Nutritional Therapy for Infants with Diarrhea

Carlos H. Lifschitz, M.D., and Robert J. Shulman, M.D.

The appropriate choice of treatment for infants with diarrhea has long provoked de-
bate. Growth of infants with diarrhea is adversely affected by associated diseases
including anorexia, malabsorption, catabolic response to infection, and iatrogenic
starvation. To prevent the negative effects of diarrhea on the nutrition of infants, con-
tinued feeding during the active and early convalescent phases has been recom-
mended. Although this concept is not new, until recently it has been little used in the
treatment of diarrhea. In this article we examine the current knowledge about, and
trends in, feeding infants with diarrhea. We will discuss treatments for the well-nour-
ished infant with acute diarrhea, the infant with prolonged diarrhea, and the mal-
nourished infant. Information regarding the use of local staples will also be provided.

The treatment of infants with diarrhea has
been a matter of controversy for many
years. Whether, what, and how much to
feed are questions that continue to pro-
voke a variety of answers. This diversity of
opinion results from a combination of fac-
tors: a lack of conclusive research results;
the biases of physicians and health-care
providers; and the folklore, beliefs, and
culture of the immediate and extended
family of the patient. Jelliffe et a1.l recently
analyzed information from 74 countries
concerning traditional feeding practices
during and after diarrhea. There was a wide
discrepancy in the results; foods avoided
by some were recommended by others.
Moreover, several population groups to-
tally withheld food during diarrhea. Never-
theless, people in many countries use di-
lute, soft preparations of local staples,
mainly rice and other cereals (wheat, corn,
millet, barley, oatmeal, sorghum), potatoes,
and cassava. Bananas, apples, carrots, and
some animal foods (such as chicken and
Dr. Lifschitz is Assistant Professor, and Dr.
Shulman is Associate Professor in the Depart-
ment of Pediatrics, Baylor College of Medicine,
Houston, TX 77030.
fish) are used by some populations when
those foods are available.
The recent worldwide implementation of
oral rehydration has reduced infant mortal-
ity that resulted from acute diarrhea.2-5
The negative effects of diarrhea on nutri-
tion and growth have also been clearly
identified."-'* Diarrhea affects growth
through anorexia,10-i2 r n a l a b ~ o r p t i o ncat-
,~~
abolic response to infection,14 and, fre-
quently, iatrogenic starvation. The combi-
nation of these factors is devastating to the
nutritional status of infants, particularly
those who suffer several bouts of diarrhea
during their first year or whose health has
already been undermined by previous ill-
nesses. The negative effect of diarrheal ill-
ness on the growth of infants and children
has been documented in both the develop-
ing7-9 and developed ~ 0 u n t r i e s . Tol ~ pre-
vent the negative effects of diarrhea on nu-
trition, the Subcommittee on Nutrition and
Diarrheal Diseases Control of the National
Research Council recommends continued
feeding during the active and early conva-
lescent phases of diarrhea.16 The primary
objective of feeding should always be to
minimize the adverse effects of the illness
on nutritional status. This objective re-
mains the same whether treatment is pro-

NUTRITION REVIEWSIVOL 48. NO SISEPTEMBER 1990 329

vided at home, in a community health
clinic, or in a hospital.
The concept of continuing to feed infants
and children during acute diarrhea is not
new. Over 40 years ago, Chungi7si8 demon-
strated that the outcome for children with
diarrhea who continued to be fed was
much better than the outcome for children
who were fasted for one or two days. Ap-
propriate feeding practices during and
after diarrhea help 1) to reduce or prevent
damage to intestinal functions that is re-
portedly induced by withholding f ~ o d , ‘ ~ - ~ l
2) to prevent or decrease the nutritional
damage caused by the d i s e a ~ e ,and ~ ~ ,3)~ ~
to facilitate catch-up growth and a return to
good nutritional conditions during conva-
l e ~ c e n c e .We
~ ~ will examine the current
trends in feeding infants with diarrhea and
discuss treatments for the well-nourished
infant with acute diarrhea, the infant with
prolonged diarrhea, and the malnourished
infant.
