Iron supplementation in early childhood: health benefits and risks

Spectrochemical Analysis of Nutritional and Toxic Metals in Different Brands of Candies Using Advanced Diagnostic Approaches

Candies are frequently consumed sweetened food products among children, and their consumption can expose them to potential toxins and contamination. The present study employed calibration-free-laser-induced breakdown spectroscopy (CF-LIBS) as a steadfast diagnostic technique to analyze the presence of nutritional and heavy metals in candies from various brands available in local markets in Haripur, Pakistan. A pulsed Nd-YAG laser was used to create a microplasma on the target surface. The emitted light was collected using a dedicated spectrometer to analyze and quantify the species present in the candies. The analysis revealed the presence of micronutrients, macronutrients, and trace toxic metals such as Ca, K, Mg, Fe, Na, Al, Pb, Cr, Mn, Zn, Cu, and Ni. The optimization of our LIBS system was achieved through a parametric dependence study. The confirmation of the assumption of local thermodynamic equilibrium was achieved by assessing McWhirter's criterion and considering the relaxation time and the diffusion length of atoms in plasma. The highest concentrations (measured in mg/kg) of Pb, Cr, and Mn were determined to be 15 mg/kg, 340 mg/kg, and 880 mg/kg, respectively. The levels of Pb and Cr were found to be well above the maximum accepted limit set by the WHO. Similarly, the concentration of Mn in S-4 and S-5 exceeded the permissible limits set by the WHO. However, Zn, Cu, and Ni were found within safe limits in all the collected samples. In addition, the abundance obtained through CF-LIBS was compared to the concentration of similar (duplicate) candies samples analyzed using a standard analytical technique like inductively coupled plasma-optical emission spectroscopy. Excellent harmony could be seen in both outcomes. Moreover, energy-dispersive X-ray spectroscopy (EDX) was also utilized to confirm the presence of detected toxins. The significance of our findings lies in creating awareness among the public about the health risks associated with consuming toxins through candies, thereby protecting numerous human lives.

Childhood undernutrition mediates the relationship between open defecation with anemia among Ethiopian children: a nationally representative cross-sectional study

BACKGROUND

Poor sanitation and/or open defecation are a significant public health problem in Ethiopia, where access to improved sanitation facilities is still limited. There is a growing body of literature about the effect of open defecation on children's linear growth failure. However, very few studies about the effects of open defecation on child anemia exist. In this study, we examine whether childhood undernutrition (i.e. stunting, wasting, and underweight) mediates the relationship between open defecation and childhood anemia in children aged 6-59 months in Ethiopia.

METHODS

We used pooled Ethiopia Demographic and Health Survey data (2005-2016) comprising 21,918 (weighted data) children aged 6-59 months. Anemia was defined as an altitude-adjusted hemoglobin (Hb) level of less than 11 g/deciliter (g/dl) for children under 5 years. Childhood undernutrition was assessed using height-for-age Z-scores (HAZ), weight-for-age Z-scores (WAZ), and weight-for-height Z-scores (WHZ) for stunting, wasting, and underweight respectively. Mediation effects were calculated using the bootstrap and the indirect effect was considered significant when the 95% bootstrap confidence intervals (95% CI) did not contain zero. Moreover, separate multilevel regression analyses were used to explore the statistical association between open defecation and child anemia, after adjusting for potential confounders.

RESULTS

Our analysis revealed that nearly half (49.6%) of children aged 6 to 59 months were anemic, 46.8% were stunted, 9.9% were wasted, and 29.5% were underweight. Additionally, 45.1% of children belonged to households that practiced open defecation (OD). Open defecation was associated with anemia (AOR: 1.28; 95% CI: 1.18-1.39) and it positively predicted anemia with direct effect of β = 0.233, p < 0.001. Childhood undernutrition showed a partial mediating role in the relationship between OD and anemia. Analyzing the indirect effects, results revealed that child undernutrition significantly mediated the relationship between open defecation and anemia (stunting (βindirect = 0.014, p < 0.001), wasting (βindirect = 0.009, p = 0.002), and underweight (βindirect = 0.012, p < 0.001)). When the mediating role of child undernutrition was accounted for, open defecation had a positive impact on anemia with a total effect of βtotal = 0.285, p < 0.001.

CONCLUSION

Open defecation showed a significant direct effect on anemia. Child undernutrition remarkably mediated the relationship between OD and anemia that further magnified the effect. This finding has an important programmatic implication calling for strengthened, accelerated and large-scale implementation of strategies to end open defecation and achieve universal access to sanitation in Ethiopia.

Use of Different Iron Preparations for Prophylaxis and Effects on Iron Status in Infancy

Aim: To evaluate using different iron preparations for iron deficiency and/or iron deficiency anemia prophylaxis in infants and their iron status. Methods: In this study, we retrospectively evaluated the electronic patient records of 651 healthy children aged 9 to 13 months who met the inclusion criteria and who were followed up in pediatric follow-up outpatient clinics between January 2023 and June 2023. Results: A total of 651 children with a mean age of 11.2 ± 1.4 months, 54.7% of whom were boys, who met the inclusion criteria were included in the study; 56.5% of the children were using Fe + 3 salt and the others were using Fe + 2 salt, microencapsulated iron, or sucrosomial iron drops. After the fifth month of prophylaxis, when the effects of the iron preparations used on the mean laboratory values were evaluated, it was found that hemoglobin, serum iron, and ferritin levels were lower in sucrosomial iron and microencapsulated iron users compared to other preparations (p = 0.001). When statistically pairwise comparisons were made between the groups, hemoglobin and serum iron values were found to be lower in the group using sucrosomial iron compared to the groups using Fe + 2 and Fe + 3 salts (p < 0.0001). Hemoglobin and ferritin levels were higher in the group using Fe + 2 salt compared to both sucrosomial iron and microencapsulated iron groups (p < 0.0001). When the infants were evaluated according to iron status, it was found that 208 (31.9%) had iron deficiency. Iron deficiency was found to be less in infants of families who defined their economic status as rich and in infants who used iron regularly (p-values 0.044 and 0.001, respectively). Iron deficiency/iron deficiency anemia was observed at a higher rate in the group using sucrosomial iron and microencapsulated iron prophylaxis (p = 0.001). Conclusions: To prevent iron deficiency, it is very important to use appropriate iron preparations for prophylaxis and to feed foods with high iron content. Although we found that families were willing to use different iron preparations other than iron salts for their infants, the results presented herein indicate that the rate of iron deficiency was lower in patients using iron salts. However, randomized controlled studies are needed to determine whether these preparations are effective in iron prophylaxis in infants.

Eating behavior during pregnancy mediates the association between depression and diet quality--a new strategy for intervention in pregnancy

Background

Depression can result in changes in eating behavior and decrease the quality of eating. It has been shown that maternal depression during pregnancy can result in malnutrition, which can have adverse effects on the pregnancy and the offspring. There is currently no clear association between depression and diet.

Methods

Five hundred and forty-nine pregnant women recruited from Danyang Maternal and Child Health Hospital in Jiangsu Province participated in this study and were administered the Intuitive Eating Scale-2 (IES-2), Edinburgh Post-natal Depression Scale (EPDS), Pregnancy Stress Scale (PPS), Self-rating Anxiety Scale (SAS), and Dietary Guidelines Adherence Index for Pregnant Women during Pregnancy (CDGCI-PW). The nutritional software collected dietary records for three consecutive days in mid-pregnancy to calculate dietary intake and nutrients that support energy production. The mediation analyses were conducted using SPSS 24.0 macro PROCESS.

Results

The relationship between depressive symptoms during pregnancy and diet quality was moderated primarily by two aspects of eating behavior, "Reliance on Hunger and Satiety Cues" (RHS) and "Body-Food Choice Congruence" (BFC). Depressive symptoms (EPDS scores) showed a negative correlation with RHS, BFC, and RHS, and BFC showed a positive correlation with diet quality, yielding a significant specific indirect effect. The multiple mediation model explained 14.7% of the variance in the diet quality.

Conclusion

This study highlights the important role of eating behaviors during pregnancy in the relationship between depressive symptoms (EPDS scores) and diet quality, and provides preliminary evidence for feasible ways pregnant women with depressive symptoms can improve diet quality, promote maternal and child health, and reduce depression.

Global warming may significantly increase childhood anemia burden in sub-Saharan Africa

Childhood anemia constitutes a global public health problem, especially in low- and middle-income countries (LMICs). However, it remains unknown whether global warming has an impact on childhood anemia. Here, we examined the association between annual temperatures and childhood anemia prevalence in sub-Saharan Africa and then projected childhood anemia burden attributable to climate change. Each 1°C increment in annual temperature was associated with increased odds of childhood anemia (odd ratio = 1.138, 95% confidence interval: 1.134-1.142). Compared with the baseline period (1985-2014), the attributable childhood anemia cases would increase by 7,597 per 100,000 person-years under a high-emission scenario in the 2090s, which would be almost 2-fold and over 3-fold more than those projected in moderate- and low-emission scenarios. Our results reveal the vulnerabilities and inequalities of children for the excess burden of anemia due to climate warming and highlight the importance of climate mitigation and adaptation strategies in LMICs.

