Association Between Infant Feeding Practices and Nutritional Status in Healthy Nicaraguan Infants

Research Article Journal of Food Nutrition and Dietetics Open Access

Association between Infant Feeding Practices and Nutritional Status in Healthy Nicaraguan Infants

Erica C. Borresen1, Milena C. Guajardo2, Luis E. Zambrana1,3,4, Johann Perez4*, Claudia Perez4, Lorann Stallones2,5, Sylvia Becker-Dreps6, Lijuan Yuan7, Samuel Vilchez4, and Elizabeth P. Ryan1,2* 1Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, CO 80523,USA 2Colorado School of Public Health, Colorado State University, Fort Collins, CO 80523, USA 3Center for Epidemiology and Health (CIDS), León, Nicaragua 4Department of Microbiology and Parasitology, Faculty of Medical Sciences, National Autonomous University of Nicaragua, León (UNAN-León), León, Nicaragua 5Department of Psychology, Colorado State University, Fort Collins, CO 80523, USA 6Department of Family Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC,27599-7595, USA 7Department of Biomedical Sciences and Pathobiology, Virginia-Maryland College of Veterinary Medicine, Virginia Polytechnic Institute and State University, Blacksburg, VA, 24061, USA

Received Date: Accepted Date: Published Date:

*Corresponding August author: 26, Elizabeth 2016, P. Ryan, Department November of Environmental 11, 2016, and Radiological November Health Sciences,25, 2016. Colorado State University, 200 W. Lake St., 1680 Campus Delivery, Fort Collins, CO 80523-1680, USA, Tel: 970-491-1536; Fax: 970-491-7569; E-mail: [email protected].

Abstract Adherence to the World Health Organization’s infant feeding infants who are provided adequate nutrition through breast milk recommendations is intended to promote optimal growth, development, and complementary feeding have a reduced risk of morbidity and mortality, reduced risk of stunting, as well as improved mental and and health for infants. Evidence from the scientific literature shows motor development [6]. that cultural and family traditions play a major role in breastfeeding Selection of infant feeding methods depends on culture, family and complementary feeding behaviors. The objectives were to describe tradition, and available food and/or economical resources [7]. feeding practices during weaning stages and to examine associations between breastfeeding, bottle use, or complementary feeding practices Multiple Latin American countries report that majority of women and nutritional status, as measured by length-for-age (LAZ), weight- do not comply with this recommendation for a variety of reasons, for-age (WAZ), and weight-for-length z-scores (WLZ) in six-month old including but not limited to, maternal employment and family Nicaraguan infants. Data was collected from fifty-one healthy infant structure [8,9]. Within the Nicaraguan Ministry of Health, there is a participants (29 males and 22 females) and included LAZ, WAZ, WLZ, as health program called the Modelo de Salud Familiar y Communitario well as breastfeeding and complementary feeding history. A majority of (Model of Family and Community Health), or MOSAFC, that works participants were partially breastfed (76% males and 82% females), and with urban and rural communities in Nicaragua. One of the MOSAFC 66% males and 59% females began using a bottle before the age of two programs includes education on infant nutrition. Local nurses and months. Common supplementary foods included fruits and vegetables, with some reported intake of rice cereal, cheese, and cow’s milk. There pediatricians educate mothers about nutrition and other important health topics that aid in the development of the child [10]. However, wasp no statistical significance between breastfeeding and nutritional status. Consumption of cow’s milk was positively associated with LAZ family members beyond the nuclear family may have an influence ( = 0.04). This report describes infant feeding behaviors on a healthy on infant weaning behaviors that are highly related to exclusive Nicaraguan infant cohort and indicates that exclusive breastfeeding breastfeeding prevalence, and early introduction to bottle feeding recommendations up to six months of age were not in full compliance. and solid foods before six months of age [8,9]. Long-term follow-up on growth and development outcomes following a variety of breastfeeding and weaning patterns can yield valuable Nearly all infants between the ages 0 to 6 months are breastfed information about community compliance to global and national dietary in Nicaragua, but few are exclusively breastfed. Reports indicate that guidelinesTrial andRegistration: may inform future policy. https:// Nicaraguan infants are exclusively breastfed for a median of 21 days, Clinicaltrials.gov: NCT02615886, 58% use a bottle at less than one month of age (not adding breast milk clinicaltrials.gov/ct2/show/NCT02615886Keywords: to the bottle) and approximately 86% are introduced to solid foods before six months of age [8,9]. In Central and Latin America, mothers Breastfeeding; Complementary feeding; Nicaragua; introduce solid foods to their children by the age of four months, and Nutritional status are more likely to support infant overfeeding [11,12]. Abbreviations Evaluating breastfeeding bottle use, and complementary feeding patterns in specific geographical locations within and LAZ: Length-for-age z-score; UNICEF: United Nations Children’s across countries is necessary to determine if recommendations are Emergency Fund; WAZ: Weight-for-age z-score; WHO: World Health adhered to, and if not, how to provide an opportunity to develop Organization;Introduction WLZ: Weight-for-length z-score. culturally-specific interventions as part of prenatal and postnatal research [7,11]. It has been shown that infants who follow the exclusive breastfeeding recommendations have a lower risk of obesity in the future compared to infants who were formula fed in Infant feeding recommendations set by the World Health the first six months [13–17]. Assessing current weaning practices is Organization and promoted by the Nicaraguan Ministry of Health an important focus of child health and nutrition research to better include being exclusively breastfed for the first six months of life, understand not only short-term health outcomes, but also possible recommendationsfollowed by appropriate has shown complementary to aid in achieving feeding optimal with continued growth, long-term health and development effects. breastfeeding until the age of two [1-3]. Adhering to these This present study utilized baseline data from an infant development, and health of an infant [1,2,4,5]. More specifically, cohort enrolled in a prospective trial located in León, Nicaragua. J Food Nutri Diete Page 1 of 6 ISSN: 2470-9794 J Food Nutri Diete ISSN: 2470-9794 Vol. 1. Issue. 3. 14000110