Feeding the Well-Nourished Infant with
Acute Diarrhea
The Breast-Fed Infant
Immediately after rehydration is com-
pleted during an episode of acute gas-
troenteritis, the continuation of breast-
feeding is a practice well accepted by
parents and health-care providers. More-
over, it has been recommended that infants
should continue to breast-feed during re-
hydration, alternating between oral rehy-
dration solutions and milk; human milk
seems to be an effective adjunct to oral re-
hydration therapy, and its use avoids the
need to provide additional ~ a t e r . To ~ ~ , ~some
determine whether a recommendation
should be made to recommence breast-
feeding before an infant is completely rehy-
drated, a study should be performed in
which the subject population is larger than
that in similar studies in the current litera-
ture. It seems likely, however, that the ex-
perience of Kassem et al.25 and Khin-
Maung-U et a1.26 can, by extrapolation to
industrialized countries, be considered
valid for most breast-fed infants with diar-
rhea. Such infants, when not severely de-
330 NUTRITION REVIEWSIVOL 48,NO SISEPTEMBER 1990
hydrated, may tolerate uninterrupted feed-
ings of human milk.
One study did indicate that 4% of a group
of well-nourished, breast-fed infants and
children up to two years of age from a vil-
lage in Africa, who were suffering from
acute gastroenteritis, had a significant ele-
vation of breath hydrogen (indicating lac-
tose malabsorption) after receiving human
milk.27Another 4% had evidence of carbo-
hydrate in the feces. Of the 13 infants who
passed a diarrheal stool during the test,
eight also had evidence of lactose intoler-
ance, as demonstrated by loose stools,
presence of fecal carbohydrate, and a pH
of ~6.0.However, the continuation of
breast-feeding during the rehydration
phase of acute diarrhea has generally re-
sulted in improved stool c o n ~ i s t e n c y re-
,~~
duced stool number, and a trend toward
decreased fecal output and better rehydra-
t ion.26
We recommend that breast-fed infants
contin ue breast-feeding during acute d iar-
rhea.
The Eutrophic Infant Who Is Not Breast-Fed
Many recent investigations have focused
on the refeeding, during and after acute
gastroenteritis, of infants who were not
being breast-fed when the illness began.
Research questions in these studies have
included: 1) Is a period of fasting necessary
for the gut to “rest”? 2) Should milk feed-
ings be reintroduced in a slow, gradually
progressive manner, or should milk or for-
mula be reintroduced rapidly? 3) Should
lactose be eliminated from the diet for
~ time? 4) Is the use of a soy protein
recommended in acute diarrhea?
Is a period of fasting necessary? The
major reason put forward by physicians for
the imposition of a period of fasting on in-
fants who have acute diarrhea is preven-
tion of the consequences of carbohydrate
malabsorption; these include acidosis, ad-
ditional fluid losses, depletion of the bile
acid pool, and possible sensitization to di-
etary protein. Few studies, however, have
addressed this issue. Brown et a1.28studied
128 nonmalnourished patients younger
than 36 months of age who were randomly
assigned to receive one of four lactose-free
dietary treatments to determine the effect
of dietary therapy on the severity and nutri-
tional outcome of diarrheal illness. Group 1
received formula in an amount sufficient to
provide 110 kcal/kg per day; group 2 re-
ceived the same formula to provide 55 kcal/
kg per day for two days and then 110 kcal/
kg per day; group 3 received oral
glucose-electrolyte solution for two days,
formula (55 kcal/kg per day) for the next
two days, then formula to provide 110 kcal/
kg per day; and group 4 received the same
diets as group 3, except that intravenous
rehydration was used for the first two days.
Therapeutic success rates were similar
among all dietary groups. Apparent net ab-
sorption of nitrogen, fat, and carbohydrate;
total energy intake; retention of nitrogen;
and increments in body weight, arm cir-
cumference, and skinfold thicknesses were
positively related to the amounts of dietary
energy consumed. The authors concluded
that continued oral feeding during the early
phase of therapy yielded improved nutri-
tional results.
