Iron therapy for improving psychomotor development and cognitive function in children under the age of three with iron deficiency anaemia

Do Vegetarian Diets Provide Adequate Nutrient Intake during Complementary Feeding? A Systematic Review

During the complementary feeding period, any nutritional deficiencies may negatively impact infant growth and neurodevelopment. A healthy diet containing all essential nutrients is strongly recommended by the WHO during infancy. Because vegetarian diets are becoming increasingly popular in many industrialized countries, some parents ask the pediatrician for a vegetarian diet, partially or entirely free of animal-source foods, for their children from an early age. This systematic review aims to evaluate the evidence on how vegetarian complementary feeding impacts infant growth, neurodevelopment, risk of wasted and/or stunted growth, overweight and obesity. The SR was registered with PROSPERO 2021 (CRD 42021273592). A comprehensive search strategy was adopted to search and find all relevant studies. For ethical reasons, there are no interventional studies assessing the impact of non-supplemented vegetarian/vegan diets on the physical and neurocognitive development of children, but there are numerous studies that have analyzed the effects of dietary deficiencies on individual nutrients. Based on current evidence, vegetarian and vegan diets during the complementary feeding period have not been shown to be safe, and the current best evidence suggests that the risk of critical micronutrient deficiencies or insufficiencies and growth retardation is high: they may result in significantly different outcomes in neuropsychological development and growth when compared with a healthy omnivorous diet such as the Mediterranean Diet. There are also no data documenting the protective effect of vegetarian or vegan diets against communicable diseases in children aged 6 months to 2-3 years.

Iron deficiency in preschool non-anemic Egyptian children

Background

Iron deficiency anemia remains a common cause of anemia in young children. The term iron deficiency without anemia, or the so-called latent iron deficiency, has become increasingly significant as it is not only difficult to identify this condition in non-anemic children, but it also adversely affects neurocognitive development, and unfortunately, some of these effects may be irreversible and not respond to treatment. This cross-sectional study was conducted to evaluate iron status in 68 apparently healthy, non-anemic Egyptian children aged 1–6 years. They were subjected to detailed history-taking, physical examination, complete blood count, and tests for serum iron, total iron binding capacity, serum ferritin, and transferrin saturation.

Results

Low serum ferritin level and low transferrin saturation were detected in 41.2% and 47% of the children, respectively. Iron deficiency parameters were significantly affected among toddlers aged “1” to “3” years compared with preschool children, and boys were found to be more affected than girls of the same age group.

Conclusions

A normal hemoglobin level does not exclude iron deficiency, which should be screened in healthy children to prevent the possible long-term effects of iron deficiency on their cognition and mental development.

Iron Status in Preschool Children with Normal Hemoglobin, Egypt

BACKGROUND: Iron deficiency (ID) anemia remains a common cause of anemia in young children. However, the more significant than anemia itself is the ID without anemia that also adversely affect neurocognitive development and unfortunately some of these effects may be irreversible. AIM: This study is a cross-sectional study aimed to asses iron status in preschool children with normal hemoglobin (Hgb) level attending Assiut University Children Hospital. METHODS: The cross-sectional study including 68 apparently healthy children aged 1–6 years old during the period from January 1, 2015 to June 30, 2015, They were subjected to detailed history, physical examination, and the following laboratory investigations: Complete blood count, Serum iron, Total Iron Binding Capacity, Serum ferritin, and Transferrin saturation. RESULTS: Low serum ferritin and low transferrin saturation were detected in 41.2% and 47% respectively of our studied children who have normal Hgb levels. CONCLUSION: Normal Hgb doesn’t exclude ID that should be screened in healthy children to prevent the possible long-term effects of ID on their cognation and mental development.

Associations between Food Group Intake, Cognition, and Academic Achievement in Elementary Schoolchildren

Nutrition plays an important role in proper physical and cognitive functioning. However, there is limited evidence on the relationship between overall diet, cognition, and academic success in children, particularly among low-income and diverse groups. The objective of this study was to examine the relationships between healthful versus less healthful food group intake, cognitive performance, and academic achievement in a diverse sample of schoolchildren. 868 urban schoolchildren (age 8 to 10 years) participated in the study. Intake of healthful (fruits, vegetables, unsweetened beverages) and less healthful (sweet and salty snacks, sugar-sweetened beverages) food groups was determined via a food frequency questionnaire. Digit Span and Stroop test scores were used to assess cognitive performance. Academic achievement was assessed via standardized test scores. Multiple Poisson and multiple linear regression were used to test the associations between diet and cognitive scores. Multiple ordered logistic regression was used to assess the associations between diet and academic achievement. Potential confounders (age, sex, body mass index (BMI) z-score, race/ethnicity, English language learner status, individualized education plan enrollment, physical activity, and parent education level) were tested for inclusion in all models. The sample included 868 children (56.7% girls; 33.2% non-Hispanic white, 26.2% Hispanic, 17.1% multiracial/other, 8.3% non-Hispanic black; 40.5% overweight/obese). The most frequently consumed foods were fruits and sweet snacks (1.9 and 1.6 servings per day, respectively). There were no statistically significant associations between diet and cognitive test scores. Greater intake of less healthful food groups (sweet snacks, salty snacks, and sweetened beverages) was associated with lower math (OR = 0.91, CI [0.84, 0.98], p = 0.014) and English standardized test scores (OR = 0.87, CI [0.80, 0.94, p = 0.001). Greater intake of sweet snacks and fruits was associated with lower English scores (OR = 0.72, 95% CI [0.59, 0.88] p = 0.001; and OR = 0.75, 95% CI [0.72, 0.94] p = 0.003, respectively). Consumption of less healthful food groups was associated with poorer academic achievement. Further research may shed light on unexpected associations between fruit consumption and achievement. Policies targeting multiple dietary components may positively influence child academic achievement and development.

Does the fortified milk with high iron dose improve the neurodevelopment of healthy infants? Randomized controlled trial

Background

Since iron plays an important role in several physiological processes, its deficiency but also overload may harm the development of children. The aim was to assess the effect of iron–fortified milk on the iron biochemical status and the neurodevelopment of children at 12 months of age.

Methods

Randomized controlled trial conducted in 133 Spanish children, allocated in two groups to receive formula milk fortified with 1.2 or 0.4 mg/100 mL of iron between 6 and 12 months of age. Psychomotor (PDI) and Mental (MDI) Development Index were assessed by the Bayley Scales before and after the intervention. Maternal obstetrical and psychosocial variables were recorded. The biochemical iron status of children was measured and data about breastfeeding, anthropometry and infections during the first year of life were registered.

Results

Children fortified with 1.2 mg/100 mL of iron, compared with 0.4 mg/100 mL, showed higher serum ferritin (21.5 vs 19.1 μg/L) and lower percentage of both iron deficiency (1.1 to 5.9% vs 3.8 to 16.7%, respectively, from 6 to 12 months) and iron deficiency anemia (4.3 to 1.1% vs 0 to 4.2%, respectively, from 6 to 12 months) at the end of the intervention. No significant differences were found on neurodevelopment from 6 to 12 months between children who received high dose of Fe compared with those who received low dose.

Conclusion

Despite differences on the iron status were observed, there were no effects on neurodevelopment of well–nourished children in a developed country after iron supplementation with doses within dietary recommendations. Follow–up studies are needed to test for long–term neurodevelopmental improvement.

Trial registration

Retrospectively registered in ClinicalTrials.gov with the ID: NCT02690675.

