The consequences of iron deficiency and anemia in pregnancy

Effects of dietary iron supplementation on reproductive performance of sows and growth performance of piglets

This experiment aimed to investigate the effects of dietary iron supplementation from different sources on the reproductive performance of sows and the growth performance of piglets. A total of 87 sows with similar farrowing time were blocked by body weight at day 85 of gestation, and assigned to one of three dietary treatments (n = 29 per treatment): basal diet, basal diet supplemented with 0.2% ferrous sulfate (FeSO4), and basal diet supplemented with 0.2% iron sucrose, respectively, with 30% iron in both FeSO4 and iron sucrose. Compared with the control (CON) group, iron sucrose supplementation reduced the rate of stillbirth and invalid of neonatal piglets (P < 0.05), and the number of mummified fetuses was 0. Moreover, it also improved the coat color of newborn piglets (P < 0.05). At the same time, the iron sucrose could also achieve 100% estrus rate of sows. Compared with the CON group, FeSO4 and iron sucrose supplementation increased the serum iron content of weaned piglets (P < 0.05). In addition, iron sucrose increased serum transferrin level of weaned piglets (P < 0.05) and the survival rate of piglets (P < 0.05). In general, both iron sucrose and FeSO4 could affect the blood iron status of weaned piglets, while iron sucrose also had a positive effect on the healthy development of newborn and weaned piglets, and was more effective than FeSO4 in improving the performance of sows and piglets.

Iron Metabolism in Normal and Pathological Pregnancies and Fetal Consequences

Iron is required for energy production, DNA synthesis, and cell proliferation, mainly as a component of the prosthetic group in hemoproteins and as part of iron-sulfur clusters. Iron is also a critical component of hemoglobin and plays an important role in oxygen delivery. Imbalances in iron metabolism negatively affect these vital functions. As the crucial barrier between the fetus and the mother, the placenta plays a pivotal role in iron metabolism during pregnancy. Iron deficiency affects 1.2 billion individuals worldwide. Pregnant women are at high risk of developing or worsening iron deficiency. On the contrary, in frequent hemoglobin diseases, such as sickle-cell disease and thalassemia, iron overload is observed. Both iron deficiency and iron overload can affect neonatal development. This review aims to provide an update on our current knowledge on iron and heme metabolism in normal and pathological pregnancies. The main molecular actors in human placental iron metabolism are described, focusing on the impact of iron deficiency and hemoglobin diseases on the placenta, together with normal metabolism. Then, we discuss data concerning iron metabolism in frequent pathological pregnancies to complete the picture, focusing on the most frequent diseases.

Maternal Iron Deficiency Modulates Placental Transcriptome and Proteome in Mid-Gestation of Mouse Pregnancy

BACKGROUND

Maternal iron deficiency (ID) is associated with poor pregnancy and fetal outcomes. The effect is thought to be mediated by the placenta but there is no comprehensive assessment of placental responses to maternal ID. Additionally, whether the influence of maternal ID on the placenta differs by fetal sex is unknown.

OBJECTIVES

To identify gene and protein signatures of ID mouse placentas at mid-gestation. A secondary objective was to profile the expression of iron genes in mouse placentas across gestation.

METHODS

We used a real-time PCR-based array to determine the mRNA expression of all known iron genes in mouse placentas at embryonic day (E) 12.5, E14.5, E16.5, and E19.5 (n = 3 placentas/time point). To determine the effect of maternal ID, we performed RNA sequencing and proteomics in male and female placentas from ID and iron-adequate mice at E12.5 (n = 8 dams/diet).

RESULTS

In female placentas, 6 genes, including transferrin receptor (Tfrc) and solute carrier family 11 member 2, were significantly changed by maternal ID. An additional 154 genes were altered in male ID placentas. A proteomic analysis quantified 7662 proteins in the placenta. Proteins translated from iron-responsive element (IRE)-containing mRNA were altered in abundance; ferritin and ferroportin 1 decreased, while TFRC increased in ID placentas. Less than 4% of the significantly altered genes in ID placentas occurred both at the transcriptional and translational levels.

CONCLUSIONS

Our data demonstrate that the impact of maternal ID on placental gene expression in mice is limited in scope and magnitude at mid-gestation. We provide strong evidence for IRE-based transcriptional and translational coordination of iron gene expression in the mouse placenta. Finally, we discover sexually dimorphic effects of maternal ID on placental gene expression, with more genes and pathways altered in male compared with female mouse placentas.

Increase in Compliance with Weekly Iron Supplementation of Adolescent Girls by An Accompanying Communication Programme in Secondary Schools in Dar-Es-Salaam, Tanzania

Insufficient compliance has been identified as a major contributing factor to the low effectiveness of iron-supplementation programmes. An experimental community trial was conducted to observe the effect of a communication programme on compliance with weekly iron supplementation in urban Tanzanian adolescent schoolgirls. A sample of 237 girls aged 14 to 17 years was randomly recruited from five schools in Dar-es-Salaam, and randomly assigned to three groups. Group A (schools 1 and 2) received one tablet weekly containing 65 mg of elemental iron with 0.25 mg of folic acid for eight consecutive weeks and participated in weekly communication sessions. Group B (school 3) received the same supplementation without communication sessions. Group C (schools 4 and 5) served as the control group, without supplementation or communication. Reported and observed compliance was checked by pill counting and stool analysis. Haemoglobin levels were determined by the cyanmethaemoglobin method before and after intervention. A knowledge test on iron-deficiency anaemia (causes, effects, and treatment) was carried out before and after intervention. Venn diagrams were drawn to identify the most influential persons. Three focus group discussions with the girls and the teachers were conducted at different stages during the study. in the group receiving supplementation and communication, the prevalence of anaemia decreased significantly (p < .001) from 49% to 5% in school 1 and from 54% to 23% in school 2. the prevalence of anaemia did not change significantly in schools 3 and 4 but increased significantly in school 5. the reported and observed compliance was 90% and 94%, respectively, in school 1, 89% and 75% in school 2, and 48% and 50% in school 3. the participants’ knowledge of iron-deficiency anaemia increased significantly in all schools after the intervention (p < .001) but was highest in schools 1 and 2, which received supplementation and communication. It is concluded that comprehensive communication strategies can influence the ingestion of iron supplements and therefore help to reduce anaemia in adolescents.

