Vitamin A supplementation for preventing morbidity and mortality in children from six months to five years of age

Measles outbreak in the Philippines: epidemiological and clinical characteristics of hospitalized children, 2016-2019

BACKGROUND

Measles outbreaks increased worldwide during 2017-19. The largest outbreak in the World Health Organisation Western Pacific region occurred in the Philippines where first-dose measles-containing vaccine (MCV1) coverage had reduced to 75% in 2018. The aim of this study was to summarise paediatric measles admissions to the national infectious diseases referral hospital in Manila during 2016 to 2019.

METHODS

A retrospective single-centre observational study including 5,562 children aged under five years admitted with measles from January 2016 to December 2019. We summarised sociodemographic and clinical characteristics, vaccine status, reported exposures, and outcomes. Univariable and multivariable logistic regression analyses were undertaken to assess associations between different characteristics of hospitalised children and death.

FINDINGS

The median age of children hospitalised with measles was 11 months (interquartile range: 7-28). 84·5% of cases were reported not to have received any MCV. The risk of mortality was 3·2%, with 41% of deaths occurring among children aged less than 9 months. No children died who had received two MCV. The following characteristics were significantly associated with mortality in the multivariable analysis: age group, residence outside of the national capital region, not having received any MCV, duration between onset of fever and hospital admission of 7-14 days compared with 0-3 days, not receiving vitamin A supplementation, having pneumonia, and gastroenteritis.

INTERPRETATION

The Philippines remains at risk of future measles epidemics. Routine immunization needs to be strengthened and earlier timing of MCV1 requires further evaluation to reduce measles incidence and mortality.

Associations between Serum Vitamin A and Metabolic Risk Factors among Eastern Chinese Children and Adolescents

Vitamin A, a fat-soluble essential vitamin, is implicated in a large range of physiological processes. Up to now, the associations between vitamin A and metabolic syndrome (MetS) or other metabolic risk factors are controversial in children and adolescents. Thus, we aimed to dig into the relationship of vitamin A with MetS and many other metabolic risk factors. This was a cross-sectional study derived from the China National Nutrition and Health Surveillance of Children and Lactating Mothers. A total of 3025 school-aged (7–17 years) children and adolescents were selected by applying multistage stratified cluster random sampling methods in the Jiangsu Province of eastern China. Through enquiry survey, anthropometric measurement and laboratory examination, relevant information and blood biochemical indexes of the participants were collected in this study. MetS was identified according to the modified criteria of the National Cholesterol Education Program–Adult Treatment Panel III (NCEP-ATP III). Multivariate logistic analysis and the generalized additive model (GAM) were used to analyze the relationship between vitamin A and various metabolic risk factors. The overweight, obesity and MetS prevalence of children and adolescents in this study was 14.0%, 11.9% and 5.1%, respectively. The risk of prevalent MetS, general obesity, high low-density lipoprotein (LDL), high total cholesterol (TC) and hyperuricemia increased with vitamin A in a dose-dependent way. Logistic regression analysis showed that serum vitamin A Z scores were positively associated with MetS and central obesity, elevated blood pressure (BP) and elevated triglyceride (TG). Sex stratification analysis showed that both in male and female participants, the risk of prevalent MetS, general obesity, high LDL, high TC and hyperuricemia still increased with vitamin A levels. MetS was at a high prevalence level in children and adolescents in Jiangsu that were 7–17 years old. Vitamin A was positively associated with obesity, MetS, dyslipidemia and hyperuricemia. More public health measures and new visions should focus on the effects of retinol on children and adolescents.

Association between Circulating Antioxidants and Longevity: Insight from Mendelian Randomization Study

Background. Antioxidants attracted long-standing attention as promising preventive agents worldwide. Previous observational studies have reported that circulating antioxidants are associated with reduced mortality; however, randomized clinical trials indicate neutral or harmful impacts. The association of long-term circulating antioxidant exposure with longevity is still unclear. Objectives. We aim to determine whether long-term circulating antioxidant exposure is causally associated with longevity in the general population using the two-sample Mendelian randomization (MR) design. Methods. Genetic instruments for circulating antioxidants (ascorbate, lycopene, selenium, beta-carotene, and retinol) and antioxidant metabolites (ascorbate, alpha-tocopherol, gamma-tocopherol, and retinol) were identified from the largest up-to-date genome-wide association studies (GWASs). Summary statistics of these instruments with individual survival to the 90th vs. 60th percentile age (11,262 cases and 25,483 controls) and parental lifespan ( $N=\mathrm{1,012,240}$ individuals) were extracted. The causal effect was estimated using the inverse-variance weighted method in the main analysis and complemented by multiple sensitivity analyses to test the robustness of results. Results. We found that genetically determined higher concentration of circulating retinol (vitamin A) metabolite was casually associated with a higher odds of longevity (OR, 1.07; 95% CI, 1.02–1.13; $P<0.01$ ) and increased parental lifespan (lifespan years per 10-fold increase: 0.17; 95% CI, 0.07–0.27; $P<0.01$ ). Present evidence did not support a causal impact of circulating ascorbate (vitamin C), tocopherol (vitamin E), lycopene, selenium or beta-carotene on life expectancy. No evidence was identified to show the pleiotropic effects had biased the results. Conclusions. Long-term higher exposure to retinol metabolite is causally associated with longevity in the general population. Future MR analyses could assess the current findings further by utilizing additional genetic variants and greater samples from large-scale GWASs.

Trends of the Global, Regional, and National Incidence of Measles, Vaccine Coverage, and Risk Factors in 204 Countries From 1990 to 2019

Background

Measles is a highly contagious disease that has caused global morbidity and mortality. Though great progress has been made in measles elimination, the resurgence of measles has been observed in recent years. As extant literature were mainly confined to data of local area, we conducted a systematic analysis to explore the trends of the incidence of measles, coverage rate, and the risk factors from 1990 to 2019 on global, regional, and national levels.

Methods

Data on cases of incidence, age standardized rate (ASR), vaccine coverage, and risk factors of measles were retrieved from the Global Burden of Disease (GBD) Study 2019 database. Estimated averaged percentage change (EAPC) of ASR was calculated to quantify the trends of measles incidence. Pearson correlation was applied to assess the association of EAPC and measles-containing vaccine coverage rate with socio-demographic index (SDI) in 2019, and the correlation between ASR and measles-containing vaccine coverage rate.

Results

Globally, there was a significant decrease in the number (84.18%) and ASR (6.13%, 95% CI: 5.41–6.84%) of measles incidence from 1990 to 2019. More than 80% of incidence cases were attributed to children under 5 and the proportion was highest in low SDI region. Countries and territories with low ASRs are mostly clustered in North America, Southern Latin America, and Western Europe, whereas those with high ASRs are mainly clustered in Africa, East Asia, and South Asia. Lower SDI was associated with higher ASR and lower vaccine coverage rate. The more the SDI value was further away from 0.6, the smaller the absolute value did EAPC have. Child wasting accounted for the most measles-related death cases, followed by child underweight, child stunting, and vitamin A deficiency.

Conclusions

Measles eradication is feasible, but urgently demands political commitment, financial support, and public engagement. In the context of COVID-19 pandemic and the global resurgence of measles, surveillance systems and routine immunization programs should be improved, while vaccine hesitancy needs to be addressed.

Evidence to Underpin Vitamin A Requirements and Upper Limits in Children Aged 0 to 48 Months: A Scoping Review

Vitamin A deficiency is a major health risk for infants and children in low- and middle-income countries. This scoping review identified, quantified, and mapped research for use in updating nutrient requirements and upper limits for vitamin A in children aged 0 to 48 months, using health-based or modelling-based approaches. Structured searches were run on Medline, EMBASE, and Cochrane Central, from inception to 19 March 2021. Titles and abstracts were assessed independently in duplicate, as were 20% of full texts. Included studies were tabulated by question, methodology and date, with the most relevant data extracted and assessed for risk of bias. We found that the most recent health-based systematic reviews and trials assessed the effects of supplementation, though some addressed the effects of staple food fortification, complementary foods, biofortified maize or cassava, and fortified drinks, on health outcomes. Recent isotopic tracer studies and modelling approaches may help quantify the effects of bio-fortification, fortification, and food-based approaches for increasing vitamin A depots. A systematic review and several trials identified adverse events associated with higher vitamin A intakes, which should be useful for setting upper limits. We have generated and provide a database of relevant research. Full systematic reviews, based on this scoping review, are needed to answer specific questions to set vitamin A requirements and upper limits.