Iron detection and remediation with a functionalized porous polymer applied to environmental water samples

Iron is one of the most abundant elements in the environment and in the human body. As an essential nutrient, iron homeostasis is tightly regulated, and iron dysregulation is implicated in numerous pathologies, including neuro-degenerative diseases, atherosclerosis, and diabetes. Endogenous iron pool concentrations are directly linked to iron ion uptake from environmental sources such as drinking water, providing motivation for developing new technologies for assessing iron(ii) and iron(iii) levels in water. However, conventional methods for measuring aqueous iron pools remain laborious and costly and often require sophisticated equipment and/or additional processing steps to remove the iron ions from the original environmental source. We now report a simplified and accurate chemical platform for capturing and quantifying the iron present in aqueous samples through use of a post-synthetically modified porous aromatic framework (PAF). The ether/thioether-functionalized network polymer, PAF-1-ET, exhibits high selectivity for the uptake of iron(ii) and iron(iii) over other physiologically and environmentally relevant metal ions. Mössbauer spectroscopy, XANES, and EXAFS measurements provide evidence to support iron(iii) coordination to oxygen-based ligands within the material. The polymer is further successfully employed to adsorb and remove iron ions from groundwater, including field sources in West Bengal, India. Combined with an 8-hydroxyquinoline colorimetric indicator, PAF-1-ET enables the simple and direct determination of the iron(ii) and iron(iii) ion concentrations in these samples, providing a starting point for the design and use of molecularly-functionalized porous materials for potential dual detection and remediation applications.

Iron Deficiency, Cognitive Functions, and Neurobehavioral Disorders in Children

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

Pediatric Screening: Development, Anemia, and Lead

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

Re-Evaluation of Serum Ferritin Cut-Off Values for the Diagnosis of Iron Deficiency in Children Aged 12-36 Months

An ongoing challenge has been determining clinically relevant serum ferritin cut-offs in the diagnosis of iron deficiency in children aged 1-3 years. We identified 2 potential clinically relevant serum ferritin cut-off values through their association with clinically important cut-off of hemoglobin as the indicator of anemia.

The Karnataka Anemia Project 2--design and evaluation of a community-based parental intervention to improve childhood anemia cure rates: study protocol for a cluster randomized controlled trial

BACKGROUND

Childhood anemia is highly prevalent worldwide. Improving the hemoglobin level of preschool age children could yield substantial benefits in cognitive and psychosocial development and overall health. While evidence-based recommendations for reducing childhood anemia in high anemia prevalence countries are available, there is no experimental evidence of community centered education and counseling programs, as a route to improved acceptance of iron supplements, demonstrating beneficial effects on anemia outcomes. We report on the evaluation protocol of a complex educational intervention led by the community lay health worker (LHW) and delivered to mothers of 12-59-month-old anemic children living in and visiting village day care centers in a large district of southern India.

METHODS AND DESIGN

The study is designed as a cluster randomized controlled trial. The intervention is based on the social cognitive theory and aims to promote among mothers, anemia awareness, dietary modifications to increase iron intake in the child, and recognition of the need for enhanced adherence to supplemental iron in the anemic child. From 270 eligible villages in the study area, a sample of 60 villages will be randomized to intervention [n = 30] or to treatment as usual [n = 30] of the study. LHWs in the intervention arm will be trained to administer the following intervention components to mothers of anemic children: 1] monthly distribution of Iron and folic acid (IFA) supplements to mothers of anemic children, and 2] five monthly counseling sessions of mothers of anemic children covering: a] anemia awareness education b] IFA adherence counseling and assessment, c] dietary modification to improve iron intake, and d] hygiene and sanitation. LHWs in the control arm will distribute IFA to mothers of anemic children as in the intervention arm but will not provide monthly education and counseling support. The primary outcome is the difference between the two experimental groups in anemia cure rates of children found to be anemic at baseline. Secondary outcomes, assessed as differences between all participants in both experimental groups, are: change in mothers' knowledge regarding anemia; 24 hour dietary iron intake; net improvement in individual hemoglobin values; serum ferritin; and the difference in overall cluster level childhood anemia prevalence. All outcomes will be measured 6 months after the start of the intervention. Multilevel linear and logistic regression models will be used to analyze differences between intervention and control groups in outcome variables.

DISCUSSION

This trial is designed to evaluate the effectiveness of an intervention intended to improve anemia cure rates in anemic children living in villages of Chamarajnagar, Karnataka a large district in south India. The extensive study of secondary endpoints will be used to identify possible weak points in the compliance to intervention delivery and uptake. This evaluation is one of the few large randomized trials evaluating the impact of an education and counseling intervention to reduce childhood anemia prevalence.

TRIAL REGISTRATION

This trial was registered with ISRCTN.com (identifier: ISRCTN68413407) on 17 September 2013.

Incorporating Informatics for Integrating Biology and the Bedside (i2b2) into Predoctoral Trainee Curriculum to Evaluate Student-Generated Hypotheses

As part of the Clinical and Translational Science Institute predoctoral TL1 training program at the Pennsylvania State University, a multidisciplinary team of predoctoral trainees representing the Chemistry, Neurosurgery, Nutritional Sciences, and Public Health Sciences departments were introduced to the NIH-sponsored Informatics for Integrating Biology and the Bedside (i2b2) database to test the following student-generated hypothesis: children with iron deficiency anemia (IDA) are at increased risk of attention deficit-hyperactivity disorder (ADHD). Children aged 4-12 and 4-17 years were categorized into IDA and control groups. De-identified medical records from the Penn State Milton S. Hershey Medical Center (HMC) and the Virginia Commonwealth University Medical Center (VCUMC) were used for the analysis. Overall, ADHD prevalence at each institution was lower than 2011 state estimates. There was a significant association between IDA and ADHD in the 4-17-year-old age group for all children (OR: 1.902 [95% CI: 1.363-2.656]), Caucasian children (OR: 1.802 [95% CI: 1.133-2.864]), and African American children (OR: 1.865 [95% CI: 1.152-3.021]). Clinical and Translational Science Award (CTSA) infrastructure is particularly useful for trainees to answer de novo scientific questions with minimal additional training and technical expertise. Moreover, projects can be expanded by collaborating within the CTSA network.

An Overview of Iron in Term Breast-Fed Infants

BACKGROUND

Iron is an essential nutrient for normal growth and neurodevelopment of infants. Iron deficiency (ID) remains the most common micronutrient deficiency worldwide. There are convincing data that ID is associated with negative effects on neurological and psychomotor development.

OBJECTIVES

In this review, we provide an overview of current knowledge of the importance of iron in normal term breast-fed infants with a focus on recommendations, metabolism, and iron requirements.

CONCLUSIONS

Health organizations around the world recommend the introduction of iron-rich foods or iron supplements for growing infants to prevent ID. However, there is no routine screening for ID in infancy. Multicenter trials with long-term follow-up are needed to investigate the association between iron fortification/supplementation and various health outcomes.

Optimizing early child development for young children with non-anemic iron deficiency in the primary care practice setting (OptEC): study protocol for a randomized controlled trial

Background

Three decades of research suggests that prevention of iron deficiency anemia (IDA) in the primary care setting may be an unrealized and unique opportunity to prevent poor developmental outcomes in children. A longitudinal study of infants with IDA showed that the developmental disadvantage persists long term despite iron therapy. Early stages of iron deficiency, termed non-anemic iron deficiency (NAID), provide an opportunity for early detection and treatment before progression to IDA. There is little research regarding NAID, which may be associated with delayed development in young children. The aim of this study is to compare the effectiveness of four months of oral iron treatment plus dietary advice, with placebo plus dietary advice, in improving developmental outcomes in children with NAID and to conduct an internal pilot study.

Methods/Design

From a screening cohort, those identified with NAID (hemoglobin ≥110 g/L and serum ferritin <14 μg/L) are invited to participate in a pragmatic, multi-site, placebo controlled, blinded, parallel group, superiority randomized trial. Participating physicians are part of a primary healthcare research network called TARGet Kids! Children between 12 and 40 months of age and identified with NAID are randomized to receive four months of oral iron treatment at 6 mg/kg/day plus dietary advice, or placebo plus dietary advice (75 per group). The primary outcome, child developmental score, is assessed using the Mullen Scales of Early Learning at baseline and at four months after randomization. Secondary outcomes include an age appropriate behavior measure (Children’s Behavior Questionnaire) and two laboratory measures (hemoglobin and serum ferritin levels). Change in developmental and laboratory measures from baseline to the end of the four-month follow-up period will be analyzed using linear regression (analysis of covariance method).

