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Finkelstein JL, Cuthbert A, Weeks J, Venkatramanan S, Larvie DY, De-Regil LM, Garcia-Casal MN. Daily oral iron supplementation during pregnancy. Cochrane Database Syst Rev 2024; 8:CD004736. [PMID: 39145520 PMCID: PMC11325660 DOI: 10.1002/14651858.cd004736.pub6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/16/2024]
Abstract
BACKGROUND Iron and folic acid supplementation have been recommended in pregnancy for anaemia prevention, and may improve other maternal, pregnancy, and infant outcomes. OBJECTIVES To examine the effects of daily oral iron supplementation during pregnancy, either alone or in combination with folic acid or with other vitamins and minerals, as an intervention in antenatal care. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Trials Registry on 18 January 2024 (including CENTRAL, MEDLINE, Embase, CINAHL, ClinicalTrials.gov, WHO's International Clinical Trials Registry Platform, conference proceedings), and searched reference lists of retrieved studies. SELECTION CRITERIA Randomised or quasi-randomised trials that evaluated the effects of oral supplementation with daily iron, iron + folic acid, or iron + other vitamins and minerals during pregnancy were included. DATA COLLECTION AND ANALYSIS Review authors independently assessed trial eligibility, ascertained trustworthiness based on pre-defined criteria, assessed risk of bias, extracted data, and conducted checks for accuracy. We used the GRADE approach to assess the certainty of the evidence for primary outcomes. We anticipated high heterogeneity amongst trials; we pooled trial results using a random-effects model (average treatment effect). MAIN RESULTS We included 57 trials involving 48,971 women. A total of 40 trials compared the effects of daily oral supplements with iron to placebo or no iron; eight trials evaluated the effects of iron + folic acid compared to placebo or no iron + folic acid. Iron supplementation compared to placebo or no iron Maternal outcomes: Iron supplementation during pregnancy may reduce maternal anaemia (4.0% versus 7.4%; risk ratio (RR) 0.30, 95% confidence interval (CI) 0.20 to 0.47; 14 trials, 13,543 women; low-certainty evidence) and iron deficiency at term (44.0% versus 66.0%; RR 0.51, 95% CI 0.38 to 0.68; 8 trials, 2873 women; low-certainty evidence), and probably reduces maternal iron-deficiency anaemia at term (5.0% versus 18.4%; RR 0.41, 95% CI 0.26 to 0.63; 7 trials, 2704 women; moderate-certainty evidence), compared to placebo or no iron supplementation. There is probably little to no difference in maternal death (2 versus 4 events, RR 0.57, 95% CI 0.12 to 2.69; 3 trials, 14,060 women; moderate-certainty evidence). The evidence is very uncertain for adverse effects (21.6% versus 18.0%; RR 1.29, 95% CI 0.83 to 2.02; 12 trials, 2423 women; very low-certainty evidence) and severe anaemia (Hb < 70 g/L) in the second/third trimester (< 1% versus 3.6%; RR 0.22, 95% CI 0.01 to 3.20; 8 trials, 1398 women; very low-certainty evidence). No trials reported clinical malaria or infection during pregnancy. Infant outcomes: Women taking iron supplements are probably less likely to have infants with low birthweight (5.2% versus 6.1%; RR 0.84, 95% CI 0.72 to 0.99; 12 trials, 18,290 infants; moderate-certainty evidence), compared to placebo or no iron supplementation. However, the evidence is very uncertain for infant birthweight (MD 24.9 g, 95% CI -125.81 to 175.60; 16 trials, 18,554 infants; very low-certainty evidence). There is probably little to no difference in preterm birth (7.6% versus 8.2%; RR 0.93, 95% CI 0.84 to 1.02; 11 trials, 18,827 infants; moderate-certainty evidence) and there may be little to no difference in neonatal death (1.4% versus 1.5%, RR 0.98, 95% CI 0.77 to 1.24; 4 trials, 17,243 infants; low-certainty evidence) or congenital anomalies, including neural tube defects (41 versus 48 events; RR 0.88, 95% CI 0.58 to 1.33; 4 trials, 14,377 infants; low-certainty evidence). Iron + folic supplementation compared to placebo or no iron + folic acid Maternal outcomes: Daily oral supplementation with iron + folic acid probably reduces maternal anaemia at term (12.1% versus 25.5%; RR 0.44, 95% CI 0.30 to 0.64; 4 trials, 1962 women; moderate-certainty evidence), and may reduce maternal iron deficiency at term (3.6% versus 15%; RR 0.24, 95% CI 0.06 to 0.99; 1 trial, 131 women; low-certainty evidence), compared to placebo or no iron + folic acid. The evidence is very uncertain about the effects of iron + folic acid on maternal iron-deficiency anaemia (10.8% versus 25%; RR 0.43, 95% CI 0.17 to 1.09; 1 trial, 131 women; very low-certainty evidence), or maternal deaths (no events; 1 trial; very low-certainty evidence). The evidence is uncertain for adverse effects (21.0% versus 0.0%; RR 44.32, 95% CI 2.77 to 709.09; 1 trial, 456 women; low-certainty evidence), and the evidence is very uncertain for severe anaemia in the second or third trimester (< 1% versus 5.6%; RR 0.12, 95% CI 0.02 to 0.63; 4 trials, 506 women; very low-certainty evidence), compared to placebo or no iron + folic acid. Infant outcomes: There may be little to no difference in infant low birthweight (33.4% versus 40.2%; RR 1.07, 95% CI 0.31 to 3.74; 2 trials, 1311 infants; low-certainty evidence), comparing iron + folic acid supplementation to placebo or no iron + folic acid. Infants born to women who received iron + folic acid during pregnancy probably had higher birthweight (MD 57.73 g, 95% CI 7.66 to 107.79; 2 trials, 1365 infants; moderate-certainty evidence), compared to placebo or no iron + folic acid. There may be little to no difference in other infant outcomes, including preterm birth (19.4% versus 19.2%; RR 1.55, 95% CI 0.40 to 6.00; 3 trials, 1497 infants; low-certainty evidence), neonatal death (3.4% versus 4.2%; RR 0.81, 95% CI 0.51 to 1.30; 1 trial, 1793 infants; low-certainty evidence), or congenital anomalies (1.7% versus 2.4; RR 0.70, 95% CI 0.35 to 1.40; 1 trial, 1652 infants; low-certainty evidence), comparing iron + folic acid supplementation to placebo or no iron + folic acid. A total of 19 trials were conducted in malaria-endemic countries, or in settings with some malaria risk. No studies reported maternal clinical malaria; one study reported data on placental malaria. AUTHORS' CONCLUSIONS Daily oral iron supplementation during pregnancy may reduce maternal anaemia and iron deficiency at term. For other maternal and infant outcomes, there was little to no difference between groups or the evidence was uncertain. Future research is needed to examine the effects of iron supplementation on other maternal and infant health outcomes, including infant iron status, growth, and development.
