Daily oral iron supplementation during pregnancy

Impact of second trimester iron deficiency on maternal and infant outcomes: A Danish cohort study

OBJECTIVE

Iron is a fundamental component during pregnancy; however, there is a lack of understanding of how iron deficiency (ID) during the second trimester affects maternal and infant outcomes. We aimed to investigate the prevalence of ID among pregnant women during the second trimester of pregnancy and to evaluate the associations with adverse maternal and infant outcomes.

STUDY DESIGN

This was an exploratory analysis of data from a longitudinal cohort study including singleton pregnant women at a single center, where P-ferritin was analyzed in blood samples drawn between 24 and 28 weeks gestation. Multivariable regression analyses with Bonferroni corrections were used to evaluate the association between ID (P-ferritin <15 µg/L) in the second trimester and maternal and infant outcomes.

RESULTS

Second trimester ID was found in 182 of the 449 included women (40.5 %), among whom anemia was present in 4.4 %. Women with ID were more often multiparous (73.1 % vs. 52.4 %) and subsequently treated with intravenous iron infusion (5.5 % vs. 1.1 %). Infants born to women with ID had a significantly higher placental weight (700 g vs. 630 g), higher birth weight (3713 g vs. 3522 g), birth weight z-score (0.3 vs. -0.1), and significantly lower prevalence of small for gestational age (2.7 % vs. 9.8 %) compared to women with normal iron levels. ID in the second trimester of pregnancy was not associated with adverse maternal or infant outcomes such as emergency cesarean section, induction of labor, preterm birth, or fetal acidosis.

CONCLUSION

Despite recommended iron supplements from 10 weeks gestation, ID was frequent among pregnant Danish women in the second trimester and associated with accelerated placental and infant growth, but not adverse pregnancy outcomes. This study indicates that the clinical relevance of the current cut-off level for ID in the second trimester of pregnancy among pregnant Danish women needs further investigation.

Long-term trends in the global burden of maternal abortion and miscarriage from 1990 to 2021: joinpoint regression and age-period-cohort analysis

BACKGROUND

Maternal abortion and miscarriage are significant contributors to the global burden of maternal health conditions. Iron deficiency remains a critical risk factor, significantly impacting reproductive health outcomes, particularly in low socio-demographic index (SDI) regions. This study aims to assess long-term trends in the incidence, mortality, and disability-adjusted life years (DALYs) of maternal abortion and miscarriage from 1990 to 2021 using the Global Burden of Disease (GBD) 2021. Additionally, we evaluate the role of iron deficiency as a risk factor and project future burden estimates up to 2051.

METHODS

Utilizing the GBD 2021 dataset across 204 countries and territories, the study retrospectively analyzed long-term trends in maternal abortion and miscarriage from 1990 to 2021. Joinpoint regression was applied to identify temporal trends in age-standardized incidence rate (ASIR), age-standardized mortality rate (ASMR), and age-standardized DALYs rate (ASDR). An age-period-cohort (APC) model was used to assess the independent effects of age, period, and cohort, while future projections were generated using Bayesian age-period-cohort (BAPC) modeling.

RESULTS

In 2021, the global ASIR of maternal abortion and miscarriage was 1001.64 per 100,000 population (95% UI: 775.97-1261.67), with the highest burden in low SDI regions (ASIR = 1715.1 per 100,000 population). The ASMR, reflecting maternal mortality due to abortion and miscarriage, was 0.42 per 100,000 population (95% UI: 0.36-0.52). The ASDR, capturing the total burden including both premature mortality and disability, was 25.73 per 100,000 population (95% UI: 21.82-31.02). The global ASIR declined at an annual percentage change (APC) of -2.32% from 1990 to 1994 and by -2.00% from 2015 to 2019.

CONCLUSION

The global burden of maternal abortion and miscarriage has decreased, with iron deficiency remaining a critical risk factor in low SDI regions, particularly among women aged 20-34. Projections suggest declines in ASIR over the next 30 years.

Global, regional and national burden of dietary iron deficiency from 1990 to 2021: a Global Burden of Disease study

Although iron deficiency is well documented, less is known about dietary involvement in symptomatic iron deficiency manifesting in medical conditions. In this study, we quantified the global burden of dietary iron deficiency, focusing on where inadequate dietary iron intake leads to clinical manifestations such as anemia. We analyzed data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 to estimate dietary iron deficiency prevalence and disability-adjusted life years (DALYs), stratified by age, sex, geography and socio-demographic index (SDI) across 204 countries. In 2021, global age-standardized prevalence and DALY rates were 16,434.4 (95% uncertainty interval (UI), 16,186.2-16,689.0) and 423.7 (285.3-610.8) per 100,000 population, with rates decreasing by 9.8% (8.1-11.3) and 18.2% (15.4-21.1) from 1990 to 2021. A higher burden was observed in female individual (age-standardized prevalence, 21,334.8 (95% UI, 20,984.8-21,697.4); DALYs, 598.0 (402.6-854.4)) than in male individual ((age-standardized prevalence, 11,684.7 (11,374.6-12,008.8); DALYs, 253.0 (167.3-371.0)). High-SDI countries presented greater improvement, with a 25.7% reduction compared to 11.5% in low-SDI countries. Despite global improvements, dietary iron deficiency remains a major health concern with a global prevalence of 16.7%, particularly affecting female individuals, children and residents in low-SDI countries. Urgent interventions through supplementation, food security measures and fortification initiatives are essential.

Calcium and Iron Nutrition through the Reproductive Life Course

BACKGROUND

Two essential micronutrients over the life course are calcium and iron, and both are especially important during the reproductive cycle. The role of calcium in maternal and offspring bone health and in the prevention of pre-eclampsia in pregnancy are well described, although results from randomised controlled trials for both outcomes vary. Iron is essential for synthesis of red blood cells, being a core component of haemoglobin, which carries oxygen around the body, and hence is key in the prevention of anaemia and sequelae.

SUMMARY

This article reviews the evidence across the reproductive life course for dietary calcium and iron intakes and health outcomes. For calcium, focusing on bone health and prevention of pre-eclampsia, for iron considering its crucial role in foetal and neonatal development and how requirements may be impacted through inflammation and infection, particularly in environments where iron availability may be low.

Dietary supplements and prevention of preeclampsia

Preeclampsia (PE) is a common pregnancy complication characterized by hypertension, proteinuria, and end-organ dysfunction. However, to date, no effective treatment has been established other than iatrogenic delivery, and the importance of prevention as an alternative approach to addressing PE has been emphasized. There is growing evidence on the effectiveness of pharmacological and non-pharmacological prophylaxis in preventing PE. In this review, we focused on dietary supplements as non-pharmacological prophylaxis for PE. Calcium is a well-documented supplement for the prevention of PE. Daily 500 mg calcium supplementation can roughly halve the risk of PE in settings where calcium intake is low, including in Japan. According to recent systematic reviews and network meta-analyses, current evidence on the efficacy of vitamin D supplementation is inconsistent. Although vitamin D is a candidate for the prevention of PE, future large-scale randomized control trials are necessary to draw definitive conclusions. We also reviewed other dietary supplements, including vitamins (vitamins A, B6, C, and E, folic acid, and multivitamins), minerals (magnesium, zinc, and iron), amino acids (l-arginine and l-carnitine), anti-oxidants (lycopene, resveratrol, and astaxanthin), and other agents (omega-3 fatty acids, coenzyme Q10, melatonin, and s-equol). In this study, we provide a comprehensive approach to help develop better preventive strategies and ultimately reduce the burden of PE.

Micro-nutrient sufficiency in mothers and babies: management of deficiencies while avoiding overload during pregnancy

Pregnancy is a period characterized by extensive physiological changes in both the mother and fetus. During this period, the nutritional status of the mother has a profound and irreversible impact on her health and the growth and development of the fetus. The fetus depends exclusively on the mother and drives nutrients through the placenta. Therefore, mothers must be provided with a well-balanced diet that is adequate in both macro- and micronutrients. Most pregnant women generally manage to get adequate macronutrients; however, many women fail to get micronutrients up to the recommended dietary allowance. Micronutrients such as vitamins and minerals are necessary for preventing congenital abnormalities and the optimal development of the brain and body of the fetus. Their inadequacy can lead to complications like anemia, hypertension, pre-eclampsia, maternal and fetal hypothyroidism, premature infants, intrauterine growth restriction, stillbirth, and other negative pregnancy outcomes. New studies recommend the use of prenatal micronutrient supplements to prevent birth defects and health issues caused by deficiencies in folic acid, iron, iodine, and calcium during pregnancy. This is especially important in developing nations where deficiencies are prevalent. Also while using these supplements, their upper limits (UL) must be considered to avoid overload. In this review, we provide an overview of the four most critical micronutrients during pregnancy: iron, folic acid, iodine, and calcium. We provide insight into their sources, RDAs, deficiency consequences, and the need for supplementation while considering the risk of micronutrient overload. To maximize the potential benefits while minimizing the risk of nutrient overload, although knowledge gaps remain.

Harnessing behavioral interventions to enhance micronutrient intake in pregnancy: A comprehensive review

Pregnancy is a pivotal moment in a woman's life, necessitating an increased focus on ensuring sufficient nutrition to promote both maternal wellbeing and fetal growth. During this period, it is crucial to emphasize the need for adequate micronutrients, including iron, calcium, and vitamin D. However, pregnant women worldwide continue to experience deficits in these essential nutrients, which increases the risk of adverse health outcomes for pregnant women and infants. Behavioral intervention presents a potentially practical approach to address this disparity by focusing on dietary modification and encouraging compliance with prescribed nutritional standards. This comprehensive review utilized a systematic literature review to collect pertinent material for the article from Scopus and Web of Science databases, ensuring scientific credibility, transparency, and comprehensiveness regarding behavioral interventions promoting increased iron, calcium, and vitamin D consumption among pregnant women. This review seeks to provide clinicians, researchers, and policymakers with information on practical techniques to enhance maternal and fetal health by improving food intake during pregnancy. Further, it will explore intervention strategies, efficacy, underlying processes, and future directions.

Comparing the Treatment Outcomes of Oral and Injectable Iron Therapies for Anemia in Pregnancy: A Meta-Analysis

Iron deficiency anemia (IDA) during pregnancy is a global public health concern, associated with significant maternal and neonatal complications. Intravenous (IV) iron therapy has emerged as a potential alternative to oral iron for rapid correction of anemia, but its impact on clinical outcomes remains unclear. This meta-analysis aimed to evaluate the effectiveness and safety of IV iron compared to oral iron in improving maternal and neonatal outcomes during pregnancy. A systematic review of randomized controlled trials (RCTs) was conducted using major databases. A total of 15 studies, involving 4,215 pregnant women, met the inclusion criteria. Meta-analyses were performed to assess maternal and neonatal complications, adverse events, and hemoglobin (Hb) improvement. The findings demonstrated that IV iron therapy significantly improved Hb levels more rapidly than oral iron, with a mean rise of 2.05 g/dL for IV iron compared to 1.65 g/dL for oral iron. Women receiving IV iron experienced 21% fewer maternal complications, although the difference was not statistically significant for individual complications. Neonatal outcomes, including birth weight, cord Hb levels, and preterm births, showed no significant differences between the two groups. Adverse events were significantly less frequent in the IV group (OR 0.38; 95% CI: 0.24-0.58; p < 0.01), indicating a better safety profile. This study highlights the superior efficacy of IV iron for rapid anemia correction and reduced adverse events in pregnant women. However, no significant advantage was observed for neonatal outcomes or individual maternal complications. The evidence quality for Hb improvement was high, while that for maternal and neonatal clinical outcomes varied from moderate to low. Further research is needed to explore the impact of IV iron on critical clinical outcomes and to determine the most cost-effective regimens for anemia management during pregnancy.