Iron Status of Preadolescents Without Clinical Pallor Attending a Tertiary Care Hospital in South India- A Cross-Sectional Analytical Study

OBJECTIVES

To determine the prevalence of Iron Deficiency (ID) in children without clinical pallor using serum ferritin and the new parameters, soluble transferrin receptor (sTfR) & the ratio of sTfR/log10 serum ferritin (sTfR-F index), as suggested by WHO. Also to assess whether these new parameters could individually predict the presence of ID.

METHODS

Consecutive 230 healthy children aged 9-11 y without clinical pallor underwent estimation of Hemoglobin (Hb), C-Reactive Protein (CRP), serum ferritin, sTfR, and sTfR-F index levels in their blood. The abilities of the sTfR and sTfR-F index in predicting ID were determined by comparing with the gold standard (normal CRP and less serum ferritin), plotting Receiver-operating characteristic (ROC) curve, and noting the area under the curve (AUC).

RESULTS

The blood reports of 114 boys and 106 girls (total = 220) were available for analysis. Overall, 57 (31 girls, 26 boys) children had ID; among children with low CRP, 45 had ID, as suggested by low serum ferritin levels. Among children with high CRP, 12 had evidence of ID as evidenced by elevated sTfR and/or sTfR-F index. The positive predictive values of both sTfR and sTfR-F were low (32.9% and 35.9%, respectively) than the negative predictive values (85.6% and 95.3%, respectively).

CONCLUSIONS

The proportion of children identified to have ID using serum ferritin, sTfR, and sTfR-index was 25.9%. sTfR and/or sTfR-F index are unlikely to be ideal individual predictors of ID.

Iron supplementation given to nonanemic infants: neurocognitive functioning at 16 years

OBJECTIVE

There is concern that high iron uptake during the critical period of early brain development carries potential risks, especially for nonanemic infants. This study examined the neurocognitive functioning of 16-year-olds who were nonanemic as infants and received iron supplementation.

METHODS

We studied 562 Chilean adolescents (M 16.2 years; 52.7% female) who participated in a randomized controlled iron supplementation trial in infancy. Between 6 and 12 months, 346 consumed an iron-fortified formula (12.7 Fe mg/L) or, if primarily breastfed, liquid vitamins with 15 mg elemental iron as ferrous sulfate, and 216 consumed unmodified cow milk without iron or liquid vitamins without iron if primarily breastfed.

RESULTS

Compared to adolescents in the no-added iron condition in infancy, those in the iron-supplemented condition had poorer visual-motor integration, quantitative reasoning skills, and incurred more errors on neurocognitive tasks. Consuming larger amounts of iron-fortified formula in infancy was associated with lower arithmetic achievement. Of adolescents who had high hemoglobin at 6 months (Hb ≥ 125 g/L), those in the iron supplemented condition had poorer performance on arithmetic, quantitative reasoning, and response inhibition tests than those in the no-added iron condition. Of adolescents who had marginally low 6-month hemoglobin (Hb > 100 and < 110 g/L), those who received no-added iron incurred more errors on a visual searching task than those in the iron-supplemented condition.

CONCLUSION

The physiologic need for iron during the period of rapid and critical brain development in young infants should be considered vis-à-vis the risks associated with supplementing nonanemic infants with high levels of iron.Clinical Trials number: NCT01166451.

Intravenous Iron-Carbohydrate Nanoparticles and Their Similars. What Do We Choose?

Anemia is highly prevalent worldwide and iron deficiency is the first cause. Iron deficiency has not only hematologic effects but also non-hematologic effects - immune, metabolic, cognitive dysfunctions and poor cardiovascular and renal outcomes - which generally precede anemia. Iron therapy not only significantly improves the hematological parameters but also has non-hematologic benefits. Given that its efficacy and safety has been revealed over the years, intravenous (IV) iron therapy is frequently used. Intravenous iron products are nanoparticles largely consisting in an iron core surrounded by a carbohydrate shell. They are classified as non-biological complex molecules, being different from small commonly used molecules, with properties and biological behavior impossible to be completely characterized only by physicochemical analysis. To date, there is no appropriate regulatory evaluation system for these medicines and several follow-on versions of the IV iron originators (e.g., iron sucrose) were approved using the same regulatory pathway as for generics. Because of this vulnerability in an adequate pathway for approval, both non-clinical and clinical studies suggested no therapeutic equivalence (thus no interchangeability) between iron sucrose originator (Venofer®), and iron sucrose similars. In this review we aimed to underline the importance of intravenous iron therapy as well as raise awareness regarding the differences between nanomedicines and their intended similar but not identical copies. The potential implications of these differences impact patients (safety, efficacy) but also the medical system (higher costs).

Iron Supplementation at the Crossroads of Nutrition and Gut Microbiota: The State of the Art

Gut microbiota has received significant attention owing to its decisive role in human health and disease. Diet exerts a significant influence on the variety and number of bacteria residing in the intestinal epithelium. On the other hand, as iron is a key micronutrient for blood formation and oxygen supply, its deficiency is highly prevalent worldwide. In fact, it is the most common cause of anemia and thus, iron supplementation is widespread. However, there is concern due to some potential risks linked to iron supplementation. Therefore, we have reviewed the available evidence of the effects that iron supplementation exerts on the gut microbiota as well as its potential benefits and risks. The compiled information suggests that iron supplementation is potentially harmful for gut microbiota. Therefore, it should be performed with caution, and by principle, recommended only to individuals with proven iron deficiency or iron-deficiency anemia to avoid potential adverse effects. In any case, large and long-term population studies are urgently needed to confirm or refute these results, mainly focused on vulnerable populations.

Effects of iron intake on neurobehavioural outcomes in African children: a systematic review and meta-analysis of randomised controlled trials

Background: Iron deficiency and developmental delay are common in African children. While experimental studies indicate an important role of iron in brain development, effects of iron on child development remain unclear. We aimed to evaluate the effects of iron supplementation or fortification on neurobehavioural outcomes in African children and further summarise these effects in children living in non-African countries for comparison. Methods: We searched PubMed, EMBASE, PsycINFO, Scopus and Cochrane Library for studies published up to 22 nd October 2021. We included randomised controlled trials (RCTs) evaluating effects of iron supplementation or fortification on neurobehavioural outcomes in children. Due to heterogeneity in study methods, we analysed all studies qualitatively and in secondary analyses only seven RCTs with 11 arms were meta-analysed. Results: We identified 2231 studies and included 35 studies (n=9988) in the systematic review. Only five studies (n=1294) included African children while 30 (n=8694) included children living in non-African countries. Of the five African studies, two (n=647) reported beneficial effects of iron supplementation on neurobehavioural outcomes in anaemic children, while three (n=647) found no beneficial effects. Of 30 studies in children living in non-African countries, 10 (n=3105) reported beneficial effects of iron supplementation or fortification on neurobehavioural outcomes, seven (n=786) reported beneficial effects only in children who had iron deficiency, iron deficiency anaemia or anaemia while 13 (n=4803) reported no beneficial effects. Conclusions: There are few studies in African children despite the high burden of iron deficiency and developmental delay in this population. Evidence on the effects of iron supplementation on neurobehavioural outcomes remains unclear and there is need for further well-powered studies evaluating these effects in African populations. PROSPERO registration: CRD42018091278 (20/03/2018).

Vitamin C supplementation for prevention and treatment of pneumonia

BACKGROUND

According to the Global Burden of Disease Study 2015, lower respiratory tract infection is the leading cause of infectious disease death, and the fifth most common cause of death overall. Vitamin C has a role in modulating resistance to infectious agents, therefore vitamin C supplementation may be important in preventing and treating pneumonia.

OBJECTIVES

To assess the impact of vitamin C supplementation to prevent and treat pneumonia in children and adults.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, PubMed, CINAHL, LILACS, Web of Science, and two trials registers to 4 March 2020. We also checked references to identify additional studies. We did not apply any publication status or language filters.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs (studies using allocation methods that are not random, e.g. date of birth, medical record number) assessing the role of vitamin C supplementation in the prevention and treatment of pneumonia in children and adults compared to control or placebo.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included five studies in the review and identified two ongoing studies. The five included studies involved a total of 2655 participants; two studies were RCTs and three were quasi-RCTs. The included studies were conducted in one high-income country (USA) and three lower-middle-income countries (Bangladesh and Pakistan). Three studies were conducted in hospital inpatient settings, one in school, and one in a military training centre. Three studies included children under five years of age, one study included school-aged children, and one study included adult participants. Two studies assessed the effect of vitamin C supplementation for pneumonia prevention; and three studies assessed the effect of vitamin C supplementation as an adjunct to pneumonia treatment. For pneumonia prevention, the included studies provided supplementation in doses of 1 g daily for 14 weeks, 2 g daily for 8 weeks, and 2 g daily for 14 weeks. For pneumonia treatment, the included studies provided vitamin C supplementation in doses of 125 mg daily and 200 mg daily until the symptoms resolved or discharge, as an adjunct to the pneumonia treatment. Overall, the included studies were judged to be at either high or unclear risk of bias for random sequence generation, allocation concealment, and blinding; and the evidence certainty was very low. Two studies assessed the effect of vitamin C supplementation for pneumonia prevention; we judged the certainty of the evidence as very low. We are uncertain about the effect of vitamin C supplementation on pneumonia incidence and adverse events (urticaria). None of the included studies reported other primary outcomes (pneumonia prevalence and mortality) or any of the secondary outcomes. Three studies assessed the effect of vitamin C supplementation as an adjunct to pneumonia treatment; we judged the certainty of the evidence as very low. We are uncertain of the effect of vitamin C supplementation on duration of illness and hospitalisation. None of the included studies reported other primary or secondary outcomes.

