Meat intake and iron status in late infancy: an intervention study

Food sources of fiber and micronutrients of concern among infants and young children in Lebanon: a national cross-sectional study

BACKGROUND

Intakes of fiber, iron, zinc, calcium, vitamin D, vitamin A, and folate were shown to be low in a substantial proportion of infants and children in Lebanon. The study aims to identify the top food sources of fiber, iron, zinc, calcium, vitamin D, vitamin A, and folate amongst infants and young children in Lebanon and to evaluate the evolution of food sources of these nutrients from the beginning of the complementary feeding journey up until the age of 47.9 months.

METHODS

A national cross-sectional survey was conducted in 2012 as part of the "Early Life Nutrition and Health in Lebanon" project using stratified cluster sampling. Dietary intakes for infants and young children aged 6-47.9 months (n = 763) were assessed using 24- Hour Dietary Recall. Food items were categorized into food groups and the percent contribution of each food group to nutrient intakes was determined to identify the top food sources of fiber and selected micronutrients for three age groups: 6-11.9 m (infants), 12-23.9 m (toddlers), and 24-47.9 m (preschoolers).

RESULTS

The top food source of fiber was vegetables among children aged 6-47.9 months. Among infants and toddlers, infant/young child formula was the main contributor to iron, zinc, calcium, vitamin D, vitamin A, and folate intakes. Baby cereals also contributed to around 14% of iron intakes among infants. Among preschoolers, meat and fish contributed to 13% of iron intakes and 29% of zinc intakes, while cow's milk was the major contributor of calcium (41%), vitamin D (81%) and vitamin A (25%) intakes. Sweetened beverages and sweet bakery were also ranked among the major food sources contributing to substantial intakes of key nutrients, including fiber, iron, zinc, calcium, vitamin A, and folate among infants, toddlers, and preschoolers.

CONCLUSIONS

In addition to milk sources, vegetables, beans and legumes, breads, meats, and rice and pasta, sweet bakery and sweetened beverages have contributed to intakes of key nutrients from early ages. This calls for implementing initiatives and designing approaches to support nutrition education and improve nutrient intakes in infancy and early childhood.

Development of a nutritional risk screening tool for preterm children in outpatient settings during a complementary feeding period: a pilot study

BACKGROUND

A complementary feeding (CF) period is necessary for nutritional and developmental reasons. Preterm children encounter more feeding problems than their term counterparts in the CF period. The goal of this study was to develop a nutritional risk screening tool specific to preterm children (the NRSP) in outpatient settings in the CF period, with the expectation of providing a standardised process to determine feeding problems and subsequently offering targeted nutritional advice.

METHODS

This study was a 2-phase study consisting of the development and evaluation phases. In the development phase, the items of the NRSP were initially developed based on references and the Delphi expert consultation method. Second, 329 preterm individuals with corrected ages from 5 to 36 months were enrolled. The participating preterm children were interviewed with the NRSP and anthropometric measurements, and underwent intellectual developmental tests and biochemistry detection (haemoglobin, red blood cell count, mean corpuscular volume, mean corpuscular haemoglobin, mean corpuscular haemoglobin concentration, serum iron, vitamin D). Third, preterm children's anthropometric parameters were remeasured 1 month (for infants whose corrected age was 5-11 months) or 3 months (for children whose corrected age was 12-36 months) after the interview. Data in the development phase were analysed via univariate and binary logistic regression analysis sequentially to assign scores for items of the NRSP and to generate the models to predict underweight, stunting, and microcephaly of the NRSP. In the evaluation phase, another 605 preterm individuals were recruited to undergo the interview, anthropometric measurements, intellectual developmental tests, and biochemistry detection as in the development phase. Interrater reliability, test-retest reliability, area under the curve (AUC), accuracy, sensitivity, specificity, the positive/negative predictive value (P/NPV), the positive/negative likelihood ratio (LR+/-), and the correlation coefficient by Spearman's correlation analysis (r_s) were used to assess the reliability and validity of the NRSP. Finally, anthropometric parameters, biochemistry levels, and intellectual development quotients (DQs) from the development and evaluation phases between the high- and low-risk groups classified by the NRSP were compared using a t-test.

RESULTS

The κ coefficients of the interrater and test-retest reliability of the NRSP were all above 0.600, which meant that the reliability of the NRSP was moderate to substantial. The NRSP exhibited relatively higher efficiency in predicting underweight and stunting, with AUCs, accuracies, specificities, and NPVs near to or greater than 0.900, sensitivities above 0.600, PPVs above 0.400, LR + s near to or greater than 10, and r_ss above 0.400. On the other hand, the NRSP manifested a weaker ability in predicting microcephaly, with most of the values of validity indicators lower than those of underweight and stunting prediction. Z scores of body weight, body length and head circumference, as well as DQs, were all higher in the low-risk groups than in the high-risk groups. There were no significant differences with respect to biochemistry levels between the high- and low-risk groups.

CONCLUSION

The NRSP shows moderate to substantial reliability and validity in predicting underweight, stunting, and microcephaly. Health care staff should shed light on improving the feeding practices of preterm children with high nutritional risk classified by the NRSP to facilitate their physical growth and intellectual development. More research is expected to promote the NRSP models.

Estimated energy and nutrient intake for infants following baby-led and traditional weaning approaches

Baby-led weaning (BLW), where infants self-feedwithout the use of spoon-feeding by a caregiver, continues to be a popular approach to starting solids. However, concerns remain amongst health professionals that infants using this method may not consume sufficient energy or nutrients from solid foods. Little research has examined how different weaning approaches shape dietary intake. The aim of this study was to use a three-day weighed diet diary to measure estimated energy and nutrient intake in infants aged 6-12 months. Diet diaries were completed by 71 parents and analysed to compareestimated infant intake from milk and solid foods for those either following a BLW or traditional spoon-feeding approach (TW). Intake was analysed for each weaning group in two age groups: 26-39 and 40-52 weeks, to account for different eating patterns at the start and end of the weaning process. For the younger infants, significant differences in estimatedenergy intake were found, with TW infants consuming 285 kcal from solid foods compared with 120 kcal for BLW infants. Conversely, BLW infants consumed more calories and nutrients from breast or formula milk, consistent with a slower transition to solid foods. No differences were found in estimated intake amongst older infants suggesting BLW infants had 'caught up' with their spoon-fed peers. Overall, few infantsregardless of weaning group met recommended intake guidelines for energy (either over or under consuming) with many deficient in iron and zinc intake. The findings are important for those supporting parents through the transition to solid foods. This article is protected by copyright. All rights reserved.

Children's consumption of rabbit meat

<p>The nutritional and dietary properties of rabbit meat make it an ideal food for children, recommended by the World Health Organisation. However, the presence of children under 18 in the home has been found to decrease the frequency of rabbit meat consumption. If we focus on households with children under 18, 52.5% of minors do not consume rabbit meat. The main reason why children (intended as people under 18 yr old) do not consume rabbit meat is the fact that they do not like it (40.9%) and because it is not bought/eaten at home (30.9%). Faced with this situation, there is a pressing need to seek appropriate strategies to adapt rabbit meat for consumption by the youngest family members. In light of the results, the following strategies are proposed. First, the development of functional foods for babies and children, such as rabbit meat enriched with ω3 and docosahexaenoic acid. Secondly, improving meat tenderness. Third, adapting rabbit meat presentations for children (burgers, nuggets, sausages, marinades …), converting them into convenience products for parents and extending their shelf life. Fourth, adapting the labelling/packaging for children to attract attention of both parents and offspring. Finally, developing communication strategies on the nutritional value of rabbit meat aimed at both children and parents. It is observed that if minors consume rabbit meat, they also eat other types of meat such as lamb and beef more often. Therefore, in this type of households a varied and complete diet is consumed in terms of meat consumption, so it would be necessary to rethink joint communication strategies among the three meat sectors. Promoting rabbit meat consumption among the under 18s has several consequences, as in the future they will be in charge of household purchases or share this responsibility.</p>

Complementary feeding and micronutrient status: a systematic review

BACKGROUND

Proper nutrition during early life is critical for growth and development.