Maternal iron status during pregnancy compared with neonatal iron status better predicts placental iron transporter expression in humans

The placenta richly expresses nonheme and heme Fe transport proteins. To address the impact of maternal and neonatal Fe status and hepcidin on the regulation of these proteins, mRNA expression and protein abundance of nonheme and heme Fe transport proteins were evaluated in placental tissue from 154 adolescents. Regression analyses found maternal Fe status was significantly associated with multiple placental nonheme and heme transporters, whereas neonatal Fe status was related to only 3 heme transporters. Across statistical analyses, maternal Fe status was consistently associated with the placental nonheme Fe importer transferrin receptor 1 (TfR1). Protein abundance of TfR1 was related to midgestation maternal serum ferritin (SF) (β = -0.32; P = 0.005) and serum TfR (β = 0.25; P = 0.024). Protein abundance of the heme importer, proton-coupled folate transporter, was related to neonatal SF (β = 0.30; P = 0.016) and serum TfR (β = -0.46; P < 0.0001). Neonatal SF was also related to mRNA expression of the heme exporter feline leukemia virus subgroup C receptor 1 (β = -0.30; P = 0.004). In summary, maternal Fe insufficiency during pregnancy predicts increased expression of the placental nonheme Fe transporter TfR1. Associations between placental heme Fe transporters and neonatal Fe status require further study.-Best, C. M., Pressman, E. K., Cao, C., Cooper, E., Guillet, R., Yost, O. L., Galati, J., Kent, T. R., O'Brien, K. O. Maternal iron status during pregnancy compared with neonatal iron status better predicts placental iron transporter expression in humans.

Individual and combined effects of maternal anemia and prenatal infection on risk for schizophrenia in offspring

BACKGROUND

Maternal iron deficiency and infection during pregnancy have individually been associated with increased risk of schizophrenia in the offspring, but possible interactions between the two remain unidentified thus far. Therefore, we determined the individual and combined effects of maternal infection during pregnancy and prepartum anemia on schizophrenia risk in the offspring.

METHODS

We conducted a population-based study with individual record linkage of the Danish Civil Registration System, the Danish Hospital Register, and the Central Danish Psychiatric Register. In a cohort of Danish singleton births 1,403,183 born between 1977 and 2002, 6729 developed schizophrenia between 1987 and 2012. Cohort members were considered as having a maternal history of anemia if the mother had received a diagnosis of anemia at any time during the pregnancy. Maternal infection was defined based on infections requiring hospital admission during pregnancy.

RESULTS

Maternal anemia and infection were both associated with increased risk of schizophrenia in unadjusted analyses (1.45-fold increase for anemia, 95% CI: 1.14-1.82; 1.32-fold increase for infection, 95% CI: 1.17-1.48). The effect of maternal infection remained significant (1.16-fold increase, 95% CI: 1.03-1.31) after adjustment for possible confounding factors. Combined exposure to anemia and an infection increased the effect size to a 2.49-fold increased schizophrenia risk (95% CI: 1.29-4.27). The interaction analysis, however, failed to provide evidence for multiplicative interactions between the two factors.

CONCLUSION

Our findings indicate that maternal anemia and infection have additive but not interactive effects, and therefore, they may represent two independent risk factors of schizophrenia.

Placental heme receptor LRP1 correlates with the heme exporter FLVCR1 and neonatal iron status

LDL receptor-related protein 1 (LRP1) is a transmembrane receptor highly expressed in human placenta. It was recently found to be the receptor for heme and its plasma-binding protein hemopexin (Hx) and is integral to systemic heme clearance. Little is known about systemic concentrations of Hx during pregnancy and whether maternal Hx and placental LRP1 contributes to fetal iron (Fe) homeostasis during pregnancy. We hypothesized that placental LRP1 would be upregulated in maternal/neonatal Fe insufficiency and would be related to maternal circulating Hx. Placental LRP1 expression was assessed in 57 pregnant adolescents (14-18 years) in relationship with maternal and cord blood Fe status indicators (hemoglobin (Hb), serum ferritin, transferrin receptor), the Fe regulatory hormone hepcidin and serum Hx. Hx at mid-gestation correlated positively with Hb at mid-gestation (r=0.35, P=0.02) and Hx at delivery correlated positively with cord hepcidin (r=0.37, P=0.005). Placental LRP1 protein expression was significantly higher in women who exhibited greater decreases in serum Hx from mid-gestation to term (r=0.28, P=0.04). Significant associations were also found between placental LRP1 protein with cord hepcidin (r=-0.29, P=0.03) and placental heme exporter feline leukemia virus C receptor 1 (r=0.34, P=0.03). Our data are consistent with a role for placental heme Fe utilization in supporting fetal Fe demands.

Study of the concentration of trace elements fe, zn, cu, se and their correlation in maternal serum, cord serum and colostrums

A study of iron, zinc, copper and selenium concentration levels was carried out in three compartments namely, maternal serum (MS), colostrums and cord blood serum (CS) of healthy Indian mothers (n = 42) who delivered healthy normal neonates without any congenital anomalies at Bhabha Atomic Research Centre hospital, Mumbai. Fe, Zn, Cu in maternal serum, cord blood and colostrums were estimated by flame atomic absorption spectrometry while Se was determined by graphite furnace absorption spectrometry. It was seen that there was a significant difference in the level of trace elements in the three compartments. The average levels of Fe in the three compartments were 1,132 ± 519, 2,312 ± 789 and 1,183 ± 602 μg/L while Zn was 514 ± 149, 819 ± 224 and 7,148 ± 2,316 μg/L respectively. Mean Cu values were 1,614 ± 295, 301 ± 77 and 392 ± 174 μg/L respectively while Se values were 70 ± 15, 36 ± 10 and 23 ± 8 μg/L respectively. The results indicated a positive correlation of Fe and Zn concentrations in MS versus CS which were (r = 0.386), (r = 0.572) respectively and Fe levels in MS and colostrums (r = 0.235). A few inter element correlations were found within compartments. Zn and Se showed a negative correlation in both MS (r = -0.489) and colostrums (r = -0.258) while a positive inter correlation of Fe and Zn was seen in MS (r = 0.44) and in CS (r = 0.54). This study gave us an overview of the serum and colostrum values of mother and neonates in Indian population, data of which are scarce.

Neonatal levels of acute phase proteins and later risk of non-affective psychosis

Mounting evidence suggests that immune disturbances in early life may be implicated in the etiology of non-affective psychoses. Our aim was to assess the levels of neonatal acute phase proteins (APPs), central to innate immune function as well as central nervous system development, in neonatal dried blood spots and their association with later risk of non-affective psychoses. This case-control study included 196 individuals with a verified register-based diagnosis of non-affective psychosis and 502 controls matched on age, sex and hospital of birth. Concentrations of nine different APPs were measured in eluates from dried blood spots using a bead-based multiplex assay. Odds ratios (OR) for non-affective psychoses were calculated for log(2)-transformed (continuous) as well as tertiles of APP concentrations. In continuous analysis, higher concentrations of two APPs, tissue plasminogen activator (tPA; OR: 0.90, 95% confidence interval (CI): 0.85-0.96) and serum amyloid P (SAP; OR: 0.88, 95% CI: 0.78-0.99) were protective in terms of risk of non-affective psychosis. These relationships were not affected by the addition of covariates relevant to maternal health, pregnancy and delivery to the model. Tertile analysis confirmed a protective relationship for higher levels of tPA and SAP, as well as for procalcitonin (highest tertile OR: 0.54, 95% CI:0.32-0.91). Our results suggest that persons who develop non-affective psychoses have lower levels of certain APPs at the time of birth. These differences may render individuals more susceptible to infectious diseases or cause deficiencies in pathways critical for neurodevelopment.