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Affiliation(s)
| | - Anna Cuthbert
- Cochrane Pregnancy and Childbirth Group, Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
| | - Jo Weeks
- Cochrane Pregnancy and Childbirth Group, Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
| | | | - Doreen Y Larvie
- Division of Nutritional Sciences, Cornell University, Ithaca, New York, USA
| | - Luz Maria De-Regil
- Multisectoral Action in Food Systems Unit, World Health Organization, Geneva, Switzerland
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Bah M, Verhoef H, Okoh E, Bah A, Prentice AM, Cerami C. Haem iron versus ferrous iron salts to treat iron deficiency anaemia in Gambian children: protocol for randomised controlled trial {1}. Trials 2024; 25:270. [PMID: 38641845 PMCID: PMC11027386 DOI: 10.1186/s13063-024-08101-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 04/10/2024] [Indexed: 04/21/2024] Open
Abstract
BACKGROUND The World Health Organization recommends universal iron supplementation for children aged 6-23 months in countries where anaemia is seen in over 40% of the population. Conventional ferrous salts have low efficacy due to low oral absorption in children with inflammation. Haem iron is more bioavailable, and its absorption may not be decreased by inflammation. This study aims to compare daily supplementation with haem iron versus ferrous sulphate on haemoglobin concentration and serum ferritin concentration after 12 weeks of supplementation. METHODS This will be a two-arm, randomised controlled trial. Gambian children aged 6-12 months with anaemia will be recruited within a predefined geographical area and recruited by trained field workers. Eligible participants will be individually randomised using a 1:1 ratio within permuted blocks to daily supplementation for 12 weeks with either 10.0 mg of elemental iron as haem or ferrous sulphate. Safety outcomes such as diarrhoea and infection-related adverse events will be assessed daily by the clinical team (see Bah et al. Additional file 4_Adverse event eCRF). Linear regression will be used to analyse continuous outcomes, with log transformation to normalise residuals as needed. Binary outcomes will be analysed by binomial regression or logistic regression, Primary analysis will be by modified intention-to-treat (i.e., those randomised and who ingested at least one supplement dose of iron), with multiple imputations to replace missing data. Effect estimates will be adjusted for baseline covariates (C-reactive protein, alpha-1-acid glycoprotein, haemoglobin, ferritin, soluble transferrin receptor). DISCUSSION This study will determine if therapeutic supplementation with haem iron is more efficacious than with conventional ferrous sulphate in enhancing haemoglobin and ferritin concentrations in anaemic children aged 6-12 months. TRIAL REGISTRATION Pan African Clinical Trial Registry PACTR202210523178727.
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Affiliation(s)
- Mamadou Bah
- Medical Research Council (MRC) Unit The Gambia at London School of Hygiene & Tropical Medicine (LSHTM), PO Box 273, Fajara, Banjul, The Gambia
- Division of Human Nutrition and Health, Wageningen University, PO Box 17, 6700, AA, Wageningen, The Netherlands
| | - Hans Verhoef
- Division of Human Nutrition and Health, Wageningen University, PO Box 17, 6700, AA, Wageningen, The Netherlands
| | - Emmanuel Okoh
- Medical Research Council (MRC) Unit The Gambia at London School of Hygiene & Tropical Medicine (LSHTM), PO Box 273, Fajara, Banjul, The Gambia
| | - Abdoulie Bah
- Medical Research Council (MRC) Unit The Gambia at London School of Hygiene & Tropical Medicine (LSHTM), PO Box 273, Fajara, Banjul, The Gambia
| | - Andrew M Prentice
- Medical Research Council (MRC) Unit The Gambia at London School of Hygiene & Tropical Medicine (LSHTM), PO Box 273, Fajara, Banjul, The Gambia
| | - Carla Cerami
- Medical Research Council (MRC) Unit The Gambia at London School of Hygiene & Tropical Medicine (LSHTM), PO Box 273, Fajara, Banjul, The Gambia.
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Delaney KM, Guillet R, Pressman EK, Ganz T, Nemeth E, O'Brien KO. Serum Erythroferrone During Pregnancy Is Related to Erythropoietin but Does Not Predict the Risk of Anemia. J Nutr 2021; 151:1824-1833. [PMID: 33982118 PMCID: PMC8245876 DOI: 10.1093/jn/nxab093] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 01/12/2021] [Accepted: 03/15/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Maintaining adequate iron status during pregnancy is important for the mother and her developing fetus. Iron homeostasis is influenced by 3 regulatory hormones: erythropoietin (EPO), hepcidin, and erythroferrone (ERFE). To date, normative data on ERFE across pregnancy and its relations to other hormones and iron status indicators are limited. OBJECTIVES The objective of this study was to characterize maternal ERFE across pregnancy and at delivery and evaluate the utility of hepcidin, ERFE, and EPO in identifying women with increased iron needs. METHODS ERFE was measured in extant serum samples collected from 2 longitudinal cohorts composed of women carrying multiple fetuses (n = 79) and pregnant adolescents (n = 218) at midgestation (∼26 wk) and delivery (∼39 wk). Receiver operating characteristic curves were generated to characterize the predictive ability of serum ERFE, hepcidin, and EPO and their ratios to identify women at increased risk of iron deficiency and anemia. RESULTS In these pregnant women, mean ERFE was 0.48 ng/mL at both ∼25 wk of gestation and at delivery. ERFE was positively associated with EPO at midgestation (β = 0.14, P = 0.002, n = 202) and delivery (β = 0.12, P < 0.001, n = 225) but was not significantly associated with maternal hepcidin at any time point surveyed. Of all hormones measured at midgestation and delivery, EPO was best able to identify women with anemia (AUC: 0.86 and 0.75, respectively) and depleted iron stores (AUC: 0.77 and 0.84), whereas the hepcidin-to-EPO ratio was best able to identify women with iron deficiency anemia (AUC: 0.85 and 0.84). CONCLUSIONS Maternal ERFE was significantly associated with EPO but was not able to identify women with gestational iron deficiency. At term, the hepcidin-to-EPO ratio, an index that accounts for both iron status and erythropoietic demand, and EPO were the strongest indicators of maternal iron deficiency and anemia. This trial was registered at clinicaltrials.gov as NCT04517734 (https://clinicaltrials.gov/ct2/show/NCT04517734).
