Effectiveness and strategies of iron supplementation during pregnancy

Use of pH-sensitive microcapsules for selective delivery of nanozymes and biological enzymes in small intestine

Unlike the intravenous route, oral delivery systems face challenges due to an acidic gastric environment, which can degrade or inactivate therapeutic compounds before they reach the small intestine (SI). Therefore, developing oral delivery strategies that protect cargo from acidic environments and release the content in the SI is imperative. Herein, a novel approach utilizes the pH-sensitivity of alginate-based microcapsules that degrade and release the contents at pH ≥ 7.0. The microcapsules were used to encapsulate gold nanoparticles (AuNPs, a model nanozyme) of varying sizes (2, 15, and 70 nm) and horseradish peroxidase (HRP, a model enzyme). The AuNPs- and HRP-loaded microcapsules (AuNPs-MCap and HRP-PEG MCap) were unaffected at acidic pH (2.0-6.0), as the intrinsic structure and properties of encapsulated AuNPs and HRP were intact. The microcapsules rapidly released the encapsulated AuNPs and HRP at pH ≥ 7.0. In vivo, oral administration of AuNPs-MCap and HRP-PEG MCap to Wistar rats also showed significantly enhanced absorption of AuNPs and HRP in SI, leading to higher concentrations in blood than in their corresponding unencapsulated forms. Overall, the results underscore the potential of pH-responsive microcapsules for protecting pH-sensitive nanozymes, biological enzymes and other bioactive compounds from the acidic gastric environment and for effective and targeted delivery to the SI.

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.

Study of anaemia in pregnancy and low birth weight in fluoride endemic area of Western Rajasthan: a cohort study

Background

Fluoride is a noxious element known to destroy gastrointestinal mucosa, leading to erythrocytes' destruction and causing anaemia. The birth weight of newborn babies is a significant indicator of a child's vulnerability to the risk of childhood diseases and chances of existence.

Methods

This prospective cohort study was planned to find linkages between fluorosis and the low-birth weight of newborn babies with anaemic mothers. Antenatal mothers until the 20th week of gestation were followed up till delivery in the Antenatal Clinic of a District Hospital in one of the known fluoride-endemic districts (Nagaur) and the other not-so-endemic district (Jodhpur) of Western Rajasthan.

Results

Around 19% of the newborn in Jodhpur and around 22% in Nagaur had low birth weight. Mean fluoride values in water samples were measured to be 0.57 (range from 0.0 to 2.7 PPM) in Jodhpur and 0.7 (range from 0.0 to 3.4 PPM) in Nagaur.

Conclusions

Thus, in fluoride endemic areas, other factors should be included besides iron and folic acid supplementation for improving anaemia in pregnant women. This calls for assessing the effectiveness of de-fluoridation activities along with the area's most common indigenous food practices.

Analysis of blood composition by porcine breeding cycle

BACKGROUND

Pigs for biomedical research are administered commercial fluids made for human consumption when they receive intravenous (IV) fluid therapy. Although pigs and humans have slightly different bodily fluid compositions, the composition shift happens at the same rate as their rapid growth.

OBJECTIVE

The study aimed to analyse the composition of porcine blood according to breeding cycle using a portable blood analyser and provides data for developing customized IV fluids for pigs.

METHODS

Pigs were sorted 25, 50, 100 and 120 days after birth, and sows were classified into candidate, pregnant and farrowing groups. A blood sample was collected from the external jugular vein and analysed using the EPOC blood analysis system using haematological, biochemical and gas parameters.

RESULTS

There was no difference among pig groups by age, but hematocrit and haemoglobin amounts decreased in sows after farrowing, but their concentrations were higher as compared to pigs. Glucose gradually reduced as age increased in pigs and during pregnancy in sows.

CONCLUSION

This study provided a comprehensive analysis of porcine blood composition by breeding cycle and highlighted the importance of glucose supplementation for IV fluid therapy in pigs.

Unraveling the Role of Maternal Serum Ferritin Levels in Preterm Delivery: A Comprehensive Review

Preterm delivery remains a critical global health concern, with numerous adverse consequences for both neonate and healthcare systems. Understanding the relationship between maternal ferritin levels, as a marker of iron status, and the risk of preterm birth is the focal point of this comprehensive review. We provide insights into the multifaceted nature of this connection, highlighting factors that influence maternal ferritin levels, including dietary intake, genetic and physiological variations, comorbidities, and iron supplementation. While evidence suggests an association between low maternal ferritin levels and preterm birth, causality remains elusive, necessitating further research with robust study designs. The potential mechanisms linking maternal iron status to preterm birth, such as inflammation, infection, and oxidative stress, are explored, underscoring the need for in-depth investigations. This comprehensive review emphasizes the clinical importance of assessing and monitoring maternal ferritin levels in prenatal care and advocates for public health initiatives to raise awareness and provide targeted interventions, particularly in high-risk populations. As we strive to address these unanswered questions and embark on innovative research directions, the aim is to ultimately enhance our understanding of the complex relationship between maternal iron status and preterm birth, leading to improved maternal and child health outcomes.

Tragacanth gum-based nano-nutraceuticals synthesis by encapsulation of beetroot juice and Ocimum basilicum leaves for micronutrient deficient population

Micronutrient deficiencies, such as iron, folic acid, and vitamins C and D, are currently prevalent due to inadequate consumption of natural food sources, namely raw vegetables and fruits. This deficiency is compounded by the growing reliance on synthetic nutraceuticals and processed food, which exhibit poor absorbency within the gastrointestinal tract. Scientific studies consistently indicate that naturally prepared whole foods are superior in terms of nutrient absorption compared to processed and synthetic supplements. To address this issue, we utilized FDA-approved tragacanth gum (TG) in the synthesis of nano-nutraceuticals by encapsulating beetroot juice and ball-milled sweet basil (Ocimum basilicum). TG, in its micro or macro form, possesses the remarkable ability to form hydrogels capable of absorbing water up to 50 times its weight. However, the hydrogel-forming property diminishes when TG is reduced to the nanoscale. We effectively exploited these properties to facilitate the synthesis of nano-nutraceuticals. The procedure involved encapsulating beetroot juice and sweet basil nanopowder using TG hydrogel, followed by freeze-drying. Subsequently, the freeze-dried encapsulated TG composite was subjected to ball-milling to achieve the desired nano-nutraceuticals. These nano-nutraceuticals naturally contain essential nutrients such as iron, folic acid, ascorbic acid, chlorophyll, niacin, and sugars, without the need for chemical processing or preservatives.

Importance of Maternal Iron Status on the Improvement of Cognitive Function in Children After Prenatal Iron Supplementation

INTRODUCTION

The effectiveness of prenatal iron supplementation improves maternal hematological outcomes, but little research has focused on child outcomes. The objective of this study was to assess whether prenatal iron supplementation adjusted to maternal needs improves children's cognitive functioning.

METHODS

The analyses included a subsample of nonanemic pregnant women recruited in early pregnancy and their children aged 4 years (n=295). Data were collected between 2013 and 2017 in Tarragona (Spain). On the basis of hemoglobin levels before the 12th gestational week, women receive different iron doses: 80 vs 40 mg/d if hemoglobin is 110-130 g/L and 20 vs 40 mg/d if hemoglobin >130 g/L. Children's cognitive functioning was assessed using the Wechsler Preschool and Primary Scale of Intelligence-IV and Developmental Neuropsychological Assessment-II tests. The analyses were carried out in 2022 after the completion of the study. Multivariate regression models were performed for assessing the association between different doses of prenatal iron supplementation and children's cognitive functioning.

RESULTS

Taking 80 mg/d of iron was positively associated with all the scales of the Wechsler Preschool and Primary Scale of Intelligence-IV and Neuropsychological Assessment-II when mothers had initial serum ferritin <15 µg/L, but it was negatively associated with Verbal Comprehension Index, Working Memory Index, Processing Speed Index, and Vocabulary Acquisition Index from Wechsler Preschool and Primary Scale of Intelligence-IV and verbal fluency index from Neuropsychological Assessment-II when mothers showed initial serum ferritin >65 µg/L. In the other group, taking 20 mg/d of iron was positively associated with Working Memory Index, Intelligence Quotient, verbal fluency, and emotion recognition indices when women had initial serum ferritin >65 µg/L.

CONCLUSIONS

Prenatal iron supplementation adjusted to the maternal hemoglobin levels and baseline iron stores improves cognitive functioning in children aged 4 years.