Residential Food Environment, Household Wealth and Maternal Education Association to Preschoolers' Consumption of Plant-Based Vitamin A-Rich Foods: The EAT Addis Survey in Addis Ababa

Vitamin A deficiency is common among preschoolers in low-income settings and a serious public health concern due to its association to increased morbidity and mortality. The limited consumption of vitamin A-rich food is contributing to the problem. Many factors may influence children's diet, including residential food environment, household wealth, and maternal education. However, very few studies in low-income settings have examined the relationship of these factors to children's diet together. This study aimed to assess the importance of residential food availability of three plant-based groups of vitamin A-rich foods, household wealth, and maternal education for preschoolers' consumption of plant-based vitamin A-rich foods in Addis Ababa. A multistage sampling procedure was used to enroll 5467 households with under-five children and 233 residential food environments with 2568 vendors. Data were analyzed using a multilevel binary logistic regression model. Overall, 36% (95% CI: 34.26, 36.95) of the study children reportedly consumed at least one plant-based vitamin A-rich food group in the 24-h dietary recall period. The odds of consuming any plant-based vitamin A-rich food were significantly higher among children whose mothers had a higher education level (AOR: 2.55; 95% CI: 2.01, 3.25), those living in the highest wealth quintile households (AOR: 2.37; 95% CI: 1.92, 2.93), and in residentials where vitamin A-rich fruits were available (AOR: 1.20; 95% CI: 1.02, 1.41). Further research in residential food environment is necessary to understand the purchasing habits, affordability, and desirability of plant-based vitamin A-rich foods to widen strategic options to improve its consumption among preschoolers in low-income and low-education communities.

Estimated effect of vitamin A supplementation on anaemia and anthropometric failure of Indian children

BACKGROUND

India has an unacceptably high burden of vitamin A deficiency (VAD) among children aged 6-59 months. To mitigate VAD and its adverse effects on child health, the Indian government runs a nationwide vitamin A supplementation (VAS) programme. However, the effect of VAS in reducing child morbidity and mortality remains inconclusive and has been debated globally. In this paper, we estimate the effect of VAS on two indicators of child nutrition-anaemia (categorized into any anaemia, and mild/moderate anaemia) and anthropometric failure (categorized into stunting, wasting, and underweight) among children aged 6-59 months.

METHODS

Using the nationally representative 2015-2016 National Family Health Survey data set from India, we set up a quasi-experimental study design and estimated household and mother fixed-effects of VAS on select types of child anaemia and anthropometric failure.

RESULTS

Findings from both the household fixed-effects and mother fixed-effects analysis showed that VAS does not influence any types of childhood anaemia and anthropometric failure in India. We discussed the findings considering existing literature and possible limitations of the study.

CONCLUSIONS

The infirm effect of Vitamin A on anaemia and anthropometric failure is probably indicative of targeted VAS intervention, as opposed to a universal VAS programme.

IMPACT

Effects of vitamin A supplementation (VAS) in treating child morbidity and mortality remain inconclusive, which calls for further rigorous studies. This study set up a quasi-experimental research design and estimated the null effect of VAS on child anaemia and childhood anthropometric failure. While the cautious interpretation of findings is urged, this study reliably supports targeted intervention of VAS, instead of the universal VAS programme. The use of nationally representative data and robust research protocol are the primary strengths of this study.

Consumption of Vitamin-A-Rich Foods and Vitamin A Supplementation for Children under Two Years Old in 51 Low- and Middle-Income Countries

Vitamin A supplementation for children 6-59 months old is an important intervention that boosts immune function, especially where children do not consume enough vitamin-A-rich foods. However, the low coverage of vitamin A supplementation is a persistent problem in low- and middle-income countries. We first estimated the percentage of children 6-23 months old receiving the minimum dietary diversity, vitamin-A-rich foods, and vitamin A supplementation, and second, the difference in the percentage receiving vitamin A supplementation between children 6-23 months old and children 24-59 months old using nationally representative cross-sectional household surveys, namely, the Demographic and Health Surveys, conducted from 2010 to 2019 in 51 low- and middle-income countries. Overall, 22% (95% CI: 22, 23) of children received the minimum dietary diversity, 55% (95% CI: 54, 55) received vitamin-A-rich foods, 59% (95% CI: 58, 59) received vitamin A supplementation, and 78% (95% CI: 78, 79) received either vitamin-A-rich foods or supplementation. A wide variation across countries was observed; for example, the percentage of children that received either vitamin-A-rich foods or supplementation ranged from 53% (95% CI: 49, 57) in Guinea to 96% (95% CI: 95, 97) in Burundi. The coverage of vitamin A supplementation should be improved, especially for children 6-23 months old, in most countries, particularly where the consumption of vitamin-A-rich foods is inadequate.

"Are We Feeding Them Enough?" Micronutrient Deficiency in Children Aged Six Months to Fourteen Years in India

In this study, we conducted a systematic literature review of the various micronutrient deficiencies (MNDs) that affect children in India and an examination of whether there is a geographic basis for MNDs.

MNDs are a common problem in the developing world, in particular, among children in South Asia. According to the United Nations Children’s Fund, millions of children suffer from stunted growth, cognitive delays, weakened immunity, and diseases because of MNDs. These physical ailments have several economic, social, and public health implications, and they can severely hamper a country’s growth. This study aims to clarify existing data on this topic and highlight the disparities between children living in urban and rural areas in India.

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed to conduct this systematic literature review of a total of five studies. Study quality was assessed using appropriate checklists, and the studies strengthened the hypothesis that MNDs are common among children in India. Because the selected studies were heterogeneous, no statistical conclusions are drawn here. However, a central premise is that MNDs in children are prevalent in India and are related to poverty. No link between geographic location and MNDs is established; rather, recommendations are made for further research on the topic.

Challenges for Estimating the Global Prevalence of Micronutrient Deficiencies and Related Disease Burden: A Case Study of the Global Burden of Disease Study

Information on the prevalence of micronutrient deficiencies is needed to determine related disease burden; underpin evidence-based advocacy; and design, deliver, and monitor safe, effective interventions. Assessing the global prevalence of deficiency requires a valid micronutrient status biomarker with an appropriate cutoff to define deficiency and relevant data from representative surveys across multiple locations and years. The Global Burden of Disease Study includes prevalence estimates for iodine, iron, zinc, and vitamin A deficiencies, for which recommended biomarkers and appropriate deficiency cutoffs exist. Because representative survey data are lacking, only retinol concentration is used to model vitamin A deficiency, and proxy indicators are used for the other micronutrients (goiter for iodine, hemoglobin for iron, and dietary food adequacy for zinc). Because of data limitations, complex statistical modeling is required to produce current estimates, relying on assumptions and proxies that likely understate the extent of micronutrient deficiencies and the consequent global health burden.

Nutrient modulation of viral infection-implications for COVID-19

The coronavirus disease 2019 (COVID-19) pandemic has put focus on the importance of a healthy immune system for recovery from infection and effective response to vaccination. Several nutrients have been under attention because their nutritional statuses showed associations with the incidence or severity of COVID-19 or because they affect several aspects of immune function. Nutritional status, immune function, and viral infection are closely interrelated. Undernutrition impairs immune function, which can lead to increased susceptibility to viral infection, while viral infection itself can result in changes in nutritional status. Here, we review the roles of vitamins A, C, D, and E, and zinc, iron, and selenium in immune function and viral infection and their relevance to COVID-19.

Excessive Vitamin A Supplementation Increased the Incidence of Acute Respiratory Tract Infections: A Systematic Review and Meta-Analysis

(1) Background: vitamin A deficiency (VAD) is highly prevalent in children living in poor conditions. It has been suggested that vitamin A supplementation (VAS) may reduce the risk of acute respiratory tract infections (ARTI). Our study provides updates on the effects of oral VAS (alone) in children on ARTI and further explores the effect on interesting subgroups. (2) Methods: eight databases were systematically searched from their inception until 5 July 2021. The assessments of inclusion criteria, extraction of data, and data synthesis were carried out independently by two reviewers. (3) Results: a total of 26 randomized trials involving 50,944 participants fulfilled the inclusion criteria. There was no significant association of VAS with the incidence of ARTI compared with the placebo (RR 1.03, 95% CI 0.92 to 1.15). Subgroup analyses showed that VAS higher than WHO recommendations increased the incidence of ARTI by 13% (RR 1.13, 95% CI 1.07 to 1.20), and in the high-dose intervention group, the incidence rate among well-nourished children rose by 66% (RR 1.66, 95% CI 1.30 to 2.11). (4) Conclusions: no more beneficial effects were seen with VAS in children in the prevention or recovery of acute respiratory infections. Excessive VAS may increase the incidence of ARTI in children with normal nutritional status.

Micronutrient supplements can promote disruptive protozoan and fungal communities in the developing infant gut

Supplementation with micronutrients, including vitamins, iron and zinc, is a key strategy to alleviate child malnutrition. However, association of gastrointestinal disorders with iron has led to ongoing debate over their administration. To better understand their impact on gut microbiota, we analyse the bacterial, protozoal, fungal and helminth communities of stool samples collected from a subset of 80 children at 12 and 24 months of age, previously enrolled into a large cluster randomized controlled trial of micronutrient supplementation in Pakistan (ClinicalTrials.gov identifier NCT00705445). We show that while bacterial diversity is reduced in supplemented children, vitamins and iron (as well as residence in a rural setting) may promote colonization with distinct protozoa and mucormycetes, whereas the addition of zinc appears to ameliorate this effect. We suggest that the risks and benefits of micronutrient interventions may depend on eukaryotic communities, potentially exacerbated by exposure to a rural setting. Larger studies are needed to evaluate the clinical significance of these findings and their impact on health outcomes.