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Affiliation(s)
| | - Ronnie Guillet
- Department of Pediatrics, Division of Neonatology, University of Rochester School of Medicine, Rochester, NY, USA
| | - Eva K Pressman
- Department of Obstetrics and Gynecology, University of Rochester School of Medicine, Rochester, NY, USA
| | - Tomas Ganz
- Center for Iron Disorders, Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Elizabeta Nemeth
- Center for Iron Disorders, Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
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Bah A, Muhammad AK, Wegmuller R, Verhoef H, Goheen MM, Sanyang S, Danso E, Sise EA, Pasricha SR, Armitage AE, Drakesmith H, Cross JH, Moore SE, Cerami C, Prentice AM. Hepcidin-guided screen-and-treat interventions against iron-deficiency anaemia in pregnancy: a randomised controlled trial in The Gambia. Lancet Glob Health 2019; 7:e1564-e1574. [PMID: 31607468 PMCID: PMC7109523 DOI: 10.1016/s2214-109x(19)30393-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 07/31/2019] [Accepted: 09/06/2019] [Indexed: 01/19/2023]
Abstract
BACKGROUND WHO recommends daily iron supplementation for pregnant women, but adherence is poor because of side-effects, effectiveness is low, and there are concerns about possible harm. The iron-regulatory hormone hepcidin can signal when an individual is ready-and-safe to receive iron. We tested whether a hepcidin-guided screen-and-treat approach to combat iron-deficiency anaemia could achieve equivalent efficacy to universal administration, but with lower exposure to iron. METHODS We did a three-arm, randomised, double-blind, non-inferiority trial in 19 rural communities in the Jarra West and Kiang East districts of The Gambia. Eligible participants were pregnant women aged 18-45 years at between 14 weeks and 22 weeks of gestation. We randomly allocated women to either WHO's recommended regimen (ie, a daily UN University, UNICEF, and WHO international multiple-micronutrient preparation [UNIMMAP] containing 60 mg iron), a 60 mg screen-and-treat approach (ie, daily UNIMMAP containing 60 mg iron for 7 days if weekly hepcidin was <2·5 μg/L or UNIMMAP without iron if hepcidin was ≥2·5 μg/L), or a 30 mg screen-and-treat approach (ie, daily UNIMMAP containing 30 mg iron for 7 days if weekly hepcidin was <2·5 μg/L or UNIMMAP without iron if hepcidin was ≥2·5 μg/L). We used a block design stratified by amount of haemoglobin at enrolment (above and below the median amount of haemoglobin on every enrolment day) and stage of gestation (14-18 weeks vs 19-22 weeks). Participants and investigators were unaware of the random allocation. The primary outcome was the amount of haemoglobin at day 84 and was measured as the difference in haemoglobin in each screen-and-treat group compared with WHO's recommended regimen; the non-inferiority margin was set at -5·0 g/L. The primary outcome was assessed in the per-protocol population, which comprised all women who completed the study. This trial is registered with the ISRCTN registry, number ISRCTN21955180. FINDINGS Between June 16, 2014, and March 3, 2016, 498 participants were randomised, of whom 167 were allocated to WHO's recommended regimen, 166 were allocated to the 60 mg per day screen-and-treat approach, and 165 were allocated to the 30 mg per day screen-and-treat approach. 78 participants were withdrawn or lost to follow-up during the study; thus, the per-protocol population comprised 140 women assigned to WHO's recommended regimen, 133 allocated to the 60 mg screen-and-treat approach, and 147 allocated to the 30 mg screen-and-treat approach. The screen-and-treat approaches did not exceed the non-inferiority margin. Compared with WHO's recommended regimen, the difference in the amount of haemoglobin at day 84 was -2·2 g/L (95% CI -4·6 to 0·1) with the 60 mg screen-and-treat approach and -2·7 g/L (-5·0 to -0·5) with the 30 mg screen-and-treat approach. Adherence, reported side-effects, and adverse events were similar between the three groups. The most frequent side-effect was stomachache, which was similar in the 60 mg screen-and-treat group (82 cases per 1906 person-weeks) and with WHO's recommended regimen (81 cases per 1974 person-weeks; effect 1·0, 95% CI 0·7 to 1·6); in the 30 mg screen-and-treat group the frequency of stomachache was slightly lower than with WHO's recommended regimen (58 cases per 2009 person-weeks; effect 0·7, 95% CI 0·5 to 1·1). No participants died during the study. INTERPRETATION The hepcidin-guided screen-and-treat approaches had no advantages over WHO's recommended regimen in terms of adherence, side-effects, or safety outcomes. Our results suggest that the current WHO policy for iron administration to pregnant women should remain unchanged while more effective approaches continue to be sought. FUNDING Bill & Melinda Gates Foundation and the UK Medical Research Council.
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Affiliation(s)
- Amat Bah
- Medical Research Council (MRC) Unit The Gambia at London School of Hygiene & Tropical Medicine (LSHTM), Serrekunda, The Gambia; LSHTM, London, UK
| | - Abdul Khalie Muhammad
- Medical Research Council (MRC) Unit The Gambia at London School of Hygiene & Tropical Medicine (LSHTM), Serrekunda, The Gambia
| | - Rita Wegmuller
- Medical Research Council (MRC) Unit The Gambia at London School of Hygiene & Tropical Medicine (LSHTM), Serrekunda, The Gambia; GroundWork, Flaesch, Switzerland
| | - Hans Verhoef
- Division of Human Nutrition and Health, Wageningen University, Wageningen, Netherlands; LSHTM, London, UK
| | - Morgan M Goheen
- Medical Research Council (MRC) Unit The Gambia at London School of Hygiene & Tropical Medicine (LSHTM), Serrekunda, The Gambia; University of North Carolina at Chapel Hill School of Medicine, Department of Microbiology and Immunology, Chapel Hill, NC, USA
| | - Saikou Sanyang
- Medical Research Council (MRC) Unit The Gambia at London School of Hygiene & Tropical Medicine (LSHTM), Serrekunda, The Gambia
| | - Ebrima Danso
- Medical Research Council (MRC) Unit The Gambia at London School of Hygiene & Tropical Medicine (LSHTM), Serrekunda, The Gambia
| | - Ebrima A Sise
- Medical Research Council (MRC) Unit The Gambia at London School of Hygiene & Tropical Medicine (LSHTM), Serrekunda, The Gambia
| | - Sant-Rayn Pasricha
- Population Health and Immunity Division, The Walter and Eliza Hall Institute of Medical Research, and Department of Medical Biology, University of Melbourne, Melbourne, VIC, Australia
| | - Andrew E Armitage
- MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Hal Drakesmith
- MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - James H Cross
- Medical Research Council (MRC) Unit The Gambia at London School of Hygiene & Tropical Medicine (LSHTM), Serrekunda, The Gambia; LSHTM, London, UK
| | - Sophie E Moore
- Medical Research Council (MRC) Unit The Gambia at London School of Hygiene & Tropical Medicine (LSHTM), Serrekunda, The Gambia; Department of Women & Children's Health, King's College London, St Thomas' Hospital, London, UK
| | | | - Andrew M Prentice
- Medical Research Council (MRC) Unit The Gambia at London School of Hygiene & Tropical Medicine (LSHTM), Serrekunda, The Gambia; LSHTM, London, UK.