Prevalence and risk factors of anemia in first, second and third trimesters of pregnancy in Iran: A systematic review and meta-analysis

Anemia is a common health problem during pregnancy worldwide that has many short-term and long-term effects on women. This study examined the Prevalence and Risk factors of anemia in first, second and third trimesters of pregnancy in Iran between 2000 and 2021. PubMed, Medline, Scopus, Google Scholar, and national databases of Magiran and SID were searched for articles, which were then subjected to PRISMA-compliant screening. A systematic review and meta-analysis (using a random-effects model in STATA version 17) were conducted on the 18 eligible cross-sectional studies (published between July 23, 2000 and September 1, 2021) that revealed significant data on the prevalence of anemia in pregnant women. This study included 18 reports with a total of 25,831 individuals in which 15% of study subjects had anemia (95% CI: 12-19%). The pooled prevalence of anemia was 13% in people older than 26 years old (95% CI: 9-17%) compared to 22% in people younger than 26 years old (95% CI: 15-29). It was 18% (95% CI: 11-27%) for pregnant women having their second child in comparison to 20% (95% CI: 11-32%) for women who have had three or more children. Anemia was thought to affect 11% of housewives (95% CI: 2-26%) and 10% of working women (95% CI: 6-16%). Anemia frequency was 22%, 17% and 13% amongst first (22%), second (17%), and third (13%) trimesters, respectively. Nevertheless, it happened much less often after the second trimester. Moreover, poor education, a history of low birth weight in children, and a low socioeconomic level within women were associated with the prevalence of anemia. The pooled prevalence of anemia in pregnant women is marginally lower than in earlier report. However, it seems to be a health problem in developing countries including Iran currently. Therefore, the study suggest that health system should design comprehensive preventive and control measurements such as more effective treatments to minimize anemia in vulnerable segments of society, particularly mothers, and improve their health through increasing access to services for mothers.

The causal association between iron status and the risk of autism: A Mendelian randomization study

Emerging evidence indicates a connection between serum iron levels and autism, but the underlying causal association is yet unclear. Thus, we performed two-sample Mendelian randomization (MR) analysis to evaluate the causal link between iron status on autism, using genetic instruments (p < 5E-08) strongly associated with iron status (N = 48,972), including serum iron, ferritin, transferrin levels, and transferrin saturation. Summary statistics of autism was obtained from two independent studies conducted by Psychiatric Genomics Consortium (PGC, Ncases = 5,305, Ncontrols = 5,305) and FinnGen Consortium (FC, Round six, Ncases = 344, Ncontrols = 258,095), respectively. Using the inverse-variance weighted (IVW) method, the combined results of PGC and FC demonstrated that genetically determined serum transferrin level was significantly associated with an increased risk of autism [odds ratio (OR) = 1.16, 95% CI: 1.03-1.30, p = 0.013]. There was no significant causal effect of serum iron (OR = 0.99, 95% CI: 0.72-1.37, p = 0.951), ferritin (OR = 0.88, 95% CI: 0.47-1.64, p = 0.676), and transferrin saturation (OR = 0.89, 95% CI: 0.72-1.09, p = 0.252) on autism. No obvious pleiotropy was found in this MR study. Taken together, our findings highlight that elevation of serum transferrin level might be associated with a high risk of autism, suggesting a potential role of iron deficiency in autism development. Future studies are warranted to clarify the underlying mechanism, which will pave a new path for the prevention and treatment of autism.

The Effect and Potential Mechanism of Maternal Micronutrient Intake on Offspring Glucose Metabolism: An Emerging Field

Diabetes has become the most common metabolic disease around the world. In addition to genetic and environmental factors in adulthood, the early life environment is critical to the progression of diabetes in adults, especially the environment during the fetal period; this concept is called “fetal programming.” Substantial evidence has illustrated the key role of early life macronutrient in programming metabolic diseases. Recently, the effect of maternal micronutrient intake on offspring glucose metabolism during later life has become an emerging field. This review focuses on updated human and animal evidence about the effect of maternal micronutrient status on offspring glucose metabolism and the underlying mechanism.

Mother’s Perception of Anemia and Compliance of Iron Tablet Consumption during Pregnancy

Backgound: Anemia cases are still the main problem found in pregnant women in East Nusa Tenggara Province, Indonesia, especially East Sumba Regency. Anemia is very common in pregnant women and iron deficiency is the main cause. Indonesia has a policy to provide iron supplements to pregnant women. Non-compliance of iron (Fe) tablets is one of the important challenge factors in fighting anemia. Objective: The research objective was to determine the relationship between perceptions and compliance of pregnant women on consuming iron tablets. Methods: This study involved 102 women, namely 34 pregnant women, 34 postpartum mothers and 34 breastfeeding mothers. After obtaining approval from the research ethics commission, data were collected by personal interview. Data were analyzed using the Spearman correlation statistical test. Results: A good perception of 77.5%, moderate 18.6% and less, 5.9%. It was found that the compliance of taking iron tablets was in the good category of 2.9%, sufficient 27.5% and less 69.6%. The results of the Spearman correlation test show a correlation coefficient of 0.164 and a significant 0.100 which means that there is a weak correlation and there is no relationship between perception and compliance of taking iron tablets. Conclusion: The perception of pregnant women about iron is mostly good and the compliance of pregnant women's in taking iron tablets is mostly sufficient. There was no relationship between perception and compliance of taking iron tablets in pregnant women.

Effect of cooking food in iron-containing cookware on increase in blood hemoglobin level and iron content of the food: A systematic review

In developing countries there is a need for simple and cost-effective strategies to reduce the prevalence of iron deficiency anemia. The objective of the current systematic review is to summarize how cooking food in iron pots or iron ingots can increase the blood hemoglobin level and iron content of the food. Literature search was conducted using databases namely PubMed, Google Scholar, Medline-Ovid, IndMed, Cochrane library, World Health Organization bulletin and by cross-referencing articles. Thirteen researches were found to be suitable for inclusion in this systematic review. Four studies reported significant increase in blood hemoglobin levels while others reported only a minor increase. Significant improvement in amount of iron in food and iron bioavailability was also observed when food was cooked using iron pot or ingots. This can be used as a strategy for reduction of iron deficiency anemia. However, more research is required to understand the efficacy of this approach.

Are Pregnant Women Who Are Living with Overweight or Obesity at Greater Risk of Developing Iron Deficiency/Anaemia?

Low-grade inflammation is often present in people living with obesity. Inflammation can impact iron uptake and metabolism through elevation of hepcidin levels. Obesity is a major public health issue globally, with pregnant women often affected by the condition. Maternal obesity is associated with increased pregnancy risks including iron deficiency (ID) and iron-deficiency anaemia (IDA)-conditions already highly prevalent in pregnant women and their newborns. This comprehensive review assesses whether the inflammatory state induced by obesity could contribute to an increased incidence of ID/IDA in pregnant women and their children. We discuss the challenges in accurate measurement of iron status in the presence of inflammation, and available iron repletion strategies and their effectiveness in pregnant women living with obesity. We suggest that pre-pregnancy obesity and overweight/obese pregnancies carry a greater risk of ID/IDA for the mother during pregnancy and postpartum period, as well as for the baby. We propose iron status and weight gain during pregnancy should be monitored more closely in women who are living with overweight or obesity.

Complementary and Alternative Medicine for Threatened Miscarriage: Advantages and Risks

Threatened miscarriage is one of the most common complications causing pregnancy loss, and it affects approximately 20% of confirmed pregnancies. More and more women are seeking treatment with complementary and alternative medicine (CAM) for this common complication, and it has been reported that women have had successful pregnancies after threatened miscarriage when being treated with CAM, which mainly includes Chinese herbal medicines, acupuncture, and nutritional supplements as well as psychological interventions and other approaches. However, many experts are concerned about the safety and adverse events of certain CAM approaches in women with threatened miscarriage. Therefore, this review focuses on the status of CAM for threatened miscarriage and presents the potential therapeutic efficacy and safety of CAM based on some clinical and experimental studies. We thus hope to provide some instructive suggestions for the application of CAM for treating threatened miscarriage in the future.

The Prevalence of Insomnia and the Link between Iron Metabolism Genes Polymorphisms, TF rs1049296 C>T, TF rs3811647 G>A, TFR rs7385804 A>C, HAMP rs10421768 A>G and Sleep Disorders in Polish Individuals with ASD

Iron deficiency have been found to be linked to sleep disorders. Both genetic and environmental factors are risk factors for skewed iron metabolism, thus sleep disruptions in autism spectrum disorders (ASD). The aim of our study was to assess the prevalence of single nucleotide polymorphisms (SNPs) within transferrin gene (TF) rs1049296 C>T, rs3811647 G>A, transferrin receptor gene (TFR) rs7385804 A>C, and hepcidin antimicrobial peptide gene (HAMP) rs10421768 A>G in Polish individuals with ASD and their impact on sleep pattern. There were 61 Caucasian participants with ASD and 57 non-ASD controls enrolled. Genotypes were determined by real-time PCR using TaqMan SNP assays. The Athens Insomnia Scale (AIS) was used to identify sleep disruptions. There were 32 cases (57.14%) with insomnia identified. In the ASD group, the defined counts of genotypes were as follows: TF rs1049296, C/C n = 41 and C/T n = 20; TF rs3811647, G/G n = 22, G/A n = 34, and A/A n = 5; TFR rs7385804, A/A n = 22, A/C n = 29, and C/C n = 10; and HAMP rs10421768, A/A n = 34, A/G n = 23, and G/G n = 4. There were no homozygous carriers of the TF rs1049296 C>T minor allele in the ASD group. All analyzed SNPs were not found to be linked to insomnia. The investigated polymorphisms are not predictors of sleep disorders in the analyzed cohort of individuals with ASD.

