Background Breast milk is the sole source of nutrition for exclusively breastfed infants in the first 6 mo of life, yet few studies have measured micronutrient concentrations in breast milk in light of maternal diet and subsequent infant micronutrient intakes. Objectives We evaluated the adequacy of micronutrient intakes of exclusively breastfed Indonesian infants by measuring milk volume and micronutrient concentrations and assessed maternal micronutrient intakes and their relationship with milk concentrations. Methods Mother–infant (2–5.3 mo) dyads (n = 113) were recruited for this cross-sectional study. Volume of breast-milk intake via the deuterium dose-to-mother technique over 14 d and analyzed micronutrient concentrations were used to calculate micronutrient intakes of exclusively breastfed infants. Maternal 3-d weighed food records were collected to assess median (IQR) micronutrient intakes. Multivariate regression analyses examined the association of usual maternal micronutrient intakes with milk micronutrient concentrations after adjustment for confounding variables. Results Mean ± SD intake of breast-milk volume was 787 ± 148 mL/d. Median daily infant intakes of iron, zinc, selenium, magnesium, sodium, and B-vitamins (thiamin, riboflavin, niacin, pantothenic acid, B-6, and B-12) were below their respective Adequate Intakes. Inadequacies in maternal intakes (as % < estimated average requirements) were >40% for calcium, niacin, and vitamins A, B-6, and B-12. Significant positive associations existed between maternal usual intakes of vitamin A, niacin and riboflavin and milk retinol, nicotinamide, and free riboflavin concentrations in both unadjusted and adjusted (for infant age, milk volume, and parity) analyses (all P < 0.05). Conclusions The majority of micronutrient intakes for these exclusively breastfed infants and their mothers fell below recommendations, with associations between maternal intakes and breast-milk concentrations for 3 nutrients. Data on nutrient requirements of exclusively breastfed infants are limited, and a better understanding of the influence of maternal nutritional status on milk nutrient concentrations and its impact on the breastfed infant is needed.

Stunting and underweight among under-five children in Indonesia are common, raising public health concerns. Whether inappropriate complementary feeding (CF) practices compromise optimal growth during late infancy in Indonesia is uncertain. Therefore we characterized and evaluated CF practices in Indonesian infants and investigated their relationship with subsequent growth. We enrolled breastfed infants at 6 months of age (n = 230); and followed them at 9 (n = 202) and 12 months of age (n = 190). We collected socio-demographic and anthropometric data and two-day in-home weighed food records. Relations between WHO CF indicators, sentinel foods, and energy and micronutrient intakes at 9 months and growth at 12 months were explored using multiple linear regression. Stunting and underweight increased from 15.8% and 4.4% at 6 months to 22.6% and 10.5% at 12 months, respectively. Median intakes of calcium, iron, zinc, and riboflavin were below WHO recommendations. Infants consuming fortified infant foods (FIFs) at 9 months had diets with a lower dietary diversity (DD) score (2.3 vs.3.0), energy density, median energy (250 vs. 310 kcal/d) and protein (6.5 vs. 9.1 g/d) intake than non-consumers (p<0.01), despite higher intakes of calcium, iron, and vitamins A and C (p<0.001). Positive relations existed for 9-month consumption of iron-rich/iron fortified infant foods with length-for-age Z-score (LAZ) at 12 months (β = 0.22; 95% CI: 0.01, 0.44; P = 0.04), and for fortified infant foods alone with both LAZ (β = 0.29; 95% CI: 0.09, 0.48; P = 0.04) and weight-for-age Z-score (β = 0.14; 95% CI: 0.02, 0.26; P = 0.02) at 12 months. The positive association of FIFs with subsequent growth may be attributed to their content of both powdered cow’s milk and multi-micronutrient fortificants. Nonetheless, mothers should not be encouraged to over-rely on FIFs as they reduce DD.

Information on micronutrient adequacy of diets of rural Indonesian lactating women is lacking, despite their high nutrient requirements. This is of concern because deficits in micronutrient intakes may compromise the health of both mothers and infants. This study aimed to assess micronutrient adequacy and dietary diversity (DD) among rural lactating women and explore relationships between micronutrient adequacy, DD, and intakes of energy and food groups consumed. We measured in-home 12-h weighed food records and 12-h recalls over three non-consecutive days from 121 exclusively breastfeeding women at 2–5 months postpartum. Next, we calculated intakes of energy and 11 micronutrients and estimated probability of adequacy (PA) for usual intakes of 11 micronutrients for each women taking into account national fortification of wheat flour with thiamin, riboflavin, folate, zinc, and iron. We assessed DD from nine food groups consumed. Energy and macronutrient balance were within recommended ranges, yet population prevalence of adequacy was less than 50% for niacin, vitamins B6 and C, and less than 60% for calcium, vitamin B12 and vitamin A, all micronutrients not targeted by the national wheat flour fortification program. In contrast, population prevalence of adequacy for the fortified micronutrients was at least 60%, with iron and zinc attaining 79% and 97%, respectively. Overall mean population prevalence of micronutrient adequacy was 57% and mean (±SD) DD score was 4.3±1.2. Mean PAs, a composite measure based on individual PAs over 11 micronutrients, were strongly correlated with energy intakes and with DD scores. In the multivariate models with maternal education and wealth index as covariates, organ meats were the most important determinant of mean PA after controlling for energy intake. In conclusion, despite wheat flour fortification, lactating mothers remained at risk of multiple micronutrient inadequacies. Increasing intakes of animal source foods including organ meats, and fruits and vegetables should be considered.

Inflammation confounds the interpretation of several micronutrient biomarkers resulting in estimates that may not reflect the true burden of deficiency. We aimed to assess and compare the micronutrient status of a cohort of Indonesian infants (n 230) at aged 6, 9 and 12 months by ignoring inflammation (unadjusted) and adjusting four micronutrient biomarkers for inflammation with C-reactive protein (CRP) and α-1-glycoprotein (AGP) using the following methods: (1) arithmetic correction factors with the use of a four-stage inflammation model; and (2) regression modelling. Prevalence of infants with any inflammation (CRP>5 mg/l and/or AGP>1 g/l) was about 25% at each age. Compared with unadjusted values, regression adjustment at 6, 9 and 12 months generated the lowest (P50 % across all ages. In conclusion, without inflammation adjustment, Fe deficiency was grossly under-estimated and vitamin A and Zn deficiency over-estimated, highlighting the importance of correcting for the influence of such, before implementing programmes to alleviate micronutrient malnutrition. However, further work is needed to validate the proposed approaches with a particular focus on assessing the influence of varying degrees of inflammation (i.e. recurrent acute infections and low-grade chronic inflammation) on each affected nutrient biomarker.