Setting the stage for child health and development: prevention of iron deficiency in early infancy

Utilization of low-grade walnut kernels for oil extraction using eco-friendly methods: a comparative analysis of oil composition, antioxidant and antimicrobial activity

Walnut oil was extracted using three different eco-friendly extraction methods, solvent extraction (using ethyl acetate [EA] and ethanol [ET]), aqueous enzymatic extraction (AEE), and ultrasound-assisted enzymatic extraction (UAEE), and their lipid yield, lipid composition, physicochemical analysis, mineral composition, total phenols, antioxidant capacity, and antimicrobial activity were analyzed and compared. The AEE technique offered a greater yield (50.6%) than the other extraction methods and gave comparatively higher linoleic acid (66.12%) content. Palmitic, oleic, linoleic, linolenic, and stearic acids were the principal components that GC/MS detected in all the oil samples. UAEE produced the most polyphenols (0.49 mgGAE/g), followed by AEE (0.46 mgGAE/g), EA (0.45 mgGAE/g), and ET (0.35 mgGAE/g). The DPPH assay results were in the order of UAEE (191 μmolTE/kg) > AEE (186 μmolTE/kg) > EA (153 μmolTE/kg) > ET (130 μmolTE/kg). The FRAP assay findings showed a similar pattern: UAEE (112 molTE/kg) > AEE (102 molTE/kg) > EA (96 molTE/kg) > ET (82 molTE/kg). Results suggested that for a higher extraction yield, AEE is the better technique and UAEE is the recommended method for enhancing walnut oil antioxidant capacity. Additionally, it was found that polyphenols considerably increased the antioxidant capacity of walnut oil and are thought to be health-promoting. The results demonstrated the antibacterial effectiveness of the extracted oil against Bacillus subtilis, Bacillus licheniformis, and Staphylococcus aureus. This study provides information about low-cost and ecofriendly technologies of walnut oil extraction for food, cosmetic, and medical uses.

The Association of Infant Birth Sizes and Anemia under Five Years Old: A Population-Based Prospective Cohort Study in China

Infant birth sizes are vital clinical parameters to predict poor growth and micronutrient deficiency in early life. However, their effects on childhood anemia remain unclear. We aimed to explore the associations between birth weight, crown-heel length, and head circumference with anemia in early childhood, as well as potential modification factors. This population-based prospective cohort study included 204,556 participants with singleton live births delivered at gestational ages of 28-42 weeks. A logistic regression model was used to estimate the associations of the measures of infant birth size and their Z-score with anemia under five years old. There were 26,802 (13.10%) children under five years old who were diagnosed has having anemia. Compared with children who did not have anemia, children who had anemia had a lower birth weight and smaller head circumference and a longer crown-heel length (all p-values < 0.05). After adjusting for confounders, not only birth weight (β coefficient, -0.008; 95% CI, -0.011--0.004; p < 0.001) and head circumference (β coefficient, -0.004; 95% CI, -0.007--0.001; p = 0.009), but also the related Z-scores were negatively associated with childhood anemia, while the trends for crown-heel length were the opposite. We further found significant interactions of folic acid use and maternal occupation with infant birth sizes. In conclusion, infants having abnormal sizes at birth are significantly associated with the risk for childhood anemia, which can be modified by folic acid use during pregnancy and maternal occupation.

Socio-economic and spatial inequalities in animal sources of iron-rich foods consumption among children 6-23 months old in Ethiopia: A decomposition analysis

Iron deficiency anaemia is the most common type of anaemia in young children which can lead to long-term health consequences such as reduced immunity, impaired cognitive development, and school performance. As children experience rapid growth, they require a greater supply of iron from iron-rich foods to support their development. In addition to the low consumption of iron-rich foods in low- and lower-middle-income countries, there are also regional and socio-economic disparities. This study aimed to assess contributing factors of wealth-related inequality and geographic variations in animal sources of iron-rich food consumption among children aged 6-23 months in Ethiopia. We used data from the Ethiopian Mini Demographic and Health Surveys (EMDHS) 2019, a national survey conducted using stratified sampling techniques. A total of 1,461 children of age 6-23 months were included in the study. Iron-rich animal sources of food consumption were regarded when parents/caregivers reported that a child took at least one of the four food items identified as iron-rich food: 1) eggs, 2) meat (beef, lamb, goat, or chicken), 3) fresh or dried fish or shellfish, and 4) organs meat such as heart or liver. Concentration indices and curves were used to assess wealth-related inequalities. A Wagstaff decomposition analysis was applied to identify the contributing factors for wealth-related inequality of iron-rich animal source foods consumption. We estimated the elasticity of wealth-related inequality for a percentage change in socioeconomic variables. A spatial analysis was then used to map the significant cluster areas of iron-rich animal source food consumption among children in Ethiopia. The proportion of children who were given iron-rich animal-source foods in Ethiopia is 24.2% (95% CI: 22.1%, 26.5%), with figures ranging from 0.3% in Dire Dawa to 37.8% in the Oromia region. Children in poor households disproportionately consume less iron-rich animal-source foods than those in wealthy households, leading to a pro-rich wealth concentration index (C) = 0.25 (95% CI: 0.12, 0.37). The decomposition model explained approximately 70% of the estimated socio-economic inequality. About 21% of the wealth-related inequalities in iron-rich animal source food consumption in children can be explained by having primary or above education status of women. Mother's antenatal care (ANC) visits (14.6%), living in the large central and metropolitan regions (12%), household wealth index (10%), and being in the older age group (12-23 months) (2.4%) also contribute to the wealth-related inequalities. Regions such as Afar, Eastern parts of Amhara, and Somali were geographic clusters with low iron-rich animal source food consumption. There is a low level of iron-rich animal source food consumption among children, and it is disproportionately concentrated in the rich households (pro-rich distribution) in Ethiopia. Maternal educational status, having ANC visits, children being in the older age group (12-23 months), and living in large central and metropolitan regions were significant contributors to these wealth-related inequalities in iron-rich animal source foods consumption. Certain parts of Ethiopia such as, Afar, Eastern parts of Amhara, and Somali should be considered priority areas for nutritional interventions to increase children's iron-rich animal source foods consumption.

Early-life adversity is associated with poor iron status in infancy

Exposure to early-life adversity (ELA) and iron deficiency early in life are known risk factors for suboptimal brain and socioemotional development. Iron deficiency may arise from and co-occur with ELA, which could negatively affect development. In the present study, we investigated whether ELA is associated with iron deficiency in infants receiving no iron supplementation. This study is a secondary analysis of extant data collected in the 1990s; participants were healthy infants from working-class communities in Santiago, Chile (N = 534, 45.5% female). We measured stressful life events, maternal depression, and low home support for child development during infancy and assessed iron status when the infant was 12 months old. Slightly more than half of the infants were iron-deficient (51%), and 25.8% were iron-deficient anemic at 12 months. Results indicated that ELA was associated with lower iron levels and iron deficiency at 12 months. The findings are consistent with animal and human prenatal models of stress and iron status and provide evidence of the association between postnatal ELA and iron status in humans. The findings also highlight a nutritional pathway by which ELA may impact development and present a nutritionally-focused avenue for future research on ELA and psychopathology.

Rapid increase in the body mass index of very preterm infants is a risk factor for iron deficiency during infancy

Iron deficiency (ID) in very preterm infants born at 28-32 weeks of gestational age (GA) can lower mental and motor test scores. This study aimed to determine whether the rapid growth of very preterm infants might be associated with ID. Among 134 very preterm born between January 2014 and December 2020 at Jeonbuk National University Hospital and discharged home, 93 were included in this study. Rapid BMI increase (RBI) was defined as a z-score difference of > 1 standard deviation between birth and 8 months. ID occurred in 23 of 93 (24.7%) infants at 8 months of corrected age (CA). ID was more common in the RBI group (50%) than in the non-RBI group (18.7%). In the multivariate logistic regression corrected for GA, infants small for gestational age (SGA) (odds ratio [OR] 6.06, 95% confidence interval [CI] 1.34-30.21) and RBI by z-score (OR 4.26, 95% CI 1.28-14.65) were identified as independent risk factors for ID at 8 months of CA. Conclusively, both SGA and RBI in the early life of very preterm were risk factors for ID at 8 months of CA.

The interplay between maternal-infant anemia and iron deficiency

Iron deficiency anemia in pregnancy is a major public health problem known to cause maternal morbidity and adverse birth outcomes, and it may also have lasting consequences on infant development. However, the impact of the maternal hematological environment on fetal and infant hemoglobin and iron stores in the first year of life remains unclear. This review of the epidemiological evidence found that severe maternal iron deficiency anemia in pregnancy is associated with lower ferritin, and to a lesser degree hemoglobin levels, in infants at birth. Emerging data also suggests that severe anemia in pregnancy increases the risk of iron deficiency and anemia in infants 6-12 months of age, although longitudinal studies are limited. Effective anemia prevention in pregnancy, such as iron supplementation, could reduce the risk of infant anemia and iron deficiency during the first year of life; however, more evidence is needed to determine the functional impact of iron supplementation in pregnancy on infant hematological indices.