Utilization of a Diet Optimization Model in Ensuring Adequate Intake among Pregnant Women in Selangor, Malaysia

Achieving nutritional requirements for pregnant women in rural or suburban households while maintaining the intake of local and culture-specific foods can be difficult. Usage of a linear programming approach can effectively generate diet optimization models that incorporate local and culturally acceptable menus. This study aimed to determine whether a realistic and affordable diet that achieves recommended nutrient intakes for pregnant women could be formulated from locally available foods in Malaysia. A cross-sectional study was conducted to assess the dietary intake of 78 pregnant women using a 24-h dietary recall and a 3-day food record. A market survey was also carried out to estimate the cost of raw foods that are frequently consumed. All linear programming analyses were done using Excel Solver to generate optimal dietary patterns. Our findings showed that the menus designed from diet optimization models using locally available foods would improve dietary adequacy for the seven food groups based on the Malaysian Dietary Guidelines 2010 (MDG 2010) and the 14 nutrients based on Recommended Nutrient Intake 2017 (RNI 2017) in pregnant women. However, inadequacies remained for iron and niacin, indicating that these nutrients may require supplementation.

Change of the levels of trace elements and heavy metals in threatened abortion

BACKROUND

This study aimed to investigate the impact of changes in the serum levels of trace elements and heavy metals in threatened abortion, which is a common complication in early pregnancy. Earlier studies have shown that changes in the serum levels of some trace elements and increased serum concentrations of heavy metals are associated with spontaneous abortion; however, this relationship has not been fully clarified.

METHODS

The patient group consisted of 45 pregnant women diagnosed with threatened abortion. There were 40 healthy nonpregnant women in the control group. Blood samples were obtained from the patients and the healthy controls, and the concentrations of serum trace elements and heavy metals were measured using atomic absorption spectrophotometry.

RESULTS

Statistically significant decreases were found in the serum zinc (Zn), iron (Fe), magnesium (Mg) and manganese (Mn) levels, and significant increases were found in the serum copper (Cu), cadmium (Cd) and lead (Pb) levels in cases of threatened abortion in comparison to the controls (p < 0.001). However, there was no difference between the groups in terms of the serum cobalt (Co) levels (p > 0.001).

CONCLUSION

Changes in the balance of some essential trace elements (especially decreases in Fe and Zn) and elevated concentrations of some toxic heavy metals in the blood may be important diagnostic and prognostic parameters for threatened abortion.

Better-Educated, Older, or Unmarried Pregnant Women Comply Less with Iron-Folic Acid Supplementation in Southern Ethiopia

Daily iron supplementation, with or without folic acid, is a proven public health intervention. Although maintaining compliance is crucial for the success of the intervention, inconsistent findings are available on compliance and its predictors in Ethiopia. The aim of this study was to estimate the iron-folic acid (IFA) supplementation compliance rate and its predictors among pregnant women in Wolaita Zone, Southern Ethiopia. A cross-sectional study was conducted in eight randomly selected health centers in Wolaita, Southern Ethiopia. A total of 647 pregnant women were included using multistage sampling procedure. Data were entered into Epi Info (a free statistical analysis software) and exported to SPSS. Bivariate relationship was explored through correlation coefficients. A multiple linear regression model was constructed to estimate the variability coefficient of the compliance rate due to selected factors. Of 647 pregnant women, only 18 (2.8%) pregnant women had received the supplement for 90 days or more. Overall, the compliance rate was 73.2% (95% CI, 70.72 to 75.79). Experiencing heartburn and vomiting significantly reduced the compliance rate. Unintended pregnancy and better education were negatively associated with compliance. By contrast, acceptability of IFA supplement, number of antenatal care (ANC) visits, and being ever married were positive predictors. On average, a pregnant woman did not take more than one-fourth of the daily IFA supplementation. During ANC visits, addressing the issues of side effects, unintended pregnancy, and acceptability of the supplement may improve compliance rate. Overall in Ethiopia, educated, older, and unmarried Ethiopian women need additional attention for successful compliance.

Macronutrient and Micronutrient Intake during Pregnancy: An Overview of Recent Evidence

Nutritional status during pregnancy can have a significant impact on maternal and neonatal health outcomes. Requirements for macronutrients such as energy and protein increase during pregnancy to maintain maternal homeostasis while supporting foetal growth. Energy restriction can limit gestational weight gain in women with obesity; however, there is insufficient evidence to support energy restriction during pregnancy. In undernourished women, balanced energy/protein supplementation may increase birthweight whereas high protein supplementation could have adverse effects on foetal growth. Modulating carbohydrate intake via a reduced glycaemic index or glycaemic load diet may prevent gestational diabetes and large-for-gestational-age infants. Certain micronutrients are also vital for improving pregnancy outcomes, including folic acid to prevent neural tube defects and iodine to prevent cretinism. Newly published studies support the use of calcium supplementation to prevent hypertensive disorders of pregnancy, particularly in women at high risk or with low dietary calcium intake. Although gaps in knowledge remain, research linking nutrition during pregnancy to maternofoetal outcomes has made dramatic advances over the last few years. In this review, we provide an overview of the most recent evidence pertaining to macronutrient and micronutrient requirements during pregnancy, the risks and consequences of deficiencies and the effects of supplementation on pregnancy outcomes.

Quercetin modulates iron homeostasis and iNOS expression of splenic macrophages in a rat model of iron deficiency anemia

Iron deficiency anemia is one of the most common micronutrient deficient conditions around the globe with various consequences, including the weakened immune system. Quercetin is widely distributed bioflavonoid; it has been debated for its dual roles in iron regulation. Quercetin-iron interaction in the body is a complex mechanism which has not been completely understood. The present study aimed to investigate the effect of quercetin on iron supplementation in iron deficiency anemia and on iNOS expression in splenic macrophages. The rat model of iron deficiency anemia was induced by feeding low iron diet to weanling rats for 20 days. The animals were then administered with ferrous sulfate, quercetin, and their combination for 30 days. Blood parameters, histopathological analysis, iron storage, CD68, iNOS and SLC40 expression in rat spleen were investigated. Our results showed that quercetin regulated iron absorption, despite SLC40 down-expression, indicating possible alternate route of iron transport, and that quercetin modulated iNOS production in splenic macrophages.

Dietary Iron Fortification Normalizes Fetal Hematology, Hepcidin, and Iron Distribution in a Rat Model of Prenatal Alcohol Exposure

BACKGROUND

Prenatal alcohol exposure (PAE) causes neurodevelopmental disability. Clinical and animal studies show gestational iron deficiency (ID) exacerbates PAE's behavioral and growth deficits. In rat, PAE manifests an inability to establish iron homeostasis, increasing hepcidin (maternal and fetal), and fetal liver iron while decreasing brain iron and promoting anemia. Here, we hypothesize dietary iron fortification during pregnancy may mitigate alcohol's disruption of fetal iron homeostasis.

METHODS

Pregnant Long-Evans rats, fed iron-sufficient (100 ppm iron) or iron-fortified (IF; 500 ppm iron) diets, received either 5 g/kg alcohol (PAE) or isocaloric maltodextrin daily on gestational days (GD) 13.5 through 19.5. Maternal and fetal outcomes were evaluated on GD20.5.

RESULTS

PAE reduced mean fetal weight (p < 0.001) regardless of maternal iron status, suggesting iron fortification did not improve fetal growth. Both PAE (p < 0.01) and IF (p = 0.035) increased fetal liver iron. In fetal brain, PAE (p = 0.015) affected total (p < 0.001) and nonheme iron (p < 0.001) such that iron fortification normalized (p = 0.99) the alcohol-mediated reductions in brain iron and nonheme iron. Iron fortification also improved fetal hematologic indices in PAE including hemoglobin, hematocrit, and mean cell volume (ps<0.001). Iron fortification also normalized hepcidin expression in alcohol-exposed maternal and fetal liver. Neither diet nor PAE affected transferrin (Tf) and ferritin (FTN) content in fetal liver, nor Tf or transferrin receptor in fetal brain. However, IF-PAE fetal brains trended to less FTN content (p = 0.074), suggesting greater availability of nonstorage iron. In PAE, hepcidin levels were linearly related to increased liver iron stores and decreased red blood cell count and brain iron.