AUTHORS' CONCLUSIONS

Due to the small number of included studies and very low certainty of the existing evidence, we are uncertain of the effect of vitamin C supplementation for the prevention and treatment of pneumonia. Further good-quality studies are required to assess the role of vitamin C supplementation in the prevention and treatment of pneumonia.

Iron intake and multiple health outcomes: Umbrella review

Iron is an essential trace element, while excess iron can lead to different levels of physical abnormalities or diseases. This umbrella review aimed to conduct a systematic evaluation of the possible relationships between iron intake and various health outcomes. We retrieved PubMed, Embase, Web of Science, Scopus, and the Cochrane Database of Systematic Reviews from inception through May 2021. A total of 34 meta-analyses with 46 unique health outcomes were identified. Heme iron intake was positively associated with nine outcomes, including colorectal cancer, type 2 diabetes mellitus, and cardiovascular disease mortality, while dietary total iron intake could decrease the risk of colorectal adenoma, esophageal cancer, coronary heart disease, and depression. Iron supplementation was a protective factor against eight outcomes. However, it was associated with decreased length and weight gain. The quality of evidence for most outcomes was "low" or "very low" with the remaining eleven as "high" or "moderate". All outcomes were categorized as class III, IV, or NS based on evidence classification. Although high iron intake has been identified to be significantly associated with a range of outcomes, firm universal conclusions about its beneficial or negative effects cannot be drawn given the low quality of evidence for most outcomes.

Nutrition-specific interventions for preventing and controlling anaemia throughout the life cycle: an overview of systematic reviews

BACKGROUND

Anaemia is a prevalent health problem worldwide. Some types are preventable or controllable with iron supplementation (pills or drops), fortification (sprinkles or powders containing iron added to food) or improvements to dietary diversity and quality (e.g. education or counselling).

OBJECTIVES

To summarise the evidence from systematic reviews regarding the benefits or harms of nutrition-specific interventions for preventing and controlling anaemia in anaemic or non-anaemic, apparently healthy populations throughout the life cycle.

METHODS

In August 2020, we searched MEDLINE, Embase and 10 other databases for systematic reviews of randomised controlled trials (RCTs) in anaemic or non-anaemic, apparently healthy populations. We followed standard Cochrane methodology, extracting GRADE ratings where provided. The primary outcomes were haemoglobin (Hb) concentration, anaemia, and iron deficiency anaemia (IDA); secondary outcomes were iron deficiency (ID), severe anaemia and adverse effects (e.g. diarrhoea, vomiting).

MAIN RESULTS

We included 75 systematic reviews, 33 of which provided GRADE assessments; these varied between high and very low. Infants (6 to 23 months; 13 reviews) Iron supplementation increased Hb levels and reduced the risk of anaemia and IDA in two reviews. Iron fortification of milk or cereals, multiple-micronutrient powder (MMNP), home fortification of complementary foods, and supplementary feeding increased Hb levels and reduced the risk of anaemia in six reviews. In one review, lipid-based nutrient supplementation (LNS) reduced the risk of anaemia. In another, caterpillar cereal increased Hb levels and IDA prevalence. Food-based strategies (red meat and fortified cow's milk, beef) showed no evidence of a difference (1 review). Preschool and school-aged children (2 to 10 years; 8 reviews) Daily or intermittent iron supplementation increased Hb levels and reduced the risk of anaemia and ID in two reviews. One review found no evidence of difference in Hb levels, but an increased risk of anaemia and ID for the intermittent regime. All suggested that zinc plus iron supplementation versus zinc alone, multiple-micronutrient (MMN)-fortified beverage versus control, and point-of-use fortification of food with iron-containing micronutrient powder (MNP) versus placebo or no intervention may increase Hb levels and reduce the risk of anaemia and ID. Fortified dairy products and cereal food showed no evidence of a difference on the incidence of anaemia (1 review). Adolescent children (11 to 18 years; 4 reviews) Compared with no supplementation or placebo, five types of iron supplementation may increase Hb levels and reduce the risk of anaemia (3 reviews). One review on prevention found no evidence of a difference in anaemia incidence on iron supplementation with or without folic acid, but Hb levels increased. Another suggested that nutritional supplementation and counselling reduced IDA. One review comparing MMN fortification with no fortification observed no evidence of a difference in Hb levels. Non-pregnant women of reproductive age (19 to 49 years; 5 reviews) Two reviews suggested that iron therapy (oral, intravenous (IV), intramuscular (IM)) increased Hb levels; one showed that iron folic acid supplementation reduced anaemia incidence; and another that daily iron supplementation with or without folic acid or vitamin C increased Hb levels and reduced the risk of anaemia and ID. No review reported interventions related to fortification or dietary diversity and quality. Pregnant women of reproductive age (15 to 49 years; 23 reviews) One review apiece suggested that: daily iron supplementation with or without folic acid increased Hb levels in the third trimester or at delivery and in the postpartum period, and reduced the risk of anaemia, IDA and ID in the third trimester or at delivery; intermittent iron supplementation had no effect on Hb levels and IDA, but increased the risk of anaemia at or near term and ID, and reduced the risk of side effects; vitamin A supplementation alone versus placebo, no intervention or other micronutrient might increase maternal Hb levels and reduce the risk of maternal anaemia; MMN with iron and folic acid versus placebo reduced the risk of anaemia; supplementation with oral bovine lactoferrin versus oral ferrous iron preparations increased Hb levels and reduced gastrointestinal side effects; MNP for point-of-use fortification of food versus iron and folic acid supplementation might decrease Hb levels at 32 weeks' gestation and increase the risk of anaemia; and LNS versus iron or folic acid and MMN increased the risk of anaemia. Mixed population (all ages; 22 reviews) Iron supplementation versus placebo or control increased Hb levels in healthy children, adults, and elderly people (4 reviews). Hb levels appeared to increase and risk of anaemia and ID decrease in two reviews investigating MMN fortification versus placebo or no treatment, iron fortified flour versus control, double fortified salt versus iodine only fortified salt, and rice fortification with iron alone or in combination with other micronutrients versus unfortified rice or no intervention. Each review suggested that fortified versus non-fortified condiments or noodles, fortified (sodium iron ethylenediaminetetraacetate; NaFeEDTA) versus non-fortified soy sauce, and double-fortified salt versus control salt may increase Hb concentration and reduce the risk of anaemia. One review indicated that Hb levels increased for children who were anaemic or had IDA and received iron supplementation, and decreased for those who received dietary interventions. Another assessed the effects of foods prepared in iron pots, and found higher Hb levels in children with low-risk malaria status in two trials, but no difference when comparing food prepared in non-cast iron pots in a high-risk malaria endemicity mixed population. There was no evidence of a difference for adverse effects. Anaemia and malaria prevalence were rarely reported. No review focused on women aged 50 to 65 years plus or men (19 to 65 years plus).

AUTHORS' CONCLUSIONS

Compared to no treatment, daily iron supplementation may increase Hb levels and reduce the risk of anaemia and IDA in infants, preschool and school-aged children and pregnant and non-pregnant women. Iron fortification of foods in infants and use of iron pots with children may have prophylactic benefits for malaria endemicity low-risk populations. In any age group, only a limited number of reviews assessed interventions to improve dietary diversity and quality. Future trials should assess the effects of these types of interventions, and consider the requirements of different populations.

Adiposity and pathogen exposure: An investigation of response to iron supplementation and hypothesized predictors in anemic pre-school-aged children living in a dual burden environment

OBJECTIVES

Peruvians are experiencing rapid dietary and lifestyle changes, resulting in a phenomenon known as the "dual burden of disease." A common manifestation of the dual burden in individuals is the co-occurrence of overweight and anemia. Despite recent initiatives introduced to address these concerns, rates continue to be public health concerns. This study investigates the relationship between immune activation and lack of response to iron supplementation after 1 month of treatment and explores variation in body fat stores as a potential moderator between immune function and response to treatment.

METHODS

Data come from children, aged 2-5 years (n = 50) from a peri-urban community in Lima, Peru. Multivariate logistic regression models were used to explore the associations between response to treatment (Hb > =11.0 g/dl) after 1 month of treatment), markers of immune activation (C-reactive protein [CRP] and reported morbidity symptoms), and measures of body fat (waist-to-height ratio, triceps skinfold thickness, and body mass index [BMI]).

RESULTS

We found that high CRP is associated with a lack of response to iron supplementation after 1 month of treatment and that BMI z-score may moderate this association. Generally, larger body size is associated with response to iron supplementation whether or not the children in this sample have high immune activation. However, the probability of anemic children responding to iron supplementation treatment differed across adiposity measures.

CONCLUSIONS

Our finding suggesting that adiposity and CRP influence response to iron supplementation, furthers our understanding of the relationship between inflammation and anemia treatment in children and has both theoretical and public health implications.

Effects of iron intake on neurobehavioural outcomes in African children: a systematic review and meta-analysis of randomised controlled trials

Background: Iron deficiency and developmental delay are common in African children. While experimental studies indicate an important role of iron in brain development, effects of iron on child development remain unclear. We aimed to evaluate the effects of iron supplementation or fortification on neurobehavioural outcomes in African children and further summarise these effects in children living in non-African countries for comparison. Methods: We searched PubMed, EMBASE, PsycINFO, Scopus and Cochrane Library for studies published up to 9 th March 2021. We included randomised controlled trials (RCTs) evaluating effects of iron supplementation or fortification on neurobehavioural outcomes in children. Due to heterogeneity in study methods, we analysed the studies qualitatively and only seven RCTs with 11 arms were meta-analysed. Results: We identified 2155 studies and included 34 studies (n=9808) in the systematic review. Only five studies (n=1294) included African children while 29 (n=8514) included children living in non-African countries. Of the five African studies, two (n=647) reported beneficial effects of iron supplementation on neurobehavioural outcomes in anaemic children while three (n=647) found no beneficial effects. Of 29 studies in children living in non-African countries, nine (n=2925) reported beneficial effects of iron supplementation or fortification on neurobehavioural outcomes, seven (n=786) reported beneficial effects only in children who had iron deficiency, iron deficiency anaemia or anaemia while 13 (n=4803) reported no beneficial effects. Meta-analysis of seven studies (n=775) in non-African countries showed no beneficial effects of iron supplementation on cognitive or motor development in children. Conclusions: There are few studies in African children despite the high burden of iron deficiency and developmental delay in this population. Evidence on the effects of iron supplementation on neurobehavioural outcomes remains unclear and there is need for further well-powered studies evaluating these effects in African populations. PROSPERO registration: CRD42018091278 (20/03/2018).

The critical roles of iron during the journey from fetus to adolescent: Developmental aspects of iron homeostasis

Iron is indispensable for human life. However, it is also potentially toxic, since it catalyzes the formation of harmful oxidative radicals in unbound form and may facilitate pathogen growth. Therefore, iron homeostasis needs to be tightly regulated. Rapid growth and development require large amounts of iron, while (especially young) children are vulnerable to infections with iron-dependent pathogens due to an immature immune system. Moreover, unbalanced iron status early in life may have effects on the nervous system, immune system and gut microbiota that persist into adulthood. In this narrative review, we assess the critical roles of iron for growth and development and elaborate how the body adapts to physiologically high iron demands during the journey from fetus to adolescent. As a first step towards the development of clinical guidelines for the management of iron disorders in children, we summarize the unmet needs regarding the developmental aspects of iron homeostasis.

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.

Effect of Daily Iron Supplementation on Infantile Iron Homeostasis in Preterm Infants

Objective: The aim of this study was to investigate the effects of unified iron supplementation and identify the factors related to the iron homeostasis among preterm infants. Method: A total of 250 preterm infants were divided into neonatal anemic (NA, n = 154) and non-neonatal anemic group (NNA, n = 96). Iron supplements at a dose of 2 mg/kg per day were given from 40 weeks' gestational age to 6 months. Iron status parameters were measured at 3 and 6 months, respectively. Prevalence of iron deficiency (ID) and iron deficiency anemia (IDA), and the correlated factors were analyzed. Growth and side-effects were monitored. Results: There were no significant differences for the prevalence of ID or IDA between the two groups. Multivariate regression analyses showed that higher Hb at birth and early treatment of blood transfusion reduced the risk of ID/IDA at 3 months (all p < 0.05); while higher level of Hb at 3 months (p = 0.004) and formula feeding reduced the occurrence of ID/IDA at 6 months (p < 0.05); males had a 3.35 times higher risk to develop ID/IDA than girls (p = 0.021). No differences in growth and side effects were found. Conclusion: A daily dose of 2 mg/kg iron supplement is beneficial to maintain iron homeostasis in majority preterm infants within 6 months regardless of their neonatal anemia history. Under the routine iron supplementation, Hb level at birth and at 3 months, early treatment of blood transfusion, gender and feeding patterns are the major factors affecting the prevalence of ID/IDA among preterm infants in infancy.

Impact of Acid Suppression Therapy on Iron Supplementation in the Pediatric Intensive Care Unit

OBJECTIVE

We assessed the impact of acid suppression therapy (i.e., ranitidine or proton pump inhibitors) on iron supplementation and its ability to maintain or alter laboratory values that are commonly associated with anemia.

METHODS

This was a prospective, observational trial. The primary outcome was changes in serum iron levels from baseline. Secondary outcomes were changes in hemoglobin (Hgb) and hematocrit (Hct), transfusions, and maintenance of an alkalotic gastric pH.

RESULTS

Thirty-four patients (mean 24 ± 43 months) met inclusion criteria. The serum iron levels increased to 50.9 ± 24.6 mcg/dL by day 3. The mean difference from baseline was 1.5 mcg/dL (95% CI, 1.14-1.98, p = 0.0056). Gastric pH increased to 4.68 ± 1.49 on day 5. The mean Hgb and Hct increased on day 5 to 10 ± 1.06 g/dL and 29.6% ± 3.27%, respectively. The mean difference of Hgb was 1.15 g/dL (95% CI, 0.51-1.78, p = 0.0009). The mean difference of Hct was 3.04% (95% CI, 1.11-4.97, p = 0.0032).

CONCLUSIONS

The use of antacids along with oral ferrous sulfate supplementation did not affect the absorption of iron. Serum iron, Hgb, and Hct all showed statistically significant increases despite combined antacid and iron therapy. Thus, despite use of antacids, combination use showed increases in iron absorption.

Nutrient Intake Adequacy from Food and Beverage Intake of US Children Aged 1-6 Years from NHANES 2001-2016

The early years, between the ages of one and six, are a period of rapid physical, social and cognitive growth and a nutritionally adequate diet is an important factor for optimum development. We investigated the micronutrient adequacy and status of young US children aged 1–6 years (n = 9848) using 24-h dietary recall interviews completed by parents and caregivers participating in the National Health and Nutrition Examination Survey (NHANES) 2001–2016. data. The proportion of the sample not meeting the Dietary Reference Intakes (DRI) increased with increasing age and was most pronounced for calcium. Despite adequate iron intake, 7.4% and 2.5% had signs of iron deficiency and anemia based on serum ferritin and hemoglobin levels, with younger children and WIC participants at most risk and Non-Hispanic Black children the least. Vitamin B6 intake was adequate, but 6.4% had serum pyridoxal-5-phosphate deficiency. For vitamin E, 69% had intakes below the estimated average requirement (EAR), yet serum deficiency was only detected in 0.9%. Vitamin D intake was inadequate for 87%, but true deficiency may be overestimated. Mean DHA intake was 24 mg/d, well below expert recommendations of 70–100 mg/day. Iron and vitamin B6 deficiency and inadequate calcium, fiber, choline, potassium and DHA intakes are a concern for a significant percentage of young children. The discrepancy between nutrient intakes and serum deficiency levels needs to be further investigated.

Multiple micronutrient supplementation improves micronutrient status in primary school children in Hai Phong City, Vietnam: a randomised controlled trial

We aimed to determine the efficacy of multiple micronutrient supplementation on the biomarkers of iron, zinc, and vitamin A status across anthropometric status categories in Vietnamese school children. In this 22-week randomised controlled trial, 347 undernourished, normal weight, or overweight/obese children aged 6–9 years were allocated to receive every school day a multiple micronutrient supplement (10 mg iron, 10 mg zinc, 400 µg vitamin A) or a placebo. Haematological indices; circulating ferritin, zinc, and retinol (corrected for inflammation); and C-reactive protein were measured at baseline and 22 weeks. At week 22, linear mixed models showed that mean corpuscular volume increased by 0.3 fL, serum ferritin by 9.1 µg/L, plasma zinc by 0.9 µmol/L, and plasma retinol by 15%, and the prevalence of zinc deficiency decreased by 17.3% points in the intervention group compared to placebo. No intervention effects were found for other haematological indices, or the prevalence of anaemia. Multiple micronutrient supplementation for 22 weeks improved the biomarkers of zinc and vitamin A status and some biomarkers of iron status, and reduced the prevalence of zinc deficiency in Vietnamese school children.

Trial registration: This trial was registered on 06/09/2016 at www.anzctr.org.au as ACTRN12616001245482.

Commercial growing up milks: usage frequency and associated child and demographic factors across four Asia Pacific countries

BACKGROUND

Commercial growing up milks (GUMs) targeted at children from 12 to 36 months of age are a rapidly growing industry, particularly across the Asia Pacific.

METHODS

The present study assessed the frequency of use and socio-demographic and child associations of commercial GUM feeding in children, aged between 12 and 36 months, in capital cities in four Asia Pacific countries. Mothers of children aged between 12 and 36 months were surveyed, assessing GUM feeding frequency in the past month. A market research company database was used to survey across Asia Pacific urban cities, including Bangkok Thailand, Jakarta Indonesia, Singapore and Australian Capital Cities (ACC).

RESULTS

More than 1000 women (n = 1051) were surveyed (Bangkok, n = 263; Jakarta, n = 275; ACC, n = 252; Singapore, n = 261). The mean (SD) age of mothers was 32.4 (5.3) years and that of children was 23.6 (6.7) months. In total, 62.7% of the children were fed GUMs more than once per week with significant country variance. In comparison with ACC, Asian countries were significantly more likely to feed GUMs ≥once per week: Bangkok [odds ratio (OR) = 5.7, 95% confidence interval (CI) = 3.8-8.6]; Jakarta (OR = 3.5, 95% CI = 2.3-5.5); and Singapore (OR = 7.4, 95% CI = 4.9-11.1). Associations of GUM feeding included: maternal tertiary education; mothers younger than 30 years; working full time; and feeding of commercial infant formula under 12 months.

