Neurologic manifestations of iron deficiency in childhood

Iron Deficiency Anemia in Children During and After PICU Stay: Single-Center Retrospective Cohort, 2021-2022

OBJECTIVES

The primary objective was to determine iron deficiency (ID) anemia (IDA) monitoring practices in children during PICU stay. A secondary objective was to determine the current follow-up practices for IDA after PICU discharge.

DESIGN

Retrospective observational study of 2 years (2021-2022).

SETTING

Single-center academic PICU in the United States.

SUBJECTS

All patients younger than 18 years and excluded patients who died in the PICU or within 6 months of PICU discharge.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Anemia was defined by a hemoglobin concentration of less than 11 g/dL. ID was defined by either a ferritin of less than 30 ng/mL or a transferrin saturation (TSAT) of less than or equal to 20%. Suspicion for functional iron deficiency (SID) was defined by ferritin greater than or equal to 30 ng/mL and TSAT less than or equal to 20%, given the hyperferritinemic effect of inflammation. We documented serum iron, total iron binding capacity, TSAT, ferritin, and hemoglobin at PICU admission and discharge and 3 and 6 months after discharge. Overall, 913 of 1275 met the inclusion criteria, and 492 patients had a hemoglobin of less than 11 g/dL. Only 93 of 492 (18.9%) had iron studies at any time during the PICU stay. Among the 93 patients with iron studies, 20 patients (22%) were lost to follow-up. Of the remaining 73 patients, 67 of 73 had a hemoglobin checked at 3 months, of which 37 of 67 (55%) were still anemic. At 6 months, there were 64 of 73 patients who had a hemoglobin checked, of which 32 of 64 (50%) were still anemic. At 3 months, 39 of 73 (53%) had iron studies performed; of these, 13 of 39 had ID, 12 of 39 had SID, and 14 of 39 had neither ID nor SID. At 6 months, 35 of 73 (48%) had iron studies; of these, ten of 35 had ID, 11 of 35 had SID, and 14 of 35 had neither ID nor SID.

CONCLUSIONS

Detection of ID and follow-up after PICU stay remain inadequate. We recommend that future studies assess the value of screening all critically ill patients for ID at the time of discharge and followed up, as necessary.

An analysis on role of iron deficiency in febrile seizure among children in 6 months to 5 years: A case-control study

Background for the Study

This study looks into the relationship between febrile seizures in children between the ages of 6 months to 5 years who suffer from iron insufficiency. Febrile seizures, which are common in early life, are associated with abrupt temperature increases, and iron deficiency impacts neurological development in young infants. Understanding this relationship would lead to interventions that mitigate febrile seizure impact.

Aim

To investigate the link between iron deficiency and febrile seizures in children between the ages of 6 months and 5 years.

Method

A "retrospective case-control study" of 300 cases and 300 controls, including demographic, seizure, and laboratory data, was conducted. Descriptive statistics were computed using "Chi-square tests for proportions" and "t-tests for means" with P ≤ 0.05 as the level of significance.

Result

Significant findings emerged, including a notably younger mean age among cases (1.75 years) compared to controls (2.93 years). Cases showed higher rates of upper respiratory tract infections (3.7% vs. 0.3% in controls) and lower occurrences of viral febrile illnesses. Notably, cases had a lower prevalence of non-vegetarian diets and a higher incidence of family histories related to seizures. "Iron deficiency anemia" was more common in these instances, evident in blood parameters, alongside increased WBC counts. Recurrent seizures correlated with a lower mean RBC count (P = 0.01).

Conclusion

The study confirms the link between "iron deficiency anemia" and "febrile seizures" among young children. Addressing iron deficiency emerges as a critical modifiable factor in potentially reducing the occurrence and impact of severe seizures, emphasizing the necessity of proactive efforts in pediatric treatment programs.

Effect of Piracetam and Iron Treatment on Heart Rate Variability in Patients With Breath-Holding Spell

BACKGROUND

Breath-holding spells are a benign condition primarily seen in 3% to 5% of healthy children aged between six months and five years. Although no specific treatment is recommended due to its benign nature, iron and piracetam are used in severe or recurrent cases. We planned to compare the heart rate variability (HRV) before and after treatment with 24-hour Holter monitoring in patients receiving iron and piracetam treatment and investigate the treatment's effectiveness.

METHODS

Twenty-five patients who applied to the outpatient clinic between 2013 and 2015 due to breath-holding spells were included in the study. The patients who received piracetam and iron therapy and underwent 24-hour rhythm Holter monitoring were evaluated retrospectively.

RESULTS

Fourteen (56%) of these patients were evaluated as having cyanotic-type and 11 (44%) patients were assessed as having pale-type breath-holding spells. A significant difference was found only between hourly peak heart rate and total power in the group receiving iron treatment. Significant differences were also found among the minimum heart rate, mean heart rate, the standard deviation of RR intervals, the mean square root of the sum of the squares of their difference between adjacent RR intervals, spectpow, and low frequency before and after the treatment in the patients who started piracetam treatment (P < 0.05).

CONCLUSIONS

Our study is critical as it is the first to investigate the effects of treatment options on various HRV in patients with breath-holding spells. There were statistically significant changes in HRV parameters in patients receiving piracetam, and the number of attacks decreased significantly. Piracetam treatment contributes positively to the breath-holding spell with regard to efficacy and HRV, therefore it can be used to treat breath-holding spells.

Anaemia in India and Its Prevalence and Multifactorial Aetiology: A Narrative Review

The prevalence of anaemia in India remains high in children, especially those in rural areas, and in women of childbearing age, and its impairment of neurological development can have serious lifelong effects. It is concerning that the most recent official data (2019-21) indicate an increased prevalence compared with 2015-16. There is also considerable variability in childhood anaemia between Indian states with socioeconomic factors, such as wealth and education contributing to the risk of anaemia among adolescent women and their children. Dietary iron deficiency is often regarded as the main contributor to anaemia but increasing evidence accumulated from the authors' ongoing literature database coupled with recent literature research suggests that it has a multifactorial aetiology, some of which is not related to nutrition. This narrative review focused on these multifactorial issues, notably the contribution of vitamin B12/folate deficiency, which also has a high prevalence in India. It was also noted that the dietary intake of bioavailable iron remains an important contributor for reducing anaemia, and the role of millets as an improved iron source compared to traditional staple cereals is briefly discussed. The overall conclusion is that anaemia has a multifactorial aetiology requiring multifactorial assessment that must include assessment of vitamin B12 status.

Overuse of EEG and ECG in children with breath-holding spells and its implication for the management of the spells

AIM

Breath-holding spells (BHS) are common in children, but evidence-based clinical guidelines are lacking. We investigated a large population-based cohort of BHS patients, to propose a refined description of typical BHS and guidelines for its management.

METHODS

In a cross-sectional retrospective study, patients diagnosed with BHS in Southern Sweden 2004-2018 were recruited. Disease characteristics and diagnostic data were collected from patient medical records.