Discussion

This trial will provide evidence regarding the association between child development and NAID, and the effectiveness of oral iron to improve developmental outcomes in children with NAID. The sample size of the trial will be recalculated using estimates taken from an internal pilot study.

Trial registration

This trial was registered with Clinicaltrials.gov (identifier: NCT01481766) on 22 November 2011.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-015-0635-z) contains supplementary material, which is available to authorized users.

Iron deficiency increases blood concentrations of neurotoxic metals in children

Iron deficiency affects approximately one-third of the world's population, occurring most frequently in children aged 6 months to 3 years. Mechanisms of iron absorption are similar to those of other divalent metals, particularly manganese, lead, and cadmium, and a diet deficient in iron can lead to excess absorption of manganese, lead, and cadmium. Iron deficiency may lead to cognitive impairments resulting from the deficiency itself or from increased metal concentrations caused by the deficiency. Iron deficiency combined with increased manganese or lead concentrations may further affect neurodevelopment. We recently showed that blood manganese and lead concentrations are elevated among iron-deficient infants. Increased blood manganese and lead levels are likely associated with prolonged breast-feeding, which is also a risk factor for iron deficiency. Thus, babies who are breast-fed for prolonged periods should be given plain, iron-fortified cereals or other good sources of dietary iron.

Home fortification of foods with multiple micronutrient powders for health and nutrition in children under two years of age (Review)

BACKGROUND

Vitamin and mineral deficiencies, particularly those of iron, vitamin A and zinc, affect more than two billion people worldwide. Young children are highly vulnerable because of rapid growth and inadequate dietary practices. Micronutrient powders (MNP) are single-dose packets containing multiple vitamins and minerals in powder form that can be sprinkled onto any semi-solid food.The use of MNP for home or point-of-use fortification of complementary foods has been proposed as an intervention for improving micronutrient intake in children under two years of age.

OBJECTIVES

To assess the effects and safety of home (point-of-use) fortification of foods with multiple micronutrient powders on nutritional, health and developmental outcomes in children under two years of age.

SEARCH METHODS

We searched the following databases in February 2011: Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE (1948 to week 2 February 2011), EMBASE (1980 to Week 6 2011), CINAHL (1937 to current), CPCI-S (1990 to 19 February 2011), Science Citation Index (1970 to 19 February 2011), African Index Medicus (searched 23 February 2011), POPLINE (searched 21 February 2011), ClinicalTrials.gov (searched 23 February 2011), mRCT (searched 23 February 2011), and World Health Organization International Clinical Trials Registry Platform (ICTRP) (searched 23 February 2011). We also contacted relevant organisations (25 January 2011) for the identification of ongoing and unpublished studies.

SELECTION CRITERIA

We included randomised and quasi-randomised trials with either individual or cluster randomisation. Participants were children under the age of two years at the time of intervention, with no specific health problems. The intervention was consumption of food fortified at the point of use with multiple micronutrient powders formulated with at least iron, zinc and vitamin A compared with placebo, no intervention or the use of iron containing supplements, which is the standard practice.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the eligibility of studies against the inclusion criteria, extracted data from included studies and assessed the risk of bias of the included studies.

MAIN RESULTS

We included eight trials (3748 participants) conducted in low income countries in Asia, Africa and the Caribbean, where anaemia is a public health problem. The interventions lasted between two and 12 months and the powder formulations contained between five and 15 nutrients. Six trials compared the use of MNP versus no intervention or a placebo and the other two compared the use of MNP versus daily iron drops. Most of the included trials were assessed as at low risk of bias. Home fortification with MNP reduced anaemia by 31% (six trials, RR 0.69; 95% CI 0.60 to 0.78) and iron deficiency by 51% (four trials, RR 0.49; 95% CI 0.35 to 0.67) in infants and young children when compared with no intervention or placebo, but we did not find an effect on growth. In comparison with daily iron supplementation, the use of MNP produced similar results on anaemia (one trial, RR 0.89; 95% CI 0.58 to 1.39) and haemoglobin concentrations (two trials, MD -2.36 g/L; 95% CI -10.30 to 5.58); however, given the limited amount of data these results should be interpreted cautiously. No deaths were reported in the trials and information on side effects and morbidity, including malaria, was scarce. It seems that the use of MNP is efficacious among infants and young children six to 23 months of age living in settings with different prevalences of anaemia and malaria endemicity, regardless of whether the intervention lasts two, six or 12 months or whether recipients are male or female.

AUTHORS' CONCLUSIONS

Home fortification of foods with multiple micronutrient powders is an effective intervention to reduce anaemia and iron deficiency in children six months to 23 months of age. The provision of MNP is better than no intervention or placebo and possibly comparable to commonly used daily iron supplementation. The benefits of this intervention as a child survival strategy or on developmental outcomes are unclear. Data on effects on malaria outcomes are lacking and further investigation of morbidity outcomes is needed. The micronutrient powders containing multiple nutrients are well accepted but adherence is variable and in some cases comparable to that achieved in infants and young children receiving standard iron supplements as drops or syrups.

Iron deficiency and cognitive functions

Micronutrient deficiencies, especially those related to iodine and iron, are linked to different cognitive impairments, as well as to potential long-term behavioral changes. Among the cognitive impairments caused by iron deficiency, those referring to attention span, intelligence, and sensory perception functions are mainly cited, as well as those associated with emotions and behavior, often directly related to the presence of iron deficiency anemia. In addition, iron deficiency without anemia may cause cognitive disturbances. At present, the prevalence of iron deficiency and iron deficiency anemia is 2%-6% among European children. Given the importance of iron deficiency relative to proper cognitive development and the alterations that can persist through adulthood as a result of this deficiency, the objective of this study was to review the current state of knowledge about this health problem. The relevance of iron deficiency and iron deficiency anemia, the distinction between the cognitive consequences of iron deficiency and those affecting specifically cognitive development, and the debate about the utility of iron supplements are the most relevant and controversial topics. Despite there being methodological differences among studies, there is some evidence that iron supplementation improves cognitive functions. Nevertheless, this must be confirmed by means of adequate follow-up studies among different groups.

Functional significance of early-life iron deficiency: outcomes at 25 years

OBJECTIVE

To evaluate adulthood function following chronic iron deficiency in infancy.

STUDY DESIGN

At 25 years, we compared 33 subjects with chronic iron deficiency in infancy to 89 who were iron-sufficient before and/or after iron therapy. Outcomes included education, employment, marital status, and physical and mental health.

RESULTS

Adjusting for sex and socioeconomic status, a higher proportion of the group with chronic iron deficiency did not complete secondary school (58.1% vs 19.8% in iron-sufficient group; Wald value = 8.74; P = .003), were not pursuing further education/training (76.1% vs 31.5%; Wald value = 3.01; P = .08; suggestive trend), and were single (83.9% vs 23.7%, Wald value = 4.49; P = .03). They reported poorer emotional health and more negative emotions and feelings of dissociation/detachment. Results were similar in secondary analyses comparing the chronic iron-deficient group with subjects in the iron-sufficient group who had been iron-deficient before treatment in infancy. Path analysis showed direct paths for chronic iron deficiency in infancy and being single and more detachment/dissociation at 25 years. There were indirect paths for chronic iron deficiency and not completing secondary school via poorer cognitive functioning in early adolescence and more negative emotions via behavior problems in adolescence, indicating a cascade of adverse outcomes.

CONCLUSION

The observational nature of this study limits our ability to draw causal inference, even when controlling for background factors. Nonetheless, our results indicate substantial loss of human potential. There may be broader societal implications, considering that many adults worldwide had chronic iron deficiency in infancy. Iron deficiency can be prevented or treated before it becomes chronic or severe.

