Perinatal iron deficiency and the developing brain

Maternal Iron and Vitamin D Status during the Second Trimester Is Associated with Third Trimester Depression Symptoms among Pregnant Participants in the APrON Cohort

BACKGROUND

The maternal status of multiple micronutrients during pregnancy and postpartum and their potential associations with maternal health outcomes are largely undescribed.

OBJECTIVES

This study aimed to examine associations between maternal iron and vitamin D status, individually and in combination, on depression symptoms in pregnant individuals.

METHODS

The Alberta Pregnancy Outcomes and Nutrition cohort study included pregnant participants and their children from Calgary and Edmonton, Canada. Iron biomarkers (serum ferritin [SF], soluble transferrin receptor, and hepcidin) were measured via immunoassays and vitamin D [25-hydroxyvitamin D3 (25(OH)D3) and 3-epi-25-hydoxyvitamin D3 (3-epi-25(OH)D3)] metabolites were quantifed using liquid chromatography with tandem mass spectroscopy. Four categories of maternal iron and vitamin D status during the second trimester were conceptualized using concentrations of SF and total 25-hydoxyvitamin D [25(OH)D], respectively. Maternal Edinburgh Postnatal Depression Scale (EPDS) scores during the third trimester (n = 1920) and 3 mo postpartum (n = 1822) were obtained.

RESULTS

Concentrations of maternal 25(OH)D3, 3-epi-25(OH)D3, and the ratio of both metabolites were significantly higher during the second trimester compared with their status at 3 mo postpartum. Higher second trimester maternal concentrations of SF (β: -0.8; 95% confidence interval [CI]: -1.5, -0.01), hepcidin (β: -0.5; 95% CI: -0.9, -0.2), and 25(OH)D3 (β: -0.01; 95% CI: -0.02, -0.004) predicted lower maternal EPDS scores during the third trimester. Pregnant individuals with a low iron (SF <15 μg/L) and replete vitamin D (25(OH)D ≥75 nmol/L) (β: 1.1; 95% CI: 0.03, 2.1) or low iron (SF <15 μg/L) and vitamin D (25(OH)D <75 nmol/L) (β: 2.2; 95% CI: 0.3, 4.2) status during midpregnancy had higher third trimester EPDS scores compared with those that were replete in both micronutrients.

CONCLUSIONS

A higher midpregnancy maternal iron and vitamin D status, independently or in combination, predicted fewer maternal depression symptoms in the third trimester. Concentrations of maternal 25(OH)D3 and 3-epi-25(OH)D3 may be lower in the postpartum period compared with midpregnancy.

Can Iron Play a Crucial Role in Maintaining Cardiovascular Health in the 21st Century?

In the 21st century the heart is facing more and more challenges so it should be brave and iron to meet these challenges. We are living in the era of the COVID-19 pandemic, population aging, prevalent obesity, diabetes and autoimmune diseases, environmental pollution, mass migrations and new potential pandemic threats. In our article we showed sophisticated and complex regulations of iron metabolism. We discussed the impact of iron metabolism on heart diseases, treatment of heart failure, diabetes and obesity. We faced the problems of constant stress, climate change, environmental pollution, migrations and epidemics and showed that iron is really essential for heart metabolism in the 21st century.

Obesity Is Associated with Changes in Iron Nutrition Status and Its Homeostatic Regulation in Pregnancy

The influence of obesity on maternal iron homeostasis and nutrition status during pregnancy remains only partially clarified. Our study objectives were (1) to describe how obesity influences broad iron nutrition spectrum biomarkers such as available or circulating iron (serum transferrin receptor (sTfr) and serum iron), iron reserves (ferritin), and functional iron (hemoglobin); and (2) to depict the regulating role of hepcidin. The above was carried out while considering influential factors such as initial iron nutrition status, iron intake, and the presence of inflammation. Ninety three non-anemic pregnant adult women were included, 40 with obesity (Ob) and 53 with adequate weight (AW); all took ≈30 mg/day of supplementary iron. Information on iron intake and blood samples were obtained at gestational weeks 13, 20, 27, and 35. A series of repeated measure analyses were performed using General Linear Models to discern the effect of obesity on each iron indicator; iron intake, hepcidin, and C-reactive protein were successively introduced as covariates. Available and circulating iron was lower in obese women: sTfr was higher (p = 0.07) and serum iron was lower (p = 0.01); and ferritin and hemoglobin were not different between groups. Hepcidin was higher in the Ob group (p = 0.01) and was a significant predictor variable for all biomarkers. Obesity during pregnancy dysregulates iron homeostasis, resembling "obesity hypoferremia".