RESULTS

In total, 519 patients, mean age at diagnosis 19.8 ± 13.8 months with equal gender distribution, were included. In 48.3%, BHS had already been diagnosed after one spell. During spells, 78.0% of patients were unresponsive. For 71.5%, atonic, tonic, tonic-clonic or myoclonic seizures were reported, and 78.0% of patients had a spell lasting less than 1 min. Electroencephalography was conducted in 30.4% and Electrocardiography in 45.1%. Six children (3.8%) had a pathological electroencephalogram, four of which had concomitant epilepsy and only 0.9% of children had electrocardiogram findings suggesting pathology, none showing long QT syndrome.

CONCLUSION

Children with BHS were frequently subjected to unnecessary diagnostic interventions. We characterise a typical presentation of BHS and propose a management-algorithm, which is expected to reduce unnecessary usage of electroencephalography and electrocardiography.

The bioaccessibility of adsorped heavy metals on biofilm-coated microplastics and their implication for the progression of neurodegenerative diseases

Microplastic (MP) tiny fragments (< 5 mm) of conventional and specialized industrial polymers are persistent and ubiquitous in both aquatic and terrestrial ecosystem. Breathing, ingestion, consumption of food stuffs, potable water, and skin are possible routes of MP exposure that pose potential human health risk. Various microorganisms including bacteria, cyanobacteria, and microalgae rapidly colonized on MP surfaces which initiate biofilm formation. It gradually changed the MP surface chemistry and polymer properties that attract environmental metals. Physicochemical and environmental parameters like polymer type, dissolved organic matter (DOM), pH, salinity, ion concentrations, and microbial community compositions regulate metal adsorption on MP biofilm surface. A set of highly conserved proteins tightly regulates metal uptake, subcellular distribution, storage, and transport to maintain cellular homeostasis. Exposure of metal-MP biofilm can disrupt that cellular homeostasis to induce toxicities. Imbalances in metal concentrations therefore led to neuronal network dysfunction, ROS, mitochondrial damage in diseases like Alzheimer's disease (AD), Parkinson's disease (PD), and Prion disorder. This review focuses on the biofilm development on MP surfaces, factors controlling the growth of MP biofilm which triggered metal accumulation to induce neurotoxicological consequences in human body and stategies to reestablish the homeostasis. Thus, the present study gives a new approach on the health risks of heavy metals associated with MP biofilm in which biofilms trigger metal accumulation and MPs serve as a vector for those accumulated metals causing metal dysbiosis in human body.

Clinical and Echocardiographic Correlates of Iron Status in Chronic Heart Failure Patients: A Cross-Sectional Descriptive Study

BACKGROUND

 Chronic heart failure (HF) is one of the conditions commonly seen in the medical outpatient departments, and iron deficiency (ID) has been reported as the commonest nutritional deficiency in these patients. The presence of ID may interfere with the clinical parameters of chronic HF. The relationship between iron status and chronic HF needs more attention and should be given more consideration in the evaluation of patients with chronic HF.

AIM

The aim of the study was to determine the relationship, if any, between iron status and clinical/echocardiographic variables in chronic HF.

METHODS AND MATERIALS

A cross-sectional descriptive study was carried out at the Lagos University Teaching Hospital (LUTH), Nigeria, where 88 patients with chronic HF were recruited to participate in this study. The participants underwent clinical and laboratory assessments. Iron status was assessed with full blood count parameters; serum ferritin and transferrin saturation (Tsat) and its relationship with clinical parameters among these participants were also studied.

RESULTS

No correlations existed between the duration of chronic HF and iron status when compared using Tsat. However, a significant weak negative correlation was observed between the duration of HF and the serum ferritin levels. The clinical characteristics of the HF participants with and without ID were compared. There was no significant difference in the frequency of prior hospitalization in both groups. However, a higher proportion of participants with severe HF (New York Heart Association (NYHA) classes III/IV) (n = 14; 46.7%) were iron-deficient compared to those with moderate chronic HF (NYHA II) (n = 11; 36.7%). This relationship was statistically significant. Left ventricular ejection fraction (LVEF) was similar in the iron-deficient and iron-replete groups (using serum ferritin or Tsat) both when compared as means and when compared after categorizing LVEF as HF with preserved ejection fraction (HFpEF) vs HF with reduced ejection fraction (HFrEF). There was no statistically significant correlation between the severity of ID and LVEF.  Conclusion: A spectrum of clinical changes occurs in patients with chronic HF. ID can make these changes more profound and the condition less amenable to standard HF treatments. These patients may therefore benefit from further evaluation for this nutritional deficiency. Laboratory measurements including Tsat and serum ferritin may help in further assessment of select patients with worse and/or non-responsive clinical parameters.

Prevalence and determinants of anemia at discharge in pediatric intensive care survivors

BACKGROUND

Restrictive transfusion practices are increasingly being followed in pediatric intensive care units (PICU); consequently, more patients are discharged anemic from PICU. Given the possible impact of anemia on long-term neurodevelopmental outcomes, we aim to describe the epidemiology of anemia at PICU discharge in a mixed (pediatric and cardiac) cohort of PICU survivors and to characterize risk factors for anemia.

STUDY DESIGN AND METHODS

We performed a retrospective cohort study in the PICU of a multidisciplinary tertiary-care university-affiliated center. All consecutive PICU survivors for whom a hemoglobin level was available at PICU discharge were included. Baseline characteristics and hemoglobin levels were extracted from an electronic medical records database.

RESULTS

From January 2013 to January 2018, 4750 patients were admitted to the PICU (97.1% survival); discharge hemoglobin levels were available for 4124 patients. Overall, 50.9% (n = 2100) were anemic at PICU discharge. Anemia at PICU discharge was also common in the cardiac surgery population (53.3%), mainly in acyanotic patients; only 24.6% of cyanotic patients were anemic according to standard definitions of anemia. Cardiac surgery patients were transfused more often and at higher hemoglobin levels than medical and non-cardiac surgery patients. Anemia at admission was the strongest predictor of anemia at discharge (odds ratios (OR): 6.51, 95% confidence interval (CI:5.40;7.85)).

DISCUSSION

Half of PICU survivors are anemic at discharge. Further studies are required to determine the course of anemia after discharge and to ascertain whether anemia is associated with adverse long-term outcomes.

A Study on the Clinical Profiles of Patients With Cerebrovascular Accident (Stroke) in a Tertiary Care Hospital in Jharkhand

Introduction Stroke is a devastating and disabling cerebrovascular disease with a significant amount of residual deficit. The prevalence of stroke is in a rising trend in India. Larger studies are needed for the evaluation of risk factors. Material and methods This cross-sectional study aimed to assess the clinical profile of patients with stroke. The demographic details of the patients were taken, comorbidities were noted, and laboratory tests were done. Observation The most common age group who presented with stroke was 61-80 years, followed by 41-60 years, comprising 47% and 46%, respectively. Ischemic stroke was more common (60%) than hemorrhagic stroke (40%). Male patients were more than female patients. Alcohol, smoking, hypertension, diabetes, anemia, and proteinuria were present in the study group. Conclusion Regular evaluation of blood pressure, blood sugar, lipid profile, and proteinuria should be routinely done in patients with diabetes and hypertension who are more than 40 years old.