CONCLUSIONS

Maternal oral iron fortification mitigated PAE's disruption of fetal iron homeostasis and improved brain iron content, hematologic indices, and hepcidin production in this rat PAE model. Clinical studies show maternal ID substantially enhances fetal vulnerability to PAE, and our work supports increased maternal dietary iron intake may improve fetal iron status in alcohol-exposed pregnancies.

Management of Iron Deficiency Anemia in Pregnancy in India

Iron deficiency anemia (IDA) continues to be the commonest etiology of anemia in pregnancy. The prevalence of iron deficiency (ID) in pregnant Indian women is amongst the highest in the world. Untreated iron deficiency (ID) has significant adverse feto-maternal consequences. Plethora of investigations are available for diagnosis of IDA, each having specific advantages and disadvantages when used in the pregnancy setting. Therapy for ID includes dietary modification, oral iron supplementation, intravenous iron and blood transfusion. Newer parenteral iron preparations are safe and there is mounting evidence to suggest their use in frontline settings for pregnancy associated IDA in the second and third trimester. Through this review, we suggest an algorithm for diagnosis and treatment of IDA in pregnancy depending on the severity of anemia and period of gestation suited for widespread use in resource limited settings. Also, we recommend ways for increasing public awareness and tackling this health issue including the observance of "National Anemia Awareness and Treatment Day."

Understanding environmental contributions to autism: Causal concepts and the state of science

The complexity of neurodevelopment, the rapidity of early neurogenesis, and over 100 years of research identifying environmental influences on neurodevelopment serve as backdrop to understanding factors that influence risk and severity of autism spectrum disorder (ASD). This Keynote Lecture, delivered at the May 2016 annual meeting of the International Society for Autism Research, describes concepts of causation, outlines the trajectory of research on nongenetic factors beginning in the 1960s, and briefly reviews the current state of this science. Causal concepts are introduced, including root causes; pitfalls in interpreting time trends as clues to etiologic factors; susceptible time windows for exposure; and implications of a multi-factorial model of ASD. An historical background presents early research into the origins of ASD. The epidemiologic literature from the last fifteen years is briefly but critically reviewed for potential roles of, for example, air pollution, pesticides, plastics, prenatal vitamins, lifestyle and family factors, and maternal obstetric and metabolic conditions during her pregnancy. Three examples from the case-control CHildhood Autism Risks from Genes and the Environment Study are probed to illustrate methodological approaches to central challenges in observational studies: capturing environmental exposure; causal inference when a randomized controlled clinical trial is either unethical or infeasible; and the integration of genetic, epigenetic, and environmental influences on development. We conclude with reflections on future directions, including exposomics, new technologies, the microbiome, gene-by-environment interaction in the era of -omics, and epigenetics as the interface of those two. As the environment is malleable, this research advances the goal of a productive and fulfilling life for all children, teen-agers and adults. Autism Res 2018, 11: 554-586. © 2018 International Society for Autism Research, Wiley Periodicals, Inc.

LAY SUMMARY

This Keynote Lecture, delivered at the 2016 meeting of the International Society for Autism Research, discusses evidence from human epidemiologic studies of prenatal factors contributing to autism, such as pesticides, maternal nutrition and her health. There is no single cause for autism. Examples highlight the features of a high-quality epidemiology study, and what comprises a compelling case for causation. Emergent research directions hold promise for identifying potential interventions to reduce disabilities, enhance giftedness, and improve lives of those with ASD.

How I treat anemia in pregnancy: iron, cobalamin, and folate

Anemia of pregnancy, an important risk factor for fetal and maternal morbidity, is considered a global health problem, affecting almost 50% of pregnant women. In this article, diagnosis and management of iron, cobalamin, and folate deficiencies, the most frequent causes of anemia in pregnancy, are discussed. Three clinical cases are considered. Iron deficiency is the most common cause. Laboratory tests defining iron deficiency, the recognition of developmental delays and cognitive abnormalities in iron-deficient neonates, and literature addressing the efficacy and safety of IV iron in pregnancy are reviewed. An algorithm is proposed to help clinicians diagnose and treat iron deficiency, recommending oral iron in the first trimester and IV iron later. Association of folate deficiency with neural tube defects and impact of fortification programs are discussed. With increased obesity and bariatric surgery rates, prevalence of cobalamin deficiency in pregnancy is rising. Low maternal cobalamin may be associated with fetal growth retardation, fetal insulin resistance, and excess adiposity. The importance of treating cobalamin deficiency in pregnancy is considered. A case of malarial anemia emphasizes the complex relationship between iron deficiency, iron treatment, and malaria infection in endemic areas; the heightened impact of combined etiologies on anemia severity is highlighted.

Routine Iron Supplementation and Anaemia by Third Trimester in a Nigerian Hospital

Background

Anaemia in pregnancy is associated with adverse maternal and fetal outcome. Unfortunately, in developing countries its prevalence has continued to rise. To improve the situation, iron supplement is routinely prescribed during pregnancy. We therefore examine the impact of the intervention as being currently practised in our clinical setting.

Methods

In total, 255 prenatal clinic attendees who had more than 8 weeks of prescribed iron supplements were sampled. Data was obtained on their socio-demographic features, haemoglobin concentration at booking, compliance with iron supplements and third trimester haemoglobin value.

Results

Observed iron supplementation compliance rate was 184(72.2%). There was a significant drop in mean haemoglobin (Hb) concentration between the two time points (booking Hb: 32.56±2.99; third trimester Hb: 31.67±3.01; mean diff: 0.89±3.04; t = 4.673; 95% CI= 0.52–1.27; p= <0.001). Anaemia increased from 132(51.8%) to 150(58.8%) by the third trimester. Increase in anaemia occurred in both iron-compliant and non-compliant groups. Non-compliance however had higher odds of predicting anaemia by the third trimester (OR: 1.83; 95% CI: 1.03–3.26; p: 0.04).

Conclusion

Although iron supplementation is still a good intervention in developing countries, it is not sufficient to reduce overall prevalence of anaemia by the third trimester. There is a need to look beyond the approach and reinforce the importance of better feeding practices, food fortification and reduced frequency of pregnancies.

The reproductive ecology of iron in women

Reproductive ecology focuses on the sensitivity of human reproduction to environmental variation. While reproductive ecology has historically focused on the relationship between energy status and reproductive outcomes, iron status is equally critical to women's reproductive health, given the wide-ranging detrimental effects of iron-deficiency anemia on maternal and infant well-being. This review interprets the vast literature on iron status and women's reproduction through an evolutionary framework. First, it will critique the evidence for iron deficiency caused by blood loss during menstruation, reinterpreting the available data as ecological variation in menses within and between populations of women. Second, it will highlight the scant but growing evidence that iron status is implicated in fertility, a relationship that has deep evolutionary roots. Third, this review proposes a new hypothesis for the transfer of iron from mother to infant via pregnancy and breastfeeding: reproductive iron withholding. In this hypothesis, mothers transfer iron to infants in a manner that helps infants avoid iron-mediated infection and oxidative stress, but trades off with potential risk of maternal and infant iron deficiency. Finally, this review explores two main factors that can modify the relationship between iron status and the gestation-lactation cycle: (1) the relationship between long-term reproductive effort (parity) and iron status and (2) supplementation schemes before and during pregnancy. The review concludes by suggesting continued research into iron homeostasis in women using evolutionary, ecological, and biocultural frameworks.

Oxidative stress during early pregnancy and birth outcomes

Objective

Routine high-dose Fe supplementation in non-anaemic pregnant women may induce oxidative stress and eventually affect birth outcomes. The aim of the present study was to measure oxidative stress markers in pregnant women with low/normal and high Hb values in trimester 1 (Hb1) and to relate these to birth weight.

Design

A cross-sectional study where selected oxidative stress markers were analysed in both maternal (trimester 1; T1) and cord blood samples and correlated with birth weight.

Setting

A tertiary hospital in urban South India.

Subjects

One hundred women were chosen based on their Hb1 values (forty women with low/normal Hb1 (<110 g/l) and sixty women with high Hb1 (≥120 g/l)).

Results

In T1, women with high Hb1 values were found to have lower paraoxonase-1 (PON-1) activity (424·7 (sd 163·7) v. 532·9 (sd 144·7) pmol p-nitrophenol formed/min per ml plasma, P=0·002) and higher lipid peroxides compared with women with low/normal Hb1. Routine supplementation of Fe to these women resulted in persistent lower PON-1 activity in cord blood (P=0·02) and directionally lower (P=0·142) birth weights. Furthermore, women with high Hb1 who delivered low-birth-weight babies were observed to have lowest PON-1 activity in T1. No changes were observed in other markers (myeloperoxidase activity and total antioxidant levels).