Burden and Determinants of Anemia among Under-Five Children in Africa: Systematic Review and Meta-Analysis

Introduction

Globally, anemia among under-five children is a serious public health problem. Even if there are pocket studies here and there, there is limited evidence on the pooled prevalence of anemia among under-five children in Africa. Therefore, the aim of this study was to determine the pooled prevalence and determinants of anemia. Methods and Analysis. This systematic review and meta-analysis was done following the PRISMA guidelines. A comprehensive search was made in PubMed/MEDLINE, Cochrane Library, HINARI, and Ethiopian Journal of Health Development for studies published since 2009. It was supplemented with Google Scholar search. Study selection, data extraction, and quality of studies were assessed by eight reviewers. The Cochrane Q test and I 2 test statistic were used to test the heterogeneity of studies. A random-effects model of DerSimonian-Laird method was used.

Result

A total of 37 articles were included in this systematic review and meta-analysis. The pooled prevalence of anemia among under-five children in Africa was 59% (95% CI: 55, 63). Being female (AOR = 0.71; 95% CI: 0.57, 0.87), maternal education (AOR = 1.47; 95% CI: 1.31, 1.66), residence (AOR = 0.80; 95% CI: 0.67, 0.95), and family size (AOR = 0.93; 95% CI: 0.89, 0.98) were the determinants of anemia among African under-five children. Conclusion and Recommendation. This pooled study revealed that anemia was a severe public health problem. Sex, maternal education, residence, and family size were the determinants of anemia. Therefore, anemia prevention strategy should include sex consideration, educating mothers through youth education, area specific intervention, and encouraging birth spacing.

Prevalence and factors associated with anaemia in children aged 6-24 months living a high malaria transmission setting in Burundi

BACKGROUND

In very young children, anaemia has been linked to increased morbidity, mortality and poor cognitive development. Although Burundi has a high burden of anaemia, which may be worsened by the high burden of malaria, little is known about the extent of the problem in very young children who are most at risk of severe disease. We estimated the prevalence, and assessed the factors associated with anaemia in children aged 6-24 months using baseline data collected as part of an on-going study evaluating the effect of Micronutrient supplementation on anaemia and cognition among children in high malaria transmission settings in Burundi.

METHODS

Between February and March 2020, surveys were conducted in 498 households within the catchment area of Mukenke Health Center. One child aged 6-24 months was selected per household to participate in the survey. Following written informed consent, we administered a questionnaire to the child's primary caregiver to capture information on child's demographics, nutritional status, food intake, health (status, and morbidity and treatment-seeking practices), as well as the household markers of wealth. A physical exam was conducted, and a blood sample was collected to: 1) assess for presence of plasmodium infection using a rapid diagnosis test; 2) estimate the haemoglobin levels using a portable haemocue machine. A stool sample was also collected to examine for the presence of helminth infections.

RESULTS

The prevalence of anaemia was 74.3% (95% confidence interval [CI] 61.5%-84.0%), with most of the anaemic study participants classified as having moderate anaemia (59.2%). A total of 62 (12.5%) participants had positive malaria rapid diagnosis tests. Factors significantly associated with higher odds of developing anaemia included not receiving deworming medication (adjusted Odd ratio [aOR] = 3.54, 95% CI 1.79-6.99, p<0.001), the child's home location (Mukenke II: aOR = 2.22, 95% CI 1.89-2.62, p<0.001; Mukenke: aOR = 2.76, 95% CI 2.46-3.10, p<0.001 and Budahunga: aOR = 3.12, 95% CI 2. 94-3.31, p<0.001) and the child's age group (Children aged 6-11 months: aOR = 2.27, 95% CI 1.32-3.91, p<0.001). Education level was inversely associated with less odds of anaemia: child's primary care giver with a secondary (aOR = 0.67; 95% CI: 0.47-0.95, p = 0,024) and tertiary education level (aOR = 0.48; 95% CI: 0.38-0.61, p<0.001).

CONCLUSION

Anaemia is highly prevalent among young children in high malaria transmission setting. Anaemia is more prevalent among children who not dewormed and those with malaria. To prevent the long-term adverse outcomes of the anaemia in children, policy makers should focus on improving uptake of the deworming and malaria prevention programs, promote preventive interventions and improve the education of women especially in families with very young children.

Prevalence of Anemia and Associated Factors among Infants under Six Months in Rural China

OBJECTIVE

To examine haemoglobin level and anaemia status among infants under six months of age in rural China.

DESIGN

A cross-sectional survey collected data among infants under six months and their primary caregivers in Sichuan, China. Anaemia was defined using both the WHO and China Pediatrics Association thresholds. Multivariable linear regression was used to identify relevant factors among two age groups (<4 months; 4-5 months).

SETTING

80 townships were selected in Sichuan, China from November to December 2019.

PARTICIPANTS

942 infants under six months, while haemoglobin level were tested for 577 infants.

RESULTS

The overall mean (±SD) haemoglobin level was 106.03 (± 12.04) g/L. About 62.6% (95%CI: 58.5, 66.6) of sample infants were anemic using the WHO threshold, and 20.5% (95%CI: 17.3, 24.1) were anemic using the China Pediatrics Association thresholds. Anaemia rates rose with increasing age in months. Multivariable linear regressions revealed that lower haemoglobin levels were significantly associated with lower birth weight (<4 months: b = 4.14, 95% CI: 0.19, 8.08; 4-5 months: b = 6.60, 95% CI: 2.94, 10.27) and delivery by cesarean section (<4 months: b = -4.64, 95%CI: -7.79, -1.49; 4-5 months: b = -4.58, 95%CI: -7.45, -1.71).

CONCLUSION

A large share of infants under six months in rural western China are anemic. Infants with low-birth-weight and cesarean-delivered should be prioritized for anaemia testing. Future studies should move the point of focus forward to at least 4 months of age and examine the link between cesarean-section and anaemia to promote health and development in infancy.

Global Prevalence of Anemia in Pregnant Women: A Comprehensive Systematic Review and Meta-Analysis

BACKGROUND

Anemia is one of the most critical health conditions affecting people worldwide. The disease is silent, with a slow progression and a few physical symptoms. Anemia during pregnancy carries the risk of premature birth, low birth weight, and fetus malformations and can impose additional costs on society and families. Therefore, the aim of this study is to conduct a systematic review and meta-analysis on the prevalence of anemia in pregnant women worldwide.

METHODS

In this work, we have conducted a systematic review and meta-analysis of the studies that have examined the prevalence of anemia in pregnant women globally. The Google Scholar, Cochrane, ScienceDirect, Medline (PubMed), and Web of Science (WoS) databases were searched for articles published between 1991 and 2021. The search keywords were anemia, pregnancy, prevalence, and meta-analysis. In order to analyze the eligible studies, the stochastic effects model was used, and the heterogeneity of the studies was examined using the I² index. Data analysis was performed within the Comprehensive Meta-Analysis software (Version 2).

RESULTS

The search resulted in 338 deduplicated studies, of which 52 studies with a total sample size of 1,244,747 people were included in this review. According to the results of the meta-analysis, the overall prevalence of anemia in pregnant women is 36.8% (95% confidence interval: 31.5-42.4%). The highest prevalence of anemia is mild at 70.8 (95% CI 58.1-81) and highest in the third trimester of pregnancy with the prevalence of 48.8 (95% CI 38.7-58.9), while the highest prevalence of anemia in pregnant women was in Africa with the prevalence of 41.7 (95% CI 32.3-49.4).

CONCLUSION

The results of this study show a high prevalence of anemia among pregnant women worldwide, and the highest of this prevalence is mild anemia. The prevalence of anemia in the third trimester was higher than in the first and second trimesters. Anemia in pregnant women in developing countries is significantly higher than in developed countries due to pregnancy's economic, sociological, and health factors.

Malnutrition and Associated Risk Factors among Children 6-59 Months Old in the Landslide-Prone Bududa District, Eastern Uganda: A Cohort Study

BACKGROUND

The United Nations Sustainable Development Goal 2.2 calls for an end to all forms of malnutrition. This might be derailed due to persistent landslide disasters in low-income countries like Uganda.

OBJECTIVES

The prevalence of malnutrition and the impact of seasonal variations and associated factors were assessed among children aged 6-59 mo in the landslide-affected households in Bududa District, eastern Uganda.

METHODS

A prospective cohort study using a 2-stage simple random technique was applied to select 422 households including 392 children during May-August (food-plenty season) 2019. After 6 mo, in January-March (food-poor season) 2020, 388 households and 366 children were assessed. Socioeconomic and demographic data were collected using structured questionnaires. Child malnutrition outcomes were defined according to WHO criteria. Factors associated with malnutrition outcomes were identified by bivariate and multivariate logistic regression.

RESULTS

Stunting, underweight, wasting, and overweight prevalences were 37.7%, 13.3%, 3.6%, and 4.3%, respectively, in the food-plenty season and 42.6%, 14.2%, 2.1%, and 2.7%, respectively, in the food-poor season. Residing in the landslide-affected sub-county increased the odds for stunting [adjusted OR (aOR): 1.68; 95% CI: 1.08, 2.59; P = 0.025] and underweight (aOR = 4.25; 95% CI: 1.10, 15.36; P = 0.032) for children in the food-plenty season. Child age, sex, breastfeeding status, a nonimproved drinking water source, migration of any household member, and parents' education were significant risk factors in the food-plenty season. In the food-poor season, parents' education status, loss of any household member, child sex, and child age were significant risk factors.

