Risk factors for poor iron status in British toddlers: further analysis of data from the National Diet and Nutrition Survey of children aged 1.5-4.5 years

Bioavailability of Australian pre-schooler iron intakes at specific eating occasions is low

PURPOSE

Poor bioavailability may contribute to iron deficiency among children in high-resource countries, but iron bioavailability of Australian pre-schooler diets is unknown. This study aimed to estimate the bioavailability of Australian pre-schooler iron intakes across the day and by eating occasions to identify optimal timing for intervention, by using five previously developed algorithms, and to estimate the proportion of children with intakes of absorbable iron below the requirements.

METHODS

Dietary data of children aged 2 to < 6 y (n = 812) from the 2011-12 National Nutrition and Physical Activity Survey were collected via two 24-h recalls. Usual food and nutrient intakes were estimated via Multiple Source Method. Phytate, polyphenol, and heme iron values were sourced from international databases or the literature. Five previously published algorithms were applied to observed dietary data to estimate iron bioavailability and calculate the prevalence of children with intakes of absorbable iron below requirements.

RESULTS

Pre-schooler daily iron bioavailability was low (2.7-10.5%) and corresponded to intakes of 0.18-0.75 mg/d of absorbable iron. The proportion of children with inadequate intakes of absorbable iron ranged between 32 and 98%. For all eating occasions, dinner offered iron of the greatest bioavailability (4.2-16.4%), while iron consumed at breakfast was of the lowest bioavailability (1.2-5.6%).

CONCLUSION

Future strategies are required to improve intakes of bioavailable iron for pre-schoolers to prevent the risk of deficiency. These strategies could include the encouragement of concomitant consumption of enhancers of iron absorption with iron-rich sources, particularly at breakfast.

Baby Food Pouches, Baby-Led Weaning, and Iron Status in New Zealand Infants: An Observational Study

Iron deficiency in infants can impact development, and there are concerns that the use of baby food pouches and baby-led weaning may impair iron status. First Foods New Zealand (FFNZ) was an observational study of 625 New Zealand infants aged 6.9 to 10.1 months. Feeding methods were defined based on parental reports of infant feeding at "around 6 months of age": "frequent" baby food pouch use (five+ times per week) and "full baby-led weaning" (the infant primarily self-feeds). Iron status was assessed using a venepuncture blood sample. The estimated prevalence of suboptimal iron status was 23%, but neither feeding method significantly predicted body iron concentrations nor the odds of iron sufficiency after controlling for potential confounding factors including infant formula intake. Adjusted ORs for iron sufficiency were 1.50 (95% CI: 0.67-3.39) for frequent pouch users compared to non-pouch users and 0.91 (95% CI: 0.45-1.87) for baby-led weaning compared to traditional spoon-feeding. Contrary to concerns, there was no evidence that baby food pouch use or baby-led weaning, as currently practiced in New Zealand, were associated with poorer iron status in this age group. However, notable levels of suboptimal iron status, regardless of the feeding method, emphasise the ongoing need for paying attention to infant iron nutrition.

Determinants of iron-rich food deficiency among children under 5 years in sub-Saharan Africa: a comprehensive analysis of Demographic and Health Surveys

BACKGROUND

Iron deficiency is a major public health problem that affects the physical and cognitive development of children under 5 years of age (under-5 children) in sub-Saharan Africa (SSA). However, the factors associated with the limited consumption of iron-rich foods in the region are poorly understood.

OBJECTIVE

This study examined the prevalence and determinants of iron-rich food deficiency among under-5 children in 26 SSA countries.

DESIGN

This nationally representative quantitative study employed pooled data from Demographic and Health Surveys conducted between 2010 and 2019.

METHODS

Representative samples comprising 296 850 under-5 children from the various countries were used. Bivariate and multivariate logistic regression models were used to determine the associations between the lack of iron-rich food uptake and various sociodemographic factors.

RESULT

The overall prevalence of iron-rich food deficiency among the children in the entire sample was 56.75%. The prevalence of iron-rich food deficiency varied widely across the 26 countries, ranging from 42.76% in Congo Democratic Republic to 77.50% in Guinea. Maternal education, particularly primary education (OR 0.62, 95% CI 0.57 to 0.68) and higher education (OR 0.58, 95% CI 0.52 to 0.64), demonstrated a reduced likelihood of iron-rich food deficiency in the sample. Likewise, paternal education, with both primary education (OR 0.69, 95% CI 0.63 to 0.75) and higher education (OR 0.66, 95% CI 0.60 to 0.73) showed decreased odds of iron-rich food deficiency. Postnatal visits contributed significantly to reducing the odds of iron-rich food deficiency (OR 0.90, 95% CI 0.83 to 0.95), along with antenatal visits, which also had a positive impact (OR 0.84, 95% CI 0.74 to 0.95). Finally, residents in rural areas showed slightly higher odds of iron-rich food deficiency (OR 1.12, 95% CI 1.10 to 1.28).

CONCLUSION

Based on the findings, interventions targeting iron-food deficiency in the SSA region should take into strong consideration the key determinants highlighted in this study.

Nutrient Intake and Status in Children and Adolescents Consuming Plant-Based Diets Compared to Meat-Eaters: A Systematic Review

Health authorities increasingly recommend sustainable and healthy diets rich in plant foods and with moderate amounts of animal foods. However, there are concerns about whether such diets can meet all nutrient requirements, especially in children and adolescents, who have relatively high nutrient needs for growth and development. Therefore, we aimed to evaluate the nutrient intake and status of children and adolescents (2-18 y) consuming plant-based (i.e., vegetarian and vegan) diets compared to those of meat-eating children following a systematic literature review of studies published between 2000 and 2022. Mean intake and status data of nutrients were calculated across studies and benchmarked to dietary reference values and cut-off values for nutrient deficiencies. A total of 30 studies were included (15 in children 2-5 y, 24 in children 6-12 y, and 11 in adolescents 13-18 y). In all diets, there were risks of inadequate intakes of vitamin D and calcium. Children consuming meat had a risk of inadequate folate and vitamin E intake; and mean fiber, SAFA, and PUFA intakes were not in line with the recommendations. Children consuming plant-based diets risked inadequate vitamin B12, iron, and zinc intakes. In contrast to vegans, vegetarian children may not meet the recommended intakes of fiber, SAFA, and possibly PUFA, but their mean intakes were more favorable than in meat-eating children. Although the data are limited and need further validation, our findings indicate that there are risks of nutritional inadequacies in all diet groups. Therefore, increasing consumption of a variety of plant-based foods, in combination with food fortification and supplementation where needed, is recommended for children and adolescents to have sustainable and nutritionally adequate diets.