Conclusions

Routine Fe supplementation in pregnant women with high Hb1 associated with increased oxidative stress, as reflected by low PON-1 activity in T1, could potentially lead to deleterious effects on birth weight.

A qualitative exploration of health workers' and clients' perceptions of barriers to completing four antenatal care visits in Morogoro Region, Tanzania

Antenatal care (ANC) remains an important contact point on the continuum of care for mothers and children in low- and middle-income countries. In Tanzania, the proportion of pregnant women completing at least four ANC visits (ANC-4) dropped from 70% to 43% between 1999 and 2010. To identify potential causes of the decline in the number of ANC visits, we conducted qualitative research at 18 health centres in Morogoro Region, exploring providers' communication about ANC visits and clients' and providers' perceptions of changes in ANC services and barriers to completing four visits. We also observed counselling messages delivered during 203 ANC consultations. Our results indicate that provider communication about ANC visit recommendations is inadequate, and confusion exists among clients about when and how often they should attend. Participants highlighted how the scale up of Prevention of Mother-to-Child Transmission, with routine human immunodeficiency virus testing for women and their male partners, presents additional barriers for some women. Changes to the timing and content of ANC services following the adoption of the Focused ANC model was described by participants as changing women's perceptions and decisions in how they utilize ANC services. In particular, condensed delivery of technical interventions fostered a sense among clients that multiple visits are unnecessary. Other barriers that may contribute to declining ANC-4 include changing norms about family planning and birth spacing, out-of-pocket costs for clients and informal practices adopted by health facilities and providers such as turning women away who attend early in pregnancy or are not accompanied by male partners. Further research is needed to determine the role and extent that these barriers may be contributing to declining ANC-4. Issues of poor communication, supply inadequacies and informal practices, deserve immediate attention from the health system.

Use of dietary supplements among Alexandria University employees, Egypt

BACKGROUND

There is insufficient information on the usage of dietary supplements among Egyptians. The aim of this study was to identify the pattern of dietary supplement usage among employees of Alexandria University.

PARTICIPANTS AND METHODS

A comparative cross-sectional study was carried out on 500 staff members, clerks, and workers of Alexandria University. The sample studied was equally allocated between seven institutions (three from medical sectors and four from nonmedical sectors), and was randomly selected from each institution after obtaining their verbal consent. Data on sociodemographic characteristics, medical history, lifestyle practices, dietary intake, and pattern of dietary supplement usage were collected from each participant.

RESULTS

The use of dietary supplement was reported by 31.2% of the participants. These supplements were mainly multivitamins, iron, or calcium. Almost half of the users (52.6%) had used supplements regularly for years. The supplements were prescribed by doctors among 70.6% of the users for protection against diseases or to improve mental and physical well-being. The daily intake of the studied nutrients for both users and nonusers was found to be lesser than their requirements; also there was no statistically significant difference in the levels of nutrients studied, except in the adequacy of riboflavin, which was found to be higher among users than among nonusers (P=0.040). Female sex, higher educational and occupational levels, and the presence of chronic diseases were associated with the increased usage of dietary supplements.

CONCLUSION AND RECOMMENDATION

Dietary intake of the studied nutrients for both users and nonusers of supplements was found to be less than their daily requirements. Nutritional education programs highlighting the importance of eating a balanced diet or the usage of dietary supplements are recommended for university employees.

Perspectives on the design and methodology of periconceptional nutrient supplementation trials

Periconceptional supplementation could extend the period over which maternal and fetal nutrition is improved, but there are many challenges facing early-life intervention studies. Periconceptional trials differ from pregnancy supplementation trials, not only because of the very early or pre-gestational timing of nutrient exposure but also because they generate subsidiary information on participants who remain non-pregnant. The methodological challenges are more complex although, if well designed, they provide opportunities to evaluate concurrent hypotheses related to the health of non-pregnant women, especially nulliparous adolescents. This review examines the framework of published and ongoing randomised trial designs. Four cohorts typically arise from the periconceptional trial design--two of which are non-pregnant and two are pregnant--and this structure provides assessment options related to pre-pregnant, maternal, pregnancy and fetal outcomes. Conceptually the initial decision for single or micronutrient intervention is central--as is the choice of dosage and content--in order to establish a comparative framework across trials, improve standardisation, and facilitate interpretation of mechanistic hypotheses. Other trial features considered in the review include: measurement options for baseline and outcome assessments; adherence to long-term supplementation; sample size considerations in relation to duration of nutrient supplementation; cohort size for non-pregnant and pregnant cohorts as the latter is influenced by parity selection; integrating qualitative studies and data management issues. Emphasis is given to low resource settings where high infection rates and the possibility of nutrient-infection interactions may require appropriate safety monitoring. The focus is on pragmatic issues that may help investigators planning a periconceptional trial.

How we diagnose and treat iron deficiency anemia

It is estimated that one-third of the world's population is anemic, the majority being due to iron deficiency (ID). In adults, ID is associated with fatigue in the absence of anemia, restless legs syndrome, pica and, in neonates, delayed growth and development. In adolescents, ID is associated with decrements in learning and behavioral abnormalities. In the absence of a clear cause, search for a source of bleeding is indicated. No single test is diagnostic of ID unless the serum ferritin is low or the percent transferrin saturation is low with an elevated total iron binding capacity. Oral iron is considered front line therapy except for conditions such as gastric bypass, heavy uterine bleeding, inflammatory bowel disease, and hereditary hemorrhagic telangiectasia. Oral iron has many unpleasant side effects, resulting in low patient adherence. For patients intolerant of, or unresponsive to, oral iron, intravenous (IV) administration is the preferred route. While early formulations were associated with a high incidence of serious adverse events (SAEs), newer formulations are much safer with SAEs occurring very infrequently. Full replacement doses can be administered in a matter of minutes to a few hours. Nevertheless, there remains a reluctance to use IV iron due to a misunderstanding of the safety of the available formulations. IV iron is safe and effective in all clinical circumstances including pregnancy. The preponderance of published evidence suggests IV iron therapy is underutilized and we believe that IV iron should be moved forward in the treatment of ID and iron deficiency anemia (IDA).

The Homozygous Hemoglobin EE Genotype and Chronic Inflammation Are Associated with High Serum Ferritin and Soluble Transferrin Receptor Concentrations among Women in Rural Cambodia

BACKGROUND

Ferritin and soluble transferrin receptor (sTfR) concentrations are commonly used to assess iron deficiency (ID); however, they are influenced by multiple factors.

OBJECTIVES

We assessed associations between numerous variables and both ferritin and sTfR concentrations in Cambodian women and compared ID prevalence through the use of study-generated correction factors (CFs) for ferritin with those from a published meta-analysis.

METHODS

Venous blood from 450 women (aged 18-45 y) was assessed for hemoglobin (Hb), ferritin, sTfR, retinol binding protein, folate, vitamin B-12, C-reactive protein, α-1 acid glycoprotein (AGP), and genetic Hb disorders. Linear regression was used to calculate geometric mean ratios (95% CIs) for ferritin and sTfR concentrations.

RESULTS

The variant Hb EE genotype was associated with 50% (14%, 96%) and 51% (37%, 66%) higher geometric mean ferritin and sTfR concentrations, respectively, than was the normal Hb AA genotype; a 1-g/L increase in AGP was associated with 99% (50%, 162%) and 48% (33%, 64%) higher concentrations in the same variables, respectively. ID prevalence in nonpregnant women (n = 420) was 2% (n = 9) with the use of ferritin <15 μg/L and 18% (n = 79) with the use of sTfR >8.3 mg/L as criteria. ID prevalence with the use of sTfR was higher in women with the Hb EE genotype (n = 17; 55%) than in those with the Hb AA genotype (n = 20; 10%); and in women with the Hb AA genotype and chronic inflammation (n = 10; 18%) than in that group of women without chronic inflammation (n = 10; 7%) (P < 0.05). No differences in ID prevalence were found with the use of ferritin between women with Hb EE and AA genotypes (P = 1.0) or by chronic inflammation status (P = 0.32). There were no differences in mean ferritin concentrations among all 450 women when study-generated CFs were compared with those from the meta-analysis (P = 0.87).

CONCLUSIONS

Compared with sTfR, ferritin concentrations appear to reflect more accurately true ID in rural Cambodian women. The CFs from a published meta-analysis were appropriate for use in this population with a high prevalence of Hb disorders and inflammation.