Pregnancy and iron homeostasis: an update

It has been nearly 15 years since the first review on pregnancy and iron deficiency was published in Nutrition Reviews. Many unresolved issues raised in that seminal review have been addressed. New proteins involved in nonheme and heme iron transport have been identified in the enterocyte, and information on the roles of these proteins in the placenta is evolving. The systemic iron regulatory hormone, hepcidin, has since been identified as a key regulator of iron homeostasis. Additional data on the efficacy and consequences of prenatal iron supplementation are available. Emerging data on developmental changes in iron absorption across early infancy have further emphasized the need to ensure that the iron endowment of the neonate at birth is optimal. This is especially important, given growing evidence linking neonatal iron status with subsequent cognitive and neurobehavioral outcomes. Along with the many advances, new questions and gaps in knowledge have been identified. This review summarizes new data on maternal iron utilization across pregnancy as it impacts the pregnant woman and the iron status of the neonate at birth.

Low maternal hemoglobin during pregnancy and diminished neuromotor and neurocognitive performance in offspring with schizophrenia

OBJECTIVE

Previous research has linked maternal anemia during pregnancy with increased risk for schizophrenia in offspring. However, no study has sought to determine whether this early insult leads to a more severe form of the disorder, characterized by worsened motor and neurocognitive functioning.

METHOD

Subjects were 24 cases diagnosed with schizophrenia and 22 controls from the Developmental Insult and Brain Anomaly in Schizophrenia (DIBS) study. Hemoglobin values were measured throughout pregnancy. Among offspring, psychiatric diagnoses were determined through semi-structured interviews and medical records review and comprehensive neurocognitive assessment batteries were conducted in adulthood.

RESULTS

Results indicated that among cases decreases in maternal hemoglobin led to significant decreases in scores on the Grooved Pegboard test, the Finger Tapping test and the Wechsler Adult Intelligent Scales (WAIS) information subtest. In contrast, controls only exhibited decreases in performance on the California Verbal Learning Test (CVLT) long-delay recall after fetal exposure to lower hemoglobin. There were also significant interactions between hemoglobin and case status for all of the motor tasks.

CONCLUSIONS

These findings support the hypothesis that fetal exposure to decreases in maternal hemoglobin is related to preferentially poorer neuromotor function among cases compared to controls, as well as general intellectual difficulties among cases. Controls were relatively unaffected by decreased maternal hemoglobin, which suggests that liability to schizophrenia renders cases susceptible to the deleterious influences of in utero exposure to decreases in maternal hemoglobin.

Maternal hepcidin is associated with placental transfer of iron derived from dietary heme and nonheme sources

The determinants of placental transport of dietary iron remain largely uncharacterized. The objective of this research was to elucidate determinants of fetal Fe transfer from maternally ingested dietary heme and non-heme Fe. The study was undertaken in 19 pregnant females (16-32 y) who ingested intrinsically labeled (58)Fe-heme and a nonheme Fe source ((57)FeSO(4)) during the third trimester of pregnancy. At delivery, maternal and cord blood was obtained to assess neonatal (57)Fe and (58)Fe enrichment as a function of maternal/neonatal Fe status [serum ferritin (SF), transferrin receptor, hemoglobin (Hb), total body Fe, and hepcidin]. There was a greater percentage of maternally absorbed (58)Fe tracer present in the neonates compared to the (57)Fe tracer (5.4 ± 2.4 vs. 4.0 ± 1.6; P < 0.0001). Net dietary nonheme Fe (mg) and heme Fe (mg) transferred to the fetus were both inversely correlated with measures of maternal serum hepcidin (P = 0.002, r(2) = 0.43; P = 0.004, r(2) = 0.39) and SF (P = 0.0008, r(2) = 0.49; P = 0.003, r(2) = 0.41) and directly associated with neonatal Hb (P = 0.004, r(2) = 0.39; P = 0.008, r(2) = 0.35). The results of this study suggest that during pregnancy there appears to be preferential fetal use of maternally ingested Fe derived from a dietary, animal-based heme source compared to Fe ingested as ferrous sulfate. Maternal serum hepcidin and maternal/neonatal Fe status may play a role in placental uptake of dietary heme and nonheme Fe.

Association between prepartum maternal iron deficiency and offspring risk of schizophrenia: population-based cohort study with linkage of Danish national registers

Recent findings suggest that maternal iron deficiency may increase the risk of schizophrenia-spectrum disorder in offspring. We initiated this study to determine whether maternal prepartum anemia influences offspring risk of schizophrenia. We conducted a population-based study with individual record linkage of the Danish Civil Registration System, the Danish Psychiatric Central Register, and the Danish National Hospital Register. In a cohort of 1,115,752 Danish singleton births from 1978 to 1998, cohort members were considered as having a maternal history of anemia if the mother had received a diagnosis of anemia at any time during the pregnancy. Cohort members were followed from their 10th birthday until onset of schizophrenia, death, or December 31, 2008, whichever came first. Adjusted for relevant confounders, cohort members whose mothers had received a diagnosis of anemia during pregnancy had a 1.60-fold (95% confidence interval = 1.16-2.15) increased risk of schizophrenia. Although the underlying mechanisms are unknown and independent replication is needed, our findings suggest that maternal iron deficiency increases offspring risk of schizophrenia.

Placental expression of the heme transporter, feline leukemia virus subgroup C receptor, is related to maternal iron status in pregnant adolescents

Little is known about the expression of heme transporters in human placenta and possible associations between these transporters and maternal or neonatal iron status. To address this area of research, relative protein expression of 2 heme transporters, Feline Leukemia Virus, Subgroup C, Receptor 1 (FLVCR1) and Breast Cancer Resistance Protein (BCRP), was assessed using Western-blot analysis in human placental tissue in relation to maternal/neonatal iron status and placental iron concentration. Placental FLVCR1 (n = 71) and BCRP (n = 83) expression were assessed at term (36.6-41.7 wk gestation) in a cohort of pregnant adolescents (13-18 y of age) at high-risk of iron deficiency. Both FLVCR1 and BCRP were detected in all placental samples assayed. Placental FLVCR1 expression was positively related to placental BCRP expression (n = 69; R(2) = 0.104; P < 0.05). Adolescents that were anemic at delivery had lower placental FLVCR1 expression (n = 49; P < 0.05). Placental FLVCR1 expression was positively associated with placental iron concentration at delivery (n = 61; R(2) = 0.064; P < 0.05). In contrast, placental BCRP expression was not significantly associated with maternal iron status or placental iron content. Both FLVCR1 and BCRP are highly expressed in human placental tissue, but only FLVCR1 was significantly inversely associated with maternal iron status and placental iron concentration. Further analysis is needed to explore potential functional roles of FLVCR1 in human placental iron transport.