participant’s well visit at the health clinic was collected as a second

Information about breastfeeding, bottle use, and complementary feeding practices were collected, alongside nutritional status. The measure and to confirm field data. This data was then calculated objectives were to describe breastfeeding and weaning practices for LAZ, WAZ, and WLZ following the World Health Organization at six months of age, and to examine any association between (WHO) child growth standards using the WHO Anthro software breastfeeding, bottle use, or complementary feeding practices and (version 3.2.2) [19]. Birth weight and premature status were also nutritional status, as measured by length-for-age (LAZ), weight-for- Statisticalcollected for Methodsdescriptive purposes. age (WAZ), and weight-for-length z-scores (WLZ). We hypothesized that breastfeeding prevalence in this area of Nicaragua would be similar to other areas in Nicaragua that have been previously Statistical analyses were® completed on participant reported between 1998-2015 [4,8,9,18] and that breastfeeding, characteristics, breastfeeding, bottle use, and complementary bottle use, and common complementary foods would be associated feeding data using IBM SPSS Statistics 23.0. The food types were withMethods nutritional status. dichotomized where ‘0’ was equal to the child never has been given Study Design this food or used to give this food, but not anymore, and ‘1’ was equal to any current consumption of the food type. Pearson’s chi- square was used to assess differences between males and females for food types consumed breastfeeding, bottle use, and household Infant participants and their families living in León, Nicaragua characteristics independently. Multiple linear regression models were enrolled in a randomized-controlled dietary intervention trial were performed in order to evaluate the association between to assess the feasibility of consuming heat-stabilized dietary rice LAZ, WAZ, and WLZ and food types independent of sex, as well bran. The intervention occurred between March 2015 and October • as number of food types consumed. Participant characteristics 2015 (NCT02615886). Eligibility included: are presented as mean ± standard deviation or percent of study vaccinationInfants between the ages of 4-6 months at time of recruitment population.p Breastfeeding bottle use, and complementary feeding with no diarrheal episodes and received three doses of rotavirus are presented by percent of study population. Significance was • No prior hospitalization definedResults as ≤ 0.05 for all analyses. •