"There is iron and iron…" Burkinabè women's perceptions of iron supplementation: a qualitative study

Most pregnant women in Burkina Faso are iron deficient and many are anemic. This study assessed women's understanding of anemia and the role of iron in preventing and treating this condition. A qualitative study was conducted within a randomized controlled trial of weekly iron supplementation in a rural malaria endemic area. Focus groups with women of similar age, parity, and marital status took place in 12 of 24 study villages. Two additional focus groups were conducted with female field workers. Tape-recorded transcripts were translated into French and analyzed using Framework analysis. Anemia, for which no Mooré term or traditional treatment for anemia was evident, was described in terms of blood volume. Moderate blood loss (diminished blood) could be easily replaced by eating well and was not considered serious. Massive blood loss (finished blood) was a rare, life-threatening illness. Iron tablets could increase blood volume and help women withstand massive blood loss at delivery, but for the latter, transfusion was indicated. Women had no knowledge of iron's role and did not readily concede that iron supplements contained elemental iron. Neither adolescents nor field workers were convinced of the benefits of supplementing non-pregnant adolescents, who were incorrectly considered to be at low risk of anemia. Young women's knowledge of anemia did not provide an adequate explanatory framework to motivate anemia prevention. Improving information on the role of iron is especially important for adolescent girls who may be incorrectly considered at low risk of anemia as they have not yet experienced pregnancy.

Prevalence and risk factors of anemia among pregnant women attending a high-volume tertiary care center for delivery

OBJECTIVE

The aim of this study was to identify the prevalence of anemia and predisposing factors contributing to anemia in pregnant women prior to delivery.

MATERIAL AND METHODS

A retrospective case-control study was conducted on 1221 women who delivered between 37 and 42 weeks of gestation between July 2014 and January 2015. Data on the subjects' socioeconomic and demographic characteristics, pregnancy outcomes, and hemoglobin levels within 24 h prior to delivery were collected. The study population was divided into two groups on the basis of the presence of anemia within 24 h prior to delivery. Anemia was defined as a hemoglobin level of <11 g/dL. The prevalence of pre-delivery anemia was estimated, and antenatal predictors of anemia were determined using multivariate logistic regression analysis.

RESULTS

The prevalence of anemia in women attending our center for delivery was 41.6% [95% confidence interval (CI) =38.84-44.37]. After multivariate logistic regression analysis, parity >3 [odds ratio (OR) =1.82, 95% CI=1.24-2.96, p=0.002], illiterate (OR=2.23, 95% CI=1.35-3.45, p=0.001) and primary educational level (OR=2.01, 95% CI=1.28-3.39, p=0.008), household monthly income per person <250 Turkish liras (OR=2.34, 95% CI=1.49-3.89, p<0.001), first admission at second (OR=1.63, 95% CI=1.24-2.81, p=0.006) and third trimester (OR=2.45, 95% CI=1.41-4.06, p<0.001), number of antenatal visits <5 (OR=1.45, 95% CI=10.5-2.11) and 5-10 (OR=1.3, 95% CI=1.03-2.09), duration of iron supplementation <3 months (OR=2.62, 95% CI=1.51-4.17) and 3-6 months (OR=1.68, 95% CI=1.13-2.91), and occurrence of preeclampsia (OR=1.55, 95% CI=1.03-2.1, p=0.041) were independently associated with anemia.

CONCLUSION

Socioeconomic determinants constitute most of the anemia cases and, hence, should be considered as major risk factors of anemia in women attending for delivery at term.

Intermittent oral iron supplementation during pregnancy

BACKGROUND

Anaemia is a frequent condition during pregnancy, particularly among women in low- and middle-income countries. Traditionally, gestational anaemia has been prevented with daily iron supplements throughout pregnancy, but adherence to this regimen due to side effects, interrupted supply of the supplements, and concerns about safety among women with an adequate iron intake, have limited the use of this intervention. Intermittent (i.e. two or three times a week on non-consecutive days) supplementation has been proposed as an alternative to daily supplementation.

OBJECTIVES

To assess the benefits and harms of intermittent supplementation with iron alone or in combination with folic acid or other vitamins and minerals to pregnant women on neonatal and pregnancy outcomes.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 July 2015), the WHO International Clinical Trials Registry Platform (ICTRP) (31 July 2015) and contacted relevant organisations for the identification of ongoing and unpublished studies (31 July 2015).

SELECTION CRITERIA

Randomised or quasi-randomised trials.

DATA COLLECTION AND ANALYSIS

We assessed the methodological quality of trials using standard Cochrane criteria. Two review authors independently assessed trial eligibility, extracted data and conducted checks for accuracy.

MAIN RESULTS

This review includes 27 trials from 15 countries, but only 21 trials (with 5490 women) contributed data to the review. All studies compared daily versus intermittent iron supplementation. The methodological quality of included studies was mixed and most had high levels of attrition.The overall assessment of the quality of the evidence for primary infant outcomes was low and for maternal outcomes very low.Of the 21 trials contributing data, three studies provided intermittent iron alone, 14 intermittent iron + folic acid and four intermittent iron plus multiple vitamins and minerals in comparison with the same composition of supplements provided in a daily regimen.Overall, for women receiving any intermittent iron regimen (with or without other vitamins and minerals) compared with a daily regimen there was no clear evidence of differences between groups for any infant primary outcomes: low birthweight (average risk ratio (RR) 0.82; 95% confidence interval (CI) 0.55 to 1.22; participants = 1898; studies = eight; low quality evidence), infant birthweight (mean difference (MD) 5.13 g; 95% CI -29.46 to 39.72; participants = 1939; studies = nine; low quality evidence), premature birth (average RR 1.03; 95% CI 0.76 to 1.39; participants = 1177; studies = five; low quality evidence), or neonatal death (average RR 0.49; 95% CI 0.04 to 5.42; participants = 795; studies = one; very low quality). None of the studies reported congenital anomalies.For maternal outcomes, there was no clear evidence of differences between groups for anaemia at term (average RR 1.22; 95% CI 0.84 to 1.80; participants = 676; studies = four; I² = 10%; very low quality). Women receiving intermittent supplementation had fewer side effects (average RR 0.56; 95% CI 0.37 to 0.84; participants = 1777; studies = 11; I² = 87%; very low quality) and were at lower risk of having high haemoglobin (Hb) concentrations (greater than 130 g/L) during the second or third trimester of pregnancy (average RR 0.53; 95% CI 0.38 to 0.74; participants = 2616; studies = 15; I² = 52%; (this was not a primary outcome)) compared with women receiving daily supplements. There were no significant differences in iron-deficiency anaemia at term between women receiving intermittent or daily iron + folic acid supplementation (average RR 0.71; 95% CI 0.08 to 6.63; participants = 156; studies = one). There were no maternal deaths (six studies) or women with severe anaemia in pregnancy (six studies). None of the studies reported on iron deficiency at term or infections during pregnancy.Most of the studies included in the review (14/21 contributing data) compared intermittent oral iron + folic acid supplementation compared with daily oral iron + folic acid supplementation (4653 women) and findings for this comparison broadly reflect findings for the main comparison (any intermittent versus any daily regimen).Three studies with 464 women examined supplementation with intermittent oral iron alone compared with daily oral iron alone. There were no clear differences between groups for mean birthweight, preterm birth, maternal anaemia or maternal side effects. Other primary outcomes were not reported.Four studies with a combined sample size of 412 women compared intermittent oral iron + vitamins and minerals supplementation with daily oral iron + vitamins and minerals supplementation. Results were not reported for any of the review's infant primary outcomes. One study reported fewer maternal side effects in the intermittent iron group, and two studies that more women were anaemic at term compared with those receiving daily supplementation.Where sufficient data were available for primary outcomes, we set up subgroups to look for possible differences between studies in terms of earlier or later supplementation; women's anaemia status at the start of supplementation; higher and lower weekly doses of iron; and the malarial status of the region in which the trials were conducted. There was no clear effect of these variables on results.

AUTHORS' CONCLUSIONS

This review is the most comprehensive summary of the evidence assessing the benefits and harms of intermittent iron supplementation in pregnant women on haematological and pregnancy outcomes. Findings suggest that intermittent regimens produced similar maternal and infant outcomes as daily supplementation but were associated with fewer side effects and reduced the risk of high levels of Hb in mid and late pregnancy, although the risk of mild anaemia near term was increased. While the quality of the evidence was assessed as low or very low, intermittent may be a feasible alternative to daily iron supplementation among those pregnant women who are not anaemic and have adequate antenatal care.