Iron Nutrition of Pre-Schoolers in High-Income Countries: A Review

Pre-schoolers are vulnerable to iron deficiency, which, in high-resource countries, is mainly caused by suboptimal or poorly absorbable iron intakes. This review examines the prevalence of inadequate iron intakes and status, and the non-dietary factors associated with these, among children aged between 2 and 5 years within high-income countries. It then considers the quality of the pre-schooler diet in terms of dietary factors, dietary patterns, and iron intakes. Additionally, it discusses the assessment of iron bioavailability and examines the various methods used to estimate the amount of absorbable iron in pre-schooler diets. Knowledge of the adequacy of iron intakes and bioavailability of iron intakes, and dietary patterns associated with iron intakes can facilitate the design and implementation of effectively targeted community-based intervention studies to improve iron intakes and iron bioavailability to minimise the risk of iron deficiency.

Maternal iron status in early pregnancy and childhood body fat measures and cardiometabolic risk factors: A population-based prospective cohort

BACKGROUND

Whether maternal iron status during pregnancy is associated with cardiometabolic health in the offspring is poorly known.

OBJECTIVES

We aimed to assess the associations of maternal iron status during early pregnancy with body fat measures and cardiometabolic risk factors in children aged 10 y.

METHODS

In a population-based cohort study among 3718 mother-child pairs, we measured ferritin, transferrin, and transferrin saturation during early pregnancy. We obtained child BMI, fat mass index, and android/gynoid fat mass ratio by DXA, subcutaneous fat index, visceral fat index, pericardial fat index, and liver fat fraction by magnetic resonance imaging and assessed systolic and diastolic blood pressure, serum lipids, glucose, insulin, and CRP at 10 y.

RESULTS

A one-standard deviation score (SDS) higher maternal ferritin was associated with lower fat mass index [difference -0.05 (95% CI: -0.08, -0.02) SDS] and subcutaneous fat index [difference -0.06 (95% CI: -0.10, -0.02) SDS] in children. One-SDS higher maternal transferrin was associated with higher fat mass index [difference 0.04 (95% CI: 0.01, 0.07) SDS], android/gynoid fat mass ratio [difference 0.05 (95% CI: 0.02, 0.08) SDS], and subcutaneous fat index [difference 0.06 (95% CI: 0.02, 0.10) SDS] in children. Iron status during pregnancy was not consistently associated with organ fat and cardiometabolic risk factors at 10 y.

CONCLUSIONS

Maternal lower ferritin and higher transferrin in early pregnancy are associated with body fat accumulation and distribution but are not associated with cardiometabolic risk factors in childhood. Underlying mechanisms and long-term consequences warrant further study.

The Influence of Intensive Nutritional Education on the Iron Status in Infants

Iron is an essential nutrient for a child’s proper development at every growth stage. It is crucial for the production of red blood and muscle cells, DNA replication, and the development of the brain, nervous and immune systems. Iron deficiency is the most common micronutrient deficiency in children worldwide. Despite widespread access to nutritional information for children, parents continue to make many feeding mistakes. This study aimed to assess whether any nutritional intervention would affect the iron status in children. The parents of 203 children were randomly assigned to one of two groups: the study group received intensive mobile nutritional education for a year, while the control group received no intervention. Blood tests were performed on both groups at the beginning of the study and one year later. The educational intervention resulted in statistically significantly higher levels of RBC (red blood cells; p = 0.020), HGB (haemoglobin; p = 0.039), HCT (haematocrit; p = 0.036), MCV (mean cell volume; p = 0.018) parameters and iron dietary intake (p ≤ 0.001). Even a non-targeted dietary intervention improves the iron status in children. As iron management is insufficient in most children, an iron-targeted nutritional intervention appears necessary.

Prevalence and Associated Factors of Iron Deficiency and Iron Deficiency Anemia Among Under-5 Children: A Systematic Review and Meta-Analysis

Background. Iron deficiency anemia is a common health problem that affects children under the age of five. Children’s cognitive performance is impaired by iron deficiency, which impacts their psychomotor development. Therefore, the aim of this study was to determine the global prevalence and associated factors of iron deficiency and iron deficiency anemia among under-5 children. Methods. Relevant publications published till March 30, 2021 were identified in databases such as Medline/PubMed, Science Direct, Popline, EMBASE, African Journals Online, Scopus, and Google Scholar. The STATA version 11 software was utilized for the analysis. To determine the level of heterogeneity, I² test statistics were used. To detect publication bias, funnel plots analysis and the Egger weighted regression test were used. Results. The global pooled prevalence of iron deficiency anemia and iron deficiency was 16.42% (95% CI: 10.82, 22.01) and 17.95% (95% CI: 13.49, 22.41), respectively. Age less than 2 years (OR = 1.26; 95% CI: 1.14, 1.38) and living in a large family size (OR = 1.38; 95% CI: 1.18, 1.58) were associated with iron deficiency anemia. Children born from anemic mother, low birth weight, and do not drink iron fortified milk (OR = 1.20; 95% CI: 1.05, 1.36), (OR = 1.15; 95% CI: 1.01, 1.36) and (OR = 1.28; 95% CI: 1.10, 1.46), respectively were associated factors of iron deficiency in under-5 children. Conclusion. The prevalence of iron deficiency anemia and iron deficiency was significant across the globe, particularly in Asia and Africa. Therefore, regular screening and treatment of iron deficiency and iron deficiency anemia are required especially in high-risk children to reduce their complication.

PROSPERO registration number: CRD42021267060

Complementary Feeding and Iron Status: "The Unbearable Lightness of Being" Infants

The complementary feeding (CF) period that takes place between 6 and 24 months of age is of key importance for nutritional and developmental reasons during the transition from exclusively feeding on milk to family meals. In 2021, a multidisciplinary panel of experts from four Italian scientific pediatric societies elaborated a consensus document on CF, focusing in particular on healthy term infants. The aim was to provide healthcare providers with useful guidelines for clinical practice. Complementary feeding is also the time window when iron deficiency (ID) and iron deficiency anemia (IDA) are most prevalent. Thus, it is appropriate to address the problem of iron deficiency through nutritional interventions. Adequate iron intake during the first two years is critical since rapid growth in that period increases iron requirements per kilogram more than at any other developmental stage. Complementary foods should be introduced at around six months of age, taking into account infant iron status.

Iron deficiency during the first 1000 days of life: are we doing enough to protect the developing brain?

Iron is essential for the functioning of all cells and organs, most critically for the developing brain in the fundamental neuronal processes of myelination, energy and neurotransmitter metabolism. Iron deficiency, especially in the first 1000 days of life, can result in long-lasting, irreversible deficits in cognition, motor function and behaviour. Pregnant women, infants and young children are most vulnerable to iron deficiency, due to their high requirements to support growth and development, coupled with a frequently inadequate dietary supply. An unrecognised problem is that even if iron intake is adequate, common pregnancy-related and lifestyle factors can affect maternal-fetal iron supply in utero, resulting in an increased risk of deficiency for the mother and her fetus. Although preterm birth, gestational diabetes mellitus and intrauterine growth restriction are known risk factors, more recent evidence suggests that maternal obesity and delivery by caesarean section further increase the risk of iron deficiency in the newborn infant, which can persist into early childhood. Despite the considerable threat that early-life iron deficiency poses to long-term neurological development, life chances and a country's overall social and economic progress, strategies to tackle the issue are non-existent, too limited or totally inappropriate. Prevention strategies, focused on improving the health and nutritional status of women of reproductive age are required. Delayed cord clamping should be considered a priority. Better screening strategies to enable the early detection of iron deficiency during pregnancy and early-life should be prioritised, with intervention strategies to protect maternal health and the developing brain.