Strategies to Reduce Diagnostic Blood Loss and Anemia in Hospitalized Patients: A Scoping Review

OBJECTIVES

Blood sampling is a recognized contributor to hospital-acquired anemia. We aimed to bundle all published neonatal, pediatric, and adult data regarding clinical interventions to reduce diagnostic blood loss.

DATA SOURCES

Four electronic databases were searched for eligible studies from inception until May 2021.

STUDY SELECTION

Two reviewers independently selected studies, using predefined criteria.

DATA EXTRACTION

One author extracted data, including study design, population, period, intervention type and comparator, and outcome variables (diagnostic blood volume and frequency, anemia, and transfusion).

DATA SYNTHESIS

Of 16,132 articles identified, we included 39 trials; 12 (31%) were randomized controlled trials. Among six types of interventions, 27 (69%) studies were conducted in adult patients, six (15%) in children, and six (15%) in neonates. Overall results were heterogeneous. Most studies targeted a transfusion reduction ( n = 28; 72%), followed by reduced blood loss ( n = 24; 62%) and test frequency ( n = 15; 38%). Small volume blood tubes ( n = 7) and blood conservation devices ( n = 9) lead to a significant reduction of blood loss in adults (8/9) and less transfusion of adults (5/8) and neonates (1/1). Point-of-care testing ( n = 6) effectively reduced blood loss (4/4) and transfusion (4/6) in neonates and adults. Bundles including staff education and protocols reduced blood test frequency and volume in adults (7/7) and children (5/5).

CONCLUSIONS

Evidence on interventions to reduce diagnostic blood loss and associated complications is highly heterogeneous. Blood conservation devices and smaller tubes appear effective in adults, whereas point-of-care testing and bundled interventions including protocols and teaching seem promising in adults and children.

Stroke-like Episodes in Inherited Neurometabolic Disorders

Stroke-like episodes (SLEs) are significant clinical manifestations of metabolic disorders affecting the central nervous system. Morphological equivalents presented in neuroimaging procedures are described as stroke-like lesions (SLLs). It is crucial to distinguish SLEs from cerebral infarction or intracerebral hemorrhage, mainly due to the variety in management. Another significant issue to underline is the meaning of the main pathogenetic hypotheses in the development of SLEs. The diagnostic process is based on the patient’s medical history, physical and neurological examination, neuroimaging techniques and laboratory and genetic testing. Implementation of treatment is generally symptomatic and includes L-arginine supplementation and adequate antiepileptic management. The main aim of the current review was to summarize the basic and actual knowledge about the occurrence of SLEs in various inherited neurometabolic disorders, discuss the possible pathomechanism of their development, underline the role of neuroimaging in the detection of SLLs and identification of the electroencephalographic patterns as well as histological abnormalities in inherited disorders of metabolism.

Metabolic-scale gene activation screens identify SLCO2B1 as a heme transporter that enhances cellular iron availability

Iron is the most abundant transition metal essential for numerous cellular processes. Although most mammalian cells acquire iron through transferrin receptors, molecular players of iron utilization under iron restriction are incompletely understood. To address this, we performed metabolism-focused CRISPRa gain-of-function screens, which revealed metabolic limitations under stress conditions. Iron restriction screens identified not only expected members of iron utilization pathways but also SLCO2B1, a poorly characterized membrane carrier. SLCO2B1 expression is sufficient to increase intracellular iron, bypass the essentiality of the transferrin receptor, and enable proliferation under iron restriction. Mechanistically, SLCO2B1 mediates heme analog import in cellular assays. Heme uptake by SLCO2B1 provides sufficient iron for proliferation through heme oxygenases. Notably, SLCO2B1 is predominantly expressed in microglia in the brain, and primary Slco2b1-/- mouse microglia exhibit strong defects in heme analog import. Altogether, our work identifies SLCO2B1 as a microglia-enriched plasma membrane heme importer and provides a genetic platform to identify metabolic limitations under stress conditions.

Impact of Blood Sampling on Anemia in the PICU: A Prospective Cohort Study

OBJECTIVES

Fifty percent of children are anemic after a critical illness. Iatrogenic blood testing may be a contributor to this problem. The objectives of this study were to describe blood sampling practice in a PICU, determine patient factors associated with increased sampling, and examine the association among blood sampling volume, anemia at PICU discharge, and change in hemoglobin from PICU entry to PICU discharge.

DESIGN

Prospective observational cohort study.

SETTING

PICU of Sainte-Justine University Hospital.

PATIENTS

All children consecutively admitted during a 4-month period.

MEASUREMENTS AND MAIN RESULTS

Four hundred twenty-three children were enrolled. Mean blood volume sampled was 3.9 (±19) mL/kg/stay, of which 26% was discarded volume. Children with central venous or arterial access were sampled more than those without access (p < 0.05). Children with sepsis, shock, or cardiac surgery were most sampled, those with a primary respiratory diagnosis; the least (p < 0.001). We detected a strong association between blood sample volume and mechanical ventilation (H, 81.35; p < 0.0001), but no association with severity of illness (Worst Pediatric Logistic Organ Dysfunction score) (R, -0.044; p = 0.43). Multivariate analysis (n = 314) showed a significant association between the volume of blood sampled (as continuous variable) and anemia at discharge (adjusted OR, 1.63; 95% CI, 1.18-2.45; p = 0.003). We lacked power to detect an association between blood sampling and change in hemoglobin from PICU admission to PICU discharge.

CONCLUSIONS

Diagnostic blood sampling in PICU is associated with anemia at discharge. Twenty-five percent of blood losses from sampling is wasted. Volumes are highest for patients with sepsis, shock, or cardiac surgery, and in patients with vascular access or ventilatory support.

Multi-Elemental Analysis of Human Optic Chiasm-A New Perspective to Reveal the Pathomechanism of Nerve Fibers' Degeneration

The effect of metals on the functioning of the human eye is multifactorial and includes enzyme activity modulation, trace metal metabolic pathways changes, and cytotoxic activity. Functional dysfunctions appear mostly as a result of the accumulation of toxic xenobiotic metals or disturbances of micronutrients’ homeostasis. So far, the affinity of selected metals to eye tissues, i.e., the cornea, choroid, lens, and anterior chamber fluid, has been most studied. However, it is known that many eye symptoms are related to damage to the optic nerve. In order to fill this gap, the aim of the study is to perform a multi-element analysis of tissue collected postmortem from optic chiasm and optic nerves. A total of 178 samples from 107 subjects were tested. The concentrations of 51 elements were quantified by inductively coupled plasma mass spectrometry (ICP-MS) after the wet-mineralization step. In terms of elemental composition, the optic chiasm is dominated by two trace elements, i.e., iron (Fe) and zinc (Zn), besides macro-elements Ca, K, Na, P, and Mg. The subjects formed a homogeneous cluster (over 70% subjects) with the highest accumulation of aluminum (Al). The remaining two departing clusters were characterized by an increased content of most of the elements, including toxic elements such as bismuth (Bi), uranium (U), lead (Pb), chromium (Cr), and cadmium (Cd). Changes in elemental composition with age were analyzed statistically for the selected groups, i.e., females, males, and subjects with alcohol use disorder (AUD) and without AUD. A tendency of women to lose Se, Cu, Zn, Fe with age was observed, and a disturbed Ca/Mg, Na/K ratio in subjects with AUD. Although the observed trends were not statistically significant, they shed new light on the risks and possible pathologies associated with metal neurotoxicity in the visual tract.