• Not taking antibiotics or on prophylactic treatment A total of 51 six-month-old infants (n = 29 males and 22 females) were recruited to participate, after meeting eligibility No current illness, known immune-compromising condition, or criteria. Participant characteristics are shown in Table 1. While use of medications. the length of six monthsp of age was not statistically significantly Participants were recruited from public health rosters provided between sexes, there was a significant difference between males by the local health ministry from the Perla Maria and Sutiava health and females for LAZ ( < 0.01). No other significant differences sectors of León, Nicaragua. between anthropometric data and sex were found. All participants received water from indoor municipal systems as opposed to The Institutional Review Boards at Colorado State University, communal municipal, wells, streams, or other public sources. Universidad Nacional Autónoma de Nicaragua – León, University Household sanitation consisted mostly of indoor toilets (67%) of North Carolina at Chapel Hill, and Virginia Polytechnic Institute followed by latrines (29%). There was one female participant and State University approved this study (protocol #s 14-5233H, who did not have either. No significant differences between the 00003342, 14-2501, and 00000657, respectively). Written householdBreastfeeding environment and Bottle factors Feeding and sex werePractices found. informed consent was obtained from the infant’s parents or responsible guardian prior to any data collection. Data used in this study was collected when the infant participants were six months Breastfeeding practices are shown in Figure 1a. The majority ofData age Collectionbefore the dietary intervention parent study began. of male (76%) and female (82%) infants were partially breastfed at six months of age, while 7% of males and 9% of females were exclusively breast feeding. 17% of males and 9% of females stopped Participants who met the eligibility criteria and completed the breastfeeding before thep age of six months and were exclusively informed consent were assigned a study identification number. bottle feeding. No significant differences were observed between At the first study visit, a study coordinator interviewed a family sex and breastfeeding ( = 0.40). Figure 1b illustrates bottle use member (e.g. mother, father, or grandparent) using a questionnaire practices, where 66% of males and 59% of females began using a that gathered breastfeeding and complementary feeding history bottle between the ages of birth to two months. Infants who were (Supplementary Figure 1). The breastfeeding questions included if exclusively breastfedp at six months (n = 4) were not included. the child was still receiving breast milk, whether the child received There was no significant difference between sex and bottle use breast milk the previous day, and if the child was using a bottle and at introductionComplementary ( = 0.42). Feeding Practices and Number of Food what age that started. The complementary feeding history included Types a list of eleven common Nicaraguan foods that are introduced to infants during weaning. Family members answered how often the infant consumed each of the eleven foods based on predetermined options. A household survey was also completed to collect mother’s Figure 2a illustrates complementary feeding practices for education level, drinking water source, household flooring type, this cohort of weaning six-month old Nicaraguan infants. The and animals present in the household (Supplementary Figure 2). most commonly consumed foods were fruit and natural juices, as reported by 93% of males and 100% of females. Vegetables were Infant participants were measured for length and weight at consumed by 90% of males and 91% of females. No significant this house visit via a portable Stadiometer and weighing balance differences were found between sex and food types. for children. Length was collected to the nearest centimeter and weight to the nearest 0.1 kg. The length and weight from infant Figure 2b shows the number of food types out of the 11 food Citation: Borresen EC, Guajardo MC, Zambrana LE, Perez J, Perez C, et al. (2016) Association between Infant Feeding Prac- Page 2 of 6 tices and Nutritional Status in Healthy Nicaraguan Infants. J Food Nutri Diete 1(3): 110. J Food Nutri Diete ISSN: 2470-9794 Vol. 1. Issue. 3. 14000110

Total Males Females p-value 0.40

Number of participants 51 29 22 2* n/a Birth weight (kg) 3* 3.07 ± 0.42 3.10 ± 0.46 3.03 ± 0.37 0.35

Premature Status 2 3 (6) 2 (7) 1 (5) Weight at six month of age (kg) 7.96 ± 1.12 8.23 ± 1.22 7.60 ± 0.87 0.53 2 < 0.01 Length at six month of age2 (cm) 65.94 ± 2.61 66.7 ± 2.94 64.91 ± 1.66 0.30

Length-for-Age Z-score2 -0.04 ± 1.11 -0.03 ± 1.37 0.05 ± 0.64 Weight-for-Age Z-score 0.26 ± 1.05 0.18 ± 1.23 0.38 ± 0.78 0.36 Mother’s Education3 2 Weight-for-Length Z-score 0.48 ± 1.17 0.36 ± 1.35 0.63 ± 0.91 0.38 None

1 (2) 0 (0) 1 (5) Some primary 11 (22) 6 (21) 5 (23) Completed primary 6 (12) 3 (10) 3 (14) 0.37 Some secondary 14 (28) 10 (35) 4 (18) Completed secondary 10 (20) 7 (24) 3 (14) Water Source3 University/Professional 9 (18) 3 (10) 6 (27) n/a Sanitation System3 Indoor municipal 51 (100) 29 (100) 22 (100)