Genetic determinants of micronutrient traits in graminaceous crops to combat hidden hunger

KEY MESSAGE

Improving the nutritional content of graminaceous crops is imperative to ensure nutritional security, wherein omics approaches play pivotal roles in dissecting this complex trait and contributing to trait improvement. Micronutrients regulate the metabolic processes to ensure the normal functioning of the biological system in all living organisms. Micronutrient deficiency, thereby, can be detrimental that can result in serious health issues. Grains of graminaceous crops serve as an important source of micronutrients to the human population; however, the rise in hidden hunger and malnutrition indicates an insufficiency in meeting the nutritional requirements. Improving the elemental composition and nutritional value of the graminaceous crops using conventional and biotechnological approaches is imperative to address this issue. Identifying the genetic determinants underlying the micronutrient biosynthesis and accumulation is the first step toward achieving this goal. Genetic and genomic dissection of this complex trait has been accomplished in major cereals, and several genes, alleles, and QTLs underlying grain micronutrient content were identified and characterized. However, no comprehensive study has been reported on minor cereals such as small millets, which are rich in micronutrients and other bioactive compounds. A comparative narrative on the reports available in major and minor Graminaceae species will illustrate the knowledge gained from studying the micronutrient traits in major cereals and provides a roadmap for dissecting this trait in other minor species, including millets. In this context, this review explains the progress made in studying micronutrient traits in major cereals and millets using omics approaches. Moreover, it provides insights into deploying integrated omics approaches and strategies for genetic improvement in micronutrient traits in graminaceous crops.

Vitamin A Levels Among Pre-School Children of Central and Western China

Objective: To investigate vitamin A deficiency of pre-school children in central and western China for developing strategies to prevent and control vitamin A deficiency (VAD) among children. Design: From November 2018 to September 2019, a total of 2,194 healthy children aged 2-6 years were enrolled. Serum retinol levels in the children were detected by liquid-phase tandem mass spectrometry. In addition, social demographic and dietary questionnaires were collected through interviews with children's caregivers. Setting: The participants were enrolled in 12 cities or their subordinate jurisdictions in the central and western regions of China. Participants: Two thousand one hundred and ninety four healthy children aged 2-6 years old. Results: Overall, 35.51% (779/2,194) of the children were found to be vitamin A insufficient (VAI, serum retinol < 1.05 μmol/L). Elder children had a higher risk to suffer from VAI, with proportions of 25.00% (87/348), 28.92% (142/491), 38.38% (256/667), and 42.73% (294/688) among children aged 2, 3, 4, and 5 years, respectively. Vitamin A levels were also positively correlated with per capita income (AOR = 1.18) and regional economic level (0.71), and the frequency of milk intake (0.91). Conclusions: The incidence of VAI was higher among children aged 2-6 years, and the incidence of VAI increases with age. VA levels were positively correlated with levels of economic development in the family and region. So prevention strategies for VAD need to focus on pre-school children, especially dairy intake and developing regions.

Increasing the availability and utilization of reliable data on population micronutrient (MN) status globally: the MN Data Generation Initiative

Micronutrient (MN) deficiencies can produce a broad array of adverse health and functional outcomes. Young, preschool children and women of reproductive age in low- and middle-income countries are most affected by these deficiencies, but the true magnitude of the problems and their related disease burdens remain uncertain because of the dearth of reliable biomarker information on population MN status. The reasons for this lack of information include a limited understanding by policy makers of the importance of MNs for human health and the usefulness of information on MN status for program planning and management; insufficient professional capacity to advocate for this information and design and implement related MN status surveys; high costs and logistical constraints involved in specimen collection, transport, storage, and laboratory analyses; poor access to adequately equipped and staffed laboratories to complete the analyses reliably; and inadequate capacity to interpret and apply this information for public health program design and evaluation. This report describes the current situation with regard to data availability, the reasons for the lack of relevant information, and the steps needed to correct this situation, including implementation of a multi-component MN Data Generation Initiative to advocate for critical data collection and provide related technical assistance, laboratory services, professional training, and financial support.

Rural-urban determinants of vitamin a deficiency among under 5 children in Bangladesh: Evidence from National Survey 2017-18

Background

Vitamin A supplementation reduces child morbidity, mortality, and blindness of people, especially in developing countries like Bangladesh. This study explores significant determinants of vitamin A deficiency among preschool children in rural and urban areas of Bangladesh.

Methods

The data set was extracted from a nationally representative survey based on a cross-sectional study, the BDHS-2017-18. The base survey was conducted using a two-stage stratified sample of households. A sample of 8364 (urban 2911, rural 5453) children under-5 years old was analyzed using bivariate and multivariate statistical techniques.

Results

Results have demonstrated that 73.9 and 73.2% of children have had a vitamin A supplementation from urban and rural areas, respectively. Logistic regression analysis showed that parents’ education plays a vital role in consuming vitamin A supplements in urban and rural areas. Children whose mothers have secondary (OR: 1.17, CI: 0.76–1.81) and higher (OR: 1.21, CI: 0.72–2.04) education were more likely to consume vitamin A supplementation than children whose mothers were illiterate in urban areas. However, in rural areas, children whose mothers have secondary education were about 24% and higher education with 60% more likely to consume vitamin A supplementation than children whose mothers were illiterate. Child’s age, regional variation and wealth index also contributing factors for vitamin A deficiency in Bangladesh.

Conclusions

These findings indicated that the consumption of vitamin A does not cover the target of sustainable development goals. Thus special national and community level efforts are required to ensure the coverage of the national vitamin A program is increased adequately to the most vulnerable groups of children in Bangladesh.

The Role of Nutrition in COVID-19 Susceptibility and Severity of Disease: A Systematic Review

BACKGROUND

Many nutrients have powerful immunomodulatory actions with the potential to alter susceptibility to coronavirus disease 2019 (COVID-19) infection, progression to symptoms, likelihood of severe disease, and survival.

OBJECTIVE

The aim was to review the latest evidence on how malnutrition across all its forms (under- and overnutrition and micronutrient status) may influence both susceptibility to, and progression of, COVID-19.

METHODS

We synthesized information on 13 nutrition-related components and their potential interactions with COVID-19: overweight, obesity, and diabetes; protein-energy malnutrition; anemia; vitamins A, C, D, and E; PUFAs; iron; selenium; zinc; antioxidants; and nutritional support. For each section we provide: 1) a landscape review of pertinent material; 2) a systematic search of the literature in PubMed and EMBASE databases, including a wide range of preprint servers; and 3) a screen of 6 clinical trial registries. All original research was considered, without restriction to study design, and included if it covered: 1) severe acute respiratory syndrome coronavirus (CoV) 2 (SARS-CoV-2), Middle East respiratory syndrome CoV (MERS-CoV), or SARS-CoV viruses and 2) disease susceptibility or 3) disease progression, and 4) the nutritional component of interest. Searches took place between 16 May and 11 August 2020.

RESULTS

Across the 13 searches, 2732 articles from PubMed and EMBASE, 4164 articles from the preprint servers, and 433 trials were returned. In the final narrative synthesis, we include 22 published articles, 38 preprint articles, and 79 trials.

CONCLUSIONS

Currently there is limited evidence that high-dose supplements of micronutrients will either prevent severe disease or speed up recovery. However, results of clinical trials are eagerly awaited. Given the known impacts of all forms of malnutrition on the immune system, public health strategies to reduce micronutrient deficiencies and undernutrition remain of critical importance. Furthermore, there is strong evidence that prevention of obesity and type 2 diabetes will reduce the risk of serious COVID-19 outcomes. This review is registered at PROSPERO as CRD42020186194.

Micronutrient Powders for Infants and Young Children

Providing standalone micronutrient products for household use is not an easy strategy, but under the right conditions, it can work. To be effective, micronutrient powder programs require robust commodity logistics and support of uptake and adherence.

Spatial distribution and geographical heterogeneity factors associated with poor consumption of foods rich in vitamin A among children age 6-23 months in Ethiopia: Geographical weighted regression analysis

INTRODUCTION

Vitamin A deficiency is a major public health problem in poor societies. Dietary consumption of foods rich in vitamin A was low in Ethiopia. This study aimed to assess the spatial distribution and spatial determinants of dietary consumption of foods rich in vitamin A among children aged 6-23 months in Ethiopia.

METHODS

Ethiopian 2016 demographic and health survey dataset using a total of 3055 children were used to conduct this study. The data were cleaned and weighed by STATA version 14.1 software and Microsoft Excel. Children who consumed foods rich in vitamin A (Egg, Meat, Vegetables, Green leafy vegetables, Fruits, Organ meat, and Fish) at least one food item in the last 24 hours were declared as good consumption. The Bernoulli model was fitted using Kuldorff's SaTScan version 9.6 software. ArcGIS version 10.7 software was used to visualize spatial distributions for poor consumption of foods rich in vitamin A. Geographical weighted regression analysis was employed using MGWR version 2.0 software. A P-value of less than 0.05 was used to declare statistically significant predictors spatially.