Iron-deficiency anaemia: the perils of excessive milk-drinking

Iron-deficiency anaemia is a widespread and largely preventable problem in the paediatric population, with numerous potential sequelae. We describe the case of a 2-year-old girl presenting with non-specific symptoms, who was found to be iron-deficient and anaemic, in the context of excessive cow's milk consumption. We explore the patient's diagnostic journey, including a neurological deterioration and the link between her iron deficiency and the final diagnosis.

Essential Metals in the Brain and the Application of Laser Ablation-Inductively Coupled Plasma-Mass Spectrometry for their Detection

Metals are natural component of the ecosystem present throughout the layers of atmosphere; their abundant expression in the brain indicates their importance in the central nervous system (CNS). Within the brain tissue, their distribution is highly compartmentalized, the pattern of which is determined by their primary roles. Bio-imaging of the brain to reveal spatial distribution of metals within specific regions has provided a unique understanding of brain biochemistry and architecture, linking both the structures and the functions through several metal mediated activities. Bioavailability of essential trace metal is needed for normal brain function. However, disrupted metal homeostasis can influence several biochemical pathways in different fields of metabolism and cause characteristic neurological disorders with a typical disease process usually linked with aberrant metal accumulations. In this review we give a brief overview of roles of key essential metals (Iron, Copper and Zinc) including their molecular mechanisms and bio-distribution in the brain as well as their possible involvement in the pathogenesis of related neurodegenerative diseases. In addition, we also reviewed recent applications of Laser Ablation Inductively Couple Plasma Mass Spectrophotometry (LA-ICP-MS) in the detection of both toxic and essential metal dyshomeostasis in neuroscience research and other related brain diseases.

Iron supplementation for hypoferritinemia-related psychological symptoms in children and adolescents

BACKGROUND

Although some studies have described the association between serum ferritin levels and specific disorders in child and adolescent psychiatry, few have focused on mental health with low serum ferritin levels in children and adolescents. This study examined the effects of iron administration on psychological state of children and adolescents with reduced serum ferritin concentration.

METHODS

This prospective study evaluated 19 participants aged 6-15 years with serum ferritin levels <30 ng/mL who visited a mental health clinic and received oral iron administration for 12 weeks. The participants were assessed using the Clinical Global Impression Severity (CGI-S), Profile of Mood States 2nd Edition Youth-Short (POMS), Center for Epidemiologic Studies Depression Scale (CES-D), and Pittsburgh Sleep Quality Index (PSQI). In addition to serum ferritin, blood biochemical values such as hemoglobin (Hb) and mean corpuscular volume (MCV) were examined. School attendance was recorded.

RESULTS

The most prevalent physical symptoms were fatigability and insomnia. The CGI-S, PSQI, and CES-D scores decreased significantly following iron supplementation, whereas the scores of almost all POMS subscales improved significantly at week 12. No participant had hemoglobin levels <12 g/dL. Serum ferritin concentration increased significantly, whereas Hb and MCV remained unchanged. At baseline, 74% of the participants did not attend school regularly; this number improved to varying degrees by week 12.

DISCUSSION

Serum ferritin levels would be preferable to be measured in children and adolescents with insomnia and/or fatigability regardless of psychiatric diagnoses or gender. Iron supplementation can improve the hypoferritinemia-related psychological symptoms of children and adolescents, such as poor concentration, anxiety, depression, low energy and/or irritability.

Anemia after Pediatric Congenital Heart Surgery

The postoperative course of infants following congenital heart surgery is associated with significant blood loss and anemia. Optimal transfusion thresholds for cardiac surgery patients while in pediatric intensive care unit (PICU) remain a subject of debate. The goal of this study is to describe the epidemiology of anemia and the transfusion practices during the PICU stay of infants undergoing congenital heart surgery. A retrospective cohort study was performed in a PICU of a tertiary university-affiliated center. Infants undergoing surgery for congenital heart disease (CDH) before 6 weeks of age between February 2013 and June 2019 and who were subsequently admitted to the PICU were included. We identified 119 eligible patients. Mean age at surgery was 11 ± 7 days. Most common cardiac diagnoses were d-Transposition of the Great Arteries (55%), coarctation of the aorta (12.6%), and tetralogy of Fallot (11.8%). Mean hemoglobin level was 14.3 g/dL prior to surgery versus 12.1 g/dL at the PICU admission. Hemoglobin prior to surgery was systematically higher than hemoglobin at the PICU entry, except in infants with Hypoplastic Left Heart Syndrome. The average hemoglobin at PICU discharge was 11.7 ± 1.9 g/dL. Thirty-three (27.7%) patients were anemic at PICU discharge. Fifty-eight percent of patients received at least one red blood cell (RBC) transfusion during PICU stay. This study is the first to describe the epidemiology of anemia at PICU discharge in infants following cardiac surgery. Blood management of this distinctive and vulnerable population requires further investigation as anemia is a known risk factor for adverse neurodevelopment delays in otherwise healthy young children.

Maternal Ferritin Levels during Pregnancy and ADHD Symptoms in 4-Year-Old Children: Results from the INMA-INfancia y Medio Ambiente (Environment and Childhood) Prospective Birth Cohort Study

Ferritin status during prenatal brain development may influence the risk of attention deficit and hyperactivity disorder (ADHD) symptoms in childhood. We investigated the association of maternal ferritin in pregnancy and ADHD-like symptoms in offspring. A total of 1095 mother-child pairs from three birth cohorts of the INMA Project (Spain) were studied. Maternal plasma ferritin in pregnancy was measured at 11.57 weeks of gestation. Children′s ADHD-like symptoms at ages 4–5 years were assessed using the ADHD Rating Scale-IV. The count model of the zero-inflated Poisson regression model showed a significant inverse association between ferritin (continuous variable) and inattention, β = −0.19 (−0.32, −0.07), for boys. Comparing ferritin level by tertiles, significant differences were observed between the first tertile ([1.98, 20.92]) and the second ([20.92, 38.79]) and third tertiles ([38.79, 216.5]) (mg/L).The number of symptoms was lower for those in the third tertile, β = −0.3 (−0.55, −0.5), and for those in the second one, β = −0.37 (−0.6, −0.14). The model stratification by sex also showed this inverse association for boys only, β = −0.21 (−0.34, −0.08). No associations were found between ferritin level and hyperactivity or total ADHD symptoms. High ferritin levels during pregnancy show a protective association with child inattentive-type ADHD symptoms.

