Impact of food supplementation during lactation on infant breast-milk intake and on the proportion of infants exclusively breast-fed.

To evaluate whether milk production can be improved by increasing food intake, a randomized, double-blind, supplementation trial was completed among 102 lactating Guatemalan women. The subjects were undernourished, as indicated by their low values for calf circumference (CC) and the small size of their infants at birth. A high-energy (2.14 MJ/d, HES) and a low-energy (0.50 MJ/d, LES) supplement were distributed 6 d/wk from wk 5 to 25 of lactation. Data were evaluated using repeated-measures analysis of variance on the increments from initial values for each outcome variable with one-tailed tests of statistical significance. The maternal energy intake increased 1.18 MJ/d (P < 0.01) more among the HES than the LES women. Benefit from supplementation was more evident among the more undernourished (CC

[Physical growth and menarche in Guatemalan adolescents]. / Crecimiento físico y menarquia en adolescentes de Guatemala.

The relationship between anthropometric measurements and age at menarche was studied in a group of Guatemalan adolescents, from urban and rural areas. The data indicate that median age at menarche is significantly higher in Indian adolescents living in rural areas than in non-Indian, the lowest age at menarche being that of adolescents living in urban areas. The age at menarche is positively associated with anthropometric measurements (weight, arm circumference and height) and body composition (body mass index), suggesting that both physical growth and sexual maturation are interacting processes of the same phenomenon known as the development age.

Differences in the epidemiology of prematurity and intrauterine growth retardation.

Although both preterm (PT) and intrauterine growth retarded (IUGR) infants can have similar birth weights, they are known to show different neonatal and post-neonatal features. Newborns (n = 623) from the Guatemalan longitudinal study of nutritional supplementation during pregnancy were studied. There were 61 PT (less than or equal to 37 wk) and 173 IUGR (less than or equal to 10th percentile) infants. Simultaneous adjustment using the long-linear model showed that calorie and/or protein supplementation during pregnancy lowered the risk of PT (adjusted odd ratios (OR) = 0.52, 95%, CI = 0.40-0.77, and 0.43 CI = 0.36-0.59, respectively), but did not affect the incidence of IUGR. Low maternal head circumference and weight increased the risk of IUGR only (OR = 1.4, CI = 1.02-1.8 and 2.3 CI = 1.8-2.7, respectively). Male fetuses were at higher risk of both PT and IUGR. These data confirm the differential effect of maternal characteristics and nutritional supplementation during pregnancy on both PT and IUGR, and strongly suggest the need to include both gestational age and birth weight as outcome measures in epidemiological studies, thus avoiding the exclusive use of LBW (less than or equal to 2500 g).

[Breast feeding practice and activities for its promotion in Central America, Panamá and Dominican Republic]. / Práctica de la lactancia natural y actividades para su promoción en Centroamérica, Panamá y la Republica Dominicana.

This paper summarizes the data presented by the representatives of Central America, Panama and the Dominican Republic at the II Regional Seminar on the Promotion of Breast-Feeding, held in Isla Contadora, Panama, April 25-29, 1983. The representatives of Costa Rica, Honduras and Panama provided up-to-date, representative data in regard to the breast-feeding practice. The average weaning age in the urban and rural areas of Costa Rica is 6 and 4 months, respectively. In Honduras and Panama, 43 and 17% of the infants from urban areas, and 21 and 37% of the babies from rural areas, respectively, were weaned before they reached four months of age. The need for availability of permanent systems to collect information on the breast-feeding practice in the different countries is pointed out. With regard to promotion actions, the absence of a national policy in favor of breast-feeding is evident. Moreover, in the national education systems, little importance is given to the subject. On the other hand, the advances achieved by some hospitals in favoring breast-feeding are mentioned. These include rooming in, the feeding of colostrum to newborns, and the establishment of human milk banks to feed premature babies whose mothers are unable to breast-feed them. Another acknowledged fact is that in the rural areas the agricultural home educators do not reinforce the breast-feeding practice. Also, there is a lack of information on the fulfillment of laws instituted for the protection of pregnant and lactating mothers, as far as pre and postnatal rest is concerned.

[Synopsis of the Seminar on Breast Feeding Promotion in Central America, Panama and the Dominican Republic. Isla Contadora, Panama, 1983]. / Sinopsis del Seminario sobre Promoción de la Lactancia Natural en Centroamérica, Panamá y la Republica Dominicana. Isla Contadora, Panamá, 1983.

The most recent and reliable information on the status of breast-feeding in Central América, Panama and the Dominican Republic indicates that during the last decades, in all of these countries there has been a decrease in the prevalence and duration of breast-feeding. In some of them, this situation would seem to be reverting. Considering the importance that breast-feeding has on children's health and nutrition, the Institute of Nutrition of Central America and Panama (INCAP), organized a Regional Seminar on the Promotion of Breast-feeding, which was held in Contadora Island, Panama, in April, 1983. Based on the discussions of the working groups, sectoral and integrated recommendations were formulated for the purpose of promoting breast-feeding. This document contains specific recommendations for each of the sectors represented in the Seminar.

Notes on mortality research. Discussion of related papers presented at the International Population Conference of the International Union for the Scientific Study of Population (IUSSP), held in Manila, Philippines, December 9-16, 1981.

PIP: This article overviews the papers presented at a session of the International Population Conference of the International Union for the Scientific Study of Population devoted to the determinants of changes in late fetal, infant, and child mortality. A strong negative association of maternal and paternal educational level and infant and child mortality was reported; however, it was recognized that this association may be spurious since education is also associated with cultural and socioeconomic variables. Improved utilization of health services may be 1 of the mechanisms through which education influences mortality. In addition, women with low levels of education tend to be of lower socioeconomic status, in turn associated with infant mortality risk factors such as delays in seeking prenatal care, short stature, poorer health, work during pregnancy, and inadequate nutrition. Other papers focused on the impact of specific interventions on infant and child mortality, e.g. family planning, tetanus immunization, and oral rehydration therapy. It was noted that technology successful in pilot studies aften fails when implemented in larger population groups. It was suggested that integrated primary health care programs with a strong education component and utilization of paramedical personnel may be most effective in reducing infant and child mortality. The application of the principles of social learning theory, which seeks to modify behavior through participant modelling and reinforcement, should be explored. Also essential is attention to the social and economic context that influences and constrains maternal and child health. Finally, a need for analyses of mortality rates by categories of functional groups (e.g. occupation of father) was noted.^ieng

[Critical analysis of the validity of arm circumference as an indicator of protein-energy nutritional status in preschool children]. / Análisis crítico de la validez del perímetro del brazo como indicador del estado nutricional proteínico-energético en niños preescolares.

Arm circumference has been recommended as a useful indicator for malnutrition screening, particularly in rural areas. The great advantages of the arm circumference over other anthropometric indicators are that the measure is easily obtained in rural areas and that the method for assessing arm circumference is simple, inexpensive and rapid. In this paper the validity (specificity and sensitivity) of arm circumference is analyzed as compared to more valid indicators of nutritional status in preschool children. We conclude that arm circumference is relatively valid for detecting global malnutrition (as indicated by weight-for-age), but of limited validity when used for detecting acute or chronic protein-calorie malnutrition. Furthermore, when compared to weight-for-age in detecting populations or individuals at high risk of acute or chronic protein-calorie malnutrition, it was found that weight-for-age has a higher level of specificity and sensitivity than arm circumference. Finally, it was found that sensitivity and specificity of arm circumference vary with age, suggesting that arm circumference cannot be considered an age-independent indicator of nutritional status. It is therefore recommended that these possible limitations of arm circumference be kept in mind when used in public health programs.

[Training needs for health and nutrition personnel in developing nations]. / Acerca de las necesidades de adiestramiento de personal de salud y nutrición en los países en desarrollo.

This paper examines some of the factors related to the training of health and nutrition personnel in developing countries in general and in Latin America in particular. It addresses both professional and technical level staff responsible for the formulation of plans and programs, and auxiliary personnel responsible for the delivery of services. Using the systems analysis model, the need for training human resources in research techniques and decision-making on a scientific basis is taken as an example for a discussion of aspects of the diagnosis, planning, execution and evaluation of health and nutrition programs. Various ways are indicated of giving training in research techniques, using the personnel available and employing simple instructions and methods, currently under-used, such as gathering anthropometric data. The authors stress that if an effort were to be made in the countries, the risk factors influencing health and nutrition, particularly among the maternal-child group, might well be identified quickly and without great cost. The case of the height census in Costa Rica is reviewed as a practical example of programs that have originated in developing countries and that make maximum use of auxiliary personnel in obtaining reliable, valid information for decision-making purposes. This census included children in the first grade of the primary cycle at the national level. The contents of the tutorial training program of the Institute of Nutrition of Central America and Panama (INCAP) are also described.

Diarrheal diseases, nutritional status and health care: analysis of their interrelationships.

PIP: The relationship between diarrheal disease, nutritional status, and health care was studied prospectively in Guatemalan Indian children 0-24 months of age. Subjects were drawn from the Patulul Project, a nutrition intervention study conducted by the Institute of Nutrition of Central America and Panama. The total population includes 7000 Indians who live on 12 coffee plantations in Guatemala. Data were collected from October 1977 to September 1978 and analyzed by quarter: October-December (dry season), April-June (rainy season), and January-March and July-September (transitional). Most diarrhea was found to occur during the rainy season, yet visits to a simplified health care clinic set up as part of the Patulul Project steadily declined from October to September. The conditional probability of visiting the clinic was calculated at less than 50% for children with either simple diarrhea or diarrhea with blood and mucus. Although there were no sex differences in the rate of diarrhea, boys with gastrointestinal disorders were more likely to be taken to the clinic than girls. When children were grouped by nutritional status (weight-for-age, length-for-age, weight-for-length), the cumulative incidence of and percent time ill with diarrhea with blood and mucus were consistently higher in malnourished children. The magnitude of the differences between nutritional groups was highest during the rainy season. The effects of diarrhea episodes and visits to the clinic on weight-for-age changes were also examined. Children with initially low weight-for-age (or=75%) and with diarrhea during the trimester gained significantly less weight-for-age during that period than children without diarrhea. In addition, children with diarrhea who visited the health clinic gained more weight-for-age than those with diarrhea who did not receive care. Diarrhea and health service utilization had less of an effect on well-nourished children. These results support the hypothesis that the negative nutritional consequences of diarrhea are more significant among malnourished children and demonstrate the positive effect of a simplified health care program on the nutritional status of children suffering from gastrointestinal disorders.^ieng

Relationship of maternal and infant nutrition to infant growth.