RESULTS

Overall, 62% (95% CI: 60.56-64.00) of children aged 6-23 months had poor consumption of foods rich in vitamin A in Ethiopia. Poor consumption of foods rich in vitamin A highly clustered in Afar, eastern Tigray, southeast Amhara, and the eastern Somali region of Ethiopia. Spatial scan statistics identified 142 primary spatial clusters located in Afar, the eastern part of Tigray, most of Amhara and some part of the Oromia Regional State of Ethiopia. Children living in the primary cluster were 46% more likely vulnerable to poor consumption of foods rich in vitamin A than those living outside the window (RR = 1.46, LLR = 83.78, P < 0.001). Poor wealth status of the household, rural residence and living tropical area of Ethiopia were spatially significant predictors.

CONCLUSION

Overall, the consumption of foods rich in vitamin A was low and spatially non-random in Ethiopia. Poor wealth status of the household, rural residence and living tropical area were spatially significant predictors for the consumption of foods rich in vitamin A in Ethiopia. Policymakers and health planners should intervene in nutrition intervention at the identified hot spot areas to reduce the poor consumption of foods rich in vitamin A among children aged 6-23 months.

Metabolism of Neonatal Vitamin A Supplementation: A Systematic Review

A systematic review was conducted to summarize the absorption, transport, storage, and metabolism of oral neonatal vitamin A supplementation (NVAS). This review focused specifically on the neonatal period (first 28 d of life for humans) to inform guidance by WHO on recommendations related to NVAS. A systematic search of international and regional databases was conducted. Inclusion criteria were human or animal studies that gave oral vitamin A as a single or limited number of doses to apparently healthy neonates. Studies evaluating fortification or food-based approaches, dosing with retinoic acid, or studies of neonatal models of disease were excluded. The search retrieved 8847 unique records. After screening by title and abstract, 88 were screened using the full text, and 35 records met inclusion criteria: 13 human and 22 animal studies. Studies indicate that high-dose NVAS is absorbed well by neonates, typically mirroring fat absorption. Doses were primarily stored in the liver and transiently increased in the lung, kidney, spleen, adrenal glands, brain, skin, and adipose tissue, generally with a dose-response. Serum retinol and retinyl esters also transiently increased following NVAS. Although minimal acute adverse effects are noted, there is a lack of data supporting NVAS for improving organ maturation or sustained delivery to target organs. Research gaps include the physiological effects of the short-term increase of vitamin A concentrations in extrahepatic tissues, or whether there are unknown adverse effects over time.

The impact on key indicators of reproductive and child health after changes in program modalities in Sierra Leone, 2019

BACKGROUND AND AIMS

In 2018, the transition to routine vitamin A supplementation (VAS) was integrated with caregivers' preparation of nutritious complementary food from local produce and confidential counseling and provision of modern contraceptives. In 2019, funding for complementary food ceased and Community Health Workers (CHWs) were trained to track defaulters, while national efforts to improve Health Management Information Systems, supply chains and reduce teenage pregnancies were intensified. We report on key indicators after these changes and in comparison, to those previously published.

METHODS

The same Lot Quality Assurance Sampling methodology was used in both assessments: 19 villages were randomly selected in each of five lots in each of three districts then caregivers of children 6-59 months age randomly selected and interviewed.

RESULTS

Coverage of VAS, Albendazole, and Pentavalent 3 before and after these changes was over 80%, 75%, and 80% respectively, equitable by sex, age, caregiver's religion, and educational status. Comparison with 2018 found more lots failed to reach 80% VAS by verbal affirmation (10 vs 2), and coverage in one district (Bo) had dropped (77.5% vs 92.3%). Fewer caregivers were aware that VAS should be taken every 6 months (27% vs 50%), that complementary feeding should start at 6 months (63% vs 77%) or were providing minimal dietary diversity (27% vs 45%). There was an increase in caregivers using modern contraception (45% vs 35%), obtaining information about contraception from a friend (14% vs 9%), while fewer thought country rope/herbs (traditional contraceptives) were "effective" (11% vs 21%) and stockouts of contraceptives at health facilities had dropped (24% vs 55%). Stipends for CHWs cost approximately $750 K vs complementary food: $112 K.

CONCLUSION

Overall coverage for VAS, Albendazole, and Pentavalent remained effective but VAS had dropped significantly in one district. Complementary feeding practices had declined. Awareness, uptake, and contraceptives supply chains had improved.

Nutritional approach for increasing public health during pandemic of COVID-19: A comprehensive review of antiviral nutrients and nutraceuticals

Background: The novel coronavirus (COVID-19) is considered as the most life-threatening pandemic disease during the last decade. The individual nutritional status, though usually ignored in the management of COVID-19, plays a critical role in the immune function and pathogenesis of infection. Accordingly, the present review article aimed to report the effects of nutrients and nutraceuticals on respiratory viral infections including COVID-19, with a focus on their mechanisms of action. Methods: Studies were identified via systematic searches of the databases including PubMed/ MEDLINE, ScienceDirect, Scopus, and Google Scholar from 2000 until April 2020, using keywords. All relevant clinical and experimental studies published in English were included. Results: Protein-energy malnutrition (PEM) is common in severe respiratory infections and should be considered in the management of COVID-19 patients. On the other hand, obesity can be accompanied by decreasing the host immunity. Therefore, increasing physical activity at home and a slight caloric restriction with adequate intake of micronutrients and nutraceuticals are simple aids to boost host immunity and decrease the clinical manifestations of COVID-19. Conclusion: The most important nutrients which can be considered for COVID-19 management are vitamin D, vitamin C, vitamin A, folate, zinc, and probiotics. Their adequacy should be provided through dietary intake or appropriate supplementation. Moreover, adequate intake of some other dietary agents including vitamin E, magnesium, selenium, alpha linolenic acid and phytochemicals are required to maintain the host immunity.

Vitamin A status, inflammation adjustment, and immunologic response in the context of acute febrile illness: A pilot cohort study among pediatric patients

BACKGROUND

Vitamin A is necessary for an adequate immune response to infections. Infection also alters vitamin A biomarkers, which interferes with assessment of vitamin A deficiency and thus impairs clinical management. Here we apply multiple strategies to adjust vitamin A biomarkers for inflammation during acute infection and evaluate associations between adjusted vitamin A status and immunologic response markers.

METHODS

We measured biomarkers in pediatric patients presenting with acute febrile illness in Guayaquil, Ecuador at paired acute and convalescent visits. Four adjustment strategies were applied to retinol-binding protein (RBP) concentrations: Thurnham correction factor (TCF), BRINDA regression correction (BRC), CRP-only adjustment factor (CRP), and proof-of-concept for a proposed interleukin 6 regression model (IL-6 RM). Adjusted RBP concentrations were compared between visits using the paired Wilcoxon signed-rank test. Multivariate regression analysis was used to assess associations between adjusted vitamin A status and immunologic response markers.

RESULTS

A sample of 57 participants completed the acute visit 1, and 18 of these individuals completed the convalescent visit 2. The IL-6 RM was the only strategy resulting in adjusted RBP concentrations that were not significantly different between paired visits (p = 0.20). Following RBP adjustment, 0.0% of participants were classified as vitamin A deficient (RBP ≤ 0.70 μmol/L) and 14.0% were classified as vitamin A insufficient (RBP ≤ 1.05 μmol/L). Adjusted vitamin A insufficiency was associated with an increase in macrophage inflammatory protein 1-alpha (MIP-1α, p = 0.03) and a pro-inflammatory immune response profile (p = 0.03) during the acute visit.

CONCLUSIONS

We introduce a strategy for adjusting vitamin A in the context of clinical illness based on IL-6 concentrations that will need to be validated in larger studies. Assessment of vitamin A during infection allows for further understanding of how vitamin A status modulates immunopathology and enables targeted strategies for vitamin A supplementation in the context of infection among children in settings with high burdens of undernutrition and infectious diseases.

Immunomodulatory diet in pediatric age

In the last few decades, the importance of a functioning immune system and health status has become more evident. Multiple factors are able to influence the development of chronic diseases and diet is one of the most important environmental factors. Evidence demonstrates that dietary patterns high in fat and low in fiber are associated with the development of non-communicable diseases. Moreover, optimal nutritional status can modulate immune maturation and response to inflammation. During inflammatory conditions, nutritional deficiencies may occur, establishing a vicious circle, consequently a balanced nutritional status is essential to prevent and counteract infections. Dietary diversity can prevent allergic diseases and nutrients such as DHA, arginine, vitamins and trace elements have an impact on physical barriers (such as gut mucosal barrier and skin), on the immune system response and on microbiome modulation. Protein deficiencies can compromise innate and adaptive immune functions; arginine availability can affect the immune response in injured states and other disease processes; EPA and DHA can modulate both innate and adaptive immunity; prebiotics have a beneficial effect on the functioning of the immune system. Zinc, copper, selenium and iron are involved in the correct development and function of the immune system. Vitamins D, E, A, B and C have a role on immune system through different mechanisms of action. Since a complex interplay exists between diet, microbiome and epigenetic factors which determine nutrient-induced changes on the immune function, the effect of each single nutrient may be difficult to study. Well-designed intervention studies, investigating the effects of whole dietary pattern, should be performed to clarify impact of foods on the immune function and disease risk.