International expert consensus on micronutrient supplement use during the early life course

BACKGROUND

Growing evidence demonstrates that maternal nutrition is crucial for the health of the mother-to-be, and early life course of the offspring. However, for most micronutrients, guidelines are inconsistent. This Delphi study aimed to investigate the level of expert consensus on maternal nutrition and micronutrient needs during preconception, pregnancy and lactation.

METHODS

We conducted a two-round web-based Delphi survey on various topics including general approaches to diet and supplement use, and existing guidelines. For the periods of preconception, pregnancy and lactation, questions focused on the importance and strength of evidence for supplement use with the following micronutrients for low- and high-risk populations: folic acid, choline, iodine, magnesium, calcium, iron, selenium, docosahexaenoic acid (DHA), and vitamins B1, B2, B6, B12, D and K.

RESULTS

Thirty-five experts participated in the panel, who were healthcare professionals (HCPs), researchers and joint HCP-researchers with expertise in nutrition, gynaecology and/or obstetrics. Panellists reached consensus on the importance of diet and dietary supplement use during pregnancy and agreed on the lack of clarity and consistency in current guidelines, and the need for education in these areas for HCPs, pregnant people and the general population. For general low-risk populations, there was consensus on the importance of supplement use with iron and vitamin D from preconception through lactation, with folic acid and iodine from preconception through the second and third trimesters, respectively, with DHA from the first trimester through lactation and with calcium during lactation. Panellists agreed that the evidence for supplement use with each of these micronutrients during these phases to improve outcomes and/or foetal development is strong, except for vitamin D (preconception), DHA (first trimester), and iron (both periods). There was also consensus that supplement use advice should be tailored for people following vegan/vegetarian diets, restricted diets due to food intolerances, obesity, polycystic ovary syndrome, diabetes mellitus, and previous nutrition-related pregnancy complications.

CONCLUSION

The findings revealed robust consensus on various aspects of maternal nutrition, including the need for education, the lack of consistency in current guidelines on supplement use, the importance of supplement use across specific phases of pregnancy and the at-risk groups requiring tailored approaches.

The benefits and harms of oral iron supplementation in non-anaemic pregnant women: a systematic review and meta-analysis

BACKGROUND

Iron deficiency during pregnancy poses a significant risk to both maternal and foetal health. Current international guidelines provide discrepant advice on antenatal iron supplementation for non-anaemic women.

OBJECTIVE

We aimed to quantify the benefits and harms of routine antenatal supplementation in non-anaemic women.

METHODS

The Cochrane Library, MEDLINE, Embase, and clinical trial registries were searched for randomized controlled trials and observational studies comparing oral iron supplementation with placebo or no supplement in non-anaemic pregnant women. Risk of bias was assessed for each study and the results were synthesized via meta-analysis.

RESULTS

Twenty-three eligible studies were identified with 4492 non-anaemic pregnant women. Supplemented groups had higher haemoglobin [mean difference = 6.95 g/l, 95% confidence interval (CI): 4.81-9.09, P < .001, moderate certainty, I2 = 91%] and ferritin (mean difference = 12.22 ng/ml, 95% CI: 6.92-17.52, P < .001, moderate certainty, I2 = 87%) and were at lower risk of anaemia (relative risk = 0.50, 95% CI: 0.34-0.74, P < .001, high certainty, I2 = 42%, number needed to treat (NNT) = 10). There was no difference in birth weight, preterm birth, and rate of caesarean section. Reporting on harms was inconsistent and there was insufficient evidence to determine an association between iron supplements and any negative outcome.

DISCUSSION

Prophylactic iron supplementation likely results in a large reduction in maternal anaemia during pregnancy. Future research should qualify the impact of this benefit on women's quality of life and determine which subpopulations benefit most. Evidence surrounding the harms of iron supplementation in the non-anaemic population is poor quality and inconsistent. Randomized controlled trials quantifying the risk of gastrointestinal (GI) disturbance and iron overload are essential to inform iron supplement use and reduce unwarranted variations in international guidelines.

How much could anemia-related interventions reduce the HIV disparity in adverse birth outcomes?

Women and other people of childbearing potential living with HIV (WLHIV) have a higher risk of adverse birth outcomes than those without HIV (WWHIV). A higher risk of anemia in WLHIV could partially explain this disparity. Using a birth outcomes surveillance study in Botswana, we emulated target trials corresponding to currently available or feasible interventions on anemia. The first target trial evaluated 2 interventions: initiate multiple micronutrient supplementation (MMS), and MMS or iron and folic acid supplementation by 24 weeks gestation. The remaining target trials evaluated the interventions: eliminate anemia before pregnancy; and jointly eliminate anemia before pregnancy and initiate MMS. We estimated the observed disparity in adverse birth outcomes between WLHIV and WWHIV and compared the observed disparity measure (ODM) to the counterfactual disparity measure (CDM) under each intervention. Of 137 499 individuals (22% WLHIV), the observed risk of any adverse birth outcome was 26.0% in WWHIV and 34.5% in WLHIV (ODM, 8.5%; 95% confidence interval [CI], 7.9-9.1%). Counterfactual disparity measures (95% CIs) ranged from 6.6% (4.8-8.4%) for the intervention to eliminate anemia and initiate MMS to 8.4% (7.7%-9.1%) for the intervention to eliminate anemia only. Preventing anemia and expanding MMS may reduce HIV disparities in birth outcomes, but interventions with greater impact should be identified.

Evaluation of factors affecting the physiological levels of copper and iron in sheep and cattle in some areas of Diyala Governorate, Iraq

Background

Trace minerals are important components of many physiological functions, including growth, development, and the immune response.

Aim

This study aimed to evaluate copper and iron status in sheep and cattle in some areas of Diyala governorate, Iraq.

Methods

One hundred blood samples were collected, 50 from sheep and 50 from cattle in order to measure the levels of copper and iron in the serum.

Results

In sheep, the serum level of copper significantly increased among females compared to males, while among cattle, the serum level of copper significantly decreased in females compared with males. The level of iron showed a significant increase in females compared with males. Serum levels of copper were increased with the age of more than 1 year accordingly compared with sheep at the first year of life or less than a year. Among cattle, age plays no significant role in the level of copper. The levels of copper and iron were significantly increased among pregnant ewes compared with non-pregnant. The levels of copper were significantly increased in lambing compared with pregnant and non-pregnant ewes in the value of copper. The level of iron was significantly decreased in lambing sheep compared with pregnant and non-pregnant sheep. The levels of copper and iron showed no significant changes between pregnant and non-pregnant cows. Sheep from Abu Saida showed significant increase in serum levels of copper and iron compared with those from Baqubah and Saadia cities. Cows with good body scores have a significant increase in serum levels of copper and iron compared with those with medium and poor body scores. There was no linear correlation between iron and copper levels in serum and the studied parameters for cows and sheep.

Conclusion

The levels of copper and iron in the body of sheep and cattle are affected by age, gender, pregnancy, and soil composition.

Exploring factors affecting adherence to multiple micronutrient supplementation during pregnancy in Cambodia: A qualitative analysis

For decades, iron-folic acid (IFA) supplements have been provided to pregnant women in Cambodia through antenatal care (ANC) services. However, mounting evidence suggests that multiple micronutrient supplements (MMS) are superior to IFA supplements in achieving positive pregnancy outcomes. The possibility of transitioning from IFA supplements to MMS in government-run health centres is currently being assessed in Cambodia. A crucial component of this assessment involves identifying factors that can influence adherence to MMS, as low adherence can reduce supplement effectiveness. Consequently, this study aimed to explore the potential barriers and enablers to MMS adherence and identify the strengths and challenges of current ANC services. Data were collected through nine focus group discussions with pregnant women (n = 19), family members (n = 18) and midwives (n = 18) and three in-depth interviews with maternal and child health chiefs (n = 3) in Cambodia and analysed via content analysis. Factors found to influence MMS adherence included attitudes, perceptions and beliefs about MMS; knowledge related to supplementation; ANC counselling; family influence; physical health; access to ANC; supply of MMS; and supplementation norms. Noted strengths of ANC services were the quality of ANC materials, tailored patient education, midwife-patient relationships and flexibility of provided services. Primary challenges related to poor availability of ANC materials, inadequate midwife training, heavy workload, limited funding and suboptimal physical spaces for delivering ANC services. To effectively promote MMS adherence, strategies must involve pregnant women, family members and community leaders; seek to address knowledge gaps and misconceptions related to MMS; and enhance the availability and accessibility of ANC services.

Evaluation of factors affecting the physiological levels of copper and iron in sheep and cattle in some areas of Diyala Governorate, Iraq

Background

Trace minerals are important components of many physiological functions, including growth, development, and the immune response.

Aim

This study aimed to evaluate copper and iron status in sheep and cattle in some areas of Diyala governorate, Iraq.

Methods

One hundred blood samples were collected, 50 from sheep and 50 from cattle in order to measure the levels of copper and iron in the serum.

Results

In sheep, the serum level of copper significantly increased among females compared to males, while among cattle, the serum level of copper significantly decreased in females compared with males. The level of iron showed a significant increase in females compared with males. Serum levels of copper were increased with the age of more than 1 year accordingly compared with sheep at the first year of life or less than a year. Among cattle, age plays no significant role in the level of copper. The levels of copper and iron were significantly increased among pregnant ewes compared with non-pregnant. The levels of copper were significantly increased in lambing compared with pregnant and non-pregnant ewes in the value of copper. The level of iron was significantly decreased in lambing sheep compared with pregnant and non-pregnant sheep. The levels of copper and iron showed no significant changes between pregnant and non-pregnant cows. Sheep from Abu Saida showed significant increase in serum levels of copper and iron compared with those from Baqubah and Saadia cities. Cows with good body scores have a significant increase in serum levels of copper and iron compared with those with medium and poor body scores. There was no linear correlation between iron and copper levels in serum and the studied parameters for cows and sheep.

Conclusion

The levels of copper and iron in the body of sheep and cattle are affected by age, gender, pregnancy, and soil composition.

Current evidence around key underrepresented women's health topics in pregnancy and postpartum nutrition: a narrative review

Adequate nutrition during pregnancy and postpartum is critical to maternal and child health, but there is often a missing focus around health outcomes specifically for women. Women's health includes sex-specific biological attributes and socially constructed gender roles framing behaviours and practices. This narrative review aims to highlight key areas where women's health has been underrepresented in pregnancy and postpartum nutrition research. Current evidence and research gaps are discussed for nutritional requirements during pregnancy and lactation, maternal mortality and morbidity nutritional risk factors, preconception and postpartum nutrition, and gendered cultural norms and inequities in access to nutritious foods during pregnancy and postpartum. Important areas for future research include strengthening empirical evidence for nutritional requirements in pregnant and lactating populations, the relationship between maternal iron status, anaemia and maternal morbidities, linkages between nutrient status among women and adolescent girls to maternal health outcomes, postpartum nutrition for recovery, lactation, and long-term women's health outcomes, and strength-based cultural practices that can support adequate maternal nutrition. There is an ongoing need to include women in nutritional requirements research, and measure health outcomes for women to ensure creation of an evidence base on both sex and gender-based datasets.