OBJECTIVES

The aim was to describe systematic reviews conducted by the Nutrition Evidence Systematic Review team for the USDA and the Department of Health and Human Services Pregnancy and Birth to 24 Months Project to answer the following: What is the relation between 1) timing of introduction of complementary foods and beverages (CFBs) or 2) types and/or amounts of CFBs consumed and micronutrient status (iron, zinc, vitamin D, vitamin B-12, folate, and fatty acid status)?

METHODS

A literature search identified articles from developed countries published from January 1980 to July 2016 that met the inclusion criteria. Data were extracted and risk of bias assessed. Evidence was qualitatively synthesized to develop a conclusion statement, and the strength of the evidence was graded.

RESULTS

Nine articles addressed the timing of CFB introduction and 31 addressed types or amounts or both of CFBs. Moderate evidence suggests that introducing CFBs at age 4 mo instead of 6 mo offers no advantages or disadvantages in iron status among healthy full-term infants. Evidence is insufficient on the timing of CFB introduction and other micronutrient status outcomes. Strong evidence suggests that CFBs containing iron (e.g., meat, fortified cereal) help maintain adequate iron status or prevent deficiency in the first year among infants at risk of insufficient iron stores or low intake. Benefits for infants with sufficient iron stores (e.g., infant formula consumers) are less clear. Moderate evidence suggests that CFBs containing zinc (e.g., meat, fortified cereal) support zinc status in the first year and CFB fatty acid composition influences fatty acid status. Evidence is insufficient with regard to types and amounts of CFBs and vitamin D, vitamin B-12, and folate status, or the relation between lower-iron-containing CFBs and micronutrient status.

CONCLUSIONS

Several conclusions on CFBs and micronutrient status were drawn from these systematic reviews, but more research that addresses specific gaps and limitations is needed.

Different Growth Patterns Persist at 24 Months of Age in Formula-Fed Infants Randomized to Consume a Meat- or Dairy-Based Complementary Diet from 5 to 12 Months of Age

OBJECTIVE

To test the long-term effect on growth status at 24 months of age in formula-fed infants who were randomized to consume a meat- or dairy-based complementary diet from 5 to 12 months of age.

STUDY DESIGN

Observational assessments, including anthropometric, dietary, and blood biomarkers, were conducted at 24 months of age, 1 year after the intervention ended.

RESULTS

The retention rate at 24 months of age was 84% for the meat group and 81% for the dairy group. Mean (±SD) protein intakes at 24 months of age were 4.1 ± 1.2 and 4.0 ± 1.1 g/kmeat (n = 27) and dairy (n = 26) groups, respectively, and comparable with the estimates of US population intake. At 24 months of age, weight-for-age z score did not differ significantly between groups and was similar to that at 12 months. Length-for-age z score remained significantly higher in the meat group compared with the dairy group, and the average length was 1.9 cm greater in the meat group. Weight-for-length z score also did not differ significantly between groups. Insulin-like growth factor 1 significantly increased from 12 to 24 months of age in both groups, but insulin-like growth factor-binding protein 3 and blood urea nitrogen did not change significantly from 12 to 24 months of age and were comparable between groups.

CONCLUSIONS

The protein source-induced distinctive growth patterns observed during infancy persisted at 24 months of age, suggesting a potential long-term impact of early protein quality on growth trajectories in formula-fed infants.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02142647.

Types and amounts of complementary foods and beverages consumed and growth, size, and body composition: a systematic review

BACKGROUND

Systematic reviews (SRs) were conducted by the Nutrition Evidence Systematic Review (NESR) team for the USDA's and the Department of Health and Human Services' Pregnancy and Birth to 24 Months Project.

OBJECTIVES

The aim was to describe the SRs examining the relationship between types and amounts of complementary foods and beverages (CFBs) and growth, size, and body-composition outcomes.

METHODS

The NESR team collaborated with subject matter experts to conduct this SR. The literature was searched and screened using predetermined criteria. For each included study, data were extracted and risk of bias was assessed. The evidence was qualitatively synthesized to develop a conclusion statement, and the strength of evidence was graded.

RESULTS

This SR includes 49 articles that examined type, amount, or both of CFBs consumed and growth, size, and body-composition outcomes. Moderate evidence suggests that consuming either different amounts of meat, meat instead of iron-fortified cereal, or types of CFBs with different fats or fatty acids does not favorably or unfavorably influence growth, size, or body composition. In relation to overweight/obesity, insufficient evidence is available with regard to the intake of meat or CFBs with different fats or fatty acids. Limited evidence suggests that type and amount of fortified infant cereal does not favorably or unfavorably influence growth, size, body composition, or overweight/obesity. Limited evidence suggests that sugar-sweetened beverage consumption during the complementary feeding period is associated with increased obesity risk in childhood but is not associated with other measures of growth, size, or body composition. Limited evidence showed a positive association between juice intake and infant weight-for-length and child body mass index z scores. Insufficient evidence is available on other CFBs or dietary patterns in relation to outcomes.

CONCLUSIONS

Although several conclusions were drawn, additional research is needed that includes randomized controlled trials, examines a wider range of CFBs, considers issues of reverse causality, and adjusts for potential confounders to address gaps and limitations in the evidence.

Effectiveness of provision of animal-source foods for supporting optimal growth and development in children 6 to 59 months of age

BACKGROUND

Adequate nutrients early in life promote cognitive development and are critical for proper growth and functioning. The effect of individual nutrients consumed through food is often not the same as consuming the same nutrients in supplementary form due to 'food synergy', the biological and chemical interrelations that occur between nutrients. Animal-source foods, such as eggs, meat, fish, and dairy, are energy dense and contain multiple micronutrients and essential fatty acids with high bioavailability. The benefits of animal-source foods may include higher food synergy relative to fortified foods as well as decreasing dependence on external suppliers of fortified foods.

OBJECTIVES

To assess the effectiveness of animal-source foods compared to any other feeding interventions or no intervention in improving growth and developmental outcomes in children aged 6 to 59 months.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL, 18 other databases, and three trials registers up to August 2018. We also contacted authors and known experts in the field for assistance in identifying ongoing or unpublished data, and searched the reference lists of included studies and reviews, and websites of relevant organizations, for other studies that may not have been captured by our electronic searches.

SELECTION CRITERIA

We included randomized controlled trials and quasi-randomized controlled trials of any duration, where children between 5 months and 59 months (6 years) of age were provided with an animal-source food (e.g. consumption of milk, meat, or eggs), prepared with any cooking method, compared with any intervention or no intervention.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial eligibility using prespecified criteria, extracted data, assessed risk of bias, and graded the quality of the evidence using the GRADE approach.

