Kayla is months away from her fifth birthday and weighs just 18 pounds, about half what a girl her age should by World Health Organization standards.
She suffers from chronic malnutrition and can barely move. Even breathing appears difficult. During a recent visit to Hospitalito Atitlan in rural Guatemala, she was cradled in her mother's arms and whisked from examination room to examination room.
Kayla's brain development is not progressing, her physical development is stunted,and she can't do simple tasks for herself, said her physical therapist Andrea Maria Sojuel.
Sojuel works for a small non-profit called ADISA, serving disabled patients in the indigenous community of Santiago Atitlan. She sees quite a few children with the same condition. Another patient of hers, a 20-month-old, weighs just eight pounds.
About 49 percent of children in Guatemala are chronically malnourished according to the World Food Program—the fourth highest ratein the world. In indigenous communities the rate is closer to 70 percent.
While most won't manifest symptoms as grave as Kayla's, they will all suffer health consequences because of the condition. Chronic malnutrition causes stunted growth, the most obvious and widespread indicator in Guatemala, but also increases the chances of children developing heart disease, diabetes and kidney damage down the line. It can cause anemia as well, greatly increasing the risk of a woman dying in child birth.
Infections that cause diarrhea play a big roll in malnutrition of infants, but for many families the root problem comes down to numbers—too many mouths to feed, not enough food.
"Sometimes it's a question of too many children. The boys will sometimes preferentially get food over the girls, I have seen that," said Mark Lepore, a visiting physician working at the hospital.
Asuncion Don Diego, from Alotenango, near Antigua, knows just how difficult these choices can be. She and her husband have seven children. He plants corn for a living, she took a job washing clothes to help pay for food.
"We would at least try to have tortillas, even if that is all we could feed them," she said through an interpreter.
Jose Andres Botran , who helped create an office in the Guatemalan government specifically to address the problem of food security, said a lack of education on what foods are important for children is part of the problem.
"A person can have 12 tortillas and a Coke and will not be hungry but they won't be well nourished," he said.
Awareness about malnutrition has grown, but necessary monitoring has not been put in place to see if the situation is improving, Botran said. The food security office has helped connect stake holders and runs initiatives to provide fortified foods and educate the population.
USAID also contributes between $16 to $18 million a year in food assistance to the country, including some higher protein commodities like beans and grains fortified with soy.
Still, says Chessa Lutter, regional advisor for the Pan American Health Organization, Guatemala continues to have some of the poorest nutrition indicators in the region and once a child has been malnourished through crucial early development, it has long-lasting implications.
PAHO reports that Guatemala has the highest rates of obesity among poor countries in Latin America, linked to malnutrition. Once a person is stunted and below-average height, it is much easier for them to become overweight.
"The same type of diet, that is heavy in carbs and cheap fats, which makes kids short and anemic also makes adults fat," Lutter said.
For Kayla, the road ahead holds more immediate concerns. She has sores in her throat that make her not want to eat, and she is actually losing weight instead of gaining. It's hard to imagine that she will ever be able to attend school.
"What I worry about most [with these children] is education, the ability to learn" said Lepore, her doctor.