Ferric carboxymaltose for anemia in late pregnancy: a randomized controlled trial

Over 46% of African pregnant women are anemic. Oral iron is recommended but often suboptimal, particularly late in pregnancy. Intravenous ferric carboxymaltose (FCM) could treat anemia in women in the third trimester in sub-Saharan Africa. In an open-label, individually randomized trial in antenatal clinics in southern Malawi, we randomized 590 women at 27-35 weeks of gestation with capillary hemoglobin <10.0 g dl-1 to FCM (20 mg kg-1 up to 1,000 mg, once at enrollment) or standard of care (60 mg elemental iron, twice daily for 90 days). Participants and their infants were followed to 4 weeks postpartum. Primary outcomes were maternal anemia at 36 weeks' gestation or delivery (whichever occurred first) and neonatal birthweight. At the primary timepoint, 126 of 270 (46.7%) of women in the FCM group were anemic, compared to 170 of 271 (67.3%) women in the standard-of-care group (PR, 0.74 (95% CI 0.64, 0.87); P = 0.0002). There was no difference between groups in birthweight (mean difference 10.9 g (-65.7, 87.5 g); P = 0.78). No serious infusion-related reactions occurred, and there were no differences in adverse events between groups. In Malawian women in late pregnancy, FCM effectively and safely reduced anemia before childbirth. Australia New Zealand Clinical Trial registration: ANZCTR12621001239853.

Agenda-setting for iron deficiency anaemia prevention and control policies in Iran by multiple streams framework

BACKGROUND

According to the WHO report and evaluations, Iran has a moderate prevalence of iron deficiency anaemia (IDA). The present study evaluates Iran's IDA prevention and control policies by analysing the agenda-setting policy using the multiple streams framework (MSF).

METHODS

The present study used Kingdon's MSF model to analyse policies related to IDA in Iran qualitatively. First, the policy documents were reviewed (n = 12), and then in-depth interviews were conducted with key stakeholders (n = 33) using the framework analysis method. MAXQDA version 2020 was used to categorize the data codes of the interviews and extract related themes.

RESULTS

The main factors of the problem stream were the prevalence of IDA among Iranian pregnant women, children and adolescents and its risk factors in Iran. The policy stream focuses on mounting the staff in health centres, preventing non-communicable diseases and parasites in the health system, and promoting health programs, such as supplementation, education and fortification. The current political stream regarding IDA shows that national and international support can provide the right political atmosphere for this issue. There are challenges and obstacles related to implementing these policies in Iran, including the preference for treatment over prevention in the health sector, the existence of many economic problems and the limitation of distribution and access to health services owing to some unforeseen issues, such as sanctions or the spread of coronavirus disease 2019 (COVID-19).

CONCLUSIONS

The topic of IDA prevention policymaking has entered a new phase. Responsible organizations, such as the Ministry of Health, should emphasize more in allocating budgets for preventive programs, and key organizations, such as the WHO, should support low- and middle-income countries to empower them towards important preventive strategies.

Prediction of preterm birth using machine learning: a comprehensive analysis based on large-scale preschool children survey data in Shenzhen of China

BACKGROUND

Preterm birth (PTB) is a significant cause of neonatal mortality and long-term health issues. Accurate prediction and timely prevention of PTB are essential for reducing associated child mortality and morbidity. Traditional predictive methods face challenges due to heterogeneous risk factors and their interaction effects. This study aims to develop and evaluate six machine learning (ML) models to predict PTB using large-scale children survey data from Shenzhen, China, and to identify key predictors through Shapley Additive Explanations (SHAP) analysis.

METHODS

Data from 84,050 mother-child pairs, collected in 2021 and 2022, were processed and divided into training, validation, and test sets. Six ML models were tested: L1-Regularised Logistic Regression, Light Gradient Boosting Machine (LightGBM), Naive Bayes, Random Forests, Support Vector Machine, and Extreme Gradient Boosting (XGBoost). Model performance was evaluated based on discrimination, calibration and clinical utility. SHAP analysis was used to interpret the importance and impact of individual features on PTB prediction.

RESULTS

The XGBoost model demonstrated the best overall performance, with the area under the receiver operating characteristic curve (AUC) scores of 0.752 and 0.757 in the validation and test sets, respectively, along with favorable calibration and clinical utility. Key predictors identified were multiple pregnancies, threatened abortion, and maternal age of conception. SHAP analysis highlighted the positive impacts of multiple pregnancies and threatened abortion, as well as the negative impact of micronutrient supplementation on PTB.

CONCLUSION

Our study found that ML models, particularly XGBoost, show promise in accurately predicting PTB and identifying key risk factors. These findings provide the potential of ML for enhancing clinical interventions, personalizing prenatal care, and informing public health initiatives.

A qualitative assessment of barriers to iron and folic acid supplementation among pregnant women in Botswana

BACKGROUND

Antenatal iron and folic acid (IFA) supplementation remains an effective strategy in the prevention of maternal anemia and low birthweight and is universally recommended by WHO. However, uptake of IFA has varied globally due to challenges with acceptability, supply and distribution, counselling and knowledge, and access to health services. In Botswana, nearly one-third of pregnant women engaged in antenatal care do not receive IFA, despite it being standard of care. The objectives of this study were to assess knowledge of and barriers and facilitators to IFA supplementation before and during pregnancy.

METHODS

We conducted qualitative interviews with two key stakeholder groups at two different levels-the individual level (pregnant women) and the service delivery level (health care providers). Here, we present results from interviews with pregnant women at two representative antenatal clinic sites in Botswana in 2022.

RESULTS

Pregnant women were motivated to be healthy and were knowledgeable about the benefits of supplementation during pregnancy to mothers and their infants; however, women knew more about the benefits of iron than folic acid. Most women were in favor of receiving IFA supplementation prior to pregnancy and receiving fortified foods. Several key barriers were identified: lack of supplement availability in the clinics, poverty, side effects, number of tablets, and adherence. Approaches to overcome these barriers included improving supplement availability, improving health education, increasing supply of nutritious and fortified foods, backyard gardens, and increasing family and monetary support.

CONCLUSIONS

Our study identified a need to 1) increase the availability of supplementation at antenatal clinics and 2) improve education regarding supplementation to include information about the benefits of folic acid and other micronutrients. Implementation research is needed to ascertain whether increasing supply and improving education could increase utilization of supplementation during pregnancy, with the ultimate goal of improving maternal and infant outcomes.

Maternal Anemia during Pregnancy and Infant Birth Outcomes: A Prospective Cohort Study in Eastern Maharashtra, India

Background

Anemia during pregnancy may be associated with poor infant outcomes, although its consequences may vary based on etiology and timing.

Objectives

We examined the associations between anemia and anemia-related biomarkers during pregnancy and infant outcomes [birthweight, gestational age at birth, birthweight-for-gestational age percentile, and infant hemoglobin (Hb) at 6 wk of age] in Nagpur, Eastern Maharashtra, India.

Methods

We conducted a prospective cohort study of 200 pregnant women. In the first trimester, venous blood was collected to assess Hb via cyanmethemoglobin analysis, micronutrient status (ferritin, vitamin B12, and folate), and inflammation (C-reactive protein). Hb was also assessed in capillary samples using a hemoglobinometer in the first and third trimesters for mothers and at 6 wk for infants. Associations were assessed using generalized linear models controlling for background characteristics.

Results

In the first trimester, high (compared with normal) venous Hb was significantly associated with lower gestational age at birth [β: -1.0 wk, 95% confidence interval (CI): -1.9, -0.2] and higher birthweight-for-gestational age percentile (β: 20.1, 95% CI: 9.0, 31.2). Mild anemia, moderate anemia, and high (compared with normal) capillary Hb were significantly associated with lower birthweight (β: -147.7 g, 95% CI: -243.4, -51.7; β: -77.7 g, 95% CI: -123.9, -31.4; and β: -236.0 g, 95% CI: -478.0, -48.1) and birthweight-for-gestational age percentile (β: -7.3, 95% CI: -13.7, -0.9; β: -8.4, 95% CI: -14.1, -2.8; and β: -8.9, 95% CI: -15.9, -1.9). Higher serum ferritin was significantly associated with higher birthweight (β: 2.0 g, 95% CI: 0.1, 3.9) and gestational age at birth (β: 0.01 wk, 95% CI: 0.00, 0.01). In the third trimester, mild anemia was significantly associated with lower gestational age at birth (β: -0.5 wk, 95% CI: -0.7, -0.3).

Conclusions

Associations between maternal anemia during pregnancy and infant outcomes were mixed indicating further studies are needed to better understand these relationships.

Associations of Maternal Nutritional Status and Supplementation with Fetal, Newborn, and Infant Outcomes in Low-Income and Middle-Income Settings: An Overview of Reviews

BACKGROUND/OBJECTIVES

Despite advances in maternal nutritional knowledge, the effect of maternal diet, micronutrient status and undernutrition, and the effect of maternal supplementation on fetal, neonatal and infant outcomes still have gaps in the literature. This overview of reviews is intended to assess the available information on these issues and identify the main maternal nutritional factors associated with offspring outcomes in low- and middle-income countries as possible targets for public health interventions.

METHODS

The literature search was performed in Medline (PubMed) and Cochrane Library datasets in June 2024. Pre-specified outcomes in offspring were pooled using standard meta-analytical methods.

RESULTS

We found consistent evidence on the impact of maternal undernutrition indicated by low body mass index (BMI), mid-upper arm circumference (MUAC), and stature, but not of individual micronutrient status, on intrauterine-growth retardation, preterm birth, low birth weight, and small for gestational age, with research showing a possible effect of maternal undernutrition in later child nutritional status. Studies on micronutrient supplementation showed possible beneficial effects of iron, vitamin D, and multiple micronutrients on birthweight and/or decreasing small for gestational age, as well as a possible effect of calcium on preterm birth reduction. Interventions showing more consistent beneficial outcomes were balanced protein-energy and lipid base supplements, which demonstrated improved weight in newborns from supplemented mothers and a decreased risk of adverse neonatal outcomes.

CONCLUSIONS

Further research is needed to identify the benefits and risks of maternal individual micronutrient supplementation on neonatal and further child outcomes.

Diagnosis and Treatment of Iron Deficiency and Iron Deficiency Anemia in Children and Adolescents: Recommendations of the Polish Pediatric Society, the Polish Society of Pediatric Oncology and Hematology, the Polish Society of Neonatology, and the Polish Society of Family Medicine

Background/Objectives. Iron deficiency is one of the most common nutritional deficiencies worldwide and is the leading cause of anemia in the pediatric population (microcytic, hypochromic anemia due to iron deficiency). Moreover, untreated iron deficiency can lead to various systemic consequences and can disrupt the child's development. Methods/Results. Therefore, a team of experts from the Polish Pediatric Society, the Polish Society of Pediatric Oncology and Hematology, the Polish Neonatology Society, and the Polish Society of Family Medicine, based on a review of the current literature, their own clinical experience, and critical discussion, has developed updated guidelines for the diagnosis, prevention, and treatment of iron deficiency in children from birth to 18 years of age. These recommendations apply to the general population and do not take into account the specifics of individual conditions and diseases.