MAIN RESULTS

Study characteristicsWe included 6 studies that analyzed data from 3036 children aged 5 to 50 months. The studies were conducted in China, the Democratic Republic of Congo, Ecuador, Guatemala, Pakistan, the USA, and Zambia, and lasted between 5 and 12 months. Three studies were funded, in part, by government entities; one study was supported by a nonprofit organization. Two studies did not report a funding source.Three studies compared the effects of feeding an animal-source food with a fortified (iron or iron and zinc), or unfortified cereal; two used a control group with no intervention; one compared a meat-based diet to a dairy-based diet. The types of animal-source foods tested included yogurt, eggs, cheese, lyophilized (freeze-dried) beef product, ground and frozen pork, puréed and jarred beef with gravy or pork, and powdered whey protein.We judged four studies to be at unclear risk of bias overall; three studies because they were funded by an industry with a plausible interest in the outcome of the intervention; and one study because there was insufficient information to assess five of the seven bias 'Risk of bias' domains. We judged two of the six studies to be at high risk of bias overall; one study because there was significant baseline imbalance in length-for-age z scores (LAZ) between groups and evidence of selective reporting; the other study because there there was both a significant baseline imbalance in LAZ and weight-for-age z scores (WAZ) between groups, and a large-scale social media campaign that may have influenced care received at home in the control group.Key resultsAnimal-source foods versus cereal-based foods or no interventionFive studies (2972 children) measured change in linear growth with either height-for-age z scores (HAZ) or LAZ. Three studies (592 children) reported a significant increase in HAZ and LAZ in the intervention group compared to the control group. Two studies (2380 children) reported a decline in LAZ in both groups. In one study (1062 children) there was no difference between the groups in the rate of decline; in the other (1318 children) the decrease in LAZ was significantly smaller in the intervention group.Five studies (2972 children) measured weight gain using WAZ. Three studies (592 children) reported a significant increase in WAZ in the intervention group compared to the control group. In two studies (2380 children), WAZ decreased in both groups. In one of these studies (1318 children), the decrease in the intervention group was significantly smaller than in the control group. In the other study (1062 children), there was no difference between the groups.Three studies (1612 children) reported impacts on all-cause morbidity, but metrics were inconsistent between studies. One study with yogurt (402 children) reported a significant reduction in duration and incidence of diarrhea and upper respiratory infections in the intervention group. One study with eggs (148 children) reported a significant increase in the incidence of diarrhea in the intervention group, but this may have been due to cultural associations with eggs and gastrointestional problems. There were no other significant differences in fever, respiratory infections, or skin conditions between groups. The third study (1062 children) found no differences between intervention and control groups across morbidity measures.No studies reported data on anemia.Meat-based diet versus dairy-based dietOne study (64 children) measured change in LAZ and WAZ in infants fed either a meat-based diet or dairy-based diet. There was a significant increase in LAZ among infants consuming the meat-based diet and a significant decrease in LAZ among infants consuming a dairy-based diet. WAZ increased in both groups, with no significant difference between groups.The study did not assess all-cause morbidity or anemia.Quality of the evidenceWe rated the quality of the evidence as very low overall due to baseline imbalances between intervention and control groups, high heterogeneity in meta-analysis, and imprecision due to wide confidence intervals and inconsistent direction of effects. We have little confidence in the results; further research is likely to change the estimate of magnitude and direction of treatment effect.

AUTHORS' CONCLUSIONS

Given the limited quality of the evidence, we are uncertain of the effects of the provision of animal-source food versus cereal products or no intervention on the growth or development of children. More adequately powered trials with deliberately selected animal-source foods are needed.

Practices of Introduction of Complementary Feeding and Iron Deficiency Prevention in the Middle East and North Africa

BACKGROUND

Iron deficiency (ID) with or without anemia is associated with impaired mental and psychomotor development. Given the paucity of information on physicians' knowledge and practices on iron (Fe) supplementation and impact of ID in the Middle East and North Africa, it was felt important to conduct a survey.

METHOD

A group of expert physicians developed a questionnaire that was randomly distributed among Middle East and North Africa doctors to assess their knowledge and practices on introduction of complementary feeding, impact of ID, its prevention, and their impression on prevalence of ID. Descriptive statistics were used.

RESULTS

We received 2444 completed questionnaires. Thirty-nine percent of physicians do not follow the European Society for Paediatric Gastroenterology, Hepatology and Nutrition guidelines regarding age of introduction of complementary feedings. Approximately 62% estimate the prevalence of ID anemia to be 40% to 70%; however, only 17% always monitor hemoglobin between 9 and 12 months of age, 43% do so "almost" always, whereas 36% do so "rarely" or (4%) "never." For the prevention of ID in infants older than 6 months of age, almost all recommend introducing Fe supplements. Ninety-seven percent agree that untreated ID during infancy may have long-term negative effects on cognitive function, whereas 53.26% consider that Fe-enriched infant cereals result in staining of the baby teeth, constipation, and dark stools.

CONCLUSIONS

Although there is awareness of the impact of ID, there are some misconceptions regarding age of introduction of complementary feedings, surveillance of Fe status, and side effects of Fe-enriched infant cereals. There is a need for educational initiatives focusing on prevention of Fe deficiency.

Protein Intake during the First Two Years of Life and Its Association with Growth and Risk of Overweight

Growth patterns early in life could exert a long-term impact on overweight and obesity development. Among all potential manipulative factors, infant diet is one of the most influential and could affect growth and subsequent health status during adolescence and adulthood. Dietary protein, as an important macronutrient in infants' diet, has been of special interest to researchers. Compared with human milk, infant formula tends to have a higher protein content and is associated with greater weight gain and later-in-life obesity risk. However, the effect of protein from other sources on infant growth trajectories during complementary feeding is not clear. Emerging research suggests that meat protein during early complementary feeding promotes linear growth while not increasing risk of overweight compared with dairy protein; and the gut microbiota might be a mediator between protein quality and growth trajectories. This review addresses the current knowledge of protein intake from birth to 24 months and its relationship with growth and risk of overweight.

An Animal-Source Food Supplement Increases Micronutrient Intakes and Iron Status among Reproductive-Age Women in Rural Vietnam

Background: Few studies have examined the impact of local animal-source foods (ASFs) on the nutritional status of reproductive-age women in developing countries.Objective: We hypothesized that a midmorning snack of local ASF for 6 mo would reduce dietary micronutrient deficiencies [usual intake less than the estimated average requirement (EAR)] and improve blood biomarkers of iron, zinc, and vitamins A and B-12 status among nonpregnant, reproductive-age women in rural Vietnam.Methods: One hundred seventeen women, 18-30 y old, were randomly assigned to receive either an ASF (mean: 144 kcal, 8.9 mg Fe, 2.7 mg Zn, 1050 μg retinoic acid equivalent vitamin A, and 5.5 μg vitamin B-12) or a control snack (mean: 150 kcal, 2.0 mg Fe, 0.9 mg Zn, 0 μg retinoic acid equivalent vitamin A, and 0 μg vitamin B-12) 5 d/wk for 6 mo. Usual nutrient intakes were estimated by repeated 24-h dietary recalls. Blood samples were collected at baseline and 3 and 6 mo. Because of the relation between nutritional status and inflammation, serum C-reactive protein, α-1-acid-glycoprotein, and urinary tract infections (UTIs) were also monitored.Results: Eighty-nine women (47 in the ASF group and 42 controls) completed the study. In the ASF group, intakes of iron and vitamins A and B-12 below the EAR were eliminated, and the prevalence of a low zinc intake was reduced to 9.6% compared with 64.7% in controls (P < 0.001). At 6 mo, a modest increase (P < 0.05) in hemoglobin and iron status occurred in the ASF group compared with the control group, but plasma zinc, retinol, and serum vitamin B-12 concentrations did not differ. UTI relative risk was 3.9 (P < 0.05) among women assigned to the ASF group who had a low whole-body iron status at baseline.Conclusions: Adding a small amount of locally produced ASF to the diets of reproductive-age Vietnamese women improved micronutrient intakes and iron status. However, the increased UTI incidence in women in the ASF group with initially lower iron stores warrants further investigation.

Complementary Feeding: A Position Paper by the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) Committee on Nutrition

This position paper considers different aspects of complementary feeding (CF), focussing on healthy term infants in Europe. After reviewing current knowledge and practices, we have formulated these recommendations: Timing: Exclusive or full breast-feeding should be promoted for at least 4 months (17 weeks, beginning of the 5th month of life) and exclusive or predominant breast-feeding for approximately 6 months (26 weeks, beginning of the 7th month) is a desirable goal. Complementary foods (solids and liquids other than breast milk or infant formula) should not be introduced before 4 months but should not be delayed beyond 6 months.

CONTENT

Infants should be offered foods with a variety of flavours and textures including bitter tasting green vegetables. Continued breast-feeding is recommended alongside CF. Whole cows' milk should not be used as the main drink before 12 months of age. Allergenic foods may be introduced when CF is commenced any time after 4 months. Infants at high risk of peanut allergy (those with severe eczema, egg allergy, or both) should have peanut introduced between 4 and 11 months, following evaluation by an appropriately trained specialist. Gluten may be introduced between 4 and 12 months, but consumption of large quantities should be avoided during the first weeks after gluten introduction and later during infancy. All infants should receive iron-rich CF including meat products and/or iron-fortified foods. No sugar or salt should be added to CF and fruit juices or sugar-sweetened beverages should be avoided. Vegan diets should only be used under appropriate medical or dietetic supervision and parents should understand the serious consequences of failing to follow advice regarding supplementation of the diet.