Malaria, intestinal helminths and other risk factors for stillbirth in Ghana

Objective. The objective of the study was to assess Plasmodium/intestinal helminth infection in pregnancy and other risk factors for stillbirth in Ghana. Methods. A cross-sectional study of women presenting for delivery in two hospitals was conducted during November-December 2006. Data collected included sociodemographic information, medical and obstetric histories, and anthropometric measures. Laboratory investigations for the presence of Plasmodium falciparum and intestinal helminths, and tests for hemoglobin levels were also performed. Results. The stillbirth rate was relatively high in this population (5%). Most of the stillbirths were fresh and 24% were macerated. When compared to women with no malaria, women with malaria had increased risk of stillbirth (OR = 1.9, 95% CI = 1.2–9.3). Other factors associated with stillbirth were severe anemia, low serum folate concentration, past induced abortion, and history of stillbirth. Conclusion. The fact that most of the stillbirths were fresh suggests that higher quality intrapartum care could reduce stillbirth rates.

Impact of a Positive Deviance Approach to Improve the Effectiveness of an Iron-Supplementation Program to Control Nutritional Anemia among Rural Senegalese Pregnant Women

Background

Iron supplementation through prenatal care remains the most widespread strategy to control anemia during pregnancy, but its effectiveness is only partial, showing the need to address other approaches.

Objective

This study was conducted to measure the impact of a positive deviance approach to improve an iron-supplementation program among pregnant women in a rural Senegalese area.

Methods

A positive deviance approach (PD Micah) was compared with an ongoing integrated nutrition and health program intervention (Micah) in a rural Senegalese area. A pre-post evaluation was conducted using independent cross-sectional samples with a total of 371 pregnant women. A sociodemographic questionnaire was administered, and biologic and anthropometric measurements were performed.

Results

After 9 months of activities, the mean hemoglobin level rose from 93.9 to 100.7 g/L in the PD Micah group. Distribution of iron supplements through community volunteers and implementation of healthy pregnancy promotion sessions on a monthly basis improved the accessibility to 23.3% in the PD Micah group. No significant change was observed in the Micah group. Logistic regression analysis showed a significantly reduced risk of anemia in the PD Micah area (adjusted odds ratio, 0.25; 95% confidence interval, 0.12 to 0.53).

Conclusions

This intervention shows that a community-based strategy, such as the positive deviance approach, can contribute to improving the effectiveness of iron supplementation during pregnancy.

Serum hepcidin is significantly associated with iron absorption from food and supplemental sources in healthy young women

BACKGROUND

Hepcidin is a key regulator of iron homeostasis, but to date no studies have examined the effect of hepcidin on iron absorption in humans.

OBJECTIVE

Our objective was to assess relations between both serum hepcidin and serum prohepcidin with nonheme-iron absorption in the presence and absence of food with the use of dual stable-iron-isotope techniques.

DESIGN

The study group included 18 healthy nonpregnant women. Women received in random order a supplemental iron source (7.6 mg FeSO4 providing 0.9 mg 58Fe as FeSO4) and 6.8 mg 57Fe ferrous sulfate tracer administered with a nonheme food source [orange-fleshed sweet potato (OFSP): 1.4 mg native Fe]. Iron absorption was determined by analyzing blood samples taken 14 d after dosing with the use of magnetic sector thermal ionization mass spectrometry. Serum hepcidin was assessed by a new competitive serum enzyme-linked immunosorbent assay (ELISA) specific for the refolded, mature 25-amino acid form, and serum prohepcidin was assessed by an ELISA specific for amino acids 28-47 of the hepcidin prohormone.

RESULTS

In these women, iron absorption averaged 14.71 +/- 10.7% from the supplemental iron compared with 3.63 +/- 6.5% from the OFSP. Absorption of nonheme iron assessed in the presence (P = 0.038) and absence (P = 0.0296) of food was significantly associated with serum hepcidin but was not significantly related to serum prohepcidin.

CONCLUSION

Serum hepcidin, but not prohepcidin, was inversely associated with iron absorption from supplemental and food-based nonheme-iron sources in iron-replete healthy women.

Weekly iron and folic acid supplementation with counseling reduces anemia in adolescent girls: a large-scale effectiveness study in Uttar Pradesh, India

BACKGROUND

Weekly iron-folic acid supplementation in small-scale research trials and as administered in institutions has been demonstrated to be effective in reducing anemia in adolescent girls.

OBJECTIVE

To assess the effectiveness of weekly iron-folic acid supplementation in a large-scale project in reducing the prevalence of anemia in adolescent girls.

METHODS

The project provided weekly iron-folic acid tablets, family life education, and deworming tablets every 6 months to 150,700 adolescent school girls and non-schoolgirls of a total district population of 3,647,834. Consumption of the iron-folic acid tablets was supervised for schoolgirls but not for non-schoolgirls. Hemoglobin levels were assessed in a random sample of non-schoolgirls at 6 and 12 months and schoolgirls at 6 months. The effect of supplementation on the prevalence of anemia and the compliance rate were assessed over a 4-year period.

RESULTS

In 4 years, the overall prevalence of anemia was reduced from 73.3% to 25.4%. Hemoglobin levels and anemia prevalence were influenced significantly at 6 months. No difference in the impact on hemoglobin or anemia prevalence was observed between supervised and unsupervised girls. Counseling on the positive effects of regular weekly iron-folic acid intake contributed to a high compliance rate of over 85%. The cost of implementation was US$0.36 per beneficiary per year.

CONCLUSIONS

Weekly iron-folic acid supplementation combined with monthly education sessions and deworming every 6 months is cost-effective in reducing the prevalence of anemia in adolescent girls. Appropriate counseling, irrespective of supervision, is critical for achieving positive outcomes.

Maternal iron deficiency and the risk of schizophrenia in offspring

CONTEXT

Iron is essential for brain development and functioning. Emerging evidence suggests that iron deficiency in early life leads to long-lasting neural and behavioral deficits in infants and children. Adopting a life course perspective, we examined the effects of early iron deficiency on the risk of schizophrenia in adulthood.

OBJECTIVE

To determine whether maternal iron deficiency, assessed by maternal hemoglobin concentration during pregnancy, increases the susceptibility to schizophrenia spectrum disorders (SSDs) among offspring.

DESIGN

Data were drawn from a population-based cohort born from 1959 through 1967 and followed up for development of SSD from 1981 through 1997.

PARTICIPANTS

Of 6872 offspring for whom maternal hemoglobin concentration was available, 57 had SSDs (0.8%) and 6815 did not (99.2%).

MAIN OUTCOME MEASURE

Prospectively assayed, the mean value of maternal hemoglobin concentration was the primary exposure. Hemoglobin concentration was analyzed as a continuous and a categorical variable.

RESULTS

A mean maternal hemoglobin concentration of 10.0 g/dL or less was associated with a nearly 4-fold statistically significant increased rate of SSDs (adjusted rate ratio, 3.73; 95% confidence interval, 1.41-9.81; P = .008) compared with a mean maternal hemoglobin concentration of 12.0 g/dL or higher, adjusting for maternal education and ethnicity. For every 1-g/dL increase in mean maternal hemoglobin concentration, a 27% decrease in the rate of SSDs was observed (95% confidence interval, 0.55-0.96; P = .02).

CONCLUSIONS

The findings suggest that maternal iron deficiency may be a risk factor for SSDs among offspring. Given that this hypothesis offers the potential for reducing the risk for SSDs, further investigation in independent samples is warranted.

