Protein requirements of infants and children: growth during recovery from malnutrition.

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

Iron nutrition in infancy.

Iron deficiency and anemia remain significant health problems worldwide. These may he associated with developmental delay and poor mental development. A source of exogenous iron, is therefore, advisable after four to five months of age for breast-fed babies. Artificially-fed infants should be given iron-fortified formula from birth.

The nutritional management of acute diarrhea.

Acute diarrhea may have a profound effect on nutritional status worldwide. After rehydration, proper nutritional management can mitigate these effects. This paper discusses the advantages and disadvantages of continued feeding, emphasizing that breastfeeding should not be stopped during episodes of acute diarrhea.

Effect of dietary fiber (soy polysaccharide) on the severity, duration, and nutritional outcome of acute, watery diarrhea in children.

OBJECTIVE: To assess the effects of dietary fiber (soy polysaccharide) on the severity, duration, and nutritional outcome of acute, watery childhood diarrhea. METHODS: A total of 34 hospitalized Peruvian male infants between 2 and 24 months of age were randomly assigned to receive a soy-protein isolate, lactose-free formula with added soy polysaccharide (group SF, n = 19) or the same diet without added fiber (group S, n = 15). The consumption of formulas, stool amount and consistency, absorption of macronutrients, and change in anthropometric status were measured. RESULTS: Children in both groups were initially similar with regard to age, nutritional status, and prior duration and severity of diarrhea. Four patients in group SF (21%) and two in group S (13%) failed therapy because of recurrent dehydration or severe purging (P = .67). Formula intakes increased slightly during hospitalization (P = .03), but did not vary by dietary group (P = .73). Stool outputs declined significantly (P < .001) during hospitalization, but there were no significant differences by dietary group in either stool wet weight (P = .83) or dry weight (P = .87). Estimated median durations of liquid stool excretion after hospitalization were 43 hours in group SF and 163 hours in group S (P = .003). There were no significant differences in fractional or net absorption of macronutrients or change in anthropometric status by dietary group. CONCLUSIONS: Soy polysaccharide, while not affecting stool output, macronutrient absorption, or nutritional status during acute, watery childhood diarrhea, significantly and markedly reduced the duration of liquid stool excretion.

Dietary management of malnourished children with a new enteral feeding.

Balance (nitrogen, fat, carbohydrate) and growth studies were carried out in nine children (6 to 26 months old) recovering from protein-energy malnutrition (PEM) using a concentrated (1 kcal/mL) formula designed specifically for 1- to 6-year-olds. The formula provided 12% of energy as protein (18% whey, 82% casein), 44% of energy as carbohydrate (69% corn syrup solids, 31% sucrose), and 44% of energy as fat (50% high-oleic safflower oil, 30% soy oil, 20% medium-chain triglycerides). Means +/- standard deviations of apparent nitrogen retention and absorption were 90 +/- 3% and 39 +/- 13%, respectively. Mean fecal fat excretion was 1.3 +/- 1.0 g/day. Length-age increased 3.0 +/- 0.8 months and weight-age increased 8.3 +/- 3.8 months during the 2.4 +/- 0.3 months of the study. (Length-age and weight-age were defined as the age (in months) to which the child's length or weight corresponded at the 50th percentile of the National Center for Health Statistics reference data). Thirteen additional 40- to 30-month-old children with kwashiorkor were fed the formula for 8 to 35 days as part of the initial management of PEM. The result was prompt weight gain and increases in serum proteins. Its formulation and the findings of our study indicate that this new formula offers a notable advantage over products designed for infants or adults in the enteral alimentation of young children.

The nutritional value of oat flour for very young children.

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

Comparative absorption of [13C]glucose and [13C]lactose by premature infants.

Oxidation of orally administered [13C]glucose and [13C]lactose and fecal recovery of malabsorbed substrates were determined in two groups of premature infants. Eighteen studies were performed with six infants at Johns Hopkins Hospital (JHH); 24 studies were performed with nine infants at Columbus Children's Hospital (CCH). The two groups differed in that JHH infants had shorter gestations but were older when studied. Fecal 13C loss after [13C]glucose administration did not differ between the two groups. Compared with glucose, the metabolism of lactose appeared to involve more malabsorption and colonic fermentation in JHH infants than in CCH infants and resulted in higher fecal losses of substrate carbon. Maturation appeared to involve increased proximal intestinal absorption and greater retention of absorbed carbohydrate. Simultaneous absorption of substrate from the small and large intestine may limit the usefulness of breath tests for 13C in the premature infant.

Digestibility and utilization of protein and energy from Nasha, a traditional Sudanese fermented sorghum weaning food.