Early refeeding with a soy-based, lac-
tose-free formula proved to be beneficial
compared to 48-h fasting. Santosham et
al.29 conducted a controlled study compar-
ing the standard method of treating hospi-
talized infants with acute diarrhea (limited
starvation) with the initiation of “early feed-
ing” using a soy-based, lactose-free for-
mula in infants 12 months of age or
younger from an American Indian tribe.29
Forty-three patients were randomly as-
signed to receive a soy-based, lactose-free
formula 4 h after hospitalization, and 44 pa-
tients received standard therapy (food was
withheld for the first 48 h of hospitaliza-
tion). After the first 48 h, the same lactose-
free formula was given to the latter group
of patients. Fluid intake and output of
stool, urine, and vomitus were measured
until the diarrhea resolved. The group that
received formula soon after admission had
a smaller mean stool output (121 ? 129
[SD] mUkg) than the other group of pa-
NUTRITION REVIEWSIVOL 48, NO SISEPTEMBER 1990 331
tients (299 ? 319 mL/kg; p < 0.001), and
the mean duration of their illness was sig-
nificantly shorter (54 k 28 h vs 93 + 56 h; p
< 0.001). The authorsz9 concluded that
soy-based, lactose-free formulas can be
used safely during the acute phase of diar-
rheal illness in infants and that their use
shortens the duration of illness and de-
creases stool output as compared with the
use of standard therapy.
In a recent review article, Brown and Mac-
Lean30 recommend that, in view of the
available evidence, current practice should
be modified to minimize food withdrawal in
most patients with diarrhea.
Should milk feedings be reintroduced in
a slow or rapid manner? Brown et a1.z8 ob-
served no benefit to the patients when ca-
loric intake was limited for the first two
days after rehydration and feedings were
reintroduced slowly. However, the rapid in-
crease in the concentration and/or volume
of feeds in young infants with diarrhea is
not supported by all authors. Placzek and
Walker-Smith31 studied 48 children
younger than 18 months of age who were
suffering from acute gastroenteritis and
were given a glucose-electrolyte mixture
for the first 24 h after hospital admission.
After 24 h, half the group received full-
strength feedings of cow’s milk immedi-
ately; the other half had milk reintroduced
gradually over a four-day period. Most in-
fants in both groups had an uncomplicated
recovery. Complications, however, were
more common in the rapid-refeeding
group. Seven patients (compared with only
one in the slow refeeding group) had an im-
mediate recurrence of symptoms of such
severity that a return to intravenous or oral
rehydration was necessary. Complications
were confined to those younger than nine
months of age. The authors3’ concluded
that children over nine months of age with
acute gastroenteritis may be given full-
strength milk immediately after rehydration
(treatment with a glucose-electrolyte solu-
tion for 24 h), but children under nine
months should be refed over several days.
Dudgale et al.,3z however, found that
abrupt reintroduction of normal feedings
had no undesirabJe effects. In fact, immedi-
ate refeeding of infants resulted in less
weight loss, fewer complications, and ear-
lier hospital discharge. Other authors agree
with this approach for the well-nourished
Numerous studies from develop-
ing countries (e.g., Egypt35r36and Saudi
Arabia3') support rapid increments of for-
mula concentration and/or volume of for-
mula fed.
One can conclude, on the basis of avail-
able information, that rapid refeeding is
well tolerated in older (nine months), well-
nourished infants. An absolute recommen-
dation cannot be made for younger infants,
and although it seems that rapid refeeding
will be tolerated by most, some may de-
velop transient formula intolerance, and
these cases should be managed with a less
aggressive approach.
Should lactose be eliminated temporarily
from the diet? Lactase deficiency, docu-
mented early in the course of gastroenter-
itis, can result in transient lactose intoler-
ance even in the well-nourished
The incidence of this problem is not well
established, but several investigations have
addressed this issue. Gardiner et al.40used
the breath hydrogen test (which underesti-
mates the true incidence of carbohydrate
malabsorption in acute diarrhea) and found
a significant increase in breath hydrogen in
only three of 18 patients with acute gas-
troenteritis. The patients had received a
lactose load of 0.5 g/kg; none developed
symptoms of i n t ~ l e r a n c e Only
. ~ ~ one of 20
who received 2 g of lactose/kg developed
lactose intolerance. Using a similar tech-
nique, Davidson et al.41studied 104 well-
nourished infants and children from an
urban environment who suffered from
acute diarrhea. They found a 50% inci-
dence of lactose malabsorption and a 32%
incidence of lactose intolerance among
this group.
Sack et studied a group of patients
with rotavirus diarrhea to determine the re-
lationship between carbohydrate malab-
sorption and the degree of acidosis and se-
332 NUTRITION REVIEWSIVOL 48,NO SISEPTEMBER 1990
verity of purging. The stools contained
large quantities of reducing substances;
this fact suggested the presence of signifi-
cant carbohydrate malabsorption. The au-
thors concluded that their findings were
consistent with the hypothesis that carbo-
hydrate malabsorption is an important sec-
ondary pathophysiologic mechanism in the
rotavirus diarrhea syndrome.