CONCLUSIONS

This is the first published study to explore commercial GUM feeding in and between countries. The incidence of GUM feeding, in contrast to international recommendations, signals the need for further research into the drivers for GUM feeding and its contribution to the diet.

Iron Deficiency and Iron Excess Differently Affect Dendritic Architecture of Pyramidal Neurons in the Hippocampus of Piglets

BACKGROUND

Both iron deficiency and overload may adversely affect neurodevelopment.

OBJECTIVES

The study assessed how changes in early-life iron status affect iron homeostasis and cytoarchitecture of hippocampal neurons in a piglet model.

METHODS

On postnatal day (PD) 1, 30 Hampshire × Yorkshire crossbreed piglets (n = 15/sex) were stratified by sex and litter and randomly assigned to experimental groups receiving low (L-Fe), adequate (A-Fe), or high (H-Fe) levels of iron supplement during the pre- (PD1-21) and postweaning periods (PD22-35). Pigs in the L-Fe, A-Fe, and H-Fe groups orally received 0, 1, and 30 mg Fe · kg weight-1 · d-1 preweaning and were fed a diet containing 30, 125, and 1000 mg Fe/kg postweaning, respectively. Heme indexes were analyzed weekly, and gene and protein expressions of iron regulatory proteins in duodenal mucosa, liver, and hippocampus were analyzed through qRT-PCR and western blot, respectively, on PD35. Hippocampal neurons stained using the Golgi-Cox method were traced and their dendritic arbors reconstructed in 3-D using Neurolucida. Dendritic complexity was quantified using Sholl and branch order analyses.

RESULTS

Pigs in the L-Fe group developed iron deficiency anemia (hemoglobin = 8.2 g/dL, hematocrit = 20.1%) on PD35 and became stunted during week 5 with lower final body weight than H-Fe group pigs (6.6 compared with 9.6 kg, P < 0.05). In comparison with A-Fe, H-Fe increased hippocampal ferritin expression by 38% and L-Fe decreased its expression by 52% (P < 0.05), suggesting altered hippocampal iron stores. Pigs in the H-Fe group had greater dendritic complexity in CA1/3 pyramidal neurons than L-Fe group pigs as shown by more dendritic intersections with Sholl rings (P ≤ 0.04) and a greater number of dendrites (P ≤ 0.016).

CONCLUSIONS

In piglets, the developing hippocampus is susceptible to perturbations by dietary iron, with deficiency and overload differentially affecting dendritic arborization.

Child, caretaker, and community: Testing predictors of anemia and response to iron supplementation in Peruvian preschool-aged children

OBJECTIVES

Despite repeated governmental and nongovernmental interventions, anemia remains a widespread public health concern in Peru. This article examines nutritional and disease factors associated with the prevalence of anemia and response to iron supplementation in Peruvian children, with the aim of understanding the lack of success of national programs.

METHODS

Data come from children, aged 2-5 years (n = 102), living in peri-urban Lima. Predictors of anemia and response to iron supplementation were explored at the individual, maternal, household, and environmental levels using logistic regression models, adjusted for clustering by household.

RESULTS

Half of the children in this sample were anemic and 50% of the anemic children responded to iron supplementation. We identified several factors that were associated with child anemia status and response to iron supplementation. Lower weight-for-age z-scores and the winter season were strong predictors of child anemia status and nonresponse to iron supplementation. Living with paternal grandparents was protective against anemia and elevated C-reactive protein at the time of the final interview was associated with a lack of response to iron supplementation.

CONCLUSIONS

The findings of this study document an association between children's anemia status and their nutritional and ecological environment, highlighting the importance of examining anemia within a specific context to better understand the factors driving this important health problem.

The Impact of Nutrition-Specific and Nutrition-Sensitive Interventions on Hemoglobin Concentrations and Anemia: A Meta-review of Systematic Reviews

Anemia is a multifactorial condition arising from inadequate nutrition, infection, chronic disease, and genetic-related etiologies. Our aim was to assess the impact of nutrition-sensitive and nutrition-specific interventions on hemoglobin (Hb) concentrations and anemia to inform the prioritization and scale-up of interventions to address the multiple causes of anemia. We performed a meta-review synthesis of information by searching multiple databases for reviews published between 1990 and 2017 and used standard methods for conducting a meta-review of reviews, including double independent screening, extraction, and quality assessment. Quantitative pooling and narrative syntheses were used to summarize information. Hb concentration and anemia outcomes were pooled in specific population groups (children aged <5 y, school-age children, and pregnant women). Methodological quality of the systematic reviews was assessed using Assessing the Methodological Quality of Systematic Reviews (AMSTAR) criteria. Of the 15,444 records screened, we identified 118 systematic reviews that met inclusion criteria. Reviews focused on nutrition-specific interventions (96%). Daily and intermittent iron supplementation, micronutrient powders, malaria treatment, use of insecticide-treated nets (ITNs), and delayed cord clamping were associated with increased Hb concentration in children aged <5 y. Among children older than 5 y, daily and intermittent iron supplementation and deworming, and in pregnant women, daily iron-folic acid supplementation, use of ITNs, and delayed cord clamping, were associated with increased Hb concentration. Similar results were obtained for the reduced risk of anemia outcome. This meta-review suggests the importance of nutrition-specific interventions for anemia and highlights the lack of evidence to understand the influence of nutrition-sensitive and multifaceted interventions on the condition.

Erythrocyte transfusions increased the risk of elevated serum ferritin in very low birthweight infants and were associated with altered longitudinal growth

Aim

There has been a lack of population‐based longitudinal data on serum ferritin in very low birthweight (VLBW) infants during hospitalisation. Our aim was to fill this gap in the knowledge and investigate risk factors for elevated serum ferritin and associations between erythrocyte transfusions and longitudinal growth.

Methods

We retrospectively reviewed longitudinal data on 126 VLBW infants treated at Umeå University Hospital, Sweden, between 2010 and 2013.

Results

The infants' mean gestational age and birthweight were 26.9 weeks and 899 g. Most (91%) received erythrocyte transfusions, and the majority had multiple erythrocyte transfusions. There was a significant correlation between serum ferritin and the volume of transfusions. Almost two‐thirds had at least one serum ferritin measurement of more than 350 µg/L, indicating iron overload. In those with complete anthropometric data (n = 78), there was no significant effect of serum ferritin concentrations in relation to longitudinal growth, but there was a positive association between the erythrocyte transfusion dose and longitudinal growth in VLBW infants born before 25 weeks.

Conclusion

This is the first population‐based study to investigate longitudinal data on serum ferritin in VLBW infants during hospitalisation. The unexpected positive finding in the subgroup born at less than 25 weeks needs further research with a larger cohort.

How 217 Pediatric Intensivists Manage Anemia at PICU Discharge: Online Responses to an International Survey

OBJECTIVE

To describe the management of anemia at PICU discharge by pediatric intensivists.

DESIGN

Self-administered, online, scenario-based survey.

SETTING

PICUs in Australia/New Zealand, Europe, and North America.

SUBJECTS

Pediatric intensivists.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Respondents were asked to report their decisions regarding RBC transfusions, iron, and erythropoietin prescription to children ready to be discharged from PICU, who had been admitted for hemorrhagic shock, cardiac surgery, craniofacial surgery, and polytrauma. Clinical and biological variables were altered separately in order to assess their effect on the management of anemia. Two-hundred seventeen responses were analyzed. They reported that the mean (± SEM) transfusion threshold was a hemoglobin level of 6.9 ± 0.09 g/dL after hemorrhagic shock, 7.6 ± 0.10 g/dL after cardiac surgery, 7.0 ± 0.10 g/dL after craniofacial surgery, and 7.0 ± 0.10 g/dL after polytrauma (p < 0.001). The most important increase in transfusion threshold was observed in the presence of a cyanotic heart disease (mean increase ranging from 1.80 to 2.30 g/dL when compared with baseline scenario) or left ventricular dysfunction (mean increase, 1.41-2.15 g/dL). One third of respondents stated that they would not prescribe iron at PICU discharge, regardless of the hemoglobin level or the baseline scenario. Most respondents (69.4-75.0%, depending on the scenario) did not prescribe erythropoietin.

CONCLUSIONS

Pediatric intensivists state that they use restrictive transfusion strategies at PICU discharge similar to those they use during the acute phase of critical illness. Supplemental iron is less frequently prescribed than RBCs, and prescription of erythropoietin is uncommon. Optimal management of post-PICU anemia is currently unknown. Further studies are required to highlight the consequences of this anemia and to determine appropriate management.

Vitamin C supplementation for prevention and treatment of pneumonia

BACKGROUND

According to the Global Burden of Disease Study 2015, lower respiratory tract infection is the leading cause of infectious disease death, and the fifth most common cause of death overall. Vitamin C has a role in modulating resistance to infectious agents, therefore vitamin C supplementation may be important in preventing and treating pneumonia.

