Dear all:

As one of the "Guatemala groupies" who finally had to opt for a dissertation topic that 
would get me to the point of finishing a PhD instead of my original topic on iodine 
deficienccy which was about 5 years too early in terms of "fundability", I have to say that 
I have looked at the Guatemala data inside out and backwards.  

This data set comes from the 1970s.  The atole used in this study was not the recipe 
shown in the post.  The atole was heavily supplemented with protein and minerals.  
Moreover, the data set may possibly be contaminated by the fact that infants also 
received some type of breast milk substitute if the mother, on her own, chose to give it.  
(I got this tidbit from a graduate student who worked at INCAP --- but never found the 
actual reference).  All mothers were also supplemented with either atole (heavily 
enriched with protein, vitamin and minerals as I mentioned) or fresco (which was 
enriched with calories and limited vitamins and minerals).  

It was supposed to be randomized to four villages.  At the time, the statisticians goofed 
and thought the sample size was the number of individuals.  It is not --- it is a nested 
design.  That means the sample size for each group was 2 villages.  One can do a more 
sophisticated nested analysis that I won't explain here.  

Another issue is that those in the fresco groups drank so little of the fresco that you 
cannnot really compare the effects of calories versus all the other nutrients because there 
was not enough overlap to look at those effects.  So, basically, the study really is a study 
of individuals who were supplemented with no real control group.  

In this data set, they only collected information on FREQUENCY and DURATION of 
breastfeeding.  Frequency of breastfeeding was almost uniform among all age groups of 
infants. This could be reporting bias (due to the tendency of mother's to report the 
cultural norm when asked about their own child-reading practices) or a real phenomenon. 
So no one knows how much breast milk these infants were getting.   The VOLUME of milk 
produced could very well have varied in this population and it could have gone either 
way.  What we do know is that not infants were not exclusive breastfeeders.  
Breastfeeding frequency was the same among those who had a lot of supplement and 
those that had just a little supplement.  

I actually looked at this data myself for my dissertation topic (never to be published in 
the formal literature because I didn't want anyone misinterpreting the results 
inappropriately).  Of 1120 boys, 390 were supplemented before 3 months of age and 119 
were given complementary food before 6 months of age.  Of the 1138 girls, 322 were 
supplemented before 3 months at 122 were supplemented before 6 months of age.  

What I found was that the largest impact of the supplement (calories was all that 
mattered not the type of supplement) on these PARTIALLY breastfed infants had it largest 
impact among three to six months olds on weight during that interval and on length gain 
at 2 years of age.  These were malnourished children overall, so this did not result in 
"obese" children by any means.  It resulted in less malnourished children.  This is NOT an 
endorsement of supplementing exclusively breastfed infants by any means!  Nor is it a 
ringing endorsement of supplementing partial breastfeeders - the devil is in the details 
here.  The work at UC Davis and elsewhere has elegantly demonstrated that infants 
should be exclusively breastfed to around 6 months.

Regression analysis on mothers' supplementation washed out of the picture, probably 
because the mothers who were consuming more supplement also had infants that were 
consuming more supplement.  So, again, you can't truly separate mothers 
supplementation and infants supplementation to see if the atole had any independent 
effect on growth.  

The other important fact to note is that the supplement was offered at a feeding center 
where the supplement was prepared under very clean conditions.

Quite frankly, my interpretation of this data was that those who were being supplemented 
were replacing a contaminated food (given their lack of latrines and availability of water) 
with a clean food.  It may have been a substitution effect that eliminated the negative 
impact of diarrhea on growth.  And in fact, those infants who were supplemented with 
atole or fresco between 3 and 6 months had the same or less diarrhea than those that 
were not.

One (IBCLC - not nutritionist) colleague of mine proposed an interesting alternative 
interpretation.  Those that may have received some higher quality less contaminated 
complementary food (rather than a watered down contaminated complementary food) 
may have fed more vigorously from the breast and stimulated the milk supply. So, here 
is yet another potential explanation for increased growth.

While it is easy to criticize these and other early supplementation studies from the 1970s 
now, they were really quite unique and large-scale trials of their day.  

Please don't extropolate this tenuous relationship from a highly enriched form of atole 
into "atole is a good galactogogue".  Such a hypothesis deserves appropriately designed 
research with the original form of atole.

Best regards, Susan Burger
(who thought her Guatemala groupie status would never come up on Lactnet)
             ***********************************************

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