CONCLUSIONS

Stunting and underweight were more prevalent in the food-poor season while wasting and overweight were more prevalent in the food-plenty season. With the exception of child age, child sex, and parents' education, child malnutrition risk factors differed between food-plenty and food-poor seasons. There is a need to address seasonality factors in program interventions targeting children <5 y in landslide-prone areas.

Pregnancy anaemia, child health and development: a cohort study in rural India

OBJECTIVE

To assess how pregnancy anaemia affects the offspring's early childhood development, child haemoglobin (Hb) levels child growth and diseases incidence 2 years after birth in a low-income setting. Furthermore, we investigate the mediating role of childhood Hb levels with disease incidences and skills.

DESIGN

Prospective cohort study.

SETTING AND PARTICIPANTS

The study participants are 941-999 mother-child dyads from rural Madhepura in Bihar, India. In 2015, the women were recruited during pregnancy from registers in mother-child centres of 140 villages for the first wave of data collection. At the time of the second wave in 2017, the children were 22-32 months old.

PRIMARY AND SECONDARY OUTCOME MEASURES

The recruited women were visited at home for a household survey and the measurement of the women's and child's Hb level, child weight and height. Data on the incidence of diarrhoea and respiratory diseases or fever were collected from interviews with the mothers. To test motor, cognitive, language and socioemotional skills of the children, we used an adapted version of the child development assessment FREDI.

RESULTS

The average Hb during pregnancy was 10.2 g/dL and 69% of the women had pregnancy anaemia. At the age of 22-32 months, a 1 g/dL increase in Hb during pregnancy was associated with a 0.17 g/dL (95% CI: 0.11 to 0.23) increase in Hb levels of the child. Children of moderately or severely anaemic women during pregnancy showed 0.57 g/dL (95% CI: -0.78 to -0.36) lower Hb than children of non-anaemic women. We find no association between the maternal Hb during pregnancy and early skills, stunting, wasting, underweight or disease incidence. While childhood anaemia does not correlate with childhood diseases, we find an association of a 1 g/dl increase in the child's Hb with 0.04 SDs higher test scores.

CONCLUSIONS

While pregnancy anaemia is a risk factor for anaemia during childhood, we do not find evidence for an increased risk of infectious diseases or early childhood development delays.

Prevalence of Anemia and Associated Factors Among Term Newborns in Nekemte Specialized Hospital, Western Ethiopia

Background

Anemia is a global public health problem that affects approximately one-third of the global population. Infants and children are the ones to develop both short-term and long-term devastating complications from anemia. Although anemia is a very big public health concern, newborns, especially in developing countries, are usually overlooked and undiagnosed.

Purpose

The aim of this study was to assess the prevalence of anemia and associated factors among term newborns in Nekemte Specialized Hospital, Western Ethiopia.

Methods

A facility-based cross-sectional study involving 278 newborns was conducted from October to November, 2020 with an interview-based questionnaire that included maternal socio-demographic and obstetrics characteristics, newborn’s weight and sex. The data were analyzed with SPSS version 20. The prevalence of newborn anemia was shown in percentage and as a pie-chart. Bivariate analysis and binary logistic regression were used to identify the predictors of anemia in the term newborn.

Results

The overall prevalence of newborn anemia in the hospital was 29.1%. Maternal anemia (AOR: 3.95, 95% C.I.: 1.97–7.92), delivery by cesarean section (AOR: 4.17, 95% C.I.: 1.89–9.20), vaginal bleeding during pregnancy (AOR: 5.43, 95% C.I.: 1.60–18.39), and maternal failure to take iron-folate supplements during pregnancy (AOR: 2.17, 95% C.I.:1.07–4.41) were factors associated with newborn anemia.

Conclusion

Anemia among newborns in the hospital was a moderate public health problem. Policy makers should consider maternal health education and appropriate health interventions to reduce the problem. In addition, further longitudinal studies are needed to identify specific causes of newborn anemia in order to prevent the possible complications.

Comprehensive Analysis of the Components of Walnut Kernel (Juglans regia L.) in China

The contents of main components in 45 walnut kernels from 5 walnut-planting provinces in China (Yunnan, Shaanxi, Shandong, Hebei, and Sichuan) were determined using colorimetry, high-performance liquid chromatography, and gas chromatography, including flavonoids, vitamin E, trace elements, fatty acids, and amino acids. The levels of flavonoids and vitamin E were higher in walnuts from Yunnan than in walnuts from the other four provinces. The levels of zinc and iron were relatively higher in walnuts from Shandong, and the calcium content in walnuts from Yunnan was much lower. No obvious difference was found in crude fat concentration for nuts from the five provinces, but differences were observed in the crude protein content. Oleic acid was the predominant unsaturated fatty acids in all walnut species; the monounsaturated fatty acid content was the highest in walnuts from Yunnan. The data obtained here provided insight into differences in walnuts resulting from different growing environments and germplasm genetic traits.

Investigation of Iron and Zinc Concentrations in Human Milk in Correlation to Maternal Factors: An Observational Pilot Study in Poland

The aim of this study was to evaluate iron and zinc concentrations in the mature human milk (HM) and to investigate the relationship between these concentrations and maternal factors. HM samples were collected between 4–6 weeks postpartum from 32 healthy, exclusively breastfeeding mothers. The assessment of dietary intake during breastfeeding was based on a food frequency questionnaire and three-day dietary records. Nutritional status of participants was assessed with body mass index and body composition analysis, measured with bioelectrical impedance. HM intake was assessed with infants’ weighting, whereas iron and zinc contents in HM were determined by inductively coupled plasma mass spectrometer. The median intake of HM was 492.5 mL (466–528.5) and the concentrations of HM iron and zinc were 0.33 mg/L (0.26–0.46) and 2.12 mg/L (1.97–2.45), respectively. Maternal total zinc and iron intake (diet + supplementation) was positively correlated with their concentrations in HM. Consumption frequency of meat, vegetables and legumes was revealed to be a significant factor influencing zinc concentration in HM. Regarding iron, it was the consumption frequency of meat, fish and seafood, vegetables and legumes, nuts and seeds. The intake of iron from HM was low, and after assuming a mean fractional iron absorption, it was only 0.038 mg/d. Our results show that maternal diet influences iron and zinc content in HM, suggesting that adequate intake of food rich in investigated minerals may be a positive factor for their concentrations in HM.

Hematological Abnormalities and Associated Factors Among Undernourished Under-Five Children Attending University of Gondar Specialized Referral Hospital, Northwest Ethiopia

Introduction

The hematopoietic system is one of the systems which can be affected by malnutrition, leading to impaired production of all blood cell lines. Undernourished children with hematological abnormalities like anemia are at higher risk of mortality. Therefore, this study aimed at determining the magnitude and associated factors of hematological abnormalities among undernourished under-five children attending at the University of Gondar Specialized Referral Hospital, Northwest Ethiopia.

Methods and Materials

An institution-based cross-sectional study was conducted on a total of 251 undernourished under-five children at University of Gondar Specialized Referral Hospital from January to May 2020. A convenient sampling technique was employed to select study participants. Data were collected using a pretested structured questionnaire. Blood samples were collected for complete blood count which were determined by Sysmex KX-21N analyzer. Stool sample was processed via direct wet mount. Thin and thick blood films were examined to assess malaria parasite. The data were entered to EpiData version 4.6.0.0 and analyzed using SPSS version 23 software. Bi-variable and multi-variable binary logistic regression model were fitted to identify factors associated with hematological abnormalities. A p-value <0.05 in the multivariable analysis was considered as statistically significant.

Results

The overall magnitude of anemia, leukocytosis, thrombocytosis, thrombocytopenia, and leukopenia was 53.4%, 26.7%, 23.9%, 8%, and 2.8%, respectively. Being male, age 6-23 months, high birth order, intestinal parasite infection, edema, not eating vegetables and fruits, and paternal occupation were found to be associated with anemia. Only the age of a child was associated with leukocytosis in undernourished children.

Conclusion

The current study demonstrated the predominant existence of anemia, leukocytosis, and thrombocytosis among undernourished under-five children. Therefore, early diagnosis, monitoring and setting intervention strategies for anemia especially among children under two years old are required to prevent further complication.

A systematic review and meta-analysis of the prevalence and predictors of anemia among children in Ethiopia

Background

Anemia is a wide-spread public health problem characterized by a decrease in hemoglobin concentration and/ or red blood cell volume below an established cut-off value. In developing countries including Ethiopia, about half of children are estimated to be anemic. Therefore, the purpose of this study was to determine the pooled prevalence of anemia and its predictor factors among children in Ethiopia.

Method

The studies were identified through explicit and exhaustive search of reputable databases (PubMed, Google scholar, Science Direct, EMBASE, Cochrane library, and the hand search of reference lists of previous prevalence studies to retrieve more related articles. Thirty-nine studies were selected based on a comprehensive list of inclusion and exclusion criteria. Data were extracted using a standardized and pre-tested data extraction checklist, and the analysis was done using STATA 14 statistical software. To assess heterogeneity, the Cochrane Q test statistic and I2 tests were used. In our analysis, considerable heterogeneity was observed. Therefore, a random effect meta-analysis model was used to estimate the pooled prevalence of anemia. Moreover, the predictor factors of anemia were examined.