METHOD

Parents should be encouraged to respond to their infant's hunger and satiety queues and to avoid feeding to comfort or as a reward.

Improving Young Child Feeding with Processed Complementary Cereals and Behavioural Change in Urban Kenya

In urban Kenya the rates of exclusive breastfeeding are low, and complementary feeding practices result in inadequate intake of energy and nutrients by young children. Although information on appropriate feeding of young children has been widely promoted through the health system for years, and mothers are knowledgeable about recommendations, inadequate feeding practices still result in high rates of malnutrition. Processed cereal blends are used by some urban mothers for infant feeding, and their cost is similar to that of porridges enriched in the home by the addition of milk, margarine, or soya flour. However, little has been done to ensure that these products are nutritionally adequate or to ensure that labelling instructions are appropriate and that they promote exclusive breastfeeding from four to six months of age. Social marketing to low-income families of fortified cereal blends that would address these concerns could be a sustainable means of improving infant-feeding practices.

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.

Prevalence and determinants of anaemia among children aged 0–59 months in a rural region of Armenia: a case–control study

Objective

Despite the trend of increasing prevalence of childhood anaemia in Armenia, no studies exploring its risk factors have been conducted in the country. The present study aimed to investigate the prevalence and determinants of childhood anaemia in rural Armenia.

Design

Blood Hb level was measured among a representative sample of children using the HemoCue Hb201+ analyser. The revealed cases with anaemia were compared with randomly selected non-anaemic controls. Mothers of cases and controls were interviewed. Logistic and linear regression models were fitted to identify the risk factors of anaemia and low Hb level, respectively.

Setting

Talin communities, Aragatsotn Province, Armenia.

Subjects

Children under 5 years of age in Talin region.

Results

Of the 729 studied children, 32·4 % were anaemic with 14·7 % having moderate/severe anaemia. Infants were the most affected group with 51·1 % being anaemic before 6 months and 67·9 % at 6–12 months of age. Fitted regression models identified the following predictors of anaemia: younger age, male gender, shorter birth length, anaemia during pregnancy, lower meal frequency per day, lack of meat in the diet, using dung cakes for heating and living in a community that received an incomplete set of nutrition interventions.

Conclusions

The study identified several modifiable risk factors that could be targeted to reduce childhood anaemia in rural Armenia and, possibly, in rural areas in other low-/middle-income countries. The suggested interventions include prevention and treatment of anaemia during pregnancy, provision of adequate complementary feeding to children with inclusion of meat in their daily diet and reduction of their exposure to biomass fuel smoke.

Development and pilot testing of Baby-Led Introduction to SolidS--a version of Baby-Led Weaning modified to address concerns about iron deficiency, growth faltering and choking

BACKGROUND

In Baby-Led Weaning (BLW), infants are offered 'finger' foods from the start of the complementary feeding period instead of being spoon-fed. Healthcare professionals have expressed concerns about adequacy of iron and energy intake, and about choking, for infants following Baby-Led Weaning.

METHODS

We developed a modified version of BLW, Baby-Led Introduction to SolidS (BLISS), to address these concerns. In a 12-week pilot study, families who had chosen to use a BLW approach were assigned to BLISS (n = 14) or BLW (n = 9). BLISS participants received 2 intervention visits, resources and on-call support. BLW participants received no intervention. Participants were interviewed weekly for 12 weeks and completed a three-day weighed record or three 24-h iron questionnaires.

RESULTS

Compared to the BLW group, the BLISS group were more likely to introduce iron containing foods during the first week of complementary feeding, and to offer more serves per day of iron containing foods at 6 months (2.4 vs 0.8 serves/day; P = 0.001); and less likely to offer high-choking-risk foods (3.24 vs 0.17 serves/day; P = 0.027).

CONCLUSIONS

This pilot study suggests BLISS may result in higher iron intakes and lower choking risk than unmodified BLW. However, the results need to be confirmed in a large randomised controlled trial.

Food Sources of Total Energy and Nutrients among U.S. Infants and Toddlers: National Health and Nutrition Examination Survey 2005-2012

Understanding the dietary intakes of infants and toddlers is important because early life nutrition influences future health outcomes. The aim of this study was to determine the dietary sources of total energy and 16 nutrients in a nationally representative sample of U.S. infants and toddlers aged 0-24 months. Data from the 2005-2012 National Health and Nutrition Examination Survey were analyzed. Dietary intake was assessed in 2740 subjects using one 24-h dietary recall. The population proportion was used to determine the contribution of foods and beverages to nutrient intakes. Overall infant formulas and baby foods were the leading sources of total energy and nutrients in infants aged 0-11.9 months. In toddlers, the diversity of food groups contributing to nutrient intakes was much greater. Important sources of total energy included milk, 100% juice and grain based mixed dishes. A number of foods of low nutritional quality also contributed to energy intakes including sweet bakery products, sugar-sweetened beverages and savory snacks. Overall non-flavored milks and ready-to-eat cereals were the most important contributors to micronutrient intakes. In conclusion this information can be used to guide parents regarding appropriate food selection as well as inform targeted dietary strategies within public health initiatives to improve the diets of infants and toddlers.

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.

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.

Efficacy and safety of new complementary feeding guidelines with an emphasis on red meat consumption: a randomized trial in Bogota, Colombia

BACKGROUND

Iron deficiency and poor linear growth are common in infants from deprived socioeconomic backgrounds and may be associated with inadequate complementary feeding (CF) practices.

OBJECTIVE

We tested the hypothesis that new CF guidelines emphasizing meat as a source of iron and zinc would improve linear growth, iron, and zinc status in infants living in poor socioeconomic circumstances in Bogota, Colombia.

DESIGN

A total of 85 term infants who were exclusively breastfed for ≥4 mo were randomly assigned at 6 mo of age to a control group [CG (n = 43); current advice] or intervention group (new guidelines group [NGG (n = 42); with counseling to 1) continue breastfeeding, 2) offer red meat ≥3 d/wk, and 3) offer fruit and vegetables daily]). Main outcomes were 1) linear growth from 6 to 12 mo of age; 2) hemoglobin, hematocrit, iron [serum ferritin (SF)], and zinc status at 12 mo of age; and 3) meat intake at 12 mo of age (by using a food-frequency questionnaire).

RESULTS

A total of 38 infants/group provided data at 12 mo of age. NGG infants had significantly higher red meat intake [mean ± SD: 5.4 ± 1.8 compared with 3.5 ± 1.7 d/wk at 12 mo of age; P < 0.001), higher hemoglobin and hematocrit at 12 mo of age, and a significantly greater increase in hemoglobin (mean ± SD change: 0.41 ± 0.8 compared with -0.13 ± 1.0; P = 0.01) and hematocrit (1.04 ± 2.2 compared with -0.15 ± 2.4; P = 0.03) from 6 to 12 mo of age than those in CG infants. There were no significant differences in linear growth from 6 to 12 mo of age or in SF or zinc.

CONCLUSIONS

The new guidelines showed efficacy with higher red meat intake and positive effects on hemoglobin and hematocrit. The intervention was acceptable and affordable for most mothers. These preliminary results suggest that the intervention merits investigation in a larger cohort with longer-term follow-up. This trial was registered at http://isrctn.org as ISRCTN57733004.