Indoor toilet 35 (67) 21 (72) 14 (64) None Latrine 15 (29) 8 (28) 7 (32) 0.46 Household floor3 1(2) 0 (0) 1(5)

Cement Tile 5 (10) 2 (7) 3 (14) Brick 21 (41) 14 (48) 7 (32) 0.31 8 (16) 3 (10) 5 (23) Animals present3, 4 Dirt 17 (33) 10 (35) 7 (32) None

15 (29) 11 (38) 4 (18) Cats Dogs 25 (51) 15 (56) 10 (46) Chickens 11 (22) 5 (19) 6 (27) Pigs 11 (22) 5 (19) 6 (27) 0.23 4 (8) 2 (7) 2 (9) Other Parrot/Parakeet/Pet bird 10 (20) 5 (19) 5 (23) Table 11: (2) 1 (4) 0 (0) 1 1 Infant participant characteristics 2Pearson’s chi-square was used to complete the statistical analysis. 34Values are means ± SD Values are number of participants (percent rounded to the nearest integer) *Multiple responses were includedp and response totals are > 100% Data collected on n = 50 participants (n = 29 males, n = 21 females) Bold indicates significance ( ≤ 0.05). n/a = not applicable

(a) (b)

Figure 1:

Breastfeeding and bottle feeding practices in male and female Nicaraguan infants at six months of age. (a) Percent of infants and breastfeeding practices, (b) Percent of infants and bottle use initiation.

Citation: Borresen EC, Guajardo MC, Zambrana LE, Perez J, Perez C, et al. (2016) Association between Infant Feeding Prac- Page 3 of 6 tices and Nutritional Status in Healthy Nicaraguan Infants. J Food Nutri Diete 1(3): 110. J Food Nutri Diete ISSN: 2470-9794 Vol. 1. Issue. 3. 14000110

(a) (b) (b)

Figure 2:

Complementary feeding practices by reported food types consumed in Nicaraguan males and females (n = 51) at 6 months of age. (a) Percent of infants and types of foods currently being consumed, (b) Percent of infants and number of food types consumed. LAZ WAZ WLZ P- P P

R-Squared value R-Squared -value R-Squared -value Number ofTable food 2:types 0.002 0.79 0.039 0.22 0.042 0.23

Linear regression analysis of number of food types and nutritional status for infants at six months of age and adjusted for sex. (LAZ: Length-for-age z-score; WAZ: Weight-for-age z-score; WLZ: Weight-for-length z-score). Food types LAZ WAZ WLZ P-value P-value P-value 0.040 R-Squared R-Squared R-Squared Brestfed yesterday 0.031 0.22 0.22 0.017 0.66 0.000 Bottle use 0.010 0.50 0.009 0.91 0.015 0.73 Cow's milk 0.04 Formula 0.90 0.011 0.76 0.015 0.75 0.084 0.024 0.39 0.015 0.71 Rice cereal 0.014 0.42 0.026 0.37 0.017 0.62 Fruit and natural juices 0.006 0.59 0.023 0.41 0.048 0.19 Chicken 0.000 Vegetables 0.015 0.39 0.031 0.30 0.077 0.07 Gallo pinto 0.98 0.013 0.68 0.018 0.62 Cheese 0.000 0.036 0.19 0.012 0.73 0.019 0.57 0.97 0.025 0.38 0.032 0.33 Soup 0.011 0.48 0.016 0.55 0.013 0.88 YogurtTable 3: 0.001 0.84 0.009 0.93 0.013 0.96

