Donor transmission intestinal carcinoma after kidney transplantation: case report.

Tumor transmission is a rare complication of organ transplantation. Despite several improvements in excluding donor malignant disease, there continue to be reports of unknown tumors in the donors. The risk of having a donor with an undetected malignancy ranges between 1.3% and 2%. The cases of two kidney transplant recipients who had intestinal carcinoma transmitted from the same deceased donor are described. The clinical presentation, previous data, and management options are discussed. As a result of the increase in the overall donor pool, using extended criteria donors, donors of extreme ages, donors with prolonged intensive care admission, and donors who may potentially transmit disease to their recipients, the risk of tumor transmission and also infections should be considered.

Single center experience with elective surgical patients as living kidney donors.

PURPOSE: To report a single center experience with elective surgical patients as living kidney donors. METHODS: We retrospectively analyzed a prospective database of 458 living kidney donors from September 2005 to May 2011. Fifteen (3.2%) of them were elective surgical patients simultaneously undergoing living donor nephrectomy. We reviewed age, gender, operative time, intraoperative blood transfusion, intra- and postoperative complications, as well as length of hospital stay. Recipients were evaluated for delayed graft function. Four hundred forty-three patients undergoing living donor nephrectomy alone composed the control group. RESULTS: Among the elective surgical patients group, the mean (range) operative time was 155 (90 to 310) minutes and mean (range) length of hospital stay was 3 (2 to 9) days. One (6.7%) recipient displayed delayed graft function. Among the regular living kidney donors group, the mean (range) operative time was 100 (70 to 150) minutes, mean (range) length of hospital stay was 3 (2 to 5) days, and delayed graft function was observed in 5.6% of recipients. Only operative time (P = .03) was significantly different between the groups. CONCLUSIONS: Elective surgical patients are potential donors who may be treated at the same time as the living donor nephrectomy.

Traditional food diversity predicts dietary quality for the Awajún in the Peruvian Amazon.

OBJECTIVE: Our goal was to assess the potential for evaluating strengths of the Awajún traditional food system using dietary assessment, a traditional food diversity score and ranking of local foods. DESIGN: The method was used for dietary data obtained from mothers and children in the Awajún culture of the Peruvian Amazon where >90% of the dietary energy is derived from local, traditional food. Traditional food diversity scores were calculated from repeat 24-hour recalls. Group mean intakes of energy, fat, protein, iron, vitamin A and vitamin C from each food item were used to rank foods by nutrient contribution. SETTING: The study took place in six remote communities along the lower Cenepa River in the Amazonas District of Peru, South America. SUBJECTS: Dietary data were collected from 49 Awajún mothers and 34 children aged 3-6 years, representative of the six communities. RESULTS: Higher traditional food diversity was associated with greater protein, fibre, vitamin and mineral intakes when controlling for energy (partial correlations = 0.37 to 0.64). Unique sources for iron, total vitamin A and vitamin C were found in the Awajún traditional food system. CONCLUSIONS: A traditional food diversity score was a useful tool for predicting nutrient adequacy for the Awajún. Promotion of the Awajún traditional food system should focus on dietary diversity and unique nutrient-dense local foods.

Improving dietary intake to prevent anemia in adolescent girls through community kitchens in a periurban population of Lima, Peru.

Peru has high rates of iron deficiency anemia. The prevalence is 35% in nonpregnant women of fertile age and 24.7% in adolescent girls in slums of periurban Lima. The major cause of anemia is low intake of dietary iron. A community-based, randomized behavioral and dietary intervention trial was conducted to improve dietary iron intake and iron bioavailability of adolescent girls living in periurban areas of Lima, Peru. Results show that there was a change in knowledge about anemia and improved dietary iron intake in the 71 girls who completed the study compared with the 66 girls in the control group. Although the 9-mo. intervention was not sufficient to improve hemoglobin levels significantly, there appeared to be a protective effect in maintaining the iron status of girls in comparison with the control group.

Recognizing the reversible nature of child-feeding decisions: breastfeeding, weaning, and relactation patterns in a shanty town community of Lima, Peru.

Researchers have normally considered weaning to be a non-reversible event. To determine the validity of this assumption, we interviewed 36 mothers of toddlers who were living in a poor shanty town of Lima, Peru. Data from 32 women were complete and used in this analysis. Mothers described their beliefs, practices, and decisions about breastfeeding, weaning, and relactation (the reintroduction of breastfeeding after weaning). We recorded attempted weaning events if the mother reported (1) purposefully not breastfeeding with the intention to wean, or (2) carrying out an action that was believed to cause the child to stop breastfeeding. Using a constant comparative approach, references to child-feeding decisions were coded, categorized, and analyzed. All mothers breastfed for at least 12 months; the median duration of breastfeeding was 25 months. There were several different patterns of child-feeding. Thirteen women never attempted to wean their children or had weaned on the first attempt. The majority (n = 19) of women, however, attempted to wean their children - some as early as 3 months of age but relactated between less than 1 day and 3 months later. Factors that influenced feeding decisions were primarily related to maternal and child health, and maternal time commitments. Children were weaned when there was a perceived problem of maternal health or time commitments and child health was not at risk of deterioration. Mothers postponed weaning because of poor child health. The primary reason for relactation was a child's negative reaction to weaning (e.g., incessant crying or refusal to eat). Personalities of the mother and child were important determinants of feeding decisions. These results demonstrate that maternal and child factors jointly influence child-feeding decisions and that these decisions are easily reversed. As relactation is culturally acceptable, health practitioners should consider recommending relactation when children have been prematurely weaned and human milk would improve their nutritional and health status.