Maternal ketone supplementation throughout gestation improves neonatal cardiac dysfunction caused by perinatal iron deficiency

Iron deficiency (ID) is common during gestation and in early infancy and has been shown to adversely affect cardiac development and function, which could lead to lasting cardiovascular consequences. Ketone supplementation has been shown to confer cardioprotective effects in numerous disease models. Here, we tested the hypothesis that maternal ketone supplementation during gestation would mitigate cardiac dysfunction in ID neonates. Female Sprague-Dawley rats were fed an iron-restricted or iron-replete diet before and throughout pregnancy. Throughout gestation, iron-restricted dams were given either a daily subcutaneous injection of ketone solution (containing β-hydroxybutyrate [βOHB]) or saline (vehicle). Neonatal offspring cardiac function was assessed by echocardiography at postnatal days (PD)3 and 13. Hearts and livers were collected post-mortem for assessments of mitochondrial function and gene expression profiles of markers oxidative stress and inflammation. Maternal iron restriction caused neonatal anemia and asymmetric growth restriction at all time points assessed, and maternal βOHB treatment had no effect on these outcomes. Echocardiography revealed reduced ejection fraction despite enlarged hearts (relative to body weight) in ID offspring, resulting in impaired oxygen delivery, which was attenuated by maternal βOHB supplementation. Further, maternal ketone supplementation affected biochemical markers of mitochondrial function, oxidative stress and inflammation in hearts of neonates, implicating these pathways in the protective effects conferred by βOHB. In summary, βOHB supplementation confers protection against cardiac dysfunction in ID neonates and could have implications for the treatment of anemic babies.

Examining the combined effect of antenatal care visits and iron-folic acid supplementation on low birth weight: a pooled analysis of two national data sets from Nepal

BACKGROUND

The prevalence of low birth weight (LBW) has stagnated at approximately 12% for the past 15 years in Nepal, significantly impacting newborn survival. While antenatal care (ANC) visits and iron-folic acid supplementation are recognised as important interventions to reduce LBW, there is a lack of evidence regarding their combined effect. This study aimed to explore the potential synergistic impact of ANC and iron-folic acid supplementation on LBW in Nepal by analyzing data from two national surveys.

METHODS

The nationally representative Nepal Demographic and Health Surveys of 2016 and 2022 were used, and the pooled dataset was analysed. Birth weight and the prevalence of LBW (i.e. birthweight < 2500 g) were reported using descriptive statistics. The associations among LBW, ANC visits, and iron-folic acid supplementation were examined using logistic regression analyses.

RESULTS

The mean birth weight was 3011 g, with an LBW prevalence of 11.2%. Not attending ANC (Adjusted Odds Ratio (AOR): 1.49; 95% Confidence Interval (CI): 1.14, 1.95) and not consuming iron-folic acid supplements (AOR: 1.43; 95% CI: 1.11, 1.84) were independently associated with a higher likelihood of having LBW. Furthermore, when considering both factors together, mothers who attended less than four ANC visits and consumed iron-folic acid for ≤ 90 days had the higher likelihood of having LBW (AOR: 1.99; 95% CI: 1.35, 2.60) compared to those who did not.

CONCLUSIONS

This study highlights that the individual and joint influence of ANC visits and iron-folic acid supplementation on having LBW. These findings underscore the significance of ANC attendance and iron-folic acid supplementation in preventing LBW. Traditionally, these two interventions were primarily considered as maternal survival strategies. However, our findings indicate that these existing interventions could be utilised further for both maternal and newborn survival. Given that these services are offered free of cost and are available near people's homes through the National Safe Motherhood Programme in Nepal, efforts to increase the uptake of these services should be strengthened while emphasising their role in preventing LBW.

Daily oral iron supplementation during pregnancy

BACKGROUND

Iron and folic acid supplementation have been recommended in pregnancy for anaemia prevention, and may improve other maternal, pregnancy, and infant outcomes.

OBJECTIVES

To examine the effects of daily oral iron supplementation during pregnancy, either alone or in combination with folic acid or with other vitamins and minerals, as an intervention in antenatal care.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Trials Registry on 18 January 2024 (including CENTRAL, MEDLINE, Embase, CINAHL, ClinicalTrials.gov, WHO's International Clinical Trials Registry Platform, conference proceedings), and searched reference lists of retrieved studies.

SELECTION CRITERIA

Randomised or quasi-randomised trials that evaluated the effects of oral supplementation with daily iron, iron + folic acid, or iron + other vitamins and minerals during pregnancy were included.

DATA COLLECTION AND ANALYSIS

Review authors independently assessed trial eligibility, ascertained trustworthiness based on pre-defined criteria, assessed risk of bias, extracted data, and conducted checks for accuracy. We used the GRADE approach to assess the certainty of the evidence for primary outcomes. We anticipated high heterogeneity amongst trials; we pooled trial results using a random-effects model (average treatment effect).

MAIN RESULTS

We included 57 trials involving 48,971 women. A total of 40 trials compared the effects of daily oral supplements with iron to placebo or no iron; eight trials evaluated the effects of iron + folic acid compared to placebo or no iron + folic acid. Iron supplementation compared to placebo or no iron Maternal outcomes: Iron supplementation during pregnancy may reduce maternal anaemia (4.0% versus 7.4%; risk ratio (RR) 0.30, 95% confidence interval (CI) 0.20 to 0.47; 14 trials, 13,543 women; low-certainty evidence) and iron deficiency at term (44.0% versus 66.0%; RR 0.51, 95% CI 0.38 to 0.68; 8 trials, 2873 women; low-certainty evidence), and probably reduces maternal iron-deficiency anaemia at term (5.0% versus 18.4%; RR 0.41, 95% CI 0.26 to 0.63; 7 trials, 2704 women; moderate-certainty evidence), compared to placebo or no iron supplementation. There is probably little to no difference in maternal death (2 versus 4 events, RR 0.57, 95% CI 0.12 to 2.69; 3 trials, 14,060 women; moderate-certainty evidence). The evidence is very uncertain for adverse effects (21.6% versus 18.0%; RR 1.29, 95% CI 0.83 to 2.02; 12 trials, 2423 women; very low-certainty evidence) and severe anaemia (Hb < 70 g/L) in the second/third trimester (< 1% versus 3.6%; RR 0.22, 95% CI 0.01 to 3.20; 8 trials, 1398 women; very low-certainty evidence). No trials reported clinical malaria or infection during pregnancy. Infant outcomes: Women taking iron supplements are probably less likely to have infants with low birthweight (5.2% versus 6.1%; RR 0.84, 95% CI 0.72 to 0.99; 12 trials, 18,290 infants; moderate-certainty evidence), compared to placebo or no iron supplementation. However, the evidence is very uncertain for infant birthweight (MD 24.9 g, 95% CI -125.81 to 175.60; 16 trials, 18,554 infants; very low-certainty evidence). There is probably little to no difference in preterm birth (7.6% versus 8.2%; RR 0.93, 95% CI 0.84 to 1.02; 11 trials, 18,827 infants; moderate-certainty evidence) and there may be little to no difference in neonatal death (1.4% versus 1.5%, RR 0.98, 95% CI 0.77 to 1.24; 4 trials, 17,243 infants; low-certainty evidence) or congenital anomalies, including neural tube defects (41 versus 48 events; RR 0.88, 95% CI 0.58 to 1.33; 4 trials, 14,377 infants; low-certainty evidence). Iron + folic supplementation compared to placebo or no iron + folic acid Maternal outcomes: Daily oral supplementation with iron + folic acid probably reduces maternal anaemia at term (12.1% versus 25.5%; RR 0.44, 95% CI 0.30 to 0.64; 4 trials, 1962 women; moderate-certainty evidence), and may reduce maternal iron deficiency at term (3.6% versus 15%; RR 0.24, 95% CI 0.06 to 0.99; 1 trial, 131 women; low-certainty evidence), compared to placebo or no iron + folic acid. The evidence is very uncertain about the effects of iron + folic acid on maternal iron-deficiency anaemia (10.8% versus 25%; RR 0.43, 95% CI 0.17 to 1.09; 1 trial, 131 women; very low-certainty evidence), or maternal deaths (no events; 1 trial; very low-certainty evidence). The evidence is uncertain for adverse effects (21.0% versus 0.0%; RR 44.32, 95% CI 2.77 to 709.09; 1 trial, 456 women; low-certainty evidence), and the evidence is very uncertain for severe anaemia in the second or third trimester (< 1% versus 5.6%; RR 0.12, 95% CI 0.02 to 0.63; 4 trials, 506 women; very low-certainty evidence), compared to placebo or no iron + folic acid. Infant outcomes: There may be little to no difference in infant low birthweight (33.4% versus 40.2%; RR 1.07, 95% CI 0.31 to 3.74; 2 trials, 1311 infants; low-certainty evidence), comparing iron + folic acid supplementation to placebo or no iron + folic acid. Infants born to women who received iron + folic acid during pregnancy probably had higher birthweight (MD 57.73 g, 95% CI 7.66 to 107.79; 2 trials, 1365 infants; moderate-certainty evidence), compared to placebo or no iron + folic acid. There may be little to no difference in other infant outcomes, including preterm birth (19.4% versus 19.2%; RR 1.55, 95% CI 0.40 to 6.00; 3 trials, 1497 infants; low-certainty evidence), neonatal death (3.4% versus 4.2%; RR 0.81, 95% CI 0.51 to 1.30; 1 trial, 1793 infants; low-certainty evidence), or congenital anomalies (1.7% versus 2.4; RR 0.70, 95% CI 0.35 to 1.40; 1 trial, 1652 infants; low-certainty evidence), comparing iron + folic acid supplementation to placebo or no iron + folic acid. A total of 19 trials were conducted in malaria-endemic countries, or in settings with some malaria risk. No studies reported maternal clinical malaria; one study reported data on placental malaria.

AUTHORS' CONCLUSIONS

Daily oral iron supplementation during pregnancy may reduce maternal anaemia and iron deficiency at term. For other maternal and infant outcomes, there was little to no difference between groups or the evidence was uncertain. Future research is needed to examine the effects of iron supplementation on other maternal and infant health outcomes, including infant iron status, growth, and development.