The HFE genotype and a formulated diet controlling for iron status attenuate experimental cerebral malaria in mice

Plasmodium falciparum infects approximately 500million individuals each year. A small but significant number of infections lead to complications such as cerebral malaria. Cerebral malaria is associated with myelin damage and neurological deficits in survivors, and iron status is thought to impact the outcome of infection. We evaluated whether a mouse model of experimental cerebral malaria with Plasmodium berghei ANKA strain was altered by dietary iron deficiency or genetic iron overload (H67D HFE). We found that H67D mice had increased survival over H67H (wild type) mice. Moreover, a specifically designed formulation diet increased survival regardless of whether the diet was iron deficient or iron adequate. To determine potential mechanisms underlying demyelination in experimental cerebral malaria, we measured Semaphorin4A (Sema4A) protein levels in the brain because we found it is cytotoxic to oligodendrocytes. Sema4A was increased in wild type mice that developed experimental cerebral malaria while consuming standard rodent chow, consistent with a decrease in myelin basic protein, an indicator of myelin integrity. The brains of iron deficient and H67D mice had lower levels of Sema4A. Myelin basic protein was decreased in brains of mice fed the iron deficient diet as has been previously reported. We also examined erythropoietin, which is under consideration for treatment of cerebral malaria, and IL-6, which is known to increase during infection. We found that plasma erythropoietin was elevated and IL-6 was low in H67D mice and in the mice fed the formulation diets. These data reveal a paradigm-shifting concept that maintaining iron status may not increase the mortality associated with malaria and provide a dietary strategy for further examination. Moreover, the data provide clues for exploring the mechanism to limit the co-morbidity associated with experimental cerebral malaria that appears to include decreased Sema4A in brain as well as elevated erythropoietin and lower IL-6 in plasma.

Daily oral iron supplementation during pregnancy

BACKGROUND

Iron and folic acid supplementation has been the preferred intervention to improve iron stores and prevent anaemia among pregnant women, and it is thought to improve other maternal and birth outcomes.

OBJECTIVES

To assess the effects of daily oral iron supplements for pregnant women, either alone or in conjunction with folic acid, or with other vitamins and minerals as a public health intervention in antenatal care.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (10 January 2015). We also searched the WHO International Clinical Trials Registry Platform (ICTRP) (26 February 2015) and contacted relevant organisations for the identification of ongoing and unpublished studies (26 February 2015) .

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

We assessed the methodological quality of trials using standard Cochrane criteria. Two review authors independently assessed trial eligibility, extracted data and conducted checks for accuracy. We used the GRADE approach to assess the quality of the evidence for primary outcomes.We anticipated high heterogeneity among trials and we pooled trial results using a random-effects model and were cautious in our interpretation of the pooled results: the random-effects model gives the average treatment effect.

MAIN RESULTS

We included 61 trials. Forty-four trials, involving 43,274 women, contributed data and compared the effects of daily oral supplements containing iron versus no iron or placebo.Preventive iron supplementation reduced maternal anaemia at term by 70% (risk ratio (RR) 0.30; 95% confidence interval (CI) 0.19 to 0.46, 14 trials, 2199 women, low quality evidence), iron-deficiency anaemia at term (RR 0.33; 95% CI 0.16 to 0.69, six trials, 1088 women), and iron deficiency at term by 57% (RR 0.43; 95% CI 0.27 to 0.66, seven trials, 1256 women, low quality evidence). There were no clear differences between groups for severe anaemia in the second or third trimester, or maternal infection during pregnancy (RR 0.22; 95% CI 0.01 to 3.20, nine trials, 2125 women, very low quality evidence; and, RR 1.21; 95% CI 0.33 to 4.46; one trial, 727 women, low quality evidence, respectively), or maternal mortality (RR 0.33; 95% CI 0.01 to 8.19, two trials, 12,560 women, very low quality evidence), or reporting of side effects (RR 1.29; 95% CI 0.83 to 2.02, 11 trials, 2423 women, very low quality evidence). Women receiving iron were on average more likely to have higher haemoglobin (Hb) concentrations at term and in the postpartum period, but were at increased risk of Hb concentrations greater than 130 g/L during pregnancy, and at term.Compared with controls, women taking iron supplements less frequently had low birthweight newborns (8.4% versus 10.3%, average RR 0.84; 95% CI 0.69 to 1.03, 11 trials, 17,613 women, low quality evidence), and preterm babies (RR 0.93; 95% CI 0.84 to 1.03, 13 trials, 19,286 women, moderate quality evidence). They appeared to also deliver slightly heavier babies (mean difference (MD) 23.75; 95% CI -3.02 to 50.51, 15 trials, 18,590 women, moderate quality evidence). None of these results were statistically significant. There were no clear differences between groups for neonatal death (RR 0.91; 95% CI 0.71 to 1.18, four trials, 16,603 infants, low quality evidence), or congenital anomalies (RR 0.88, 95% CI 0.58 to 1.33, four trials, 14,636 infants, low quality evidence).Twenty-three studies were conducted in countries that in 2011 had some malaria risk in parts of the country. In some of these countries/territories, malaria is present only in certain areas or up to a particular altitude. Only two of these studies reported malaria outcomes. There is no evidence that iron supplementation increases placental malaria. For some outcomes heterogeneity was higher than 50%.

AUTHORS' CONCLUSIONS

Supplementation reduces the risk of maternal anaemia and iron deficiency in pregnancy but the positive effect on other maternal and infant outcomes is less clear. Implementation of iron supplementation recommendations may produce heterogeneous results depending on the populations' background risk for low birthweight and anaemia, as well as the level of adherence to the intervention.

Multiple micronutrient powders for home (point-of-use) fortification of foods in pregnant women

BACKGROUND

It is estimated that 32 million pregnant women suffer from anaemia worldwide. Due to increased metabolic demands, pregnant women are particularly vulnerable to anaemia and vitamin and mineral deficiencies, leading to adverse health effects in both the mother and her baby. Despite the demonstrated benefits of prenatal supplementation with iron and folic acid or multiple micronutrients, poor adherence to routine supplementation has limited the effectiveness of this intervention in many settings. Micronutrient powders for point-of-use fortification are packed, single-dose sachets containing vitamins and minerals that can be added onto prepared food to improve its nutrient profile. The use of multiple micronutrient powders for point-of-use fortification of foods in pregnant women could be an alternative intervention to prenatal micronutrient supplementation.

OBJECTIVES

To assess the effects of prenatal home (point-of-use) fortification of foods with multiple micronutrient powders on maternal and newborn health.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 January 2015) and the International Clinical Trials Registry Platform (ICTRP) (31 January 2015). We also contacted relevant agencies to identify ongoing and unpublished studies.

SELECTION CRITERIA

Randomised controlled trials (both individual and cluster randomisation) and quasi-randomised trials, irrespective of language or publication status.The intervention was micronutrient powders for point-of-use fortification of foods, containing at least three micronutrients with one of them being iron, provided to pregnant women of any gestational age and parity. Five comparison groups were considered: no intervention/placebo, iron and folic acid supplements, iron-only supplements, folic-acid only supplements, and multiple micronutrients in supplements.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the eligibility of studies, extracted and checked data accuracy, and assessed the risk of bias of included studies.

MAIN RESULTS

Our search identified 12 reports (relating to six studies). We included two cluster-randomised controlled trials (involving 1172 women) - these trials were considered to be at a moderate to high risk of bias due to methodological limitations. One trial is ongoing, and three studies were excluded. Micronutrient powders for point-of-use fortification of foods versus iron and folic acid supplementsOne trial (involving 478 pregnant women attending 42 antenatal care centres) compared micronutrient powders containing iron, folic acid, vitamin C and zinc with iron and folic acid tablets provided daily from 14 to 22 weeks to 32 weeks' gestation. The trial did not report on any of this review's primary outcomes: maternal anaemia at or near term, maternal iron deficiency, maternal mortality, adverse effects, low birthweight, preterm births. Nor did the trial report on the majority of this review's secondary outcomes, with the exception of maternal adherence. Adherence to micronutrient powders was lower than adherence to iron and folic acid supplements (risk ratio (RR) 0.76, 95% confidence interval (CI) 0.66 to 0.87, one study, n = 405). Micronutrient powders for point-of-use fortification of foods versus same multiple micronutrients in supplementsOne study (involving 694 pregnant women from 18 communities), compared micronutrient powders containing iron, folic acid, vitamin C, zinc, iodine, vitamin E and vitamin B12 with tablets containing the same seven micronutrients. There was no difference in maternal anaemia at 37 weeks of gestation (RR 0.92, 95% CI 0.53 to 1.59, one study, n = 470, very low quality evidence). The trial did not report on any of this review's other primary outcomes in relation to maternal iron deficiency, maternal mortality, adverse effects, low birthweight, or preterm birth. In terms of this review's secondary outcomes, the included trial did not report on the majority of this review's prespecified secondary outcomes with one exception - there was no clear difference in maternal haemoglobin Hb or near term (mean difference (MD) 1.0 g/L, 95% CI -1.77 to 3.77, one study, n = 470).