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Gilder ME, Simpson JA, Bancone G, McFarlane L, Shah N, van Aalsburg R, Paw MK, Pimanpanarak M, Wiladphaingern J, Myat Min A, Turner C, Rijken MJ, Boel M, Hoogenboom G, Tun NW, Charunwatthana P, Carrara VI, Nosten F, McGready R. Evaluation of a treatment protocol for anaemia in pregnancy nested in routine antenatal care in a limited-resource setting. Glob Health Action 2019; 12:1621589. [PMID: 31203791 PMCID: PMC6586122 DOI: 10.1080/16549716.2019.1621589] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Background: Anaemia in pregnancy is typically due to iron deficiency (IDA) but remains a complex and pervasive problem, particularly in low resource settings. At clinics on the Myanmar–Thailand border, a protocol was developed to guide treatment by health workers in antenatal care (ANC). Objective: To evaluate the clinical use of a protocol to treat anaemia in pregnancy. Methods: The design was a descriptive retrospective analysis of antenatal data obtained during the use of a standard anaemia treatment protocol. Two consecutive haematocrits (HCT) <30% prompted a change from routine prophylaxis to treatment doses of haematinics. Endpoints were anaemia at delivery (most recent HCT before delivery <30%) and timeliness of treatment initiation. Women whose HCT failed to respond to the treatment were investigated. Results: From August 2007 to July 2012, a median [IQR] of five [4–11] HCT measurements per woman resulted in the treatment of anaemia in 20.7% (2,246/10,886) of pregnancies. Anaemia at delivery was present in 22.8% (511/2,246) of treated women and 1.4% (123/8,640) who remained on prophylaxis. Human error resulted in a failure to start treatment in 97 anaemic women (4.1%, denominator 2,343 (2,246 + 97)). Fluctuation of HCT around the cut-point of 30% was the major problem with the protocol accounting for half of the cases where treatment was delayed greater than 4 weeks. Delay in treatment was associated with a 1.5 fold higher odds of anaemia at delivery (95% CI 1.18, 1.97). Conclusion: There was high compliance to the protocol by the health workers. An important outcome of this evaluation was that the clinical definition of anaemia was changed to diminish missed opportunities for initiating treatment. Reduction of anaemia in pregnancy requires early ANC attendance, prompt treatment at the first HCT <30%, and support for health workers.
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Affiliation(s)
- Mary Ellen Gilder
- a Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine , Mahidol University , Mae Sot , Thailand
| | - Julie A Simpson
- b Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health , The University of Melbourne , Melbourne , Australia
| | - Germana Bancone
- a Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine , Mahidol University , Mae Sot , Thailand.,c Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine , University of Oxford , Oxford , UK
| | - Laura McFarlane
- a Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine , Mahidol University , Mae Sot , Thailand
| | - Neha Shah
- a Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine , Mahidol University , Mae Sot , Thailand
| | - Rob van Aalsburg
- a Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine , Mahidol University , Mae Sot , Thailand
| | - Moo Koh Paw
- a Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine , Mahidol University , Mae Sot , Thailand
| | - Mupawjay Pimanpanarak
- a Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine , Mahidol University , Mae Sot , Thailand
| | - Jacher Wiladphaingern
- a Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine , Mahidol University , Mae Sot , Thailand
| | - Aung Myat Min
- a Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine , Mahidol University , Mae Sot , Thailand
| | - Claudia Turner
- c Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine , University of Oxford , Oxford , UK.,d Cambodia Oxford Medical Research Unit , Angkor Hospital for Children , Siem Reap , Cambodia
| | - Marcus J Rijken
- a Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine , Mahidol University , Mae Sot , Thailand.,e Department of Obstetrics and Gynaecology , University Medical Centre Utrecht, Utrecht University , Utrecht , The Netherlands
| | - Machteld Boel
- a Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine , Mahidol University , Mae Sot , Thailand
| | - Gabie Hoogenboom
- a Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine , Mahidol University , Mae Sot , Thailand
| | - Nay Win Tun
- a Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine , Mahidol University , Mae Sot , Thailand
| | - Prakaykaew Charunwatthana
- f Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine , Mahidol University , Bangkok , Thailand
| | - Verena I Carrara
- a Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine , Mahidol University , Mae Sot , Thailand.,g Department of Medicine , Swiss Tropical and Public Health Institute , Basel , Switzerland
| | - François Nosten
- a Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine , Mahidol University , Mae Sot , Thailand.,c Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine , University of Oxford , Oxford , UK
| | - Rose McGready
- a Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine , Mahidol University , Mae Sot , Thailand.,c Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine , University of Oxford , Oxford , UK
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Muriuki JM, Mentzer AJ, Band G, Gilchrist JJ, Carstensen T, Lule SA, Goheen MM, Joof F, Kimita W, Mogire R, Cutland CL, Diarra A, Rautanen A, Pomilla C, Gurdasani D, Rockett K, Mturi N, Ndungu FM, Scott JAG, Sirima SB, Morovat A, Prentice AM, Madhi SA, Webb EL, Elliott AM, Bejon P, Sandhu MS, Hill AVS, Kwiatkowski DP, Williams TN, Cerami C, Atkinson SH. The ferroportin Q248H mutation protects from anemia, but not malaria or bacteremia. SCIENCE ADVANCES 2019; 5:eaaw0109. [PMID: 31517041 PMCID: PMC6726445 DOI: 10.1126/sciadv.aaw0109] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Accepted: 08/06/2019] [Indexed: 06/10/2023]
Abstract
Iron acquisition is critical for life. Ferroportin (FPN) exports iron from mature erythrocytes, and deletion of the Fpn gene results in hemolytic anemia and increased fatality in malaria-infected mice. The FPN Q248H mutation (glutamine to histidine at position 248) renders FPN partially resistant to hepcidin-induced degradation and was associated with protection from malaria in human studies of limited size. Using data from cohorts including over 18,000 African children, we show that the Q248H mutation is associated with modest protection against anemia, hemolysis, and iron deficiency, but we found little evidence of protection against severe malaria or bacteremia. We additionally observed no excess Plasmodium growth in Q248H erythrocytes ex vivo, nor evidence of selection driven by malaria exposure, suggesting that the Q248H mutation does not protect from malaria and is unlikely to deprive malaria parasites of iron essential for their growth.
