Why iron deficiency is important in infant development

Potential Micronutrient Deficiencies in the First 1000 Days of Life: The Pediatrician on the Side of the Weakest

PURPOSE OF REVIEW

This study is to examine potential micronutrient deficiencies and any need for supplementation in children following specific diet plans in the first 1000 days of life.

RECENT FINDINGS

Optimal nutrition in the first 1000 days of life has a lifelong positive impact on child development. Specific intrauterine and perinatal factors, pathological conditions, and dietary restrictions can represent potential risk factors for micronutrient deficiencies in the first 1000 days of life, which can have negative systemic consequences. Preterm and low-birth-weight infants are intrinsically at risk because of immature body systems. Children affected by cystic fibrosis are prone to malnutrition because of intestinal malabsorption. The risk of micronutrient deficiency can increase in various situations, including but not limited to children following selective dietary regimens (vegetarian and vegan diets and children affected by specific neuropsychiatric conditions) or specific dietary therapies (children affected by food allergies or specific metabolic disorders and children following restricted diet as a part of therapeutic approach, i.e., ketogenic diet for epilepsy). In light of this situation, the micronutrient status in these categories of children should be investigated in order to tailor strategies specific to the individual's metabolic needs, with a particular focus on deficiencies which can impair or delay the physical and cognitive development of children, namely, vitamin B12, vitamin D and folic acid, as well as oligo-elements such as iron, zinc, calcium, sodium, magnesium, and phosphorus, and essential fatty acids such as omega-3. Identification of micronutrient deficiency in the first 1000 days of life and timely supplementation proves essential to prevent their long-term consequences.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Perspectives on Iron Deficiency as a Cause of Human Disease in Global Public Health

Iron (Fe) is a necessary trace element in numerous pathways of human metabolism. Therefore, Fe deficiency is capable of causing multiple health problems. Apart from the well-known microcytic anemia, lack of Fe can cause severe psychomotor disorders in children, pregnant women, and adults in general. Iron deficiency is a global health issue, mainly caused by dietary deficiency but aggravated by inflammatory conditions. The challenges related to this deficiency need to be addressed on national and international levels. This review aims to summarize briefly the disease burden caused by Fe deficiency in the context of global public health and aspires to offer some hands-on guidelines.

Effect of Iron Polymaltose Complex Prophylaxis on Frequency of Iron Deficiency and Iron Deficiency Anemia

OBJECTIVES

To evaluate the effectiveness of national iron prophylaxis policy in 9-12 mo-old infants in Turkey.

METHODS

This study was planned as a cross-sectional study, and it included healthy infants aged 9 to 12 mo who presented to the pediatric outpatient clinic for routine check-ups. Parents were interviewed to identify risk factors for iron deficiency (ID) and gather information on Fe+3 - iron polymaltose complex (IPC) prophylaxis usage. Blood samples were collected for hemogram and ferritin analysis. Multiple logistic regression analyses were conducted to determine risk factors for ID and iron deficiency anemia (IDA).

RESULTS

The study included 317 infants. In the non-prophylaxis group, the frequency of IDA was 31.1%, compared to 13.4% in the regular prophylaxis group. Iron deficiency was detected in 25% of individuals receiving regular prophylaxis and 13.1% of those without prophylaxis. The risk factors for IDA were insufficient iron diets (OR 2.45, 95% CI: 1.35-4.45) and not receiving Fe+3 - IPC prophylaxis (OR 2.57, 95% CI: 1.24-5.31). The relationship between Fe+3 - IPC prophylaxis and ID did not reach statistical significance (p = 0.253).

CONCLUSIONS

Fe+3 - IPC prophylaxis is associated with a lower risk of iron deficiency anemia, but not iron deficiency.

Biology of Anemia: A Public Health Perspective

Our goal is to present recent progress in understanding the biological mechanisms underlying anemia from a public health perspective. We describe important advances in understanding common causes of anemia and their interactions, including iron deficiency (ID), lack of other micronutrients, infection, inflammation, and genetic conditions. ID develops if the iron circulating in the blood cannot provide the amounts required for red blood cell production and tissue needs. ID anemia develops as iron-limited red blood cell production fails to maintain the hemoglobin concentration above the threshold used to define anemia. Globally, absolute ID (absent or reduced body iron stores that do not meet the need for iron of an individual but may respond to iron supplementation) contributes to only a limited proportion of anemia. Functional ID (adequate or increased iron stores that cannot meet the need for iron because of the effects of infection or inflammation and does not respond to iron supplementation) is frequently responsible for anemia in low- and middle-income countries. Absolute and functional ID may coexist. We highlight continued improvement in understanding the roles of infections and inflammation in causing a large proportion of anemia. Deficiencies of nutrients other than iron are less common but important in some settings. The importance of genetic conditions as causes of anemia depends upon the specific inherited red blood cell abnormalities and their prevalence in the settings examined. From a public health perspective, each setting has a distinctive composition of components underlying the common causes of anemia. We emphasize the coincidence between regions with a high prevalence of anemia attributed to ID (both absolute and functional), those with endemic infections, and those with widespread genetic conditions affecting red blood cells, especially in sub-Saharan Africa and regions in Asia and Oceania.

Intra-uterine exposure to lower maternal haemoglobin concentration is associated with impaired cognitive function in stunted adolescents: results from a 17-year longitudinal cohort study in Indonesia

The long-term impact of maternal anaemia on cognitive performance remains unknown. Indonesian longitudinal cohort data of 363 paired pregnant mothers and their 10-14-year-old offspring were used to investigate the association between maternal haemoglobin (Hb) concentration and their offspring's cognitive function (assessed by Raven's Progressive Matrices test) during adolescence. The weighted anaemia prevalence was 49.3% in pregnant mothers and 22.2% in adolescents. Adolescents who were stunted, anaemic, or living in a rural area had significantly lower cognitive scores than their counterparts. Maternal Hb was not associated with adolescent cognitive function (β: 0.14; 95%CI: -0.052-0.340). However, the effect of maternal Hb concentration on offspring's cognitive function was modified by stunting status (β, stunted: 0.44; 95%CI: 0.05-0.82; non-stunted: 0.01; 95%CI: -0.02-0.24). This study shows adverse cognitive outcomes at adolescent age are likely multi-causal and can be partially explained by intra-uterine exposure to low maternal Hb concentrations.

Examining the Role of a Functional Deficiency of Iron in Lysosomal Storage Disorders with Translational Relevance to Alzheimer's Disease

The recently presented Azalea Hypothesis for Alzheimer's disease asserts that iron becomes sequestered, leading to a functional iron deficiency that contributes to neurodegeneration. Iron sequestration can occur by iron being bound to protein aggregates, such as amyloid β and tau, iron-rich structures not undergoing recycling (e.g., due to disrupted ferritinophagy and impaired mitophagy), and diminished delivery of iron from the lysosome to the cytosol. Reduced iron availability for biochemical reactions causes cells to respond to acquire additional iron, resulting in an elevation in the total iron level within affected brain regions. As the amount of unavailable iron increases, the level of available iron decreases until eventually it is unable to meet cellular demands, which leads to a functional iron deficiency. Normally, the lysosome plays an integral role in cellular iron homeostasis by facilitating both the delivery of iron to the cytosol (e.g., after endocytosis of the iron-transferrin-transferrin receptor complex) and the cellular recycling of iron. During a lysosomal storage disorder, an enzyme deficiency causes undigested substrates to accumulate, causing a sequelae of pathogenic events that may include cellular iron dyshomeostasis. Thus, a functional deficiency of iron may be a pathogenic mechanism occurring within several lysosomal storage diseases and Alzheimer's disease.

Cross-cultural measurement invariance of a developmental assessment tool in a small-scale intervention study

Development tests are widely used in the scope of cross-cultural and comparative research to support intervention studies and health care projects concerning early childhood development. Therefore, it is crucial to use culturally sensitive assessment tools. A culturally adapted version of the German development test FREDI 0-3 (Maehler, Cartschau, & Rohleder, 2016) was used to assess a German (n = 405) and an Indian (n = 2075) sample of children between ten and thirty-two months. Measurement invariance indicates psychometric equivalence of a construct across groups and is a prerequisite for test applications in a cross-cultural setting. Confirmatory factor analyses for single cohorts per age group and multi-group measurement invariance analyses were used to examine the data equivalence of the test across groups. Weak measurement invariance could be established across both groups in all four age groups (10-14; 15-21; 22-26; 27-32 months) suggesting that the development factor was measured in the same way in both groups and accounted similarly for performance differences in the developmental subdomains for the German and the Indian sample. However, scalar and strict measurement invariance were violated in almost all group comparisons suggesting differences in scale difficulty and reliability across the German and the Indian sample. This suggests that a culture-sensitive adaptation process like it was carried out within this project is necessary but not sufficient in order to create a culturally comparable development test. It is essential to always carry out measurement invariance testing to determine the psychometric equivalence of the test and additionally reduce linguistic and cultural bias through an adaption process based on empirical proven methodological principles.