Iron therapy for improving psychomotor development and cognitive function in children under the age of three with iron deficiency anaemia

BACKGROUND

Iron deficiency and iron deficiency anaemia (IDA) are common in young children. It has been suggested that the lack of iron may have deleterious effects on children's psychomotor development and cognitive function. To evaluate the benefits of iron therapy on psychomotor development and cognitive function in children with IDA, a Cochrane review was carried out in 2001. This is an update of that review.

OBJECTIVES

To determine the effects of iron therapy on psychomotor development and cognitive function in iron deficient anaemic children less than three years of age.

SEARCH METHODS

We searched the following databases in April 2013: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, PsycINFO, LILACS, ClinicalTrials.gov and World Health Organization International Clinical Trials Registry Platform (ICTRP). We also searched the reference lists of review articles and reports, and ran citation searches in the Science Citation Index for relevant studies identified by the primary search. We also contacted key authors.

SELECTION CRITERIA

Studies were included if children less than three years of age with evidence of IDA were randomly allocated to iron or iron plus vitamin C versus a placebo or vitamin C alone, and assessment of developmental status or cognitive function was carried out using standardised tests by observers blind to treatment allocation.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles and abstracts retrieved from the searches and assessed full-text copies of all potentially relevant studies against the inclusion criteria. The same review authors independently extracted data and assessed the risk of bias of the eligible studies. Data were analysed separately depending on whether assessments were performed within one month of beginning iron therapy or after one month.

MAIN RESULTS

We identified one eligible study in the update search that had not been included in the original review. In total, we included eight trials.Six trials, including 225 children with IDA, examined the effects of iron therapy on measures of psychomotor development and cognitive function within 30 days of commencement of therapy. We could pool data from five trials. The pooled difference in pre- to post-treatment change in Bayley Scale Psychomotor Development Index (PDI) between iron and placebo groups was -1.25 (95% confidence interval (CI) -4.56 to 2.06, P value = 0.65; I(2) = 33% for heterogeneity, random-effects meta-analysis; low quality evidence) and in Bayley Scale Mental Development Index (MDI) was 1.04 (95% CI -1.30 to 3.39, P value = 0.79; I(2) = 31% for heterogeneity, random-effects meta-analysis; low quality evidence).Two studies, including 160 randomised children with IDA, examined the effects of iron therapy on measures of psychomotor development and cognitive function more than 30 days after commencement of therapy. One of the studies reported the mean number of skills gained after two months of iron therapy using the Denver Developmental Screening Test. The intervention group gained 0.8 (95% CI -0.18 to 1.78, P value = 0.11, moderate quality of evidence) more skills on average than the control group. The other study reported that the difference in pre- to post-treatment change in Bayley Scale PDI between iron-treated and placebo groups after four months was 18.40 (95% CI 10.16 to 26.64, P value < 0.0001; moderate quality evidence) and in Bayley Scale MDI was 18.80 (95% CI 10.17 to 27.43, P value < 0.0001; moderate quality evidence).

AUTHORS' CONCLUSIONS

There is no convincing evidence that iron treatment of young children with IDA has an effect on psychomotor development or cognitive function within 30 days after commencement of therapy. The effect of longer-term treatment remains unclear. There is an urgent need for further large randomised controlled trials with long-term follow-up.

The role of nutrition in children's neurocognitive development, from pregnancy through childhood

This review examines the current evidence for a possible connection between nutritional intake (including micronutrients and whole diet) and neurocognitive development in childhood. Earlier studies which have investigated the association between nutrition and cognitive development have focused on individual micronutrients, including omega-3 fatty acids, vitamin B12, folic acid, choline, iron, iodine, and zinc, and single aspects of diet. The research evidence from observational studies suggests that micronutrients may play an important role in the cognitive development of children. However, the results of intervention trials utilizing single micronutrients are inconclusive. More generally, there is evidence that malnutrition can impair cognitive development, whilst breastfeeding appears to be beneficial for cognition. Eating breakfast is also beneficial for cognition. In contrast, there is currently inconclusive evidence regarding the association between obesity and cognition. Since individuals consume combinations of foods, more recently researchers have become interested in the cognitive impact of diet as a composite measure. Only a few studies to date have investigated the associations between dietary patterns and cognitive development. In future research, more well designed intervention trials are needed, with special consideration given to the interactive effects of nutrients.

Integrated strategies needed to prevent iron deficiency and to promote early child development

Iron deficiency (ID) and iron deficiency anemia (IDA) are global public health problems that differentially impact pregnant women and infants in low and middle income countries. IDA during the first 1000 days of life (prenatally through 24 months) has been associated with long term deficits in children's socio-emotional, motor, cognitive, and physiological functioning. Mechanisms linking iron deficiency to children's development may include alterations to dopamine metabolism, myelination, and hippocampal structure and function, as well as maternal depression and unresponsive caregiving, potentially associated with maternal ID. Iron supplementation trials have had mixed success in promoting children's development. Evidence suggests that the most effective interventions to prevent iron deficiency and to promote early child development begin early in life and integrate strategies to ensure adequate iron and nutritional status, along with strategies to promote responsive mother-child interactions and early learning opportunities.

Oral iron supplements for children in malaria-endemic areas

BACKGROUND

Iron-deficiency anaemia is common during childhood. Iron supplementation has been claimed to increase the risk of malaria.

OBJECTIVES

To assess the effect of iron on malaria and deaths.

SEARCH STRATEGY

We searched The Cochrane Library, PUBMED, MEDLINE, LILACS; and trial registry databases, all up to June 2011. We scanned references of included trials.

SELECTION CRITERIA

Individually and cluster randomized controlled trials conducted in hypoendemic to holoendemic malaria regions and including children below 18 years of age. We included trials comparing orally administered iron, iron with antimalarial treatment, or iron with folic acid versus placebo or no treatment. Iron fortification was excluded. Antihelminthics could be administered to either group. Additional micronutrients had to be administered equally to both groups.

DATA COLLECTION AND ANALYSIS

The primary outcomes were clinical (symptomatic) malaria, severe malaria, and death. Two authors independently selected the studies and extracted the data. We assessed heterogeneity and conducted subgroup analyses by the presence of anaemia at baseline, age, and malaria endemicity. We assessed risk of bias using domain-based evaluation. We performed a fixed-effect meta-analysis for all outcomes and random-effects meta-analysis for hematological outcomes. We adjusted analyses for cluster randomized trials.

MAIN RESULTS

Seventy-one trials (45,353 children) were included. For clinical malaria, no significant difference between iron alone and placebo was detected, (risk ratio (RR) 0.99, 95% confidence intervals (CI) 0.90 to 1.09, 13 trials). The results were similar in the subgroups of non-anaemic children and children below 2 years of age. There was no significant difference in deaths in hyper- and holoendemic areas, risk difference +1.93 per 1000 children (95% CI -1.78 to 5.64, 13 trials, 17,898 children). Iron administered for treatment of anaemia resulted in a larger increase in haemoglobin than iron given for prevention, and the benefit was similar in hyper- or holoendemic and lower endemicity settings. Iron and folic acid supplementation resulted in mixed results for severe malaria. Overall, the risk for clinical malaria was higher with iron or with iron plus folic acid in trials where services did not provide for malaria surveillance and treatment. Iron with antimalarial treatment significantly reduced malaria. Iron supplementation during an acute attack of malaria did not increase the risk for parasitological failure, (RR 0.96, 95% CI 0.74 to 1.24, three trials) or deaths.

AUTHORS' CONCLUSIONS

Iron alone or with antimalaria treatment does not increase the risk of clinical malaria or death when regular malaria surveillance and treatment services are provided. There is no need to screen for anaemia prior to iron supplementation.