[Validation of a questionnaire for the diagnosis of headache in an outpatient clinic at a university hospital]. / Validação de questionário para diagnóstico de cefaléia em ambulatório de hospital universitário.

Headache is a common complaint with a high prevalence in ambulatory settings. The physical and neurological examinations are frequently normal. The use of questionnaires as a screening methods for patients with primary headache could facilitate the diagnosis in non-specialized medical centers. In the present study, we used a questionnaire, based on the IHS criteria and modified by the authors, applied to 204 patients from the outpatient clinic of the Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. Half of the patients were submitted to a clinical interview. We compared the results of the questionnaire with the results of the medical interview (gold standard). Most of the headaches we studied were primary headaches (89.6%). The questionnaire revealed a sensitivity of 90.2% and specificity of 57.9% for migraine detection with a chance corrected agreement (kappa) of 0.47 and a positive predictive (PPV) value of 65.7% and a negative predictive value (NPV) de 86.8%. The sensitivity for tension-type headache detection was 60.8% and the specificity 87.1% with a kappa value of 0.49 and a PPV of 77.8% and a NPV of 75.9%. We conclude that this questionnaire can be used as a screening method for diagnosing headache and that it can be applied by non-medical personnel. This questionnaire could also be used for population studies.

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.

Congratulations to the mothers. Breastfeeding.

PIP: In Lima, Peru, a study was conducted that evaluated the influences on mothers' decisions regarding breastfeeding. Local views and health professional advice was ascertained. A follow-up study of a group of pregnant women was conducted to assess knowledge, attitude, and practice in regard to the early feeding of their children. The women were interviewed in their homes before delivery, as soon as possible after delivery, and twice a week until their babies were 1 month old. The experience of the mother was the key factor, but advice from relatives, neighbors, and health professionals was also important. A lack of information about exclusive breast feeding was common. Although the women knew breast feeding was good, they were unaware that exclusive breast feeding was best. Health workers knew to advise against other milks, but failed to advise mothers against the use of herbal teas and sweetened water as supplements. The women commonly believed they were unable to produce enough milk to feed their children because of their own undernourishment. Others believed exclusive breast feeding would worsen their own health, while some experienced difficulties breast feeding. This led to supplementation with other milks; herbal teas were given to cure colic and to quench infants' thirst. Based on these findings, the project focused educational efforts on providing better information to mothers. Messages stressed the thirst quenching property of breast milk and its similar benefits to herbal tea, which should be consumed by the mother, rather than the infant. Since breast feeding practices were closely linked to mothers' beliefs about their own needs, the project emphasized the value and needs of the mother and the benefits of breast feeding for her. Educational activities, which continued for 12 months, included videos shown to small groups of mothers, posters, distribution of pamphlets, and messages broadcast over loudspeakers. A significant increase in the number of children aged 0-4 months being exclusively breast fed was observed; however, the increase only occurred in the second, third, and fourth month. This seemed to be a direct result of the decrease in use of herbal teas and sweetened waters. The number of women using other milks as supplements did not decrease significantly.^ieng

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.

Potential for misclassification of infants' usual feeding practices using 24-hour dietary assessment methods.

Feeding patterns of 131 low income Peruvian infants were assessed by 1574 single-day studies (12-h observations plus 12-h recall) of dietary intake and by mothers' monthly reports of usual feeding practices to determine whether feeding pattern classification depends on the assessment method used. Results suggest that single-day studies produce a different view of feeding practices than do mothers' reports of usual behavior. Exclusive breast-feeding in infants younger than 4 mo was observed 25% more often than reported. Non-human milk consumption was reported 30% more often than observed. Disagreement between reported and observed practices was related by logistic regression analyses to mother's age and education, number of children younger than 5 y in the home and infant age and illness on the observation day. Most disagreement between reported and observed behavior could have been due to daily variation in feeding practices. Consumption during the past 24 h should not be used alone as the basis for classifying infant feeding practices in survey research.

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.

Indicators for monitoring the growth of peruvian infants: weight and length gain vs attained weight and length.

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

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.

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.

Feeding during acute diarrhea as a risk factor for persistent diarrhea.

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

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.

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.

Incidence and etiology of infantile diarrhea and major routes of transmission in Huascar, Peru.

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

Longitudinal studies of infectious diseases and physical growth of infants in Huascar, an underprivileged peri-urban community in Lima, Peru.

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

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.