Toddlers may be getting enough iron in long day-care services after all

BACKGROUND

Previous research has suggested that toddlers are not provided with adequate dietary iron in long-day care (LDC) services. However, the iron bioavailability provided is unknown. The present study aimed to investigate the amount and bioavailability of iron provided to toddlers aged 2-3 years at LDC services.

METHODS

A cross-sectional audit was conducted using a 2-day weighed food record of 30 LDC services. Iron provision (not child intake) in LDC services across Perth, Australia was compared with the estimated average requirements (EAR) and LDC services provision guidelines (50% of EAR = 2 mg/day based on a 14% bioavailability factor). Bioavailability was estimated per mealtime using haem and non-haem iron, ascorbic acid, animal protein, calcium, soy, eggs and phytates using two pre-existing algorithms (by A. P. Rickard and colleagues and H. Hallberg and H. Hulten).

RESULTS

Median iron supplied (2.52 mg/day, interquartile range [IQR] = 2.43-3.17) was above the 50% of EAR of 2.0 mg/day (p < 0.001). Median bioavailable iron was 0.6 mg/day (IQR = 0.54-0.8) using the method of Rickard et al. and 0.51 mg/day (IQR = 0.43, 0.76 using that of Hallberg and Hulthen). The top three foods contributing to iron provision were bread, breakfast cereals and beef.

CONCLUSIONS

Our results suggest that LDC services in Perth are meeting the minimum recommendation of provision of 50% of the iron EAR, and also that toddlers are provided with sufficient bioavailable iron. Future strategies should focus on promoting food combinations to maintain the iron bioavailability in meals currently served at LDC services.

Are Twin Pregnancies at Higher Risk for Iron and Calcium Deficiency than Singleton Pregnancies?

The aim of this study was to compare the iron and calcium status in singleton and twin pregnancies and to assess whether there is an increased risk for iron and calcium deficiency in twin gestation. The study included 105 singleton and 9 twin pregnancies at or above 35 weeks of gestation. Information on prenatal supplementation with iron or calcium was acquired, and adverse perinatal outcomes were recorded. Biosamples from all 114 mothers and 73 newborns (61 singleton and 12 twin newborns) were finally analyzed. Total iron and calcium concentrations in serum were measured through total reflection X-ray fluorescence analysis. The results indicated no significant differences in maternal serum iron and calcium concentrations between singleton and twin pregnancies. Similarly, iron and calcium concentrations in newborn umbilical cord serum samples were not different between singleton and twin pregnancies. The comparison of total iron and calcium between mothers and umbilical cord serum indicated significantly lower concentrations in the mothers, with the differences being not homogenous but rather pair-specific. A significant positive correlation between maternal serum and umbilical cord serum calcium concentration was noticed. Prenatal iron supplementation was associated with higher iron concentrations in both mothers and newborns, supporting the efficiency of supplementation and the quality of the study methods. Collectively, the data indicate no significant differences in serum iron and calcium concentrations with regard to singleton or twin pregnancies and the efficiency of iron supplementation during pregnancy for increasing iron status.

Fortification of condiments and seasonings with iron for preventing anaemia and improving health

BACKGROUND

Anaemia affects approximately 1.8 billion people worldwide; over 60% of anaemia cases globally are due to iron deficiency (ID). Iron deficiency and anaemia contribute to the global burden of disease and affect physical and cognitive development in children, and work productivity and economic well-being in adults. Fortification of food with iron, alone or in combination with other nutrients, is an effective intervention to control ID. Condiments and seasonings are ideal food vehicles for iron fortification in countries where they are commonly used.

OBJECTIVES

To determine the effects and safety of condiment and seasoning fortification with iron alone or iron plus other micronutrients on iron deficiency, anaemia, and health-related outcomes in the general population.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL, and other databases up to 24 January 2023. We also searched the International clinical trials registry platform (ICTRP) for any ongoing trials.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) (randomisation at individual or cluster level), non-randomised controlled trials, interrupted time series with at least three measure points both before and after intervention, and controlled before-after studies. Participants were populations of any age (including pregnant women), from any country, excluding those with critical illness or severe co-morbidities. We included interventions in which condiments or seasonings have been fortified with any combination of iron and other vitamins and minerals, irrespective of the fortification technology used.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened and assessed the eligibility of studies. Disagreements were resolved through discussion or input from a third review author. Two review authors extracted the data and assessed the risk of bias in all the included studies. We followed the methods laid out by Cochrane and used GRADE criteria for assessing certainty of the evidence.

MAIN RESULTS

Our search identified 15,902 records after removal of duplicates. We included 16 studies with 20,512 participants (18,410 participants after adjusting for clustering effects). They were all carried out in upper-middle- and lower-middle-income countries. Three studies were controlled before-after studies, one was non-randomised trial, and 12 were RCTs (including three cluster RCTs). Six studies took place in schools; seven in communities; and one each in a nursery/kindergarten, tea estate, and factory. Three studies involved only women, one study involved both women and their children, and all other studies focused on children and/or adolescents. Nine studies used salt as a vehicle for iron fortification, three used fish sauce, two used soy sauce, one used curry powder, and one a "seasoning powder". The dose of iron received by participants ranged from 4.4 mg to 55 mg/day. The sample sizes in the trials ranged from 123 to 14,398, and study durations ranged from three months to two years. Twelve RCTs contributed data for meta-analysis. Six trials compared iron-fortified condiments versus the unfortified condiment, and six trials provided data comparing iron fortification in combination with other micronutrients versus the same condiment with other micronutrients, but no added iron. In one trial, the fortificant contained micronutrients that may have affected the absorption of iron. Overall no studies were assessed as having a low risk of bias. All included studies were assessed to have a high overall risk of bias, with the most concerns being around allocation concealment, blinding, and random sequence generation. There was very high heterogeneity amongst studies in almost all examined outcomes. Condiments/seasonings fortified with iron versus unfortified condiments/seasonings We are uncertain about whether consuming condiments/seasonings fortified with iron in comparison to the same unfortified condiment reduces anaemia at the end of intervention (risk ratio (RR) 0.34, 95% confidence interval (CI) 0.18 to 0.65; 2328 participants; 4 studies; very low-certainty of evidence). We are uncertain about whether consuming iron-fortified condiments increases haemoglobin concentrations (mean difference (MD) 6.40 (g/L), 95% CI -0.62 to 13.41; 2808 participants; 5 studies; very low-certainty evidence). Fortification of condiments/seasonings with iron probably slightly reduces ID (RR 0.33, 95% CI 0.11 to 1.01; 391 participants; 2 studies; moderate-certainty evidence). We are uncertain about whether fortification with iron increases ferritin concentration (MD 14.81 (µg/L), 95% CI 5.14 to 24.48; 4459 participants; 6 studies; very low-certainty evidence). Condiments/seasonings fortified with iron plus other micronutrients versus condiments/seasonings fortified with other micronutrients except iron Consuming condiments/seasonings fortified with iron plus other micronutrients may reduce anaemia (RR 0.59, 95% CI 0.40 to 0.89; 1007 participants; 4 studies; low-certainty evidence). We are uncertain about whether fortification of condiments/seasonings with iron plus other micronutrients will improve haemoglobin concentration (MD 6.22 g/dL, 95% CI 1.60 to 10.83; 1270 participants; 5 studies; very low-certainty evidence). It may reduce ID (RR 0.36, 95% CI 0.19 to 0.69; 1154 participants; 4 studies; low-certainty evidence). We are uncertain about whether fortification with iron plus other micronutrients improves ferritin concentration (MD 10.63 µg/L, 95% CI 2.40 to 18.85; 1251 participants; 5 studies; very low -certainty evidence). Condiments/seasonings fortified with iron versus no intervention No trial reported data on this comparison. No studies reported adverse effects. Funding sources do not appear to have distorted the results in any of the assessed trials.