Home fortification of foods with multiple micronutrient powders for health and nutrition in children under two years of age

BACKGROUND

Vitamin and mineral deficiencies, particularly those of iron, vitamin A and zinc, affect more than two billion people worldwide. Young children are highly vulnerable because of rapid growth and inadequate dietary practices. Micronutrient powders (MNP) are single-dose packets containing multiple vitamins and minerals in powder form that can be sprinkled onto any semi-solid food.The use of MNP for home or point-of-use fortification of complementary foods has been proposed as an intervention for improving micronutrient intake in children under two years of age.

OBJECTIVES

To assess the effects and safety of home (point-of-use) fortification of foods with multiple micronutrient powders on nutritional, health and developmental outcomes in children under two years of age.

SEARCH STRATEGY

We searched the following databases in February 2011: Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE (1948 to week 2 February 2011), EMBASE (1980 to Week 6 2011), CINAHL (1937 to current), CPCI-S (1990 to 19 February 2011), Science Citation Index (1970 to 19 February 2011), African Index Medicus (searched 23 February 2011), POPLINE (searched 21 February 2011), ClinicalTrials.gov (searched 23 February 2011), mRCT (searched 23 February 2011), and World Health Organization International Clinical Trials Registry Platform (ICTRP) (searched 23 February 2011). We also contacted relevant organisations (25 January 2011) for the identification of ongoing and unpublished studies.

SELECTION CRITERIA

We included randomised and quasi-randomised trials with either individual or cluster randomisation. Participants were children under the age of two years at the time of intervention, with no specific health problems. The intervention was consumption of food fortified at the point of use with multiple micronutrient powders formulated with at least iron, zinc and vitamin A compared with placebo, no intervention or the use of iron containing supplements, which is the standard practice.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the eligibility of studies against the inclusion criteria, extracted data from included studies and assessed the risk of bias of the included studies.

MAIN RESULTS

We included eight trials (3748 participants) conducted in low income countries in Asia, Africa and the Caribbean, where anaemia is a public health problem. The interventions lasted between two and 12 months and the powder formulations contained between five and 15 nutrients. Six trials compared the use of MNP versus no intervention or a placebo and the other two compared the use of MNP versus daily iron drops. Most of the included trials were assessed as at low risk of bias.Home fortification with MNP reduced anaemia by 31% (six trials, RR 0.69; 95% CI 0.60 to 0.78) and iron deficiency by 51% (four trials, RR 0.49; 95% CI 0.35 to 0.67) in infants and young children when compared with no intervention or placebo, but we did not find an effect on growth.In comparison with daily iron supplementation, the use of MNP produced similar results on anaemia (one trial, RR 0.89; 95% CI 0.58 to 1.39) and haemoglobin concentrations (two trials, MD -2.36 g/L; 95% CI -10.30 to 5.58); however, given the limited amount of data these results should be interpreted cautiously.No deaths were reported in the trials and information on side effects and morbidity, including malaria, was scarce.It seems that the use of MNP is efficacious among infants and young children six to 23 months of age living in settings with different prevalences of anaemia and malaria endemicity, regardless of whether the intervention lasts two, six or 12 months or whether recipients are male or female.

AUTHORS' CONCLUSIONS

Home fortification of foods with multiple micronutrient powders is an effective intervention to reduce anaemia and iron deficiency in children six months to 23 months of age. The provision of MNP is better than no intervention or placebo and possibly comparable to commonly used daily iron supplementation. The benefits of this intervention as a child survival strategy or on developmental outcomes are unclear. Data on effects on malaria outcomes are lacking and further investigation of morbidity outcomes is needed. The micronutrient powders containing multiple nutrients are well accepted but adherence is variable and in some cases comparable to that achieved in infants and young children receiving standard iron supplements as drops or syrups.

Alternative positions for the baby at birth before clamping the umbilical cord

BACKGROUND

The third stage of labour is from birth of the baby until delivery of the placenta. Clamping the umbilical cord is one component of active management of the third stage. Deferring cord clamping allows blood flow between the baby and the placenta to continue; net transfer to the baby is called placental transfusion. If the cord is clamped immediately placental transfusion is restricted. Gravity is one of several factors that may influence the volume and duration of placental transfusion at both vaginal and caesarean births. Hence raising or lowering the baby whilst the cord is intact may influence placental transfusion, which in turn may affect outcome for the baby and the woman.

OBJECTIVES

To compare the effects of alternative positions for the baby between birth and cord clamping on outcome for the baby, outcome for the mother and on use of health service resources.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (July 2010).

SELECTION CRITERIA

Randomised trials comparing alternative positions for the baby at vaginal and caesarean birth, before clamping of the umbilical cord.

DATA COLLECTION AND ANALYSIS

We independently assessed trial eligibility and quality. When necessary, we contacted study authors for additional information.

MAIN RESULTS

Thirty-seven studies (7559 mother-infant pairs) were excluded: 33 (7296) because they did not compare alternative positions for the baby before clamping the umbilical cord and four (263) due to quasi-random allocation. No studies met the inclusion criteria. One additional trial is ongoing.

AUTHORS' CONCLUSIONS

No randomised trials have assessed the influence of gravity on placental transfusion. Large, well-designed randomised trials are needed to assess whether gravity influences placental transfusion at vaginal and caesarean births and, if so, whether this affects short-term and long-term outcome for the baby and for the mother.

Iron deficiency in children with mitochondrial disease

Mitochondrial disease is an energy metabolic disorder with various organ involvement. Iron is widely known to be one of the most important nutriments required for normal brain development and several essential metabolic functions. We retrospectively studied the laboratory data on iron deficiency (ID) in 69 children with mitochondrial respiratory chain complex (MRC) defects by biochemical enzyme assay using muscle tissue. We analyzed the differences between groups of mitochondrial disease based on the presence of ID. ID has higher prevalence in children with mitochondrial disease than in the normal population. There were 6 (9%) patients with low hemoglobin, 12 (17%) with low serum ferrtin, and 22 (32%) with low transferrin saturation levels among children with MRC defects. In comparisons between the ID and the non-ID group of MRC-defect patients, the frequency of MRC I defect was significantly higher in the ID group while that of MRC IV defect was higher in the non-ID group. Abnormal brain magnetic resonance imaging (MRI) findings were more frequently detected in the ID group. The incidence of failure to thrive and gastrointestinal symptoms were significantly higher in the ID group. Early diagnosis and proper treatment of ID are recommended. Especially in cases with risk factors such as failure to thrive or gastrointestinal manifestation, active evaluation of ID should be encouraged.

Evidence for perinatal and child health care guidelines in crisis settings: can Cochrane help?

BACKGROUND

It is important that healthcare provided in crisis settings is based on the best available research evidence. We reviewed guidelines for child and perinatal health care in crisis situations to determine whether they were based on research evidence, whether Cochrane systematic reviews were available in the clinical areas addressed by these guidelines and whether summaries of these reviews were provided in Evidence Aid.

METHODS

Broad internet searches were undertaken to identify relevant guidelines. Guidelines were appraised using AGREE and the clinical areas that were relevant to perinatal or child health were extracted. We searched The Cochrane Database of Systematic Reviews to identify potentially relevant reviews. For each review we determined how many trials were included, and how many were conducted in resource-limited settings.

RESULTS

Six guidelines met selection criteria. None of the included guidelines were clearly based on research evidence. 198 Cochrane reviews were potentially relevant to the guidelines. These reviews predominantly addressed nutrient supplementation, breastfeeding, malaria, maternal hypertension, premature labour and prevention of HIV transmission. Most reviews included studies from developing settings. However for large portions of the guidelines, particularly health services delivery, there were no relevant reviews. Only 18 (9.1%) reviews have summaries in Evidence Aid.

CONCLUSIONS

We did not identify any evidence-based guidelines for perinatal and child health care in disaster settings. We found many Cochrane reviews that could contribute to the evidence-base supporting future guidelines. However there are important issues to be addressed in terms of the relevance of the available reviews and increasing the number of reviews addressing health care delivery.