Iron supplementation is positively associated with increased serum ferritin levels in 9-month-old Danish infants

Fe deficiency is still common in infancy, even in affluent societies, and has prompted Fe fortification of food products and use of Fe supplements in many populations. In the present study, we tested the hypothesis that Fe status among 9-month-old infants following the Danish Fe supplementation recommendation (>400 ml Fe-fortified formula or 8 mg Fe/d) is associated with more favourable levels of Fe status indicators compared to those not following the recommendation. A random sample of 9-month-old infants living in Copenhagen was established and 312 healthy term infants were examined at 9·1 (sd0·3) months of age. Blood samples were available from 278 infants. Overall, twenty infants (7·8 %) had Fe deficiency (serum ferritin < 12 μg/l) and < 1 % had Fe deficiency anaemia (serum ferritin < 12 μg/l and Hb < 100 g/l). Serum ferritin was positively associated with birth weight (P < 0·001), intake of fortified formula and follow-on formula (P = 0·001), and female sex (P < 0·001). Cow's milk intake and length of exclusive breast-feeding were negatively associated with Hb levels (P = 0·013 andP < 0·001). Serum ferritin levels were significantly higher (P < 0·0001) and transferrin receptor (TfR) was significantly lower (P = 0·003) among infants (n188) meeting the Fe supplementation recommendation compared to those (n67) not meeting the recommendation. No significant difference between these two groups was found for Hb. In conclusion, this study confirmed that Fe status of infants following the Danish Fe supplementation recommendation was significantly associated with increased serum ferritin and decreased levels of TfR indicating more favourable Fe status, compared to infants not following the recommendation.

Evaluation of meat as a first complementary food for breastfed infants: impact on iron intake

The rationale for promoting the availability of local, affordable, non-fortified food sources of bioavailable iron in developing countries is considered in this review. Intake of iron from the regular consumption of meat from the age of 6 months is evaluated with respect to physiological requirements. Two major randomized controlled trials evaluating meat as a first and regular complementary food are described in this article. These trials are presently in progress in poor communities in Guatemala, Pakistan, Zambia, Democratic Republic of the Congo, and China.

Complementary feeding: a Global Network cluster randomized controlled trial

Background

Inadequate and inappropriate complementary feeding are major factors contributing to excess morbidity and mortality in young children in low resource settings. Animal source foods in particular are cited as essential to achieve micronutrient requirements. The efficacy of the recommendation for regular meat consumption, however, has not been systematically evaluated.

Methods/Design

A cluster randomized efficacy trial was designed to test the hypothesis that 12 months of daily intake of beef added as a complementary food would result in greater linear growth velocity than a micronutrient fortified equi-caloric rice-soy cereal supplement. The study is being conducted in 4 sites of the Global Network for Women's and Children's Health Research located in Guatemala, Pakistan, Democratic Republic of the Congo (DRC) and Zambia in communities with toddler stunting rates of at least 20%. Five clusters per country were randomized to each of the food arms, with 30 infants in each cluster. The daily meat or cereal supplement was delivered to the home by community coordinators, starting when the infants were 6 months of age and continuing through 18 months. All participating mothers received nutrition education messages to enhance complementary feeding practices delivered by study coordinators and through posters at the local health center. Outcome measures, obtained at 6, 9, 12, and 18 months by a separate assessment team, included anthropometry; dietary variety and diversity scores; biomarkers of iron, zinc and Vitamin B₁₂ status (18 months); neurocognitive development (12 and 18 months); and incidence of infectious morbidity throughout the trial. The trial was supervised by a trial steering committee, and an independent data monitoring committee provided oversight for the safety and conduct of the trial.

Discussion

Findings from this trial will test the efficacy of daily intake of meat commencing at age 6 months and, if beneficial, will provide a strong rationale for global efforts to enhance local supplies of meat as a complementary food for young children.

Trial registration

NCT01084109

Importância das práticas alimentares no primeiro ano de vida na prevenção da deficiência de ferro

A reconhecida relevância da anemia por deficiência de ferro, em termos de saúde pública, decorre não apenas da magnitude de sua ocorrência, mas, principalmente, dos efeitos deletérios que ocasiona à saúde da criança. Com o objetivo de investigar as práticas alimentares no primeiro ano de vida e sua associação com a deficiência de ferro, realizou-se revisão da literatura científica nacional e internacional sobre a questão, selecionando os artigos mais relevantes. Crianças que nascem atermo e com peso adequado, ao receberem o leite materno de forma exclusiva suprem suas necessidades de ferro, sendo desnecessário qualquer complemento nos primeiros seis meses de vida. Próximo aos seis meses de idade ocorre gradualmente o esgotamento das reservas de ferro e a alimentação complementar passa a ter papel predominante no atendimento às necessidades desse nutriente. O papel do aleitamento materno na ocorrência da deficiência de ferro é ainda controverso e parece depender do país, região e tipo de leite utilizado em substituição ao leite materno. Na impossibilidade da continuidade do aleitamento materno, a substituição deste por leite de vaca aumenta o risco de a criança apresentar deficiência de ferro. Práticas complementares que comprovadamente contribuem com a prevenção da deficiência de ferro são: alimentação complementar com alta biodisponibilidade de ferro, alimentos fortificados e suplemento de ferro em doses profiláticas. Dieta com alta biodisponibilidade de ferro é aquela que contém os alimentos básicos da família, desde que saudáveis, com a presença de carne, vitamina A e vitamina C. A alimentação no primeiro ano de vida tem papel importante na prevenção da anemia por deficiência de ferro e, para sua adequada implementação, é necessário que suas diretrizes sejam adotadas como rotina nas unidades básicas de saúde.

Science base of complementary feeding practice in infancy

PURPOSE OF REVIEW

The review presents a selection of publications on complementary feeding in industrialized countries during 2008-2009, after the publication of the ESPGHAN position paper in early 2008.

RECENT FINDINGS

The WHO recommendation for introduction of complementary feeding at 6 months is adapted in many countries, but the issue is still discussed and many mothers introduce complementary feeding as early as before 4 months. The European Food Safety Authority recently published a comprehensive review on the appropriate age for the introduction of complementary feeding and concluded that introduction between 4 and 6 months is safe. One study showed that delaying introduction of complementary feeding up to 6 months resulted in lower risk of overweight as adult. Milk protein is stimulating insulin-like growth factor-1 and growth and a recent study supports a long-term programming of the insulin-like growth factor-1 axis. There is now a broad consensus that there is no need to delay the introduction of hyperallergenic foods, which might even increase the risk of allergic disease. Randomized studies show that docosahexaenoic acid may affect heart rate and thereby cardiovascular regulation.

SUMMARY

Despite some recent interesting publications, there is still a need for more large randomized studies to further explore to what degree the time of introduction and composition of complementary foods have effects on growth, development and especially the long-term risk of diseases.

Iron supplementation of low-income infants: a randomized clinical trial of adherence with ferrous fumarate sprinkles versus ferrous sulfate drops

OBJECTIVE

To determine whether low-income infants' adherence to nutritional supplementation with ferrous fumarate sprinkles was better than that with ferrous sulfate drops.

STUDY DESIGN

The study was a randomized clinical trial of healthy 6-month-old infants. Each infant received either a daily packet of sprinkles or a dropperful of liquid. Follow-up included alternating telephone and home visits biweekly for 3 months. Adherence was defined as high if the infant's caregiver reported supplement use on 5 to 7 days during the week before assessment. Side effects and caregiver attitude about supplements were secondary outcomes. Analyses were conducted using generalized estimating equations and chi(2) and Wilcoxon rank-sum tests.

RESULTS

A total of 150 of 225 eligible infants were enrolled. Adherence to supplementation was generally poor. High adherence ranged from 32% to 63% at any assessment in the subjects receiving drops, compared with 30% to 46% in those receiving sprinkles. The drops group was more likely to have at least four assessments with high adherence (22% vs 9.5%; P = .03). Caregivers of the drops infants were more likely to report greater than usual fussiness (P < .01); however, fussiness had no consistent impact on adherence.

CONCLUSIONS

The use of ferrous fumarate sprinkles rather than traditional ferrous sulfate drops did not improve adherence with daily iron supplementation in low-income infants.