Pathophysiology and management of iron deficiency anaemia in pregnancy: a review

According to World Health Organization (WHO), iron deficiency anaemia (IDA) is considered the most prevalent nutritional deficiency worldwide, affecting approximately 30% of the global population. While gastrointestinal bleeding and menstruation in women are the primary causes of IDA, insufficient dietary iron intake and reduced iron absorption contribute to the condition. The aim of IDA treatment is to restore iron stores and normalise haemoglobin levels in affected patients. Iron plays a critical role in various cellular mechanisms, including oxygen delivery, electron transport, and enzymatic activity. During pregnancy, the mother's blood volume increases, and the growing foetus requires a significant increase in iron. Iron deficiency during pregnancy is associated with adverse outcomes such as maternal illness, low birth weight, preterm birth, and intrauterine growth restriction. Iron supplementation is commonly used to treat IDA; however, not all patients benefit from this therapy due to factors such as low compliance and ineffectiveness. In the past, IV iron therapy was underutilised due to its unfavourable and occasionally unsafe side effects. Nevertheless, the development of new type II and III iron complexes has improved compliance, tolerability, efficacy, and safety profiles. This article aims to provide an updated overview of the diagnosis and management of IDA during pregnancy. It will discuss the advantages and limitations of oral versus intravenous iron and the pathophysiology, diagnosis, treatment, and overall management of IDA in pregnancy.

Efficacy of daily versus intermittent oral iron supplementation for prevention of anaemia among pregnant women: a systematic review and meta-analysis

Background

The World Health Organization recommends daily oral supplementation of iron for prevention of maternal anaemia. However, the adverse effects due to daily supplementation leads to poor compliance among pregnant women. Also, the mucosal block theory suggests that intermittent oral iron may be more efficient than daily iron with respect to optimum absorption. Our meta-analysis reviewed the existing clinical studies for the efficacy of daily versus intermittent oral iron supplementation.

Methods

In this systematic review and meta-analysis [PROSPERO ID:CRD42024498180], we searched PubMed, Google Scholar, Scopus, Science Direct and Cochrane database for studies published from 1st January 1970 to 31st December, 2023. Studies comparing daily and intermittent iron supplementation in pregnant women were included. The median intermittent iron dose was 120 mg/day and daily iron dose was 60 mg/day. The primary outcome was endpoint haemoglobin levels after iron supplementation. The data was analysed using the 'meta' and 'metafor' packages in RStudio using random effects model. The heterogeneity, publication bias, risk of bias and certainty of evidence were assessed using I2 statistics, funnel plots, Cochrane Risk of Bias 2 (ROB2) tool, and the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) approach respectively.

Findings

Of 4615 search results, 26 studies (n = 4365 participants) were included in this meta-analysis. There was no significant difference (p = 0.18) between the endpoint mean haemoglobin levels of the daily versus intermittent oral iron groups (standardized mean difference (SMD): 0.51, 95% CI: -0.23 to 1.24, I2 = 97%, low certainty evidence) irrespective of baseline anaemic status. However, the endpoint ferritin levels were significantly higher in the daily supplementation group (SMD: 0.85, 95% CI: 0.15-1.54, p = 0.02, I2 = 97%, low certainty evidence). The adjusted odds ratio for nausea, (adjusted odds ratio (OR) 3.56, 95% CI: 2.23-5.69, p < 0.001, I2 = 9%, moderate certainty evidence), diarrhoea (adjusted OR 5.40, 95% CI: 1.90-15.33, p = 0.002, I2 = 0%, low certainty evidence) and constipation (adjusted OR 1.95, 95% CI: 1.21-3.14, p = 0.006, I2 = 0%, moderate certainty evidence) was significantly higher in daily oral iron supplementation group.

Interpretation

Intermittent oral iron supplementation with a median dose of 120 mg/day demonstrates comparable efficacy to daily oral iron supplementation median dose of 60 mg/day in increasing haemoglobin levels among pregnant women with a significant reduction in adverse events.

Funding

There was no funding for this study.

Gastric Ulcer From Prolonged Oral Iron Therapy: A Case Report and Literature Review

Iron deficiency is a leading cause of anemia worldwide and is commonly treated with oral iron supplements, which are known for their GI side effects. We present a case of a 66-year-old woman with a history of GI bleeding and multiple comorbidities who developed a gastric ulcer after prolonged oral iron therapy. Although GI side effects are frequent with iron supplements, ulceration is rare, with only a few documented cases. Endoscopic and histopathological evaluations identified iron deposition in the ulcer bed, confirming the diagnosis. Discontinuing the oral iron led to the resolution of symptoms. This case underscores the importance of recognizing and managing iron-induced gastric ulcers to ensure safe and effective treatment of iron deficiency.

A Systematic Review of Methods and Practice for Integrating Maternal, Fetal, and Child Health Outcomes, and Family Spillover Effects into Cost-Utility Analyses

BACKGROUND

Maternal-perinatal interventions delivered during pregnancy or childbirth have unique characteristics that impact the health-related quality of life (HRQoL) of the mother, fetus, and newborn child. However, maternal-perinatal cost-utility analyses (CUAs) often only consider either maternal or child health outcomes. Challenges include, but are not limited to, measuring fetal, newborn, and infant health outcomes, and assessing their impact on maternal HRQoL. It is also important to recognize the impact of maternal-perinatal health on family members' HRQoL (i.e., family spillover effects) and to incorporate these effects in maternal-perinatal CUAs.

OBJECTIVE

The aim was to systematically review the methods used to include health outcomes of pregnant women, fetuses, and children and to incorporate family spillover effects in maternal-perinatal CUAs.

METHODS

A literature search was conducted in Medline, Embase, EconLit, Cochrane Collection, Cumulative Index to Nursing and Allied Health Literature (CINAHL), International Network of Agencies for Health Technology Assessment (INAHTA), and the Pediatric Economic Database Evaluation (PEDE) databases from inception to 2020 to identify maternal-perinatal CUAs that included health outcomes for pregnant women, fetuses, and/or children. The search was updated to December 2022 using PEDE. Data describing how the health outcomes of mothers, fetuses, and children were measured, incorporated, and reported along with the data on family spillover effects were extracted.

RESULTS

Out of 174 maternal-perinatal CUAs identified, 62 considered the health outcomes of pregnant women, and children. Among the 54 quality-adjusted life year (QALY)-based CUAs, 12 included fetal health outcomes, the impact of fetal loss on mothers' HRQoL, and the impact of neonatal demise on mothers' HRQoL. Four studies considered fetal health outcomes and the effects of fetal loss on mothers' HRQoL. One study included fetal health outcomes and the impact of neonatal demise on maternal HRQoL. Furthermore, six studies considered the impact of neonatal demise on maternal HRQoL, while four included fetal health outcomes. One study included the impact of fetal loss on maternal HRQoL. The remaining 26 only included the health outcomes of pregnant women and children. Among the eight disability-adjusted life year (DALY)-based CUAs, two measured fetal health outcomes. Out of 174 studies, only one study included family spillover effects. The most common measurement approach was to measure the health outcomes of pregnant women and children separately. Various approaches were used to assess fetal losses in terms of QALYs or DALYs and their impact on HRQoL of mothers. The most common integration approach was to sum the QALYs or DALYs for pregnant women and children. Most studies reported combined QALYs and incremental QALYs, or DALYs and incremental DALYs, at the family level for pregnant women and children.

CONCLUSIONS

Approximately one-third of maternal-perinatal CUAs included the health outcomes of pregnant women, fetuses, and/or children. Future CUAs of maternal-perinatal interventions, conducted from a societal perspective, should aim to incorporate health outcomes for mothers, fetuses, and children when appropriate. The various approaches used within these CUAs highlight the need for standardized measurement and integration methods, potentially leading to rigorous and standardized inclusion practices, providing higher-quality evidence to better inform decision-makers about the costs and benefits of maternal-perinatal interventions. Health Technology Assessment agencies may consider providing guidance for interventions affecting future lives in future updates.

Current understanding of essential trace elements in intrahepatic cholestasis of pregnancy

Trace elements are important components in the body and have fundamental roles in maintaining a healthy and balanced pregnancy process. Either deficiency or excess of trace elements, including selenium, iron, zinc, copper, and magnesium can lead to pregnancy complications. As a rare disorder during pregnancy of unknown aetiology, intrahepatic cholestasis of pregnancy (ICP) poses a significant risk to the fetus of perinatal mortality. ICP is a multifactorial complication of which the pathogenesis is still an enigma. Epidemiological studies have demonstrated the association of ICP with some trace elements. Evidence from retrospective studies in humans further revealed the possible contributing roles of trace elements in the pathogenesis of ICP. The published literature on the association of trace elements with ICP was reviewed. Recent advances in molecular biological techniques from animal studies have helped to elucidate the possible mechanisms by how these trace elements function in regulating oxidative reactions, inflammatory reactions and immune balance in the maternal-fetal interface, as well as the influence on hepato-intestinal circulation of bile acid. The scenario regarding the role of trace elements in the pathogenesis of ICP is still developing. The administration or depletion of these trace elements may have promising effects in alleviating the symptoms and improving the pregnancy outcomes of ICP.

Determinants of Hemoglobin Among Pregnant Women at Agro-Pastoralist Communities in South Omo Zone, Ethiopia: Community Based Cross-Sectional Study, Nutrition Experience from Movable Community

Background

Low hemoglobin level is the most common public health problem during pregnancy in developing countries including Ethiopia, which is affecting both mother and fetus. However, the determinants of anemia among pregnant women are not well studied.

Objective

To assess the determinates of hemoglobin among pregnant women in rural agro-pastoralist communities in the South Omo zone, Ethiopia.

Method

Community-based cross-sectional study was done in rural agro-pastoralist communities. A multistage stratified sampling technique was used to select 526 pregnant women. Data were collected by using structured questionnaires. Hemoglobin level was measured by using HemoCue ® Hb301. Data were analyzed by using a statistical package for the social science version 26. Descriptive (Mean, standard deviation, frequency, range), bivariate and multivariate analysis was carried out to check the association between lower hemoglobin levels and independent variables. The output is presented in tables and figures.

Result

The mean (±SD) of hemoglobin concentration was 11.8 ± 1.7. The overall prevalence of anemia was 39.9% [95% CI: 35.5, 44.4], 19.4% (95% CI: 16.0, 23.2) was mild, 19.6% (95% CI: 16.27, 2.5) was moderate and 0.9% (95% CI: 0.25, 2.25) was severe anemia. Not taking IFA (AOR = 5.7(3.3, 9.8)), severe under nutrition (AOR = 8.9(2.1, 37.3)), no fish food (AOR = 2.4(1.3, 4.5)), drinking coffee (AOR = 1.6(1.0, 2.6)), moderate food insecurity (AOR = 2.5(1.4, 4.6)), and no malaria infection (AOR = 0.6(0.4, 0.9)) were statistically significant with anemia.

Conclusion

The anaemia is a public health problem in this study area. Therefore, nutrition education and counselling to enhance iron supplementation, dietary diversity and a flesh diets are very essential to enhance haemoglobin levels.

