Predictors of improvement in hemoglobin concentration among toddlers enrolled in the Massachusetts WIC Program

Qualitative assessments of anemia-related programs in Ghana reveal gaps and implementation challenges

In spite of multiple program efforts in Ghana, progress in reducing the burden of anemia is slow. The objective was to conduct multilevel assessments of existing childhood (<5 years) anemia prevention and treatment programs according to UNICEF's conceptual framework of malnutrition, and to elucidate implementation gaps in Ghana. Purposive and snowball sampling strategies recruited 25 program personnel from 20 organizations to participate in audiorecorded interviews conducted through in‐person, telephone, or email correspondence in August 2018. Interview guides constructed around UNICEF's conceptual framework of malnutrition identified context‐specific immediate, underlying, and basic causes of anemia, and corresponding programs. Interviews were transcribed, coded, and analyzed using the Dedoose software version 8.1.8. Few programs addressed identified basic causes of anemia, such as inadequate human resources, housing/water/toilet facilities, and poverty/poor access to financial resources. Organizations implemented programs addressing ≥1 underlying cause. Five organizations provided food rations and/or supplements to address immediate causes. A key food‐based gap identified was minimal education on fruit intake or antinutritive factors in foods; however, no interventions included vitamin C supplements. Food manufacturers mainly used cereals and grains in commercial food products. Multiple organizations worked in the same region on anemia with instances of an overlapping program focus. Food sources of vitamin C or supplements could be promoted in food‐based interventions to increase the absorption of nonheme iron consumed.

Dynamic Anemia Status from Infancy to Preschool-Age: Evidence from Rural China

Anemia is a serious nutritional deficiency among infants and toddlers in rural China. However, it is unclear how the anemia status changes among China's rural children as they age. This study investigates the prevalence of anemia as children grow from infancy to preschool-age, as well as the dynamic anemia status of children over time. We conducted longitudinal surveys of 1170 children in the Qinba Mountain Area of China in 2013, 2015 and 2017. The results show that 51% of children were anemic in infancy (6-12 months), 24% in toddlerhood (22-30 months) and 19% at preschool-age (49-65 months). An even larger share of children (67%) suffered from anemia at some point over the course of study. The data also show that although only 4% of children were persistently anemic from infancy to preschool-age, 8% of children saw their anemia status deteriorate. We further found that children may be at greater risk for developing anemia, or for having persistent anemia, during the period between toddlerhood and preschool-age. Combined with the finding that children with improving anemia status showed higher cognition than persistently anemic children, there is an urgent need for effective nutritional interventions to combat anemia as children grow, especially between toddlerhood and preschool age.

Recovery From Malnutrition Among Refugee Children Following Participation in the Special Supplemental Nutrition for Women, Infants, and Children (WIC) Program in Massachusetts, 1998-2010

OBJECTIVES

(1) To examine patterns of catch-up growth and anemia correction in refugee children younger than 5 years after participation in the Special Supplemental Nutrition for Women, Infants, and Children (WIC) program, and (2) to identify factors associated with recovery from growth abnormalities.

DESIGN

Records on 1731 refugee children younger than 5 years who arrived in Massachusetts between 1998-2010 were matched to WIC program records and then restricted to 779 children who had at least 2 WIC visits. Kaplan-Meier curves and Cox proportional hazards models were used to examine how sex affected time to recovery from malnutrition and anemia. Factors associated with recovery were analyzed in SAS using multivariate logistic regression.

SETTING

Massachusetts.

PARTICIPANTS

Refugee children younger than 5 years on arrival, who visited a WIC program at least twice between 1998 and 2010.

MAIN OUTCOME MEASURES

(1) Proportion of children who recovered from low height-for-age (stunting), low weight-for-age, low weight-for-height (wasting), and anemia; (2) odds ratios for factors associated with recovery; and (3) Kaplan-Meier curves showing recovery over time from low height-for-age, low weight-for-age, and low weight-for-height.

RESULTS

The number of WIC visits was associated with recovery from stunting, wasting, low weight-for-age, and anemia; results reached statistical significance for stunting (odds ratio [OR] = 8.64; 95% confidence interval [CI], 2.25-33.19), low weight-for-age (OR = 5.28; 95% CI, 1.35-20.73), and anemia (OR = 6.50; 95% CI, 2.69-15.69). Female sex was associated with recovery from stunting, wasting, and low weight-for-age, whereas male sex was associated with recovery from anemia; the associations were statistically significant between female sex and stunting (OR = 9.14; 95% CI, 1.93-43.29), wasting (OR = 14.78; 95% CI, 1.57-138.85), and low weight-for-age (OR = 4.29; 95% CI, 1.09-16.79).

CONCLUSIONS

Children who remained engaged in WIC may recover better from malnutrition than children with fewer WIC visits, although there are limitations to the available data.These findings suggest that those working with refugee families should prioritize outreach toward initiating and maintaining WIC program enrollment for eligible refugee children.