Nutritional indicators of adverse pregnancy outcomes and mother-to-child transmission of HIV among HIV-infected women

BACKGROUND

Poor nutrition may be associated with mother-to-child transmission (MTCT) of HIV and other adverse pregnancy outcomes.

OBJECTIVE

The objective was to examine the relation of nutritional indicators with adverse pregnancy outcomes among HIV-infected women in Tanzania, Zambia, and Malawi.

DESIGN

Body mass index (BMI; in kg/m(2)) and hemoglobin concentrations at enrollment and weight change during pregnancy were prospectively related to fetal loss, neonatal death, low birth weight, preterm birth, and MTCT of HIV.

RESULTS

In a multivariate analysis, having a BMI < 21.8 was significantly associated with preterm birth [odds ratio (OR): 1.82; 95% CI: 1.34, 2.46] and low birth weight (OR: 2.09; 95% CI: 1.41, 3.08). A U-shaped relation between weight change during pregnancy and preterm birth was observed. Severe anemia was significantly associated with fetal loss or stillbirth (OR: 3.67; 95% CI: 1.16, 11.66), preterm birth (OR: 2.08; 95% CI: 1.39, 3.10), low birth weight (OR: 1.76; 95% CI: 1.07, 2.90), and MTCT of HIV by the time of birth (OR: 2.26; 95% CI: 1.18, 4.34) and by 4-6 wk among those negative at birth (OR: 2.33; 95% CI: 1.15, 4.73).

CONCLUSIONS

Anemia, poor weight gain during pregnancy, and low BMI in HIV-infected pregnant women are associated with increased risks of adverse infant outcomes and MTCT of HIV. Interventions that reduce the risk of wasting or anemia during pregnancy should be evaluated to determine their possible effect on the incidence of adverse pregnancy outcomes and MTCT of HIV.

Lack of association between iron status at birth and growth of preterm infants

OBJECTIVE

To assess the association between iron status at birth and growth of preterm infants.

METHODS

Ninety-five premature babies (26 to 36 weeks of gestational age) born from July 2000 to May 2001 in a public hospital in Rio de Janeiro, Southeastern Brazil, were followed up for six months, corrected by gestational age. Iron measurements at birth were available for 82 mothers and 78 children: hemoglobin, hematocrit, mean corpuscular volume and plasma iron. All children received free doses of iron supplement (2 mg/kg/day) during the follow-up period and up to two years of age. Multivariate linear regression analyses with repeated measurements were performed to assess factors associated to linear growth.

RESULTS

Growth was more pronounced up to 40 weeks of gestational age, increasing about 1.0 cm/week and then slowing down to 0.75 cm/week. The multivariate analysis showed growth was positively associated with birth weight (0.4 cm/100 g; p<0.001) and negatively associated with gestational age at birth (-0.5 cm/week; p<0.001). There was no association between cord iron and mother iron measurements and growth (p>0.60 for all measures). Only two children had anemia at birth, whereas 43.9% of mothers were anemic (hemoglobin <11 g/dl). Also, there was no correlation between anemia indicators of mothers and children at birth (r<0.15; p>0.20).

CONCLUSIONS

Maternal anemia was not associated with anemia in preterm infants and iron status of mothers and children at birth was not associated with short-term growth of preterm infants.

A double-blind randomized controlled trial of antenatal mebendazole to reduce low birthweight in a hookworm-endemic area of Peru

OBJECTIVE

To assess the effect on birthweight of antenatal mebendazole plus iron vs. placebo plus iron in a highly hookworm-endemic area.

METHODS

Double-blind, randomized controlled trial set in rural and peri-urban communities in the Peruvian Amazon region. A total of 1042 second trimester pregnant women between the ages of 18 and 44 years were recruited from April to November 2003, and followed to July 2004. Women were randomly assigned to receive either mebendazole (500 mg single dose) plus iron supplements (60 mg elemental iron daily) or placebo plus iron supplements. The primary outcome was mean infant birthweight and secondary measures included proportion of low birthweight babies and maternal anaemia.

RESULTS

The prevalence of hookworm infection was 47.5%. There were no differences between intervention groups in mean birthweight (3104 g vs. 3090 g, P = 0.629), proportion of low birthweight (<2500 g; 8.1%vs. 8.7%, P = 0.755) or maternal anaemia in the third trimester [33.0% (158/479) vs. 32.3% (152/471), P = 0.815]. However, the proportion of very low birthweight (<1500 g) was significantly lower in the mebendazole group [0% (0/479) vs. 1.5% (7/471), P = 0.007].

CONCLUSIONS

This trial provides additional evidence for the use of anthelmintics, over and above iron supplementation, within antenatal care programmes in hookworm-endemic areas. Benefits of de-worming may be higher in countries not having an antenatal iron supplementation programme or where intensity of hookworm infections is higher.

Risk of stillbirth in relation to maternal haemoglobin concentration during pregnancy

The authors determined the association between maternal haemoglobin concentration measured at <28 weeks' gestation and late fetal death at >or=28 weeks' gestation (stillbirth). Data were derived from the National Maternal and Infant Health Survey--a nationally representative survey of US deliveries in 1988. Analysis was restricted to women with a singleton live birth (n = 4,199) or a stillbirth (n = 1,375) for whom maternal prenatal care, haemoglobin, smoking status and gestational age data were available. Haemoglobin concentrations during first and second trimesters, respectively, were classified as mild (10.0 to <11.0 and 9.5 to <10.5 g dL(-1)) or moderate (9.0 to <10.0 and 8.5 to <9.5 g dL(-1)) anaemia, or high haemoglobin (>or=14.6 g dL(-1) in either trimester). Hazard ratios (HR) and 95% confidence intervals (CI) for stillbirth were derived from discrete proportional hazards regression models after adjusting for confounders. Stillbirth was not associated with mild anaemia or high haemoglobin in either the first or second trimester of pregnancy. Moderate anaemia measured before 28 weeks' gestation was significantly associated with an increased risk of stillbirth among non-black women (adjusted HR: 4.4; 95% CI: 1.02, 19.01). Moderate anaemia was not associated with stillbirths among black women. Further investigation regarding causal mechanisms for this association is warranted.

School-Based Iron and Folic Acid Supplementation for Adolescent Girls: Findings from Manica Province, Mozambique

Background

The 1997 Demographic and Health Survey in Mozambique shows that 47% of girls 15 to 19 years old living in Manica province (west-central Mozambique) are pregnant or have already had a child. A recent survey also shows that 45% of girls 10 to 18 years old attending school are anemic. Strategies are needed to build iron stores before pregnancy and to control seasonal and chronic iron deficiency and anemia in school-aged girls.

Objective

To assess the program effectiveness of two school-based weekly iron and folic acid (IFA) supplementation regimes (5-month supplementation vs. 8-month supplementation) in girls 10 to 18 years old attending school in Manica province.