Too Much of a Good Thing? Cerebral Sinovenous Thrombosis Due to Excessive Milk Intake Associated Anemia

INTRODUCTION

In young children, excessive cow's milk intake causes iron-deficiency anemia, which is associated with hypercoagulable states. We present a case series of 4 toddlers with excessive milk intake iron-deficiency anemia and cerebral sinovenous thrombosis.

METHODS

Retrospective chart review of 4 patients was performed for patients with cerebral sinovenous thrombosis and iron-deficiency anemia secondary to excessive milk intake. Iron-deficiency anemia was defined as hemoglobin <11 mg/dL, mean corpuscular volume <70 fL, and serum ferritin <12 μg/L. Excessive milk intake was defined as consumption of >24 oz daily. Clinical, laboratory, and radiographic features were reviewed.

RESULTS

Age ranged from 12 to 24 months. Average hemoglobin, hematocrit, mean corpuscular volume, and ferritin levels were 6.1 g/dL, 22.7 g/dL, 52.7 fL, and 3.2 ng/mL, respectively. Daily milk consumption ranged from 40 to 60 oz. All patients presented with focal neurologic deficits, including seizures in 3. The location of cerebral sinovenous thrombosis varied, and 3 patients had venous infarcts, one of them hemorrhagic. All patients had a limited diet and were described as "picky eaters" by their parents, and only 1 had transitioned of a bottle. All patients were treated with anticoagulation, iron supplementation, and extensive dietary counseling to reduce cow's milk intake.

CONCLUSION

Iron-deficiency anemia due to excessive milk intake is an important and preventable etiology of pediatric cerebral sinovenous thrombosis. Focused anticipatory guidance is necessary for at-risk groups to prevent this neurologic emergency.

Bilateral vertical gaze palsy due to midbrain infarct associated with iron deficiency anemia in a young boy

An 8-year-old boy presented with complaints of sudden-onset binocular vertical diplopia of one day duration. Ophthalmic examination showed restricted up- and downgaze movement with rotatory nystagmus. Systemic investigations revealed iron-deficiency anemia and localized acute infarct in the left paramedian rostral and dorsal part of the upper midbrain at the level of the red nucleus on magnetic resonance imaging. The patient was started on oral iron supplement, which resulted in symptomatic as well as clinical improvement after 2 weeks.

Effects of iron deficiency anemia on peripapillary and macular vessel density determined using optical coherence tomography angiography on children

PURPOSE

To evaluate retinal vascular parameters by optical coherence tomography angiography (OCT-A) in iron deficiency anemia (IDA).

METHODS

Thirty-two patients with IDA (study group) and 30 healthy children (control group) were enrolled in the study. All subjects underwent a complete ocular examination. OCT-A scans were performed in a 6 × 6 mm area centered on the macula. Foveal avascular zone (FAZ), non-flow area (NFA), FAZ perimeter (PERIM), acircularity index (AI) of FAZ, and foveal density (FD) were measured in the superficial capillary plexus (SCP) and deep capillary plexus (DCP). SCP and DCP were also scanned centered on the optic disk. Hemoglobin (Hb), mean corpuscular volume (MCV), serum iron, total iron-binding capacity (TIBC), and ferritin were also studied and compared for both groups.

RESULTS

The mean age was 12.22 ± 4.48 years (ranged 5-18 years) in the study group and 12.37 ± 3.76 years (ranged 6-18 years) in the control group. The mean FAZ value was 0.290 ± 0.09 mm² in the study group and 0.298 ± 0.11 mm² in the control group. The mean NFA value was 0.477 ± 0.10 mm² in the study group and 0.486 ± 0.13 mm² in the control group (p > 0.05). FD and AI were not statistically significant between the study group and control group (p > 0.05). The mean value for SCP was statistically significant between the study group and control group (p < 0.05). The mean value for DCP was not significantly different between the study and control groups (p > 0.05). The mean values for capillary density on optic disk were also statistically significant between the study group and control group (p < 0.05). A negative correlation was found between serum iron, TIBC, and capillary plexus density (p < 0.05). A positive correlation was found between MCV and ferritin values and capillary plexus density (p < 0.05).

CONCLUSION

IDA had significantly lower capillary plexus density. We detected retinal microvascular changes in young IDA patients before significant ocular anomalies, especially ischemic changes, developed.

Evaluation of dietary intake in children and college students with and without attention-deficit/hyperactivity disorder

Objectives: To evaluate dietary intake among individuals with and without attention-deficit hyperactivity disorder (ADHD), to evaluate the likelihood that those with ADHD have inadequate intakes. Methods: Children, 7-12 years old, with (n = 23) and without (n = 22) ADHD, and college students, 18-25 years old, with (n = 21) and without (n = 30) ADHD comprised the samples. Children's dietary intake was assessed by a registered dietitian using 24-hour recalls over 3 days. College students kept a detailed food record over three days. Dietary information for both groups was entered into the Nutrition Data Systems for Research database, and output was analyzed using SAS 9.4. Nutrient analyses included the Healthy Eating Index-2010, Micronutrient Index (as a measure of overall micronutrient intake), and individual amino acids necessary for neurotransmission. Logistic regression was used to model the association of nutrient intake with ADHD. Models were adjusted for age, sex, IQ (or GPA), and energy intake (or total protein intake) as appropriate. Significance was evaluated at P = 0.05, and using the Benjamini-Hochberg corrected P-value for multiple comparisons. Results: No evidence existed for reduced nutrient intake among those with ADHD compared to controls in either age group. Across both groups, inadequate intakes of vitamin D and potassium were reported in 95% of participants. Children largely met nutrient intake guidelines, while college students failed to meet these guidelines for nine nutrients. In regards to amino acid intake in children, an increased likelihood of having ADHD was associated with higher consumption of aspartate, OR = 12.61 (P = 0.01) and glycine OR = 11.60 (P = 0.05); and a reduced likelihood of ADHD with higher intakes of glutamate, OR = 0.34 (P = 0.03). Among young adults, none of the amino acids were significantly associated with ADHD, though glycine and tryptophan approached significance. Discussion: Results fail to support the hypothesis that ADHD is driven solely by dietary micronutrient inadequacy. However, amino acids associated with neurotransmission, specifically those affecting glutamatergic neurotransmission, differed by ADHD status in children. Amino acids did not reliably vary among college students. Future larger scale studies are needed to further examine whether or not dietary intake of amino acids may be a modulating factor in ADHD.