Linear regression analysis of complementary feeding practices, breastfeeding, bottle use and nutritional status for infants at six months of age and adjusted for sex. p (LAZ: Length-for-age z-score; WAZ: Weight-for-age z-score; WLZ: Weight-for-length z-score Bold indicates significance ( ≤ 0.05)). types assessed that were consumed in this Nicaraguan infant The unstandardized coefficient reveals that there is a positive cohort. A majority of infants consumed between four and seven association between cow milk consumption and LAZ, when different food types (totaling 83% of males and 82% of females). Discussioncontrolling for sex. The most common number of food groups consumed by males was 4 (28%), while 32% of females consumed 5 different food types. A multiple linear regression analysis was performed to evaluate This study described the breastfeeding and weaning practices number of food types with nutritional status and independent of of a six-month-old Nicaraguan infant cohort, and also examined sex (Table 2). The model did not yield any statistically significant associations between breastfeeding, bottle use, and complementary findings between number of food types consumed and nutritional feeding on nutritional status, as measured by LAZ, WAZ, and WLZ. statusDifferences among malesin Complementary and female infant Feeding participants. Practices among While no relationships were detected with regards to nutrition Infants status or household environment factors, this study did identify a significant difference between sex and LAZ. This may have been influenced by the LAZ range of healthy male infants (-2.31 to 2.83) Multiple linear regression analysis was performed to assess compared to females (-1.35 to 0.86). For breastfeeding and bottle the effects of complementary feeding practices, breastfeeding and use practices, 76% of males and 82% of females were partially bottle use on nutritional status, independent of sex (Tablep 3). The breastfed, and 7% of males and 9% of females were exclusively model with LAZ as the dependent variable and cow’s milk and sex breastfed. While this study shows the introduction to bottle feeding as the independent variables was statistically significant ( = 0.04), was common for infants that were younger than two months of where 8.4% of LAZ was predicted by cow’s milk consumption. age, there were no differences between breastfeeding or bottle use Citation: Borresen EC, Guajardo MC, Zambrana LE, Perez J, Perez C, et al. (2016) Association between Infant Feeding Prac- Page 4 of 6 tices and Nutritional Status in Healthy Nicaraguan Infants. J Food Nutri Diete 1(3): 110. J Food Nutri Diete ISSN: 2470-9794 Vol. 1. Issue. 3. 14000110