A Review of Interventions Based on Dietary Diversification or Modification Strategies with the Potential to Enhance Intakes of Total and Absorbable Zinc

Dietary diversification or modification has the potential to prevent deficiencies of zinc and other coexisting limiting micronutrients simultaneously, without risk of antagonistic interactions. In this review, we have addressed the following. The first section focuses on strategies with the potential to enhance intake and/or bioavailability of zinc, and includes interventions (with and without nutrition education) based on agriculture, production or promotion of animal-source foods through animal husbandry or aquaculture, and commercial and household processing strategies to enhance zinc absorption. Outcome indicators include intakes of foods or nutrients (although rarely zinc) and, in some cases, zinc status, or zinc-related functional responses. The next two sections address whether dietary diversification or modification can achieve increases in absorbable zinc that are sufficient to enhance zinc status or zinc-related functional responses in breastfed infants and toddlers and in older children and women of reproductive age. Evidence for the impact of dietary diversification or modification on behavior change and on nutritional status in the short and long term, and the possible role of modifying factors (e.g., baseline nutritional status, socioeconomic status, infection, sex, age, and life-stage group) is the emphasis of the next section. The following section highlights the evidence for three potential adverse effects of dietary diversification or modification: aflatoxin contamination from germinated cereals, loss of water-soluble nutrients, and displacement of breastmilk. Finally, an example of a dietary diversification or modification program (Homestead Food Production) developed and implemented by Helen Keller International is given, together with the critical steps needed to scale up dietary diversification or modification for programs and future research needs.

Effectiveness of fortification of corn flour-derived products with hydrogen-reduced elemental iron on iron-deficiency anaemia in children and adolescents in southern Brazil

OBJECTIVE

To find the ideal combination of Fe fortifier and its food vehicle is an essential measure in developing countries. However, its cost also plays an important role. In the present study, the effect on blood parameter values of corn flour-derived products fortified with powdered elemental Fe in the form of H2-reduced Fe was investigated in children and adolescents.

METHODS

One hundred and sixty-two individuals (eighty-six boys and seventy-six girls) from public educational centres in Londrina, Paraná (southern Brazil) participated in the study. Fe-deficiency anaemia (IDA) was defined when Hb and serum ferritin values fell below 12 g/dl and 20 microg/l, respectively; Fe deficiency (ID) was considered when serum ferritin was below 20 microg/l.

RESULTS

The prevalence of ID and IDA decreased from 18.0 % and 14.9 %, values found at the beginning of the study, to respectively 5.6 % and 1.2 % after 6 months. Changes from altered to normal values occurred more often than normal to altered values with transferrin saturation (14.2 % v. 6.8 %; P < 0.04) and ferritin (12.4 % v. 0 %; P < 0.001). Hb, transferrin saturation and ferritin showed differences between normal and altered parameters after 6 months (P < 0.001).

CONCLUSION

A pronounced reduction in the prevalence of ID and IDA was observed in children and adolescents following 6 months' ingestion of corn flour-derived products enriched with elemental Fe.

Complementary feeding: a commentary by the ESPGHAN Committee on Nutrition

This position paper on complementary feeding summarizes evidence for health effects of complementary foods. It focuses on healthy infants in Europe. After reviewing current knowledge and practices, we have formulated these conclusions: Exclusive or full breast-feeding for about 6 months is a desirable goal. Complementary feeding (ie, solid foods and liquids other than breast milk or infant formula and follow-on formula) should not be introduced before 17 weeks and not later than 26 weeks. There is no convincing scientific evidence that avoidance or delayed introduction of potentially allergenic foods, such as fish and eggs, reduces allergies, either in infants considered at increased risk for the development of allergy or in those not considered to be at increased risk. During the complementary feeding period, >90% of the iron requirements of a breast-fed infant must be met by complementary foods, which should provide sufficient bioavailable iron. Cow's milk is a poor source of iron and should not be used as the main drink before 12 months, although small volumes may be added to complementary foods. It is prudent to avoid both early (<4 months) and late (>or=7 months) introduction of gluten, and to introduce gluten gradually while the infant is still breast-fed, inasmuch as this may reduce the risk of celiac disease, type 1 diabetes mellitus, and wheat allergy. Infants and young children receiving a vegetarian diet should receive a sufficient amount ( approximately 500 mL) of breast milk or formula and dairy products. Infants and young children should not be fed a vegan diet.

Food Fortification Strategy—Preventing Iron Deficiency Anemia: A Review

Iron deficiency anemia (IDA) is a significant challenge in developing countries. It increases the risk of premature delivery and low birth weight. In children, IDA retards growth, impairs cognitive performance, and reduces physical activity. It also accelerates the mortality and morbidity rate in women. The key factors responsible include dietary elevated iron demand, socioeconomic, and disease status. To overcome IDA, disease control measures, dietary diversification, supplementation and iron fortification in food have been adopted. Iron fortification in food is considered a long term and sustainable strategy in the present scenario. For an efficient fortification program, the combination of iron fortificants and food vehicle must be safe, acceptable, and consumed by the target population. Moreover, it should not adversely affect acceptability and stability of the end product.

Associations of iron status with dietary and other factors in 6-year-old children

OBJECTIVE

To investigate the associations of iron status at 6 years of age with dietary and other factors.

DESIGN

In a cross-sectional study, children's dietary intakes (3-day weighed food record) were recorded, body size was measured and blood samples were taken near their sixth birthday.

SUBJECTS

A sample of 188 children, from two previous studies (cohorts 1 and 2), was contacted, and 139 (74%) agreed to participate.

RESULTS

Multiple regression analyses with dietary and other factors showed that meat and fish consumption, multivitamin/mineral supplement intake (both positively) and cow's milk product consumption (negatively) were associated with log serum ferritin (SF) (adjusted R (2)=0.125; P=0.028; n=129), and juices and residence (rural>urban) with haemoglobin (Hb) (adjusted R (2)=0.085; P=0.034; n=127). Of 21 multivitamin/mineral consumers, none had depleted iron stores compared to 21 iron-depleted of 108 non-consumers (P=0.024). Children living in rural areas (<10,000 inhabitants) (n=33) had higher mean corpuscular volume (MCV) (83.3+/-2.3 fl) than those living in urban areas (>10,000 inhabitants) (82.1+/-3.2 fl; n=103) (P=0.048). Multiple regression analyses with dietary and other factors and growth showed in cohort 1 that residence (rural>urban), weight gain 0-1years (negatively), and meat and fish intake (positively) were associated with Hb (adjusted R (2)=0.323; P=0.030; n=51), meat and fish (positively) with both log SF (adjusted R (2)=0.069; P=0.035; n=52) and MCV (adjusted R (2)=0.064; P=0.035; n=52), and in cohort 2 cow's milk product consumption (negatively) was associated with log SF (adjusted R (2)=0.119; P=0.017; n=41) and residence (rural>urban) with MCV (adjusted R (2)=0.102; P=0.025; n=41).

CONCLUSIONS

Consumption of meat and fish and possibly also juices, as well as multivitamin/mineral intake might affect iron status in 6-year-old children positively, whereas cow's milk product consumption might affect iron status negatively. Slower growth in the first year of life and rural residence are positively related to iron status of 6-year-olds.

Meat consumption is positively associated with psychomotor outcome in children up to 24 months of age

OBJECTIVE

The impact of specific complementary foods on health outcomes has been poorly studied. We aimed to determine if meat consumption and breastfeeding influence growth and neurocognitive outcome in infants up to 24 months of age.

METHODS

In a longitudinal cohort study, 144 full-term infants were recruited at 4 months. Their red and white meat consumption was recorded in sequential 7-day weighed food intake diaries at 4, 8, 12, 16, 20 and 24 months. Growth data were collected at the same census points as the dietary data. Neurocognitive outcome (psychomotor developmental indices and mental developmental indices) derived from the Bayley Scales of Infant Development II was measured at 22 months.

RESULTS

Meat intake from 4-12 months was positively and significantly related to weight gain (P < 0.05); further analysis suggested this association might be mediated via protein intake but was independent of energy, zinc or iron intake. There was no interaction between meat intake and breastfeeding on growth. Meat intake from 4-12 and 4-16 months was positively and significantly related to psychomotor developmental indices (P < 0.02 and 0.013, respectively) but there was no association between breastfeeding and psychomotor developmental indices nor any interaction between meat intake and breastfeeding. Conversely, breastfeeding was positively and significantly related to mental developmental indices (P < 0.01) but there was no association between meat intake and mental developmental indices nor any interaction between breastfeeding and meat intake. These findings remained after adjustment for potential confounding factors.