AUTHORS' CONCLUSIONS

We are uncertain whether consuming iron-fortified condiments/seasonings reduces anaemia, improves haemoglobin concentration, or improves ferritin concentration. It may reduce ID. Findings about ferritin should be interpreted with caution since its concentrations increase during inflammation. Consuming condiments/seasonings fortified with iron plus other micronutrients may reduce anaemia, and we are uncertain whether this will improve haemoglobin concentration or ferritin concentration. More studies are needed to determine the true effect of iron-fortified condiments/seasonings on preventing anaemia and improving health. The effects of this intervention on other health outcomes like malaria incidence, growth and development are unclear.

Distortion product otoacoustic emissions in newborn babies with and without late-term maternal iron deficiency anaemia

Background

Studies on animals have demonstrated that maternal iron deficiency anaemia (IDA) could result in decreased cochlear sensory hair cells and reduced amplitudes of distortion-product otoacoustic emissions (DPOAEs) of young guinea pigs. Thus, it is essential to study the functioning of cochlear hair cells using DPOAEs in human newborn babies with maternal IDA. The current study explores maternal IDA's effect on DPOAEs in newborn babies.

Method

A total of 110 newborn babies with gestational age ≥34 weeks were considered and a 'between-subjects' design was used. The participants were divided into 3 groups- "Normal" (61 babies without maternal IDA), "Mild" (28 babies with mild maternal IDA) and "Moderate" (21 babies with moderate maternal IDA). The cord blood was collected and the DPOAEs were recorded for each baby for a range of frequencies (1 k - 8 kHz) and a range of intensities (70-40 dB SPL in 10 dB steps).

Results

The analysis of both DP-gram and DP input-output (I/O) function showed that there was no significant difference (p > 0.05) across the normal, mild, and moderate groups in the overall presence of DPOAEs as well as the amplitude across frequencies or intensities (70-40 dB SPL). Also, the overall correlation of RBC indices with DPOAE amplitude across frequencies as well as the slope of the I/O function showed no relationship.

Conclusion

The current study concludes that there is no effect of late-term maternal IDA on the DPOAEs of newborn babies.

Iron Nutrition of Pre-Schoolers in High-Income Countries: A Review

Pre-schoolers are vulnerable to iron deficiency, which, in high-resource countries, is mainly caused by suboptimal or poorly absorbable iron intakes. This review examines the prevalence of inadequate iron intakes and status, and the non-dietary factors associated with these, among children aged between 2 and 5 years within high-income countries. It then considers the quality of the pre-schooler diet in terms of dietary factors, dietary patterns, and iron intakes. Additionally, it discusses the assessment of iron bioavailability and examines the various methods used to estimate the amount of absorbable iron in pre-schooler diets. Knowledge of the adequacy of iron intakes and bioavailability of iron intakes, and dietary patterns associated with iron intakes can facilitate the design and implementation of effectively targeted community-based intervention studies to improve iron intakes and iron bioavailability to minimise the risk of iron deficiency.

Quality Evaluation of Complementary Food Produced by Solid-State Fermentation of Fonio, Soybean and Orange-Fleshed Sweet Potato Blends

During infancy and early childhood, obtaining the adequate amount of appropriate nutrition has paramount importance for the full development of a child’s potential. The focus of this study was to evaluate the complementary food produced by solid-state fermentation of fonio and soybean using Rhizopusoligosporus (2710) and orange-fleshed sweet potatoes (OFSP) using Lactobacillus planterum (B-41621). Solid-state fermentation (SSF) was carried out by inoculating fonio and soybean with a spore suspension (1 × 10⁶ spores/mL) of Rhizopusoligosporus (2710) and OFSP with a spore suspension (1 × 10⁶ spores/mL) of Lactobacillus plantarium (B-41621). The samples were blended in the following ratios: fonio and soybean 100: 100 (AS), fonio/soybean and OFSP 50: 50(ASO). These were compared with a commercial infant formula, which served as the control (CTRL). Quality characteristics of the samples were evaluated. The results showed that moisture, crude protein, fiber, ash content, beta carotene, iron and titratable acidity ranged from 54.97–56.27, 17.10–19.02%, 7.08–7.60%, 2.09–2.38%, 15.80–17.35 mg/100 g, 6.57–8.41 mg/100 g and 0.16–0.48%, respectively. An increase in fermentation time significantly (p < 0.05) increased these contents. In sensory scores, there were no significant (p > 0.05) differences between the average mean scores of the samples. This study shows that nutrient-rich complementary food of acceptable quality can be produced from blends using SSF for the optimum growth and development of infants.

Prevalence and Associated Risk Factors of Anemia Among Hospitalized Children in a Tertiary Level Hospital in Botswana

Anemia is a global health concern and has been associated with long term cognitive and behavioral adverse effects. A cross sectional study was conducted to determine the prevalence of and risk factors for anemia in infants and children between 6 months to 5 years of age admitted to a tertiary hospital in Botswana. Baseline full blood count of every patient admitted during the study period was assessed to determine if anemia was present. Data were collected from patient's medical inpatient chart, electronic medical record (Integrated Patient Management System (IPMS)), and through interviewing parents and caregivers. Multivariate logistic regression model was used to identify risk factors of anemia. A total of 250 patients were included in the study. Prevalence of anemia in this cohort was 42.8%. There were 145 (58%) males. Of the patients with anemia, 56.1%, 39.2%, and 4.7% had mild, moderate, and severe anemia, respectively. Microcytic anemia consistent with iron deficiency was identified in 61 (57%) patients. Age was the only independent predictor of anemia. Children aged 24 months and more had a 50% lower risk of having anemia than their younger counterparts (odds ratio (OR) 0.52; 95% Confidence Interval (95% CI) 0.30 to 0.89). The findings of this study demonstrate anemia as a serious health concern in the pediatric population in Botswana.

Prevalence, treatment status, medical costs, quality of life, and productivity loss in Japanese adult patients with anemia: a real-world database study

AIMS

To investigate the prevalence, treatment status, and effect of anemia on medical costs, quality of life (QOL), and productivity loss in Japan.

METHODS

This cross-sectional study used a database containing claims, health check-ups, and questionnaire data. Adults with hemoglobin data at 2020 check-ups were included. QOL and productivity loss were evaluated using EuroQol 5-Dimension (EQ-5D) and Work Productivity and Activity Impairment questionnaire data available for a subset of the population. Nationwide anemia prevalence, including both diagnosed as having anemia and undiagnosed but with low hemoglobin levels, were estimated. Treatment status was described by hemoglobin levels. Differences in medical costs, QOL, and productivity loss were compared between individuals with and without anemia. Subgroup analyses were performed using the Charlson Comorbidity Index (CCI).

RESULTS

The study population included 554,798 individuals. Anemia prevalence was estimated at 15.1% with 55.3% undiagnosed. In patients with anemia, 85.3% were untreated; 79.5% of the treated patients received only oral iron drugs. In patients with anemia, monthly medical costs were ¥17,766 higher, EQ-5D score was 0.0118 lower, and productivity loss was 2.6% higher than in those without anemia. The trends were consistent even in limited patients with CCI = 0. Nationwide annual excess medical costs, deficit QOL, and productivity loss in patients with anemia were estimated at ¥3.32 trillion, 138,000 quality-adjusted life-years, and ¥1.13 trillion, respectively.

LIMITATIONS

As the study population only included individuals who underwent health check-ups, they may be healthier than general population. Whether the differences in medical costs, QoL, and productivity loss are caused by anemia or other underlying differences in patient characteristics is unclear, given the likelihood of residual confounding.

CONCLUSIONS

The results suggest that more than half of patients with anemia were undiagnosed and untreated. Patients with anemia had higher medical costs, lower QOL, and greater productivity loss than those without anemia.

The effect of iron deficiency on quality of life outcomes after surgery for obstructive sleep apnoea

AIM

This study aimed to assess the effect of iron deficiency on parent-reported changes in quality of life (QOL) among children receiving an adenotonsillectomy for paediatric obstructive sleep apnoea (OSA).

METHODS

This was a retrospective review study that recruited children under 16 years of age undergoing an adenotonsillectomy, adenoidectomy, or tonsillectomy for clinically diagnosed paediatric OSA between June 2020 and January 2021 inclusive, in Western Australia. The main outcome measures for this study were changes in QOL by age group and iron status, defined by an absolute change of more than 3 points on OSA-18 survey domains.

RESULTS

About 249 participants had iron studies performed on perioperative blood samples drawn at operation and completed both pre-operative and post-operative OSA-18 QOL questionnaires at initial consultation and 8-12 weeks post-surgery, respectively. 41.8% were iron deficient, 53.8% were borderline iron deficient and 4.4% had normal iron levels. Following surgery, a decrease was observed for all OSA-18 score domains in post-operation scores compared to pre-operation scores in both iron-deficient and borderline iron-deficient cohorts. 'Daytime Problems' in the <2 years group, within the iron-deficient cohort, was the only domain that found to be non-superior (i.e. 'not better') following surgery.