OBJECTIVES

To assess the impact of vitamin C supplementation to prevent and treat pneumonia in children and adults.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, PubMed, CINAHL, LILACS, Web of Science, and two trials registers to 4 March 2020. We also checked references to identify additional studies. We did not apply any publication status or language filters.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs (studies using allocation methods that are not random, e.g. date of birth, medical record number) assessing the role of vitamin C supplementation in the prevention and treatment of pneumonia in children and adults compared to control or placebo.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included seven studies in the review and identified two ongoing studies. The seven included studies involved a total of 2774 participants; five studies were RCTs and two were quasi-RCTs. The included studies were conducted in high-income countries (UK, USA and Chile) and lower-middle-income countries (Bangladesh and Pakistan). Four studies were conducted in hospital inpatient settings, two in schools, and one in a military training centre. Three studies included children under five years of age, two school-aged children, one adult participants, and one older participants aged 60 to 90 years. Two studies assessed the effect of vitamin C supplementation for pneumonia prevention; four studies assessed the effect of vitamin C supplementation as an adjunct to pneumonia treatment; and one study assessed the role of vitamin C for both prevention and treatment of pneumonia. For pneumonia prevention, the included studies provided supplementation in doses of 500 mg daily for 14 weeks, 2 g daily for 8 weeks, and 2 g daily for 12 weeks. For pneumonia treatment, the included studies provided vitamin C supplementation in doses of 125 mg daily (until discharge), 200 mg for 4 weeks, and 200 mg until discharge, as an adjunct to the pneumonia treatment. We assessed the included studies as at overall either high or unclear risk of bias for random sequence generation, allocation concealment, and blinding. We judged the quality of the evidence as very low. Three studies assessed the effect of vitamin C supplementation for pneumonia prevention; we judged the quality of the evidence as very low. We are uncertain about the effect of vitamin C supplementation on pneumonia incidence (risk ratio (RR) 0.46, 95% confidence interval (CI) 0.06 to 3.61; 2 studies, 736 participants; I² = 75%; very low-quality evidence) and adverse events (urticaria) (RR 3.11, 95% CI 0.13 to 76.03; 1 study, 674 participants; very low-quality evidence). No included studies reported our other primary outcomes (pneumonia prevalence and mortality) or any of our secondary outcomes. Five studies assessed the effect of vitamin C supplementation as an adjunct to pneumonia treatment; we judged the quality of the evidence as very low. One study reported a decrease in the duration of illness in the vitamin C supplementation group (3.4 days ± 2.54) compared to the control group (4.5 days ± 2.35), and one study reported a decrease in number of days required for improvement in oxygen saturation (1.03 days ± 0.16 versus 1.14 days ± 1.0) and respiratory rate (3.61 days ± 1.50 versus 4.04 days ± 1.62) in the vitamin C supplementation group compared to the control group. We are uncertain of the effect of vitamin C supplementation on mortality due to pneumonia (RR 0.21, 95% CI 0.03 to 1.66; 1 study, 57 participants; very low-quality evidence). One study reported that the mean duration of hospital stay was 6.75 days amongst children in the vitamin C supplementation group and 7.75 days in the control group; another study reported a lower mean duration of hospital stay in the vitamin C supplementation group compared to the control group (109.55 hours ± 27.89 versus 130.64 hours ± 41.76).

AUTHORS' CONCLUSIONS

Due to the small number of included studies and very low quality of the existing evidence, we are uncertain of the effect of vitamin C supplementation for the prevention and treatment of pneumonia. Further good-quality studies are required to assess the role of vitamin C supplementation in the prevention and treatment of pneumonia.

Iron supplementation in preterm and low-birth-weight infants: a systematic review of intervention studies

Context

Enteral iron supplementation in preterm infants is recommended to supply sufficient iron for growth and development without increasing the risk of iron overload. However, the current recommendations date from 2010 and are based on limited evidence.

Objective

This systematic review aimed to investigate the effects of enteral iron supplementation on iron status, growth, neurological development, and adverse clinical outcomes in preterm (<37 weeks’ gestation) and low-birth-weight (LBW, <2500 g) infants.

Data sources

The PubMed/Medline and Cochrane Library databases were searched to 31 October 2018.

Data extraction

Of the 684 records identified, 27 articles, describing 18 randomized controlled trials (RCTs) plus 4 nonrandomized interventions, were included. Using the Cochrane Collaboration’s criteria, study quality was found to be poor to fair overall.

Results

Most articles (23/27) reported iron status indices; supplementation for ≥8 weeks resulted in increased hemoglobin and ferritin concentrations and a reduction in iron deficiency and anemia. No article reported on iron overload. Growth-related parameters reported in 12 articles were not affected by supplementation. Among the 7 articles on neurological development, a positive effect on behavior at 3.5 and 7 years was observed in one Swedish RCT. No association was found between supplementation and adverse clinical outcomes in the 9 articles reporting on studies in which such data was collected.

Conclusions

Long-term iron supplementation appears to result in improved iron status and a reduction in iron deficiency and anemia in preterm and LBW infants. However, high-quality evidence regarding the long-term effects of supplementation on functional health outcomes is lacking. Iron overload has largely been ignored. Well-designed, long-term, dose-response RCTs are required to ascertain the optimal dose and delivery method for the provision of dietary iron in preterm infants, with consideration of short- and long-term health effects.

Systematic Review Registration

PROSPERO registration no. CRD42018085214.

Effects of intrauterine latent iron deficiency on auditory neural maturation in full-term newborns

OBJECTIVE

This study analyzed the relationship between latent iron deficiency evaluated by ferritin, and the myelination of the central nervous system evaluated through the brainstem evoked response audiometry test.

METHOD

A total of 109 full-term newborns, born without anemia and risk factor for hearing deficiency, were enrolled. After delivery, umbilical cord blood was collected to determine ferritin and hematocrit levels. The brainstem evoked response audiometry test was carried out in the first 28 days of life. Analysis was performed between the control group (n=71) with ferritin greater than 75ng/mL, and the latent iron deficiency group (n=38) with ferritin between 11 and 75ng/mL. Results were presented as mean±standard deviation. Statistical analysis was performed using GraphPad prism7 and SPSS with a significance level of 5%.

RESULTS

A significant higher V-wave (p=0.02) and interpeak intervals I-III (p=0.014), I-V (p=0.0003), and III-V (p=0.0002) latencies were found in the latent iron deficiency group, as well as a significant inversely proportional correlation between ferritin and the same wave and intervals (p=0.003, p=0.0013, p=0.0002, p=0.009, respectively). Multiple correlation analysis showed a significant correlation of latent iron deficiency with all interpeak intervals, even taking into account newborn gestational age.

CONCLUSION

Iron deficiency anemia is a prevalent pathology; this study showed auditory delayed maturation associated to intrauterine iron deficiency, even in its latent form. This reinforces the importance of adopting effective measures, on a global scale, to prevent and treat this pathology in different life periods, especially in the most vulnerable population.

Can School Feeding Programs Reduce Malnutrition in Rural China?

BACKGROUND

Childhood malnutrition is commonplace among poor rural communities in China. In 2012, China launched its first nationwide school-feeding program (SFP) to address this problem. This study examines the prevalence of malnutrition before and after the SFP and identifies possible reasons for the trends observed.

METHODS

Ordinary least squares regression and propensity score matching were used to analyze data from 2 cross-sectional surveys of 100 rural primary schools in northwestern China. Participants were fourth-and fifth-grade students. Outcome measures include anemia rates, hemoglobin levels, body mass index, and height for age Z scores.

RESULTS

Three years after implementation of the SFP, malnutrition rates among sample students had not fallen. The SFP had no statistically significant effect on either anemia rates or BMI, but was linked to an increase in the proportion of students with below normal height for age Z scores. Meals provided to students fell far short of national recommendations that the SPF should provide 40% of the recommended daily allowance of micronutrients.

CONCLUSIONS

Despite significant budgetary outlays between 2012 and 2015, China's SFP has not reduced the prevalence of malnutrition among sample students. To make the SFP more effective, funding and human resources both need to be increased.

Source apportionment of micronutrients in the diets of Kilimanjaro,Tanzania and Counties of Western Kenya

Soil, water and food supply composition data have been combined to primarily estimate micronutrient intakes and subsequent risk of deficiencies in each of the regions studied by generating new data to supplement and update existing food balance sheets. These data capture environmental influences, such as soil chemistry and the drinking water sources to provide spatially resolved crop and drinking water composition data, where combined information is currently limited, to better inform intervention strategies to target micronutrient deficiencies. Approximately 1500 crop samples were analysed, representing 86 food items across 50 sites in Tanzania in 2013 and >230 sites in Western Kenya between 2014 and 2018. Samples were analysed by ICP-MS for 58 elements, with this paper focussing on calcium (Ca), copper (Cu), iron (Fe), magnesium (Mg), selenium (Se), iodine (I), zinc (Zn) and molybdenum (Mo). In general, micronutrient supply from food groups was higher from Kilimanjaro,Tanzania than Counties in Western Kenya, albeit from a smaller sample. For both countries leafy vegetable and vegetable food groups consistently contained higher median micronutrient concentrations compared to other plant based food groups. Overall, calculated deficiency rates were <1% for Cu and Mo and close to or >90% for Ca, Zn and I in both countries. For Mg, a slightly lower risk of deficiency was calculated for Tanzania at 0 to 1% across simplified soil classifications and for female/males, compared to 3 to 20% for Kenya. A significant difference was observed for Se, where a 3 to 28% risk of deficiency was calculated for Tanzania compared to 93 to 100% in Kenya. Overall, 11 soil predictor variables, including pH and organic matter accounted for a small proportion of the variance in the elemental concentration of food. Tanzanian drinking water presented several opportunities for delivering greater than 10% of the estimated average requirement (EAR) for micronutrients. For example, 1 to 56% of the EAR for I and up to 10% for Se or 37% for Zn could be contributed via drinking water.