Results

The forest plot of 39 included studies revealed that the overall pooled prevalence of anemia among children in Ethiopia was 34.4% (95% CI: 29.1, 39.7%). Sub-group analysis showed that the highest anemia prevalence was observed in Somali Region with a prevalence of 49.4 % (95% CI: 20.9, 77.8). Also, anemia in children was found to be highest in the age group of less than five years (45.2, 95% CI: 39.6,50.8). Low literacy of families: 1.3 (95% CI: 1.1, 1.7), low family socioeconomic status: 1.9 (95% CI: 1.1,3.01.3), having housewife mothers or with no job: 1.5 (95% CI: 1.4, 1.9) and rural residence: 3.3 (95% CI: 1.7,6.1) were found to be predictors of anemia among children.

Conclusion

In this study, one in three children were anemic in Ethiopia. It is a moderate public health problem in children in this study. Low literacy, low socioeconomic status as well as rural residence of the families and helminthic infection of the children were found to be predictors of anemia in the children. Community and school-based interventions should be strengthened to improve the problem.

Annual Prevalence, Health Expenditures, and Co-Morbidities Trend of Iron Deficiency Anemia in Korea: National Health Insurance Service Data from 2002 to 2013

Despite improvements in nutritional status, iron deficiency anemia (IDA) remains a debilitating nutritional problem worldwide. We estimate annual IDA prevalence rates by sex and age and the trends therein in Korea. We also calculate the health expenditures of IDA and its co-morbidities by analyzing claims data in the National Health Information Database from 2002 to 2013. All analyses were performed based on diagnosis codes of IDA (D50, D50.0, D50.8, and D50.9) regardless of whether IDA was the principal or a coexisting disease. Trends in IDA prevalence rates were evaluated by calculating annual percent changes (APCs) in prevalence. The health expenditures of IDA were calculated based on the direct medical costs (outpatient and hospitalization costs, pharmaceutical costs) and direct non-medical costs (travel costs). The overall IDA prevalence in both sexes increased approximately 2.3-fold from 2002 to 2013; the APC was +7.6%. In females, the prevalence of IDA was highest in aged 30–39 and 40–49 years. The APC was highest in those aged <10 years (+18.2%), followed by those aged ≥80 (+14.7%) and 70–79 (+9.8%) years. In males, the prevalence rates were highest in aged <10 years, followed by those aged ≥60 years. The APC was highest in those aged <10 years (+19.1%), followed by those aged ≥80 years (+10.5%). The total health expenditures increased 2.8-fold during 12 years. Diseases of the respiratory or gastrointestinal tract were the most prevalent co-morbidities in both males and females. The annual prevalence of IDA continues to rise in association with adverse health expenditures and co-morbidities in spite of improvements in nutritional status. Most importantly, infants and young children, the elderly, and females aged 30–49 years are at highest risk of IDA. A national, prospective, and well-organized effort to improve iron status and to manage IDA is required.

Appropriate age range for introduction of complementary feeding into an infant's diet

Following a request from the European Commission, the Panel on Nutrition, Novel Foods and Food Allergens (NDA) revised its 2009 Opinion on the appropriate age for introduction of complementary feeding of infants. This age has been evaluated considering the effects on health outcomes, nutritional aspects and infant development, and depends on the individual's characteristics and development. As long as foods have an age-appropriate texture, are nutritionally appropriate and prepared following good hygiene practices, there is no convincing evidence that at any age investigated in the included studies (< 1 to < 6 months), the introduction of complementary foods (CFs) is associated with adverse health effects or benefits (except for infants at risk of iron depletion). For nutritional reasons, the majority of infants need CFs from around 6 months of age. Infants at risk of iron depletion (exclusively breastfed infants born to mothers with low iron status, or with early umbilical cord clamping (< 1 min after birth), or born preterm, or born small-for-gestational age or with high growth velocity) may benefit from earlier introduction of CFs that are a source of iron. The earliest developmental skills relevant for consuming pureed CFs can be observed between 3 and 4 months of age. Skills for consuming finger foods can be observed in some infants at 4 months, but more commonly at 5-7 months. The fact that an infant may be ready from a neurodevelopmental perspective to progress to a more diversified diet before 6 months of age does not imply that there is a need to introduce CFs. There is no reason to postpone the introduction of potentially allergenic foods (egg, cereals, fish and peanut) to a later age than that of other CFs as far as the risk of developing atopic diseases is concerned. Regarding the risk of coeliac disease, gluten can be introduced with other CFs.

Rapid growth is a dominant predictor of hepcidin suppression and declining ferritin in Gambian infants

Iron deficiency and iron deficiency anemia are highly prevalent in low-income countries, especially among young children. Hepcidin is the major regulator of systemic iron homeostasis. It controls dietary iron absorption, dictates whether absorbed iron is made available in circulation for erythropoiesis and other iron-demanding processes, and predicts response to oral iron supplementation. Understanding how hepcidin is itself regulated is therefore important, especially in young children. We investigated how changes in iron-related parameters, inflammation and infection status, seasonality, and growth influenced plasma hepcidin and ferritin concentrations during infancy using longitudinal data from two birth cohorts of infants in rural Gambia (n=114 and n=193). This setting is characterized by extreme seasonality, prevalent childhood anemia, undernutrition, and frequent infection. Plasma was collected from infants at birth and at regular intervals, up to 12 months of age. Hepcidin, ferritin and plasma iron concentrations declined markedly during infancy, with reciprocal increases in soluble transferrin receptor and transferrin concentrations, indicating declining iron stores and increasing tissue iron demand. In cross-sectional analyses at 5 and 12 months of age, we identified expected relationships of hepcidin with iron and inflammatory markers, but also observed significant negative associations between hepcidin and antecedent weight gain. Correspondingly, longitudinal fixed effects modeling demonstrated weight gain to be the most notable dynamic predictor of decreasing hepcidin and ferritin through infancy across both cohorts. Infants who grow rapidly in this setting are at particular risk of depletion of iron stores, but since hepcidin concentrations decrease with weight gain, they may also be the most responsive to oral iron interventions.

Zinc Protoporphyrin-to-Heme Ratio and Ferritin as Measures of Iron Sufficiency in the Neonatal Intensive Care Unit

OBJECTIVES

To evaluate ferritin and zinc protoporphyrin-to-heme (ZnPP/H) ratios as biomarkers of iron status in neonates, determine how specific clinical events affected these measures, and assess how iron status changed during hospitalization.

STUDY DESIGN

We performed a retrospective study of all infants with paired ferritin and ZnPP/H measurements between October 2014 and May 2016. Concordance of these measurements, effects of sepsis, red blood cell transfusion, erythropoietin treatment, and iron supplementation were assessed. Iron status was measured over time.

RESULTS

A total of 228 patients (mean birth weight 1.3 kg, median gestational age 29 weeks) were evaluated. Mean log ZnPP/H values in infants with and without sepsis were not significantly different (4.98 µmol/mol vs 4.97 µmol/mol, adjusted P = .103), whereas log-transformed ferritin values increased significantly during infection (5.23 ng/mL vs 4.04 ng/mL, adjusted P < .001). Ferritin also increased more significantly than ZnPP/H following red blood cell transfusion (ferritin: mean 5.03 ng/mL vs 4.0 ng/mL, P < .001; ZnPP/H: mean 4.85 µmol/mol vs 4.98 µmol/mol, P < .001). The mean iron supplementations at 30, 60, and 90 days were 5.4, 6.9, and 7.4 mg/kg/day, respectively. Ferritin values decreased with advancing postnatal age (adjusted P < .001), with 66% of ferritin values less than 76 ng/mL. Treatment with erythropoietin increased ZnPP/H, but not ferritin levels.

CONCLUSIONS

Ferritin is more significantly affected by inflammatory events such as sepsis and transfusion than ZnPP/H, thus, ZnPP/H may be a more reliable marker of iron status in this population. Infants showed worsening iron sufficiency over time despite supplementation above American Academy of Pediatrics guidelines.

Serum hepcidin levels, iron status, and HFE gene alterations during the first year of life in healthy Spanish infants

The aims of this study were to describe hepcidin levels and to assess their associations with iron status and the main variants in the HFE gene in healthy and full-term newborns during the first year of life, as a longitudinal study conducted on 140 infants. Anthropometric and biochemical parameters, hepcidin, hemoglobin (Hb), serum ferritin (SF), transferrin saturation (TS), mean corpuscular volume (MCV), and C-reactive protein (CRP), were assessed in 6- and 12-month-olds. Infants were genotyped for the three main HFE variants: C282Y, H63D, and S65C. Hepcidin levels increased from 6 to 12 months of age (43.7 ± 1.5 to 52.0 ± 1.5 ng/mL; p < 0.001), showing higher levels in infants with better iron status compared to those with iron deficiency (ID) (44.8 ± 1.5 vs 37.9 ± 1.3 ng/mL, p < 0.018, and 54.3 ± 1.5 vs 44.0 ± 1.4 ng/mL, p < 0.038, in 6- and 12-month-olds, respectively). In multivariate linear regression models, iron status was found to be associated with hepcidin levels in infants with wild-type HFE gene (p = 0.046 and p = 0.048 in 6- and 12-month-olds, respectively). However, this association was not found in HFE-alteration-carrying infants. Hepcidin levels increased in healthy infants during the first year of life and were positively associated with iron levels only in infants with wild-type HFE gene, a situation that requires further investigation.