AUTHORS' CONCLUSIONS

Limited evidence suggests that micronutrient powders for point-of-use fortification of foods have no clear difference as multiple micronutrient supplements on maternal anaemia (very low quality evidence) and Hb at or near term. There is limited evidence to suggest that women were more likely to adhere to taking tablets than using micronutrient powders.The overall quality of evidence was judged very low (due to methodological limitations), and no evidence was available for the majority of primary and secondary outcomes. Therefore, more evidence is needed to assess the potential benefits or harms of the use of micronutrient powders in pregnant women on maternal and infant health outcomes. Future trials should also assess adherence to micronutrient powders and be adequately powered to evaluate the effects on birth outcomes and morbidity.

Association of genetic variants with response to iron supplements in pregnancy

The incidence of iron deficiency anemia in pregnancy is high in India where iron supplementation is a regular practice. The response to oral iron is influenced by several factors such as age, body mass index, gravida, socioeconomic status, food, vitamin deficiency and compliance to supplements. The major challenge is to understand the various modulators of iron status in this high-risk group so that we can improve the diagnosis and the management of these patients. The current study was designed to evaluate the iron status during pregnancy and to identify factors which might be influencing their response to oral iron. We investigated a total of 181 pregnant women with anemia (Hb < 11 g/dl) and evaluated the impact of probable factors on anemia and their iron status. Assessment of the response was based on hemoglobin and serum ferritin or transferrin saturation level after 8 and 20 weeks of iron supplementation. Socioeconomic, clinical, hematological, biochemical and genetic factors were all evaluated. Molecular analysis revealed that HFE variant allele (G) (rs1799945) was significantly associated with an adequate response to iron supplementation. We identified five subjects with a sustained poor response, and targeted re-sequencing of eleven iron-related genes was performed in them. We have identified seven novel variants in them, and in silico analysis suggested that these variants may have an iron regulatory effect. Taken together, our findings underscore the association of genetic variants with response to supplements in pregnancy, and they can be extended to other diseases where anemia and iron deficiency coexist.

Post-partum anemia and factors that work against alleviation of the anemia

AIM

This study aimed to clarify conditions of women experiencing post-partum anemia and identify factors that work against the alleviation of anemia.

METHODS

This was a retrospective longitudinal study, involving 246 women giving birth at five participating institutions, diagnosed with anemia on day 3 post-partum, and given a blood sample at the medical examination 1 month after the birth. With answers about alleviation of anemia during the 1 month post-partum period as an objective variable, and explanatory variables, multiple logistic regression analysis was performed. The explanatory variables included demographic data of the participants, information about anemia, following the nutrition instruction advice for anemia alleviation, family structure and others assisting the participants, and self-management skills (measured by the Self-Management Skill [SMS] scale).

RESULTS

The present authors collected 211 valid responses; the average age was 32.6 years. The mean hemoglobin values on the 3rd and 30th days post-partum were 9.6 and 12.0 g/dL, respectively. One fifth of the participants (21.3%) showed no anemia alleviation. The mean value on the SMS scale was 28.35, and the anemia alleviated group (30.78) was significantly higher than the non-alleviated group (19.38). Results of the multiple logistic regression analysis showed a strong relationship between anemia risk and self-management skills. The absence of anemia alleviation increased 2.51 times as the total score of the SMS decreased 1 point.

CONCLUSION

There is an urgent need to develop an intervention program to alleviate post-partum anemia focusing on the low score items because self-management skills strongly affect alleviation improvement.

Survey of women's perceptions of information provided in the prevention or treatment of iron deficiency anaemia in an Australian tertiary obstetric hospital

BACKGROUND

There is limited literature to understand the perceptions of Australian women regarding the information provided by healthcare professionals relating to the prevention and treatment of iron deficiency anaemia in pregnancy.

AIM

To establish an insight into the key themes and trends within a tertiary obstetric hospital related to the provision of dietary advice and use of iron supplements in pregnancy.

METHODS

A prospective patient survey of pregnant women and women up to 4 weeks postnatal attending hospital.

FINDINGS

Of the 110 women who participated, 73.6% were provided with information on iron rich foods and 67% made dietary changes. Eighty percent of women were advised to take oral iron and 65.5% of women were taking it at the time of the survey. In women who had independently ceased oral iron, 41.7% failed to inform their healthcare professional. In the women who did inform their healthcare professional 89.5% received advice to help overcome the reason that led to cessation. The main causes included forgetfulness and side effects. Women were less likely to require intravenous iron if oral iron was commenced early.

CONCLUSIONS

Compliance with recommended oral iron is variable within a population of pregnant women. Women are provided with information on a range of issues relating to the prevention and treatment of iron deficiency anaemia; yet there is a disparity between the information provided and the resulting action. Further research should focus on targeted measures to improve understanding and compliance with treatment from the both women's and health professionals perspective.

Maternal intake of supplemental iron and risk of autism spectrum disorder

Iron deficiency affects 40%-50% of pregnancies. Iron is critical for early neurodevelopmental processes that are dysregulated in autism spectrum disorder (ASD). We examined maternal iron intake in relation to ASD risk in California-born children enrolled in a population-based case-control study (the Childhood Autism Risks from Genetics and the Environment (CHARGE) Study) from 2003 to 2009 with a diagnosis of ASD (n = 520) or typical development (n = 346) that was clinically confirmed using standardized assessments. Mean maternal daily iron intake was quantified on the basis of frequency, dose, and brands of supplements and cereals consumed each month from 3 months before pregnancy through the end of pregnancy and during breastfeeding (the index period), as reported in parental interviews. Mothers of cases were less likely to report taking iron-specific supplements during the index period (adjusted odds ratio = 0.63, 95% confidence interval: 0.44, 0.91), and they had a lower mean daily iron intake (51.7 (standard deviation, 34.0) mg/day) than mothers of controls (57.1 (standard deviation, 36.6) mg/day; P = 0.03). The highest quintile of iron intake during the index period was associated with reduced ASD risk compared with the lowest (adjusted odds ratio = 0.49, 95% confidence interval: 0.29, 0.82), especially during breastfeeding. Low iron intake significantly interacted with advanced maternal age and metabolic conditions; combined exposures were associated with a 5-fold increased ASD risk. Further studies of this link between maternal supplemental iron and ASD are needed to inform ASD prevention strategies.

A question mark on iron deficiency in 185 million people of Pakistan: its outcomes and prevention

Micronutrient deficiency especially the iron deficiency is the bane of our lives, affecting all strata of society. Unfortunately, the women during pregnancy, adolescence, and children are under this curse particularly in developing countries like Pakistan. It is one of the biggest reasons of complications during pregnancy and malnourished children under five years of age. Maternal death, still-births, and underweight births are most common consequences of iron deficiency and these outbreaks as iron-deficiency anemia in Pakistan. Disastrous nature of iron deficiency requires an urgent call to eradicate it. Hence, the solution should not be frail comparing with the huge economic loss and other incompatibilities. Flour fortification, supplementation, dietary diversification, and especially maternal education are possible solutions for combating this micronutrient deficiency.

Preventing vitamin B12 deficiency in South Asian women of childbearing age: a randomised controlled trial comparing an oral vitamin B12 supplement with B12 dietary advice

BACKGROUND/OBJECTIVES

To examine the effectiveness, acceptability and sustainability of interventions to reduce vitamin B12 (B12) deficiency in South Asian women before conception.

SUBJECTS/METHODS

A 6-month randomised controlled trial conducted in Auckland, New Zealand. Participants (62 South Asian women, 18-50 years old) were stratified by dietary practices, then randomised to three treatment groups: B12 Supplement (oral cyanocobalamin 6 μg/day) (n=21), Placebo (n=21), or B12 Dietary Advice (n=20). Primary outcome measures were changes in B12 biomarkers (serum B12 and holotranscobalamin (holoTC)) at 6 months. Dietary B12 intake was estimated from a B12 food-specific frequency questionnaire (B12FFQ). Intention-to-treat analysis was applied using 'last observation carried forward' method. Changes in B12 biomarkers by treatment were compared using analysis of variance. Pearson's correlations tested relationships between dietary B12 intake and B12 biomarkers.

RESULTS

At baseline, 48% of women tested as insufficient or deficient in serum B12 (<222 pmol/l) and 51% as insufficient or deficient in holoTC (<45 pmol/l). B12 status was moderately correlated with dietary B12 intake (r=0.5, 95% confidence interval (CI) (0.3-0.7)) and 44% of women reported insufficient dietary intake (<2.4 μg/day). B12 Supplement was the only treatment group to record a significant increase in B12 biomarkers over 6 months: serum B12 by 30% (95% CI (11-48%)) and holoTC by 42% (12-72%).

CONCLUSIONS

The prevalence of B12 insufficiency among Auckland South Asian women is high and moderately correlated with inadequate intake of foods that contain B12. Cyanocobalamin supplementation (6 μg/day) was associated with improved B12 biomarkers, with a potential to improve preconception B12 status in South Asian women.