Inverse association between maternal serum concentrations of trace elements and risk of spontaneous preterm birth: a nested case-control study in China

Few studies have evaluated the joint effect of trace elements on spontaneous preterm birth (SPTB). This study aimed to examine the relationships between the individual or mixed maternal serum concentrations of Fe, Cu, Zn, Se, Sr and Mo during pregnancy, and risk of SPTB. Inductively coupled plasma MS was employed to determine maternal serum concentrations of the six trace elements in 192 cases with SPTB and 282 controls with full-term delivery. Multivariate logistic regression, weighted quantile sum regression (WQSR) and Bayesian kernel machine regression (BKMR) were used to evaluate the individual and joint effects of trace elements on SPTB. The median concentrations of Sr and Mo were significantly higher in controls than in SPTB group (P < 0·05). In multivariate logistic regression analysis, compared with the lowest quartile levels of individual trace elements, the third- and fourth-quartile Sr or Mo concentrations were significantly associated with reduced risk of SPTB with adjusted OR (aOR) of 0·432 (95 CI < 0·05). In multivariate logistic regression analysis, compared with the lowest quartile levels of individual trace elements, the third- and fourth-quartile Sr or Mo concentrations were significantly associated with reduced risk of SPTB with adjusted aOR of 0·432 (95 % CI 0·247, 0·756), 0·386 (95 % CI 0·213, 0·701), 0·512 (95 % CI 0·297, 0·883) and 0·559 (95 % CI 0·321, 0·972), respectively. WQSR revealed the inverse combined effect of the trace elements mixture on SPTB (aOR = 0·368, 95 % CI 0·228, 0·593). BKMR analysis confirmed the overall mixture of the trace elements was inversely associated with the risk of SPTB, and the independent effect of Sr and Mo was significant. Our findings suggest that the risk of SPTB decreased with concentrations of the six trace elements, with Sr and Mo being the major contributors.

Effect of low-molecular-weight heparin on placenta-mediated fetal growth restriction in a tertiary referral hospital: A 7-year retrospective cohort study

OBJECTIVE

To investigate the effect of low-molecular-weight heparin (LMWH) on placenta-mediated fetal growth restriction (FGR).

METHODS

A cohort of 570 pregnant women diagnosed with placenta-mediated FGR were enrolled from January 1, 2015 through to December 31, 2021. A birth database, including demographic data, antenatal complications, and detailed delivery and newborn data, was created to collect variables from the Hospital Information System (HIS) Database. The unique personal registration number, assigned to each patient on first registration with HIS in the West China Second University Hospital, was used to link these patients. LMWH use was defined as at least 1-week prescription from diagnosis of placenta-mediated FGR. Pregnant women received LMWH (Enoxaparin 4000 IU/day) by self-administered subcutaneous injection only when they agreed and signed informed consent. Primary outcome was intrauterine fetal death after 20 weeks of pregnancy. Secondary outcomes included preterm birth (PB), Apgar score less than 7 at 1 min, admission to neonatal intensive care unit (NICU), and birth weight. Logistic regression analysis was conducted to compute adjusted odds ratio (aOR) with 95% confidence intervals (CI) for outcomes.

RESULTS

After controlling for confounders, LMWH use was associated with a decreased risk of intrauterine fetal death (aOR 2.49, 95% CI 1.35-4.57, P = 0.003), PB before 37 weeks of pregnancy (aOR 3.35, 95% CI 2.14-5.23, P < 0.001), PB before 34 weeks of pregnancy (aOR 2.25, 95% CI 1.36-3.74, P = 0.002), Apgar score less than 7 at 1 min (aOR 2.25, 95% CI 1.36-3.74, P = 0.002), NICU admission (aOR 2.29, 95% CI 1.48-3.55, P < 0.001). Using LMWH increased the mean birth weight in PB before 32 weeks of pregnancy (mean ± standard deviation [SD] 1126.4 ± 520.0 g, P = 0.020), PB before 37 weeks of pregnancy (mean ± SD 1563.9 ± 502.7 g, P = 0.019), early-onset FGR (mean ± SD 2125.2 ± 665.7 g, P < 0.001), late-onset FGR (mean ± SD 2343.4 ± 507.9, P < 0.001), and non-severe FGR (mean ± SD 2231.1 ± 607.2 g, P < 0.001).

CONCLUSION

Use of LMWH can significantly improve the fetal and neonatal outcomes among pregnant women with placenta-mediated FGR, particularly reducing the risk of intrauterine fetal death.

Prevalence and predictors of anemia among six-week-old infants in Kwale County, Kenya: A cross-sectional study

Anemia is a significant public health problem among children worldwide. The etiology of anemia is multifactorial but iron deficiency (ID) is the most common cause of anemia in low- and middle-income countries. ID and anemia in infancy can impair growth and cognitive development. The aim of this study was to determine the prevalence and predictors of anemia among six-week-old infants in Kwale County, Kenya. This cross-sectional study included 424 mother-infant pairs. Structured questionnaires were administered to the mothers to obtain information on socio-demographic variables, maternal characteristics and birth information. Anthropometric data was collected for each child. A heel prick was done to measure hemoglobin and zinc protoporphyrin concentration levels. Chi-square test, bivariate and multivariate regression analyses were done to determine factors associated with anemia. The prevalence of ID, anemia and IDA was 60.4% (95%CI: 55.9-65.2), 21.0% (95%CI: 17.5-25.2) and 15.8% (95%CI: 12.7-19.7) respectively. Bivariate analysis showed that the risk of anemia was significantly higher among male infants (odds ratio (OR) = 2.20 (95%CI: 1.33-3.63), p = 0.002), iron deficient infants (OR = 2.35 (95%CI: 1.39-3.99), p = 0.001) and infants from Msambweni Sub-County (OR = 2.80 (95%CI: 1.40-4.62), p<0.001). Multivariate analysis revealed that odds of anemia were significantly higher in infants born to mothers who did not use iron supplements during pregnancy (adjusted odds ratio (aOR) = 74.01 (95%CI: 2.45-2238.21), p = 0.013 and significantly lower in infants born to mothers with parity ≥ 4 (aOR = 0.05 ((95%CI: 0.00-0.77), p = 0.024). In six-week-old infants in rural Kenya, anemia prevalence was 21.0% with ID accounting for 75.3% of anemia cases. Given the physical and cognitive impairments associated with ID and anemia in early infancy, it may be prudent to re-evaluate the current Kenyan pediatric protocols to include anemia screening and potential treatment of infants less than 6-months of age.

Synergistic associations of antenatal care visits and iron-folic acid supplementation with low birth weight: a pooled analysis of national surveys from six south Asian countries

BACKGROUND

The prevalence of low birth weight (LBW) has remained high (24.9%) in the South Asian region with a significant impact on newborn survival. This region bears nearly 40% of global burden of LBW. While antenatal care (ANC) and iron-folic acid supplementation independently have been considered effective for improving maternal and newborn outcomes, the evidence on the combined effect of these two supplements on LBW is lacking. This study aimed to examine the synergistic association of ANC and iron-folic acid supplementation on LBW in the South Asian region using pooled data from six South Asian countries.

METHODS

Nationally representative surveys from Nepal, India, Bangladesh, Pakistan, Maldives, and Afghanistan were included in the study. Birth weight and the prevalence of LBW for singleton last-born children were reported using descriptive statistics. The association between LBW and ANC visits and the interaction between iron-folic acid consumption and ANC were examined using multiple logistic regression.

RESULTS

The mean birth weight in the region was 2841.8 g with an LBW prevalence of 17.1%. Country-specific prevalence ranged from 11.4% in Nepal to 22.4% in Pakistan. Not attending ANC visits (adjusted odds ratio (AOR): 1.24; 95% confidence interval (CI): 1.16, 1.34) and not consuming iron-folic acid (AOR: 1.14; 95% CI: 1.08, 1.21) were significantly associated with a higher likelihood of LBW. Furthermore, jointly, having < 4 ANC visits and < 180 days of iron-folic acid supplementation was associated with a higher likelihood (AOR: 1.29; 95% CI: 1.22, 1.36) of having LBW compared to those who had  ≥ 4 ANC visits and ≥ 180 days of iron-folic acid consumption after controlling for key confounding factors.

CONCLUSIONS

The current study provides important evidence on the synergy between ANC visits and iron-folic acid consumption during pregnancy to capitalize on the existing national maternal health programs in the South Asian region, including low-and middle-income countries for positive foetal outcomes.

Iron - a background article for the Nordic Nutrition Recommendations 2023

Iron absorption from foods is generally lower than that of most other nutrients and is highly variable depending on individual iron status and iron bioavailability in the meal. Several large population groups in the Nordic and Baltic countries are at risk of iron deficiency, including infants, young children, menstruating females, pregnant women as well as vegetarians. Iron deficiency leads to anemia, fatigue, and limited capacity for physical activity. Of particular concern is that iron deficiency anemia in young children is associated with impaired neurodevelopment. A comprehensive literature search has been performed and summarized. New factorial calculations have been performed considering iron losses, iron absorption and iron requirements in various population groups. Recent data on iron intakes and the prevalence of iron deficiency in the Nordic countries are presented. Average requirements and tentative recommended intakes are presented for 12 different population groups. Pregnant women and those with high menstrual blood losses should consume iron-rich food and undergo screening for iron deficiency. Infants should consume iron-rich complementary foods and cow's milk should be avoided as a drink before 12 months of age and limited to < 500 mL/day in toddlers. Vegetarians should consume a diet including wholegrains, legumes, seeds, and green vegetables together with iron absorption enhancers. There is no evidence that iron intake per se increases the risk of cancer or diabetes. Iron absorption from foods is generally lower than that of most other nutrients and can vary between <2 and 50% depending on individual iron status and iron bioavailability in the meal.

Iron deficiency in healthy, term infants aged five months, in a pediatric outpatient clinic: a prospective study

BACKGROUND

Iron deficiency (ID) is prevalent in Malaysian children. The incidence of ID in infants under 6 months of age is unknown. Our aim was to determine the prevalence of iron deficiency (ID) and iron deficiency anemia (IDA) in healthy, term infants aged below 6 months in our hospital population.

METHODS

A prospective longitudinal pilot study of mother-infant pairs was conducted on infants receiving routine immunizations in a mother and child clinic at a university hospital, in Kuala Lumpur, Malaysia. Mothers completed standardized questionnaires at 3- and 5-month postnatal visits. Maternal and infant full blood count, ferritin, and C-reactive protein (CRP) levels were measured at 3 months and for the infants repeated at 5 months. Infant anthropometric measurements were obtained at both visits. We conducted a univariate analysis to identify factors associated with ID and IDA.

RESULTS

Altogether, 91 mother-infant pairs were enrolled, with 88 completing the study. No infant had ID or IDA at 3 months; the lowest ferritin level was 16.6 µg/L. At 5 months, 5.9% (5/85) of infants had ID, and 2.4% (2/85) had IDA. Median (interquartile range) infant ferritin levels significantly declined from 113.4 (65.0-183.6) µg/L at 3 months to 50.9 (29.2-70.4) µg/L at 5 months, p < 0.001. Exclusive breastfeeding until 3 or 5 months was significantly associated with ID at 5 months (p = 0.020, and p = 0.008, respectively) on univariate analysis. The drop in ferritin between 3-5 months was significantly associated with weight and length gains between 0-3 months (p = 0.018, p = 0.009, respectively). Altogether, 14.3% of infants exclusively breastfed until 5 months developed ID. At 5 months, 3.4% of infants were underweight, 1.1% stunted, and 10.2% wasted.

CONCLUSIONS

In exclusively breastfed term infants, ID occurred by 5 months. Early introduction of iron-rich foods should be considered in exclusively breastfed babies. A high prevalence of wasting suggests a calorie deficit in this population and will lead to stunting if not addressed.

Vitamin B12 supplementation during pregnancy for maternal and child health outcomes

BACKGROUND

Vitamin B12 deficiency is a major public health problem worldwide, with the highest burden in elderly people, pregnant women, and young children. Due to its role in DNA synthesis and methylation, folate metabolism, and erythropoiesis, vitamin B12 supplementation during pregnancy may confer longer-term benefits to maternal and child health outcomes.