Caesarean delivery and anaemia risk in children in 45 low- and middle-income countries

Caesarean delivery (CD) may reduce placental transfusion and cause poor iron-related haematological indices in the neonate. We aimed to explore the association between CD and anaemia in children aged <5 years utilising data from Demographic and Health Surveys conducted between 2005 and 2015 in 45 low- and middle-income countries (N = 132,877). We defined anaemia categories based on haemoglobin levels, analysed each country's data separately using propensity-score weighting, pooled the country-specific odds ratios (ORs) using random effects meta-analysis, and performed meta-regression to determine whether the association between CD and anaemia varies by national CD rate, anaemia prevalence, and gross national income. Individual-level CD was not associated with any anaemia (OR 0.95, 95% confidence interval (CI) [0.86, 1.06]; I²  = 40.2%), mild anaemia (OR 0.91, 95% CI [0.81, 1.02]; I²  = 24.8%), and moderate/severe anaemia (OR 0.97, 95% CI [0.85, 1.11]; I²  = 47.7%). CD tended to be positively associated with moderate/severe anaemia in upper middle-income countries and negatively associated with mild anaemia in lower middle-income countries; however, meta-regression did not detect any variation in the association between anaemia and CD by the level of income, CD rate, and anaemia prevalence. In conclusion, there was no evidence for an association between CD and anaemia in children younger than 5 years in low- and middle-income countries. Our conclusions were consistent when we looked at only countries with CD rate >15% with data stratified by individual-level wealth status and type of health facility of birth.

Preconception Micronutrient Supplementation with Iron and Folic Acid Compared with Folic Acid Alone Affects Linear Growth and Fine Motor Development at 2 Years of Age: A Randomized Controlled Trial in Vietnam

Background: Maternal health and nutrition play a crucial role in early child growth and development. However, little is known about the benefits of preconception micronutrient interventions beyond the role of folic acid (FA) and neural tube defects.Objective: We evaluated the impact of weekly preconception multiple micronutrient (MM) or iron and folic acid (IFA) supplementation on child growth and development through the age of 2 y compared with FA alone.Methods: We followed 1599 offspring born to women who participated in a randomized controlled trial of preconception supplementation in Vietnam. Women received weekly supplements that contained either 2800 μg FA, 60 mg Fe and 2800 μg FA, or 15 MMs including IFA, from baseline until conception followed by daily prenatal IFA supplements until delivery. Child anthropometry was measured at birth and at 3, 6, 12, 18, and 24 mo. Child development was measured with the use of the Bayley Scales for Infant Development III at 24 mo.Results: The groups were similar for baseline maternal and offspring birth characteristics. At 24 mo of age, the offspring in the IFA group had significantly higher length-for-age z scores (LAZs) (0.14; 95% CI: 0.03, 0.26), reduced risk of being stunted (0.87; 95% CI: 0.76, 0.99), and smaller yearly decline in LAZs (0.10; 95% CI: 0.04, 0.15) than the offspring in the FA group. Similar trends were found for the offspring in the MM group compared with the FA group for LAZs (0.10; 95% CI: -0.02, 0.22) and the risk of being stunted (0.88; 95% CI: 0.77, 1.01). Offspring in the IFA group had improved motor development (P = 0.03), especially fine motor development (0.41; 95% CI: 0.05, 0.77), at the age of 24 mo, but there were no differences for measures of cognition or language.Conclusions: Preconception supplementation with IFA improved linear growth and fine motor development at 2 y of age compared with FA. Future studies should examine whether these effects persist and improve child health and schooling. The trial was registered at clinicaltrials.gov as NCT01665378.

Longitudinal Analysis of the Interaction Between Obesity and Pregnancy on Iron Homeostasis: Role of Hepcidin

BACKGROUND AND AIMS

When pregnancy occurs in obese women, two opposite mechanisms for iron homeostasis concur: increased need for available iron to support erythropoiesis and decreased iron mobilization from diets and stores due to obesity-related inflammation linked to overexpressed hepcidin. Few studies have examined the role of hepcidin on maternal iron homeostasis in the context of obese pregnancy. The aim of the study was to evaluate the combined effect of maternal obesity and pregnancy on hepcidin and maternal iron status while accounting for inflammation and iron supplementation.

METHODS

We conducted a secondary analysis of a cohort of pregnant women recruited from a referral obstetric hospital in Mexico City. Circulating biomarkers of iron status (hepcidin, ferritin [SF], transferrin receptor [sTfR], erythropoietin [EPO]), and inflammation (C-reactive protein [CRP], tumor necrosis factor-[TNF]α, and interleukin-[IL]6) were determined monthly throughout pregnancy. Repeated measures ANOVA and logistic regression models were used for statistics.

RESULTS

Twenty-three obese (Ob) and 25 lean (Lc) women were studied. SF and hepcidin declined, and EPO and sTfR increased throughout pregnancy in both groups. sTfR increased more in Ob than in Lc (p = 0.024). The smallest hepcidin decline occurred in iron-supplemented Ob women compared to non-supplemented Lc women (p = 0.022). The risk for iron deficiency at the end of pregnancy was higher for Ob than for Lc (OR = 4.45, 95% CI = 2.07-9.58) after adjusting for iron supplementation and hepcidin concentration.

CONCLUSION

Pre-gestational obesity increases the risk of maternal iron deficiency despite iron supplementation. Overexpressed hepcidin appears to be a potential mechanism.

Risk factors of infant anemia in the perinatal period

BACKGROUND

Infants are at particular risk of iron-deficiency anemia. We investigated changes in the blood count of the mother and infant as well as the relationship between them and the relationship between infant nutrition method and infant anemia.

METHODS

This retrospective cohort study included healthy neonates born between August 2011 and July 2014 at St Luke's International Hospital, Tokyo, Japan. Data from maternal blood samples obtained during late pregnancy and those of infants obtained at birth and at the age of 3, 6, and 9 months were analyzed. Using multivariate logistic regression, we investigated nutrition methods, maternal anemia, and other clinically relevant parameters that were potential risk factors for infant anemia.

RESULTS

In total, data for 3472 infants and their mothers were analyzed. Nutrition method was the most significant risk factor for infant anemia, with risk of future anemia decreasing in the following order: exclusive breast-feeding, partial breast-feeding, and formula feeding. Furthermore, low umbilical cord blood hemoglobin led to a tendency toward anemia in the child.

CONCLUSION

Infant nutrition method was the most significant factor related to anemia in late infancy. Infants with low umbilical cord blood hemoglobin are more likely to develop anemia in late infancy.

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.

Prenatal anemia control and anemia in children aged 6-23 months in sub-Saharan Africa

It is unclear whether routine prenatal anemia control interventions can reduce anemia risk in young children. This study examines the associations between prenatal iron supplementation and/or deworming and anemia in children aged 6-23 months in sub-Saharan Africa (SSA). We analyzed data from Demographic and Health Surveys conducted between 2003 and 2014 in 25 SSA countries. The surveys collected data on prenatal iron supplementation and deworming and determined children's hemoglobin levels through blood testing. We assessed the associations between prenatal iron supplementation and/or deworming and anemia using multinomial logistic regression. The study included 31,815 mother-child pairs: 25.0%, 41.4%, and 4.8% of children had mild, moderate, and severe anemia, respectively. Compared with children whose mothers did not take iron and deworming drugs prenatally, the risk of moderate/severe anemia was reduced among children whose mothers took only iron supplements for ≥6 months (odds ratio [OR]: 0.58; 95% confidence interval [CI]: 0.45-0.76); only deworming drugs (OR: 0.73; 95% CI: 0.56-0.93); deworming drugs plus iron for <6 months (OR: 0.79; 95% CI: 0.67-0.93); and deworming drugs plus iron for ≥6 months (OR: 0.77; 95% CI: 0.59-0.99). Prenatal use of only iron for <6 months was not associated with moderate/severe anemia. Prenatal iron and/or deworming drugs had no effect on mild anemia. Prenatal anemia control interventions are associated with reduced risk of moderate/severe anemia but not with mild anemia in young children in SSA. Iron supplements should be taken for ≥6 months or with deworming drugs prenatally to reduce moderate/severe anemia risk in children.

Role of Breastfeeding and Complementary Food on Hemoglobin and Ferritin Levels in a Cambodian Cross-Sectional Sample of Children Aged 3 to 24 Months

BACKGROUND

Iron deficiency derives from a low intake of dietary iron, poor absorption of iron, and high requirements due to growth as well as blood loss. An estimated number of about 50% of all anemia may be attributed to iron deficiency among young children in Cambodia.