Prevalence and associated factors of iron deficiency in Spanish children aged 1 to 11 years

Iron deficiency (ID) is the most common nutritional deficiency affecting children worldwide. Most traditional laboratory parameters to assess ID can be altered by infections or other inflammatory states, including obesity. The aims of this study were to determine the prevalence of ID in healthy children and to analyse associated factors, avoiding potential confounding factors through the use of serum transferrin receptor (sTfR), reticulocyte haemoglobin content and sTfR/log ferritin index. A cross-sectional population-based study was conducted on 951 children aged 1 to 11 years in Almería (Spain). ID was detected in 7.7% of children and iron deficiency anaemia in 0.9%. Multivariate analysis identified the following as independent risk factors: age under 5 years (OR: 2.2, 95% CI: 1.35-3.6); excessive consumption of cow's milk and dairy products (OR: 1.87, 95% CI: 1.13-3.1); and insufficient consumption of vegetables (OR: 2.7, 95% CI: 1.2-6.1).Conclusions: Using a combination of iron status parameters with greater discriminatory power than classical measures, this study detected a considerable iron deficiency prevalence in Spanish children. Younger children and specific dietary habits exhibit a particular risk for ID, so special attention should be paid to this population. What is Known: • Iron deficiency remains the most prevalent nutritional deficit worldwide, and children aged under 3 years are the most vulnerable to this condition. • Accurate assessment of iron status, based on a combination of biochemical indicators, can often be complicated. What is New: • Iron deficiency continues to present a health problem in Spanish children aged 1 to 11 years, considering the serum transferrin receptor and reticulocyte haemoglobin content for diagnosis. • Excessive consumption of dairy products and low consumption of vegetables are independent risk factors for iron deficiency.

Dietary patterns of Australian pre-schoolers and associations with haem and non-haem iron intakes

PURPOSE

To describe Australian pre-schooler dietary patterns and examine their associations with dietary iron intakes.

METHODS

Dietary data of children (n = 812, 2 to < 6 years old) from the 2011-12 National Nutrition and Physical Activity Survey were collected via two non-consecutive 24-h recalls and analysed using AUSNUT 2011-13. Usual food and nutrient intakes were estimated via Multiple Source Method. Principal component analysis was used to extract dietary patterns from 32 food groups. Associations between dietary patterns and energy-adjusted iron intakes were assessed using linear regression, accounting for the complex survey design.

RESULTS

Mean (SD) usual total dietary and haem iron intakes were 6.3 (1.9) and 0.5 (0.3) mg/day, respectively. Three dietary patterns were identified, explaining 14% of the variance. Pattern 1 (positive loadings for cheese, breads, fats and oils, and water) was positively associated with total dietary iron intakes (β = 0.08, 95% CI 0.01, 0.15). Pattern 3 (positive loadings for red meat, fortified fruit and vegetable products, and sauces and spreads) was negatively associated with total dietary iron (β = - 0.08, 95% CI - 0.14, - 0.01) and non-haem iron (β = - 0.09, 95% CI - 0.15, - 0.02) intakes. No dietary patterns were associated with haem iron intakes.

CONCLUSIONS

Three main patterns characterise Australian pre-schooler diets. The pattern with which dietary iron is positively associated is predominately characterised by non-haem iron sources and non-iron-fortified foods. Future research is required to estimate the iron bioavailability of Australian pre-schooler diets.

Association between iron deficiency anaemia and complementary feeding in children under 2 years assisted by a Conditional Cash Transfer programme

OBJECTIVE

To evaluate the association between Fe deficiency anaemia (IDA) and complementary feeding in children under 2 years old assisted by the Conditional Cash Transfer programme, Bolsa Família (BFP).

DESIGN

Cross-sectional study. Data were obtained through a standardised form, questionnaire to assess the eating habits of children under 2 years of age, capillary Hb (HemoCue®) and the Brazilian Household Food Insecurity Measurement Scale. Associations were calculated using hierarchical Poisson regression, adjusted at the last level by socio-economic, demographic and environmental variables from previous hierarchical levels.

SETTING

Six municipalities from the State of Alagoas, Brazil.

PARTICIPANTS

Children aged 6-24 months assisted by BFP.

RESULTS

A total of 1604 children were evaluated, among whom 58·1 % had anaemia. A higher number of food groups consumed (prevalence ratio (PR) = 0·97; 95 % CI 0·95, 0·99; P = 0·009), the consumption of dairy (PR = 0·86; 95 % CI 0·79, 0·84; P = 0·001) and meat (PR = 0·90; 95 % CI 0·83, 0·99; P = 0·030) in addition to bottle feeding (PR = 0·88; 95 % CI 0·82, 0·96; P = 0·004) were associated with a lower prevalence of IDA.

CONCLUSIONS

IDA is still a serious public health problem in children under 2 years old assisted by BFP in Alagoas. We highlight the importance of promoting complementary feeding based on a diversified dietary intake, as well strengthening prophylactic supplementation programmes to increase children's adherence in conjunction with the implementation of food and nutrition education to help reduce the prevalence of this condition.

Adequacy of iron intakes and socio-demographic factors associated with iron intakes of Australian pre-schoolers

PURPOSE

To estimate the prevalence of inadequate iron intakes and identify socio-demographic factors associated with iron intakes of Australian children aged 2-5 years.

METHODS

Data from the 2011-2012 National Nutrition and Physical Activity Survey component of the Australian Health Survey were analysed (n = 783, 2-5 years old). Dietary intake was assessed via two non-consecutive 24-h recalls. Prevalence of inadequate iron intake was estimated using the full probability approach after estimating the distribution of usual intakes with PC-SIDE. Associations between potential socio-demographic factors and energy-adjusted iron intakes were assessed via linear regression accounting for the complex survey design.

RESULTS

Mean (SD) iron intakes for pre-schoolers were 7.9 (1.9) mg/day and the prevalence of inadequate iron intake was 10.1% (95% CI 7.9%, 12.1%). Male sex (mean difference between boys and girls: - 0.22 (95% CI - 0.03, - 0.41) mg/day; p = 0.022) and age (each additional year was associated with 0.11 (95% CI - 0.22, - 0.00) mg/day lower iron intake; p = 0.048) were negatively associated with pre-schooler iron intakes.

CONCLUSIONS

This study provides current data relating to the iron nutrition of Australian pre-schoolers. Poor iron intakes continue to be a problem for 10% of Australian children beyond the second year of life, with iron intakes being lower for boys compared to girls and declining with age. Future research should examine strategies to improve iron intakes of young children, with a focus on promoting iron-rich food sources.