CONCLUSIONS

Following adenotonsillectomy, patients with paediatric OSA reported significant improvements in QOL regardless of their iron status. Those undergoing an adenotonsillectomy for paediatric OSA had a high prevalence of iron deficiency at operation, especially those under 6 years of age.

Infancy Dietary Patterns, Development, and Health: An Extensive Narrative Review

Correct dietary patterns are important for a child’s health from birth to adulthood. Understanding a child’s health as a state of entire physical, mental, and social well-being is essential. However, reaching adulthood in a complete health proper state is determined by feeding and dietary habits during preconception, pregnancy, or children infancy. Different factors, such as the mother’s lifestyle, culture, or socioeconomic status, are crucial during all these phases. In this review, we aimed to assess the long-term associations between infancy dietary patterns and health and their influence on development and growth. To reach this objective, a consensus critical review was carried out using primary sources such as scientific articles, and secondary bibliographic indexes, databases, and web pages. PubMed, SciELO, and Google Scholar were the tools used to complete this research. We found that high-income countries promote high-calorie foods and, consequently, obesity problems among children are rising. However, undernutrition is a global health issue concerning children in low- and middle-income countries; thus, parental socioeconomic status in early life is essential to children’s health and development, showing that biological, social, and environmental influences are increased risk factors for chronic diseases. This narrative review is aimed to collect evidence for early nutritional intervention and future disease prevention.

Anaemia in Children Receiving Home Parenteral Nutrition: A Common Problem?

OBJECTIVES

Children receiving home parenteral nutrition (HPN) are at risk of iron deficiency anaemia. Our aim was to determine the incidence of iron deficiency anaemia in paediatric HPN and efficacy of each therapeutic approach.

METHODS

Retrospective data collection from children receiving HPN at a tertiary referral centre over a 12-month period (2015). Full blood count, and whenever available, ferritin and C-reactive protein were collected at least 3 times for each patient. Liver function tests were checked at the beginning and end of the study and number of blood transfusions/iron infusions recorded.

RESULTS

Forty-one HPN patients (61% girls; 51% motility disorder, 29% enteropathy, 20% short bowel syndrome) were identified. Eighty-three percent of children were anaemic at the beginning of the study with the number decreasing to 73% by the end. Iron deficiency anaemia was most commonly seen and treated with blood transfusion in 46% of cases and iron infusions in 29%. There was no statistical difference in the level of haemoglobin improvement between the 2 treatments (50% vs 33%, P  = 0.657) nor a significant difference in haemoglobin (g/L) level achieved. The results for both were, however, more favourable in the infusion group. Patients receiving transfusions had a significantly higher incidence of abnormal liver function compared with those who hadinfusions (93% vs 37%, P = 0.009).

CONCLUSIONS

Iron deficiency anaemia is common in children receiving HPN. A large proportion of patients still receive blood transfusions as first-line therapy but intravenous iron can be a suitable alternative. Treatment guidelines are required.

Low Hemoglobin Levels Are Associated with Reduced Psychomotor and Language Abilities in Young Ugandan Children

Children living in Sub-Saharan Africa are vulnerable to developmental delay, particularly in the critical first five years due to various adverse exposures including disease and nutritional deficiencies. Anemia and iron deficiency (ID) are highly prevalent in pregnant mothers and young children and are implicated in abnormal brain development. However, available evidence on the association between anemia, ID and neurodevelopment in sub-Saharan Africa is limited. Using data from the Entebbe Mother and Baby Study prospective birth cohort, we examined the effect of maternal and child hemoglobin (Hb) levels and child iron status on developmental scores in 933 and 530 pre-school Ugandan children respectively. Associations between Hb levels, iron status and developmental scores were assessed using regression analyses adjusting for potential confounders. Lower maternal and child Hb levels were associated with reduced psychomotor scores at 15 months, while only lower Hb levels in infancy were associated with reduced language scores. We found no evidence that anemia or ID was associated with cognitive or motor scores at five years. This study emphasizes the importance of managing anemia in pregnancy and infancy and highlights the need for further studies on the effects of anemia and ID in children living in Sub-Saharan Africa.

Reducing infantile anemia: insight on patterns of process and outcome indicators by ethnicity and socioeconomic class during a 10-year intervention program and 5 years after

Background

In 2005, Clalit Health Services (CHS), the largest health maintenance organization in Israel, initiated an intervention program aimed at reducing the prevalence rate of infantile anemia (IA). This study evaluated the progress made during the intervention (2005–2014) and its yield 5 years after it ended (2019).

Methods

The CHS database was retrospectively reviewed twice yearly from 2005 to 2014 for repetitive samples of children aged 9 to 18 months regarding the previous half-year interval, and a single sample in 2019. Data were collected on gender, ethnicity (Jewish/non-Jewish), socioeconomic class (SEC; low/intermediate/high), hemoglobin testing (yes/no), and hemoglobin level (if tested). Excluded were infants with documented or suspected hemoglobinopathy.

Results

At study initiation, the rate of performance of hemoglobin testing was 54.7%, and the IA prevalence rate was 7.8%. The performance rate was lower in the Jewish than the non-Jewish subpopulation. The low-SEC subpopulation had a similar hemoglobin testing rate to the high-SEC subpopulation but double the IA prevalence rate. Overall, by the end of the intervention (2014), the performance rate increased to 87.5%, and the AI prevalence rate decreased to 3.4%. In 2019, there was little change in the performance rate from the end of the intervention (88%) and the IA prevalence was further reduced to 2.7%. The non-Jewish and low-SEC subpopulations showed the most improvement which was maintained and even bettered 5 years after the intervention ended.

Conclusions

The 10-year IA intervention program introduced by CHS in 2005 led to a reduction in IA prevalence rate to about 3.5% in all sub-populations evaluated. By program end, the results in the weaker subpopulations, which had the highest prevalence of IA at baseline, were not inferior to those in the stronger subpopulations. We recommended to the Israel Ministry of Health to adopt the intervention countrywide, and we challenge other countries to consider similar interventions.

Reticulocyte hemoglobin content changes after treatment of anemia of prematurity

BACKGROUND

Iron deficiency during infancy is associated with poor neurological development, but iron overload causes severe complications. Appropriate iron supplementation is therefore vital. Reticulocyte hemoglobin content (RET-He) provides a real-time assessment of iron status and chracterezes hemoglobin synthesis in preterm infants. However, the existing literature lacks detailed reports assessing chronological changes in RET-He. The aim of this study was to assess the chronological changes in RET-He during oral iron dietary supplementation, and concomitant therapy with recombinant human erythropoietin (rHuEPO) in preterm very low birthweight infants.

METHODS

Very low birthweight infants, admitted to our neonatal intensive care unit were analyzed retrospectively. Hemoglobin (Hb), reticulocyte percentage (Ret), mean corpuscular volume, RET-He, serum iron (Fe), and serum ferritin were recorded. Data at birth (T0), the initial day of rHuEPO therapy (T1), the initial day of oral iron supplementation (T2), 1-2 weeks (T3), 3-4 weeks (T4), 5-6 weeks (T5), and 7-8 weeks (T6) from the initial day of oral iron supplementation were extracted, and their changes over time were examined.

RESULTS

Reticulocyte hemoglobin content was highest at birth and declined rapidly thereafter, especially after starting rHuEPO therapy. There was no upward trend in RET-He after the initiation of oral iron supplementation, with a slower increase during 5-6 weeks after the initiation of iron therapy.

CONCLUSIONS

During the treatment of anemia of prematurity, low RET-He levels may be prolonged. Anemia of prematurity should therefore be assessed and treated on a case-by-case basis, while considering the iron metabolic capacity of preterm infants.

Phytic Acid and Whole Grains for Health Controversy

Phytate (PA) serves as a phosphate storage molecule in cereals and other plant foods. In food and in the human body, PA has a high affinity to chelate Zn²⁺ and Fe²⁺, Mg²⁺, Ca²⁺, K⁺, Mn²⁺ and Cu²⁺. As a consequence, minerals chelated in PA are not bio-available, which is a concern for public health in conditions of poor food availability and low mineral intakes, ultimately leading to an impaired micronutrient status, growth, development and increased mortality. For low-income countries this has resulted in communications on how to reduce the content of PA in food, by appropriate at home food processing. However, claims that a reduction in PA in food by processing per definition leads to a measurable improvement in mineral status and that the consumption of grains rich in PA impairs mineral status requires nuance. Frequently observed decreases of PA and increases in soluble minerals in in vitro food digestion (increased bio-accessibility) are used to promote food benefits. However, these do not necessarily translate into an increased bioavailability and mineral status in vivo. In vitro essays have limitations, such as the absence of blood flow, hormonal responses, neural regulation, gut epithelium associated factors and the presence of microbiota, which mutually influence the in vivo effects and should be considered. In Western countries, increased consumption of whole grain foods is associated with improved health outcomes, which does not justify advice to refrain from grain-based foods because they contain PA. The present commentary aims to clarify these seemingly controversial aspects.