METHODS

A cross-sectional survey was conducted in rural Cambodia in September 2012. Villages in pre-selected communes were randomly chosen using stunting as a primary indicator of nutritional status. In total, 928 randomly selected households with children aged 3-23 months were included. Hemoglobin, ferritin, soluble transferrin receptor (sTfR), and retinol binding protein (RBP) were assessed from capillary blood samples. In addition, length/height and weight of mothers and children were taken and data on dietary diversity was collected. A child feeding index (CFI) was created. Associations between biomarkers of iron and vitamin A status and nutritional status or food intake were explored.

RESULTS

Anemia prevalence was highest among 6- to 12-months-olds (71%). Ferritin and sTfR inversely correlated and were significantly associated with hemoglobin concentrations. The consumption of animal source foods (ASF) significantly impacts on the interaction between ferritin, sTfR and hemoglobin. Concentrations of RBP were significantly higher in children who had received a vitamin A supplement. The CFI was associated with sTfR and hemoglobin. Lower length and weight were associated with lower ferritin levels and showed an indirect effect on hemoglobin through ferritin.

CONCLUSION

Nutrition programs targeting children under 2 years of age need to focus on the preparation of complementary foods with high nutrient density to sustainably prevent micronutrient deficiency and generally improve nutritional status. Future assessments of the micronutrient status should include identification of hemoglobinopathies and parasitic infections to better understand all causes of anemia in Cambodian infants and young children.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00004379.

Differential ferritin interpretation methods that adjust for inflammation yield discrepant iron deficiency prevalence

We reassessed the iron deficiency (ID) prevalence in a South African trial that formed part of the International Research on Infant Supplementation study by comparing four methods that account for the high prevalence of acute (28.6%) and chronic (41.8%) inflammation observed in the study. Serum ferritin (SF) was measured as marker of iron status in 192 apparently healthy, 4-13-month-old infants. Alpha-1 glycoprotein and C-reactive protein concentrations were determined to indicate chronic and acute inflammation, respectively. The ID prevalence was obtained by four methods that adjust for inflammation: (1) excluding infants with inflammation; (2) using a higher cut-off (SF < 30 μg L(-1) ); (3) using different cut-offs for infants with vs. without inflammation (SF < 30 μg L(-1) vs. SF < 12 μg L(-1) ); and (4) adjusting SF concentrations with correction factors (CFs) were compared with a reference method (SF < 12 μg L(-1) ) not accounting for inflammation. Using the higher SF cut-off method resulted in the highest ID prevalence (52.1%), followed by using two different cut-offs (31.8%), using CFs (21.9%) and excluding subjects with inflammation (17.6%). The CF method showed the best agreement with the reference method. Disregarding inflammation resulted in a significantly lower ID prevalence (17.2%). ID anaemia (IDA) prevalence ranged from 13.2% to 24.5%, with the lowest prevalence (12.0%) for the reference method. Our analysis highlights the challenge of assessing ID and IDA using only SF as marker of iron status in the presence of inflammation. We demonstrate the importance of measuring inflammation markers to account for their elevating effect on SF.

[Prevalence and determinants of anemia in young children in French-speaking Africa. Role of iron deficiency]

Anemia and iron deficiency are major public health issues worldwide and particularly in Africa. Reliable information about their prevalence and associated factors is required to allow for effective actions. In this study, we used data from recent (2006-2012) large population health surveys, carried out in 11 French-speaking African countries (Benin, Burkina Faso, Cameroon, Congo Brazzaville, Ivory Coast, Gabon, Guinea, Mali, Niger, Democratic Republic of Congo, and Senegal). Hemoglobin (Hb) was assessed and demographic and health-related parameters were obtained from nation-representative samples of children aged 6-59 months. Anemia (Hb<11g/dL) was found in 72.4% of the children (60.2-87.8%), with no gender difference but a slightly lower incidence in older children (62% at age 4-5 years versus 85% at age 9 months), especially for the more severe forms (2.1% versus 8.7%, respectively). Anemia was only slightly but significantly affected by location (75.5% in rural areas versus 67.3% in towns), income (79.8% in lower quintile of income versus 62.3% in higher quintile), or maternal education (74.1% in children from non-educated mothers versus 62.4% in children whose mothers had secondary education). Nearly 50% of women of child-bearing age had anemia. In the countries that report this information, less than 50% (17-65%) of children consumed iron-rich foods regularly and only 12% (7.4-20.5%) received iron supplementation. Infection and parasitism are known to affect some markers of iron status, because of the inflammatory reaction, thereby making the diagnosis of iron deficiency difficult. In the study countries, acute respiratory diseases and diarrhea affected 6.2 and 15.6% of children aged between 6 and 59 months, respectively; their distribution according to age and location is very different from the one of anemia, which is also the case for the distribution of malaria. It is thus likely that a large part of the anemia observed in young children is due to iron deficiency, although further research is needed to confirm this. This fully justifies the nationwide programs of iron fortification of flour, currently undergoing in most countries of French-speaking Africa. Their formal evaluation is still pending but the initial data suggest some efficacy, although far from optimal. It is thus likely that a more holistic approach, including iron fortification, actions against undernutrition and parasitism in children, and actions in favor of improving young women's iron and nutritional status, together with appropriate communication and education objectives, would be more effective.

Prevalence and determinants of anaemia among children aged 0–59 months in a rural region of Armenia: a case–control study

Objective

Despite the trend of increasing prevalence of childhood anaemia in Armenia, no studies exploring its risk factors have been conducted in the country. The present study aimed to investigate the prevalence and determinants of childhood anaemia in rural Armenia.

Design

Blood Hb level was measured among a representative sample of children using the HemoCue Hb201+ analyser. The revealed cases with anaemia were compared with randomly selected non-anaemic controls. Mothers of cases and controls were interviewed. Logistic and linear regression models were fitted to identify the risk factors of anaemia and low Hb level, respectively.

Setting

Talin communities, Aragatsotn Province, Armenia.

Subjects

Children under 5 years of age in Talin region.

Results

Of the 729 studied children, 32·4 % were anaemic with 14·7 % having moderate/severe anaemia. Infants were the most affected group with 51·1 % being anaemic before 6 months and 67·9 % at 6–12 months of age. Fitted regression models identified the following predictors of anaemia: younger age, male gender, shorter birth length, anaemia during pregnancy, lower meal frequency per day, lack of meat in the diet, using dung cakes for heating and living in a community that received an incomplete set of nutrition interventions.

Conclusions

The study identified several modifiable risk factors that could be targeted to reduce childhood anaemia in rural Armenia and, possibly, in rural areas in other low-/middle-income countries. The suggested interventions include prevention and treatment of anaemia during pregnancy, provision of adequate complementary feeding to children with inclusion of meat in their daily diet and reduction of their exposure to biomass fuel smoke.

Development and pilot testing of Baby-Led Introduction to SolidS--a version of Baby-Led Weaning modified to address concerns about iron deficiency, growth faltering and choking

BACKGROUND

In Baby-Led Weaning (BLW), infants are offered 'finger' foods from the start of the complementary feeding period instead of being spoon-fed. Healthcare professionals have expressed concerns about adequacy of iron and energy intake, and about choking, for infants following Baby-Led Weaning.

METHODS

We developed a modified version of BLW, Baby-Led Introduction to SolidS (BLISS), to address these concerns. In a 12-week pilot study, families who had chosen to use a BLW approach were assigned to BLISS (n = 14) or BLW (n = 9). BLISS participants received 2 intervention visits, resources and on-call support. BLW participants received no intervention. Participants were interviewed weekly for 12 weeks and completed a three-day weighed record or three 24-h iron questionnaires.

RESULTS

Compared to the BLW group, the BLISS group were more likely to introduce iron containing foods during the first week of complementary feeding, and to offer more serves per day of iron containing foods at 6 months (2.4 vs 0.8 serves/day; P = 0.001); and less likely to offer high-choking-risk foods (3.24 vs 0.17 serves/day; P = 0.027).

CONCLUSIONS

This pilot study suggests BLISS may result in higher iron intakes and lower choking risk than unmodified BLW. However, the results need to be confirmed in a large randomised controlled trial.

Antiretroviral Treatment Is Associated With Iron Deficiency in HIV-Infected Malawian Women That Is Mitigated With Supplementation, but Is Not Associated With Infant Iron Deficiency During 24 Weeks of Exclusive Breastfeeding

OBJECTIVE

In resource-limited settings without safe alternatives to breastfeeding, the WHO recommends exclusive breastfeeding and antiretroviral (ARV) prophylaxis. Given the high prevalence of anemia among HIV-infected women, mothers and their infants (through fetal iron accretion) may be at risk of iron deficiency. We assessed the effects of maternal micronutrient-fortified lipid-based nutrient supplements (LNS) and maternal ARV treatment or infant ARV prophylaxis on maternal and infant iron status during exclusive breastfeeding from birth to 24 weeks.

METHODS

The Breastfeeding, Antiretrovirals, and Nutrition study was a randomized controlled trial conducted in Lilongwe, Malawi, from 2004 to 2010. HIV-infected mothers (CD4 >200 cells/μL) and their infants were randomly assigned to 28-week interventions: maternal LNS/maternal ARV (n = 424), maternal LNS/infant ARV (n = 426), maternal LNS (n = 334), maternal ARV (n = 425), infant ARV (n = 426), or control (n = 334). Longitudinal models tested intervention effects on hemoglobin (Hb). In a subsample (n = 537) with multiple iron indicators, intervention effects on Hb, transferrin receptors (TfR), and ferritin were tested with linear and Poisson regression.