Iron status of young children in Europe

Iron deficiency (ID) is common in young children aged 6-36 mo. Although the hazards associated with iron deficiency anemia (IDA) are well known, concerns about risks associated with excess iron intake in young children are emerging. To characterize iron status in Europe, we describe the prevalence of ID, IDA, iron repletion, and excess stores with the use of published data from a systematic review on iron intake and deficiency rates, combined with other selected iron status data in young European children. Various definitions for ID and IDA were applied across studies. ID prevalence varied depending on socioeconomic status and type of milk fed (i.e., human or cow milk or formula). Without regard to these factors, ID was reported in 3-48% of children aged ≥12 mo across the countries. For 6- to 12-mo-old infants, based on studies that did not differentiate these factors, ID prevalence was 4-18%. IDA was <5% in most studies in Northern and Western Europe but was considerably higher in Eastern Europe (9-50%). According to current iron status data from a sample of healthy Western European children aged 12-36 mo, 69% were iron replete, and the 97.5th percentile for serum ferritin (SF) was 64.3 μg/L. In another sample, 79% of 24-mo-old children were iron replete, and the 97.5th percentile for SF was 57.3 μg/L. Average iron intake in most countries studied was close to or below the UK's Recommended Dietary Allowance. In conclusion, even in healthy European children aged 6-36 mo, ID is still common. In Western European populations for whom data were available, approximately three-quarters of children were found to be iron replete, and excess iron stores (SF >100 μg/L) did not appear to be a concern. Consensus on the definitions of iron repletion and excess stores, as well as on ID and IDA, is needed.

Variation in iodine food composition data has a major impact on estimates of iodine intake in young children

BACKGROUND/OBJECTIVES

The reliability of an estimate of iodine intake is largely dependent on the quality of the food composition data. We aimed to assess the impact of variations in food composition data for iodine and season on the estimates of iodine intake in young children.

SUBJECTS/METHODS

Cross-sectional dietary intake study of Irish 2-year-olds participating in the Cork BASELINE Birth Cohort Study (n=468; 30% of the cohort at the 2-year follow-up) were used to assess the impact of variation in iodine food composition data on estimates of iodine intake, dietary adequacy and risk of exceeding the tolerable upper intake level (UL).

RESULTS

Mean (SD) iodine intakes calculated using UK (147 (71)) and Irish (177 (93)) food composition data were significantly different (P < 0.001) (mean difference (95% confidence interval) = 30 (26-33) µg/day) and largely adequate (7-14% below the estimated average requirement). Intakes at the 95th percentile were 138% and 173% of the UL using UK and Irish food composition data, respectively, of which milk accounted for 106% and 150% of the UL. This translated into 22% and 35% of toddlers exceeding the UL, using UK and Irish composition data, respectively. The mean (SD) daily intake of cow's milk among the 91% of consumers was 309 (208) ml. Intakes of cow's milk at the 75th and 95th percentiles were 452 and 706 ml, respectively. Using Irish composition data for iodine in cows' milk, a daily intake of 450 ml could result in a toddler exceeding the UL from milk alone.

CONCLUSIONS

Variability in food composition has a large impact on assessments of iodine intake, particularly among young children for whom milk contributes a large proportion of their daily nutrient intake. Although this is unlikely to result in long-term adverse effects, our study highlights the need for development of valid biomarkers of individual iodine status.

Longitudinal modelling of the exposure of young UK patients with PKU to acesulfame K and sucralose

Artificial sweeteners are used in protein substitutes intended for the dietary management of inborn errors of metabolism (phenylketonuria, PKU) to improve the variety of medical foods available to patients and ensure dietary adherence to the prescribed course of dietary management. These patients can be exposed to artificial sweeteners from the combination of free and prescribed foods. Young children have a higher risk of exceeding acceptable daily intakes (ADI) for additives than adults, due to higher food intakes per kg body weight. Young patients with PKU aged 1-3 years can be exposed to higher levels of artificial sweeteners from these dual sources than normal healthy children and are at a higher risk of exceeding the ADI. Standard intake assessment methods are not adequate to assess the additive exposure of young patients with PKU. The aim of this study was to estimate the combination effect on the intake of artificial sweeteners and the impact of the introduction of new provisions for an artificial sweetener (sucralose, E955) on exposure of PKU patients using a validated probabilistic model. Food consumption data were derived from the food consumption survey data of healthy young children in the United Kingdom from the National Diet and Nutrition Survey (NDNS, 1992-2012). Specially formulated protein substitutes as foods for special medical purposes (FSMPs) were included in the exposure model to replace restricted foods. Inclusion of these protein substitutes is based on recommendations to ensure adequate protein intake in these patients. Exposure assessment results indicated the availability of sucralose for use in FSMPs for PKU leads to changes in intakes in young patients. These data further support the viability of probabilistic modelling as a means to estimate food additive exposure in patients consuming medical nutrition products.

Very low prevalence of iron deficiency among young French children: A national cross-sectional hospital-based survey

Although iron deficiency (ID) is considered the most frequent micronutrient deficiency in industrialized countries and is associated with impaired neurodevelopment when occurring in early years, accurate recent estimations of its prevalence are lacking. Our objective was to estimate ID prevalence and associated sociodemographic markers in young children in France. The Saturn-Inf national cross-sectional hospital-based survey recruited 3,831 French children <6 years old between 2008 and 2009 to assess lead poisoning prevalence and to establish a biobank. This secondary analysis measured serum ferritinemia (SF) in sera kept frozen at -80 °C for children with sufficient serum aliquots and C-reactive protein <10 mg/L. For the 657 participating children (17% of the Saturn-Inf study), the median age was 3.9 years (interquartile range: 2.2-5.1); 52% were boys. The median SF was 44 μg/L (interquartile range: 28-71). ID prevalence was 2.8% (95% confidence interval [1.7, 4.7]) and 3.2% (95% confidence interval [2.0, 5.1]) with an SF threshold of 10 and 12 μg/L, respectively. Low SF was significantly associated (p < .05) with mother being a migrant (32 vs. 45 μg/L for a mother born in France) or unemployed (37 vs. 50 μg/L for a mother employed). In this first national cross-sectional hospital-based study in France, ID prevalence was much lower than that in other French and European studies performed in underprivileged populations but close to the lowest values observed in other population-based studies in Europe.

Association Between Meat and Meat-Alternative Consumption and Iron Stores in Early Childhood

OBJECTIVE

To prevent iron deficiency, 2014 Canadian recommendations for healthy term infants from 6 to 24 months recommend iron-rich complementary foods such as meat and meat alternatives 2 or more times a day. The purpose of our study was to evaluate the association between meat and meat-alternative consumption and iron status in young children and the association between red meat consumption and iron status among children meeting recommendations.

METHODS

Healthy children aged 12 to 36 months were recruited. A cross-sectional study was conducted. Meat and meat-alternative consumption was measured using the NutriSTEP questionnaire. Adjusted multivariable regression analyses were used to evaluate an association between meat consumption and serum ferritin, and iron deficiency (serum ferritin <14 μg/L).