Prevalence and determinant factors of anemia in children aged 6-12 months after starting an iron supplement in the east of Iran

OBJECTIVE

Anemia in infants is a common problem, with regular iron supplementation the suggested policy for prevention and control of anemia. The aim of this study was to determine the prevalence and the determining factors of anemia as well as the benefits of regular iron supplementation in 6- to 12-month-old children.

DESIGN/SETTING/SUBJECTS

In this cross-sectional study, 897 children aged from 6 to 12 months cared for at the Tabas Health Centers, affiliated with Birjand University of Medical Sciences, South Khorasan, Iran, were enrolled in the study. Demographic and anthropometric data as well as the level of hemoglobin were collected through interviews and laboratory tests, respectively. Data analysis was performed using SPSS-22 and stata-13. Chi², polychromic PCA, and logistic regression were used. The statistical significance level was 0.05.

RESULT

The prevalence of anemia, according to the WHO criterion for hemoglobin, was 36.8% (95% CI, 33.6-40.0). Its prevalence showed a decreasing trend as age and duration of iron supplement increased. Each 1-month increase in infant age was associated with a decreased risk of anemia [OR=0.88 (95% CI, 0.80-0.98)]. Anemia was not significantly different between genders. Individuals in the highest category for parity (≥3) were at a 2.3-fold greater risk of anemia compared with the lowest category [OR=2.35 (95% CI, 1.43-3.84)]. In contrast, individuals in the highest category for maternal age (>35 years) had a 62% lower risk of anemia compared with the reference category (<25 years) [OR=0.38 (95% CI, 0.20-0.72)].

CONCLUSION

Implementation of an iron supplementation plan in Iran has decreased anemia among 6- to 12-month-old children.

Effect of a Community Health Worker-Delivered Parental Education and Counseling Intervention on Anemia Cure Rates in Rural Indian Children: A Pragmatic Cluster Randomized Clinical Trial

IMPORTANCE

Iron deficiency anemia, the largest cause of anemia worldwide, adversely affects cognitive development in children. Moreover, the imperceptible childhood anemia prevalence reduction in response to anemia control measures is associated with tremendous social and economic cost.

OBJECTIVE

To evaluate the effects of community-based parental education/counseling when combined with usual treatment on children's anemia cure rate.

DESIGN, SETTING, AND PARTICIPANTS

A pragmatic cluster randomized clinical trial in children aged 12 to 59 months from 55 villages from the rural Chamrajnagar district in southern India was conducted between November 2014 and July 2015; 6-month follow-up ended in January 2016. Villages were randomly assigned to either usual treatment (n = 27) or to the intervention (n = 28). Among 1144 participating children, 534 were diagnosed as having anemia (hemoglobin levels <11 g/dL and >7.9 g/dL; to convert to grams per liter, multiply by 10) and constituted the study sample in this analysis. Data were analyzed between July 2016 and September 2017.

INTERVENTIONS

Iron and folic acid (IFA), 20 mg/d, 5 times daily per week, for 5 months (usual treatment) or health worker-delivered education/counseling combined with usual treatment (intervention).

MAIN OUTCOMES AND MEASURES

The primary outcome was anemia cure rate defined as hemoglobin level at or greater than 11 g/dL during follow-up.

RESULTS

Of the children included in the study, the mean age was 30 months, with a slightly higher ratio of boys to girls. Of 534 children with anemia (intervention n = 303; usual treatment n = 231), 517 were reassessed after 6 months (intervention n = 298; usual treatment n = 219) while 17 were lost to follow-up (intervention n = 5 and usual treatment n = 12). Anemia cure rate was higher in children in the intervention group compared with children receiving usual treatment (55.7% [n = 166 of 298] vs 41.4% [n = 90 of 219]). The risk ratio derived through multilevel logistic regression was 1.37 (95% CI, 1.04-1.70); the model-estimated risk difference was 15.1% (95% CI, 3.9-26.3). Intervention-group children demonstrated larger mean hemoglobin increments (difference, intervention vs control: 0.25 g/dL; 95% CI, 0.07-0.44 g/dL) and improved IFA adherence (61.7%; 95% CI, 56.2-67.3 vs 48.4%; 95% CI, 41.7-55.1 consumed >75% of tablets provided). Adverse events were mild (intervention: 26.8%; 95% CI, 21.8-31.9 vs usual treatment: 21%; 95% CI, 15.6-26.4). To cure 1 child with anemia, 7 mothers needed to be counseled (number needed to treat: 7; 95% CI, 4-26).

CONCLUSIONS AND RELEVANCE

Parental education and counseling by a community health worker achieved perceivable gains in curing childhood anemia. Policy makers should consider this approach to enhance population level anemia control.

TRIAL REGISTRATION

ISRCTN identifier: ISRCTN68413407.

How Lifestyle Factors Affect Cognitive and Executive Function and the Ability to Learn in Children

In today's research environment, children's diet, physical activity, and other lifestyle factors are commonly studied in the context of health, independent of their effect on cognition and learning. Moreover, there is little overlap between the two literatures, although it is reasonable to expect that the lifestyle factors explored in the health-focused research are intertwined with cognition and learning processes. This thematic review provides an overview of knowledge connecting the selected lifestyle factors of diet, physical activity, and sleep hygiene to children's cognition and learning. Research from studies of diet and nutrition, physical activity and fitness, sleep, and broader influences of cultural and socioeconomic factors related to health and learning, were summarized to offer examples of research that integrate lifestyle factors and cognition with learning. The literature review demonstrates that the associations and causal relationships between these factors are vastly understudied. As a result, current knowledge on predictors of optimal cognition and learning is incomplete, and likely lacks understanding of many critical facts and relationships, their interactions, and the nature of their relationships, such as there being mediating or confounding factors that could provide important knowledge to increase the efficacy of learning-focused interventions. This review provides information focused on studies in children. Although basic research in cells or animal studies are available and indicate a number of possible physiological pathways, inclusion of those data would distract from the fact that there is a significant gap in knowledge on lifestyle factors and optimal learning in children. In a climate where childcare and school feeding policies are continuously discussed, this thematic review aims to provide an impulse for discussion and a call for more holistic approaches to support child development.

Effect of Iron Supplementation on the Outcome of Non-Progressive Pulmonary Mycobacterium tuberculosis Infection

The human response to Mycobacterium tuberculosis (Mtb) infection is affected by the availability of iron (Fe), which is necessary for proper immune cell function and is essential for the growth and virulence of bacteria. Increase in host Fe levels promotes Mtb growth and tuberculosis (TB) pathogenesis, while Fe-supplementation to latently infected, asymptomatic individuals is a significant risk factor for disease reactivation. However, the effect of Fe-supplementation on the host immunity during latent Mtb infection remains unclear, due partly to the paucity in availability of animal models that recapitulate key pathophysiological features seen in humans. We have demonstrated that rabbits can develop non-progressive latency similar to infected humans. In this study, using this model we have evaluated the effect of Fe-supplementation on the bacterial growth, disease pathology, and immune response. Systemic and lung Fe parameters, gene expression profile, lung bacterial burden, and disease pathology were determined in the Mtb-infected/Fe- or placebo-supplemented rabbits. Results show that Fe-supplementation to Mtb-infected rabbits did not significantly change the hematocrit and Hb levels, although it elevated total Fe in the lungs. Expression of selected host iron- and immune-response genes in the blood and lungs was perturbed in Mtb-infected/Fe-supplemented rabbits. Iron-supplementation during acute or chronic stages of Mtb infection did not significantly affect the bacterial burden or disease pathology in the lungs. Data presented in this study is of significant relevance for current public health policies on Fe-supplementation therapy given to anemic patients with latent Mtb infection.

Effect of iron supplementation from neonatal period on the iron status of6-month-old infants at-risk for early iron deficiency: a randomized interventional trial

OBJECTIVE

To investigate the effects of iron supplementation from the second day after birth on 6-month hemoglobin (Hb), serum ferritin and motor development in infants at risk of early iron deficiency.

STUDY DESIGN

Term (37-41 weeks) infants of anemic (Hb ≤ 100 g L^-1; N = 100) and non-anemic (Hb > 100 g L^-1; N = 100) mothers were randomized to daily iron supplementation at a dose of 2 mg kg^-1 from 36 h of age (N = 50, each of anemic and non-anemic mothers) or no iron-supplementation (N = 50 each of anemic and non-anemic mothers). Hb, serum ferritin and motor development at 6 months were compared in the two groups.

RESULTS

Iron-supplemented infants had higher Hb (103.7 ± 9.3 g L^-1 versus 97.0 ± 9.4 g L^-1, p < .0001) and serum ferritin (133.93 ± 52.41 ng mL^-1 versus 78.09 ± 42.03 ng mL^-1, p < .001) concentrations, compared with the no iron-supplementation group. Their motor development was closer to age-appropriate norms than the no iron-supplementation group (5.83 ± 0.69 versus 5.18 ± 1.35, p < .01).

CONCLUSION

Early Iron supplementation is effective for improving iron status and motor development at 6 months in infants at risk for early iron deficiency.

