Indices of iron deficiency and anaemia in Bedouin and Jewish toddlers in southern Israel

Complementary feeding and micronutrient status: a systematic review

BACKGROUND

Proper nutrition during early life is critical for growth and development.

OBJECTIVES

The aim was to describe systematic reviews conducted by the Nutrition Evidence Systematic Review team for the USDA and the Department of Health and Human Services Pregnancy and Birth to 24 Months Project to answer the following: What is the relation between 1) timing of introduction of complementary foods and beverages (CFBs) or 2) types and/or amounts of CFBs consumed and micronutrient status (iron, zinc, vitamin D, vitamin B-12, folate, and fatty acid status)?

METHODS

A literature search identified articles from developed countries published from January 1980 to July 2016 that met the inclusion criteria. Data were extracted and risk of bias assessed. Evidence was qualitatively synthesized to develop a conclusion statement, and the strength of the evidence was graded.

RESULTS

Nine articles addressed the timing of CFB introduction and 31 addressed types or amounts or both of CFBs. Moderate evidence suggests that introducing CFBs at age 4 mo instead of 6 mo offers no advantages or disadvantages in iron status among healthy full-term infants. Evidence is insufficient on the timing of CFB introduction and other micronutrient status outcomes. Strong evidence suggests that CFBs containing iron (e.g., meat, fortified cereal) help maintain adequate iron status or prevent deficiency in the first year among infants at risk of insufficient iron stores or low intake. Benefits for infants with sufficient iron stores (e.g., infant formula consumers) are less clear. Moderate evidence suggests that CFBs containing zinc (e.g., meat, fortified cereal) support zinc status in the first year and CFB fatty acid composition influences fatty acid status. Evidence is insufficient with regard to types and amounts of CFBs and vitamin D, vitamin B-12, and folate status, or the relation between lower-iron-containing CFBs and micronutrient status.

CONCLUSIONS

Several conclusions on CFBs and micronutrient status were drawn from these systematic reviews, but more research that addresses specific gaps and limitations is needed.

Caffeine in the Diet: Country-Level Consumption and Guidelines

Coffee, tea, caffeinated soda, and energy drinks are important sources of caffeine in the diet but each present with other unique nutritional properties. We review how our increased knowledge and concern with regard to caffeine in the diet and its impact on human health has been translated into food-based dietary guidelines (FBDG). Using the Food and Agriculture Organization list of 90 countries with FBDG as a starting point, we found reference to caffeine or caffeine-containing beverages (CCB) in 81 FBDG and CCB consumption data (volume sales) for 56 of these countries. Tea and soda are the leading CCB sold in African and Asian/Pacific countries while coffee and soda are preferred in Europe, North America, Latin America, and the Caribbean. Key themes observed across FBDG include (i) caffeine-intake upper limits to avoid risks, (ii) CCB as replacements for plain water, (iii) CCB as added-sugar sources, and (iv) health benefits of CCB consumption. In summary, FBDG provide an unfavorable view of CCB by noting their potential adverse/unknown effects on special populations and their high sugar content, as well as their diuretic, psycho-stimulating, and nutrient inhibitory properties. Few FBDG balanced these messages with recent data supporting potential benefits of specific beverage types.

Hematologic Manifestations of Brucellosis in Children

BACKGROUND

Brucellosis is a common zoonosis in the Bedouin population of southern Israel. Limited data exist for the rate and risk factors of hematologic complication of brucellosis in children. We assessed anemia, leukopenia, thrombocytopenia and pancytopenia in childhood brucellosis in southern Israel.

METHODS

Our medical center is the sole hospital in southern Israel. All medical files of brucellosis, 2005-2014, identified through positive blood cultures or International Classification of Diseases 9th revision coding with positive serology, were reviewed retrospectively.

RESULTS

Overall, 511 brucellosis episodes were identified; 42% (N = 214) with ≥1 cytopenia, including 13% (N = 68) anemia, 28% (N = 144) leukopenia, 14% (N = 74) thrombocytopenia and 2% (N = 9) pancytopenia. Overall, 99.8% of episodes were in Bedouin children and 70% in males. In 79% of episodes, blood culture was positive for Brucella melitensis. Acute infections comprised 84% of all episodes. In univariate analysis, older age (10.49 ± 4.81 vs. 9.25 ± 4.89 years), fever (92% vs. 78%), positive blood culture (84% vs. 75%) and IgM ≥1:640 levels (50% vs. 39%) were associated with cytopenia. In contrast, arthralgia was associated with noncytopenic episodes. In multivariate analyses, older age (odds ratio = 1.063) and fever (odds ratio = 3.127) were associated with cytopenia.