Trounce and Walker-SmithM found sugar
intolerance in 31 of 200 children admitted
to hospital with acute gastroenteritis. In 28
of the 31, the intolerance was transient and
disappeared rapidly, but in the remaining
three i t indicated a more serious and per-
sistent complication. The most important
predisposing factor was viral infection, par-
ticularly rotavirus. Disaccharide intoler-
ance did develop in 15 of the infants within
five days of reintroducing cow milk. The
however, do not recommend the
routine use of lactose-free formulas in well-
nourished infants with acute gastroenter-
itis.
An important addition to the literature re-
garding lactose intolerance is the work of
Groothuis et aI.& They studied infants with
mild acute gastroenteritis to determine
whether routine feeding of a nonlactose
formula was justified. Eighty-five infants
with mild acute gastroenteritis were stud-
ied prospectively. Infants were blindly and
randomly assigned to receive a formula of
20 kcal/oz (0.67 kcal/mL) containing one of
four carbohydrates: lactose, sucrose-glu-
cose polymers, or combined sucrose-glu-
cose polymers. Daily diaries were kept by
parents, and patients were reexamined on
days 2, 7, and 14 of the study. Symptoms
resolved in most patients within seven
days, but five infants were subsequently
hospitalized. Stool frequency, weight gain,
and need for hospitalization did not differ
significantly among the groups. Recovery
from mild acute gastroenteritis occurred
within two weeks irrespective of the spe-
cific carbohydrate ingested.
The experience of Bhan et in India
also supports these findings. These au-
thors studied 60 children younger than two
years of age suffering from mild acute gas-
troenteritis with <5% dehydration. The pa-
tients were randomly assigned to two dif-
ferent isocaloric feeding regimens: a
locally prepared milk-free formulation of
rice, lentils, sugar, and coconut oil, and a
spray-dried commercial cow milk formula.
There were two treatment failures in the
first group and one in the second group.
The duration of diarrhea after intervention
was 11.O & 10.0days for the former group,
which was higher than in the latter group
(7.6 ? 10.8 days), but these differences
were not significant. Their findings suggest
that, after initial rehydration with oral rehy-
dration solution, most infants with mild
acute gastroenteritis will tolerate a cow’s
milk-based formula. The infants who were
fed the milk-free, cereal-based diet showed
significantly less energy intake and gained
weight less rapidly than those who were
fed the cow’s milk-based formula.
We conclude from the results of these
studies that systematic elimination of lac-
tose is not necessary for well-nourished in-
fants and children with acute gastroenter-
itis.
Is the use of a soy protein recommended
in acute diarrhea? It is not necessary to
substitute soy protein for cow’s milk pro-
tein to prevent sensitization in well-nour-
ished infants with acute diarrhea. Sensiti-
zation to cow’s milk protein is not common
in infants with acute diarrhea, and soy pro-
tein does not seem to be less a l l e r g e n i ~ . ~ ~ covering from acute gastroenteritis re-
lsolauri et al.47 studied 38 infants be-
tween six and 34 months of age who were
hospitalized for acute gastroenteritis; they
were treated with oral rehydration and
rapid reintroduction of full feedings appro-
priate for age.47Cow’s milk and milk prod-
ucts were eliminated from the diet of 27 in-
fants, whereas the remaining 38 continued
to receive their usual milk and milk prod-
ucts as parts of the mixed diet. There was
no difference between groups in clinical re-
covery from diarrhea. No child had pro-
longed diarrhea, no new cases of clinical
atopy were observed at a one-month fol-
low-up, and no significant increases oc-
curred in the total or milk-specific IgE
levels. Serum IgG and IgA antibodies to p-
lactoglobulin and a-casein were initially
present in the majority of the children, but
no appreciable changes occurred in these
antibodies to cow’s milk components after
gastroenteritis, regardless of the type of
diet. The authors47 concluded that cow’s
milk and its products can be given safely to
children over six months of age who have
acute gastroenteritis.