Methods

Twelve schools were included in the study. Schools were ordered by descending mean hemoglobin concentration, and assigned alternately to study group 5 (six schools; 5-month supplementation) or study group 8 (six schools; 8-month supplementation). In both study groups, the weekly supplement contained 60 mg of elemental iron and 400 μg of folic acid. All girls received a single dose of mebendazol (500 mg) twice—once at the beginning of the study (T0) and once six months later (T6). Supplementation was implemented and supervised by the teachers of the schools included in the study. Between T0 and T3, girls in study group 8 received IFA supplements weekly whereas girls in study group 5 did not. Between T3 and T8, all girls in both groups received weekly IFA supplements.

Results

At T0, mean hemoglobin concentration and anemia prevalence were comparable in study groups 8 and 5 (125.3 ± 12.6 g/L vs. 123.8 ± 12.8 g/L; 28% vs. 29%, respectively). At T3, the mean hemoglobin concentration in study group 8 was significantly higher (126.3 ± 14.3 g/L vs. 121.5 g/dL ± 11.9 g/L p < .001) and the prevalence of anemia was lower (28% vs. 35%, p = .076) than in study group 5. At T8, after an additional 5-month supplementation period in both study groups, mean hemoglobin concentration and anemia prevalence in study groups 8 and 5 were not significantly different (126.5 ± 12.6 g/L vs. 124.9 ± 12.3 g/L; 23% vs. 27%, respectively).

Conclusion

In Manica Province, school-based weekly IFA supplementation is a feasible and effective intervention to prevent seasonal drops in hemoglobin concentration and increases in anemia prevalence. Short supplementation periods can have an important impact on girls' hematological status. However, the size of girls' hematological response in this study was significantly lower that that observed in studies with similar population groups, initial anemia prevalence, supplement dosing, and/or supplementation regime.

A prospective, partially randomized study of pregnancy outcomes and hematologic responses to oral and intramuscular iron treatment in moderately anemic pregnant women

BACKGROUND

Daily oral iron supplementation during pregnancy fails to reduce the prevalence of anemia. However, 2 or 3 intramuscular doses of iron given at monthly intervals were recently found to be effective.

OBJECTIVE

We compared the safety and efficacy in treating pregnancy anemia of 3 intramuscular doses of iron given at monthly intervals with those of daily oral iron supplementation.

DESIGN

In a prospective, partially randomized study, 148 pregnant women received daily oral doses of 100 mg elemental Fe and 500 micro g folic acid, and 106 pregnant women received 3 intramuscular doses of 250 mg elemental Fe as iron dextran at 1-mo intervals and oral doses of 5 mg folic acid twice weekly. One hundred women in each group completed the study. Changes in hemoglobin, iron indicators, pregnancy outcomes, and birth weight were compared between the 2 groups.

RESULTS

Hemoglobin and iron indicators improved significantly with both treatments. The increase in serum ferritin concentration after parenteral iron treatment was significantly higher than that after oral iron treatment. No significant differences between the 2 groups in pregnancy outcomes and birth weight were observed. Systemic side effects were more common in the parenteral iron group, whereas gastrointestinal side effects were more common in the oral iron group.

CONCLUSIONS

The intramuscular administration of 3 doses of 250 mg Fe at monthly intervals appears to have good compliance and efficacy and may be used in women who cannot tolerate oral administration of iron. However, intramuscular administration of iron is appropriate only in hospital settings well equipped to treat anaphylactic crises.

Hemoglobin concentrations influence birth outcomes in pregnant African-American adolescents

Relationships between hemoglobin concentrations and birth outcomes have not been well characterized in African-American adolescents despite the fact that this group is at a higher risk of early childbearing. To address this issue, we characterized the prevalence of anemia and maternal factors associated with anemia in pregnant African-American adolescents. A retrospective medical chart review was undertaken of 918 adolescents who had received prenatal care at an inner-city maternity clinic between 1990 and 2000. Multiple log-linear regression analyses were used to address relationships between hemoglobin and adverse birth outcomes. The prevalence of anemia during the third trimester averaged 57-66% and was substantially higher than typically reported in adolescent and adult women. Multiparity, inadequate prenatal care, low prepregnancy BMI, history of self-reported cigarette use and infection with sexually transmitted diseases were significantly associated with lower hemoglobin during pregnancy. Adolescents with pre-eclampsia had higher hemoglobin (P < 0.01). Compared with the reference group (106-120 g/L), high hemoglobin (>120 g/L) during the second and third trimester significantly increased the risk of low birth weight (risk ratio (RR) = 3.11; [CI] 1.35, 7.13), and in the second-trimester cohort only, high hemoglobin concentrations increased the risk of preterm delivery (RR = 2.33; [CI] 1.07, 5.05). A U-shaped distribution between hemoglobin concentration and adverse birth outcomes was found in the third-trimester cohort when the reference range was decreased to 96-105 g/L to adjust for potentially lower hemoglobin concentrations among the African-American population. Our results suggest that additional medical attention may be warranted in pregnant African-American adolescents with hemoglobin concentrations of <or=95 g/L or >120 g/L.

A micronutrient-fortified beverage prevents iron deficiency, reduces anemia and improves the hemoglobin concentration of pregnant Tanzanian women

Maternal malnutrition continues to be a major contributor to adverse reproductive outcomes in developing countries, despite longstanding efforts to fortify foods or to distribute medicinal supplements to pregnant women. The objective of this study was to test the effect of a micronutrient-fortified beverage containing 11 micronutrients (iron, iodine, zinc, vitamin A, vitamin C, niacin, riboflavin, folate, vitamin B-12, vitamin B-6 and vitamin E) on the hemoglobin, iron and vitamin A status of pregnant women in Tanzania. A group of 259 pregnant women with gestational ages of 8 to 34 wk were enrolled in a randomized double-blind controlled trial in which study women received 8 wk of supplementation. Hemoglobin, ferritin and dried blood spot retinol were measured at baseline and at the end of the supplementation period. The supplement resulted in a 4.16 g/L increase in hemoglobin concentration and a 3 micro g/L increase in ferritin and reduced the risk of anemia and iron deficiency anemia by 51 and 56%, respectively. The risk of iron deficiency was reduced by 70% among those who had iron deficiency at baseline and by 92% among those who had adequate stores. The micronutrient-fortified beverage may be a useful and convenient preventative measure, one that could help improve the nutritional status of women both before and during pregnancy and thereby help avoid some of the potential maternal and fetal consequences of micronutrient deficiencies.

Maternal iron status influences iron transfer to the fetus during the third trimester of pregnancy

BACKGROUND

The effect of maternal iron status on fetal iron deposition is uncertain.

OBJECTIVE

We used a unique stable-isotope technique to assess iron transfer to the fetus in relation to maternal iron status.

DESIGN

The study group comprised 41 Peruvian women. Of these women, 26 received daily prenatal supplements containing iron and folate (n = 11; Fe group) or iron, folate, and zinc (n = 15; Fe+Zn group) from week 10-24 of pregnancy to 1 mo postpartum. The remaining 15 women (control group) received iron supplementation only during the final month of pregnancy. During the third trimester of pregnancy (+/- SD: 32.9 +/- 1.4 wk gestation) oral 57Fe (10 mg) and intravenous 58Fe (0.6 mg) stable iron isotopes were administered to the women, and isotope enrichment and iron-status indicators were measured in cord blood at delivery.