CONCLUSION

Meat intake, possibly via its effect on protein intake, is associated with increased weight gain in infants up to 12 months of age. Meat intake is also positively associated with psychomotor development at 22 months. These findings highlight the need for further investigation of the role of complementary foods in relation to health outcomes.

Participatory nutrition education and adoption of new feeding practices are associated with improved adequacy of complementary diets among rural Malawian children: a pilot study

OBJECTIVE

To introduce practices for improving complementary feeding and evaluate their adoption and association with improved dietary intakes.

DESIGN

A quasiexperimental pilot study comparing dietary intakes from complementary foods among three intervention communities and one control community before and after the intervention, and adoption of new complementary feeding practices among intervention communities following the intervention.

SETTING

Rural subsistence communities in southern Malawi, Central Africa.

SUBJECTS

Mothers and their children aged 6 to 23 months receiving complementary foods.

INTERVENTIONS

A participatory, nutrition education intervention based on four locally adapted lessons for complementary feeding practices designed to increase: (i) total complementary food intake; (ii) energy and nutrient density of the complementary diet, and; (iii) iron and zinc bioavailability of the complementary diet.

RESULTS

Adoption rates for the four practices ranged from 25% for preparation of enriched porridges, to 10% for preparing soaked, pounded maize. The amount of complementary foods (g/day) and intakes of energy, animal protein, niacin, riboflavin, calcium, iron, and zinc, but not vitamin A, were significantly greater (P<0.05) in the intervention compared to control group, as were the energy, iron, and riboflavin density, and the estimated amount of bioavailable iron and zinc.

CONCLUSIONS

Several intervention practices were well accepted and adopted and were associated with improved adequacy of energy and nutrient intakes from the complementary diet. Such improvements were attributed mainly to greater total intakes and, to a lesser extent, enhanced dietary quality of the complementary foods.

Daily multivitamins with iron to prevent anemia in high-risk infants: a randomized clinical trial

OBJECTIVE

The goal of this study was to assess the effectiveness of multivitamins with iron as prophylaxis against iron deficiency and anemia in infancy.

METHODS

The study was a double-blinded, randomized, pragmatic, clinical trial conducted at 3 urban primary care clinics. Subjects included healthy, full-term infants who were enrolled at their 6-month well-child visit. Infants were randomly assigned to receive standard-dose multivitamins with or without iron (10 mg/day). Parents administered multivitamins by mouth daily for 3 months. Laboratory results at 9 months of age were analyzed for the presence of anemia and/or iron deficiency. Anemia was defined as hemoglobin level <11.0 g/dL. Iron deficiency was initially defined as any abnormal laboratory value of the following: mean corpuscular volume combined with red cell distribution width or zinc protoporphyrin (with blood lead level <10 microg/dL) for most subjects and ferritin, transferrin saturation, or reticulocyte hemoglobin content for a subset. Subsequent analyses defined iron deficiency as any 2 abnormalities of the above laboratory outcomes, except hemoglobin.

RESULTS

The control (n = 138) and intervention (n = 146) groups were equivalent with respect to all important sociodemographic and nutritional variables. At 9 months of age, anemia was found in 21% of infants (n = 58). A total of 229 (81%) had iron deficiency on the basis of 1 abnormal laboratory indicator and 139 (49%) on the basis of 2 abnormal laboratory indicators. No difference existed in the occurrence of anemia and iron deficiency between the intervention and control groups. In the intervention group, 22% and 78% of 138, respectively, were anemic or had 1 abnormal laboratory outcome indicative of iron deficiency. In the control group, 19% and 84% of 144 were anemic or iron deficient. When stratified by adherence, no differences in hematologic outcomes between groups were noted. However, in multivariate logistic regression, infants whose mothers were anemic during pregnancy were 2.15 times more likely than others to have any laboratory abnormality (95% confidence interval: 1.14-4.07). Increasing adherence, regardless of group assignment, was associated with a 0.56 times reduced risk of any abnormality (95% confidence interval: 0.41-0.76).

CONCLUSION

On the basis of intention-to-treat analysis, multivitamins with iron was not effective in preventing iron deficiency or anemia in 9-month-old infants. However, effective prevention and treatment of maternal anemia during pregnancy and giving multivitamins with or without additional iron during infancy may prove to be important approaches to the prevention of iron deficiency among high-risk children. Because of the consequences of iron deficiency and its high prevalence among low-income infants, additional investigation in these areas is warranted.

Comparative Effects of the Addition of Meat from Beef, Chicken, Mullet and Hake to a Bean Seed Ragout on Iron Metabolism and Iron Status in Growing Rats

AIMS

The objective was to study the comparative effects of the addition of meat from beef, chicken, mullet and hake to a bean seed ragout (BSR) on iron metabolism and iron status in growing rats.

METHODS

The iron metabolism and the iron status were investigated through the exploration of the total iron in the blood and the reserve of iron stored in the liver, spleen, intestine, heart and tibia.

RESULTS

Our findings showed that the iron concentration in total blood significantly increased only in the BSR + beef group by 23% (p < 0.006) as compared to the control group (BSR). However, it significantly decreased in the BSR + chicken group by 19.3% (p < 0.002). The reserve of iron stored in the liver significantly increased in the BSR + beef and the BSR + hake groups by 69.5% (p < 0.003) and 160% (p < 2.5.10(-7)) respectively, as compared to the control group. The effect of hake was more pronounced than beef. However, in the BSR + chicken and the BSR + mullet groups, the reserve of iron stored in the liver did not significantly differ from the control group. The reserve of iron stored in the spleen increased significantly in all groups. The increase has reached 370% in the BSR + hake group (p < 1.10(-7)). In the intestine, the reserve of iron was significantly enhanced only in the group fed BSR + beef by 120% (p < 0.01). In contrast, this reserve was lower in the rats fed BSR + mullet than in the other groups, a reduction of 64% (p < 1.10(-5)) as compared to the control group. In the heart, iron concentration significantly increased between 36.5 and 50%, as compared to the control group. The iron stored in the tibia significantly increased only in the beef and the hake groups by 88% (p < 0.05) and 57.4% (p < 0.02) respectively.

CONCLUSIONS

Our findings demonstrated that beef, chicken, mullet and hake did not have the same effect on iron metabolism and iron status in growing rats fed BSR diets. The rats fed BSR + beef have a better iron status than those fed BSR + hake, BSR + chicken or BSR + mullet in descending order.

Effects of weaning cereals with different phytate contents on hemoglobin, iron stores, and serum zinc: a randomized intervention in infants from 6 to 12 mo of age

BACKGROUND

Weaning foods frequently contain phytate, an inhibitor of iron and zinc absorption, which may contribute to the high prevalence of iron and zinc deficiency seen in infancy.

OBJECTIVE

The objective was to investigate whether either an extensive reduction in the phytate content of infant cereals or the use of milk-based, iron-fortified infant formula would improve iron and zinc status in infants.

DESIGN

In a double-blind design, infants (n = 300) were randomly assigned to 3 cereal groups from 6 to 12 mo of age: commercial milk-based cereal drink (MCD) and porridge (CC group), phytate-reduced MCD and phytate-reduced porridge (PR group), or milk-based infant formula and porridge with the usual phytate content (IF group). Venous blood samples were collected at 6 and 12 mo. Dietary intake was recorded monthly. After the intervention, 267 infants remained in the analysis.

RESULTS

Hemoglobin concentrations of < 110 g/L, serum ferritin concentrations of < 12 microg/L, and serum zinc concentrations of < 10.7 micromol/L had overall prevalences at baseline and 12 mo of 28% and 15%, 9% and 18%, and 22% and 27%, respectively. After the intervention, there were no significant differences in any measure of iron or zinc status between the CC and the PR groups. However, hemoglobin was significantly higher (120 g/L compared with 117 g/L; P = 0.012) and the prevalence of anemia was lower (13% compared with 23%; P = 0.06) in the PR group than in the IF group, which could be explained by differences in daily iron intake between the 2 groups.