Periconception weight management in the Women, Infants, and Children program

INTRODUCTION

Reproductive age women, particularly low-income and minority women, are at risk for obesity. As an integral service provider for these women, the US Department of Agriculture Special Supplemental Nutrition Program for Women, Infants, and Children is uniquely positioned to refine its focus and efforts.

METHODS

Strategies for accomplishing this goal include identifying pregnant, inter-partum and post-partum women in need of targeted patient-centred services including education, counselling and support to address weight loss or appropriate gestational weight gain.

RESULTS

These services may include calorie-controlled diets, behavioural strategies, alternative methods of education delivery and extending post-partum benefits. Implementation of these strategies is feasible through collaboration with related government subsidized programs and reallocation of funds, staff and other resources.

CONCLUSIONS

Given the magnitude of the problem and the adverse outcomes that obesity has on health and quality of life, Women, Infants, and Children can more positively impact the lives of our most vulnerable families, which face an obesogenic environment.

Breastfeeding, Mixed, or Formula Feeding at 9 Months of Age and the Prevalence of Iron Deficiency and Iron Deficiency Anemia in Two Cohorts of Infants in China

OBJECTIVE

To assess associations between breastfeeding and iron status at 9 months of age in 2 samples of Chinese infants.

STUDY DESIGN

Associations between feeding at 9 months of age (breastfed as sole milk source, mixed fed, or formula fed) and iron deficiency anemia (IDA), iron deficiency, and iron sufficiency were determined in infants from Zhejiang (n = 142) and Hebei (n= 813) provinces. Iron deficiency was defined as body iron < 0 mg/kg, and IDA as iron deficiency + hemoglobin < 110 g/L. Multiple logistic regression assessed associations between feeding pattern and iron status.

RESULTS

Breastfeeding was associated with iron status (P < .001). In Zhejiang, 27.5% of breastfed infants had IDA compared with 0% of formula-fed infants. The odds of iron deficiency/IDA were increased in breastfed and mixed-fed infants compared with formula-fed infants: breastfed vs formula-fed OR, 28.8 (95% CI, 3.7-226.4) and mixed-fed vs formula-fed OR, 11.0 (95% CI, 1.2-103.2). In Hebei, 44.0% of breastfed infants had IDA compared with 2.8% of formula-fed infants. With covariable adjustment, odds of IDA were increased in breastfed and mixed-fed groups: breastfed vs formula-fed OR, 78.8 (95% CI, 27.2-228.1) and mixed-fed vs formula-fed OR, 21.0 (95% CI, 7.3-60.9).

CONCLUSIONS

In both cohorts, the odds of iron deficiency/IDA at 9 months of age were increased in breastfed and mixed-fed infants, and iron deficiency/IDA was common. Although the benefits of breastfeeding are indisputable, these findings add to the evidence that breastfeeding in later infancy identifies infants at risk for iron deficiency/IDA in many settings. Protocols for detecting and preventing iron deficiency/IDA in breastfed infants are needed.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT00642863 and NCT00613717.

Association between total duration of breastfeeding and iron deficiency

OBJECTIVE

To determine whether there is an association between the total breastfeeding duration and iron stores, iron deficiency, and iron deficiency anemia in healthy urban children.

METHODS

A cross-sectional study of healthy children, aged 1 to 6 years, seen for primary health care between December 2008 and July 2011 was conducted through the TARGet Kids! practice-based research network. Univariate and adjusted regression analyses were used to evaluate an association between total breastfeeding duration and serum ferritin, iron deficiency, and iron deficiency anemia.

RESULTS

Included were 1647 healthy children (median age 36 months) with survey, anthropometric, and laboratory data. An association was found between increasing duration of breastfeeding and lower serum ferritin (P = .0015). Adjusted logistic regression analysis revealed the odds of iron deficiency increased by 4.8% (95% confidence interval: 2%-8%) for each additional month of breastfeeding. Exploratory analysis suggested an increasing cumulative probability of iron deficiency with longer total breastfeeding duration with an adjusted odds ratio of 1.71 (95% confidence interval: 1.05-2.79) for iron deficiency in children breastfed over versus under 12 months of age. The relationship between total breastfeeding duration and iron deficiency anemia did not meet statistical significance.

CONCLUSIONS

Increased total breastfeeding duration is associated with decreased iron stores, a clinically important association warranting additional investigation.

The use of multiple logistic regression to identify risk factors associated with anemia and iron deficiency in a convenience sample of 12-36-mo-old children from low-income families

BACKGROUND

The prevalence of iron deficiency (ID) anemia among preschool-age children remains relatively high in some areas across the United States. Determination of risk factors associated with ID is needed to allow children with identifiable risk factors to receive appropriate education, testing, and follow-up.

OBJECTIVE

We aimed to evaluate risk factors associated with anemia and ID in a sample of children participating in or applying for the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC).

DESIGN

The study was a cross-sectional study of a convenience sample of 12-36-mo-old children recruited from WIC clinics in 2 California counties (n = 498).