Nevertheless, the use of a soy-based, lac-
tose-free formula has been well tolerated
by infants with acute g a s t r o e n t e r i t i ~In
. ~a~
selected sample of 18 infants with acute
gastroenteritis, lyngkaran et aI.@ studied
the effect of soy protein on the small bowel
mucosa. After rehydration the infants were
maintained on a protein hydrolysate for-
mula for six to eight weeks, after which
they were readmitted to hospital for soy-
protein challenge studies. Jejunal biopsies
were performed before and 24 h after the
challenge. Three groups were identified on
the basis of the clinical and histologic reac-
tions to soy-protein challenge: 1) three in-
fants had clinical and histologic reactions;
2) seven infants had a histologic reaction
but no clinical symptoms (two developed a
clinical reaction when rechallenged with
soy protein two and 90 days later); and 3)
eight infants had neither a clinical nor a
histologic reaction.
The authors concluded that the small-
bowel mucosa of some young infants re-
mains sensitive to soy protein for a variable
period of time. They further cautioned that
feeding soy protein to these infants may re-
sult in persistent mucosal damage and
continuing diarrhea. We conclude that the
routine feeding of a soy-protein formula
provides no benefit to the infant with acute
diarrhea.
Feeding Malnourished Infants with
Gastroenteritis and Infants with More
Severe Gastroenteritis
Malnourished infants who develop acute
gastroenteritis are at serious risk. They are
predisposed to a prolonged course of ill-
ness because of underlying infections and/
NUTRITION REVIEWSIVOL 48,NO SISEPTEMBER 1990 333
or intestinal parasitosis, conditions asso-
ciated with carbohydrate malabsorption
and/or intolerance to dietary protein. Black
et al.49demonstrated that malnutrition was
associated with a prolonged duration of di-
arrhea but not with its incidence.49Lactose
malabsorption is also a frequent problem
among these infants.50
Feeding recommendations for malnour-
ished infants are less well defined than
those for well-nourished infants. From a
practical standpoint, malnourished infants
who have diarrhea may be refed according
to the same steps indicated for the well-
nourished patient, until evidence of intoler-
ance occurs. In that light, after oral or intra-
venous rehyd ration, breast-fed infants
should be allowed to breast-feed.
Slow increments in concentration and/or
volume of cow’s milk may have a place in
the refeeding process of malnourished in-
fants who are not breast-fed. Although
there are no published data, we believe that
most centers located in developing coun-
tries do not routinely use lactose-free for-
mulas for infants with malnutrition unless
there is evidence of carbohydrate malab-
sorption. Particular attention must be paid
to any evidence of milk intolerance: large
stool volumes, recurrent dehydration, car-
bohydrate or blood in feces, and/or a low
fecal pH (<5.5). Abdominal distention or
severe vomiting are indications to discon-
tinue feedings. Necrotizing enterocolitis
can occur in these patients.
Some infants with diarrhea, malnutrition,
and lactose-sucrose intolerance can also
develop intolerance to glucose poly-
m e r . ~ .Glucose
~ ~ , ~ ~polymers are hydrolyzed
by pancreatic amylase and glucoamylase, a
brush-border enzyme that is better pre-
served than other disaccharidases in in-
fants with prolonged diarrhea.53 We have
observed that infants with diarrhea have a
decreased small-bowel absorption of glu-
cose polymers as compared with
The capacity to tolerate carbohydrate can
be delayed considerably in infants who are
recovering from severe diarrhea, and in
some cases tolerance to lactose will not
reoccur until three or four months after re-
334 NUTRITION REVIEWSIVOL 48,NO SISEPTEMBER 1990
c o v e r ~In
. ~our
~ experience, infants who are
recovering from severe, prolonged diar-
rhea and who can tolerate lactose will re-
gain their appropriate weight when fed a
lactose-containing formula, if allowed to
ingest sufficient calories.56
In addition to carbohydrate malabsorp-
tion, protein hypersensitivity may compli-
cate the refeeding process. Elemental and
semielemental diets have been used to re-
feed infants who have protein and/or
mono- and disaccharide i n t ~ l e r a n c e . ~ ’ - ~ ~
Such formulas, however, are extremely ex-
pensive and sometimes unavailable in de-
veloping countries. Chicken-based for-
mulas have been used successfully, mainly
for infants with intolerance for proteins of
cow’s milk and soy milk.60
Other approaches have been used to
overcome the problem of lactose intoler-
ance and protein hypersensitivity. The use
of local, customary foods has been evalu-