OBJECTIVES

To evaluate the benefits and harms of oral vitamin B12 supplementation during pregnancy on maternal and child health outcomes.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry Platform (ICTRP) on 2 June 2023, and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs), quasi-RCTs, or cluster-RCTs evaluating the effects of oral vitamin B12 supplementation compared to placebo or no vitamin B12 supplementation during pregnancy.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Four review authors independently assessed trial eligibility. Two review authors independently extracted data from included studies and conducted checks for accuracy. Three review authors independently assessed the risk of bias of the included studies using the Cochrane RoB 1 tool. We used GRADE to evaluate the certainty of evidence for primary outcomes.

MAIN RESULTS

The review included five trials with 984 pregnant women. All trials were conducted in low- and middle-income countries, including India, Bangladesh, South Africa, and Croatia. At enrolment, 26% to 51% of pregnant women had vitamin B12 deficiency (less than 150 pmol/L), and the prevalence of anaemia (haemoglobin less than 11.0 g/dL) ranged from 30% to 46%. The dosage of vitamin B12 supplementation varied from 5 μg/day to 250 μg/day, with administration beginning at 8 to 28 weeks' gestation through to delivery or three months' postpartum, and the duration of supplementation ranged from 8 to 16 weeks to 32 to 38 weeks. Three trials, involving 609 pregnant women, contributed data for meta-analyses of the effects of vitamin B12 supplementation compared to placebo or no vitamin B12 supplementation. Maternal anaemia: there may be little to no difference for maternal anaemia by intervention group, but the evidence is very uncertain (70.9% versus 65.0%; risk ratio (RR) 1.08, 95% confidence interval (CI) 0.93 to 1.26; 2 trials, 284 women; very low-certainty evidence). Maternal vitamin B12 status: vitamin B12 supplementation during pregnancy may reduce the risk of maternal vitamin B12 deficiency compared to placebo or no vitamin B12 supplementation, but the evidence is very uncertain (25.9% versus 67.9%; RR 0.38, 95% CI 0.28 to 0.51; 2 trials, 272 women; very low-certainty evidence). Women who received vitamin B12 supplements during pregnancy may have higher total vitamin B12 concentrations compared to placebo or no vitamin B12 supplementation (mean difference (MD) 60.89 pmol/L, 95% CI 40.86 to 80.92; 3 trials, 412 women). However, there was substantial heterogeneity (I2 = 85%). Adverse pregnancy outcomes: the evidence is uncertain about the effect on adverse pregnancy outcomes, including preterm birth (RR 0.97, 95% CI 0.55 to 1.74; 2 trials, 340 women; low-certainty evidence), and low birthweight (RR 1.50, 95% CI 0.93 to 2.43; 2 trials, 344 women; low-certainty evidence). Two trials reported data on spontaneous abortion (or miscarriage); however, the trials did not report quantitative data for meta-analysis and there was no clear definition of spontaneous abortion in the study reports. No trials evaluated the effects of vitamin B12 supplementation during pregnancy on neural tube defects. Infant vitamin B12 status: children born to women who received vitamin B12 supplementation had higher total vitamin B12 concentrations compared to placebo or no vitamin B12 supplementation (MD 71.89 pmol/L, 95% CI 20.23 to 123.54; 2 trials, 144 children). Child cognitive outcomes: three ancillary analyses of one trial reported child cognitive outcomes; however, data were not reported in a format that could be included in quantitative meta-analyses. In one study, maternal vitamin B12 supplementation did not improve neurodevelopment status (e.g. cognitive, language (receptive and expressive), motor (fine and gross), social-emotional, or adaptive (conceptual, social, practical) domains) in children compared to placebo (9 months, Bayley Scales of Infant and Toddler Development Third Edition (BSID-III); 1 trial; low-certainty evidence) or neurophysiological outcomes (72 months, event-related potential measures; 1 trial; low-certainty evidence), though children born to women who received vitamin B12 supplementation had improved expressive language domain compared to placebo (30 months, BSID-III; 1 trial; low-certainty evidence).

AUTHORS' CONCLUSIONS

Oral vitamin B12 supplementation during pregnancy may reduce the risk of maternal vitamin B12 deficiency and may improve maternal vitamin B12 concentrations during pregnancy or postpartum compared to placebo or no vitamin B12 supplementation, but the evidence is very uncertain. The effects of vitamin B12 supplementation on other primary outcomes assessed in this review were not reported, or were not reported in a format for inclusion in quantitative analyses. Vitamin B12 supplementation during pregnancy may improve maternal and infant vitamin B12 status, but the potential impact on longer-term clinical and functional maternal and child health outcomes has not yet been established.

Sensory evaluations of a novel iron and zinc-enriched powder for the potential treatment and prevention of iron deficiency in women of reproductive age

Iron deficiency (ID) and ID with anaemia (IDA) are serious global health problems that disproportionately affect women aged 15-49 years. Although food fortification is one of the most effective and sustainable ways to combat nutritional deficiencies, iron remains one of the most difficult micronutrients to fortify, given its tendency to react strongly with food constituents. Therefore, it is important to assess the sensory properties of foods fortified with iron to determine the acceptability and palatability in target populations. We aimed to determine the palatability and acceptability of a novel iron and zinc-enriched powder fortified in tap water by conducting sensory evaluations in 35 women of reproductive age using a 9-point hedonic scale, where participants rated the sensory properties of six samples containing different amounts of the active or placebo powder. We found significant differences between samples reconstituted at 1, 2, and 3 g/L for sensory properties, including overall taste. Participants were found to be more willing to drink the mineral-enriched powder when prepared at the lowest concentration (1 g/L) compared to higher concentrations. Our results provide important insight into the sensory qualities of a novel formulation of an iron and zinc-enriched powder for at-home fortification and indicate consumer acceptability in reproductive-aged women, a key group at risk for ID/IDA. If found to improve iron status, novel treatments like this product will contribute to global efforts to develop safe, acceptable and sustainable interventions for ID and IDA.

Prenatal iron supplementation adjusted to maternal iron stores reduces behavioural problems in 4-year-old children

Prenatal iron supplementation improves children's health and cognitive performance, but few studies explore behavioural development. This study assessed the effects of adjusting prenatal iron supplementation to maternal iron stores during early pregnancy on children's behavioural problems. Randomized controlled trial conducted in Tarragona (Spain) involving 230 nonanaemic pregnant women and their children after a 4-year follow-up. Based on haemoglobin (Hb) levels before gestational week (GW) 12, women receive different iron doses: those with Hb = 110-130 g/L were randomized to receive 80 or 40 mg/day and those with Hb > 130 g/L were randomized to receive 20 or 40 mg/day. Maternal iron stores at GW12 were classified using serum ferritin (SF) as low (SF < 15 µg/L), normal (SF = 15-65 µg/L), and normal-high (SF > 65 µg/L). Children's behaviour was assessed by parents using the Child Behaviour Checklist for ages 1.5-5 years and the Behaviour Rating Inventory of Executive Function-Preschool Version, and by teachers using the Teacher's Report Form for ages 1.5-5 years. Multivariable regression models were performed. Taking 80 mg/day of iron improved child behaviour when women had low iron stores but worsened it when mothers had normal-high iron stores, except for depressive and attention/hyperactivity problems. Taking 20 mg/day of iron improved behaviour only in those children whose mothers had SF > 65 µg/L in early pregnancy. Additionally, executive functioning improved at high doses of prenatal iron when maternal baseline SF < 15 µg/L. Adjusting prenatal iron supplementation to both maternal baseline Hb levels and iron stores reduces behavioural problems in 4-year-old children.

A blueprint for fortification planning and programming: Lessons learned from an analytical review of existing fortification frameworks

With multiple food fortification frameworks, countries can find it challenging to determine optimal methods for planning and implementing food fortification programmes to combat vitamin and mineral deficiencies, especially without additional technical support. To address this challenge, this study aimed to review existing frameworks to determine consistencies, differences, strengths, and weaknesses across the frameworks, and based on the review findings, formulate an enhanced and streamlined fortification framework. Nineteen frameworks were ultimately examined following a comprehensive literature review and key informant interviews. Generally, the reviewed frameworks amply describe motives and methods for the determination of fortification need and feasibility, industry engagement/quality assurance and quality control, and impact evaluations/surveillance. However, there was limited inclusion or discussion throughout the reviewed frameworks around harmonization of fortification with existing micronutrient interventions; fortification policy and/or strategy; enforcement, incentives, and penalties to ensure producer compliance with industry standards; and periodic fortification programme review and reassessment. The findings were used to develop a comprehensive Fortification Blueprint that aims to provide structured guidance and a library of tools and resources to fortification programme managers and key stakeholders to ensure optimal and sustainable programme design.

Protocol and statistical analysis plan for a randomized controlled trial of the effect of intravenous iron on anemia in Malawian pregnant women in their third trimester (REVAMP - TT)

Background

Anemia affects 40% of pregnant women globally, leading to maternal mortality, premature birth, low birth weight, and poor baby development. Iron deficiency causes over 40% of anemia cases in Africa. Oral iron supplementation is insufficient for Low-and-Middle-Income-Countries (LMICs) to meet current WHO targets. We hypothesized that a single intravenous dose of Ferric Carboxymaltose (FCM) may be more effective than oral iron treatment for anemia recovery, particularly in these settings where women present late for antenatal care.

Methods

This is a two-arm parallel open-label individual-randomized controlled trial in third trimester, in malaria Rapid Diagnostic Test-negative pregnant women with moderate or severe anemia - capillary hemoglobin <10 g/dL - who are randomized to receive either parenteral iron - with FCM - or standard-of-care oral iron for the remainder of pregnancy. This is the sister trial to the second-trimester REVAMP trial, funded by the Bill and Melinda Gates Foundation (trial registration ACTRN12618001268235, Gates Grant number INV-010612). In REVAMP-TT, recruitment and treatment are performed within primary health centers. The trial will recruit 590 women across Zomba district, Malawi. The primary outcome is the proportion of anemic women - venous hemoglobin <11 g/dL - at 36 weeks' gestation or delivery (whichever occurs first). Other pre-specified key secondary clinical and safety outcomes include maternal iron-status and hypophosphatemia, neonate birth weight, infant growth and infant iron and hematological parameters.

Discussion

This study will determine whether FCM, delivered within primary health centers, is effective, safe and feasible for treating moderate to severe anemia in third-trimester pregnant Malawian women. This intervention could have long-term benefits for maternal and child health, resulting in improved survival and child development.

Effectiveness of nutrition counseling for pregnant women in low- and middle-income countries to improve maternal and infant behavioral, nutritional, and health outcomes: A systematic review

Background

Nutritional counseling, which includes two-way interactive education, has been hypothesized to improve the health and nutritional status of pregnant women, but little is known about the impact such practice of care might have on maternal and infant health and behavioral outcomes of pregnant women living in low income, low-middle income, and upper-middle-income countries (LMIC)s.

Objectives

We conducted a systematic review to appraise the effectiveness and impact on health equity of two-way nutritional counseling practices in LMICs on maternal and infant behavioral, nutritional, and health outcomes.

Search Methods

We conducted electronic searches for relevant studies on Medline, Embase, CINAHL, PsychInfo, and the Cochrane CENTRAL for randomized and non-randomized trials on the effectiveness of two-way interactive nutritional counseling among pregnant women from the date of database inception up to June 22, 2021. In addition, we searched references of included studies in systematic reviews, gray literature resources, and unpublished studies or reports that satisfied our eligibility criteria using a focused Google search.

Selection Criteria

We included randomized and non-randomized controlled studies (NRS), controlled before and after, and interrupted time series that assessed the effectiveness of two-way interactive nutrition counseling targeting pregnant women in LMICs.

Data Collection and Analysis

Data extraction and risk of bias were conducted in duplicate. The risk of bias (ROB) for randomized trials (RCT) was assessed according to the Cochrane Handbook of Systematic Reviews, and ROB for NRS was assessed using the Newcastle-Ottawa scale (NOS). RCT and NRS were meta-analyzed separately.

Main Results

Our search identified 6418 records and 52 studies met our inclusion criteria, but only 28 were used in the quantitative analysis. Twenty-eight studies were conducted in Asia, the most in Iran. Eight studies were conducted in Africa. Two-way interactive nutritional counseling during pregnancy may improve dietary caloric intake (mean difference [MD]: 81.65 calories, 95% confidence interval [CI], 15.37-147.93, three RCTs; I 2 = 42%; moderate certainty of evidence using GRADE assessment), may reduce hemorrhage (relative risk [RR]: 0.63; 95% CI, 0.25-1.54, two RCTs; I 2 = 40%; very low certainty of evidence using GRADE assessment), may improve protein (MD: 10.44 g, 95% CI, 1.83-19.05, two RCTs; I 2 = 95%; high certainty of evidence using GRADE assessment), fat intake (MD: 3.42 g, 95% CI, -0.20 to 7.04, two RCTs; I 2 = 0%; high certainty of evidence using GRADE assessment), and may improve gestational weight gain within recommendations (RR: 1.84; 95% CI, 1.10-3.09, three RCTs; I 2 = 69%). Nutrition counseling probably leads to the initiation of breastfeeding immediately after birth (RR: 1.72; 95% CI, 1.42-2.09, one RCT). There was little to no effect on reducing anemia (RR: 0.77; 95% CI, 0.50-1.20, three RCTs; I 2 = 67%; very low certainty of evidence using GRADE assessment) risk of stillbirths (RR: 0.81; 95% CI, 0.52-1.27, three RCTs; I 2 = 0%; moderate certainty of evidence using GRADE assessment) and risk of cesarean section delivery (RR: 0.96; 95% CI, 0.76-1.20, four RCTs; I 2 = 36%; moderate certainty of evidence using GRADE assessment).

Authors’ Conclusions

Our review highlights improvements in maternal behavioral and health outcomes through interactive nutrition counseling during pregnancy. However, we are uncertain about the effects of nutrition counseling due to the low certainty of evidence and a low number of studies for some key outcomes. Moreover, the effects on health equity remain unknown. More methodologically rigorous trials that focus on a precise selection of outcomes driven by the theory of change of nutrition counseling to improve maternal and infant behavioral and health outcomes and consider equity are required.

Maternal gestational iron status and infant haematological and neurodevelopmental outcomes

Prevention of iron deficiency (ID), the most common micronutrient deficiency in infants and children, begins prenatally by ensuring adequate fetal loading. Adequate intrauterine iron status is crucial for normal fetal brain development, postnatal brain performance and prevention of early postnatal iron deficiency, particularly in infants fed exclusively human milk. Adequate fetal loading may be achieved in some cases through adequate maternal iron levels prior to pregnancy and oral iron supplementation during pregnancy. However, because so many women are iron-deficient leading up to pregnancy, coupled with the negative iron balance induced by pregnancy, a large number of women remain iron-deficient during pregnancy. More consistent iron-specific early screening and more effective iron delivery approaches are needed to solve this global problem.

Review of intervention products for use in the prevention and control of anemia

Anemia remains a major public health problem, especially in low- and middle-income countries. The World Health Organization recommends several interventions to prevent and manage anemia in vulnerable population groups, including young children, menstruating adolescent girls and women, and pregnant and postpartum women. Daily iron supplementation reduces the risk of anemia in infants, children, and pregnant women, and intermittent iron supplementation reduces anemia risk in menstruating girls and women. Micronutrient powders reduce the risk of anemia in children. Fortifying wheat flour with iron reduces the risk of anemia in the overall population, whereas the effect of fortifying maize flour and rice is still uncertain. Regarding non-nutrition-related interventions, malaria treatment and deworming have been reported to decrease anemia prevalence. Promising interventions to prevent anemia include vitamin A supplementation, multiple micronutrient supplementation for pregnant women, small-quantity lipid-based supplements, and fortification of salt with iodine and iron. Future research could address the efficacy and safety of different iron supplementation formulations, identify the most bioavailable form of iron for fortification, examine adherence to supplementation regimens and fortification standards, and investigate the effectiveness of integrating micronutrient, helminth, and malaria control programs.

Effect of community based nutritional education on knowledge, attitude and compliance to IFA supplementation among pregnant women in rural areas of southwest Ethiopia: a quasi experimental study

BACKGROUND

Compliance with the iron folic acid supplementation is low and not at the required level to prevent anaemia during pregnancy in many countries, including Ethiopia, even though an iron-folic acid supplementation program is being implemented. The aims of this study were to determine the effect of community-based nutritional education on knowledge, attitude, and compliance to IFA supplementation in Ilu Aba Bor zone of southwest Ethiopia.

METHOD

A pretest-posttest quasi-experimental study design consisting of intervention and control group was conducted among pregnant women. The total sample size of 472, therefore, 236 pregnant women for each interventional and control group from 16 kebeles were randomly selected in two districts. A multi-stage sampling technique was used to select the study participants. Then, individual study units were selected using a simple random sampling technique and followed until the end of the study period. Effect of community-based nutritional education on knowledge, attitude, and compliance to IFA supplementation among pregnant women in rural areas were measured.

RESULTS

A total of 472 pregnant women participated in the study during the baseline and 437 (92.6%) were in the study until the end. The majority (49.2%) of respondents were 21-25 years of age, with a mean age of 23.4 (SD = 3.7) years. Community-based nutrition has resulted in a statistically significant increase in levels of maternal knowledge of IFAS by 15.2% in the intervention group compared to 5.1% in the control group. Similarly, the intervention group had odds of developing a positive attitude toward IFA 5.6 (4.01, 7.85) times higher than the control group. Moreover, in this study, the odds of compliance towards IFA supplementation were 3.9 (2.67, 5.57) times higher among those who received nutrition education than those women who did not.

CONCLUSION

This study revealed that community-based nutritional education can result in a significant change in knowledge, attitude, and compliance towards IFA supplementation and supports the literature suggesting the importance of the intervention to overcome the problem of poor compliance and its associated consequences.

Iron supplements in pregnant women with normal iron status: A systematic review and meta-analysis

INTRODUCTION

Effects of daily iron supplementation in iron replete pregnancy are unclear. This systematic review aimed to assess benefits and harms of oral iron supplements in pregnant women without anemia and iron deficiency.

MATERIAL AND METHODS

We predefined and registered a protocol in PROSPERO (CRD42020186210) and performed the review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology. We searched for randomized clinical trials (RCTs) and observational studies comparing daily oral iron supplementation with no iron supplements in non-anemic iron replete pregnant women. Searches were conducted in MEDLINE (by PubMed), EMBASE (by OVID), Cochrane Library, and ClinicalTrials.gov from inception to September 2022 without language restrictions. Two authors independently screened records, extracted data, and assessed risk of bias using the revised Cochrane risk of bias tool (RoB2). One author read full-texts, assessed certainty of evidence by GRADE and conducted meta-analyses using a random-effects model. Primary outcomes included iron deficiency anemia, iron deficiency, hemoglobin >130 g/L, elevated iron status, small for gestational age newborns, low birthweight newborns, preterm birth, and congenital anomalies.

RESULTS

Eight RCTs (2822 women) but no observational studies were eligible for inclusion. Daily oral iron supplementation in pregnancy probably reduces iron deficiency anemia at term (risk ratio [RR]: 0.51, 95% confidence interval [CI]: 0.38-0.70; 4 RCTs, 1670 women; I2  = 13%; moderate-certainty evidence) and the incidence of low birthweight babies (RR: 0.30, 95% CI: 0.13-0.68; 2 RCTs, 361 infants; I2  = 0%; moderate-certainty evidence). In addition, it may reduce iron deficiency at term (RR: 0.74, 95% CI: 0.60-0.92; 4 RCTs, 1663 women; I2  = 58%; low-certainty evidence) and the incidence of small for gestational age babies (RR: 0.39, 95% CI: 0.17-0.86; 1 RCT, 213 infants; I2 not estimable; low-certainty evidence).

CONCLUSIONS

Daily iron supplementation in iron replete non-anemic pregnant women probably reduces the risk of maternal iron deficiency anemia at term and low birthweight.

Ferroptosis and its potential role in gestational diabetes mellitus: updated evidence from pathogenesis to therapy

Background

Studies have demonstrated that high iron status is positively associated with gestational diabetes mellitus (GDM), implying that iron overload and ferroptosis play important roles in the development of GDM. The aim of this study was to explore effective therapeutic drugs from traditional Chinese medicine (TCM)formulas for the treatment of GDM based on ferroptosis.

Methods

In this study, the presence of ferroptosis in the placenta was verified through clinical and experimental data, and key genes were subsequently screened for association with ferroptosis in the development of GDM. The analysis was based on transcriptome sequencing of datasets combined with differentially expressed genes (DEGs) analysis and weighted gene correlation network analysis (WGCNA); functional enrichment analysis was also performed. A protein-protein interaction (PPI) network was constructed and pivotal genes were identified using Cytoscape. Finally, traditional Chinese medicine (TCM)formulas related to treating GDM were collected, then the proteins corresponding to the key genes were molecularly docked with the small molecular structures of clinically proven effective herbal tonics, and molecular dynamic simulations were performed to select the best candidates for pharmacological compounds.

Results

Elevated ferritin levels in patients with GDM were verified using clinical data. The presence of ferroptosis in placental tissues of patients with GDM was confirmed using electron microscopy and western blotting. Ninety-nine key genes with the highest correlation with ferroptosis were identified from DEGs and weighted gene co-expression network analysis (WGCNA). Analysis using the Kyoto Encyclopedia of Genes and Genomes demonstrated that the DEGs were primarily involved in the oxidative phosphorylation pathway. The key genes were further screened by PPI; two key genes, SF3B14 and BABAM1, were identified by combining the gene corresponding to protein structure and function, followed by molecular docking and molecular dynamic simulation. Coptis chinensis was proposed as the best candidate for herbal treatment at the molecular level.

Conclusion

This data revealed the presence of ferroptosis in patients with GDM and identified possible modulatory roles of ferroptosis-related genes involved in the molecular mechanisms of GDM, providing new insights into the pathogenesis of GDM, which also provided new directions for the systematic optimization of TCM formulas for the management and targeted treatment of GDM.