RESULTS

Current WIC participation by the child and a greater rate of weight gain were negatively associated, and current maternal pregnancy was positively associated with anemia (hemoglobin < 110 g/L at 12-<24 mo or < 111 g/L at 24-36 mo) after control for age, sex, and ethnicity. Maternal WIC participation during pregnancy, child age, and the intake of > or =125 mL orange or tomato juice/d were negatively associated, and being male and living in an urban location were positively associated with ID (> or =2 of the following abnormal values: ferritin < or = 8.7 microg/L, transferrin receptors > or = 8.4 microg/mL, and transferrin saturation < or = 13.2%).

CONCLUSIONS

Current WIC participation by the child and maternal WIC participation during pregnancy were negatively associated with anemia and ID, respectively. It is anticipated that the risk factors identified in this study will be included in the development of an educational intervention focused on reducing the risk factors for ID and ID anemia in young children.

Full breastfeeding duration and risk for iron deficiency in U.S. infants

BACKGROUND

National and international authorities recommend exclusive breastfeeding for an infant's first 6 months. Effects of these recommendations on iron status of U.S. children are unknown.

OBJECTIVE

To ascertain if full breastfeeding for 6 months versus 4 months places U.S. children at greater risk for iron deficiency.

DESIGN/METHODS

Data regarding 2268 children ages 6 to <24 months from NHANES III, a nationally representative cross-sectional survey conducted from 1988-1994, were analyzed. Similar analyses were conducted for 526 children ages 12 to <24 months from NHANES 1999-2002. Anemia (low hemoglobin or history of anemia) and iron status (serum ferritin) were compared for five groups: formula fed only (n = 1142), or full breastfeeding for: 1 month "FullBF<1" (n = 425), 1 to <4 months "FullBF1-3+" (n = 343), 4 to <6 months "FullBF4-5+" (n = 222), and >or= 6 months "FullBF6" (n = 136). Laboratory data were available for children 12 to 24 months (n = 745). SUDAAN software was used to account for the complex sampling design. Logistic regression adjusted for confounding factors.

RESULTS

In unadjusted analyses (NHANES III), 10.0% of "FullBF6+" versus 2.3% of "FullBF4-5+" had a history of anemia (p = 0.007) but unadjusted between group serum ferritin and hemoglobin differences were insignificant in both surveys. Adjusting for birth weight and demography revealed persistently lower risk of history of anemia (NHANES III, odds ratio [OR] 0.20, confidence interval [CI] 0.06, 0.63) and low serum ferritin (NHANES 1999-2002, OR 0.19, CI 0.06, 0.57) but not low hemoglobin at time of survey "FullBF4-5+" versus "FullBF6."

CONCLUSIONS

Young children in the United States fully breastfed for 6 months may be at increased risk of iron deficiency. Adequate iron may not be provided by typical complementary infant foods. Healthcare providers should be vigilant to prevent iron deficiency in this group of infants.

Continuing anemia prevention strategies are needed throughout early childhood in low-income preschool children

OBJECTIVE

To assess anemia incidence and persistence in low-income preschool children in the United States.

STUDY DESIGN

Using 2000 to 2004 data from Center for Disease Control and Prevention's Pediatric Nutrition Surveillance System, we constructed 4 cohorts. Children in each cohort had a baseline hemoglobin measurement at either age 12 +/- 2 months (n = 583,149), 18 +/- 2 months (n = 399,223), 24 +/- 2 months (n = 382,605), or 36 +/- 2 months (n = 300,817) and a follow-up hemoglobin measurement 12 +/- 2 months later, when they were approximately 24, 30, 36, or 48 months old. Defining anemia as a hemoglobin level < 11.0 g/dL (< 24 months old) or hemoglobin < 11.1 g/dL (> or = 24 mo), we calculated anemia incidence and persistence in each cohort and used multiple logistic regression to identify associated factors (race, sex, birthweight, height, weight, breastfeeding).

RESULTS

Anemia incidence declined with age. Persistence remained approximately 30%. In each cohort, 70% of follow-up anemia cases were incident. Compared with white children, black children had greater odds of incident anemia at each follow-up age (odds ratio [OR], 1.84-2.09), while Native American children had lower odds at 36 and 48 months of age (OR, 0.68, 0.65). Both Asian and black children had greater odds of persistent anemia than white children at each age (OR, 1.73-2.60).

CONCLUSIONS

Most follow-up anemia in each cohort was incident, underscoring the importance of anemia prevention throughout early childhood in this population. Investigation of the causes of anemia is warranted.

Community empowerment: a partnership approach to public health program implementation

Public policy implementation models reflect who makes decisions, how success is defined, and whether learning is built into decision making. The extant implementation models capture many important features of public policy implementation, including the desire of large public bureaucracies to impose order and rationality on implementation structures that include many public and private organizations. Analysis of the three-decades-long process of implementation of the Special Supplemental Nutrition Program for Women, Infants, and Children suggests that a new public policy implementation model is needed. The new model builds on the iterative learning cycles and shared decision making of community participatory research and better addresses the transactional relationship between program targets and providers than do current implementation models.