RESULTS

A total of 1043 children were included. Seventy-three percent of children met the recommended daily intake of meat and meat alternatives, and 66% ate red meat in the past 3 days. Eating meat and meat alternatives was not associated with serum ferritin (0.13 μg/L, 95% confidence interval -0.05, 0.31, P = .16), but it was associated with a decreased odds of iron deficiency (odds ratio 0.97, 95% confidence interval 0.94, 0.99, P = .03). Associations between red meat consumption and iron status were not statistically significant. Statistically significant covariates associated with increased odds of iron deficiency included longer breast-feeding duration, daily cow's milk intake of >2 cups, and a higher body mass index z score.

CONCLUSIONS

Daily cow's milk intake of >2 cups, longer breast-feeding duration, and a higher body mass index z score were modifiable risk factors associated with iron deficiency. Eating meat according to recommendations may be a promising additional target for the prevention of iron deficiency in early childhood.

Iron intakes and status of 2-year-old children in the Cork BASELINE Birth Cohort Study

Young children are at risk of iron deficiency and subsequent anaemia, resulting in long-term consequences for cognitive, motor and behavioural development. This study aimed to describe the iron intakes, status and determinants of status in 2-year-old children. Data were collected prospectively in the mother-child Cork BASELINE Birth Cohort Study from 15 weeks' gestation throughout early childhood. At the 24-month assessment, serum ferritin, haemoglobin and mean corpuscular volume were measured, and food/nutrient intake data were collected using a 2-day weighed food diary. Iron status was assessed in 729 children (median [IQR] age: 2.1 [2.1, 2.2] years) and 468 completed a food diary. From the food diary, mean (SD) iron intakes were 6.8 (2.6) mg/day and 30% had intakes < UK Estimated Average Requirement (5.3 mg/day). Using WHO definitions, iron deficiency was observed in 4.6% (n = 31) and iron deficiency anaemia in five children (1.0%). Following an iron series workup, five more children were diagnosed with iron deficiency anaemia. Twenty-one per cent had ferritin concentrations <15 µg/L. Inadequate iron intakes (OR [95% CI]: 1.94 [1.09, 3.48]) and unmodified cows' milk intakes ≥ 400 mL/day (1.95 [1.07, 3.56]) increased the risk of low iron status. Iron-fortified formula consumption was associated with decreased risk (0.21 [0.11, 0.41] P < 0.05). In this, the largest study in toddlers in Europe, a lower prevalence of low iron status was observed than in previous reports. Compliance with dietary recommendations to limit cows' milk intakes in young children and consumption of iron-fortified products appears to have contributed to improved iron status at two years.

Iron intakes of Australian infants and toddlers: findings from the Melbourne Infant Feeding, Activity and Nutrition Trial (InFANT) Program

Fe deficiency remains the most common nutritional deficiency worldwide and young children are at particular risk. Preventative food-based strategies require knowledge of current intakes, sources of Fe, and factors associated with low Fe intakes; yet few data are available for Australian children under 2 years. This study's objectives were to determine intakes and food sources of Fe for Australian infants and toddlers and identify non-dietary factors associated with Fe intake. Dietary, anthropometric and socio-demographic data from the Melbourne Infant Feeding, Activity and Nutrition Trial Program were analysed for 485 infants (mean age: 9·1 (sd 1·2) months) and 423 toddlers (mean age: 19·6 (sd 2·6) months) and their mothers. Dietary intakes were assessed via 24-h recalls over 3 non-consecutive days. Prevalence of inadequate Fe intake was estimated using the full probability approach. Associations between potential non-dietary predictors (sex, breast-feeding status, age when introduced to solid foods, maternal age, maternal education, maternal employment status and mother's country of birth) and Fe intakes were assessed using linear regression. Mean Fe intakes were 9·1 (sd 4·3) mg/d for infants and 6·6 (sd 2·4) mg/d for toddlers. Our results showed that 32·6 % of infants and 18·6 % of toddlers had inadequate Fe intake. Main food sources of Fe were Fe-fortified infant formula and cereals for infants and toddlers, respectively. Female sex and current breast-feeding were negatively associated with infant Fe intakes. Introduction to solid foods at or later than 6 months was negatively associated with Fe intake in toddlers. These data may facilitate food-based interventions to improve Australian children's Fe intake levels.

Theoretical Impact of Replacing Whole Cow's Milk by Young-Child Formula on Nutrient Intakes of UK Young Children: Results of a Simulation Study

Background: Research into the role of young-child formulae (YCF) in a child's diet is limited and there is no consensual recommendation on its use. We evaluated the theoretical nutritional impact of replacing the existing practice of consuming cow's milk by YCF. Methods: From the UK Diet and Nutrition Survey of Infants and Young Children, whole cow's milk consumers, aged 12-18 months (n = 591) were selected for simulation scenarios. In Scenario 1, we tested the replacement of all whole cow's milk (434 ± 187 ml/day) by a matching volume of YCF, and in Scenario 2, all whole cow's milk was replaced by the on-pack recommended daily intake of 300 ml. Nutrient intakes before and after simulation scenarios were compared and evaluated against nutrient recommendations. Results: Intakes of protein and saturated fatty acids were significantly decreased, whereas essential fatty acid intakes were increased. The prevalence of nutrient inadequacy before simulation was 95.2% for vitamin D and 53.8% for iron. After simulation, inadequacy decreased to 4.9% (Scenario 1) and 0% (Scenario 2) for vitamin D and to 2.7% (Scenario 1) and 1.1% (Scenario 2) for iron. Conclusions: Replacement of habitual cow's milk intake by a matching volume or 300 ml of YCF may lead to nutritional intakes more in line with recommendations in young children.

An Overview of Iron in Term Breast-Fed Infants

BACKGROUND

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

OBJECTIVES

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

CONCLUSIONS

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

Dietary intake in Australian children aged 4–24 months: consumption of meat and meat alternatives

Meat/meat alternatives (M/MA) are key sources of Fe, Zn and protein, but intake tends to be low in young children. Australian recommendations state that Fe-rich foods, including M/MA, should be the first complementary foods offered to infants. The present paper reports M/MA consumption of Australian infants and toddlers, compares intake with guidelines, and suggests strategies to enhance adherence to those guidelines. Mother–infant dyads recruited as part of the NOURISH and South Australian Infants Dietary Intake studies provided 3 d of intake data at three time points: Time 1 (T1) (n482, mean age 5·5 (sd1·1) months), Time 2 (T2) (n600, mean age 14·0 (sd1·2) months) and Time 3 (T3) (n533, mean age 24 (sd0·7) months). Of 170 infants consuming solids and aged greater than 6 months at T1, 50 (29 %) consumed beef, lamb, veal (BLV) or pork on at least one of 3 d. Commercial infant foods containing BLV or poultry were the most common form of M/MA consumed at T1, whilst by T2 BLV mixed dishes (including pasta bolognaise) became more popular and remained so at T3. The processed M/MA increased in popularity over time, led by pork (including ham). The present study shows that M/MA are not being eaten by Australian infants or toddlers regularly enough; or in adequate quantities to meet recommendations; and that the form in which these foods are eaten can lead to smaller M/MA serve sizes and greater Na intake. Parents should be encouraged to offer M/MA in a recognisable form, as one of the first complementary foods, in order to increase acceptance at a later age.