Dysmaturation of Premature Brain: Importance, Cellular Mechanisms, and Potential Interventions

Prematurity, especially preterm birth (less than 32 weeks' gestation), is common and associated with high rates of both survival and neurodevelopmental disability, especially apparent in cognitive spheres. The neuropathological substrate of this disability is now recognized to be related to a variety of dysmaturational disturbances of the brain. These disturbances follow initial brain injury, particularly cerebral white matter injury, and involve many of the extraordinary array of developmental events active in cerebral white and gray matter structures during the premature period. This review delineates these developmental events and the dysmaturational disturbances that occur in premature infants. The cellular mechanisms involved in the genesis of the dysmaturation are emphasized, with particular focus on the preoligodendrocyte. A central role for the diffusely distributed activated microglia and reactive astrocytes in the dysmaturation is now apparent. As these dysmaturational cellular mechanisms appear to occur over a relatively long time window, interventions to prevent or ameliorate the dysmaturation, that is, neurorestorative interventions, seem possible. Such interventions include pharmacologic agents, especially erythropoietin, and particular attention has also been paid to such nutritional factors as quality and source of milk, breastfeeding, polyunsaturated fatty acids, iron, and zinc. Recent studies also suggest a potent role for interventions directed at various experiential factors in the neonatal period and infancy, i.e., provision of optimal auditory and visual exposures, minimization of pain and stress, and a variety of other means of environmental behavioral enrichment, in enhancing brain development.

A study on association of iron deficiency with attention deficit hyperactivity disorder in a tertiary care center

BACKGROUND

Iron is important for brain development and cognitive function. Iron deficiency may cause alteration of neurotransmitters and may be manifested by different central nervous system disorders including attention deficit hyperactivity disorder (ADHD).

AIMS

As studies are scarce in the Indian context, we had undertaken this study to find out the association between iron deficiency and ADHD.

SETTINGS AND DESIGN

Hospital-based cross-sectional study.

MATERIALS AND METHODS

Hematological parameters indicating iron status (hemoglobin [Hb], ferritin, Iron, total iron binding capacity [TIBC], mean corpuscular volume [MCV], and mean corpuscular Hb [MCH]) were measured among 119 ADHD patients selected by complete enumeration method and 119 controls.

STATISTICAL ANALYSIS

Shapiro-Wilk test, Mann-Whitney U-test, Spearman's correlation, and binary logistic regression were used. P < 0.01 was taken as statistically significant.

RESULTS

Hb, iron, ferritin, MCV, and MCH were lower among cases and negatively correlated to ADHD, while reverse is true for TIBC and ADHD. Iron deficiency anemia makes one 3.82 times more prone for ADHD.

CONCLUSION

Iron deficiency was associated with ADHD.

Status of essential elements in autism spectrum disorder: systematic review and meta-analysis

Autism spectrum disorder (ASD) is a lifelong neurodevelopmental disorder that imposes heavy financial burden on governments and families of affected children. It is considered a multifactorial condition, where trace elements are among environmental factors that may contribute to ASD. Meanwhile, the between-study variance is high. The present systematic review was designed to investigate the difference in trace element measures between patients with ASD and control subjects. Meta-analyses showed that the hair concentrations of chromium (p=0.024), cobalt (p=0.012), iodine (p=0.000), iron (p=0.017), and magnesium (p=0.007) in ASD patients were significantly lower than those of control subjects, while there were higher magnesium levels in the hair of ASD patients compared to that of controls (p=0.010). Patients with ASD had higher blood levels of copper (p=0.000) and lower levels of zinc compared to controls (p=0.021). Further urinary iodine levels in patients with ASD were decreased in comparison with controls (p=0.026). Sensitivity analyses showed that ASD patients in non-Asian but not in Asian countries had lower hair concentrations of chromium compared to controls. Also, such analyses indicated that ASD patients in Asian countries had lower hair zinc concentrations, whereas ASD patients in non-Asian countries had higher hair zinc concentrations in comparison with control subjects. This study found significant differences in the content of trace elements between patients with ASD compared to controls. The findings help highlighting the role of trace elements as environmental factors in the etiology of ASD.

Anemia and stroke: Where do we stand?

Anemia seems to have a clear relationship with cerebrovascular events (CVEs), as there is a direct connection between central nervous system, blood supply, and tissue oxygen delivery. Anemia is considered a hyperkinetic state which disturbs endothelial adhesion molecule genes that may lead to thrombus formation. Furthermore, blood flow augmentation and turbulence may result in the migration of this thrombus, thus producing artery-to-artery embolism. It is for this reason that anemia is characterized as "the fifth cardiovascular risk factor." Anemia is consistently present in patients with acute stroke, ranging from 15% to 29%, while the mortality rate was significantly higher in patients suffering from anemia at the time of admission. Different types of anemia (sickle cell disease, beta thalassemia, iron deficiency anemia [IDA]) have been associated with increased cardiovascular and CVE risk. The relation between hemoglobin level and stroke would require further investigation. Unfortunately, treatment of anemia in cardiovascular and cerebrovascular disease still lacks clear targets and specific therapy has not developed. However, packed red blood cell transfusion is generally reserved for therapy in patients with CVEs. What is more, treatment of IDA prevents thrombosis and the occurrence of stroke; although iron levels should be checked, chronic administration favors thrombosis. Regarding erythropoietin (EPO), as there is lack of studies in anemic stroke patients, it would be desirable to utilize both neuroprotective and hematopoietic properties of EPO in anemic stroke patients. This review aims to clarify the poorly investigated and defined issues concerning the relation of anemia and CVEs.

Neurological Complications of Nutritional Disease

Vitamins and minerals have essential functions in the body, from signal transduction to acting as cofactors for numerous enzymatic processes. Nutritional deficiencies and excess of certain vitamins and minerals can have profound effects on the central and peripheral nervous systems from early development into adulthood. This article summarizes the role of various nutritional factors in the nervous system and the neurological symptoms that can arise from deficiency or excess.

Tactile stimulation partially prevents neurodevelopmental changes in visual tract caused by early iron deficiency

Iron deficiency has a critical impact on maturational mechanisms of the brain and the damage related to neuroanatomical parameters is not satisfactorily reversed after iron replacement. However, emerging evidence suggest that enriched early experience may offer great therapeutic efficacy in cases of nutritional disorders postnatally, since the brain is remarkably responsive to its interaction with the environment. Given the fact that tactile stimulation (TS) treatment has been previously shown to be an effective therapeutic approach and with potential application to humans, here we ask whether exposure to TS treatment, from postnatal day (P) 1 to P32 for 3min/day, could also be employed to prevent neuroanatomical changes in the optic nerve of rats maintained on an iron-deficient diet during brain development. We found that iron deficiency changed astrocyte, oligodendrocyte, damaged fiber, and myelinated fiber density, however, TS reversed the iron-deficiency-induced alteration in oligodendrocyte, damaged fiber and myelinated fiber density, but failed to reverse astrocyte density. Our results suggest that early iron deficiency may act by disrupting the timing of key steps in visual system development thereby modifying the normal progression of optic nerve maturation. However, optic nerve development is sensitive to enriching experiences, and in the current study we show that this sensitivity can be used to prevent damage from postnatal iron deficiency during the critical period.