A longitudinal study on the effects of previous stillbirth or abortion on subsequent pregnancies and infants

BACKGROUND

This study was conducted to assess the effects of stillbirth and abortion on the health of the subsequent newborns.

METHODS

A prospective cohort study was implemented. The data were collected from January 2015 to August 2019. The study participants were selected using the simple random sampling technique. The data were collected using interviewing the pregnant mothers, reviewing medical charts, analyzing the blood samples from the newborn and scheduled medical checkups. The general linear model was used to assess the effects of stillbirth and abortion on the health of the newborn, Poisson regression was used to identify predictors of childhood infectious disease episodes and Kaplan-Meier survival curves were used to estimate time to childhood pneumonia and diarrhea.

RESULTS

Two thousand, eight hundred and seventy-two infants were included giving a response rate of 88.97%. Neonates born from mothers with a previous history of stillbirth or abortion had low birth-weight, low serum iron and zinc levels. High infection episodes of diarrhea and pneumonia were observed among infants born from a previous history of stillbirth and abortion mothers. The infection episodes during the childhood period were determined by serum zinc level [incident rate ratio (IRR): 0.71; 95% confidence interval (CI): 0.61-0.83], birth-weight (IRR: 0.86; 95% CI: 0.81-0.91) and breastfeeding frequency (IRR: 0.9; 95% CI: 0.87-0.93).

CONCLUSION

The birth-weight, serum iron and zinc levels of neonates born from the previous history of stillbirth and abortion were lower. The infection episodes of newborns born from mothers with a previous history of stillbirth or abortion were higher.

Reference Range of Complete Blood Count in Healthy Term Newborns 1 Week after Birth

BACKGROUND: Determination of the complete blood count (CBC) and reticulocyte reference range helps diagnose a disease related to changes in erythrocyte indices, white blood count, platelets, and reticulocytes, especially in newborns. AIM: The aim study is to establish a reference range for CBC and reticulocyte in healthy term newborns 1 week after birth. MATERIAL AND METHODS: The study method is prospective analyses of CBC and reticulocyte in term newborns within 1 week after birth. Inclusion criteria are term newborn (gestational age 37–42 weeks) with good tone, breathing, or crying immediately, do not have resuscitation, and the birth weight is ≥2500 g. RESULTS: Two hundred and seventy-seven term newborns met the inclusion criteria. There were 145 (52.35%) male infants and 132 (47.65%) female infants. The reference range of newborns for hemoglobin (Hb) at P2.5–P97.5, P3–P97, P5–P95, and mean ± 2 standard deviation (SD) was 11.70–19.60 g/dL, 11.90–19.57 g/dL, 12.20–19.20 g/dL, and 11.35–19.63 g/dL, respectively. In addition, reference range of male newborns for Hb at P2.5–P97.5, P3–P97, P5–P95, and mean ± 2SD was 12.20–20.14 g/dL, 12.28–19.91 g/dL, 12.63–19.38 g/dL, and 11.47–20.15 g/dL, respectively. The reference range of female newborns for Hb at P2.5–P97.5, P3–P97, P5–P95, and mean ± 2 SD was 11.37–19.20 g/dL, 11.50–19.20 g/dL, 11.80–19.20 g/dL, and 11.37–18.93 g/dL, respectively. CONCLUSION: The reference range of CBC and reticulocyte for healthy term newborns, male newborns, and female newborns in this study can be used as a benchmark.

Iron deficiency in pregnancy: Influence on sleep, behavior, and molecular markers of adult male offspring

Iron restriction during pregnancy can lead to iron deficiency and changes in the dopaminergic system in the adulthood of offspring, and restless legs syndrome (RLS) is closely related to these changes. Objectives: Analyze whether iron restriction during pregnancy would cause changes in the behavior, sleep, and dopaminergic system of the male offspring. In addition, we aimed to assess whether exercise would be able to modulate these variables. The pregnant rats (Wistar) were divided into four groups with different concentrations of iron in the diet: standard (St), supplementation (Su), restriction since weaning (R1), and restriction only during pregnancy (R2). After birth, the offspring were assigned to their respective groups according to the dams diet (St, Su, R1, and R2) and distributed into sedentary (SD) and exercised (EX) (for 8 weeks of training), reaching eight groups of offspring (O): OSt SD, OSt EX, OSu SD, OSu EX, OR1 SD, OR1 EX, OR2 SD, and OR2 EX. Sleep, behavior, and analysis of key genes of dopaminergic system (D2, DAT) were performed after 8 weeks. The results for trained offspring that the mother received supplementation diet were the most expressive, with increased freezing and the OR1 SD group showed an increase in DAT protein content. These changes may have been due to the association between the dams diet during pregnancy and the practice of exercise by the offspring. The different concentrations of iron during pregnancy caused changes in the offspring, however, they were not associated with fetal programming in the context of RLS.

The High Burden and Predictors of Anemia Among Infants Aged 6 to 12 Months in Dar es Salaam, Tanzania

BACKGROUND

Despite several interventions, the prevalence of anemia and related complications remains high among infants in Tanzania.

OBJECTIVE

We sought to determine the predictors of iron-deficiency anemia (IDA) among infants of HIV-negative women in Dar es Salaam, Tanzania.

METHODS

Cross-sectional analysis of 2826 mother-infant pairs who participated in a trial of vitamins and perinatal outcomes in Dar es Salaam, Tanzania. Hemoglobin and mean corpuscular volume were used to determine the prevalence of anemia among infants at 6 and 12 months. Multiple logistic regression was used to determine the maternal and infant risk factors for anemia during infancy.

RESULTS

We found high prevalence of anemia (90%) and IDA (44.2%) among infants. Higher maternal education (odds ratio [OR] = 0.52), maternal normal hemoglobin at enrollment (OR = 0.68) and during the early postpartum period reduced the odds of IDA at 6 months (OR = 0.56). The odds of IDA at 6 months were higher among males (OR = 1.65), wealth score below median (OR = 1.35), low birth weight (LBW; OR = 1.75), and small for gestational age (SGA) infants below the third centile (OR = 1.95) or third to less than fifth centile (OR = 2.29). Higher maternal education lowered the odds of IDA at 12 months (OR = 0.25). Wealth score below median (OR = 1.44), preterm delivery (OR = 1.94), SGA (less than third centile; OR = 2.40), and LBW (OR = 2.89) increased the odds of IDA during infancy in the study population. Dietary diversity was low for infants and women in the study sample.

CONCLUSION

Interventions to reduce the risk of infant IDA should address women's education, improvement of wealth status, and optimal care for premature, SGA, and LBW infants.

Genetic differences in ethanol consumption: effects on iron, copper, and zinc regulation in mouse hippocampus

One common characteristic of neurodegenerative diseases is dysregulation of iron, usually with observed increases in its concentration in various regions. Heavy alcohol consumption is believed to contribute to such iron dysregulation in the brain with accompanying dementia. To examine this effect and related genetic-based individual differences in an animal model, we subjected female mice from 12 BXD recombinant inbred strains to 16 weeks of alcohol consumption using the drinking in the dark (DID) method. Daily consumption was recorded and at the end of 16 weeks hippocampus tissues harvested. Concentrations of iron, copper and zinc were measured using X-ray fluorescence technology. The results showed that, DID increased iron overall across all strains, ranging from 3 to 68%. Copper and Zinc both decreased, ranging from 0.4-42 and 5-35% respectively. Analysis of variance revealed significant strain by treatment interactions for all three metals. Additionally, in the DID group, we observed strain differences in reduction of hippocampus mass. These findings are particularly interesting to us because high alcohol consumption in humans has been associated with neurodegeneration and dementia related to disruption of iron regulation. The findings of alcohol consumption associated decreases in copper and zinc are novel. The role of copper regulation and neurological function related to alcohol consumption is as yet largely unexplored. The role of zinc is better known as a neuromodulator in the hippocampus and appears to be protective against neurological damage. It would seem then, that the alcohol-related decrease in zinc in the hippocampus would be of concern and warrants further study.