RESULTS

In longitudinal models, LNS effects on maternal and infant Hb were minimal. In subsample mothers, maternal ARVs were associated with tissue iron depletion (TfR >8.3 mg/L) (risk ratio: 3.1, P < 0.01), but not in ARV-treated mothers receiving LNS (P = 0.17). LNS without ARVs was not associated with iron deficiency or anemia (P > 0.1). In subsample infants, interventions were not associated with impaired iron status (all P > 0.1).

CONCLUSIONS

Maternal ARV treatment with protease inhibitors is associated with maternal tissue iron depletion; but LNS mitigates adverse effects. ARVs do not seem to influence infant iron status; however, extended use needs to be evaluated.

Maternal intestinal HIF-2α is necessary for sensing iron demands of lactation in mice

The mechanisms that are essential for the maintenance of nutrient status in breast milk are unclear. Our data demonstrate that the intestine via hypoxia-inducible factor (HIF)-2α is an essential regulatory mechanism for maintaining the quality of breast milk. During lactation, intestinal HIF-2α is highly increased, leading to an adaptive induction of apical and basolateral iron transport genes. Disruption of intestinal HIF-2α (but not HIF-1α) or the downstream target gene divalent metal transporter (DMT)-1 in lactating mothers did not alter systemic iron homeostasis in the mothers, but led to anemia, decreased growth, and truncal alopecia in pups which was restored following weaning. Moreover, pups born from mothers with a disruption of intestinal HIF-2α led to long-term cognitive defects. Cross-fostering experiments and micronutrient profiling of breast milk demonstrated that the defects observed were due to decreased maternal iron delivery via milk. Increasing intestinal iron absorption by activation of HIF-2α or parenteral administration of iron-dextran in HIF-2α knockout mothers ameliorated anemia and restored neonatal development and adult cognitive functions. The present work details the importance of breast milk iron in neonatal development and uncovers an unexpected molecular mechanism for the regulation of nutritional status of breast milk through intestinal HIF-2α.

Factors Associated with Anemia among Children Aged 6-23 Months Attending Growth Monitoring at Tsitsika Health Center, Wag-Himra Zone, Northeast Ethiopia

Background. Globally, about 47.4% of children under five are suffering from anemia. In Ethiopia, 60.9% of children under two years are suffering from anemia. Anemia during infancy and young childhood period is associated with poor health and impaired cognitive development, leading to reduced academic achievement and earnings potential in their adulthood life. However, there is scarcity of information showing the magnitude of iron deficiency anemia among young children in Ethiopia. Therefore, this study aimed at assessing prevalence and associated factors of iron deficiency anemia among children under two (6-23 months). Methods. Institution based cross-sectional study was carried out from March to May, 2014, at Tsitsika Health Center in Wag-Himra Zone, Northeast Ethiopia. Systematic random sampling technique was employed. Automated hemoglobin machine was used to determine the hemoglobin level. Socioeconomic and demographic data were collected by using a pretested and structured questionnaire. Binary logistic regression analysis was used to identify associated factors and odds ratio with 95% CI was computed to assess the strength of association. Results. Total of 347 children participated in this study. The overall prevalence of anemia was 66.6%. In multivariate logistic regression analysis, male sex (AOR = 3.1 (95% CI: 1.60-5.81)), 9-11 months of age (AOR = 9.6 (95% CI: 3.61-25.47)), poor dietary diversity (AOR = 3.2 (95% CI: 1.35-7.38)), stunting (AOR = 2.7 (95% CI: 1.20-6.05)), diarrhea (AOR = 4.9 (1.63-14.59)), no formal education (AOR = 2.6 (95% CI: 1.26-5.27)), early initiation of complementary food (AOR = 11.1 (95% CI: 4.08-30.31)), and lowest wealth quintile (AOR = 3.0 (95% CI: 1.01-8.88)) were significantly associated with anemia. Conclusion. The overall prevalence of anemia among children who aged 6-23 months has sever public health importance in the study area. Integrated efforts need to be prioritized to improve health as well as appropriate infant and young child feeding practice among children under.

Effect of maternal iron deficiency anemia on the iron store of newborns in ethiopia

Iron deficiency anemia among pregnant women is a widespread problem in developing countries including Ethiopia, though its influence on neonatal iron status was inconsistently reported in literature. This cross-sectional study was conducted to compare hematologic profiles and iron status of newborns from mothers with different anemia status and determine correlation between maternal and neonatal hematologic profiles and iron status in Ethiopian context. We included 89 mothers and their respective newborns and performed complete blood count and assessed serum ferritin and C-reactive protein levels from blood samples collected from study participants. Maternal median hemoglobin and serum ferritin levels were 12.2 g/dL and 47.0 ng/mL, respectively. The median hemoglobin and serum ferritin levels for the newborns were 16.2 g/dL and 187.6 ng/mL, respectively. The mothers were classified into two groups based on hemoglobin and serum ferritin levels as iron deficient anemic (IDA) and nonanemic (NA) and newborns of IDA mothers had significantly lower levels of serum ferritin (P = 0.017) and hemoglobin concentration (P = 0.024). Besides, newborns' ferritin and hemoglobin levels showed significant correlation with maternal hemoglobin (P = 0.018; P = 0.039) and ferritin (P = 0.000; P = 0.008) levels. We concluded that maternal IDA may have an effect on the iron stores of newborns.

Chilean complementary feeding program reduces anemia and improves iron status in children aged 11 to 18 months

BACKGROUND

Iron deficiency is the most prevalent nutritional deficiency in the world, primarily affecting infants, young children, and women of childbearing age.

OBJECTIVE

To evaluate the impact of the National Complementary Feeding Program (NCFP) on anemia and iron status in Chilean children aged 11 to 18 months.

METHODS

Two studies were performed. The first study was performed at one public outpatient health center in Santiago, using data collected in 1999 (n = 128) and 2000 (n = 125), before and after the national introduction of iron-fortified milk. Subsequently, a study of a representative sample (n = 320) from the two most populated areas of the country was performed in 2009.

RESULTS

One year after fortification, the prevalence of anemia was 9%; significantly lower (p < .001) than the 27% prevalence observed 1 year before. Ten years after fortification, 14% of children were anemic and 77% of children with anemia (12% of all children) suffered from iron-deficiency anemia. In 2009, 11% of children consuming iron-fortified milk delivered by the NCFP (73%) were anemic, significantly lower (p = .028) than the 21% prevalence of anemia observed in children without consumption. Consumption of iron-fortified milk was positively associated with hemoglobin concentration (r = 0.28, p = .022) and was associated with a lower prevalence of anemia after adjusting for confounding factors (odds ratio, 0.50; 95% CI, 0.26 to 0.96).

CONCLUSIONS

In Chile, the NCFP has had an impact on the reduction of anemia and improved the iron status of children aged 11 to 18 months. Increasing the consumption of this iron-fortified milk could enhance the impact of the NCFP.

Changes in soluble transferrin receptor and hemoglobin concentrations in Malawian mothers are associated with those values in their exclusively breastfed, HIV-exposed infants

Infant iron status at birth is influenced by maternal iron status during pregnancy; however, there are limited data on the extent to which maternal iron status is associated with infant iron status during exclusive breastfeeding. We evaluated how maternal and infant hemoglobin and iron status [soluble transferrin receptors (TfR) and ferritin] were related during exclusive breastfeeding in HIV-infected women and their infants. The Breastfeeding, Antiretrovirals, and Nutrition Study was a randomized controlled trial in Lilongwe, Malawi, in which HIV-infected women were assigned with a 2 × 3 factorial design to a lipid-based nutrient supplement (LNS), or no LNS, and maternal, infant, or no antiretroviral drug, and followed for 24 wk. Longitudinal models were used to relate postpartum maternal hemoglobin (n = 1926) to concurrently measured infant hemoglobin, adjusting for initial infant hemoglobin values. In a subsample, change in infant iron status (hemoglobin, log ferritin, log TfR) between 2 (n = 352) or 6 wk (n = 167) and 24 wk (n = 519) was regressed on corresponding change in the maternal indicator, adjusting for 2 or 6 wk values. A 1 g/L higher maternal hemoglobin at 12, 18, and 24 wk was associated with a 0.06 g/L (P = 0.01), 0.10 g/L (P < 0.001), and 0.06 g/L (P = 0.01), respectively, higher infant hemoglobin. In the subsample, a reduction in maternal log TfR and an increase in hemoglobin from initial measurement to 24 wk were associated with the same pattern in infant values (log TfR β = -0.18 mg/L, P < 0.001; hemoglobin β = 0.13 g/L, P = 0.01). Given the observed influence of maternal and initial infant values, optimizing maternal iron status in pregnancy and postpartum is important to protect infant iron status. This trial was registered at clinicaltrials.gov as NCT00164736.

The influences of factors associated with decreased iron supply to the fetus during pregnancy on iron status in healthy children aged 0.5 to 3 years

OBJECTIVE

To investigate whether maternal anemia, pregnancy-induced diabetes, hypertension and smoking contributed to the recently found high prevalence of iron deficiency in a population of otherwise healthy children.