The Role of Elements in Anxiety

Elements (bioelements) are necessary factors required for the physiological function of organisms. They are critically involved in fundamental processes of life. Extra- and intracellular message and metabolic pathway factors as well as structural components include one or many elements in their functional structure. Recent years have seen an intensification in terms of knowledge gained about the roles of elements in anxiety disorders. In this chapter we present a review of the most important current data concerning the involvement of zinc, magnesium, copper, lithium, iron, and manganese, and their deficiency, in the pathophysiology and treatment of anxiety.

Using Machine Learning to Predict Laboratory Test Results

OBJECTIVES

While clinical laboratories report most test results as individual numbers, findings, or observations, clinical diagnosis usually relies on the results of multiple tests. Clinical decision support that integrates multiple elements of laboratory data could be highly useful in enhancing laboratory diagnosis.

METHODS

Using the analyte ferritin in a proof of concept, we extracted clinical laboratory data from patient testing and applied a variety of machine-learning algorithms to predict ferritin test results using the results from other tests. We compared predicted with measured results and reviewed selected cases to assess the clinical value of predicted ferritin.

RESULTS

We show that patient demographics and results of other laboratory tests can discriminate normal from abnormal ferritin results with a high degree of accuracy (area under the curve as high as 0.97, held-out test data). Case review indicated that predicted ferritin results may sometimes better reflect underlying iron status than measured ferritin.

CONCLUSIONS

These findings highlight the substantial informational redundancy present in patient test results and offer a potential foundation for a novel type of clinical decision support aimed at integrating, interpreting, and enhancing the diagnostic value of multianalyte sets of clinical laboratory test results.

Metals and Neurodegeneration

Metals play important roles in the human body, maintaining cell structure and regulating gene expression, neurotransmission, and antioxidant response, to name a few. However, excessive metal accumulation in the nervous system may be toxic, inducing oxidative stress, disrupting mitochondrial function, and impairing the activity of numerous enzymes. Damage caused by metal accumulation may result in permanent injuries, including severe neurological disorders. Epidemiological and clinical studies have shown a strong correlation between aberrant metal exposure and a number of neurological diseases, including Alzheimer’s disease, amyotrophic lateral sclerosis, autism spectrum disorders, Guillain–Barré disease, Gulf War syndrome, Huntington’s disease, multiple sclerosis, Parkinson’s disease, and Wilson’s disease. Here, we briefly survey the literature relating to the role of metals in neurodegeneration.

Dietary LC-PUFA in iron-deficient anaemic pregnant and lactating guinea pigs induce minor defects in the offsprings' auditory brainstem responses

OBJECTIVES

We previously demonstrated that a mild pre-natal/early post-natal iron-deficient anaemic (IDA) diet devoid of long-chain polyunsaturated fatty acids (LC-PUFA) affected development, neurophysiology, and cerebral lipid biochemistry of the guinea pigs' progeny. Impacts of dietary LC-PUFA on altered cerebral development resulting from pre-natal IDA are unknown. To address this health issue, impacts of mild gestational IDA in the presence of dietary LC-PUFA on the offsprings' neural maturation were studied in guinea pigs using auditory brainstem responses (ABRs) and assessments of brain fatty acids (FAs).

METHODS

Female guinea pigs (n = 10/group) were fed an iron sufficient (IS) or IDA diet (146 and 12.7 mg iron/kg, respectively) with physiological amounts of LC-PUFA, during the gestation and lactation periods. From post-natal day (PNd) 9 onwards, the IS + PUFA diet was given to both groups of weaned offspring. Cerebral tissue and offsprings' ABR were collected on PNd24.

RESULTS

There was no difference in peripheral and brainstem transmission times (BTTs) between IS + PUFA and IDA + PUFA siblings (n = 10/group); the neural synchrony was also similar in both groups. Despite the absence of differences in auditory thresholds, IDA + PUFA siblings demonstrated a sensorineural hearing loss in the extreme range of frequencies (32, 4, and 2 kHz), as well as modified brain FA profiles compared to the IS + PUFA siblings.

DISCUSSION

The present study reveals that siblings born from dams exposed to a moderate IDA diet including balanced physiological LC-PUFA levels during pregnancy and lactation demonstrate minor impairments of ABR compared to the control siblings, particularly on the auditory acuity, but not on neural synchrony, auditory nerve velocity and BTT.

Assessing the iron delivery efficacy of transferrin in clinical samples by native electrospray ionization mass spectrometry

Serum transferrin is a key player in iron homeostasis, and its ability to deliver iron to cells via the endosomal pathway critically depends on the presence of carbonate that binds this protein synergistically with ferric ion. Oxalate is another ubiquitous anionic species that can act as a synergistic anion, and in fact its interaction with transferrin is notably stronger compared to carbonate, preventing the protein from releasing the metal in the endosomal environment. While this raises concerns that high oxalate levels in plasma may interfere with iron delivery to tissues, concentration of free oxalate in blood appears to be a poor predictor of impeded availability of iron, as previous studies showed that it cannot displace carbonate from ferro-transferrin on a physiologically relevant time scale under the conditions mimicing plasma. In this work we present a new method that allows different forms of ferro-transferrin (carbonate- vs. oxalate-bound) to be distinguished from each other by removing this protein from plasma without altering the composition of the protein/metal/synergistic anion complexes, and determining their accurate masses using native electrospray ionization mass spectrometry (ESI MS). The new method has been validated using a mixture of recombinant proteins, followed by its application to the analysis of clinical samples of human plasma, demonstrating that native ESI MS can be used in clinical analysis.

Schoolchildren with Learning Difficulties Have Low Iron Status and High Anemia Prevalence

Background. In developing countries there is high prevalence of iron deficiency anemia, which reduces cognitive performance, work performance, and endurance; it also causes learning difficulties and negative impact on development for infant population.Methods. The study concerns a case-control study; data was collected from an appropriate sample consisting of schoolchildren aged 8 years. The sample was divided into two subgroups: those with deficient initial reading skills (DIRS) (case) and those without (control). Blood samples were taken to analyze hemoglobin and serum ferritin levels. These results were then used to compare the two groups with Student’st-test. Association between DIRS and anemia was analyzed using odds ratio (OR).Results. Hemoglobin and serum ferritin levels of schoolchildren with DIRS were statistically lower when compared to those without, hemoglobinp=0.02and serum ferritinp=0.04. DIRS was statistically associated with a risk of anemia with a weighted OR of 1.62.Conclusions. In this study, schoolchildren with DIRS had lower hemoglobin and serum ferritin levels when compared to those without.

Enhancing endogenous stem cells in the newborn via delayed umbilical cord clamping

There is currently no consensus among clinicians and scientists over the appropriate or optimal timing for umbilical cord clamping. However, many clinical studies have suggested that delayed cord clamping is associated with various neonatal benefits including increased blood volume, reduced need for blood transfusion, increased cerebral oxygenation in pre-term infants, and decreased frequency of iron deficiency anemia in term infants. Human umbilical cord blood contains significant amounts of stem and progenitor cells and is currently used in the treatment of several life-threatening diseases. We propose that delayed cord clamping be encouraged as it enhances blood flow from the placenta to the neonate, which is accompanied by an increase supply of valuable stem and progenitor cells, as well as may improve blood oxygenation and increase blood volume, altogether reducing the infant's susceptibility to both neonatal and age-related diseases.