Maternal anemia and pediatric neurological morbidity in the offspring - Results from a population based cohort study

OBJECTIVE

Maternal anemia (Hemoglobin, <11 mg/dl) has been shown to affect fetal growth and pregnancy outcome. We aimed to study a possible association between maternal anemia and the risk for neurological morbidity in the offspring, during a follow-up period of up to 18 years.

STUDY DESIGN

A population-based cohort analysis was performed at the Soroka University Medical Center (SUMC), a single regional tertiary center comparing total and specific subtypes of neurological morbidities associated with hospitalizations among children stratified by three maternal post-partum hemoglobin categories: ≥11 mg/dl (no anemia); 11.0 mg/dl > Hb ≥ 7 mg/dl (mild-to-moderate anemia) and <7 mg/dl (severe anemia). Data on pregnancy course and outcome, and later offspring hospitalizations, were compared between the three study groups. All singleton deliveries between the years 1991-2014 were included in the analysis, and congenital malformations were excluded. A Kaplan-Meier survival curve was used to compare cumulative hospitalization incidence based on maternal anemia status, and a Weibull survival multivariable hazard model was constructed to adjust for confounding variables.

RESULTS

The study population included 217,358 deliveries of which 50.6% were in mothers who were not anemic, 49.0% in mothers with moderate anemia and 0.4% in mothers with severe anemia. During the follow up period (0-18 years, median 10.22 years), 2.1% of offspring were hospitalized with a neurological diagnoses. Neurological hospitalization incidence decreased from 2.95/1000 person years, in the severe anemia group, to 2.32/1000 person years and 2.01/1000 person years, among the mild-to-moderate and no anemia groups, respectively (p = 0.007). The association between maternal anemia and offspring long-term pediatric neurological morbidity remained significant in a Weibull hazards model controlled for gestational age, delivery mode, SGA and insufficient prenatal care (adjusted HR 1.55; 1.05-2.31 and adjusted HR 1.13; 1.06-1.20; among the severe and mild-to-moderate anemia, vs. no anemia, respectively).

CONCLUSION

Children born to anemic mothers are at an increased risk for pediatric neurological-related hospitalizations.

Biomarkers of Nutrition for Development (BOND)-Iron Review

This is the fifth in the series of reviews developed as part of the Biomarkers of Nutrition for Development (BOND) program. The BOND Iron Expert Panel (I-EP) reviewed the extant knowledge regarding iron biology, public health implications, and the relative usefulness of currently available biomarkers of iron status from deficiency to overload. Approaches to assessing intake, including bioavailability, are also covered. The report also covers technical and laboratory considerations for the use of available biomarkers of iron status, and concludes with a description of research priorities along with a brief discussion of new biomarkers with potential for use across the spectrum of activities related to the study of iron in human health.The I-EP concluded that current iron biomarkers are reliable for accurately assessing many aspects of iron nutrition. However, a clear distinction is made between the relative strengths of biomarkers to assess hematological consequences of iron deficiency versus other putative functional outcomes, particularly the relationship between maternal and fetal iron status during pregnancy, birth outcomes, and infant cognitive, motor and emotional development. The I-EP also highlighted the importance of considering the confounding effects of inflammation and infection on the interpretation of iron biomarker results, as well as the impact of life stage. Finally, alternative approaches to the evaluation of the risk for nutritional iron overload at the population level are presented, because the currently designated upper limits for the biomarker generally employed (serum ferritin) may not differentiate between true iron overload and the effects of subclinical inflammation.