Successful delivery of nutrition programs and the sustainable development goals

Malnutrition affects millions of people globally, especially women, children, and other vulnerable populations. Sustainable Development Goals (SDGs) were set in 2015 to end poverty, protect the planet, and improve the lives and prospects of everyone by 2030. To achieve the SDG goals effective nutrition interventions and programs need to be efficiently delivered to those most in need. Nutrition directly affects 2 SDGs (2 and 3) and indirectly influences five others. In addition, almost all SDGs influence nutrition and thus attaining the SDG goals is also a pre-requisite to achieving the Global Nutrition targets set in 2012. Evidence-based nutrition interventions, for which there is strong evidence of their biological impact, have the potential to directly influence SDGs 2 and 3 if successfully delivered at scale in high-burden countries. Nevertheless, delivery of nutrition programs is a complex process, where policy, government commitment, adequate budget allocation, supplies and delivery systems, training of service providers, informed beneficiaries and program monitoring and evaluation all need to be in place and aligned with each other. Although in the past decade there has been progress in the SDGs that nutrition directly affects, many goals are still off-track, likely due to several pending gaps at policy-level, program-level, and intervention-level. To accelerate the progress toward reaching the SDG goals that are directly influenced by nutrition, countries need to be supported to successfully and sustainably deliver proven interventions and to scale-up and deliver new interventions in new and innovative ways, and the evidence base should be built in promising areas especially integrating (rather than prioritizing over each other) nutrition-specific and sensitive approaches.

Effects of neonatal nutrition interventions on neonatal mortality and child health and development outcomes: A systematic review

Background

The last two decades have seen a significant decrease in mortality for children <5 years of age in low and middle-income countries (LMICs); however, neonatal (age, 0-28 days) mortality has not decreased at the same rate. We assessed three neonatal nutritional interventions that have the potential of reducing morbidity and mortality during infancy in LMICs.

Objectives

To determine the efficacy and effectiveness of synthetic vitamin A, dextrose oral gel, and probiotic supplementation during the neonatal period.

Search Methods

We conducted electronic searches for relevant studies on the following databases: PubMed, CINAHL, LILACS, SCOPUS, and CENTRAL, Cochrane Central Register for Controlled Trials, up to November 27, 2019.

Selection Criteria

We aimed to include randomized and quasi-experimental studies. The target population was neonates in LMICs. The interventions included synthetic vitamin A supplementation, oral dextrose gel supplementation, and probiotic supplementation during the neonatal period. We included studies from the community and hospital settings irrespective of the gestational age or birth weight of the neonate.

Data Collection and Analysis

Two authors screened the titles and extracted the data from selected studies. The risk of bias (ROB) in the included studies was assessed according to the Cochrane Handbook of Systematic Reviews. The primary outcome was all-cause mortality. The secondary outcomes were neonatal sepsis, necrotizing enterocolitis (NEC), prevention and treatment of neonatal hypoglycaemia, adverse events, and neurodevelopmental outcomes. Data were meta-analyzed by random effect models to obtain relative risk (RR) and 95% confidence interval (CI) for dichotomous outcomes and mean difference with 95% CI for continuous outcomes. The overall rating of evidence was determined by the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach.

Main Results

Sixteen randomized studies (total participants 169,366) assessed the effect of vitamin A supplementation during the neonatal period. All studies were conducted in low- and middle-income (LMIC) countries. Thirteen studies were conducted in the community setting and three studies were conducted in the hospital setting, specifically in neonatal intensive care units. Studies were conducted in 10 different countries including India (four studies), Guinea-Bissau (three studies), Bangladesh (two studies), and one study each in China, Ghana, Indonesia, Nepal, Pakistan, Tanzania, and Zimbabwe. The overall ROB was low in most of the included studies for neonatal vitamin A supplementation. The pooled results from the community based randomized studies showed that there was no significant difference in all-cause mortality in the vitamin A (intervention) group compared to controls at 1 month (RR, 0.99; 95% CI, 0.90-1.08; six studies with 126,548 participants, statistical heterogeneity I 2 0%, funnel plot symmetrical, grade rating high), 6 months (RR, 0.98; 95% CI, 0.89-1.07; 12 studies with 154,940 participants, statistical heterogeneity I 2 43%, funnel plot symmetrical, GRADE quality high) and 12 months of age (RR, 1.04; 95% CI, 0.94-1.14; eight studies with 118,376 participants, statistical heterogeneity I 2 46%, funnel plot symmetrical, GRADE quality high). Neonatal vitamin A supplementation increased the incidence of bulging fontanelle by 53% compared to control (RR, 1.53; 95% CI, 1.12-2.09; six studies with 100,256 participants, statistical heterogeneity I 2 65%, funnel plot symmetrical, GRADE quality high). We did not identify any experimental study that addressed the use of dextrose gel for the prevention and/or treatment of neonatal hypoglycaemia in LMIC. Thirty-three studies assessed the effect of probiotic supplementation during the neonatal period (total participants 11,595; probiotics: 5854 and controls: 5741). All of the included studies were conducted in LMIC and were randomized. Most of the studies were done in the hospital setting and included participants who were preterm (born < 37 weeks gestation) and/or low birth weight (<2500 g birth weight). Studies were conducted in 13 different countries with 10 studies conducted in India, six studies in Turkey, three studies each in China and Iran, two each in Mexico and South Africa, and one each in Bangladesh, Brazil, Colombia, Indonesia, Nepal, Pakistan, and Thailand. Three studies were at high ROB due to lack of appropriate randomization sequence or allocation concealment. Combined data from 25 studies showed that probiotic supplementation reduced all-cause mortality by 20% compared to controls (RR, 0.80; 95% CI, 0.66-0.96; total number of participants 10,998, number needed to treat 100, statistical heterogeneity I 2 0%, funnel plot symmetrical, GRADE quality high). Twenty-nine studies reported the effect of probiotics on the incidence of NEC, and the combined results showed a relative reduction of 54% in the intervention group compared to controls (RR, 0.46; 95% CI, 0.35-0.59; total number of participants 5574, number needed to treat 17, statistical heterogeneity I 2 24%, funnel plot symmetrical, GRADE quality high). Twenty-one studies assessed the effect of probiotic supplementation during the neonatal period on neonatal sepsis, and the combined results showed a relative reduction of 22% in the intervention group compared to controls (RR, 0.78; 95% CI, 0.70-0.86; total number of participants 9105, number needed to treat 14, statistical heterogeneity I 2 23%, funnel plot symmetrical, GRADE quality high).

Authors' Conclusions

Vitamin A supplementation during the neonatal period does not reduce all-cause neonatal or infant mortality in LMICs in the community setting. However, neonatal vitamin A supplementation increases the risk of Bulging Fontanelle. No experimental or quasi-experimental studies were available from LMICs to assess the effect of dextrose gel supplementation for the prevention or treatment of neonatal hypoglycaemia. Probiotic supplementation during the neonatal period seems to reduce all-cause mortality, NEC, and sepsis in babies born with low birth weight and/or preterm in the hospital setting. There was clinical heterogeneity in the use of probiotics, and we could not recommend any single strain of probiotics for wider use based on these results. There was a lack of studies on probiotic supplementation in the community setting. More research is needed to assess the effect of probiotics administered to neonates in-home/community setting in LMICs.

Nutraceuticals in the Prevention of Viral Infections, including COVID-19, among the Pediatric Population: A Review of the Literature

In recent years, there has been a growth in scientific interest in nutraceuticals, which are those nutrients in foods that have beneficial effects on health. Nutraceuticals can be extracted, used for food supplements, or added to foods. There has long been interest in the antiviral properties of nutraceuticals, which are especially topical in the context of the ongoing COVID-19 pandemic. Therefore, the purpose of this review is to evaluate the main nutraceuticals to which antiviral roles have been attributed (either by direct action on viruses or by modulating the immune system), with a focus on the pediatric population. Furthermore, the possible applications of these substances against SARS-CoV-2 will be considered.

Adequate vitamin A liver stores estimated by the modified relative dose response test are positively associated with breastfeeding but not vitamin A supplementation in Senegalese urban children 9-23 months old: A comparative cross-sectional study

Vitamin A supplementation (VAS) in 6-59-month-old children is recommended but its sustainability is currently questioned. In Senegal, available data suggest that VAS should be maintained, but geographic and age-related specificities need to be addressed to better implement and target VAS programming. The objective of this comparative cross-sectional study, conducted in urban settings of Dakar, was to compare the vitamin A liver stores (VALS) assessed using the modified-relative dose response (MRDR) test between supplemented and non-supplemented 9-23 month-old children and to study their relationship with VAS. The supplemented group (n = 119) received VAS (either 100 000 UI or 200 000 UI) 2 to 6 months before evaluation while the non-supplemented group (n = 110) had not received VAS during the past 6 months. In addition to MRDR, serum retinol concentrations (SR), and biomarkers of subclinical inflammation were measured. Children's health-related data and feeding patterns were collected. Mean MRDR values (VAS: 0.030 ± 0.017, non-VAS: 0.028 ± 0.016, P = 0.389) and inflammation-adjusted SR (VAS: 1.34 ± 0.37, non-VAS: 1.3 ± 0.35, P = 0.515) of children were adequate. Low prevalence of VALS (VAS: 5.2%, non-VAS: 5.4%) and inflammation-adjusted VAD (VAS: 2.6%, non-VAS: 0.9%) were detected despite high presence of infections and inflammation. Children were mostly still being breastfed (VAS: 85.7%, non-VAS: 77.3%) and complementary feeding indicators were similar in both groups. Only breastfeeding was associated with VALS and was found to reduce by 76% at least, the odds of VAD (adjusted OR = 0.24, 95% CI: 0.07-0.8, P = 0.020). Based on MRDR values, VAS was not related to improved VALS and SR as well as VAD reduction among these children with adequate VALS. Reinforcing breastfeeding advocacy and morbidity prevention/control are essential in this setting. Scaling-back VAS in this subpopulation should be examined regarding the risk of hypervitaminosis A after an evaluation of dietary vitamin A intake sufficiency and a more quantitative assessment of VALS.