CONCLUSION

Extensive reduction in the phytate content of weaning cereals had little long-term effect on the iron and zinc status of Swedish infants.

Iron status at 12 months of age -- effects of body size, growth and diet in a population with high birth weight

OBJECTIVE

To investigate effects of growth and food intake in infancy on iron status at the age of 12 months in a population with high birth weight and high frequency of breast-feeding.

DESIGN

In a longitudinal observational study infants' consumption and growth were recorded. Weighed 2 day food records at the ages of 6, 9 and 12 months were used to analyse food and nutrient intake.

SETTING

Healthy-born participants were recruited from four maternity wards. Blood samples and growth data were collected from healthcare centres and food consumption data at home.

SUBJECTS

Newborn infants (n=180) were selected randomly according to the mother's domicile and 77% (n=138) participated, of them, 83% (n=114), or 63% of original sample, came in for blood sampling.

RESULTS

Every fifth child was iron-deficient (serum ferritin <12 microg/l and mean corpuscular volume<74 fl) and 2.7% were also anaemic (Hb<105 g/l). Higher weight gain from 0 to 12 months was seen in infants who were iron-deficient at 12 months (6.7+/-0.9 kg) than in non-iron-deficient infants (6.2+/-0.9 kg) (P=0.050). Serum transferrin receptors at 12 months were positively associated with length gain from 0 to 12 months (adjusted r(2)=0.14; P=0.045) and mean corpuscular volume negatively to ponderal index at birth (adjusted r(2)=0.14; P=0.019) and 12 months (adjusted r(2)=0.17; P=0.006). Iron-deficient infants had shorter breast-feeding duration (5.3+/-2.2 months) than non-iron-deficient (7.9+/-3.2 months; P=0.001). Iron status indices were negatively associated with cow's milk consumption at 9-12 months, significant above 460 g/day, but were positively associated with iron-fortified breakfast cereals, fish and meat consumption.

CONCLUSIONS

: In a population of high birth weight, iron deficiency at 12 months is associated with faster growth and shorter breast-feeding duration from 0 to 12 months of age. The results suggest that a diet of 9-12-month-olds should avoid cow's milk above 500 g/day and include fish, meat and iron-fortified breakfast cereals to improve iron status.

The role of meat to improve the critical iron balance during weaning

BACKGROUND

Iron requirements during the weaning period are the highest per unit body weight during human life, and diet is often insufficient to cover iron needs. For the first time in infant nutrition the absorption of both nonheme and heme iron from a typical weaning gruel after addition of meat with and without ascorbic acid (AA) to improve bioavailability was studied.

METHODS

Nonheme and heme iron absorption from gruel was measured in 33 adults using 2 radioiron isotopes--an inorganic iron salt to label nonheme iron, the other biosynthetically labeled rabbit hemoglobin to label heme iron. Iron absorption was measured from the basal gruel (based on milkpowder and cereals) and from basal gruel added 20 g red powdered meat, alone and together with 20 mg AA in 4 different trials.

RESULTS

Nonheme iron absorption from the basal meal was 0.33 mg/1000 kcal and the increase from added 20 mg AA was 39%, whereas addition of red meat increased nonheme iron absorption by 85%. This latter increase was unexpectedly high. Total iron absorption was further increased by heme iron absorption of 0.23 mg Fe/1000 kcal. When adding both meat and AA, total iron absorption amounted to 1.08 mg iron/1000 kcal, ie, exceeding 1 mg/1000 kcal, a level estimated to correspond with daily iron requirements in 95% of infants aged 12 months.

CONCLUSIONS

Addition of powdered red meat to weaning gruels markedly increased total iron absorption. A weaning diet with added powdered meat and AA may serve as a viable option to satisfy the body's high iron requirements during this critical period.

Zinc and breastfed infants: if and when is there a risk of deficiency?

Infancy is a time of relatively high zinc requirements. Human milk provides an excellent source of highly bioavailable zinc and generally meets the needs of the healthy young exclusively breastfed infants for the first several months of life. Investigations of exclusively breastfed infants less than 6 mo of age have generally found zinc homeostasis and status to be adequate, although there are indications that zinc intake from human milk alone may become limiting by around 6 mo of age. Exceptions may be small for gestational age and low birth weight infants, who may well benefit from increased zinc intake before 6 mo of age. The older infant clearly becomes dependent on non-human milk sources of zinc, i.e., from complementary foods. Traditional early complementary foods, such as cereals, fruits, and vegetables provide very modest amounts of zinc, and for those high in phytic acid, bioavailability may be low. Introduction of animal products or zinc supplementation may be important to meet the older infant's zinc requirements This is likely to be particularly important in less protected environments with a high infectious burden and limited dietary options.

Iron bioavailability and weight gains to iron-deficient rats fed a commonly consumed Tunisian meal 'bean seeds ragout' with or without beef and with green or black tea decoction

The Fe bioavailability and the weight gains were evaluated in rats fed a commonly consumed Tunisian meal 'bean seeds ragout' (BSR), with or without beef and with black or green tea decoction. The Fe bioavailability was evaluated in Fe-deficient rats by the hemoglobin repletion method and the Fe stored in the liver. The addition of beef to the BSR significantly increased the Fe bioavailability from this meal by 147% and the reserve of Fe stored in the liver by 77% (P < 0.001). In contrast, both black and green tea decoctions caused a significant decrease of the Fe bioavailability from BSR meal (-19.6 +/- 4.9% and -14.9 +/- 4.1%, respectively). The reserve of Fe stored in the liver was significantly lower in the BSR, the black and the green tea groups than in the positive control group (FeSO4). The weight gains were significantly lower in the black and the green tea groups (3.9 +/- 5.7 g, 13 +/- 1.9 g, respectively) than in the BSR group (24.9 +/- 6 g). The addition of beef to BSR meal counteracted the inhibitory effect of the kidney bean and considerably improved the Fe bioavailability and the Fe stored in the liver of rats. The green tea decoction, which constitutes an important source of antioxidant factors, had the same inhibitory effect as the black tea decoction on the Fe bioavailability from BSR meal. In addition, both black and green teas significantly reduced the weight gains, where the black tea decoction has the most effect.

Nonheme-iron absorption from a phytate-rich meal is increased by the addition of small amounts of pork meat

BACKGROUND

Muscle tissue from various sources is known to promote nonheme-iron absorption. However, systematic studies of the dose dependency of this effect of meat on iron absorption from an inhibitory meal with low amounts of meat are lacking.

OBJECTIVE

We investigated the dose-response effect of small amounts of meat on nonheme-iron absorption from a meal presumed to have low iron bioavailability.

DESIGN

Forty-five healthy women with a mean (+/-SD) age of 24 +/- 3 y were randomly assigned to 1 of 3 groups, each of which was served (A) a basic meal (rice, tomato sauce, pea purée, and a wheat roll) and (B) the basic meal with either 25, 50, or 75 g pork (longissimus muscle). Meal A contained 2.3 mg nonheme iron, 7.4 mg vitamin C, and 220 mg (358 micro mol) phytate. Each meal was served twice, and the order of the meals was ABBA or BAAB. The meals were extrinsically labeled with (55)Fe or (59)Fe. Iron absorption was determined from measurements of (59)Fe whole-body retention and the activity of (55)Fe and (59)Fe in blood samples.

RESULTS

Twenty-five grams meat did not increase nonheme-iron absorption significantly (P = 0.13), whereas absorption increased 44% (P < 0.001) and 57% (P < 0.001), respectively, when 50 and 75 g meat were added to the basic meal. In absolute values, this corresponds to an absorption that was 2.6% and 3.4% higher, respectively, than that with the basic meal after adjustment of the data to a level of 40% absorption from a reference dose.

CONCLUSION

Small amounts of meat (>or=50 g) significantly increase nonheme-iron absorption from a phytate-rich meal low in vitamin C.