CONCLUSIONS

Brucellosis is commonly presented with cytopenia, especially in bacteremic episodes with fever. However, pancytopenia is uncommon and its finding should alert the physician to look for other possible etiologies.

Iron Deficiency in Inflammatory Bowel Disease: The Use of Zincprotoporphyrin and Red Blood Cell Distribution Width

OBJECTIVES

Iron deficiency (ID) in children with inflammatory bowel disease (IBD) is either an absolute (depleted iron stores) or a functional deficiency (caused by chronic inflammation). Differentiating between these 2 types of ID is important because they require a different therapeutic approach. Zinc protoporphyrin (ZPP) and red blood cell distribution width (RDW) are parameters of functional ID. Studies using these parameters to differentiate are nonexistent. We aimed to evaluate the prevalence of and risk factors for absolute and functional ID in paediatric IBD patients while using ZPP and RDW.

METHODS

We evaluated the iron status and medical charts of 59 paediatric IBD patients in a secondary hospital in the Netherlands. Absolute ID was defined as serum ferritin <15 μg/L in the absence of infection and/or acute inflammation (C-reactive protein <10 mg/L). Iron deficiency anaemia (IDA) was defined as absolute ID in combination with anaemia. Functional ID, in patients without absolute ID, was defined as ZPP >70 μmol/mol haem and/or an RDW >14%. Anaemia of chronic disease (ACD) was defined as functional ID in combination with anaemia.

RESULTS

Absolute and functional ID were found in 19/59 (32.2%) and 32/40 (80%) patients, respectively. The prevalence of IDA and ACD was 27.1% (16/59) and 20% (8/40), respectively. Multivariate analyses showed that absolute ID and IDA were both associated with a more recent IBD-diagnosis (both P < 0.05).

CONCLUSIONS

Absolute and functional ID are common in paediatric IBD patients, and this differentiation is important because of therapeutic consequences. Furthermore, absolute ID and IDA are associated with a more recent IBD-diagnosis.

What is Known About Health and Morbidity in the Pediatric Population of Muslim Bedouins in Southern Israel: A Descriptive Review of the Literature from the Past Two Decades

The Bedouins comprise one of the ethnic groups in Israeli society. They are Muslims, most of who live in the Negev desert region of southern Israel and live by their unique traditions and customs. At the present they are going through a period of "society in transition", a unique condition that has ramifications for health and morbidity. In recent years the number of publications on the health of Bedouins in the Negev has increased. Recognition of unique socio-economic features, characteristics of health and diseases can help the medical team treat various health problems in this population as well as other populations with similar characteristics. In the present paper we survey and discuss publications on the health of Bedouin children over the past 20 years.

Red Blood Cell Distribution Width and the Platelet Count in Iron-deficient Children Aged 0.5-3 Years

Early detection of iron deficiency (ID) and iron deficiency anemia (IDA) in young children is important to prevent impaired neurodevelopment. Unfortunately, many biomarkers of ID are influenced by infection, thus limiting their usefulness. The aim of this study was to investigate the value of red blood cell distribution width (RDW) and the platelet count for detecting ID(A) among otherwise healthy children. A multicenter prospective observational study was conducted in the Netherlands to investigate the prevalence of ID(A) in 400 healthy children aged 0.5-3 years. ID was defined as serum ferritin (SF) <12 μg/L in the absence of infection (C-reactive protein [CRP] <5 mg/L) and IDA as hemoglobin <110 g/L combined with ID. RDW (%) and the platelet count were determined in the complete blood cell count. RDW was inversely correlated with SF and not associated with CRP. Calculated cutoff values for RDW to detect ID and IDA gave a relatively low sensitivity (53.1% and 57.1%, respectively) and specificity (64.7% and 69.9%, respectively). Anemic children with a RDW >14.3% had a 2.7 higher odds (95% confidence interval [CI]: 1.2-6.3) to be iron deficient, compared with anemic children with a RDW <14.3%. The platelet count showed a large range in both ID and non-ID children. In conclusion, RDW can be helpful for identifying ID as the cause of anemia in 0.5- to 3-year-old children, but not as primary biomarker of ID(A). RDW values are not influenced by the presence of infection. There appears to be no role for the platelet count in diagnosing ID(A) in this group of children.