Association between iron deficiency and febrile seizures

OBJECTIVE

The relationship between iron status and febrile seizures has been examined in various settings, mainly in the Developing World, with conflicting results. The aim of this study was to investigate any association between iron deficiency and febrile seizures (FS) in European children aged 6-60 months.

DESIGN

Prospective, case-control study.

SETTING

Greek population in Thessaloniki.

PATIENTS

50 patients with febrile seizures (cases) and 50 controls (children presenting with fever, without seizures).

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Haematologic parameters (haemoglobin concentration, haematocrit, mean corpuscular volume, red cell distribution width), plasma iron, total iron-binding capacity, plasma ferritin, transferrin saturation and soluble transferrin receptors were compared in cases and controls.

RESULTS

Plasma ferritin was lower (median [range]: 42.8 (3-285.7) vs 58.3 (21.4-195.3 ng/ml; p = 0.02) and Total Iron Binding Capacity (TIBC) higher (mean [Standard Deviation] 267 [58.9] vs 243 [58.45] μg/dl, p = 0.04) in cases than in controls. Results were similar for 12 complex FS cases (ferritin 30 (3-121 vs 89 (41.8-141.5ng/lL; TIBC 292.92 [68.0] vs 232.08 [36.27] μg/dL). Iron deficiency, defined as ferritin <30 ng/ml, was more frequent in cases (24%) than controls (4%; p = 0.004). Ferritin was lower and TIBC higher in 18 with previous seizures than in 32 with a first seizure although haemoglobin and mean cell haemoglobin concentration were higher.

CONCLUSIONS

European children with febrile seizures have lower Ferritin than those with fever alone, and iron deficiency, but not anaemia, is associated with recurrence. Iron status screening should be considered as routine for children presenting with or at high risk for febrile seizures.

Cognitive impairment associated with low ferritin responsive to iron supplementation

BACKGROUND

Iron deficiency is the most common nutritional deficiency in children. It affects 9% of children ages 1-3 years. Iron is essential for effective mitochondrial electron transport and neurotransmitter synthesis. Iron deficiency has been correlated with impaired psychomotor development, pica, attention deficit disorder, periodic limb movements of sleep, and breath-holding spells. Ferritin is the storage form of iron.

PATIENT SERIES

We assessed three children referred for developmental concerns. Extensive testing and neuroimaging were all unremarkable except for low iron stores. Dietary histories revealed excessive milk consumption in two of the children. After dietary adjustments and iron supplementation, iron stores normalized.

CONCLUSIONS

This cohort demonstrated a dramatic improvement in cognition once iron stores were repleted, suggesting iron studies should be considered as part of initial investigations of patients with cognitive concerns.

Cerebral sinovenous thrombosis associated with iron deficiency anemia secondary to severe menorrhagia: a case report

Cerebral sinovenous thrombosis is a rare condition presenting with a wide spectrum of nonspecific symptoms that can make early diagnosis difficult. Cerebral sinovenous thrombosis has been associated with various etiologies. Iron deficiency anemia associated with cerebral sinovenous thrombosis in teenagers is rare. We present a teenage patient with complete thrombosis of the vein of Galen, straight sinus, and left internal cerebral vein associated with iron deficiency anemia due to severe menorrhagia. Mechanisms that can explain the association between iron deficiency anemia and thrombosis are discussed.

Mild iron deficiency anaemia during pregnancy and lactation in guinea pigs alters amplitudes and auditory nerve velocity, but not brainstem transmission times in the offspring's auditory brainstem response

OBJECTIVES

It is well known that postnatal/early childhood iron deficiency (ID) anaemia (IDA) adversely affects infants' cognitive development and neurophysiology. However, the effects of IDA during gestation and lactation on the offspring are largely unknown. To address this health issue, the impact of mild IDA during gestation and lactation on the offsprings' neural maturation was studied in the guinea pig, using auditory brainstem responses (ABRs) latencies and amplitudes.

METHODS

Female guinea pigs (n = 10/group) were fed an iron sufficient (ISD) or deficient diet (IDD) (144 and 11.7 mg iron/kg) during the gestation and lactation periods. From postnatal day (PNd) 9 onward, the ISD was given to both groups of weaned offspring. The offsprings' ABRs were collected on PNd24 using a broad range of stimulus intensities in response to 2, 4, 8, 16, and 32 kHz tone pips.

RESULTS

Although the IDA siblings (n = 8) did not differ in brainstem transmission times (BTTs) compared to the IS siblings (n = 8), they showed significant delayed peak I latency at 100 and 80 dB, respectively. Additionally, significantly higher ABR wave amplitudes were observed in the IDA female offspring between 35 and 50 dB (4 kHz), a phenomenon suggestive of a neural hyperactivity (hyperacusis).

DISCUSSION

In support to our previous findings, the present results indicate that a mild IDA during gestation and lactation can have detrimental effects on early development of the offsprings' hearing and nervous systems, particularly on neural synchrony and auditory nerve conduction velocity, but not on BTT.

Iron deficiency anemia as a risk factor for cerebrovascular events in early childhood: a case-control study

In recent years, iron-deficiency anemia (IDA) has been suggested to have an association with childhood-onset ischemic stroke in otherwise healthy children, but few cases have proven it thus far. In this study, we aimed to investigate whether iron-deficiency anemia is a risk factor for cerebrovascular events and childhood-onset ischemic stroke in previously healthy children. This was a case-control study that included 21 stroke cases with patients who had previously been generally healthy, and matched with age and gender of 100 healthy control subjects. Patients were included if a diagnosis of definite stroke had been made and other known etiologies of childhood onset stroke were excluded. For all subjects, iron parameters including serum iron, ferritin, transferrin, total iron binding capacity, and transferrin saturation were assessed. We screened all case patients for prothrombotic factors including level of hemoglobin S, protein C, protein S, antithrombin III, lupus anticoagulant, factor V Leiden, and prothrombin gene mutation (G20210A). Brain magnetic resonance images (MRI), magnetic resonance angiography (MRA), and magnetic resonance venography (MRV) were performed to all case patients. All case patients have normal results regarding functional, immunological, and molecular assay for prothrombotic factors screening. Our results showed that IDA was disclosed in 57.1 % of stroke cases with no identified cause, as compared to 26 % of controls. Our study suggest that previously healthy children who developed stroke are 3.8 times more likely to have IDA than healthy children, who do not develop stroke (OR, 3.8; 95 % CI:1.3-11.2 P = 0.005). In addition, there was significant interaction between IDA and thrombocytosis among studied cases (OR, 10.5; 95 % CI, 1.0-152 P = 0.02). There were nonsignificant differences between stroke patients with IDA and those with normal iron parameters regarding stroke subtype (P > 0.05). Public health messages on the importance of early detection of iron-deficiency anemia in young children, especially in our developing countries so that it can be treated before a life-threatening complication like stroke develops.