A Path Analysis of Nutrition, Stimulation, and Child Development Among Young Children in Bihar, India

Nutrition plays an important role in the development of a child, particularly in low‐ and middle‐income countries where malnutrition is often widespread. The relation between diet, hemoglobin, nutritional status, motor development, stimulation and mental development was examined in a cross‐sectional sample of 1,079 children 12–18 months of age living in rural Bihar, India. Path analysis revealed associations between (a) length‐for‐age z‐scores and motor development, standardized β (β) = .285, p < .001, and (b) motor and all mental development outcomes (language: β = .422; personal‐social: β = .490; memory: β = .139; and executive function: β = .072, all p < .001). Additionally, stimulation was significantly associated with language scores and hemoglobin concentration with memory. These findings inform interventions aimed at improving child development in Northern India.

Measuring the Effect of Soil-Transmitted Helminth Infections on Cognitive Function in Children: Systematic Review and Critical Appraisal of Evidence

Recently the role of soil-transmitted helminth (STH) infections in children's cognitive developmental impairment has been under scrutiny. We conducted a systematic review of the evidence for associations between STH infections and cognitive function of children using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol. We aimed to identify the domains of cognitive function in three age strata (<24months, 24-59months and ≥60months) and critically appraise the general design protocol of the studies, with a focus on the cognitive function measurement tools used. A total of 42 papers fulfilled the inclusion criteria, including 10 studies from a recent Cochrane review. Our findings demonstrate variation in tested domains, lack of consistency in the use of measurement tools and analysis of results. Cognitive function measures in children aged under 59months have been mainly limited to domains of gross motor, fine motor and language skills, whereas in children aged 60months and above most studies tested domains such as memory and processing speed. Even within the same age group the results on the association between STH infections and measures of cognitive development were often conflicting. The current study highlights the need for methodological consensus in the use of measurement tools and data analysis protocols if the effect of STH infections on cognitive function domains in children is to be correctly established. This will be an imperative next step to generate conclusive evidence of the role of STH infections in cognitive development in children.

Nutritional status and social behavior in preschool children: the mediating effects of neurocognitive functioning

Early malnutritional status has been associated with reduced cognitive ability in childhood. However, there are almost no studies on the effect of malnutrition on positive social behavior, and no tests of possible mediating mechanisms. This study tests the hypothesis that poor nutritional status is associated with impaired social functioning in childhood, and that neurocognitive ability mediates this relationship. We assessed 1553 male and female 3-year-olds from a birth cohort on measures of malnutrition, social behavior and verbal and spatial neurocognitive functions. Children with indicators of malnutrition showed impaired social behavior (p < .0001) as compared with children in the control group with adequate nutritional status. These associations even persisted after controlling for social adversity and parental education. Findings were not moderated by gender or ethnicity, and there was no interaction effect with parental education. A dose-response relationship was observed between degree of malnutrition and degree of social behavior, with increased malnutrition associated with more impaired social behavior. Neurocognitive ability was found to mediate the nutrition-social behavior relationship. The mediation effect of neurocognitive functioning suggests that poor nutrition negatively impacts brain areas that play important roles in developing positive social behavior. Findings suggest that reducing poor nutrition, alternatively promoting good nutrition, may help promote positive social behavior in early childhood during a critical period for social and neurocognitive development, with implications for improving positive health in adulthood.

Improving the Quality of Students’ Dietary Intake in the School Setting

The dramatic increase in our understanding of the brain’s development throughout childhood has increased our knowledge of the significance of micronutrients, such as iron and vitamin B-12, for this development. Deficiencies of these micronutrients have been shown to have an impact on students’ cognitive development. Regardless of this knowledge, students continue to make unhealthy food choices and develop poor dietary habits. School environments are places where there is an opportunity to practice healthy eating habits. Yet many school policies fail to address the sale of foods of minimal nutritional value in the school setting. School nurses can play a vital role in planning policies at the local and national level that support and encourage healthy food environments, performing assessments of the nutritional status of students, and spearheading the implementation of evidence-based health promotion programs. It is time for school nurses to take the lead in efforts aimed at improving the quality of students’ dietary intake in the school setting.

Maternal Iron Status in Pregnancy and Long-Term Health Outcomes in the Offspring

Iron is an essential micronutrient and is important not only in carrying oxygen but also to the catalytic activity of a variety of enzymes. In the fetus, it is vital to the synthesis of hemoglobin and in brain development. Iron deficiency (ID) anemia in pregnancy is a common problem, even in high-income country settings. Around 50% of pregnant women worldwide are anemic, with at least half of this burden due to ID. Iron supplements are widely recommended and used during pregnancy globally. However, the evidence on the extent of benefit they contribute to the offspring's health is not well established, and their routine use has its side effects and drawbacks. Dietary iron intake is difficult to assess accurately and it is unlikely to be sufficient to meet the demands of pregnancy if women start with inadequate body iron stores at conception. Evidence from experimental animal models suggests that maternal ID during pregnancy is associated with fetal growth restriction, as well as offspring obesity and high blood pressure later in life. The possible biological mechanisms for this observed association may be due to ID-induced changes in placental structure and function, enzyme expression, nutrient absorption, and fetal organ development. However, such evidence is limited in human studies. Prenatal ID in experimental animal models also adversely affected the developing brain structures, neurotransmitter systems, and myelination resulting in acute brain dysfunction during the period of deficiency and persistence of various postnatal neurobehavioral abnormalities as well as persistent dysregulation of some genes into adult life after iron repletion pointing to the possibility of gene expression changes. The evidence from human population studies is limited and heterogeneous and more research is needed in the future, investigating the effects of ID in pregnancy on future offspring health outcomes.

Identifying the threshold of iron deficiency in the central nervous system of the rat by the auditory brainstem response

The deleterious effects of anemia on auditory nerve (AN) development have been well investigated; however, we have previously reported that significant functional consequences in the auditory brainstem response (ABR) can also occur as a consequence of marginal iron deficiency (ID). As the ABR has widespread clinical use, we evaluated the ability of this electrophysiological method to characterize the threshold of tissue ID in rats by examining the relationship between markers of tissue ID and severity of ABR latency defects. To generate various levels of ID, female Long-Evans rats were exposed to diets containing sufficient, borderline, or deficient iron (Fe) concentrations throughout gestation and offspring lifetime. We measured hematological indices of whole body iron stores in dams and offspring to assess the degree of ID. Progression of AN ID in the offspring was measured as ferritin protein levels at different times during postnatal development to complement ABR functional measurements. The severity of ABR deficits correlated with the level of Fe restriction in each diet. The sufficient Fe diet did not induce AN ID and consequently did not show an impaired ABR latency response. The borderline Fe diet, which depleted AN Fe stores but did not cause systemic anemia resulted in significantly increased ABR latency isolated to Peak I.The low Fe diet, which induced anemia and growth retardation, significantly increased ABR latencies of Peaks I to IV. Our findings indicate that changes in the ABR could be related to various degrees of ID experienced throughout development.

Prenatal Iron Deficiency in Guinea Pigs Increases Locomotor Activity but Does Not Influence Learning and Memory

The objective of the current study was to determine whether prenatal iron deficiency induced during gestation in guinea pigs affected locomotor activity and learning and memory processes in the progeny. Dams were fed either iron-deficient anemic or iron-sufficient diets throughout gestation and lactation. After weaning, all pups were fed an iron-sufficient diet. On postnatal day 24 and 40, the pups’ locomotor activity was observed within an open-field test, and from postnatal day 25 to 40, their learning and memory processes were assessed within a Morris Water Maze. The behavioural and cognitive tests revealed that the iron deficient pup group had increased locomotor activity, but solely on postnatal day 40, and that there were no group differences in the Morris Water Maze. In the general discussion, we propose that prenatal iron deficiency induces an increase in nervousness due to anxiety in the progeny, which, in the current study, resulted in an increase of locomotor activity.

Inhibition of iron absorption by calcium is modest in an iron-fortified, casein- and whey-based drink in Indian children and is easily compensated for by addition of ascorbic acid

BACKGROUND

Calcium inhibits and ascorbic acid (AA) enhances iron absorption from iron-fortified foods. Absorption efficiency depends on iron status, although the interaction is unclear.

OBJECTIVE

We investigated the ability of AA to overcome calcium-induced inhibition of iron absorption in children differing in iron status.

METHODS

The effect of calcium (0, 100, and 200 mg/test meal) on iron absorption in the absence and presence of AA (0, 42.5, and 85 mg/test meal) from a casein/whey-based drink fortified with ferrous sulfate was assessed in a series of randomized crossover studies both in iron-replete (IR) Indian schoolchildren and in children with iron deficiency anemia (IDA) (6-11 y; n = 14-16/group) by using stable isotopes.

RESULTS

In the absence of calcium and AA, iron absorption from the casein/whey-based drink was 20% lower in IR children than in children with IDA. The addition of calcium reduced mean iron absorption by 18-27%, with the effect being stronger for high added calcium (P < 0.01). AA at a 2:1 or 4:1 molar ratio enhanced iron absorption by a factor of 2-4 and greatly overcompensated for the inhibitory effect of calcium on iron absorption in a dose-dependent manner (P < 0.001). The dose-response effect tended to be stronger (P < 0.1) in the IDA group, and iron status was of far less influence on iron absorption than the enhancing effect of AA.

CONCLUSION

When adding AA to iron-fortified milk products, care should be taken not to provide absorbable iron in excess of needs.

Effect of multivitamin supplementation on the neurodevelopment of HIV-exposed Tanzanian infants: a randomized, double-blind, placebo-controlled clinical trial

BACKGROUND

Micronutrient deficiencies and in utero exposure to HIV may impair infant neurodevelopment.

OBJECTIVE

To evaluate the effect of daily multivitamin supplementation on the cognitive, language and motor development of HIV-exposed Tanzanian infants.

METHODS

A total of 2387 infants were randomized to receive daily oral supplementation of multivitamins (B-complex, C and E) or placebo from age 6 weeks for 24 months. The cognitive, language and motor scales of the Bayley Scales of Infant and Toddler Development, third edition, were administered to a subset of 206 infants at age 15 months.

RESULTS

Multivitamin supplementation did not improve measures of cognitive development, expressive or receptive language or gross motor capabilities. There was a trend toward improved fine motor skills among infants randomized to the multivitamin group (difference in mean score = 0.38; 95% CI = -0.01, 0.78, p = 0.06).

CONCLUSION

Daily provision of multivitamins to HIV-exposed infants does not substantially improve developmental outcomes at age 15 months.

Mild maternal iron deficiency anemia induces DPOAE suppression and cochlear hair cell apoptosis by caspase activation in young guinea pigs

Iron deficiency (ID) anemia (IDA) alters auditory neural normal development in the mammalian cochlea. Previous results suggest that mild maternal IDA during pregnancy and lactation altered the hearing and nervous system development of the young offspring, but the mechanisms underlying the association are incompletely understood. The objective of this study was to evaluate the role of apoptosis in the development of sensory hair cells following mild maternal IDA during pregnancy and lactation. We established a maternal anemia model in female guinea pigs by using a mild iron deficient diet. The offspring were weaned on postnatal day (PND) 9 and then was given the iron sufficient diet. Maternal blood samples were collected on gestational day (GD) 21, GD 42, GD 63 and PND 9, serum level of iron (SI) or hemoglobin (Hb) was measured. Blood samples of pups were collected on PND 9 for SI measurement. On PND 24, pups were examined the distortion product otoacoustic emission (DPOAE) task, and then the cochleae were harvested for assessment of apoptosis by immunohistochemistry of cysteine-aspartic acid proteases 3/9 (caspase-3/9) and terminal deoxynucleotidyl transferase-mediated dUTP nick end-labeling (TUNEL) assay, and by double immunofluorescence for the colocalization of TUNEL and caspase-3. Blood samples of pups were collected on PND 24 for SI and Hb measurements. Here we show that mild maternal IDA during pregnancy and lactation resulted in hearing impairment, decreased hair cell number, caspase-3/9 activation and increased apoptotic cell number of young guinea pigs. These results indicate a key role for apoptosis in inhibition of hair cell development, caused by mild maternal IDA during pregnancy and lactation.

Iron Deficiency Anemia among Hospitalized Children in Konya, Turkey

The aim of this study was to investigate the characteristics of our hospitalized patients with the diagnosis of iron deficiency anemia (IDA) and effects of the IDA prevention project of the Turkish Ministry of Health which was started in 2004. The recommended dose of prophylactic iron supplementation was 1-2 mg/kg/day. The files of 1519 patients who were hospitalized to Konya Education and Research Hospital Pediatrics Clinic were reviewed. A total of 50 patients consisting of 35 boys and 15 girls with the mean age of 16,59 ± 1,68 months were included into the study. The prevalence of IDA was 3.29% (boys: 4.23%, girls: 2.1%). Hgb and Hct of the patients >24 months were significantly higher than those of the patients with the age of 6–12 months. Iron supplementation receiving rates were very low. Of the 28 patients older than 12 months, only 44% of them had received a full course of iron supplementation for 8 months. In conclusion, although prophylactic iron supplementation lowered the prevalences of IDA, receiving rates of iron supplementation were not adequate. While IDA is still a public health problem, prophylactic approaches should be carried out more effectively.

Latent iron deficiency in utero is associated with abnormal auditory neural myelination in ≥ 35 weeks gestational age infants

OBJECTIVE

To determine whether cord serum ferritin level is associated with auditory brainstem evoked response interpeak latencies, an index of auditory neural myelination, in infants at ≥ 35 weeks gestational age (GA).

STUDY DESIGN

This prospective study compared auditory neural myelination in infants with latent iron deficiency (cord serum ferritin, 11-75 ng/mL) and infants with normal iron status (cord serum ferritin, >75 ng/mL) at birth. Our inclusion criteria were infants born at ≥ 35 weeks GA who had cord blood collected soon after birth and had 1 or more of the following risk factors for poor in utero iron status: maternal diabetes mellitus, pregnancy-induced hypertension, and intrauterine growth restriction. Cord serum ferritin level was measured using the chemiluminescence immunoassay method. Auditory brainstem evoked response was measured using 80-dB normal hearing level click stimuli at a rate of 69.9/second within 48 hours after birth to evaluate interpeak latencies, a measure of nerve conduction velocity or myelination.

RESULTS

Of the 45 infants studied, 12 had latent iron deficiency. On repeated-measures ANCOVA using interpeak latencies I-III, III-V, and I-V as multiple outcomes, infants with latent iron deficiency had significantly prolonged interpeak latencies (P = .01) compared with infants with normal iron status after controlling for confounders.

CONCLUSION

In utero latent iron deficiency is associated with abnormal auditory neural myelination at birth in infants born at ≥ 35 weeks GA.

Spatial memory deficits in maternal iron deficiency paradigms are associated with altered glucocorticoid levels

"The goal of this study was to examine the effect of maternal iron deficiency on the developing hippocampus in order to define a developmental window for this effect, and to see whether iron deficiency causes changes in glucocorticoid levels. The study was carried out using pre-natal, post-natal, and pre+post-natal iron deficiency paradigm. Iron deficient pregnant dams and their pups displayed elevated corticosterone which, in turn, differentially affected glucocorticoid receptor (GR) expression in the CA1 and the dentate gyrus. Brain Derived Neurotrophic Factor (BDNF) was reduced in the hippocampi of pups following elevated corticosterone levels. Reduced neurogenesis at P7 was seen in pups born to iron deficient mothers, and these pups had reduced numbers of hippocampal pyramidal and granule cells as adults. Hippocampal subdivision volumes also were altered. The structural and molecular defects in the pups were correlated with radial arm maze performance; reference memory function was especially affected. Pups from dams that were iron deficient throughout pregnancy and lactation displayed the complete spectrum of defects, while pups from dams that were iron deficient only during pregnancy or during lactation displayed subsets of defects. These findings show that maternal iron deficiency is associated with altered levels of corticosterone and GR expression, and with spatial memory deficits in their pups."

Association between neonatal iron overload and early human brain development in premature infants

BACKGROUND

Emerging evidence suggests that excess iron may be detrimental for brain development. However, little is known regarding the association between neonatal iron overload and subsequent neurodevelopment during infancy in vulnerable premature infants.

AIMS

To evaluate the association between neonatal iron overload and neurodevelopment in premature infants.

STUDY DESIGN

Prospective cohort study.

SUBJECTS

24-32 weeks gestational age infants who had serum ferritin (SF) measured at 34-35 weeks post-menstrual age (PMA) and did not meet exclusion criteria: SF<76 ng/ml, toxoplasmosis, syphilis, rubella, cytomegalovirus, herpes infections, chromosomal disorders, or craniofacial anomalies were eligible. In addition, infants with sepsis or elevated C-reactive protein within 10 days before their SF measurement were excluded.

OUTCOME MEASURES

Infants were evaluated for neurodevelopmental outcome at 8-12 months of age and were deemed to have neurodevelopmental impairment if they had one or more of the following: mental developmental index<70, abnormal neurological examination, bilateral blindness, bilateral deafness, or required occupational, physical, or speech therapy.

RESULTS

95 infants were studied. 70 had normal iron status (SF 76-400 ng/ml) while 25 were deemed to have iron overload (SF >400 ng/ml) at 34-35 weeks PMA. There was a marginal increase in neurodevelopmental impairment among infants with iron overload compared to infants with normal iron status (64% vs. 41%, p=0.05). However, after controlling for confounders, iron overload was not associated with neurodevelopmental impairment (Adjusted OR 0.71, 95% CI, 0.21-2.5).

CONCLUSION

Modest neonatal iron overload is not associated with neurodevelopmental impairment during infancy in premature infants.

Pre-discharge iron status and its determinants in premature infants

OBJECTIVE

To evaluate pre-discharge iron status and identify its determinants in infants' ≤ 32 weeks gestational age (GA).

METHODS

In a prospective observational study, 24-32 weeks GA infants who did not meet exclusion criteria: congenital viral infections, chromosomal disorders, or cranio-facial anomalies were eligible. Iron status was evaluated by measuring serum ferritin (SF) at 35 weeks post-menstrual age (PMA). Infants with infection or elevated C-reactive protein within 10 days prior to evaluation of iron status were excluded.

RESULTS

Of 131 infants studied, 23% had latent iron deficiency (SF < 76 ng/ml), 58% had normal iron status (75-400 ng/ml), and 19% had iron overload (SF > 400 ng/ml). On bivariate analysis, preeclampsia, GA, birth weight, patent ductus arteriosus, prior erythrocyte transfusion, phlebotomy loss, and chronic lung disease were associated with iron status. On ordered logistic regression, prior erythrocyte transfusion (frequency [OR 1.41, 95% CI:1.2-1.6] or cumulative amount [OR 1.03, 95% CI:1.02-1.04]) or net erythrocyte balance (amount of erythrocyte transfusion minus phlebotomy loss; OR 1.04, 95% CI:1.02-1.05) was significantly associated with iron status. Among infants who received > three erythrocyte transfusions, 50% developed iron overload.

CONCLUSIONS

Iron status at 35 weeks PMA is extremely variable and is predicted by prior erythrocyte transfusions or net erythrocyte balance in premature infants.

Iron in pregnancy: How do we secure an appropriate iron status in the mother and child?

Iron deficiency and iron deficiency anemia (IDA) during pregnancy are risk factors for preterm delivery, prematurity, and small for gestational age birth weight. Iron deficiency has a negative effect on intelligence and behavioral development in the infant. It is essential to prevent iron deficiency in the fetus by preventing iron deficiency in the pregnant woman. The requirements for absorbed iron increase during pregnancy from ∼1.0 mg/day in the first trimester to 7.5 mg/day in the third trimester. More than 90% of Scandinavian women of reproductive age have a dietary iron intake below the recommended 15 mg/day. