ways of life and population growth, leading to crowding and underdevelopment, favours endemic malnutrition due to the interaction of malnutrition and infection. Although important features of the traditional culture--breast-feeding, protective child rearing--may remain intact, they are not enough, and such populations exhibit high rates of infectious disease, malnutrition and premature death. In modern industrialized societies, malnutrition often appears related to child abuse and neglect. Organic and metabolic forms are observed but social pathology appears to be the main determinant of most malnutrition observed. Prevention and control of malnutrition requires improvement of the environment and interventions applied in a holistic manner. Emphasis should be given to education and maternal technology, and to promotion of mother-infant interactions, breast-feeding, adequate weaning procedures and detection of factors that may lead to child deprivation and abuse. Improvement is feasible for most developing nations if social forces become conscious of the needed changes, but positive elements of traditinal culture should be preserved.

PIP: Traditional populations made up of small tribal groups living in close contact with nature may be virtually free from endemic malnutrition because of the relative absence of infectious diseases. Transition toward modern ways of life and population growth, resulting in crowding and underdevelopment, favors endemic malnutrition because of the interaction of malnutrition and infection. Attention is directed to 2 societies, the Guaymi aborigines who live in Villa Palacios in Costa Rica and who have satisfactory nutrition and the Maya Cakchiquel Indians who live in the Guatemalan highlands and who are experiencing malnutrition. The Guaymi live in dwellings scattered in the forests and jungles bordering Panama. The women deliver the babies at home in the traditional way, and breastfeeding is customary. These circumstances seem to ensure an adequate level of nutrition and health disturbed only by occasional epidemics of infectious diseases following the arrival of visitors or travel outside the village. Weaning was not studied in detail, but the healthy condition and stocky build of mothers would indicate that an infant's supply of human milk is adequate in the 1st year of life. Weaning begins after 6 months with the introduction of poorly prepared traditional foods. The diet is monotonous and, by Western standards and international dietary recommendations, poor in quality and quantity. The prevalence of stunting of infants was doubled in the 2nd year of life, but wastage (deficit in weight for height greater than 20%) was not observed, a situation contrasting with other Indian populations such as the Cakchiquels of Guatemala. Better nutrition and health may result from adequate child rearing practices in an environment relatively free of stress, especially infection, even in the absence of abundant and well balanced diets. The genesis of protein energy malnutrition (PEM) was observed during a study of infants from birth until school age in Santa Maria Cauque, a Maya Cakchiquel Indian village located in the Guatemalan highlands. This traditional village is in slow transition toward modern ways of life and resembles many other crowded and poor communities of Latin America. The dominant features of the village are socioeconomic underdevelopment, preservation of traditional ways of child birth and child rearing, and subsistence on traditional agriculture. Infection, particularly enteric, stands out as a primary determinant of PEM. The origin of PEM in societies in transition is frequently different from that described for traditional communities. Characteristics such as early mother infant attachment and breastfeeding have been disturbed by obstetric practices and artificial feeding, and there is a pronounced increase in social pathology, i.e., stress and anxiety, alcohol and drug consumption, family disruption, and aggression. In societies in transition intervention must recognize the origin and nature of the problem and holistic measures must be adopted.

Effect of infection on food intake and the nutritional state: perspectives as viewed from the village.

Data from a prospective study of a Guatemalan village population revealed an exceedingly high force of infection which may effect nutrition and growth from gestation onward. Maternal morbidity was higher and fetal antigenic stimulation was more frequent than in industrial societies. Infection of the young child was a common occurrence and although a great many infections were silent, morbidity rates were extremely high, particularly during the protracted weaning period (6 to 24 months). Infectious disease was found to be an important cause of weight loss, arrest in height, and impaired physical growth. Also, it was a common precipitating factor of severe malnutrition and death. Analysis of the dietary data of fully weaned children did not reveal a deficit in protein intake. Most children, however, had very low calorie intakes. Infectious disease was a common cause of anorexia and of marked reduction in calorie intake, followed by weight loss and impaired physical growth. A strong inverse correlation was detected between infectious disease and calorie intake in the 2nd year of life, when children were being weaned. Infection is the most important isolated factor in the causation of malnutrition in the village. A reorientation of health and nutrition policies seems in line in view of failures of food supplementation programs, particularly with protein, in many parts of the world.

PIP: A prospective study of a Guatemalan village population demonstrated the adverse effects of infection on the nutritional and growth status of the population from gestation onward. There was a higher rate of maternal morbidity and fetal antigenic stimulation compared to industrialized societies. Infection of the young child was common, and although many infections were silent, morbidity rates were extremenly high, particularly during the protracted weaning period (6 to 24 months). Infectious diseases contributed significantly to weight loss, arrest in height, and impaired physical growth, as well as to severe malnutrition and death. Although analysis of the dietary data of fully weaned children revealed no deficiency in protein intake, most children were found to have very low calorie intake. Infectious diseases were a common cause of anorexia and of marked reduction in calorie intake. A strong inverse relationship was found between infectious disease and calorie intake in the second year of life, when children were being weaned. Infection is the most critical factor in the causation of malnutrition in the village. Health and nutrition policies should be reoriented in view of failures of food supplement programs in many parts of the world.

Characterization of an R-plasmid associated with ampicillin resistance in Shigella dysenteriae type 1 isolated from epidemics.

Ampicillin-resistant strains of Shigella dysenteriae type 1 isolated in epidemics in Mexico, Central America, and Bangla Desh were examined for the presence of plasmid deoxyribonucleic acid (DNA) by gel electrophoresis. All strains contained a heterogeneous population of plasmids. Transfer experiments to Escherichia coli K-12 indicated that the ampicillin resistance determinant (Ap(r)) was located on a 5.5-megadalton (Mdal) plasmid identical in all Shiga strains examined, as judged by DNA hybridization and by its molecular properties. This 5.5-Mdal plasmid contained the ampicillin transposon (TnA) sequences. There was not a high degree of homology between the Shiga Ap(r) plasmid DNA and DNA obtained from Ap(r)Salmonella typhi strains isolated from typhoid epidemics in Mexico, previous to the dysentery outbreaks. Although low, the degree of reassociation observed indicated that probably part of the TnA sequence was present in S. typhi DNA. The DNA hybridization experiments showed, in addition, that there was a high degree of homology among Ap(r) plasmids isolated from different enterobacteria, and this identity was confirmed by restriction endonuclease activity. These results together with their similarities in molecular and replicative properties indicate that the Ap(r) plasmids, as was suggested for the Sm(r) Su(r) plasmids, possibly evolved once and then epidemiologically spread in the Enterobacteriaceae.

Antenatal events and postnatal growth and survival of children in a rural Guatemalan village.

The biological features of all pregnant women and newborn infants in a typical rural village of Guatemala have been studied form 1964 to the present; 458 pregnancied have been analysed. The mothers averaged 143.1 cm in height 52.9 kg in weight and 9 mm in triceps skinfold. The diet of most was adequate in percentage protein but inadequate in iron and other nutrients. Infection was common, two or more episodes occurring in 40 per cent of pregnancies. The newborn population had a birthweight averaging 2533 g and length 45.6 cm. Thirty-four per cent were less than 2501 g at 37 weeks gestation or over; seven per cent were pre-term. The infants' growth was followed till age six years. Survival correlated strongly with birth weight and gestational age. Pre-term infants showed the poorest survival in neonatal and postneonatal infancy; but the survivors thrived therafter. The term-small-for-gestational age infants had poor survival in infancy and during the second and third years. Term infants with adequate weight-for-gestational age had the best survival rate. Postnatal physical growth correlated with birth weight and gestational age but pre-term adequate-for-gestational age infants showed a rate of growth as good as that of term infants.

[Considerations on malnutrition in Central America with special reference to Costa Rica]. / Consideraciones sobre la desnutrición en Centro América, con especial referencia a Costa Rica

This paper analyzes aspects relevant to the nutritional situation in Costa Rica and to a lesser extent the rest of Central America. The nutritional problems have been dealt in a realistic way trying to avoid magnification of the situation. The available data show that calorie-protein malnutrition, anemia and goiter are the problems that, in that order, should receive attention in public health planning. Deficient maternal education and infection of the child play a preponderant role in the etiology of calorie-protein malnutrition and anemia. Analyses presented here show the convenience to revise periodically the criteria used to characterize the nutritional status, in order to adequately plan health actions. Also, the necessity to carry out basic and applied research in the field is emphasized. The future of the nutritional situation is uncertain for the majority of the Central American countries. However, some demographic indicators reveal that nations such as Costa Rica probably will reach an adequate nutrition in a not too distant future.

Systems analysis in nutrition and health planning: approximate model relating birth weight and age to risk of deficient growth.

This paper summarizes the initial phase of an effort to develop semiquantitative methods for nutrition and health planning. The general approach is to utilize the methods of systems analysis and operations research where appropriate, but the emphasis is on developing a simplified, approximate analysis that government planning groups could conveniently apply in evaluating various potential programs for attaining specific nutrition and health objectives, while satisfying certain constraints (e.g., budget, facilities, personnel). An essential element of the analysis is a model that provides an approximate description of malnutrition (inadequate growth, as indicated by weight for age) and mortality in terms of those variables that can be affected by intervention programs. We have concentrated initially on using the results of two INCAP longitudinal studies to develop models relating the incidence of malnutrition (second and third degree on the Gomez scale) to age and previous growth, including birth weight. The two studies cover rural Guatemalan communities with considerable variability in ethnic, socioeconomic, and ecological conditions. Because they are tentative, the resulting models are discussed only qualitatively and not quantitatively. The models may serve as baselines to estimate the consequences of potential programs aimed at different target groups, such as pregnant women and children whose weights at birth or thereafter fall below prescribed levels. The possible benefits of using models of this nature in nutrition and health planning are discussed.

Breast-feeding, weaning and the diarrhoeal syndrome in a Guatemalan Indian village.

Prospective studies in Mayan Indian children living in their natural setting were carried out from 1964 through 1974; observations began at birth and extended at least throughout the first three years of life. Adequate growth and survival were characteristic of exclusively breast-fed infants in the first months of life. Despite the high rate of infection, children exhibited a considerable resistance to intestinal protozoa, enterobacteriaceae and enteric viruses. Resistance against colonic invaders is attributed to the bifidus flora, and that against agents acting in the small bowel, to specific antibodies present in colostrum and milk. Diarrhoeal disease was least in this period and increased with weaning to reach maximum peaks at the time of weaning. The protracted weaning consisted of progressive administration of foods of low biological value given under deficient sanitary conditions. The nutrient value of the diet as a function of the child's weight was adequate in protein but in most cases it was markedly deficient in calories. Infectious diseases, particularly diarrhoea, were found associated with pronounced reductions in the already deficient calorie intake. Infection and infectious disease were common particularly during the first 6 to 18 months of life. Weight loss was a frequent finding during and after episodes of disease. The consequence of the malnutrition-infection interaction is a marked stunting of growth, clearly evident from examination of the growth curves of village children. Nutrient intake did not correlate with growth velocity. By contrast, the duration of breast-feeding was strongly associated with growth in the linear segment of the curve, while in the period of faster growth the correlation was inverse. On the other hand, morbidity was inversely correlated with calorie and protein intake and this was more obvious in the second than in the first year of life. The data indicate that infection is one of the leading factors associated with reduced calorie (and protein) intakes during the critical period of onset of malnutrition and mortality in childhood. By preventing infection, particularly diarrhoea, the food intake, nutrition and growth of children could be significantly improved.

The environment of the malnourished child.

The study of the relation of man to his environment in developing countries emphasizes the inevitable need for societies to recognize the true causes of infection, malnutrition, and poverty. The need is for improvement in the quality of human life in less developed nations, a recommendation easy to prescribe but difficult to accomplish. Although our pool of knowledge is incomplete, it is adequate to suggest ways to diminish infection, increase food production, utilize food more efficiently, improve education, and provide systems of justice to protect the classes most in need. The physical environment in tropical and subtropical regions, and the socioeconomic characteristics of the population inhabiting such regions, favor maintenance and transmission of a variety of viruses, bacteria, and parasites that make agricultural progress and social development difficult, and that contribute to poor fetal growth, nutrient wastage, and deficient postnatal physical growth, accounting for most of the childhood morbidity and mortality. In this regard, infections contribute indirectly to the overall food problem in a similar fashion as pests do in terms of food losses and spoilage. The overall effect could be comparable or greater than that resulting from an inadequate capacity to produce or to purchase the food needed. Thus, my objective has been to stress, within the whole environment, the importance of infection and the need to diminish it. Ways to control and prevent infection are readily known. They have to do with education of the population to improve personal and environmental hygiene. Economic investment is necessary to improve housing and water supply systems, waste disposal, and such preventive measures as immunization programs. Although such measures may appear expensive when first implemented, they have long-lasting effects and many require minimal expenditure once they are established. Large segments of the population stand to benefit, and other development interventions can then be introduced. However, these measures should not be implemented singly. They should be accompanied by community development, family planning, social legislation--in other words, the holistic approach to health and welfare. To do otherwise may aggravate the problem by stimulating demographic growth, perpetuating malnutrition and infection, and maintaining underdevelopment.