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.

Iron Deficiency in Celiac Disease: Prevalence, Health Impact, and Clinical Management

Iron is an essential nutrient to life and is required for erythropoiesis, oxidative, metabolism, and enzymatic activities. It is a cofactor for mitochondrial respiratory chain enzymes, the citric acid cycle, and DNA synthesis, and it promotes the growth of immune system cells. Thus, iron deficiency (ID) leads to deleterious effects on the overall health of individuals, causing significant morbidity. Iron deficiency anemia (IDA) is the most recognized type of anemia in patients with celiac disease (CD) and may be present in over half of patients at the time of diagnosis. Folate and vitamin B12 malabsorption, nutritional deficiencies, inflammation, blood loss, development of refractory CD, and concomitant Heliobacter pylori infection are other causes of anemia in such patients. The decision to replenish iron stores and the route of administration (oral or intravenous) are controversial due, in part, to questions surrounding the optimal formulation and route of administration. This paper provides an algorithm based on the severity of symptoms; its impact on the health-related quality of life (HRQL); the tolerance and efficiency of oral iron; and other factors that predict a poor response to oral iron, such as the severity of histological damage, poor adherence to GFD, and blood loss due to mucosal lesions.

Influence of serum iron test results on the diagnosis of iron deficiency in children: a retrospective observational study

BACKGROUND AND OBJECTIVE

Serum iron results are not indicative of iron deficiency yet may be incorrectly used to diagnose iron deficiency instead of serum ferritin results. Our objective was to determine the association between serum iron test results and iron-deficiency diagnosis in children by general practitioners.

DESIGN, SETTING, PATIENTS AND MAIN OUTCOME MEASURES

A retrospective observational study of 14 187 children aged 1-18 years with serum ferritin and serum iron test results from 137 general practices in Victoria, Australia, between 2008 and 2018. Generalised estimating equation models calculating ORs were used to determine the association between serum iron test results (main exposure measure) and iron-deficiency diagnosis (outcome measure) in the following two population groups: (1) iron-deplete population, defined as having a serum ferritin <12 µg/L if aged <5 years and <15 µg/L if aged ≥5 years and (2) iron-replete population, defined as having a serum ferritin >30 µg/L.

RESULTS

3484 tests were iron deplete and 15 528 were iron replete. Iron-deplete children were less likely to be diagnosed with iron deficiency if they had normal serum iron levels (adjusted OR (AOR): 0.73; 95% CI 0.57 to 0.96). Iron-replete children had greater odds of an iron-deficiency diagnosis if they had low serum iron results (AOR: 2.59; 95% CI 1.72 to 3.89). Other contributors to an iron-deficiency diagnosis were female sex and having anaemia.

CONCLUSION

Serum ferritin alone remains the best means of diagnosing iron deficiency. Reliance on serum iron test results by general practitioners is leading to significant overdiagnosis and underdiagnosis of iron deficiency in children.

Brain iron assessment in patients with First-episode schizophrenia using quantitative susceptibility mapping

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Patients with first-episode schizophrenia had significantly decreased QSM values in the bilateral substantia nigra, left red nucleus and left thalamus.

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Patients with first-episode schizophrenia had significantly increased regional volumes in the bilateral putamen and bilateral substantia nigra.

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QSM provides superior sensitivity over R₂* mapping in the evaluation of schizophrenia-related iron alterations.

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QSM values in regions that showed intergroup differences did not exhibited significant correlations with PANSS scores.

Purpose

Decreased serum ferritin level was recently found in schizophrenia. Whether the brain iron concentration in schizophrenia exists abnormality is of research significance. Quantitative susceptibility mapping (QSM) was used in this study to assess brain iron changes in the grey matter nuclei of patients with first-episode schizophrenia.

Methods

The local ethics committee approved the study, and all subjects gave written informed consent. Thirty patients with first-episode schizophrenia and 30 age and gender-matched healthy controls were included in this study. QSM and effective transverse relaxation rate (R₂*) maps were reconstructed from a three-dimensional multi-echo gradient-echo sequence. The inter-group differences of regional QSM values, R₂* values and volumes were calculated in the grey matter nuclei, including bilateral caudate nucleus, putamen, globus pallidus, substantia nigra, red nucleus, and thalamus. The diagnostic performance of QSM and R₂* was evaluated using receiver operating characteristic curve. The correlations between regional iron variations and clinical PANSS (Positive and Negative Syndrome Scale) scores were assessed using partial correlation analysis.

Results

Compared to healthy controls, patients with first-episode schizophrenia had significantly decreased QSM values (less paramagnetic) in the bilateral substantia nigra, left red nucleus and left thalamus (p < 0.05, FDR correction). QSM proved more sensitive than R₂* regarding inter-group differences. The highest diagnostic performance for first-episode schizophrenia was observed in QSM value of the left substantia nigra (area under the curve, AUC = 0.718, p = 0.004). Regional volumes of bilateral putamen and bilateral substantia nigra were increased (p < 0.05, FDR correction) in first-episode schizophrenia. However, both QSM and R₂* values did not show significant correlations with PANSS scores (p > 0.05).

Conclusion

This study reveals decreased iron concentration in grey matter nuclei of patients with first-episode schizophrenia. QSM provides superior sensitivity over R₂* in the evaluation of schizophrenia-related brain iron changes. It demonstrated that QSM may be a potential biomarker for further understanding the pathophysiological mechanism of first-episode schizophrenia.

Dopamine-related striatal neurophysiology is associated with specialization of frontostriatal reward circuitry through adolescence

Characterizing developmental changes in frontostriatal circuitry is critical to understanding adolescent development and can clarify neurobiological mechanisms underlying increased reward sensitivity and risk-taking and the emergence of psychopathology during this period. However, the role of striatal neurobiology in the development of frontostriatal circuitry through human adolescence remains largely unknown. We examined background connectivity during a reward-guided decision-making task ("reward-state"), in addition to resting-state, and assessed the association between age-related changes in frontostriatal connectivity and age-related changes in reward learning and risk-taking through adolescence. Further, we examined the contribution of dopaminergic processes to changes in frontostriatal circuitry and decision-making using MR-based assessments of striatal tissue-iron as a correlate of dopamine-related neurobiology. Connectivity between the nucleus accumbens (NAcc) and ventral anterior cingulate, subgenual cingulate, and orbitofrontal cortices decreased through adolescence into adulthood, and decreases in reward-state connectivity were associated with improvements reward-guided decision-making as well as with decreases in risk-taking. Finally, NAcc tissue-iron mediated age-related changes and was associated with variability in connectivity, and developmental increases in NAcc R2' corresponded with developmental decreases in connectivity. Our results provide evidence that dopamine-related striatal properties contribute to the specialization of frontostriatal circuitry, potentially underlying changes in risk-taking and reward sensitivity into adulthood.

Iron Deficiency in Obesity and after Bariatric Surgery

Iron deficiency (ID) is particularly frequent in obese patients due to increased circulating levels of acute-phase reactant hepcidin and adiposity-associated inflammation. Inflammation in obese subjects is closely related to ID. It induces reduced iron absorption correlated to the inhibition of duodenal ferroportin expression, parallel to the increased concentrations of hepcidin. Obese subjects often get decreased inflammatory response after bariatric surgery, accompanied by decreased serum hepcidin and therefore improved iron absorption. Bariatric surgery can induce the mitigation or resolution of obesity-associated complications, such as hypertension, insulin resistance, diabetes mellitus, and hyperlipidemia, adjusting many parameters in the metabolism. However, gastric bypass surgery and sleeve gastrectomy can induce malabsorption and may accentuate ID. The present review explores the burden and characteristics of ID and anemia in obese patients after bariatric surgery, accounting for gastric bypass technique (Roux-en-Y gastric bypass-RYGB) and sleeve gastrectomy (SG). After bariatric surgery, obese subjects' iron status should be monitored, and they should be motivated to use adequate and recommended iron supplementation.

Functional reference limits: a case study of serum ferritin

Reference intervals depend on the distribution of results within a reference population and can be influenced by subclinical disease. Functional reference limits present an opportunity to derive clinically relevant reference limits from routinely collected data sources, which consist of mixed populations of unhealthy and healthy groups. Serum ferritin is a good example of the utility of functional reference limits. Several studies have identified clinically relevant reference limits through examining the relationship between serum ferritin and erythrocyte parameters. These ferritin functional limits often represent the inflection point at which erythrocyte parameters change significantly. Comparison of ferritin functional reference limits with those based on population distributional reference limits reveals that the lower reference limit may fall below the point at which patients become clinically unwell. Functional reference limits may be considered for any biomarker that exhibits a correlated relationship with other biomarkers.