Possible involvement of transcriptional activation of nuclear factor erythroid 2-related factor 2 (Nrf2) in the protective effect of caffeic acid on paraquat-induced oxidative damage in Drosophila melanogaster

Paraquat (PQ) is a widely used herbicide with no antidote which is implicated in the pathogenesis of the Parkinson's disease. The present study then investigated the potential of caffeic acid (CA), a known antioxidant, cardioprotective and neuroprotective molecule to counteract oxidative stress mediated by PQ. In addition, molecular docking was performed to understand the mechanism underlying the inhibitory effect of CA against PQ poisoning. The fruit fly, Drosophila melanogaster, was exposed to PQ (0.44 mg/g of diet) in the absence or presence of CA (0.25, 0.5, 1 and 2 mg/g of died) for 7 days. Data showed that PQ-fed flies had higher incidence of mortality which was associated with mitochondrial dysfunction, increased free Fe(II) content and lipid peroxidation when compared to the control. Co-exposure with CA reduced mortality and markedly attenuated biochemical changes induced by PQ. The mechanism investigated using molecular docking revealed a strong interaction (-6.2 Kcal/mol) of CA with D. melanogaster transcriptional activation of nuclear factor erythroid 2-related factor 2 (Nrf2). This was characterized by the binding of CA to keap-1 domain of Nrf2. Taking together these results indicate the protective effect of CA against PQ-induced oxidative damage in D. melanogaster was likely through its coordination which hinders Nrf2-keap-1 binding leading to an increase of the antioxidant defense system.

The Importance of Iron Status for Young Children in Low- and Middle-Income Countries: A Narrative Review

Early childhood is characterised by high physiological iron demand to support processes including blood volume expansion, brain development and tissue growth. Iron is also required for other essential functions including the generation of effective immune responses. Adequate iron status is therefore a prerequisite for optimal child development, yet nutritional iron deficiency and inflammation-related iron restriction are widespread amongst young children in low- and middle-income countries (LMICs), meaning iron demands are frequently not met. Consequently, therapeutic iron interventions are commonly recommended. However, iron also influences infection pathogenesis: iron deficiency reduces the risk of malaria, while therapeutic iron may increase susceptibility to malaria, respiratory and gastrointestinal infections, besides reshaping the intestinal microbiome. This means caution should be employed in administering iron interventions to young children in LMIC settings with high infection burdens. In this narrative review, we first examine demand and supply of iron during early childhood, in relation to the molecular understanding of systemic iron control. We then evaluate the importance of iron for distinct aspects of physiology and development, particularly focusing on young LMIC children. We finally discuss the implications and potential for interventions aimed at improving iron status whilst minimising infection-related risks in such settings. Optimal iron intervention strategies will likely need to be individually or setting-specifically adapted according to iron deficiency, inflammation status and infection risk, while maximising iron bioavailability and considering the trade-offs between benefits and risks for different aspects of physiology. The effectiveness of alternative approaches not centred around nutritional iron interventions for children should also be thoroughly evaluated: these include direct targeting of common causes of infection/inflammation, and maternal iron administration during pregnancy.

Iron Deficiency, Cognitive Functions, and Neurobehavioral Disorders in Children

More than 25% of the world's population is affected by anemia, of which more than 50% suffers from iron deficiency anemia (IDA). Children below 7 years of age are the population group that is most vulnerable to iron deficiency. Iron is an essential element in brain metabolism. Iron deficiency can cause changes in neurotransmitter homeostasis, decrease myelin production, impair synaptogenesis, and decline the function of the basal ganglia. Therefore, IDA adversely affects cognitive functions and psychomotor development. Research has shown that iron deficiency is a frequent comorbidity in attention-deficit/hyperactivity disorder (ADHD) and autism spectrum disorder. Iron deficiency may also induce or exacerbate deficiency of other essential nutrients, which may have a negative impact on the developing brain and other organs in infants. Many nations of the world have programs to control IDA based on the use of iron supplementation, intake of fortified food and drinks, improved food safety, and monitoring of dietary diversity. Based on the current recommendations of the World Health Organization on cost-effectiveness (WHO-CHOICE), iron fortification and iron supplementation programs can be considered cost-effective or even highly cost-effective in most countries of the world to averting cognitive impairment.

Supplementation with Small-Quantity Lipid-Based Nutrient Supplements Does Not Increase Child Morbidity in a Semiurban Setting in Ghana: A Secondary Outcome Noninferiority Analysis of the International Lipid-Based Nutrient Supplements (iLiNS)-DYAD Randomized Controlled Trial

BACKGROUND

Adequate knowledge about the safety of consumption of small-quantity lipid-based nutrient supplements (SQ-LNSs) is needed.

OBJECTIVE

We aimed to test the hypothesis that SQ-LNS consumption is noninferior to control with respect to child morbidity.

METHODS

Women (n = 1320) ≤20 wk pregnant were assigned to iron and folic acid until delivery with no supplementation for offspring; or multiple micronutrient supplements until 6 mo postpartum with no supplementation for offspring; or SQ-LNSs until 6 mo postpartum, and SQ-LNSs for offspring (6 mg Fe/d) from 6 to 18 mo of age [the lipid-based nutrient supplement (LNS) group]. We assessed noninferiority (margin ≤20%) between any 2 groups during 0-6 mo of age, and between the non-LNS and LNS groups during 6-18 mo of age for caregiver-reported acute respiratory infection, diarrhea, gastroenteritis, fever/suspected malaria, poor appetite, and "other illnesses."

RESULTS

During 0-6 mo of age, 1197 infants contributed 190,503 infant-days. For all morbidity combined, overall mean incidence (per 100 infant-days) was 3.3 episodes, overall mean prevalence (percentage of infant-days) was 19.3%, and the 95% CIs of the incidence rate ratio (IRR) and longitudinal prevalence rate ratio (LPRR) between any 2 groups were ≤1.20. During 6-18 mo, there were 240,097 infant-days for the non-LNS group and 118,698 for the LNS group. For all morbidity combined, group mean incidences were 4.3 and 4.3, respectively (IRR: 1.0; 95% CI: 1.0, 1.1), and mean prevalences were 28.2% and 29.3%, respectively (LPRR: 1.0; 95% CI: 1.0, 1.1). Noninferiority was inconclusive for diarrhea, fever/suspected malaria, and poor appetite.

CONCLUSIONS

SQ-LNS consumption does not increase reported overall child morbidity in this population compared with the 2 other treatments.This trial was registered at clinicaltrials.gov as NCT00970866.

Maternal and Infant Supplementation with Small-Quantity Lipid-Based Nutrient Supplements Increases Infants' Iron Status at 18 Months of Age in a Semiurban Setting in Ghana: A Secondary Outcome Analysis of the iLiNS-DYAD Randomized Controlled Trial

Background

Interventions are needed to address iron deficiency in low-income settings.

Objective

This secondary outcome analysis aimed to compare the hemoglobin (Hb) and iron status [zinc protoporphyrin (ZPP)] of children born to women enrolled in the iLiNS-DYAD trial in Ghana.

Methods

Women ≤20 wk pregnant (n = 1320) were assigned to receive 60 mg Fe/d and 400 µg folic acid/d until delivery and placebo thereafter, and no supplementation for infants (IFA group); or multiple micronutrients containing 20 mg Fe/d until 6 mo postpartum and no supplementation for infants (MMN); or small-quantity lipid-based nutrient supplements (SQ-LNSs) containing 20 mg Fe/d until 6 mo postpartum, and SQ-LNSs for infants from 6 to 18 mo of age (LNS). We compared infants' Hb (g/L) and ZPP (µmol/mol heme) at 6 and 18 mo of age.

Results

At 6 mo of age, groups did not differ in mean ± SD Hb (overall: 113 ± 9.9 g/L) or geometric mean (95% CI) ZPP [overall: 62.6 (60.6, 64.7)]. At 18 mo of age, mean ± SD Hb (overall: 112 ± 10.4 g/L) did not differ significantly between groups, whereas geometric mean (95% CI) ZPP was lower (P = 0.031) in the LNS group [53.9 (50.7, 57.3)] than the IFA [60.4 (56.7, 64.3)] but not the MMN [58.8 (55.6, 62.2)] group. Further, the LNS group, compared with the IFA and MMN groups combined, had a lower prevalence of elevated (>70) ZPP (27.5% compared with 35%; P = 0.02) and a marginally lower prevalence of anemia (38.7% compared with 44.9%; P = 0.06). These results generally remained unchanged when controlling for prespecified covariates or correcting for inflammation.

Conclusions

In this setting, providing SQ-LNSs or multiple micronutrients with 20 mg Fe/d, compared with iron (60 mg/d) and folic acid, to pregnant women does not affect their infants' Hb or iron status at 6 mo of age, but maternal and infant supplementation with SQ-LNSs increases infants' iron status at 18 mo of age. This trial was registered at clinicaltrials.gov as NCT00970866.

Pediatric Screening: Development, Anemia, and Lead

Screening and prevention are important components of general pediatric health care. Infants and young children should be screened for iron deficiency anemia, lead poisoning, and developmental disorders as essential parts of the well-child visit. Developmental and behavioral screening early in childhood is necessary to identify developmental delays and facilitate timely treatment. Lead screening is recommended for at-risk pediatric patients to treat children with elevated lead levels. Infants and children are also at risk for iron deficiency anemia and must be screened appropriately. Familiarization with pediatric screening guidelines is critical for primary care providers caring for children.

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.