Breastfeeding and Complementary Feeding Practices of Children with Stunting in Guatemala

Background: Stunting is a pervasive issue in low‑ and middle‑income countries, reflecting biological processes that adversely affect childhood cognitive development and increase the risk of chronic disease in adulthood. Nutritional intake is an important causative factor in stunting. Understanding the nutritional intake patterns of children with stunting can help inform nutrition program development. Objective: To characterize breastfeeding and dietary patterns from a clinical cohort of children with stunting in Guatemala and identify factors associated with linear growth. Methods: We included children with at least one diet record and one length/height‑for‑age z‑score below -2 from ages 0-5 years. We excluded children enrolled in complex care for severe non‑nutritional illness and records from prior to 6 months of age. We described adherence to World Health Organization infant and young child feeding indicators upon program enrollment. We longitudinally characterized breastfeeding and complementary feeding patterns of the cohort using generalized additive mixed modeling. We identified and quantified associations between various nutritional factors and linear growth using linear mixed effects models. Results: The final analytical dataset included 19,476 patient encounters from 2,352 children. Most children did not meet World Health Organization standards for dietary adequacy upon enrollment in the program. Dietary intakes were predominantly carbohydrate‑based. The factors most strongly associated with linear growth were food insecurity (negatively associated), portion size, and continued breastfeeding from 12 to 23 months. Adherence to the infant and young child feeding indicators was positively associated with linear growth. The intake of most food groups was also positively associated with linear growth. Conclusions: These findings suggest that the nutritional focus of interventions should be on adequate dietary diversity, earlier introduction and higher frequency of the less frequently consumed food groups, age‑appropriate portion sizes, and breastfeeding through 2 years of age. Public policy measures to address food insecurity are also necessary.