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Affiliation(s)
- John Muthii Muriuki
- Kenya Medical Research Institute (KEMRI) Wellcome Trust Research Programme, Kilifi, Kenya
| | - Alexander J. Mentzer
- Wellcome Centre for Human Genetics, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Gavin Band
- Wellcome Centre for Human Genetics, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - James J. Gilchrist
- Wellcome Centre for Human Genetics, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Department of Paediatrics, University of Oxford, Oxford, UK
| | | | - Swaib A. Lule
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene & Tropical Medicine Uganda Research Unit, Entebbe, Uganda
- London School of Hygiene and Tropical Medicine, London, UK
| | - Morgan M. Goheen
- Medical Research Council Unit The Gambia at London School of Hygiene and Tropical Medicine, Banjul, The Gambia
- University of North Carolina School of Medicine, CB 7435, Chapel Hill, North Carolina USA
| | - Fatou Joof
- Medical Research Council Unit The Gambia at London School of Hygiene and Tropical Medicine, Banjul, The Gambia
| | - Wandia Kimita
- Kenya Medical Research Institute (KEMRI) Wellcome Trust Research Programme, Kilifi, Kenya
| | - Reagan Mogire
- Kenya Medical Research Institute (KEMRI) Wellcome Trust Research Programme, Kilifi, Kenya
| | - Clare L. Cutland
- Medical Research Council: Respiratory and Meningeal Pathogens Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Amidou Diarra
- Centre de Recherche Action en Sante (GRAS), 06 BP 10248, Ouagadougou 06, Burkina Faso
| | - Anna Rautanen
- Wellcome Centre for Human Genetics, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | | | | | - Kirk Rockett
- Wellcome Centre for Human Genetics, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Neema Mturi
- Kenya Medical Research Institute (KEMRI) Wellcome Trust Research Programme, Kilifi, Kenya
| | - Francis M. Ndungu
- Kenya Medical Research Institute (KEMRI) Wellcome Trust Research Programme, Kilifi, Kenya
| | - J. Anthony G. Scott
- Kenya Medical Research Institute (KEMRI) Wellcome Trust Research Programme, Kilifi, Kenya
- London School of Hygiene and Tropical Medicine, London, UK
| | - Sodiomon B. Sirima
- Centre de Recherche Action en Sante (GRAS), 06 BP 10248, Ouagadougou 06, Burkina Faso
| | - Alireza Morovat
- Department of Clinical Biochemistry, Oxford University Hospitals, Oxford, UK
| | - Andrew M. Prentice
- Medical Research Council Unit The Gambia at London School of Hygiene and Tropical Medicine, Banjul, The Gambia
| | - Shabir A. Madhi
- Medical Research Council: Respiratory and Meningeal Pathogens Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Emily L. Webb
- London School of Hygiene and Tropical Medicine, London, UK
| | - Alison M. Elliott
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene & Tropical Medicine Uganda Research Unit, Entebbe, Uganda
- London School of Hygiene and Tropical Medicine, London, UK
| | - Philip Bejon
- Kenya Medical Research Institute (KEMRI) Wellcome Trust Research Programme, Kilifi, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | | | - Adrian V. S. Hill
- Wellcome Centre for Human Genetics, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Centre for Clinical Vaccinology and Tropical Medicine and the Jenner Institute Laboratories, University of Oxford, Oxford, UK
| | - Dominic P. Kwiatkowski
- Wellcome Centre for Human Genetics, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Wellcome Sanger Institute, Hinxton, Cambridge, UK
| | - Thomas N. Williams
- Kenya Medical Research Institute (KEMRI) Wellcome Trust Research Programme, Kilifi, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Department of Medicine, Imperial College, London, UK
| | - Carla Cerami
- Medical Research Council Unit The Gambia at London School of Hygiene and Tropical Medicine, Banjul, The Gambia
| | - Sarah H. Atkinson
- Kenya Medical Research Institute (KEMRI) Wellcome Trust Research Programme, Kilifi, Kenya
- Department of Paediatrics, University of Oxford, Oxford, UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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7
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Lewies A, Zandberg L, Baumgartner J. Interventions to prevent iron deficiency during the first 1000 days in low-income and middle-income countries: recent advances and challenges. Curr Opin Clin Nutr Metab Care 2019; 22:223-229. [PMID: 30893089 DOI: 10.1097/mco.0000000000000557] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Iron deficiency remains highly prevalent in women and young children in low-income and middle-income countries. To prevent the potentially life-long consequences of iron deficiency when occurring during early life, the WHO recommends iron supplementation of pregnant women and young children. However, increasing evidence of limited efficacy and risk of current iron intervention strategies are cause of concern. This review aims to highlight recent advances and challenges of established and novel intervention strategies for the prevention of iron deficiency during the first 1000 days in low-income and middle-income countries. RECENT FINDINGS Recent meta-analyses and trials challenged the WHO's current recommendation to provide iron-folic acid rather than multiple micronutrient supplements during routine antenatal care. Furthermore, several studies explored optimal windows for iron supplementation, such as prior to conception. Studies are demonstrating that infectious and noninfectious inflammation is compromising the efficacy of iron interventions in vulnerable groups. Therefore, strategies addressing iron deficiency should focus on targeting infection and inflammation while simultaneously providing additional iron. Furthermore, both iron deficiency and iron supplementation may promote an unfavourable gut microbiota. Recent trials in infants indicate that the provision of a prebiotic together with iron may alleviate the adverse effects of iron on the gut microbiome and gut inflammation, and may even enhance iron absorption. SUMMARY Recent studies highlight the need for and potential of novel intervention strategies that increase the efficacy and limit the potential harm of universal iron supplementation.