Iron Intake and Status of Children Aged 6-36 Months in Europe: A Systematic Review

Background: Iron deficiency is the most common nutritional disorder in the world. Young children are particularly vulnerable to the consequences of iron deficiency because of their rapidly developing brain. This review evaluates the prevalence of inadequate iron intake and iron deficiency (anaemia) in European children aged 6-36 months. Summary: Computerized searches for relevant articles were performed in November 2013. A total of 7,297 citations were screened and 44 studies conducted in 19 European countries were included in this review. In both infants (6-12 months) and young children (12-36 months), the mean value of iron intakes in most countries was close to the RDA. Nevertheless, proportions of inadequate intakes were considerable, ranging from about 10% in the Netherlands up to 50% in Austria, Finland and the United Kingdom. The prevalence of iron deficiency varied between studies and was influenced by children's characteristics. Two to 25% of infants aged 6-12 months were found to be iron deficient, with a higher prevalence in those who were socially vulnerable and those who were drinking cow's milk as a main type of drink in their first year of life. In children aged 12-36 months, prevalence rates of iron deficiency varied between 3 and 48%. Prevalence of iron deficiency anaemia in both age groups was high in Eastern Europe, as high as 50%, whereas the prevalence in Western Europe was generally below 5%. Key Messages: In most European countries, mean iron intakes of infants and children aged 6 to 36 months were found to be close to the RDA. Nevertheless, high proportions of inadequate intakes and high prevalence rates of iron deficiency were observed. Health programs should (keep) focus(ing) on iron malnutrition by educating parents on food choices for their children with iron-rich and iron-fortified foods, and encourage iron supplementation programmes where iron intakes are the lowest.

Cohort Profile: The Applied Research Group for Kids (TARGet Kids!)

The Applied Research Group for Kids (TARGet Kids!) is an ongoing open longitudinal cohort study enrolling healthy children (from birth to 5 years of age) and following them into adolescence. The aim of the TARGet Kids! cohort is to link early life exposures to health problems including obesity, micronutrient deficiencies and developmental problems. The overarching goal is to improve the health of Canadians by optimizing growth and developmental trajectories through preventive interventions in early childhood. TARGet Kids!, the only child health research network embedded in primary care practices in Canada, leverages the unique relationship between children and families and their trusted primary care practitioners, with whom they have at least seven health supervision visits in the first 5 years of life. Children are enrolled during regularly scheduled well-child visits. To date, we have enrolled 5062 children. In addition to demographic information, we collect physical measurements (e.g. height, weight), lifestyle factors (nutrition, screen time and physical activity), child behaviour and developmental screening and a blood sample (providing measures of cardiometabolic, iron and vitamin D status, and trace metals). All data are collected at each well-child visit: twice a year until age 2 and every year until age 10. Information can be found at: http://www.targetkids.ca/contact-us/.

Prevalence of anaemia and its associated factors in African children at one and three years residing in the Capricorn District of Limpopo Province, South Africa

Objective: The present study evaluated the prevalence of anaemia and its determinants in one- and three-year-old children from the Capricorn District of Limpopo Province, South Africa. Methods: A prospective cohort study conducted in rural villages in the Capricorn District of Limpopo Province, South Africa. At birth, a cohort of 219 children was followed until they were one and three years of age. Data collected included the children’s anthropometric measurements, blood for biochemical analysis (full blood count, ferritin, folate and vitamin B12) and socio-demographic status.Results: At one year, anaemia (Hb < 11 g/dL) was present in 52% of the children, decreasing to 22% by the third year. Iron deficiency (ferritin < 12 µg/mL) was common in these children (39% and 33% at one year and three years, respectively) particularly in the presence of anaemia. Folate and vitamin B12 deficiencies (< 5 ng/mL and < 145 pg/mL, respectively) were common at one year, with the children accumulating enough vitamin B12 by three years; however, folate deficiency levels remained fairly constant between the two time points.Conclusion: There was a high prevalence of anaemia in the study participants at one year and three years of age. Factors that increased the risk of anaemia at three years were: a mother with only a primary school education, anaemia at one year, male gender, overweight, and combined overweight and stunting. Protective factors against anaemia were having a younger mother who served as the main caregiver.

Prevalence and risk factors of iron deficiency in healthy young children in the southwestern Netherlands

OBJECTIVES

Iron deficiency (ID) and iron deficiency anemia (IDA), during the first years of life, are associated with delayed motor and neurological development. Many studies evaluated iron status without an assessment of an acute-phase protein to identify infection. Because most indicators of iron status are influenced by infection, these data may underestimate the ID prevalence. A food consumption survey in the Netherlands showed that the mean iron intake of children ages 2 to 3 years was below the advised adequate intake of 7 mg/day. The aim of the study was to investigate iron status in a well-defined, healthy population of young children in the southwestern region of the Netherlands and to identify risk factors for ID.

METHODS

We conducted a multicenter, observational study in healthy children ages 0.5 to 3 years. We defined ID as ferritin <12 μg/L and IDA when, in addition, hemoglobin was <110 g/L. Children with elevated C-reactive protein levels (>5 mg/L) or underlying causes for anemia were excluded. Parents filled in a questionnaire to identify risk factors for ID.

RESULTS

We included 400 children in the study. ID and IDA were detected in 18.8% and 8.5% of the children, respectively. The present use of formula and the visit of preschool/day care were associated with a lower prevalence of ID, and a high intake of cow's milk was associated with a higher prevalence of ID, after adjustment for age.

CONCLUSIONS

ID is present in 18.8% of healthy children ages 0.5 to 3 years and living in the southwestern region of the Netherlands. The present visit of preschool/day care and the use of formula are associated with a reduced risk of ID, whereas a high intake of cow's milk is associated with an increased risk of ID.

Iron requirements of infants and toddlers

Iron deficiency (ID) is the most common micronutrient deficiency worldwide and young children are a special risk group because their rapid growth leads to high iron requirements. Risk factors associated with a higher prevalence of ID anemia (IDA) include low birth weight, high cow's-milk intake, low intake of iron-rich complementary foods, low socioeconomic status, and immigrant status. The aim of this position paper was to review the field and provide recommendations regarding iron requirements in infants and toddlers, including those of moderately or marginally low birth weight. There is no evidence that iron supplementation of pregnant women improves iron status in their offspring in a European setting. Delayed cord clamping reduces the risk of ID. There is insufficient evidence to support general iron supplementation of healthy European infants and toddlers of normal birth weight. Formula-fed infants up to 6 months of age should receive iron-fortified infant formula, with an iron content of 4 to 8 mg/L (0.6-1.2 mg(-1) · kg(-1) · day(-1)). Marginally low-birth-weight infants (2000-2500 g) should receive iron supplements of 1-2 mg(-1) · kg(-1) · day(-1). Follow-on formulas should be iron-fortified; however, there is not enough evidence to determine the optimal iron concentration in follow-on formula. From the age of 6 months, all infants and toddlers should receive iron-rich (complementary) foods, including meat products and/or iron-fortified foods. Unmodified cow's milk should not be fed as the main milk drink to infants before the age of 12 months and intake should be limited to <500 mL/day in toddlers. It is important to ensure that this dietary advice reaches high-risk groups such as socioeconomically disadvantaged families and immigrant families.

Anemia and iron deficiency in children: association with red meat and poultry consumption

OBJECTIVE

The aim of this study was to study the relative contribution of dietary sources of iron in children with high prevalence of anemia and iron deficiency (ID).

METHODS

A cross-sectional study in 263 healthy, 1.5- to 6-year-old children in the Jewish sector of Jerusalem, Israel. Venous blood samples and a qualitative Food Frequency Questionnaire on iron-rich foods were obtained. Anemia was defined as hemoglobin <11 g/dL for children younger than 4 years and <11.5 g/dL for children older than 4 years; ID was defined as ferritin <12 μg/L.

RESULTS

Anemia was found in 11.2%, ID in 22%, and iron-deficiency anemia in 3.7%. The prevalence of anemia was higher in toddlers ages 1.5 to 3 years compared with children ages 3 to 6 years (17.7% vs 7.3%, P = 0.01). Children with extremely low red meat consumption (seldom) had 4-fold higher rates of ID than those who consumed ≥2 times per week (odds ratio 3.98; 95% confidence interval 1.21-13.03; P = 0.023), whereas poultry consumption was not associated with ID. Soy consumption was inversely associated with ferritin (marginally significant, r = -0.134, P = 0.057).

CONCLUSIONS

The high prevalence of anemia and ID found in this study, mainly in children 1.5 to 3 years old, is related to low red meat consumption. The characteristically high poultry consumption in the Israeli population was not protective. The shift toward reduced red meat consumption and higher poultry consumption in developed countries may result in increasing the risk of ID.

Health effects of different dietary iron intakes: a systematic literature review for the 5th Nordic Nutrition Recommendations

BACKGROUND

The present literature review is part of the NNR5 project with the aim of reviewing and updating the scientific basis of the 4th edition of the Nordic Nutrition Recommendations (NNR) issued in 2004.

OBJECTIVE

The objective of this systematic literature review was to assess the health effects of different intakes of iron, at different life stages (infants, children, adolescents, adults, elderly, and during pregnancy and lactation), in order to estimate the requirement for adequate growth, development, and maintenance of health.

METHODS

The initial literature search resulted in 1,076 abstracts. Out of those, 276 papers were identified as potentially relevant. Of those, 49 were considered relevant and were quality assessed (A, B, or C). An additional search on iron and diabetes yielded six articles that were quality assessed. Thus, a total of 55 articles were evaluated. The grade of evidence was classified as convincing (grade 1), probable (grade 2), suggestive (grade 3), and inconclusive (grade 4).

RESULTS

There is suggestive evidence that prevention or treatment of iron deficiency (ID) and iron deficiency anemia (IDA) improves cognitive, motoric, and behavioral development in young children, and that treatment of IDA improves attention and concentration in school children and adult women. There is insufficient evidence to show negative health effects of iron intakes in doses suggested by the NNR 4. There is insufficient evidence to suggest that normal birth weight, healthy, exclusively breast-fed infants need additional dietary iron before 6 months of life in the Nordic countries. An iron concentration of 4-8 mg/L in infant formulas seems to be safe and effective for normal birth weight infants. There is probable evidence that iron supplements (1-2 mg/kg/day) given up to 6 months of age to infants with low birth weight (<2,500 g) prevents IDA and possibly reduce the risk of behavioral problems later on. There is probable evidence that ID and IDA in pregnant women can be effectively prevented by iron supplementation at a dose of 40 mg/day from week 18-20 of gestation. There is probable evidence that a high intake of heme iron, but not total dietary, non-heme or supplemental iron, is associated with increased risk of type 2 diabetes (T2D) and gestational diabetes.

CONCLUSIONS

Overall, the evidence does not support a change of the iron intakes recommended in the NNR 4. However, one could consider adding recommendations for infants below 6 months of age, low birth weight infants and pregnant women.

Iron status and dietary iron intake of vegetarian children from Poland

BACKGROUND/AIM

In Poland, vegetarian diets are becoming more and more popular. The aim of this study was to examine the effect of iron intake on iron status in vegetarian children.

METHODS

Dietary iron intake, iron food sources, blood count, serum iron, ferritin level and total iron-binding capacity were estimated in two groups of children, namely vegetarians (n = 22) and omnivores (n = 18) of both sexes, aged from 2 to 18 years. Seven-day food records were used to assess their diet.

RESULTS

Dietary iron intake in vegetarians and omnivores was low (up to 65.0 and 60.1% of the recommended dietary allowance). A significantly higher intake of vitamin C was observed in vegetarians compared with omnivores (p = 0.019). The main sources of iron in vegetarians were cereal products, followed by vegetables and mushroom products, then fruit. The prevalence of iron deficiency (ID) was higher in the vegetarian group (p = 0.023). The serum ferritin level and mean corpuscular volume in the vegetarians were also lower than in the omnivores (p = 0.01 and p = 0.014, respectively).

CONCLUSIONS

Children who follow a vegetarian diet may suffer from ID in spite of having a high vitamin C intake. This indicates the need to introduce dietary education and iron status monitoring.

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.

Consumption of cow's milk as a cause of iron deficiency in infants and toddlers

Consumption of cow's milk (CM) by infants and toddlers has adverse effects on their iron stores, a finding that has been well documented in many localities. Several mechanisms have been identified that may contribute to iron deficiency in this young population group. The most important of these is probably the low iron content of CM, which makes it difficult for infants to obtain the amounts of iron needed for growth. A second mechanism is the occult intestinal blood loss associated with CM consumption during infancy, a condition that affects about 40% of otherwise healthy infants. Loss of iron in the form of blood diminishes with age and ceases after the age of 1 year. A third mechanism is the inhibition of non-heme iron absorption by calcium and casein, both of which are present in high amounts in CM. Fortification of CM with iron, as practiced in some countries, can protect infants and toddlers against CM's negative effects on iron status. Consumption of CM produces a high renal solute load, which leads to a higher urine solute concentration than consumption of breast milk or formula, thereby narrowing the margin of safety during dehydrating events, such as diarrhea. The high protein intake from CM may also place infants at increased risk of obesity in later childhood. It is thus recommended that unmodified, unfortified CM not be fed to infants and that it be fed to toddlers in modest amounts only.

Effect of delayed versus early umbilical cord clamping on neonatal outcomes and iron status at 4 months: a randomised controlled trial

OBJECTIVE

To investigate the effects of delayed umbilical cord clamping, compared with early clamping, on infant iron status at 4 months of age in a European setting.

DESIGN

Randomised controlled trial.

SETTING

Swedish county hospital.

PARTICIPANTS

400 full term infants born after a low risk pregnancy.

INTERVENTION

Infants were randomised to delayed umbilical cord clamping (≥ 180 seconds after delivery) or early clamping (≤ 10 seconds after delivery).

MAIN OUTCOME MEASURES

Haemoglobin and iron status at 4 months of age with the power estimate based on serum ferritin levels. Secondary outcomes included neonatal anaemia, early respiratory symptoms, polycythaemia, and need for phototherapy.

RESULTS

At 4 months of age, infants showed no significant differences in haemoglobin concentration between the groups, but infants subjected to delayed cord clamping had 45% (95% confidence interval 23% to 71%) higher mean ferritin concentration (117 μg/L v 81 μg/L, P < 0.001) and a lower prevalence of iron deficiency (1 (0.6%) v 10 (5.7%), P = 0.01, relative risk reduction 0.90; number needed to treat = 20 (17 to 67)). As for secondary outcomes, the delayed cord clamping group had lower prevalence of neonatal anaemia at 2 days of age (2 (1.2%) v 10 (6.3%), P = 0.02, relative risk reduction 0.80, number needed to treat 20 (15 to 111)). There were no significant differences between groups in postnatal respiratory symptoms, polycythaemia, or hyperbilirubinaemia requiring phototherapy.

CONCLUSIONS

Delayed cord clamping, compared with early clamping, resulted in improved iron status and reduced prevalence of iron deficiency at 4 months of age, and reduced prevalence of neonatal anaemia, without demonstrable adverse effects. As iron deficiency in infants even without anaemia has been associated with impaired development, delayed cord clamping seems to benefit full term infants even in regions with a relatively low prevalence of iron deficiency anaemia. Trial registration Clinical Trials NCT01245296.

Nutrition and Iron Status of 1-Year Olds following a Revision in Infant Dietary Recommendations

A previous study showed low iron status in 12-month-old Icelandic infants associated most strongly with cow's milk intake and growth. Infant dietary recommendations were revised in 2003. This study investigated nutrition and iron status in a new infant cohort. Subjects/Methods. Randomly selected infants were prospectively investigated for diet, anthropometry, and iron status (n = 110–141). Results. Breastfeeding initiation rate was 98%; 38% of 5-month olds were exclusively and 20% of 12-month olds partially breastfed. Formula was given to 21% of 6-month olds and 64% of 12-month olds, but cow's milk to 2.5% and 54.4% of 6- and 12-month olds, respectively. Iron depletion (serum ferritin < 12 μg/L) affected 5.8%, 1.4% were also iron deficient (MCV < 74 fl), and none were anemic (Hb < 105 g/l). Iron status associated negatively with growth and breastfeeding duration and positively with meat and formula intake at 9–12 months, but not with cow's milk. Conclusion. Improved iron status might be explained by a shift from cow's milk to formula in the diet of Icelandic 6–12-month olds. Dietary changes altered associations between foods and iron status.

Food-based strategies improve iron status in toddlers: a randomized controlled trial12

BACKGROUND

Nonanemic iron deficiency is common in toddlers in developed countries. Food-based strategies are safe methods to control and prevent mild micronutrient deficiencies.

OBJECTIVE

Our objective was to determine the efficacy of an increased intake of red meat, or the consumption of iron-fortified milk, in improvement of iron status in toddlers at a population level.

DESIGN

In this 20-wk randomized placebo-controlled trial, 225 healthy nonanemic 12-20-mo-old children were assigned to 1 of 3 groups: red meat (toddlers encouraged to consume approximately 2.6 mg iron from red meat dishes daily), fortified milk [toddlers' regular milk replaced with iron-fortified (1.5 mg iron/100 g prepared milk) cow milk], or control [toddlers' regular milk replaced with nonfortified (0.01 mg iron/100 g prepared milk) cow milk]. Blood samples were collected at baseline and at 20 wk for hemoglobin, serum ferritin, serum transferrin receptor, and C-reactive protein. The prevalence of suboptimal iron status (ie, depleted iron stores, iron-deficient erythropoiesis, and iron deficiency anemia) was determined, and body iron was calculated.

RESULTS

No intervention effects were shown on the prevalence of suboptimal iron status. Serum ferritin increased by 44% (95% CI: 14%, 82%; P = 0.002) in the fortified milk group, did not change (+10%) in the red meat group (95% CI: -7%, 30%; P = 0.241), and tended to decrease (-14%) in the control group (95% CI: -27%, 1%; P = 0.063). By 20 wk, in comparison with the control group, serum ferritin and body iron were significantly higher in the fortified milk group (both P < 0.001), and serum ferritin was significantly higher in the red meat group (P = 0.033).

CONCLUSIONS

Consumption of iron-fortified milk can increase iron stores in healthy nonanemic toddlers, whereas increased intakes of red meat can prevent their decline. This trial was registered at actr.org.au as ACTRN12605000487617.

Excessive Cow's Milk Consumption and Iron Deficiency in Toddlers

Elimination of iron deficiency and iron deficiency anemia in children is a crucial public health concern because these conditions have been linked to cognitive and behavioral deficits. In the infant age group, great strides have been made to reduce iron deficiency and iron deficiency anemia significantly. However, similar progress has not yet been made with toddlers. Cow's milk consumption has long been associated with iron deficiency and iron deficiency anemia in children. Because cow's milk is a staple in the diet of most toddlers, they are at particular risk for these conditions. Two unusual presentations of anemia in toddlers caused by excessive cow's milk consumption are described: one in a child with congestive heart failure, the other in a child with profound eosinophilia. The role of cow's milk in iron deficiency and iron deficiency anemia is also examined.

Relationship between iron status and dietary fruit and vegetables based on their vitamin C and fiber content

BACKGROUND

Dietary fruits and vegetables may enhance iron status because of their high vitamin C content. The potential association between iron status and intakes of specific fruits and vegetables, according to sex and menopausal status, must be investigated.

OBJECTIVE

The objective was to assess the relation between dietary fruits, vegetables, and juices (FVJ) according to their vitamin C and fiber contents and serum ferritin and hemoglobin concentrations.

DESIGN

A total of 4358 subjects, aged 35-60 y, of the Supplementation with Antioxidant Vitamins and Minerals (SU.VI.MAX) cohort were selected. Subjects had completed at least six 24-h-dietary records over 2 y. The relation between serum ferritin and hemoglobin, measured at inclusion, and dietary FVJ according to their vitamin C and fiber contents was assessed by multiple regression analysis.

RESULTS

In premenopausal women, serum ferritin was positively associated with intakes of fiber-poor FVJ (up to 10% higher serum ferritin in the third tertile compared with the first tertile). In the whole sample, hemoglobin was positively associated with fruits, vitamin C-rich FVJ, FVJ ascorbic acid, and fiber-poor FVJ categories (up to 1.5 g/L higher hemoglobin concentration).

CONCLUSIONS

Intakes of fiber-poor FVJ were associated with higher serum ferritin concentrations in premenopausal women and with higher hemoglobin concentrations in the whole sample. Our results suggest that the fiber content of fruits and vegetables influences iron stores in premenopausal women but has no influence in groups in whom nonheme-iron absorption is limited because of high iron stores. Other mechanisms are likely to be involved in the case of hemoglobin.

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.