Iron Deficiency and Iron-deficiency Anemia in Toddlers Ages 18 to 36 Months: A Prospective Study

In young children, iron deficiency (ID)-the most common cause of anemia-may adversely affect long-term neurodevelopment and behavior. We prospectively evaluated the prevalence of ID and iron deficiency anemia (IDA) in 256 healthy 18- to 36-month-old children in Northern Israel. Complete blood count and ferritin evaluation were performed, and risk factors were assessed. Hemoglobin (Hgb) was compared with first-year routine screening. Complete data were obtained from 208 children: 56.2% were boys; the mean age was 26.1±5.27 months. A prevalence of 5.8% IDA, 16.3% ID without anemia, 9.6% anemia with normal ferritin, and 68.3% normal Hgb and ferritin was found. In nonanemic infants at 1 year of age (n=156), ID/IDA was found in 19.9%, and 12.8% became anemic at study evaluation. Despite iron supplementation in the first year, and normal Hgb at first-year screening, ID and IDA were still prevalent, and might develop during the second year of life. Recognition of this child subset and consideration of iron supplementation are mandatory.

Maternal perceptions of social context and adherence to maternal and child health (MCH) clinic recommendations among marginalized Bedouin mothers

National maternal and child health (MCH) care systems often deliver universal health care recommendations that do not take into consideration the social context of infant care (IC) for marginalized groups. We examined associations between maternal perceptions of social context (MPSC) and adherence by minority Bedouin mothers in Israel to three commonly recommended IC practices. We conducted personal interviews with 464 mothers visiting 14 MCH clinics using a structured questionnaire based on findings from a previous focus-group study, and guided by constructs of the Health Beliefs Model. Items were tested for validity and reliability. We used multivariate analysis to identify MPSC constructs associated with adherence to MCH clinic recommendations (timely postnatal first visit, sustaining breastfeeding, and use of infant car seat). Social context, when perceived as a barrier to IC, was negatively associated with adherence to timely first postnatal MCH clinic visit (odds ratio, 95 %, confidence intervals (OR 1.45, 95 % CI 1.24, 1.70) and use of infant car seat (OR 1.43, 95 % CI 1.21, 1.69). However, social context was positively associated with sustained breastfeeding (OR 0.54, 95 % CI 0.37, 0.79). Perceptions of the severity of infant health problems, and family financial and relationship problems had less significant associations with adherence to MCH clinic recommendations. Adherence by marginalized mothers to MCH clinic recommendations is related to their perceptions of social context. When there are higher financial and other living conditions barriers mothers tend toward lower adherence to these recommendations. MCH policy makers and service providers must consider MPSC in planning and delivery of MCH recommendations.

The social ecology of maternal infant care in socially and economically marginalized community in southern Israel

This study aims to better understand the social ecology of infant care (IC) as experienced and perceived by mothers living in a deprived Arab Bedouin community in Israel, where children's health indicators are poor. We used the integrative model of García Coll et al. (García Coll C, Lamberty G, Jenkins R et al. An integrative model for the study of developmental competencies in minority children. Child Dev 1996; 67: 1891-914) and constructs of the Health Beliefs Model as a study framework for conducting focus groups with 106 mothers in 2007. Results show that mothers believe IC and infant well-being are high priorities. However, distal barriers, including land disputes, a transition from herding to low-paid labor and lifestyle changes have interacted with proximal barriers in Bedouin families, including poor living conditions, poverty and weakened familial relations to inhibit adequate IC practices. Specifically, distal and proximal barriers affect IC directly (e.g. lack of nearby clinics) or indirectly (mothers' self-efficacies) to limit mothers' choices and control over IC, thereby posing threats to infant health. Our findings demonstrate the importance of understanding the complexity of social context in shaping IC among marginalized minority mothers and suggest new ground for addressing proximal and distal barriers through policy interventions. Without contending with both, interventions to strengthen mothers' self-efficacy will have limited success in improving the environment of IC and, consequently, infant health.

Anemia in children with down syndrome

Background. Iron deficiency anemia impacts on cognitive development. The objective of this study was to determine the prevalence of anemia and iron deficiency in children with Down syndrome and identify risk factors for anemia. Methods. We conducted a prolective cross-sectional study of children attending a multidisciplinary Down syndrome medical center. One hundred and forty nine children with Down syndrome aged 0–20 years were enrolled in the study. Information obtained included a medical history, physical and developmental examination, nutritional assessment, and the results of blood tests. Results. Of the patients studied, 8.1% were found to have anemia. Among the 38 children who had iron studies, 50.0% had iron deficiency. In a multivariate analysis, Arab ethnicity and low weight for age were significantly associated with anemia. Gender, height, the presence of an eating disorder, and congenital heart disease were not risk factors for anemia. Conclusions. Children with Down syndrome are at risk for anemia and iron deficiency similar to the general population. Children with Down syndrome should be monitored for anemia and iron deficiency so that prompt intervention can be initiated.