Recent studies of iron deficiency during brain development in nonhuman primates

Recent studies of the effects of developmental iron deficiency (ID) and iron deficiency anemia in nonhuman primates have provided new insights into this widespread and well-recognized human nutritional deficiency. The rhesus monkey was the animal model in these experiments, which used extensive hematological and behavioral evaluations in addition to noninvasive brain measures. Two important findings were as follows: 1) different behavioral consequences depending on the timing of ID relative to brain developmental stages and 2) the potential for long-lasting changes in brain iron regulatory systems. Further work in this model, including integration with studies in humans and in laboratory rodents, is ongoing.

The effects of oral iron supplementation on cognition in older children and adults: a systematic review and meta-analysis

BACKGROUND

In observational studies anaemia and iron deficiency are associated with cognitive deficits, suggesting that iron supplementation may improve cognitive function. However, due to the potential for confounding by socio-economic status in observational studies, this needs to be verified in data from randomised controlled trials (RCTs).

AIM

To assess whether iron supplementation improved cognitive domains: concentration, intelligence, memory, psychomotor skills and scholastic achievement.

METHODOLOGY

Searches included MEDLINE, EMBASE, PsychINFO, Cochrane CENTRAL and bibliographies (to November 2008). Inclusion, data extraction and validity assessment were duplicated, and the meta-analysis used the standardised mean difference (SMD). Subgrouping, sensitivity analysis, assessment of publication bias and heterogeneity were employed.

RESULTS

Fourteen RCTs of children aged 6+, adolescents and women were included; no RCTs in men or older people were found. Iron supplementation improved attention and concentration irrespective of baseline iron status (SMD 0.59, 95% CI 0.29 to 0.90) without heterogeneity. In anaemic groups supplementation improved intelligence quotient (IQ) by 2.5 points (95% CI 1.24 to 3.76), but had no effect on non-anaemic participants, or on memory, psychomotor skills or scholastic achievement. However, the funnel plot suggested modest publication bias. The limited number of included studies were generally small, short and methodologically weak.

CONCLUSIONS

There was some evidence that iron supplementation improved attention, concentration and IQ, but this requires confirmation with well-powered, blinded, independently funded RCTs of at least one year's duration in different age groups including children, adolescents, adults and older people, and across all levels of baseline iron status.

Understanding the role of nutrition in the brain and behavioral development of toddlers and preschool children: identifying and addressing methodological barriers

The preschool years (i.e. 1-5 years of age) is a time of rapid and dramatic postnatal brain development (i.e. neural plasticity), and of fundamental acquisition of cognitive development (i.e. working memory, attention and inhibitory control). Also, it is a time of transition from a direct maternal mediation/selection of diet-based nutrition to food selection that is more based on self-selection and self-gratification. However, there have been fewer published studies in preschool children than in infants or school-aged children that examined the role of nutrition in brain/mental development (125 studies versus 232 and 303 studies, respectively during the last 28 years). This may arise because of age-related variability, in terms of individual differences in temperament, linguistic ability, and patterns of neural activity that may affect assessment of neural and cognitive development in pre-school children. In this review, we suggest several approaches for assessing brain function in children that can be refined. It would be desirable if the discipline developed some common elements to be included in future studies of diet and brain function, with the idea that they would complement more targeted measures based on time of exposure and understanding of data from animal models. Underlining this approach is the concept of 'window of sensitivity' during which nutrients may affect postnatal neural development: investigators and expert panels need to look specifically for region-specific changes and do so with understanding of the likely time window during which the nutrient was, or was not available.

Oral iron supplementation for preventing or treating anaemia among children in malaria-endemic areas

BACKGROUND

Iron-deficiency anaemia is common during childhood. Iron supplementation has been claimed to increase the risk of malaria.

OBJECTIVES

To assess the effect of iron on malaria and deaths.

SEARCH STRATEGY

We searched The Cochrane Library (2009, issue 1); MEDLINE; EMBASE; LILACS and metaRegister of Controlled Trials, all up to March 2009. We scanned references of included trials.

SELECTION CRITERIA

Individually and cluster-randomized controlled trials conducted in hypoendemic to holoendemic malaria regions and including children < 18 years. We included trials comparing orally administered iron with or without folic acid vs. placebo or no treatment. Iron fortification was excluded. Antimalarials and/or antiparasitics could be administered to either group. Additional micronutrients could only be administered equally to both groups.

DATA COLLECTION AND ANALYSIS

The primary outcomes were malaria-related events and deaths. Secondary outcomes included haemoglobin, anaemia, other infections, growth, hospitalizations, and clinic visits. We assessed risk of bias using domain-based evaluation. Two authors independently selected studies and extracted data. We contacted authors for missing data. We assessed heterogeneity. We performed fixed-effect meta-analysis and presented random-effects results when heterogeneity was present. We present pooled risk ratios (RR) with 95% confidence intervals (CIs). We used adjusted analyses for cluster-randomized trials.

MAIN RESULTS

Sixty-eight trials (42,981 children) fulfilled the inclusion criteria. Iron supplementation did not increase the risk of clinical malaria (RR 1.00, 95% CI 0.88 to 1.13; 22,724 children, 14 trials, random-effects model). The risk was similar among children who were non-anaemic at baseline (RR 0.96, 95% CI 0.85 to 1.09). An increased risk of malaria with iron was observed in trials that did not provide malaria surveillance and treatment. The risk of malaria parasitaemia was higher with iron (RR 1.13, 95% CI 1.01 to 1.26), but there was no difference in adequately concealed trials. Iron + antimalarial was protective for malaria (four trials). Iron did not increase the risk of parasitological failure when given during malaria (three trials). There was no increased risk of death across all trials comparing iron versus placebo (RR 1.11, 95% CI 0.91 to 1.36; 21,272 children, 12 trials). Iron supplementation increased haemoglobin, with significant heterogeneity, and malaria endemicity did not affect this effect. Growth and other infections were mostly not affected by iron supplementation.

AUTHORS' CONCLUSIONS

Iron does not increase the risk of clinical malaria or death, when regular malaria surveillance and treatment services are provided. There is no need to screen for anaemia prior to iron supplementation.

Iron supplementation for reducing morbidity and mortality in children with HIV

BACKGROUND

The most prevalent haematologic disturbance associated with HIV in children (apart from CD4 lymphocytopenia) is anaemia. Anaemia associated with HIV arises from multiple mechanisms, including the direct inhibitory effect of HIV on red cell precursors, other locally prevalent and/or opportunistic infections, micronutrient deficiency, anaemia of chronic disease, and as a consequence of medicines given for HIV and/or other concurrent illnesses. Iron deficiency is the most common cause of nutritional anaemia globally. There is significant geographical overlap of areas of the world where iron deficiency anaemia (IDA) and paediatric HIV are distributed. Given the high prevalence of IDA, it is likely that many HIV-infected children also are iron deficient. The contribution of iron deficiency to anaemia in HIV-infected children has been described but is incompletely understood. Currently, iron supplementation for anaemic infants and children is routinely practiced without any obvious effect in most developing countries, which bear most of the burden of global paediatric HIV infections.Because iron deficiency and IDA are common in HIV-infected children in high-prevalence areas and because there are concerns about possible deleterious effects of iron, this review aims to assess the evidence for iron supplementation for reducing morbidity and mortality in HIV-infected children.

OBJECTIVES

To determine whether iron supplementation improves clinical, immunologic, and virologic outcomes in children infected with HIV SEARCH STRATEGY: We used the comprehensive search strategy developed specifically by the Cochrane HIV/AIDS Review Group to identify HIV/AIDS randomised controlled trials, and searched the following electronic databases: MEDLINE (searched November 2007); Embase (searched December 2007); and CENTRAL (December 2007). This search was supplemented with a search of AIDSearch (searched December 2007) and NLM Gateway (searched December 2007) to identify relevant conference abstracts, as well as a search of the reference lists of all eligible articles. The search was not limited by language or publication status.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of iron supplementation in any form and dose in HIV-infected children aged 12 years and younger.