Dietary patterns of Australian pre-schoolers and associations with haem and non-haem iron intakes

PURPOSE

To describe Australian pre-schooler dietary patterns and examine their associations with dietary iron intakes.

METHODS

Dietary data of children (n = 812, 2 to < 6 years old) from the 2011-12 National Nutrition and Physical Activity Survey were collected via two non-consecutive 24-h recalls and analysed using AUSNUT 2011-13. Usual food and nutrient intakes were estimated via Multiple Source Method. Principal component analysis was used to extract dietary patterns from 32 food groups. Associations between dietary patterns and energy-adjusted iron intakes were assessed using linear regression, accounting for the complex survey design.

RESULTS

Mean (SD) usual total dietary and haem iron intakes were 6.3 (1.9) and 0.5 (0.3) mg/day, respectively. Three dietary patterns were identified, explaining 14% of the variance. Pattern 1 (positive loadings for cheese, breads, fats and oils, and water) was positively associated with total dietary iron intakes (β = 0.08, 95% CI 0.01, 0.15). Pattern 3 (positive loadings for red meat, fortified fruit and vegetable products, and sauces and spreads) was negatively associated with total dietary iron (β = - 0.08, 95% CI - 0.14, - 0.01) and non-haem iron (β = - 0.09, 95% CI - 0.15, - 0.02) intakes. No dietary patterns were associated with haem iron intakes.

CONCLUSIONS

Three main patterns characterise Australian pre-schooler diets. The pattern with which dietary iron is positively associated is predominately characterised by non-haem iron sources and non-iron-fortified foods. Future research is required to estimate the iron bioavailability of Australian pre-schooler diets.

Mathematical modelling of fungi-initiated siderophore-iron interactions

Nearly all life forms require iron to survive and function. Microorganisms utilize a number of mechanisms to acquire iron including the production of siderophores, which are organic compounds that combine with ferric iron into forms that are easily absorbed by the microorganism. There has been significant experimental investigation into the role, distribution and function of siderophores in fungi but until now no predictive tools have been developed to qualify or quantify fungi-initiated siderophore-iron interactions. In this investigation, we construct the first mathematical models of siderophore function related to fungi. Initially, a set of partial differential equations are calibrated and integrated numerically to generate quantitative predictions on the spatio-temporal distributions of siderophores and related populations. This model is then reduced to a simpler set of equations that are solved algebraically giving rise to solutions that predict the distributions of siderophores and resultant compounds. These algebraic results require the calculation of zeros of cross products of Bessel functions and thus new algebraic expansions are derived for a variety of different cases that are in agreement with numerically computed values. The results of the modelling are consistent with experimental data while the analysis provides new quantitative predictions on the time scales involved between siderophore production and iron uptake along with how the total amount of iron acquired by the fungus depends on its environment. The implications to bio-technological applications are briefly discussed.

Determining the Actual Zinc and Iron Intakes in Breastfed Infants: Protocol for a Longitudinal Observational Study

BACKGROUND

Zinc and iron deficiencies among breastfed infants during the first 6 months of life have been reported in previous studies. The amounts of zinc and iron intakes from breast milk are factors that contribute to the zinc and iron status of breastfed infants.

OBJECTIVE

This study aims to quantitatively determine zinc and iron intakes by breastfed infants during the first 4 months of life and to investigate the factors that predict zinc and iron status in breastfed infants.

METHODS

Pregnant women at 28 to 34 weeks of gestation were enrolled. Zinc and iron status during pregnancy was assessed. At delivery, cord blood was analyzed for zinc and iron levels. Participants and their babies were followed at 2 and 4 months postpartum. Maternal dietary intakes and anthropometric measurements were performed. The amount of breast milk intake was assessed using the deuterium oxide dose-to-mother technique. Breast milk samples were collected for determination of zinc and iron levels. The amount of zinc and iron consumed by infants was calculated. Zinc and iron status was determined in mothers and infants at 4 months postpartum.

RESULTS

A total of 120 pregnant women were enrolled, and 80 mother-infant pairs completed the study (56 provided full breastfeeding, and 24 provided breast milk with infant formula). All data are being managed and cleaned. Statistical analysis will be done.

CONCLUSIONS

This study will provide information on zinc and iron intakes in exclusively breastfed infants during the first 4 months of life and explore predictive factors and the possible association of zinc and iron intakes with infant growth and nutrient status.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/19119.

Clinical thresholds for diagnosing iron deficiency: comparison of functional assessment of serum ferritin to population based centiles

Low serum ferritin is diagnostic of iron deficiency, yet its published lower cut-off values are highly variable, particularly for pediatric populations. Lower cut-off values are commonly reported as 2.5th percentiles, and is based on the variation of ferritin values in the population. Our objective was to determine whether a functional approach based on iron deficient erythropoiesis could provide a better alternative. Utilizing 64,443 ferritin test results from pediatric electronic health records, we conducted various statistical techniques to derive 2.5th percentiles, and also derived functional reference limits through the association between ferritin and erythrocyte parameters: hemoglobin, mean corpuscular volume, mean cell hemoglobin concentration, and red cell distribution width. We find that lower limits of reference intervals derived as centiles are too low for clinical interpretation. Functional limits indicate iron deficiency anemia starts to occur when ferritin levels reach 10 µg/L, and are largely similar between genders and age groups. In comparison, centiles (2.5%) presented with lower limits overall, with varying levels depending on age and gender. Functionally-derived limits better reflects the underlying physiology of a patient, and may provide a basis for deriving a threshold related to treatment of iron deficiency and any other biomarker with functional outcomes.

Irritability and Perceived Expressed Emotion in Adolescents With Iron Deficiency and Iron Deficiency Anemia: A Case-Control Study

The objective of this study was to assess the difference in irritability and perceived expressed emotion (EE) between adolescents with iron deficiency (ID) or iron deficiency anemia (IDA) and their healthy peers. In addition, we aimed to investigate the relationship between hemogram parameters, irritability, and perceived EE in adolescents with ID and IDA. The sample of this single-center cross-sectional case-control study consisted of 89 adolescents from 12 to 17 years of age. Of the participants, 19 had been diagnosed with ID, 31 had IDA, and 39 were healthy controls. Significant differences in the self-reported and parent-reported irritability scores were observed between the ID group and the control group and between the IDA group and the control group. There was also a significant difference in the subscale of irritability between the ID group and the control group. The difference between the IDA and control groups in the intrusiveness subscale was found to be significant as well. Adolescents with IDA and ID exhibited significantly perceived irritability compared with the control group. In terms of irritability, adolescents with IDA and ID revealed greater irritability than their healthy peers. The results of this study suggest that irritability and perceived EE should be investigated in cases of ID, whether with or without anemia. As chronic diseases may benefit substantially from psychiatric consultation, psychosocial evaluation and intervention should be considered a complementary treatment option in the management of ID and IDA.

Efficacy of an iron-fortified infant cereal to reduce the risk of iron deficiency anemia in young children in East Cameroon

Complementary foods in Africa are often poor sources of bioavailable iron. We assessed the efficacy of iron-fortified wheat-based infant cereal (IC) to reduce the risk of iron deficiency anemia in children aged 18-59 months in Cameroon. A 6-month double-blind, cluster-randomized controlled trial was conducted in 2017 among anemic (hemoglobin 7-11 g/dl) but otherwise healthy children. In conjunction with usual diet, children received two 50 g servings/day of a standard, micronutrient-fortified IC (providing 3.75 mg iron/serving; n = 106) or the same IC without iron fortification (n = 99). Anthropometric measurements, blood sampling, and systematic deworming were performed in all children at baseline (pre-intervention), 3, and 6 months. Mean hemoglobin, ferritin adjusted for C-reactive protein (CRP), serum iron, transferrin saturation, prevalence of anemia, iron deficiency, and iron deficiency anemia as well as anthropometrics were compared between the groups at baseline, 3, and 6 months. Compared to the control group, children consuming the iron-fortified IC had significantly higher baseline-adjusted mean hemoglobin (10.0 ± 1.8 vs. 9.7 ± 1.4 g/dl, respectively; p = .023), ferritin adjusted for CRP (16.1 ± 8.3 vs. 9.5 ± 7.5 μg/L, p < .001), serum iron (14.5 ± 3.9 vs. 11.2 ± 4.4 μg/dl; p < .001), and transferrin saturation (19.0 ± 17.4 vs. 10.7 ± 12.5%; p ˂ .001) at 6 months. The prevalence of anemia, iron deficiency, and iron deficiency anemia at 6 months decreased by a larger extent in the iron-fortified group versus controls (all p < .01). In addition, at 6 months, children in the iron-fortified group demonstrated higher weight-for-age z-scores (p = .016) compared to the control group. Wheat-based IC fortified with 7.5 mg ferrous fumarate administered daily for 6 months improved iron and nutritional status and decreased the prevalence of iron deficiency anemia in children aged 18-59 months in Salapoumbé, Cameroon.