Effect of Enteral Vitamin A on Fecal Calprotectin in Extremely Preterm Infants: A Nested Prospective Observational Study

BACKGROUND

Vitamin A has anti-inflammatory and immune-modulating properties. We aimed to assess whether enteral water-soluble vitamin A supplementation in extremely preterm infants decreases fecal calprotectin, a marker of intestinal inflammation.

METHODS

This was a prospective observational study nested in a randomized, double-blind, placebo-controlled clinical trial investigating enteral vitamin A (5,000 IU/day) for reducing the severity of bronchopulmonary dysplasia (BPD) in extremely preterm infants. Fecal calprotectin levels were measured using enzyme-linked immunosorbent assay after 28 days of Vitamin A or placebo supplementation.

RESULTS

Fecal calprotectin was measured in 66 infants (Vitamin A: 33, Placebo: 33). The mean (standard deviation) gestational age (25.5 [1.55] vs. 25.8 [1.48]; p = 0.341) (week), birth weight (810 [200] vs. 877 [251]; p = 0.240) (gram), and factors influencing fecal calprotectin levels were comparable between the vitamin A versus placebo group infants. All infants were exclusively fed with mother's or donor's human breast milk if mother's milk was unavailable using a standardized feeding regimen and received prophylactic probiotic supplementation. Fecal calprotectin levels (median; 25th-75th centiles) (micrograms/gram of feces) were not significantly different between vitamin A (152; 97-212) and placebo groups (179; 91-313) (p = 0.195). Two infants in the vitamin A group developed definite necrotizing enterocolitis compared to none in the placebo group. Incidence of BPD at 36 weeks postmenstrual age was similar between the groups (vitamin A: 18/33, placebo: 13/33, p = 0.218).

CONCLUSION

Enteral supplementation with water-soluble vitamin A did not affect fecal calprotectin levels in extremely preterm infants. Studies with a larger sample size are required to confirm the findings.

Assessment of Vitamin A Supplementation Practices in Countries of the Eastern Mediterranean Region: Evidence to Implementation

Vitamin A is an essential nutrient necessary for human growth and development, with critical roles in vision, immune function reproduction and maintenance of epithelial cellular integrity. Inadequate intake of vitamin A places populations at risk of developing diseases associated with vitamin A deficiency (VAD). VAD is highly prevalent across the Eastern Mediterranean Region (EMR) in children under 5 y and women of childbearing age. Therefore, infants and young children, pregnant women and postpartum women are commonly targeted by supplementation programs. Although, vitamin A supplementation has been shown to decrease preventable childhood diseases and deaths related to VAD, supplementation of vitamin A has been greatly misused in several countries within the EMR raising concern around the process of supplementing the target population. Countries across the EMR have reported different supplementation practices depending on the income level of the country, the availability of vitamin A and the prevalence rates of VAD. Although some countries had higher supplementation rates than others, the concern lies in the middle-income countries and their supplementation practices. Some of the countries across the region do not follow the World Health Organization's (WHO) guidelines for vitamin A supplementation for the recommended age groups. The objective of this study is to assess the vitamin A supplementation practices across the countries in the EMR, determine the gaps in the supplementation practices and the issue with supplementing to healthy populations where VAD is not a public health concern, and provide recommendations for proper vitamin A supplementation within the region.

Vitamin A supplementation and estimated number of averted child deaths in Ethiopia: 15 years in practice (2005-2019)

Vitamin A supplementation (VAS), started as a short‐term strategy pending dietary improvements, has been implemented in Ethiopia for the last 15 years. We aimed to describe the trends in VAS coverage and estimated the associated reductions in child mortality. VAS coverage data obtained from the District Health Information System and the Demographic and Health Surveys were linked to child mortality data from the United Nations Interagency Group for Child Mortality Estimation (UN IGME). The number of child deaths averted was modelled assuming 12% and 24% reductions in all‐cause mortality. From 2006 to 2011, VAS was delivered through campaigns, and coverage was above 85%. However, from 2011 onwards, VAS delivery was integrated to the routine health system, and the coverage declined to <60% with significant disparities by wealth quintile and rural–urban residence. VAS has saved between 167,563 to 376,030 child lives (2005–2019), but additional lives (>42,000) could have been saved with a universal coverage (95%). Inconsistent supply of vitamin A capsules, but more importantly, low access to health care, and the limited contact opportunities for children after 24 months may have contributed to the declining VAS coverage. Any changes in target or scale‐up should thus consider these spatial and socioeconomic variations. Increasing the coverage of VAS and closing the equity gap in access to nutrition services is critical. However, with alternative programmes like vitamin A fortification being set‐up, the benefits and safety of VAS need to be closely monitored, particularly in areas where there will be overlap.

High-Dose Neonatal Vitamin A Supplementation to Bangladeshi Infants Increases the Percentage of CCR9-Positive Treg Cells in Infants with Lower Birthweight in Early Infancy, and Decreases Plasma sCD14 Concentration and the Prevalence of Vitamin A Deficiency at Two Years of Age

BACKGROUND

Vitamin A (VA) stores are low in early infancy and may impair development of the immune system.

OBJECTIVE

This study determined if neonatal VA supplementation (VAS) affects the following: 1) development of regulatory T (Treg) cells; 2) chemokine receptor 9 (CCR9) expression, which directs mucosal targeting of immune cells; and 3) systemic endotoxin exposure as indicated by changed plasma concentrations of soluble CD14 (sCD14). Secondarily, VA status, growth, and systemic inflammation were investigated.

METHODS

In total, 306 Bangladeshi infants were randomly assigned to receive 50,000 IU VA or placebo (PL) within 48 h of birth, and immune function was assessed at 6 wk, 15 wk, and 2 y. Primary outcomes included the following: 1) peripheral blood Treg cells; 2) percentage of Treg, T, and B cells expressing CCR9; and 3) plasma sCD14. Secondary outcomes included the following: 4) VA status measured using the modified relative dose-response (MRDR) test and plasma retinol; 5) infant growth; and 6) plasma C-reactive protein (CRP). Statistical analysis identified group differences and interactions with sex and birthweight.

RESULTS

VAS increased (P = 0.004) the percentage of CCR9+ Treg cells (13.2 ± 1.37%) relative to PL (9.17 ± 1.15%) in children below the median birthweight but had the opposite effect (P = 0.04) in those with higher birthweight (VA, 9.13 ± 0.89; PL, 12.1 ± 1.31%) at 6 and 15 wk (values are combined mean ± SE). VAS decreased (P = 0.003) plasma sCD14 (1.56 ± 0.025 mg/L) relative to PL (1.67 ± 0.032 mg/L) and decreased (P = 0.034) the prevalence of VA deficiency (2.3%) relative to PL (9.2%) at 2 y.

CONCLUSIONS

Neonatal VAS enhanced mucosal targeting of Treg cells in low-birthweight infants. The decreased systemic exposure to endotoxin and improved VA status at 2 y may have been due to VA-mediated improvements in gut development resulting in improved barrier function and nutrient absorption. This trial was registered at clinicaltrials.gov as NCT01583972 and NCT02027610.

Ending malnutrition in all its forms requires scaling up proven nutrition interventions and much more: a 129-country analysis

BACKGROUND

Sustainable Development Goal (SDG) 2.2 calls for an end to all forms of malnutrition, with 2025 targets of a 40% reduction in stunting (relative to 2012), for wasting to occur in less than 5% of children, and for a 50% reduction in anaemia in women (15-49 years). We assessed the likelihood of countries reaching these targets by scaling up proven interventions and identified priority interventions, based on cost-effectiveness.

METHODS

For 129 countries, the Optima Nutrition model was used to compare 2019-2030 nutrition outcomes between a status quo (maintained intervention coverage) scenario and a scenario where outcome-specific interventions were scaled up to 95% coverage over 5 years. The average cost-effectiveness of each intervention was calculated as it was added to an expanding package of interventions.