DATA COLLECTION AND ANALYSIS

We independently screened the results of the search to select potentially relevant studies and to retrieve the full articles. We independently applied the inclusion criteria to the potentially relevant studies. No studies were identified that fulfilled the selection criteria.

MAIN RESULTS

No RCTs of iron supplementation in HIV-infected children were found.

IMPLICATIONS FOR CLINICAL PRACTICE

The current clinical practice of iron supplementation in HIV-infected children is based on weak evidence comprising observational studies and expert opinions.

IMPLICATIONS FOR RESEARCH

High-quality RCTs of iron supplementation are urgently required, especially in areas with significant overlap of high prevalence of HIV, iron deficiency anaemia, and malaria. Policy makers should prioritise funding for these trials.

Effects of vitamin B12 and folate deficiency on brain development in children

Folate deficiency in the periconceptional period contributes to neural tube defects; deficits in vitamin B12 (cobalamin) have negative consequences on the developing brain during infancy; and deficits of both vitamins are associated with a greater risk of depression during adulthood. This review examines two mechanisms linking folate and vitamin B12 deficiency to abnormal behavior and development in infants: disruptions to myelination and inflammatory processes. Future investigations should focus on the relationship between the timing of deficient and marginal vitamin B12 status and outcomes such as infant growth, cognition, social development, and depressive symptoms, along with prevention of folate and vitamin B12 deficiency.

Association between iron-deficiency anemia and stroke in young children

OBJECTIVE

Iron-deficiency anemia occurs with a peak prevalence of 4% to 8% in children between 1 and 3 years of age. Case reports have suggested an association between iron-deficiency anemia in healthy children and ischemic stroke. Our objective was to investigate whether iron-deficiency anemia is associated with stroke in young children.

METHODS

A case-control study was conducted of case patients who were selected from the stroke registry at the Hospital for Sick Children (Toronto, Ontario, Canada) and control subjects selected from a database of healthy children who were prospectively enrolled in an outpatient setting. Children were aged 12 to 38 months and were previously healthy with no identifiable risk factors for stroke. Age, gender, mean corpuscular volume, platelet count, and hemoglobin and ferritin levels were collected. Iron-deficiency anemia was defined as a hemoglobin level of <110 g/L, mean corpuscular volume <73 fL, and serum ferritin level <12 microg/L. Stroke was defined according to clinical and radiologic criteria.

RESULTS

Case (n = 15) and control (n = 143) subjects were similar with respect to median age and percentage of boys. Case patients had a lower median hemoglobin level and mean corpuscular volume and a higher median platelet count. Iron-deficiency anemia was significantly more common among case patients (8 [53%] of 15) than control subjects (13 [9%] of 143).

CONCLUSIONS

Previously healthy children with stroke were 10 times more likely to have iron-deficiency anemia than healthy children without stroke. Furthermore, children with iron-deficiency anemia accounted for more than half of all stroke cases in children without an underlying medical illness, which suggests that iron-deficiency anemia is a significant risk factor for stroke in otherwise healthy young children. Primary prevention and early identification of iron-deficiency anemia must remain a priority.

Anemia em menores de seis anos: estudo de base populacional em Pelotas, RS

OBJETIVO: Analisar a prevalência de anemia em crianças menores de seis anos, em uma amostra probabilística de área urbana. MÉTODOS: Foi realizado estudo com crianças de zero a cinco anos de idade, na cidade de Pelotas, RS, em 2004. Foram coletadas informações sobre características demográficas, socioeconômicas, antropométricas, de morbidade e sobre alimentação, por meio de questionário aplicado às mães ou responsáveis. As crianças foram pesadas e medidas. A concentração de hemoglobina foi medida com hemoglobinômetro portátil, HemoCue e anemia foi definida como valores de hemoglobina <11 g/dL. A associação entre anemia e preditores foi expressa como razão de prevalência. Foi realizada análise multivariada por regressão de Poisson a partir de um modelo conceitual, considerando o efeito do delineamento do estudo. RESULTADOS: Foram identificadas 534 crianças e as perdas e recusas totalizaram 27 crianças (5,1%). A prevalência de anemia foi 30,2% (IC 95%: 23,5%;37,0%). Na análise multivariada, somente idade e renda familiar permaneceram significativamente associadas com anemia. CONCLUSÕES: A anemia foi, em grande parte, socialmente determinada na população estudada. Intervenções com o objetivo de combatê-la devem ser delineadas para amenizar esta condição em curto prazo e direcionadas para populações menos favorecidas economicamente.

Effects of iron deficiency in infancy on patterns of motor development over time

This longitudinal study of the effects of iron deficiency in infancy assessed motor development over time in 185 healthy Costa Rican children who varied in iron status at 12-23 months. Longitudinal analyses (hierarchical linear modeling) used the Bayley Psychomotor Index before and both 1 week and 3 months after iron treatment in infancy and the Bruninks-Oseretsky Test of Motor Proficiency - long form at 5 years and short form at 11-14 years. Children with chronic severe iron deficiency in infancy had lower motor scores at the beginning of the study and a lower but parallel trajectory for motor scores through early adolescence. Thus, there was no evidence of catch-up in motor development, despite iron therapy in infancy that corrected iron deficiency anemia in all cases.

Double burden of iron deficiency in infancy and low socioeconomic status: a longitudinal analysis of cognitive test scores to age 19 years

OBJECTIVE

To assess change in cognitive functioning after iron deficiency in infancy, depending on socioeconomic status (SES; middle vs low).

DESIGN

Longitudinal study.

SETTING

Urban community in Costa Rica (infancy phase [July 26, 1983, through February 28, 1985] through 19-year follow-up [March 19, 2000, through November 4, 2002]).

PARTICIPANTS

A total of 185 individuals enrolled at 12 to 23 months of age (no preterm or low-birth-weight infants or infants with acute or chronic health problems). The participants were assessed in infancy and at 5, 11 to 14, 15 to 18, and 19 years of age. A total of 97% were evaluated at 5 or 11 to 14 years and 78% at 15 to 18 or 19 years. Individuals who had chronic iron deficiency in infancy (iron deficiency with hemoglobin concentrations < or =10.0 g/dL or, with higher hemoglobin concentrations, not fully corrected within 3 months of iron therapy) were compared with those who had good iron status as infants (hemoglobin concentrations > or =12.0 g/dL and normal iron measures before and/or after therapy).

MAIN OUTCOME MEASURES

Cognitive change over time (composite of standardized scores at each age).

RESULTS

For middle-SES participants, scores averaged 101.2 in the group with chronic iron deficiency vs 109.3 in the group with good iron status in infancy and remained 8 to 9 points lower through 19 years (95% confidence interval [CI], -10.1 to -6.2). For low-SES participants, the gap widened from 10 points (93.1 vs 102.8; 95% CI for difference, -12.8 to -6.6) to 25 points (70.4 vs 95.3; 95% CI for difference, 20.6 to 29.4).

CONCLUSIONS

The group with chronic iron deficiency in infancy did not catch up to the group with good iron status in cognitive scores over time. There was a widening gap for those in low-SES families. The results suggest the value of preventing iron deficiency in infancy.