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Affiliation(s)
- Angélique Lewies
- Centre of Excellence for Nutrition, North-West University, Potchefstroom, South Africa
| | - Lizelle Zandberg
- Centre of Excellence for Nutrition, North-West University, Potchefstroom, South Africa
| | - Jeannine Baumgartner
- Centre of Excellence for Nutrition, North-West University, Potchefstroom, South Africa
- Laboratory of Human Nutrition, Institute of Food, Nutrition and Health, ETH Zurich, Switzerland
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8
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Abbas AM, Abdelbadee SA, Alanwar A, Mostafa S. Efficacy of ferrous bis-glycinate versus ferrous glycine sulfate in the treatment of iron deficiency anemia with pregnancy: a randomized double-blind clinical trial. J Matern Fetal Neonatal Med 2018; 32:4139-4145. [PMID: 29843553 DOI: 10.1080/14767058.2018.1482871] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Objective: The aim of this study is to compare the efficacy and tolerability of oral ferrous bis-glycinate versus ferrous glycine sulfate in the treatment of iron deficiency anemia (IDA) with pregnancy.Methods: A randomized double-blind clinical trial (NCT02590224) conducted at a tertiary University Hospital in the period between 1 January 2016 and 31 July 2017 included pregnant women at 14-18 weeks of gestation with mild to moderate IDA. Patients were randomized into two groups: (Group I) received oral ferrous bis-glycinate tablets once daily for eight consecutive weeks and (Group II) received oral ferrous glycine sulfate capsules in the same dose and duration. The primary outcome of the study was the rate of increase of hemoglobin (HB) level after 8 weeks of iron treatment.Results: The study included 187 women in the final analysis. The mean increase in HB level after 8 weeks of treatment in ferrous bis-glycinate group was 2.48 ± 0.12 g/dL versus 1.32 ± 0.18 g/dL in ferrous glycine sulfate group (p ≤ .0001). The percentage of women with HB level more than 11 g/dL after 8 weeks of treatment was 89.2% in ferrous bis-glycinate group versus 71.3% in ferrous glycine sulfate group (p < .0001). The rate of adverse effects was significantly higher in ferrous glycine sulfate group (p = .001).Conclusions: Pregnant women with second trimester IDA could be supplied with ferrous bis-glycinate which is more efficient in increasing HB level. Moreover, it has tolerable adverse effects and high compliance than ferrous glycine sulfate.
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Affiliation(s)
- Ahmed M Abbas
- Department of Obstetrics & Gynecology, Faculty of Medicine, Assiut University, Egypt
| | - Safaa A Abdelbadee
- Department of Obstetrics & Gynecology, Faculty of Medicine, Assiut University, Egypt
| | - Ahmed Alanwar
- Department of Obstetrics & Gynecology, Faculty of Medicine, Ain Shams University, Egypt
| | - Sayed Mostafa
- Department of Obstetrics & Gynecology, Faculty of Medicine, Assiut University, Egypt
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9
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Tandon R, Jain A, Malhotra P. Management of Iron Deficiency Anemia in Pregnancy in India. Indian J Hematol Blood Transfus 2018; 34:204-215. [PMID: 29622861 PMCID: PMC5885006 DOI: 10.1007/s12288-018-0949-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 03/08/2018] [Indexed: 01/28/2023] Open
Abstract
Iron deficiency anemia (IDA) continues to be the commonest etiology of anemia in pregnancy. The prevalence of iron deficiency (ID) in pregnant Indian women is amongst the highest in the world. Untreated iron deficiency (ID) has significant adverse feto-maternal consequences. Plethora of investigations are available for diagnosis of IDA, each having specific advantages and disadvantages when used in the pregnancy setting. Therapy for ID includes dietary modification, oral iron supplementation, intravenous iron and blood transfusion. Newer parenteral iron preparations are safe and there is mounting evidence to suggest their use in frontline settings for pregnancy associated IDA in the second and third trimester. Through this review, we suggest an algorithm for diagnosis and treatment of IDA in pregnancy depending on the severity of anemia and period of gestation suited for widespread use in resource limited settings. Also, we recommend ways for increasing public awareness and tackling this health issue including the observance of "National Anemia Awareness and Treatment Day."
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Affiliation(s)
- Rimpy Tandon
- Department of Obstetrics and Gynaecology, Government Medical College and Hospital-32, Chandigarh, India
| | - Arihant Jain
- Department of Internal Medicine (Clinical Hematology Division), PGIMER, Chandigarh, India
| | - Pankaj Malhotra
- Department of Internal Medicine (Clinical Hematology Division), PGIMER, Chandigarh, India
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10
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Goheen MM, Bah A, Wegmüller R, Verhoef H, Darboe B, Danso E, Prentice AM, Cerami C. Host iron status and erythropoietic response to iron supplementation determines susceptibility to the RBC stage of falciparum malaria during pregnancy. Sci Rep 2017; 7:17674. [PMID: 29247172 PMCID: PMC5732269 DOI: 10.1038/s41598-017-16896-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Accepted: 11/14/2017] [Indexed: 01/14/2023] Open
Abstract
Anaemia and malaria are both common in pregnant women in Sub-Saharan Africa. Previous evidence has shown that iron supplementation may increase malaria risk. In this observational cohort study, we evaluated P. falciparum pathogenesis in vitro in RBCs from pregnant women during their 2nd and 3rd trimesters. RBCs were collected and assayed before (n = 327), 14 days (n = 82), 49 days (n = 112) and 84 days (n = 115) after iron supplementation (60 mg iron as ferrous fumarate daily). P. falciparum erythrocytic stage growth in vitro is reduced in anaemic pregnant women at baseline, but increased during supplementation. The elevated growth rates parallel increases in circulating CD71-positive reticulocytes and other markers of young RBCs. We conclude that Plasmodium growth in vitro is associated with elevated erythropoiesis, an obligate step towards erythroid recovery in response to supplementation. Our findings support current World Health Organization recommendations that iron supplementation be given in combination with malaria prevention and treatment services in malaria endemic areas.
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Affiliation(s)
- Morgan M Goheen
- Department of Microbiology and Immunology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Amat Bah
- Nutrition Theme, MRC Unit The Gambia, MRC International Nutrition Group, Keneba, The Gambia
| | - Rita Wegmüller
- Nutrition Theme, MRC Unit The Gambia, MRC International Nutrition Group, Keneba, The Gambia
| | - Hans Verhoef
- London School of Hygiene & Tropical Medicine, London, UK.,Division of Human Nutrition and Cell Biology and Immunology Group, Wageningen University, Wageningen, The Netherlands
| | - Bakary Darboe
- Nutrition Theme, MRC Unit The Gambia, MRC International Nutrition Group, Keneba, The Gambia
| | - Ebrima Danso
- Nutrition Theme, MRC Unit The Gambia, MRC International Nutrition Group, Keneba, The Gambia
| | - Andrew M Prentice
- Nutrition Theme, MRC Unit The Gambia, MRC International Nutrition Group, Keneba, The Gambia.,London School of Hygiene & Tropical Medicine, London, UK
| | - Carla Cerami
- Nutrition Theme, MRC Unit The Gambia, MRC International Nutrition Group, Keneba, The Gambia.
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11
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Friedrisch JR, Friedrisch BK. Prophylactic Iron Supplementation in Pregnancy: A Controversial Issue. BIOCHEMISTRY INSIGHTS 2017; 10:1178626417737738. [PMID: 29123406 PMCID: PMC5661664 DOI: 10.1177/1178626417737738] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Accepted: 09/25/2017] [Indexed: 12/12/2022]
Abstract
In our world today, iron deficiency (ID) is the most frequent nutritional deficiency and it is being considered as an epidemic public health crisis. Women of reproductive age and infants are at particular risk of ID, especially in underdeveloped countries. During pregnancy, iron deficiency anemia is a specific risk factor associated with negative maternal and perinatal outcomes. Many countries have iron supplementation (IS) programs-as recommended by the World Health Organization-during pregnancy; however, IS clinical benefits and risks are unclear. This review aims to discuss the threats and benefits of routine IS on maternal and infant outcomes.