Prevalence and Correlates of Asymptomatic Malaria and Anemia on First Antenatal Care Visit among Pregnant Women in Southeast, Tanzania

Asymptomatic malaria and anemia during pregnancy increase the risk of negative birth outcomes. This cross-sectional study investigated the prevalence and correlates of asymptomatic malaria and anemia during first antenatal care (ANC) visit among pregnant women in a rural district, Tanzania. HIV-uninfected pregnant women without symptoms of malaria (n = 819) attending their first ANC at Kibiti Health Centre were enrolled from February 2017 to February 2018. Asymptomatic malaria was detected by malaria rapid-diagnostic tests (mRDT) and real-time PCR. Hemoglobin concentration was determined by HemoCue Hemoglobin 201+. The study outcomes were the prevalence of asymptomatic malaria and anemia (Hemoglobin level <11 g/dL). The overall prevalence of asymptomatic malaria was 36.4% (95% CI: 33.1, 39.8). The monthly prevalence of asymptomatic malaria remained >25% throughout the year, and the highest prevalence (40%) was recorded during the rainy season. Asymptomatic malaria was significantly associated with primigravida, younger maternal age, and anemia. The prevalence of anemia was 68.5% (95% CI: 65.2, 71.6). Asymptomatic malaria, primigravida, younger maternal age and low Body Mass Index were significant predictors of low hemoglobin concentration. We report high prevalence of asymptomatic malaria and anemia among pregnant women on the first ANC visit. Screening of malaria and anemia during the first ANC visit is recommended for targeted interventions.

Alleviation of Salinity Induced Oxidative Stress in Chenopodium quinoa by Fe Biofortification and Biochar—Endophyte Interaction

Iron-biofortification is a sustainable food-based approach to combat iron deficiency by increasing iron content and bioavailability in agronomic crops. Siderophore producing microbes offer a sustainable and low-cost way to increase iron supply in crops. Also, certain substances released from organic amendments act as iron-chelators which increase the solubility as well as the availability of iron to plants. Present study investigated the role of siderophore-producing endophytic bacteria and biochar on iron-fortification of a novel crop quinoa in iron-limited saline conditions. The surface-disinfected seeds of quinoa were inoculated with Burkholderia phytofirmans PsJN (CFU = 109) and sown in saline soil (EC 20 dS m−1) amended with biochar (1% w/w). Results revealed that biochar and PsJN particularly when applied together significantly enhanced plant growth, grain yield, and grain nutrient contents of quinoa. Strikingly, iron concentration in quinoa grains was increased up to 71% by the combined application of biochar and PsJN. Moreover, plant physiological parameters were also improved significantly by the integrated application. However, enzymatic/non-enzymatic antioxidants activities were decreased by integrated treatment thus ameliorated salinity stress. Our study suggests that integrated application of siderophore-producing bacteria and biochar could be a promising, sustainable and cost-effective strategy which is easily integratable into the existing farming practices to achieve food fortification with micronutrients in developing countries.

Micronutrient-fortified infant cereal improves Hb status and reduces iron-deficiency anaemia in Indian infants: an effectiveness study

Anaemia affects approximately 69 % of Indian children aged 6–12 months, with Fe deficiency (ID) being a common cause. The effectiveness of micronutrient-fortified infant cereal in improving Fe status and neurodevelopment was evaluated in non-anaemic and mildly anaemic Indian infants. An intervention group (IC) enrolled at age 6 months consumed 50 g/d of rice-based cereal providing 3·75 mg Fe/d as ferrous fumarate for 6 months (n 80) and was compared with a matched static cross-sectional control group (CG) without intervention enrolled at age 12 months (n 80). Mean Hb was higher in IC (118·1 (sd 10·2) g/l) v. CG (109·5 (sd 16·4) g/l) at age 12 months (adjusted mean difference: 9·7 g/l; 95 % CI 5·1, 14·3; P < 0·001), while geometric mean serum ferritin tended to be higher (27·0 (–1 sd 13·4, +1 sd 54·4) v. 20·3 (–1 sd 7·5, +1 sd 55·0) ng/ml); P = 0·085) and soluble transferrin receptor was lower (1·70 (–1 sd 1·19, +1 sd 2·43) v. 2·07 (–1 sd 1·29, +1 sd 3·33) mg/l; P = 0·014). Anaemia (23 v. 45 %; P = 0·007) and ID (17 v. 40 %; P = 0·003) were lower in IC v. CG. Bayley Scales of Infant and Toddler Development Third Edition scores for language (P = 0·003), motor development (P = 0·018), social-emotional (P = 0·004) and adaptive behaviour (P < 0·001), but not cognitive development (P = 0·980), were higher in IC v. CG. No significant difference in anthropometric Z-scores was observed between the groups. Consuming a micronutrient-fortified infant cereal daily for 6 months during complementary feeding promoted better Fe status while reducing the risk for anaemia and ID and was associated with superior neurodevelopmental scores.

A General Pediatrician's Approach to Anemia in Childhood

Anemia may be defined as a reduction in red blood cell mass or blood hemoglobin concentration. Physiologically, this represents a hemoglobin level that is too low to meet cellular oxygen demands. Practically, the lower limit of normal is set at 2 standard deviations below the mean based on age, gender, and ethnicity/race. Anemia can lead to impaired growth, development, and poor neurocognitive outcome. As such, it is essential for pediatricians to recognize and conduct appropriate testing for a child with anemia. [Pediatr Ann. 2020;49(1):e10-e16.].

Building a prediction model for iron deficiency anemia among infants in Shanghai, China

Iron deficiency anemia (IDA) is a common micronutrient deficiency worldwide in infants. Iron deficiency anemia, during infancy, can have long-lasting detrimental effects on the immune and neural systems; the damage is irreversible. This study aimed to build a prediction model to predict the potential risk of IDA among infants. To collect relevant information for model building, we recruited 528 infants from Fenglin Community Health Service Center in Shanghai, China, and collected the information of infants and their parents by using a structured questionnaire. We also got the blood routine examination results of the infants. Then, we used a multilayer perceptron model (MLP) of the neural network model in IBM SPSS Modeler 18.0 to construct the prediction model. Of the 528 included infants, 80 (15.2%) of them had lower hemoglobin values (<110 g/L) and were finally diagnosed with IDA. Based on the accuracy of different models, the model with the highest accuracy rate (97.3%) was chosen, and all the preselected 26 variables were included in the model. After the modeling, the results indicated that the number of months of exclusive breastfeeding was the most important predictive variable, followed by the mother having anemia during pregnancy, and then the number of months of feeding the infant with iron-fortified rice flour. The model has good sensitivity (100%) and specificity (100%). By using this model, we can predict the potential risk of an infant having IDA and can take the initiative to prevent iron deficiency through the improvement of feeding methods.

Nutritional Gaps and Supplementation in the First 1000 Days

Optimized nutrition during the first 1000 days (from conception through the 2nd birthday) is critical for healthy development and a healthy life for the newborn. Pregnancy and the postpartum period are accompanied by physiological changes, increased energy needs, and changing requirements in the nutrients critical for optimal growth and development. Infants and toddlers also experience physiological changes and have specific nutritional needs. Food and nutrition experts can provide women of childbearing age with adequate dietary advice to optimize nutrition, as well as guidance on selecting appropriate dietary supplements. Considering the approaching 2020-2025 Dietary Guidelines for Americans (DGA) will be making specific recommendations for children, it is important to provide accurate scientific information to support health influencers in the field of nutrition. The purpose of this review is to summarize the nutrition and supplementation literature for the first 1000 days; to highlight nutritional and knowledge gaps; and to educate nutrition influencers to provide thoughtful guidance to mothers and families. Optimal nutrition during pregnancy through early childhood is critical for supporting a healthy life. Nutrition influencers, such as dietitians, obstetricians/gynecologists, and other relevant health professionals, should continue guiding supplement and food intake and work closely with expectant families and nutrition gatekeepers.