practices on nutritional status. Infant participants were also being Study limitations herein included the lack of information weaned on several food types, with the most common foods being regarding mother’s occupation to contribute to family economic fruit and natural juices, and vegetables. Cow milk consumption was status. Prior data supported that Nicaraguan housewives were the only food type that had a positive association with nutritional more likely to exclusively breastfeed compared to working mothers status (LAZ). [18]. Additionally, data was not collected in a manner whereby the amounts of each food type and specific combinations of foods could The breastfeeding and bottle behavior results from this cohort be calculated as a percent of total dietary intake. Furthermore, our were similar to that previously reported in the literature [4,8,9,18]. Ruel and Menon analyzed child feeding practices that included data could not be interpreted to specify how many times mothers five Latin American countries and found that approximately were including formula, breast milk, cow’s milk, fruit juices, water, 70% of Nicaraguan infants between the ages of 6–9 months were or other liquids into the baby bottles. Bottle‒feeding behaviors breastfeeding and 81% were using baby bottles [4]. According which can include non-nutritive liquids, such as fresca (a common to Espinoza, approximately 30% of infants three months of age fresh fruit drink with added sugar and water) and carbonated sugar- or less were exclusively breastfed, 61% were partially breast fed sweetened beverages is a global child obesity concern [8,24]. Recall and 9% were not receiving breast milk [9]. While this analysis bias was another possible limitation of the study dietary records. was performed during infant ages where exclusive breastfeeding Although the Nicaraguan Ministry of Health promotes the is preferred and recommended, it still confirms our finding that WHO’s exclusive breastfeeding recommendations for the first six Nicaraguan infants are being weaned off breast milk earlier than months of life [3] and provides child health nutrition education six months of age. Additionally, women living in the urbanized to mothers [10], there were very few infants that were exclusively Pacific regions had a lower prevalence of exclusively breastfeeding breastfed and many infants were already receiving a variety of compared to mothers living in rural and central areas of the country complementary food types. Further postnatal breastfeeding [9]. Other Latin American countries, such as Mexico, have only 8% education is necessary in this region since we and others have of infants reported to be exclusively breastfed at six months of age shown that Latin American mothers are more likely to practice [20]. nonexclusive breastfeeding behaviors as they introduce solid foods This descriptive analysis showed high levels of partial before the six-month mark [4,9,18,25]. Improving breastfeeding breastfeeding in both males and females at six months of age, and rates for working Nicaraguan mothers was identified in a recent was an important update to another recent report highlighting report by the United Nations Children’s Emergency Fund (UNICEF). Nicaragua as the least common of several Latin American countries This effort would aid to develop breast milk extraction rooms and to continue breastfeeding between six months and two years [18]. a breastfeeding counseling program as part of an alliance between Cultural preferences that drift from current recommendations may the Better Work/International Labor Organization, UNICEF, and be attributed to less understood beliefs of Nicaraguan mothers. For SoyNica. The program increased exclusive breastfeeding rates instance, exclusive breastfeeding in infants less than one year old may amongConclusion female workers from 12% in 2013 to 60% in 2015 [26]. not be perceived to be helpful to growth, and rather viewed as being an inconvenience to mothers, particularly working mothers [9,21]. A large majority of infants in this cohort were consuming fruits Breastfeeding infant feeding recommendations are not being and natural juices, followed by vegetables. Other food types such closely adhered to for six-month old infants, and family structure as cow’s milk, rice cereal, gallo pinto, cheese, and yogurt were and cultural perceptions are influential factors. While this analysis consumed by fewer numbers of infants. It was expected that brown did not reveal any negative consequences on nutritional status rice was not consumed by infants at all. Early introduction of fruits from diets of healthy Nicaraguan 6-month old infants, continued and vegetables has been previously reported, indicating that these investigation on growth and development outcomes from weaning are popular weaning food types in Latin American countries [20]. patterns is necessary to bolster culturally-appropriate and relevant Formula was another common food type consumed, indicating that trainingsSources on of infant Support nutrition in Nicaragua. the partially breastfed participants were likely receiving formula in addition to breast milk. The majority (83% of males and 82% of females) in this cohort consumed between four and seven different food types at six months of age. Future investigations may consider Grand Challenges Explorations in Global Health award from the evaluating when these infants begin eating these food types and Bill and Melinda Gates Foundation (OPP1043255) and a Fulbright whether dietary weaning patterns emerge prior to this six-month FacultyDisclaimers Development and scholarshipConflict of award. Interest Declaration assessment. Prior results from the literature have indicated that over 90% of Latin American mothers start weaning their baby to to report. solid foods before the age of six months [12]. The authors declare no conflict of interest and no disclaimers Acknowledgements In this study, the introduction to consuming common Nicaraguan food types had limited effects on the nutrition status of these infants at 6 months of age. The finding that consumption of cow’s milk was positively associated with LAZ was consistent with This study was supported by the Grand Challenges Explorations previous reports [22,23]. There have been several studies from in Global Health award from the Bill and Melinda Gates Foundation different geographical locations, including China, Jamaica, Mexico, (OPP1043255) and the Fulbright Faculty Development scholarship and Brazil, that have shown consumption of cow’s milk favorably award. The authors would like to thank Claudia Cortez, Silvia affects length growth in infants and young children [22]. The Altamirano, and Ridder Guido for their assistance in data collection, as recommendation to introduce complementary foods when children wellReferences as the participating families for their contributions to this study. are six months old was based on the increased nutritional needs for healthy growth and development that breast milk alone cannot provide [6,7], yet in this study, we did not find that dietary intake 1. World Health Organization. The. optimal duration of exclusive with a greater number of food types correlated with nutritional breastfeeding: A systematic review. Geneva: WHO; 2001. WHO/ status in males and females at six months of age. NHD/01.08;WHO/FCH/CAH/01.23 Citation: Borresen EC, Guajardo MC, Zambrana LE, Perez J, Perez C, et al. (2016) Association between Infant Feeding Prac- Page 5 of 6 tices and Nutritional Status in Healthy Nicaraguan Infants. J Food Nutri Diete 1(3): 110. J Food Nutri Diete ISSN: 2470-9794 Vol. 1. Issue. 3. 14000110

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Elizabeth P. Ryan, Department of Environmental and Radiological Health Sciences, Colorado State University, 200 W. Lake St., Received1680 Campus Date: Delivery, Fort Collins,Accepted CO 80523-1680, Date: USA, Tel: 970-491-1536;Published Fax: Date:970-491-7569; E-mail: [email protected]. Copyright: August 26, 2016, November 11, 2016, November 25, 2016. © 2016 Borresen EC, et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestrictedCitation: use, distribution, and reproduction in any medium, provided the original work is properly cited. Borresen EC, Guajardo MC, Zambrana LE, Perez J, Perez C, et al. (2016) Association between Infant Feeding Practices and Nutritional Status in Healthy Nicaraguan Infants. J Food Nutri Diete 1(3): 110.

Citation: Borresen EC, Guajardo MC, Zambrana LE, Perez J, Perez C, et al. (2016) Association between Infant Feeding Prac- Page 6 of 6 tices and Nutritional Status in Healthy Nicaraguan Infants. J Food Nutri Diete 1(3): 110.