RESULTS

The net amount of 57Fe in the neonates' circulation (from maternal oral dosing) was significantly related to maternal iron absorption (P < 0.005) and inversely related to maternal iron status during the third trimester of pregnancy: serum ferritin (P < 0.0001), serum folate (P < 0.005), and serum transferrin receptors (P < 0.02). Significantly more 57Fe was transferred to the neonates in non-iron-supplemented women: 0.112 +/- 0.031 compared with 0.078 +/- 0.042 mg in the control group (n = 15) and the Fe and Fe+Zn groups (n = 24), respectively (P < 0.01). In contrast, 58Fe tracer in the neonates' circulation was not significantly related to maternal iron status.

CONCLUSION

The transfer of dietary iron to the fetus is regulated in response to maternal iron status at the level of the gut.

Maternal and perinatal outcome in varying degrees of anemia

OBJECTIVES

To analyze the maternal and perinatal outcome in varying degrees of anemia.

METHODS

A total of 447 pregnant women were divided into group I (Hb>11 g%, n=123 women), group II (Hb 9-10.9 g%, n=214 women), group III (Hb 7-8.9 g%, n=79 women) group IV (Hb<7 g%, n=31 women). Their maternal and perinatal outcome, mode of delivery, duration of labor and postpartum complications were noted and analyzed using multiple logistic regression to calculate odds ratios (95% CI) for duration of labor, mode of delivery and low birth babies. Chi square or Fisher's exact test was employed for difference in proportions and Student's t-test for testing difference between means.

RESULTS

Mean age (27+/-4.25 years) and number of women with parity >3 were highest in group IV. The patients with Hb<8.9 g% had a 4-6-fold higher risk of prolonged labor compared to Hb>11 g%. The odds ratios for abnormal delivery (cesarean and operative vaginal deliveries) showed a 4.8-fold higher risk (95% CI 1.82, 12.7) in patients with Hb </=7.5 g%. The mean birth weight was maximum in the 9.6-10.5 g% category that fell with both increasing and decreasing hemoglobin values, being lowest in Group IV. Women in Group II had lowest number of low birth weight and IUGR babies, no stillbirths and neonatal deaths, lowest induction and operative delivery rates.

CONCLUSIONS

Mild anemia fared best in maternal and perinatal outcome. Severe anemia was associated with increased low birth weight babies, induction rates, operative deliveries and prolonged labor.

Preventive nutritional supplementation throughout the reproductive life cycle

Current interest in preventive nutritional supplementation strategies during the reproductive cycle in developed countries focuses mainly on iron and folic acid. Iron deficiency is the most common cause of anaemia. Inadequate iron nutrition is mainly a problem in developing countries but it also seems to affect a large proportion of pregnant women in the industrialised world. There is no chance for diet modification alone to meet iron requirements during pregnancy. However, dietary advice must be provided to increase iron intake and iron bioavailability. The best choice is prescribed supplementation adapted to the individual's needs. Folic acid supplementation during the periconceptional period reduces the occurrence and recurrence of neural tube defects (NTDs). According to the updated edition of American Dietary Reference Intakes, recommended dietary allowance for folate for women of childbearing age varies throughout the reproductive cycle from 400 microg day(-1) of dietary folate equivalents (DFEs) for non-pregnant women, to 600 microg day(-1) DFEs for pregnant women and 500 microg day(-1) DFEs in lactating women. Increasing dietary folate, fortifying staple foods with folic acid or use of folic acid supplements can increase folate intake.

Iron deficiency in Europe

In Europe, iron deficiency is considered to be one of the main nutritional deficiency disorders affecting large fractions of the population, particularly such physiological groups as children, menstruating women and pregnant women. Some factors such as type of contraception in women, blood donation or minor pathological blood loss (haemorrhoids, gynaecological bleeding...) considerably increase the difficulty of covering iron needs. Moreover, women, especially adolescents consuming low-energy diets, vegetarians and vegans are at high risk of iron deficiency. Although there is no evidence that an absence of iron stores has any adverse consequences, it does indicate that iron nutrition is borderline, since any further reduction in body iron is associated with a decrease in the level of functional compounds such as haemoglobin. The prevalence of iron-deficient anaemia has slightly decreased in infants and menstruating women. Some positive factors may have contributed to reducing the prevalence of iron-deficiency anaemia in some groups of population: the use of iron-fortified formulas and iron-fortified cereals; the use of oral contraceptives and increased enrichment of iron in several countries; and the use of iron supplements during pregnancy in some European countries. It is possible to prevent and control iron deficiency by counseling individuals and families about sound iron nutrition during infancy and beyond, and about iron supplementation during pregnancy, by screening persons on the basis of their risk for iron deficiency, and by treating and following up persons with presumptive iron deficiency. This may help to reduce manifestations of iron deficiency and thus improve public health. Evidence linking iron status with risk of cardiovascular disease or cancer is unconvincing and does not justify changes in food fortification or medical practice, particularly because the benefits of assuring adequate iron intake during growth and development are well established. But stronger evidence is needed before rejecting the hypothesis that greater iron stores increase the incidence of CVD or cancer. At present, currently available data do not support radical changes in dietary recommendations. They include all means for increasing the content of dietary factors enhancing iron absorption or reducing the content of factors inhibiting iron absorption. Increased knowledge and increased information about factors may be important tools in the prevention of iron deficiency in Europe.

Biological mechanisms that might underlie iron's effects on fetal growth and preterm birth

A negative association between anemia and duration of gestation and low birth weight has been reported in the majority of studies, although a causal link remains to be proven. This paper explores potential biological mechanisms that might explain how anemia, iron deficiency or both could cause low birth weight and preterm delivery. The risk factors for preterm delivery and intrauterine growth retardation are quite similar, although relatively little is understood about the influence of maternal nutritional status on risk of preterm delivery. Several potential biological mechanisms were identified through which anemia or iron deficiency could affect pregnancy outcome. Anemia (by causing hypoxia) and iron deficiency (by increasing serum norepinephrine concentrations) can induce maternal and fetal stress, which stimulates the synthesis of corticotropin-releasing hormone (CRH). Elevated CRH concentrations are a major risk factor for preterm labor, pregnancy-induced hypertension and eclampsia, and premature rupture of the membranes. CRH also increases fetal cortisol production, and cortisol may inhibit longitudinal growth of the fetus. An alternative mechanism could be that iron deficiency increases oxidative damage to erythrocytes and the fetoplacental unit. Iron deficiency may also increase the risk of maternal infections, which can stimulate the production of CRH and are a major risk factor for preterm delivery. It would be useful to explore these potential biological mechanisms in randomized, controlled iron supplementation trials in anemic and iron-deficient pregnant women.