STUDY DESIGN

Iron status was assessed in 400 children aged 0.5 to 3 years. We obtained information on the mothers' laboratory results, the presence of diabetes and hypertension, smoking habits and use of medication while pregnant.

RESULT

We found no influence of maternal anemia, diabetes, hypertension or smoking during pregnancy on iron status in the children. Mean corpuscular volume (MCV) values of the children were positively correlated to maternal MCV values.

CONCLUSION

In this population, iron status in children is not affected by maternal anemia or maternal factors that are associated with a decreased iron transport during pregnancy. The correlation between MCV values in mothers and their children might be explained by genetic and/or shared environmental factors.

Perinatal iron deficiency and neurocognitive development

Iron deficiency is the most common form of nutrient deficiency worldwide. It is highly prevalent due to the limited availability of high quality food in developing countries and poor dietary habits in industrialized countries. According to the World Health Organization, it affects nearly 2 billion people and up to 50% of women who are pregnant. Maternal anemia during pregnancy is especially burdensome to healthy neurodevelopment in the fetus because iron is needed for proper neurogenesis, development, and myelination. Maternal anemia also increases the risk of low birth weight, either due to premature birth or fetal growth restriction, which is associated with delayed neurocognitive development and even psychiatric illness. As rapid neurodevelopment continues after birth infants that received sufficient iron in utero, but that receive a low iron diet after 6 months of age, also show deficits in neurocognitive development, including impairments in learning and memory. Unfortunately, the neurocognitive complications of iron deficiency during critical pre- and postnatal periods of brain development are difficult to remedy, persisting into adulthood. Thus, preventing iron deficiency in the pre- and postnatal periods is critical as is devising new means to recapture cognitive function in individuals who experienced early iron deficiency. This review will discuss the prevalence of pre- and postnatal iron deficiency, the mechanism, and effects of iron deficiency on brain and cognitive development.

Control of iron deficiency anemia in low- and middle-income countries

Despite worldwide economic and scientific development, more than a quarter of the world’s population remains anemic, and about half of this burden is a result of iron deficiency anemia (IDA). IDA is most prevalent among preschool children and women. Among women, iron supplementation improves physical and cognitive performance, work productivity, and well-being, and iron during pregnancy improves maternal, neonatal, infant, and even long-term child outcomes. Among children, iron may improve cognitive, psychomotor, and physical development, but the evidence for this is more limited. Strategies to control IDA include daily and intermittent iron supplementation, home fortification with micronutrient powders, fortification of staple foods and condiments, and activities to improve food security and dietary diversity. The safety of routine iron supplementation in settings where infectious diseases, particularly malaria, are endemic remains uncertain. The World Health Organization is revising global guidelines for controlling IDA. Implementation of anemia control programs in developing countries requires careful baseline epidemiologic evaluation, selection of appropriate interventions that suit the population, and ongoing monitoring to ensure safety and effectiveness. This review provides an overview and an approach for the implementation of public health interventions for controlling IDA in low- and middle-income countries, with an emphasis on current evidence-based recommendations.

Effects of daily iron supplementation in 2- to 5-year-old children: systematic review and meta-analysis

BACKGROUND AND OBJECTIVES

Iron deficiency (ID) is the most common cause of anemia worldwide. The prevalence is highest among preschool-aged children. Iron is widely administered to children with or at risk for ID, but evidence of benefit among 2- to 5-year-old children has not been evaluated by systematic review. We summarize the evidence for the benefit and safety of daily iron supplementation with regard to hematologic, growth, and cognitive parameters in 2 to 5 year olds.

METHODS

Electronic databases, regional databases, thesis repositories, gray literature, and references of studies and previous reviews were searched. We included randomized controlled trials that compared daily oral iron supplementation with control in 2 to 5 year olds. A random-effects meta-analysis was used to synthesize predefined outcomes reported by at least 2 studies.

RESULTS

Of 9169 references, 15 studies met the inclusion criteria, none of which were at low risk of bias. Children receiving iron supplementation had a mean end point hemoglobin of 6.97 g/L (P < .00001; I(2) = 82%) greater than controls, whereas mean end point ferritin was 11.64 µg/L (P < .0001; I(2) = 48%) greater. No trials reported the effects of iron supplementation on ID or iron deficiency anemia, and only one reported on anemia. Limited evidence suggested that iron supplementation produced a small improvement in cognitive development but had no effect on physical growth.

CONCLUSIONS

In 2 to 5 year olds, daily iron supplementation increases hemoglobin and ferritin. There is a concerning lack of data on the effect of iron supplementation on clinically important outcomes including anemia, ID anemia, ID, and cognitive development. Additional interventional studies in this age group are needed.

Anaemia and iron deficiency between 2003 and 2007 in Amazonian children under 2 years of age: trends and associated factors

OBJECTIVE

To describe trends in the prevalence of anaemia and Fe deficiency in children under 2 years of age living in a town in western Brazilian Amazonia.

DESIGN

Temporal analysis of two cross-sectional population-based surveys. Information on socio-economic status, morbidity and breast-feeding was obtained using a structured questionnaire. Child weight and length were measured for anthropometric evaluation. Concentrations of blood Hb, plasma ferritin and soluble transferrin receptor were measured.

SETTING

The town of Acrelândia, state of Acre, north-west Brazil.

SUBJECTS

A total of 170 and 224 participants of the 2003 and 2007 surveys, respectively.

RESULTS

Comparison between the 2003 and 2007 surveys revealed no statistically significant differences in the prevalence of anaemia (48 (95% CI 39, 56)% to 40 (95% CI 33, 47)%) or Fe-deficiency anaemia (39 (95% CI 30, 48)% to 37 (95% CI 30, 45)%), respectively. However, an increase in the overall prevalence of Fe deficiency from 62 (95% CI 51, 68)% to 81 (95% CI 75, 86)% was observed (χ2 test, P≤0.001). In age- and sex-adjusted analyses for risk of Fe deficiency, only early introduction of cow's milk (<90 d) was associated with Fe deficiency in 2003 (prevalence ratio (PR)=0.76; 95% CI 0.57, 1.01), while caesarean section (PR=1.18; 95% CI 1.03, 1.35) and birth weight <3500 g (PR=1.15; 95% CI 1.00, 1.34) were associated with Fe deficiency in 2007.

CONCLUSIONS

No improvements were observed in the prevalence of anaemia, exposing a worrying scenario for public health, while a significant increase was found in the prevalence of Fe deficiency in the studied infants and toddlers.

Cord blood haemoglobin and ferritin concentrations in newborns of anaemic and non-anaemic mothers in Lagos, Nigeria

BACKGROUND

Pre-delivery haemoglobin and serum ferritin concentrations of anaemic and non-anaemic mothers were determined, and cord blood haemoglobin and serum ferritin concentrations of their newborns were compared. This is to establish the mean values for pre-delivery haemoglobin and serum ferritin concentrations of anaemic and non-anaemic mothers and the cord blood haemoglobin and serum ferritin concentrations of their newborns at term.

MATERIALS AND METHODS

A case-control study was done involving 142 pregnant women and their newborns. They were divided into two groups - the anaemic group (n = 65) and the non-anaemic (n = 77) group. Five millilitres of blood was collected from each woman and 2 ml was collected from the cord of their newborns into ethylenediaminetetraacetic acid (EDTA) bottle and plain bottle for full blood count analysis and ferritin assay, respectively.

RESULTS

The mean pre-delivery haemoglobin concentrations of the women in anaemic group and non-anaemic group were 9.5 ± 1.01 g/dl and 12.15 ± 1.07 g/dl, respectively, and their mean serum ferritin concentrations were 64.45 ± 138.76 μg/l and 32.83 ± 35.36 μg/l, respectively. The mean cord blood haemoglobin concentrations for anaemic and for non-anaemic groups were 12.54 ± 2.54 g/dl and 13.44 ± 2.23 g/dl (P = 0.02), respectively, and the mean cord blood serum ferritin concentrations (non-anaemic, 69.38 ± 78.88 μg/l; anaemic, 7.26 ± 115.60 μg/l) (P = 0.00) were higher in the newborns of non-anaemic than of anaemic mothers. Significant association was found between maternal anaemia and cord blood ferritin concentrations (P = 0.025).

CONCLUSION

Maternal anaemia has significant effects on cord blood haemoglobin and serum ferritin concentrations.

Effect of iron supplementation on development of iron deficiency anemia in breastfed infants

This trial aimed to investigate the effect of iron supplementation on the development of iron deficiency anemia. The study encompassed 6-month-old infants who had been exclusively breastfed in the first 4 months of life. Infants in the supplemented group were given 1 mg kg(-1 )day(-1) ferrous sulfate for 6 months starting at 6 months of age. Blood samples were taken at age 12 months. A 3-day-diet was evaluated at 1 year of age. Data of 51 infants in the supplemented and 54 infants in the control group were analyzed. Mean hemoglobin values were similar in the two groups at the age of 12 months. Mean ferritin level of the supplemented group was significantly higher than that of the control. There was a significant positive correlation between dietary iron intake and hemoglobin levels. Nutrition might be more important than iron supplementation in preventing iron deficiency anemia during infancy.