Whole grain sorghum flour was fermented into Nasha, a traditional Sudanese food, and freeze-dried or drum-dried. It was cooked and fed to convalescent malnourished infants and small children as 61% of total diet calories and all of 6.4% protein calories, with (Lys+) and without lysine supplementation to 3% of protein. Apparent absorptions of nitrogen were 73 +/- 5 and 74 +/- 6% of intake, significantly (P less than 0.01) less than those from preceding (Cas-1, 86 +/- 3%) and following (Cas-2, 85 +/- 3%) isonitrogenous casein diets. Apparent retentions of nitrogen from Nasha (26 +/- 10%) were significantly lower than those from Lys + (34 +/- 9%, P less than 0.05), Cas-1 (35 +/- 11%, P less than 0.01) or Cas-2 (49 +/- 9%, P less than 0.01). Retentions from Cas-2 were higher than those from Cas-1 or Lys + (P less than 0.01). Fecal wet and dry weights were higher (P less than 0.02) during both Nasha diets and Cas-2 than during Cas-1. Fecal energy and carbohydrate were significantly (P less than 0.01) higher from either Nasha diet than from either casein diet; fecal fat was not different. Two children received drum-dried Nasha without further cooking; digestibilities were not different from those of the cooked product but biological value was much lower. When properly cooked and consumed along with small amounts of a good source of lysine, Nasha is a satisfactory weaning food.

Efficient storage system for breath hydrogen.

Recommended materials for breath hydrogen collection (plastic syringes with twist lock closure) are only adequate for relatively brief periods because of gradual hydrogen loss and considerable variability between duplicate samples. To document the most favorable storage conditions for breath hydrogen, we compared hydrogen retention in plastic syringes using a conventional twist-in-lock closure versus a simple, inexpensive syringe closure, a Critocap. Hydrogen retention was studied at 25, 5, and -20 degrees C in two different syringe brands over 72 h of storage. An analysis of variance confirms the superiority of Critocaps over twist-in-lock closures (p less than 0.001). Reliability was maximal when samples were placed in environments less than 5 degrees C. When storage time was extended to 7 days, mean hydrogen retention was 86 +/- 6% (means +/- SD).

Survey: methods of feeding low-birth-weight infants.

The directors of 269 neonatal intensive care units were surveyed to determine how low-birth-weight infants are being fed. Feeding practices were based on birth weight, with the smallest infants receiving parenteral nutrition for the longest time after birth. First enteral feedings usually were given by the nasogastric route in infants with birth weight of 1,500 g or less, but transpyloric feedings were used in 15% of neonatal intensive care units for infants with birth weight less than 1,000 g. The initial enteral feeding was sterile water in 56% to 58% of the neonatal intensive care units, but was glucose water or milk in the others. Once enteral feeding was established, both human milk from the infant's own mother and commercial formula were used. Whether human milk was mixed or alternated with infant formula, or whether some infants in the nursery were fed human milk while others were fed formula, was not determined. The type of infant formula fed to low-birth-weight infants depended on the infant's birth weight and clinical status. Both human milk and formula were supplemented with energy (fat or carbohydrates) and vitamins, but not with calcium and phosphorus, in most neonatal intensive care units. Some vitamins, such as vitamins A and D, may be oversupplemented, while others, such as folic acid, may be undersupplemented.

Nutritional management of acute diarrhea: an appraisal of the alternatives.

Whether fasting during an episode of acute diarrhea is necessary or desirable has recently been questioned. The principal argument advanced for limited fasting is the avoidance of the consequences of malabsorption, namely acidosis, excessive fluid losses, depletion of the bile acid pool, and possible mucosal injury from unabsorbed foods. Advocates of continued feeding during acute diarrhea suggest that the practice will prevent deficits of intakes of protein and calories, maintain or stimulate repair of the intestinal mucosa, and sustain breast-feeding in the breast-fed infant. There are only a limited number of clinical studies that address the issue. Available evidence suggests that, in most cases, current practice should be modified to minimize food withdrawal.

Plasma and red blood cell fatty acid composition in children with protein-calorie malnutrition.

Plasma and red cell fatty acids were measured in 44 children with third degree malnutrition: 22 children with marasmus, 11 children with kwashiorkor, and 11 with marasmic kwashiorkor (MK). The presence of edema, dermatosis, hair changes, and hypoalbuminemia were positively correlated with the red cell percentage linoleic acid and negatively correlated with red cell percentage arachidonic acid. Red cell percentage linoleic acid in kwashiorkor was decreased from the control value of 15.3% to 10.9%. In marasmus and MK, there were significantly greater decreases, to 7.7% and 8.0%, respectively. Red cell arachidonic acid in kwashiorkor was significantly (P less than 0.001) decreased to 9.8% (control value of 13.1%) whereas in marasmus there was no significant change. Only one sample, plasma from an infant with marasmus, had any detectable eicosatrienoic acid (20:3,omega 9). Similar changes in fatty acid composition have been reported in infants with acrodermatitis enteropathica, in an infant with biotin deficiency, and in biotin-deficient rats.