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Affiliation(s)
- João Ricardo Friedrisch
- Hematology and Bone Marrow Transplantation Service, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
| | - Bruno Kras Friedrisch
- Departamento de Biologia e Farmácia, Universidade de Santa Cruz do Sul (UNISC), Santa Cruz do Sul, Brazil
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12
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Calje E, Skinner J. The challenge of defining and treating anemia and iron deficiency in pregnancy: A study of New Zealand midwives' management of iron status in pregnancy and the postpartum period. Birth 2017; 44:181-190. [PMID: 28233929 DOI: 10.1111/birt.12282] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2016] [Revised: 01/16/2017] [Accepted: 01/16/2017] [Indexed: 01/03/2023]
Abstract
BACKGROUND Early recognition and management of low maternal iron status is associated with improved maternal, fetal, and neonatal outcomes. However, existing international guidelines for the testing and management of maternal iron-deficiency anemia are variable, with no national guideline for New Zealand midwives. Clinical management is complicated by normal physiological hemodilution, and complicated further by the effects of inflammation on iron metabolism, especially in populations with a high prevalence of obesity or infection. This study describes how midwives in one New Zealand area diagnose and treat anemia and iron deficiency, in the absence of established guidelines. METHODS Data on demographics, laboratory results, and documented clinical management were retrospectively collected from midwives (n=21) and women (n=189), from September to December 2013. Analysis was predominantly descriptive. A secondary analysis of iron status and body mass index (BMI) was undertaken. RESULTS A total of 46% of 186 women, with hemoglobin testing at booking, did not have ferritin tested; 86% (of 385) of ferritin tests were not concurrently tested with C-reactive protein. Despite midwives prescribing iron for 48.7% of second trimester women, 47.1% still had low iron status before birth. Only 22.8% of women had hemoglobin testing postpartum. There was a significant difference between third trimester median ferritin levels in women with BMI ≥25.00 (14 μg/L) and BMI <25.00 (18 μg/L) (P=.05). DISCUSSION There was a wide range in the midwives' practice. Maternal iron status was difficult to categorize, because of inconsistent testing. This study indicates the need for an evidence-based clinical guideline for New Zealand midwives and maternity care providers.
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Affiliation(s)
- Esther Calje
- Christchurch Women's Hospital, Christchurch, New Zealand.,Victoria University of Wellington, Wellington, New Zealand
| | - Joan Skinner
- Victoria University of Wellington, Wellington, New Zealand
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13
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Abstract
There are numerous blood-based biomarkers for assessing iron stores, but all come with certain limitations. Hepcidin is a hormone primarily produced in the liver that has been proposed as the 'master regulator' of dietary uptake and iron metabolism, and has enormous potential to provide a 'real time' indicator of body iron levels. In this Minireview, the biochemical function of hepcidin in regulating iron levels will be discussed, with a specific focus on how hepcidin can aid in the assessment of iron stores and clinical diagnosis of iron deficiency, iron deficiency anaemia and other iron-related disorders. The role hepcidin itself plays in diseases of iron metabolism will be examined, and current efforts to translate hepcidin assays into the clinic will be critically appraised. Potential limitations of hepcidin as a marker of iron need will also be addressed, as well as the development of new therapies that directly target the hormone that sits atop the hierarchy of systemic iron metabolism.
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Affiliation(s)
- Dominic J Hare
- The Florey Institute of Neuroscience and Mental Health, The University of Melbourne, 30 Royal Parade, Parkville, Victoria 3052, Australia.
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14
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Bah A, Pasricha SR, Jallow MW, Sise EA, Wegmuller R, Armitage AE, Drakesmith H, Moore SE, Prentice AM. Serum Hepcidin Concentrations Decline during Pregnancy and May Identify Iron Deficiency: Analysis of a Longitudinal Pregnancy Cohort in The Gambia. J Nutr 2017; 147:1131-1137. [PMID: 28424258 PMCID: PMC5443464 DOI: 10.3945/jn.116.245373] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Revised: 02/06/2017] [Accepted: 03/20/2017] [Indexed: 01/01/2023] Open
Abstract
Background: Antenatal anemia is a risk factor for adverse maternal and fetal outcomes and is prevalent in sub-Saharan Africa. Less than half of antenatal anemia is considered responsive to iron; identifying women in need of iron may help target interventions. Iron absorption is governed by the iron-regulatory hormone hepcidin. Objective: We sought to characterize changes in hepcidin and its associations with indexes of iron stores, erythropoiesis, and inflammation at weeks 14, 20, and 30 of gestation and to assess hepcidin’s diagnostic potential as an index of iron deficiency. Methods: We measured hemoglobin and serum hepcidin, ferritin, soluble transferrin receptor (sTfR), and C-reactive protein (CRP) at 14, 20, and 30 wk of gestation in a cohort of 395 Gambian women recruited to a randomized controlled trial. Associations with hepcidin were measured by using linear regression, and hepcidin’s diagnostic test accuracy [area under the receiver operating characteristic curve (AUCROC), sensitivity, specificity, cutoffs] for iron deficiency at each time point was analyzed. Results: The prevalence of anemia increased from 34.6% at 14 wk of gestation to 50.0% at 20 wk. Hepcidin concentrations declined between study enrollment and 20 wk, whereas ferritin declined between 20 and 30 wk of gestation. The variations in hepcidin explained by ferritin, sTfR, and CRP declined over pregnancy. The AUCROC values for hepcidin to detect iron deficiency (defined as ferritin <15 μg/L) were 0.86, 0.83, and 0.84 at 14, 20, and 30 wk, respectively. Hepcidin was superior to hemoglobin and sTfR as an indicator of iron deficiency. Conclusions: In Gambian pregnant women, hepcidin appears to be a useful diagnostic test for iron deficiency and may enable the identification of cases for whom iron would be beneficial. Hepcidin suppression in the second trimester suggests a window for optimal timing for antenatal iron interventions. Hemoglobin does not effectively identify iron deficiency in pregnancy. This trial was registered at www.isrctn.com as ISRCTN49285450.