A cohort of all infants born between January 1, 1969 and February 28, 1977 in four rural villages in Eastern Guatemala which were participating in a longitudinal project of nutrition and mental development was studied. As part of the study, prospective information on anthropometric measurements, morbidity, dietary intake and socioeconomic and cultural characteristics was collected. In addition, two types of food supplements were distributed: calorie and protein-calorie. Attendance at the feeding centers in each village and the amount of supplements consumed by children and pregnant and lactating mothers were recorded daily. We studied the effect of the supplements consumed by the mother during pregnancy and lactation and by the infant on trimestral infant weight and length changes during the first year of life. The data indicate that infant calorie supplementation before three months of age is significantly and negatively associated with infant growth; after three months of age, supplemental calories consumed by the infant are significantly and positively associated with infant weight and length gains. In addition, a small positive association was found between maternal caloric supplementation during lactation and infant growth during the first two trimesters of life, after controlling for potentially confounding factors for which data are available in this study.

PIP: The interrelationships between maternal nutrition, breastfeeding, infant nutrition, and infant growth in the context of a quasi-experimental longitudinal investigation carried out in rural Guatemala was examined. This is the 1st publication from the Guatemalan study to focus on the relationship of maternal and infant nutrition to infant growth during lactation utilizing all data collected between 1969-1977. The subjects were inhabitants of 4 agricultural villages participating in a longitudinal study of the relationship between malnutrition, physical growth, and mental development, which was conducted between 1969 and 1977. The entire population of the 4 communities was 3359 in 1975. The sample for these analyses was all children born between January 1, 1969 and February 28, 1977 (n=1106) and who were followed up to 12 months of age. Data on a variety of anthropometric measurements were taken by trained and standardized anthropometrists at specific ages (15 days, 3, 6, 9, and 12 months for children and quarterly for mothers during pregnancy and lactation). The main independent variable is nutrient intake, which includes supplement consumed at the feeding center and home diet and supplement intake. In general, the results of the longitudinal study attest to an effect of maternal dietary supplementation on infant growth, particularly infant weight gain from birth to 3 months and from 3-6 months of age. The data indicate that infant supplementation prior to 3 months of age is significantly and negatively correlated with infant growth, after controlling for potentially confounding factors for which data are available in this study. After 3 months of age, supplemental calories consumed by the infant are significantly, positively correlated to infant weight and length gains. The small association between maternal food suppplementation and infant growth could be due, in part, to the fact that only a small fraction of the energy consumed by the infant is utilized for growth after the 1st trimester of age and infant adaptation to limited caloric intake could be achieved by a reduction of physical activities. The negative association between infant supplementation and infant growth is probably because mothers whose infants were not growing adequately began to give supplements to the infants earlier than those with more adequate growth. The results also reflect the previously reported relationship between such factors as anthropometric measurement of the parents, obstetrical characteristics, infant morbidity, lactation, and infant growth.

Nutrition, lactation, and birth interval components in rural Guatemala.

The effects of maternal nutritional status and food supplementation ingested by the infant on the duration of postpartum amenorrhea and on the duration of the menstruating interval was examined. A significant negative association was found between the nutritional status of the mother during the 3rd trimester of pregnancy and infant supplementation, on the one hand, and the length of postpartum amenorrhea on the other hand. These associations remained significant after controlling for each other and for other potentially confounding factors for which data wee collected. These results support the hypothesis that maternal nutritional status, by determining the amount of breast milk available, hence the frequency, duration, and intensity of suckling, is indirectly, negatively associated to the length of postpartum amenorrhea. Furthermore, no association between maternal nutritional status and the length of the menstruating interval was found.

Maternal stature, fertility and infant mortality.

PIP: 380 women of parity 1 or more living in coffee plantations of the Pacific lowlands of Guatemala were studied during the 18-month period from October 1977 to March 1979 to investigate the relationship between maternal stature, parity, offspring mortality, and number of surviving children. Average height was 142 cm or 4 feet 8 inches, average age was 28 years, and average parity was 4.4 children per woman: average number of surviving children per woman was 3. Simple correlation analysis shows that although shorter women appeared to have greater parities but fewer surviving children, the relationships were not statistically significant (p.05). However, when age and/or parity were adjusted, the association between maternal stature and number of surviving children became statistically significant (p.05). Children of shorter mothers exhibited high mortality rates which were not affected by adjustments for maternal age and parity (p.001). A possible explanation of the link between maternal stature and offspring survival is that taller women generally have heavier babies. This study suggests that maternal height can be used to identify infants at high mortality risk; this can have potential use in developing nations where many women do not get examined more than once during pregnancy.^ieng