RESULTS

Of the 129 countries modelled, 46 (36%), 66 (51%) and 0 (0%) were on track to achieve the stunting, wasting and anaemia targets respectively. Scaling up 18 nutrition interventions increased the number of countries reaching the SDG 2.2 targets to 50 (39%), 83 (64%) and 7 (5%) respectively. Intermittent preventative treatment of malaria during pregnancy (IPTp), infant and young child feeding education, vitamin A supplementation and lipid-based nutrition supplements for children produced 88% of the total impact on stunting, with average costs per case averted of US$103, US$267, US$556 and US$1795 when interventions were consecutively scaled up, respectively. Vitamin A supplementation and cash transfers produced 100% of the total global impact on prevention of wasting, with average costs per case averted of US$1989 and US$19,427, respectively. IPTp, iron and folic acid supplementation for non-pregnant women, and multiple micronutrient supplementation for pregnant women produced 85% of the total impact on anaemia prevalence, with average costs per case averted of US$9, US$35 and US$47, respectively.

CONCLUSIONS

Prioritising nutrition investment to the most cost-effective interventions within the country context can maximise the impact of funding. A greater focus on complementing nutrition-specific interventions with nutrition-sensitive ones that address the social determinants of health is critical to reach the SDG targets.

Challenging microalgal vitamins for human health

BACKGROUND

Vitamins' deficiency in humans is an important threat worldwide and requires solutions. In the concept of natural biofactory for bioactive compounds production, microalgae represent one of the most promising targets filling many biotechnological applications, and allowing the development of an eco-sustainable production of natural bioactive metabolites. Vitamins are probably one of the cutting edges of microalgal diversity compounds.

MAIN TEXT

Microalgae can usefully provide many of the required vitamins in humans, more than terrestrial plants, for instance. Indeed, vitamins D and K, little present in many plants or fruits, are instead available from microalgae. The same occurs for some vitamins B (B12, B9, B6), while the other vitamins (A, C, D, E) are also provided by microalgae. This large panel of vitamins diversity in microalgal cells represents an exploitable platform in order to use them as natural vitamins' producers for human consumption. This study aims to provide an integrative overview on vitamins content in the microalgal realm, and discuss on the great potential of microalgae as sources of different forms of vitamins to be included as functional ingredients in food or nutraceuticals for the human health. We report on the biological roles of vitamins in microalgae, the current knowledge on their modulation by environmental or biological forcing and on the biological activity of the different vitamins in human metabolism and health protection.

CONCLUSION

Finally, we critically discuss the challenges for promoting microalgae as a relevant source of vitamins, further enhancing the interests of microalgal "biofactory" for biotechnological applications, such as in nutraceuticals or cosmeceuticals.

Complementary Feeding: Pitfalls for Health Outcomes

The term complementary feeding is defined as the period in which a progressive reduction of breastfeeding or infant-formula feeding takes place, while the infant is gradually introduced to solid foods. It is a crucial time in the infant's life, not only because of the rapid changes in nutritional requirements and the consequent impact on infant growth and development, but also for a generation of lifelong flavor preferences and dietary habits that will influence mid and long-term health. There is an increasing body of evidence addressing the pivotal role of nutrition, especially during the early stages of life, and its link to the onset of chronic non-communicable diseases, such as obesity, hypertension, diabetes, and allergic diseases. It is clear that the way in which a child is introduced to complementary foods may have effects on the individual's entire life. The aim of this review is to discuss the effects of complementary feeding timing, composition, and mode on mid and long-term health outcomes, in the light of the current evidence. Furthermore, we suggest practical tips for a healthy approach to complementary feeding, aiming at a healthy future, and highlight gaps to be filled.

Promotion of unproved and potential dangerous measures in fighting COVID-19 pandemic: urgent need for vigilant appropriate public communication and generation of scientific evidence

The ultimate cure for COVID-19 has not yet been discovered, but there is a lot of promoted traditional and food supplements claimed to be effective against the disease. Some of the promoted measures are not only associated with other adverse health outcome, but also create a sense of false protection; leading to failure to follow appropriate measures. It is crucial to identify, correct this misinformation, and to conduct clinical trials to generate evidence among those which are scientifically sound.

The Role of Micronutrients in Support of the Immune Response against Viral Infections

Viral infections are a leading cause of morbidity and mortality worldwide, and the importance of public health practices including handwashing and vaccinations in reducing their spread is well established. Furthermore, it is well known that proper nutrition can help support optimal immune function, reducing the impact of infections. Several vitamins and trace elements play an important role in supporting the cells of the immune system, thus increasing the resistance to infections. Other nutrients, such as omega-3 fatty acids, help sustain optimal function of the immune system. The main aim of this manuscript is to discuss of the potential role of micronutrients supplementation in supporting immunity, particularly against respiratory virus infections. Literature analysis showed that in vitro and observational studies, and clinical trials, highlight the important role of vitamins A, C, and D, omega-3 fatty acids, and zinc in modulating the immune response. Supplementation with vitamins, omega 3 fatty acids and zinc appears to be a safe and low-cost way to support optimal function of the immune system, with the potential to reduce the risk and consequences of infection, including viral respiratory infections. Supplementation should be in addition to a healthy diet and fall within recommended upper safety limits set by scientific expert bodies. Therefore, implementing an optimal nutrition, with micronutrients and omega-3 fatty acids supplementation, might be a cost-effective, underestimated strategy to help reduce the burden of infectious diseases worldwide, including coronavirus disease 2019 (COVID-19).

Multiplying the efficiency and impact of biofortification through metabolic engineering

Ending all forms of hunger by 2030, as set forward in the UN-Sustainable Development Goal 2 (UN-SDG2), is a daunting but essential task, given the limited timeline ahead and the negative global health and socio-economic impact of hunger. Malnutrition or hidden hunger due to micronutrient deficiencies affects about one third of the world population and severely jeopardizes economic development. Staple crop biofortification through gene stacking, using a rational combination of conventional breeding and metabolic engineering strategies, should enable a leap forward within the coming decade. A number of specific actions and policy interventions are proposed to reach this goal.

Vitamin A supplementation boosts control of antibiotic-resistant Salmonella infection in malnourished mice

Disseminated disease from non-typhoidal Salmonella enterica strains results in >20% mortality globally. Barriers to effective treatment include emerging multidrug resistance, antibiotic treatment failure, and risk factors such as malnutrition and related micronutrient deficiencies. Individuals in sub-Saharan Africa are disproportionately affected by non-typhoidal S. enterica bloodstream infections. To inform a clinical trial in people, we investigated vitamin A as a treatment in the context of antibiotic treatment failure in a mouse model of vitamin A deficiency. Vitamin A-deficient (VAD) mice exhibited higher systemic bacterial levels with a multidrug-resistant clinical isolate in comparison to mice on a control diet. Sex-specific differences in vitamin A deficiency and disseminated infection with S. enterica serotype Typhimurium (S. Typhimurium) were observed. VAD male mice had decreased weight gain compared to control male mice. Further, infected VAD male mice had significant weight loss and decreased survival during the course of infection. These differences were not apparent in female mice. In a model of disseminated S. Typhimurium infection and antibiotic treatment failure, we assessed the potential of two consecutive doses of vitamin A in alleviating infection in male and female mice on a VAD or control diet. We found that subtherapeutic antibiotic treatment synergized with vitamin A treatment in infected VAD male mice, significantly decreasing systemic bacterial levels, mitigating weight loss and improving survival. These results suggest that assessing vitamin A as a therapy during bacteremia in malnourished patients may lead to improved health outcomes in a subset of patients, especially in the context of antibiotic treatment failure.

Non-typhoidal Salmonella serotypes generally cause diarrhea in people. However, there are certain factors that make people at risk of developing a more severe infection where the bacteria can enter the blood and cause fever and whole-body symptoms. Patients with this infection are usually hospitalized, and about one in five patients do not survive. The factors that make this bloodstream infection possible include pathogen features like resistance to antibiotics and patient factors like a malnourished state. Better treatments are needed. In this study, the authors assess vitamin A as a treatment during antibiotic treatment failure in a mouse model. Vitamin A-deficient male mice have better outcomes with vitamin A and antibiotic co-therapy, whereas female mice do not benefit. Despite similar levels of bacteria causing infection systemically, female mice show better outcomes in terms of weight loss and survival than male mice overall. This research provides evidence that a clinical study assessing vitamin A as a treatment in people could lead to improved survival for malnourished patients presenting with severe bloodstream infection.