Behavioral consequences of developmental iron deficiency in infant rhesus monkeys

Human studies have shown that iron deficiency and iron deficiency anemia in infants are associated with behavioral impairment, but the periods of brain development most susceptible to iron deficiency have not been established. In the present study, rhesus monkeys were deprived of iron by dietary iron restriction during prenatal (n=14, 10 microg Fe/g diet) or early postnatal (n=12, 1.5 mg Fe/L formula) brain development and compared to controls (n=12, 100 microg Fe/g diet, 12 mg Fe/L formula) in behavioral evaluations conducted during the first four months of life in the nonhuman primate nursery. Iron deficiency anemia was detected in the pregnant dams in the third trimester and compromised iron status was seen in the prenatally iron-deprived infants at birth, but no iron deficiency was seen in either the prenatally or postnatally iron-deprived infants during the period of behavioral evaluation. Neither prenatal nor postnatal iron deprivation led to significant delays in growth, or gross or fine motor development. Prenatally deprived infants demonstrated a 20% reduced spontaneous activity level, lower inhibitory response to novel environments, and more changes from one behavior to another in weekly observation sessions. Postnatally deprived infants demonstrated poorer performance of an object concept task, and greater emotionality relative to controls. This study indicates that different syndromes of behavioral effects are associated with prenatal and postnatal iron deprivation in rhesus monkey infants and that these effects can occur in the absence of concurrent iron deficiency as reflected in hematological measures.

Opportunistic screening for iron-deficiency in 6-36 month old children presenting to the Paediatric Emergency Department

BACKGROUND

The Complete Blood Count (CBC) is a test frequently performed on children presenting to the Pediatric Emergency Department (PED), usually for the evaluation of an infectious illness. The CBC also allows for screening for Iron-deficiency Anemia. This study aims to determine the prevalence of a low Mean Cell Volume (MCV) in children having a CBC performed during a PED visit and whether physicians acted upon the abnormal value.

METHODS

We present a retrospective cohort study. We reviewed the PED charts of all children 6-36 months of age who had a CBC performed during a 4-month period and the red blood cell mean cell volume was low. Our main outcome variable was whether or not the possible iron deficiency was addressed through documentation of either iron therapy or further investigation.

RESULTS

938 children had a CBC performed during the two periods. Of these, 78 (8%) had an abnormal MCV or Hemoglobin with no previously identified explanation. Physicians documented either treatment or follow-up investigations in 27 cases (35%, 95% CI: 24-46%). Factors associated with the physician documenting either treatment or investigation plan were the following: hemoglobin level (OR 12.6; 95%CI: 4.0, 39) and age < or = 18 months (OR 4.2; 95%CI: 1.4, 13).

CONCLUSION

Children who have had a CBC in the PED can be screened for iron deficiency at no additional cost. Physicians may be under-utilizing this information.

Anemia is a poor predictor of iron deficiency among toddlers in the United States: for heme the bell tolls

CONTEXT

Many toddlers in the United States have their hemoglobin (Hb) measured periodically. Is this worthwhile?

OBJECTIVE

To determine if the presence of anemia correctly diagnoses iron deficiency (ID) and if the absence of anemia correctly rules out ID in young children.

METHODOLOGY

An analysis of data from the US National Health and Nutrition Examination Survey III (1988-1994) was performed. Subjects were children 12 to 35 months old for whom complete blood counts and cardinal measures of iron nutrition (ferritin, transferrin saturation, and free erythrocyte protoporphyrin) were reported.

RESULTS

In the US National Health and Nutrition Examination Survey III, the prevalence of ID ranged from 6% to 18% in various subpopulations of toddlers. In the general population, the positive predictive value of Hb concentration ([Hb]) <110 g/L for ID was 29% (95% confidence interval [CI]: 20-38%), and the sensitivity was 30% (95% CI: 20-40%). Changing the diagnostic cutoff point to [Hb] <107 g/L resulted in a positive predictive value of 38% (95% CI: 24-52%) but lowered the sensitivity to 15% (95% CI: 7-22%).

CONCLUSIONS

ID remains common in the United States. In agreement with other reports, anemia in toddlers in developed countries is more likely to be due to causes other than ID. Conversely, most children with ID are not anemic. Many false-positive and false-negative results render the measurement of Hb a screening test of relatively little value. The current detection strategy needlessly treats and retests many children without ID and leaves many iron-deficient toddlers unattended.

Gaps in the evidence for well-child care: a challenge to our profession

BACKGROUND

Up to one third of visits to pediatricians involve health supervision (well-child care), and recommendations for office-based preventive interventions have dramatically expanded. We reviewed the evidence for the effectiveness of these interventions.

METHODS

The well-child care recommendations of 7 major North American organizations were tabulated. Three types of health supervision interventions were recommended, ie, behavioral counseling, screening, and prophylaxis. For recommendations common to at least 2 of the 7 organizations, evidence of effectiveness was sought from systematic reviews and clinical trials. Immunizations were not considered for this review, because they have been reviewed elsewhere.

RESULTS

Forty-two preventive interventions were recommended by > or =2 of the organizations. Limited clinical trials show that counseling can change some health risk behaviors; repeated intensive counseling is most likely to be effective. Harmful effects were shown for a few behavioral counseling interventions. Trials have been conducted for only 2 of the recommended screening interventions; therefore, rigorous evidence supporting screening is very limited. Trials support the use of folate to prevent neural tube defects, trials of iron supplementation do not address developmental outcomes, and trials were not found for the other recommended prophylactic interventions.

CONCLUSIONS

Limited direct evidence was found to support the recommended interventions. Because a large number of interventions are routinely recommended and often mandated and because the implementation of any recommendation may cause harm (including the displacement of other beneficial activities), these recommendations should be based on the strongest possible evidence. When recommendations are made, supporting evidence should be clearly stated.

Iron and zinc supplementation promote motor development and exploratory behavior among Bangladeshi infants

BACKGROUND

Iron and zinc deficiency are prevalent during infancy in low-income countries.

OBJECTIVES

The objectives were to examine whether a weekly supplement of iron, zinc, iron+zinc, or a micronutrient mix (MM) of 16 vitamins and minerals would alter infant development and behavior.

DESIGN

The participants were 221 infants from rural Bangladesh at risk of micronutrient deficiencies. Development and behavior were evaluated at 6 and 12 mo of age by using the Bayley Scales of Infant Development II and the Home Observation Measurement of Environment (HOME) scale. In this double-blind trial, the infants were randomly assigned to 1 of 5 treatment conditions: iron (20 mg), zinc (20 mg), iron+zinc, MM (16 vitamins and minerals, including iron and zinc), or riboflavin weekly from 6 to 12 mo. Multivariate analyses were conducted to examine the change in development and behavior for each supplementation group, with control for maternal education, HOME score, months breastfed, anemia, growth at 6 mo, and change in growth from 6 to 12 mo.

RESULTS

Iron and zinc administered together and with other micronutrients had a beneficial effect on infant motor development. Iron and zinc administered individually and in combination had a beneficial effect on orientation-engagement. Two-thirds of the infants were mildly anemic, no treatment effects on hemoglobin concentration were observed, and hemoglobin was not associated with measures of development or behavior.

CONCLUSION

The beneficial effects of weekly iron and zinc supplementation on motor development and orientation-engagement suggest that infants benefit from these minerals when administered together.

Micronutrient deficiencies and cognitive functioning

The relationship between four micronutrient deficiencies (iodine, iron, zinc and vitamin B-12) and children's cognitive functioning is reviewed. Iodine deficiency during pregnancy has negative and irreversible effects on the developing fetus. Although there is some evidence that postnatal iodine deficiency is associated with cognitive deficits, the findings are controversial. Iron deficiency is widespread and has been associated to cognitive deficits, but the results of prevention trials are inconsistent. Zinc deficiency has been linked with low activity and depressed motor development among the most vulnerable children. Associations with cognitive development are less clear and may be limited to specific neuropsychological processes. Vitamin B-12 deficiency has been associated with cognitive problems among the elderly, but little is known about its effect on children's cognitive functioning. Rates of vitamin B-12 deficiency are likely to be high because animal products are the only source of vitamin B-12. Although micronutrient deficiencies often co-occur in the context of poverty, little is known about the impact of multiple micronutrient deficiencies on cognitive development.