ated in a series of studies in clinical and in-
stitutional settings. Although many of the
studies can be criticized for their design
(some did not have adequate controls or
large numbers of patients), they generally
conclude that a wide variety of foods, many
of vegetable origin, can be used for refeed-
ing to overcome lactose intolerance and
protein sensitivity. Compared with more
conventionally accepted therapeutic diets,
those based on local traditional foods have
resulted in a considerable decrease in the
duration of diarrhea. Alarcon et a1.61 from
the lnstituto Nacional del Niiio in Lima,
Peru, reported a mean duration of diarrhea
of 1.5 days for children fed “Sanquito”
(toasted pea flour, toasted wheat flour, car-
rot, oil, and sugar), as compared with 2.7
days for children fed with a potato-and-
milk diet, and 4.9 days for those fed with a
soy-protein formula (IsomiP). TorurP2 ob-
served a median duration of diarrhea of 1.8
days for 31 children fed “lncaparina” (corn,
cottonseed flour, lysine, mineral-vitamin
mix, and sugar) and a pap of rice, corn,
black beans, oil, and sugar, as compared
with 5.3 days for 22 children fed lactose-hy-
drolyzed milk and a pap of rice, egg, oat-
meal, oil, and sugar. Among children fed
with the lncaparina diet, diarrhea lasted for
less than one day in 32% and for more than
10 days in 3%; among children fed with the
milk diet, diarrhea lasted for less than one
day in 14% and for more than 10 days in
23%.
Fermented milks and yogurts have also
been used successfully to feed children
with lactose intolerance in hospitals or in
communities where such dairy prepara-
tions are culturally a ~ c e p t a b l e .Feeding
~~
nutrients other than milk is particularly im-
portant for treating older infants and chil-
dren with diarrhea. Choice of foods, mode
of preparation, and frequency of feeding
depend on the child’s age, feeding history,
and physiologic status. Food choices
should be based on the foods eaten by the
child before the onset of diarrhea.
Although there is a reduction in appetite
during both acute and chronic diarrhea, af-
fected children still eat significant amounts
of food.22923,64The decrease in appetite
seems related to fever and malaise rather
than to diarrhea itself.23 Many children
have a compensatory increase in appetite
during c o n v a l e ~ c e n c e . ~ ~
When children are hospitalized and
refuse to eat, it is reasonable to consider
cont in uo us nasogast r ic feed ing .3959,65T h is
technique takes full advantage of residual
digestive and absorptive capacities
through the slow, constant introduction of
small quantities of food; it can be used with
persons of all ages. Nasogastric feeding
might increase stool frequency without
markedly increasing stool volume. The first
meal by this route should consist of a 50%
dilution of a formulation containing 0.7
kcal/mL; it should be followed in 3-4 hr by
a meal diluted by 25%, then by a full-
strength meal at the next feeding.3 Various
strategies should be considered. For exam-
ple, in the early phases of treatment, large
volumes of dilute feedings might be toler-
ated better than equivalent amounts of nu-
trients in more concentrated feedings.
Nasogastric feeding may induce compli-
cations such as excessive fluid intake and
edema, particularly if the patient is hypo-
proteinemic. When continuous nasogastric
NUTRITION RNIEWSIVOL 48,NO 9ISEPTEMBER 1990 335
feeding is chosen, special care must be
taken to ensure that the protocols for prep-
aration and delivery include steps to mini-
mize contamination.
Some infants with chronic diarrhea de-
velop such a degree of carbohydrate mal-
absorption that even formulas containing
monosaccharides result in severe purging,
carbohydrate in the stools, and/or a fecal
pH below 5.5. The effective management of
such patients is a considerable challenge.
A reduction in the small-bowel surface area
has been found in patients affected with
acquired monosaccharide malabsorp-
tion.66 Factors that increase the risk of de-
veloping monosaccharide malabsorption
include younger age, malnutrition, pro-
longed diarrhea before hospitalization, and
a greater degree of dehydration upon ad-
mission than is found in those infants
whose illness had a less complicated
course.6’
Acknowledgment: This project was funded in
part with funds from the U S . Department of
Agriculture, Agricultural Research Service
under Cooperative Agreement no. 58-7MN1-6-
100. The contents of this publication do not nec-
essarily reflect the views or policies of the U.S.
Department of Agriculture, nor does mention of
trade names, commercial products, or organiza-
tions imply endorsement by the U.S. govern-
ment.
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