Interventions to improve linear growth during complementary feeding period for children aged 6-24 months living in low- and middle-income countries: a systematic review and network meta-analysis

Background: Optimizing linear growth in children during complementary feeding period (CFP) (6-24 months) is critical for their development. Several interventions, such as micronutrient and food supplements, deworming, maternal education, and water, sanitation and hygiene (WASH), could potentially be provided to prevent stunting, but their comparative effectiveness are currently unclear. In this study, we evaluated comparative effectiveness of interventions under these domains on child linear growth outcomes of height-for-age z-score (HAZ) and stunting (HAZ <-2SD) Methods: For this study, we searched for low- and middle-income country (LMIC)-based randomized clinical trials (RCTs) of aforementioned interventions provided to children during CFP. We searched for reports published until September 17, 2019 and hand-searched bibliographies of existing reviews. We performed random-effects network meta-analysis (NMA) for HAZ and stunting. Results: The evidence base for our NMA was based on 79 RCTs (96 papers) involving 81,786 children. Among the micronutrients, compared to standard-of-care, iron + folic acid (IFA) (mean difference =0.08; 95% credible interval [CrI]: 0.01, 0.15) and multiple micronutrients (MMN) (mean difference =0.06; 95%CrI: 0.01, 0.11) showed improvements for HAZ; MMN also reduced the risks for stunting (RR=0.86; 95%Crl: 0.73, 0.98), whereas IFA did not (RR=0.92; 95%Crl: 0.64, 1.23). For food supplements, flour in the caloric range of 270-340 kcal (RR=0.73; 95%Crl: 0.51, 1.00) and fortified lipid-based nutrient supplements (LNS) containing 220-285 kcal (RR=0.80; 95%Crl: 0.66, 0.97) decreased the risk of stunting compared to standard-of-care, but these interventions and other food supplements did not show improvements for HAZ. Deworming, maternal education, and WASH interventions did not show improvements for HAZ nor stunting. Conclusion: While we found micronutrient and food supplements to be effective for HAZ and/or stunting, the evidence base for other domains in this life stage was limited, highlighting the need for more investigation. Registration: PROSPERO CRD42018110449; registered on 17 October 2018.

Impact of the intestinal environment on the immune responses to vaccination

Vaccination has contributed greatly to the control of infectious diseases; however, regional and individual differences are occasionally observed in the efficacy of vaccination. As one explanation for these differences, much attention has focused on the intestinal environment constructed by the interaction of diet and the gut microbiota. The intestinal environment has several physiological effects on the host immune system, both locally and systemically, and consequently influences the efficacy of vaccination. In this review, we discuss the impact of the gut microbiota and dietary nutrients on systemic and oral vaccination as well as their applications in various strategies for immunoregulation, including use as vaccine adjuvants. This information could contribute to establishing methods of personalized vaccination that would optimize host immunity by changing the gut environment to maximize vaccine effects.

Antimicrobial and micronutrient interventions for the management of infants under 6 months of age identified with severe malnutrition: a literature review

BACKGROUND

Infants under 6 months (U6M) contribute a significant proportion of the burden and mortality of severe malnutrition globally. Evidence of underlying aetiology in this population is sparse, but it is known that the group includes ex-preterm and low birthweight (LBW) infants. They represent a unique population given their dependence on breastmilk or a safe, secure alternative. Nutrition agencies and health providers struggle to make programming decisions on which interventions should be provided to this group based upon the 2013 WHO Guidelines for the 'Management of Severe Acute Malnutrition in Infants and Young Children' since there are no published interventional trial data focussed on this population. Interim guidance for this group might be informed by evidence of safety and efficacy in adjacent population groups.

METHODOLOGY

A narrative literature review was performed of systematic reviews, meta-analyses and randomised controlled trials of antimicrobial and micronutrient interventions (antibiotics, deworming, vitamin A, vitamin D, iron, zinc, folic acid and oral rehydration solution (ORS) for malnutrition) across the population groups of low birthweight/preterm infants, infants under 6 months, infants and children over 6 months with acute malnutrition or through supplementation to breastfeeding mothers. Outcomes of interest were safety and efficacy, in terms of mortality and morbidity.

RESULTS

Ninety-four articles were identified for inclusion within this review. None of these studied interventions exclusively in severely malnourished infants U6M. 64% reported on the safety of studied interventions. Significant heterogeneity was identified in definitions of study populations, interventions provided, and outcomes studied. The evidence for efficacy and safety across population groups is reviewed and presented for the interventions listed.

CONCLUSIONS

The direct evidence base for medical interventions for severely malnourished infants U6M is sparse. Our review identifies a specific need for accurate micronutrient profiling and interventional studies of micronutrients and oral fluid management of diarrhoea amongst infants U6M meeting anthropometric criteria for severe malnutrition. Indirect evidence presented in this review may help shape interim policy and programming decisions as well as the future research agenda for the management of infants U6M identified as malnourished.

Importance of Dietary Changes During the Coronavirus Pandemic: How to Upgrade Your Immune Response

The new coronavirus pandemic continues to spread causing further public health, social, and economic issues. The disparities in the rates of death between countries poses questions about the importance of lifestyle habits and the immune status of populations. An exploration of dietary habits and COVID-19-related death might unravel associations between these two variables. Indeed, while both nutritional excess and deficiency are associated with immunodeficiency, adequate nutrition leading to an optimally functioning immune system may be associated with better outcomes with regards to preventing infection and complications of COVID-19, as well as developing a better immune response to other pathogenic viruses and microorganisms. This article outlines the key functions of the immune system and how macronutrients, micronutrients, and metabolites from the gut microbiome can be essential in the development of an efficient immune system. In addition, the effects of intermittent fasting on the inflammatory state as well as metabolic parameters will be discussed.

Prediction of Vitamin A Stores in Young Children Provides Insights into the Adequacy of Current Dietary Reference Intakes

BACKGROUND

Limited data were available in infants and children when vitamin A (VA) DRIs were established; recommendations were developed based on average breast milk VA intake and extrapolation of data from adults.

OBJECTIVES

Our objective was to evaluate whether DRIs and reported intakes, with and without VA from intervention programs, would be sufficient to develop adequate VA stores from birth to age 5 y in Bangladeshi, Filipino, Guatemalan, and Mexican children.

METHODS

A mathematical relationship was established, defined by a series of equations, to predict VA total body stores (TBS) as a function of age based on VA intake and utilization. TBS calculated using reported VA intakes, with and without additional VA from intervention programs, were compared to those predicted using DRIs (specifically, Adequate Intake and RDA). Liver VA concentrations were also estimated.

RESULTS

Our predictions showed that for these 4 groups, DRIs were sufficient to attain liver VA concentrations >0.07 μmol/g by 1 wk of age and sustain positive VA balance for 5 y. Using reported intakes, which were lowest in Bangladeshis from 1 y on and highest in Guatemalans, predicted VA stores in Bangladeshi and Filipino children increased until ∼2-3 y, then TBS stabilized and liver VA concentrations decreased with age. When VA interventions were included, stores exceeded those predicted using DRIs by 12-18 mo. In contrast, reported intakes alone in Guatemalan and Mexican children resulted in VA stores that surpassed those calculated using DRIs. For all populations, reported intakes were sufficient to build liver concentrations >0.07 μmol/g by 3 mo.

CONCLUSIONS

Although more information is needed to better define dietary VA requirements in children, our results suggest that for an average, generally healthy child in a low- or middle-income country, current DRIs are sufficient to maintain positive VA balance during the first 5 y of life.

Liver is widely eaten by preschool children in the Northern Cape province of South Africa: Implications for routine vitamin A supplementation

Previous research has demonstrated a virtual absence of vitamin A deficiency and adequacy of vitamin A intake through consumption of liver in preschool children of a community in the Northern Cape province of South Africa where sheep farming is common, and liver, an exceptionally rich source of vitamin A, is frequently eaten. Only 60-75 g of liver per month is needed to meet the vitamin A requirement of preschool children. Because this may have implications for routine vitamin A supplementation, and because liver consumption for the rest of the province is unknown, the study aim was to establish the prevalence and frequency of liver intake in a provincial-wide survey. An unquantified liver-specific food frequency questionnaire, covering a period of 1 month, complemented by a 1-year recall, was administered to mothers of 2- to 5-year-old children (n = 2,864) attending primary health care facilities in all five districts and 26 subdistricts. A total of 86% of children were reported to eat liver, which was eaten in all districts by at least 80% of children. The overall median frequency of liver intake was 1.0 [25th, 75th percentiles: 0.5, 3.0] times per month and ranged from 1.0 [0.3, 2.0] to 2.0 [1.0, 4.0] for the various districts. Based on a previously reported portion size of 66 g, these results suggest vitamin A dietary adequacy in all districts and possibly also vitamin A intake exceeding the Tolerable Upper Intake Level in some children. Routine vitamin A supplementation in this province may not be necessary and should be reconsidered.

Appropriate and inappropriate vitamin supplementation in children

The vitamin status of a child depends on many factors and most of the clinical studies do not take into account the different access to adequate nutrition of children coming from different countries and the consequent major differences in micronutrients or vitamin deficits between low-income and high-income countries. Vitamin supplements are included in the general field of dietary supplements. There is a large amount of not always factual material concerning vitamin supplements, and this may sometimes create confusion in clinicians and patients. Inadequate information may lead to the risk of attributing beneficial properties leading to their over-use or misuse in the paediatric field. Vitamin supplementation is indicated in all those conditions in which a vitamin deficiency is found, either because of a reduced intake due to reduced availability of certain foods, restrictive diets or inadequate absorption. The lack of guidelines in these fields may lead paediatricians to an improper use of vitamins, both in terms of excessive use or inadequate use. This is due to the fact that vitamin supplementation is often intended as a therapy of support rather than an essential therapeutic tool able to modify disease prognosis. In fact, various vitamins and their derivatives have therapeutic potential in the prevention and treatment of many diseases, especially in emerging conditions of paediatric age such as type 2 diabetes and the metabolic syndrome. The aim of the present article is to analyse the state of the art and consider new perspectives on the role of vitamin supplements in children.