Hookworms, malaria and vitamin A deficiency contribute to anemia and iron deficiency among pregnant women in the plains of Nepal

Anemia and iron deficiency during pregnancy are prevalent in developing countries, but their causes are not always known. We assessed the prevalence and severity of anemia and iron deficiency and their association with helminths, malaria and vitamin A deficiency in a community-based sample of 336 pregnant women in the plains of Nepal. Hemoglobin, erythrocyte protoporphyrin (EP) and serum ferritin were assessed in venous blood samples. Overall, 72.6% of women were anemic (hemoglobin < 110 g/L), 19.9% had moderate to severe anemia (hemoglobin < 90 g/L) and 80.6% had iron deficiency (EP > 70 micromol/mol heme or serum ferritin < 10 microg/L). Eighty-eight percent of cases of anemia were associated with iron deficiency. More than half of the women (54.2%) had a low serum retinol concentration (<1.05 micromol/L), 74.2% were infected with hookworms and 19.8% had Plasmodium vivax malaria parasitemia. Hemoglobin, EP and serum ferritin concentrations were significantly worse and the prevalence of anemia, elevated EP and low serum ferritin was increased with increasing intensity of hookworm infection. Hookworm infection intensity was the strongest predictor of iron status, especially of depleted iron stores. Low serum retinol was most strongly associated with mild anemia, whereas P. vivax malaria and hookworm infection intensity were stronger predictors of moderate to severe anemia. These findings reinforce the need for programs to consider reducing the prevalence of hookworm, malaria infection and vitamin A deficiency where indicated, in addition to providing iron supplements to effectively control anemia.

Nutrition and maternal mortality in the developing world

This review relates nutritional status to pregnancy-related death in the developing world, where maternal mortality rates are typically >/=100-fold higher than rates in the industrialized countries. For 3 of the central causes of maternal mortality (ie, induced abortion, puerperal infection, and pregnancy-induced hypertension), knowledge of the contribution of nutrition is too scanty for programmatic application. Hemorrhage (including, for this discussion, anemia) and obstructed labor are different. The risk of death is greatly increased with severe anemia (Hb <70 or 80 g/L); there is little evidence of increased risk associated with mild or moderate anemia. Current programs of universal iron supplementation are unlikely to have much effect on severe anemia. There is an urgent need to reassess how to approach anemia control in pregnant women. Obstructed labor is far more common in short women. Unfortunately, nutritional strategies for increasing adult stature are nearly nonexistent: supplemental feeding appears to have little benefit after 3 y of age and could possibly be harmful at later ages, inducing accelerated growth before puberty, earlier menarche (and possible earlier marriage), and unchanged adult stature. Deprived girls without intervention typically have late menarche, extended periods of growth, and can achieve nearly complete catch-up growth. The need for operative delivery also increases with increased fetal size. Supplementary feeding could therefore increase the risk of obstructed labor. In the absence of accessible obstetric services, primiparous women <1.5 m in height should be excluded from supplementary feeding programs aimed at accelerating fetal growth. The knowledge base to model the risks and benefits of increased fetal size does not exist.

Improving prenatal nutrition in developing countries: strategies, prospects, and challenges

In developing countries, the health and nutrition of females throughout their entire life is affected by complex and highly interrelated biological, social, cultural, and health service-related factors. Rather than focusing exclusively on the prenatal period, we describe a life cycle approach to improving maternal nutrition, which goes beyond the traditional provision of nutrition services during pregnancy, by addressing risk factors that are present well before pregnancy, even before childbearing age. This approach involves specific policy initiatives and a "minimum package" program that is targeted at females. Policy actions and the components for effective implementation of the program are described. The prospects and challenges to be overcome-which include translating scientific knowledge into action, removing conceptual and implementational constraints, identifying biologically meaningful indicators for problem identification, and improving understanding of physiologic and social adaptation mechanisms-are discussed, as are persistent problems with health care delivery systems.

Long-term weekly iron supplementation improves and sustains nonpregnant women's iron status as well or better than currently recommended short-term daily supplementation

This 7-mo double-blind study compared the efficacy of two iron supplementation schemes in improving iron nutrition among 116 healthy fertile-age women. They were randomly distributed in three groups, receiving: Group 1, iron + folate (60 mg and 250 microg, respectively) daily for 3 mo (currently recommended scheme), and folate (250 microg) weekly the subsequent 4 mo. Group 2, folate daily, and 60 mg iron only once weekly for 3 mo, and then weekly iron + folate for 4 mo. Group 3, folate daily for 3 mo and then weekly for 4 mo. At baseline, 16% had depleted stores (plasma ferritin <15 microg/L) and 16% had hemoglobin levels <125 g/L. Eight percent had hemoglobin levels <120 g/L. In Group 1 hemoglobin and ferritin increased at 3 mo but returned to near basal conditions after 4 mo of weekly folate. In Group 2, hemoglobin and ferritin increased progressively throughout the 7 mo but mostly after 3 mo. Group 3 did not change. Side effects were highest with daily iron. Weekly iron supplementation over 7 mo (30 doses) improved and sustained iron nutrition at least as effectively and was better tolerated than 90 daily iron supplements consumed during 3 mo.

Iron supplementation for the control of iron deficiency in populations at risk

Iron supplementation, mostly with a therapeutic orientation, has been a key strategy for the short-term control of iron deficiency and ferropenic anemia. It has been used almost exclusively in antenatal clinics, but in spite of its confirmed efficacy in supervised trials, it has proven ineffective in practice in most developing countries. Poor effectiveness has been attributed to various factors including insufficient dose and time of supplementation and poor adherence. These problems have led to the administration of high iron doses, which have proven equally ineffective in practice. This paper introduces four concepts: (1) that iron supplementation targeted to pregnant women should cover the full reproductive cycle, from prepregnancy to at least the end of lactation instead of only the pregnant women; (2) that entering pregnancy with iron deficiency contributes to the failure of antenatal iron supplementation and that prepregnancy iron reserves increase the effectiveness of antenatal supplementation; (3) that medium- to long-term weekly ingestion of proper iron-folate supplements, with a preventive aim and directed to all risk groups, should be community based rather than health service based but supervised by the latter (in this sense, preventive supplementation is equal to targeted iron fortification); and (4) that preventive supplementation, based on weekly dosing, has proven efficacious. Problem-oriented research to evaluate the sustainability and medium- to long-term efficacy of these concepts is called for. The bases for the concepts and suggestions are summarized in this paper.

Pregnancy and iron deficiency: unresolved issues

Iron deficiency and iron deficiency anemia are prevalent among pregnant women. The extent to which iron deficiency affects maternal and neonatal health is uncertain. Existing data suggest that maternal iron deficiency anemia may be associated with adverse outcomes, including preterm delivery and higher maternal mortality. Further research is needed on the maternal and neonatal benefits of iron supplementation during pregnancy.

Anemia

OBJECTIVES

To provide an overview of the disorders that cause anemia and to review clinical and laboratory assessment and medical and nursing management of the anemic patient.

DATA SOURCES

Published articles and book chapters that pertain to red blood cell physiology and the major causes and types of anemia.

CONCLUSIONS

Advances in molecular and genetic aspects of anemia are leading to new developments in the diagnosis and management of all types of anemia. Symptomatic relief to maintain quality of life is essential for all anemic patients.

IMPLICATIONS FOR NURSING PRACTICE

Nurses can play a major role in the supportive care of patients with anemia through interventions related to pharmacological therapy, blood transfusions, nutritional counseling, and symptom management.