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Affiliation(s)
- Amat Bah
- Medical Research Council (MRC) Unit The Gambia-MRC International Nutrition Group, Banjul, Gambia;
| | - Sant-Rayn Pasricha
- MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, United Kingdom
| | - Momodou W Jallow
- Medical Research Council (MRC) Unit The Gambia-MRC International Nutrition Group, Banjul, Gambia
| | - Ebrima A Sise
- Medical Research Council (MRC) Unit The Gambia-MRC International Nutrition Group, Banjul, Gambia
| | - Rita Wegmuller
- Medical Research Council (MRC) Unit The Gambia-MRC International Nutrition Group, Banjul, Gambia
| | - Andrew E Armitage
- MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, United Kingdom
| | - Hal Drakesmith
- MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, United Kingdom
| | - Sophie E Moore
- Division of Women's Health, King's College London, London, United Kingdom; and
| | - Andrew M Prentice
- MRC Unit The Gambia-MRC International Nutrition Group and London School of Hygiene and Tropical Medicine, London, United Kingdom
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15
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How I treat anemia in pregnancy: iron, cobalamin, and folate. Blood 2017; 129:940-949. [DOI: 10.1182/blood-2016-08-672246] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Accepted: 12/21/2016] [Indexed: 01/28/2023] Open
Abstract
AbstractAnemia of pregnancy, an important risk factor for fetal and maternal morbidity, is considered a global health problem, affecting almost 50% of pregnant women. In this article, diagnosis and management of iron, cobalamin, and folate deficiencies, the most frequent causes of anemia in pregnancy, are discussed. Three clinical cases are considered. Iron deficiency is the most common cause. Laboratory tests defining iron deficiency, the recognition of developmental delays and cognitive abnormalities in iron-deficient neonates, and literature addressing the efficacy and safety of IV iron in pregnancy are reviewed. An algorithm is proposed to help clinicians diagnose and treat iron deficiency, recommending oral iron in the first trimester and IV iron later. Association of folate deficiency with neural tube defects and impact of fortification programs are discussed. With increased obesity and bariatric surgery rates, prevalence of cobalamin deficiency in pregnancy is rising. Low maternal cobalamin may be associated with fetal growth retardation, fetal insulin resistance, and excess adiposity. The importance of treating cobalamin deficiency in pregnancy is considered. A case of malarial anemia emphasizes the complex relationship between iron deficiency, iron treatment, and malaria infection in endemic areas; the heightened impact of combined etiologies on anemia severity is highlighted.
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16
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Wray K, Allen A, Evans E, Fisher C, Premawardhena A, Perera L, Rodrigo R, Goonathilaka G, Ramees L, Webster C, Armitage AE, Prentice AM, Weatherall DJ, Drakesmith H, Pasricha SR. Hepcidin detects iron deficiency in Sri Lankan adolescents with a high burden of hemoglobinopathy: A diagnostic test accuracy study. Am J Hematol 2017; 92:196-203. [PMID: 27883199 PMCID: PMC5324588 DOI: 10.1002/ajh.24617] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Revised: 11/22/2016] [Accepted: 11/23/2016] [Indexed: 12/23/2022]
Abstract
Anemia affects over 800 million women and children globally. Measurement of hepcidin as an index of iron status shows promise, but its diagnostic performance where hemoglobinopathies are prevalent is unclear. We evaluated the performance of hepcidin as a diagnostic test of iron deficiency in adolescents across Sri Lanka. We selected 2273 samples from a nationally representative cross-sectional study of 7526 secondary schoolchildren across Sri Lanka and analyzed associations between hepcidin and participant characteristics, iron indices, inflammatory markers, and hemoglobinopathy states. We evaluated the diagnostic accuracy of hepcidin as a test for iron deficiency with estimation of the AUCROC , sensitivity/specificity at each hepcidin cutoff, and calculation of the Youden Index to find the optimal threshold. Hepcidin was associated with ferritin, sTfR, and hemoglobin. The AUCROC for hepcidin as a test of iron deficiency was 0.78; hepcidin outperformed Hb and sTfR. The Youden index-predicted cutoff to detect iron deficiency (3.2 ng/mL) was similar to thresholds previously identified to predict iron utilization and identify deficiency in African populations. Neither age, sex, nor α- or β-thalassemia trait affected diagnostic properties of hepcidin. Hepcidin pre-screening would prevent most iron-replete thalassemia carriers from receiving iron whilst still ensuring most iron deficient children were supplemented. Our data indicate that the physiological relationship between hepcidin and iron status transcends specific populations. Measurement of hepcidin in individuals or populations could establish the need for iron interventions. Am. J. Hematol. 92:196-203, 2017. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Katherine Wray
- MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford; Oxford UK
- BRC Blood Theme; NIHR Oxford Biomedical Research Centre; Oxford UK
| | - Angela Allen
- Liverpool School of Tropical Medicine; Centre for Tropical and Infectious Diseases; Liverpool UK
| | - Emma Evans
- Department of Biochemistry and Immunology; Birmingham Heartlands Hospital; Birmingham UK
| | - Chris Fisher
- MRC Molecular Haematology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford; Oxford UK
| | | | - Lakshman Perera
- Department of Medicine; University of Kelaniya; Colombo Sri Lanka
| | - Rexan Rodrigo
- Department of Medicine; University of Kelaniya; Colombo Sri Lanka
| | | | - Lebbe Ramees
- Department of Medicine; University of Kelaniya; Colombo Sri Lanka
| | - Craig Webster
- Department of Biochemistry and Immunology; Birmingham Heartlands Hospital; Birmingham UK
| | - Andrew E Armitage
- MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford; Oxford UK
| | - Andrew M Prentice
- MRC Unit The Gambia, MRC Keneba; The Gambia
- MRC International Nutrition Group, London School of Hygiene and Tropical Medicine; London UK
| | - David J Weatherall
- MRC Molecular Haematology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford; Oxford UK
| | - Hal Drakesmith
- MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford; Oxford UK
- BRC Blood Theme; NIHR Oxford Biomedical Research Centre; Oxford UK
| | - Sant-Rayn Pasricha
- MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford; Oxford UK
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17
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Ali MK, Abbas AM, Abdelmagied AM, Mohammed GE, Abdalmageed OS. A randomized clinical trial of the efficacy of single versus double-daily dose of oral iron for prevention of iron deficiency anemia in women with twin gestations. J Matern Fetal Neonatal Med 2016; 30:2884-2889. [DOI: 10.1080/14767058.2016.1266478] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Mohammed K. Ali
- Department of Obstetrics and Gynecology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Ahmed M. Abbas
- Department of Obstetrics and Gynecology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Ahmed M. Abdelmagied
- Department of Obstetrics and Gynecology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Ghada E. Mohammed
- Department of Internal Medicine, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Osama S. Abdalmageed
- Department of Obstetrics and Gynecology, Faculty of Medicine, Assiut University, Assiut, Egypt
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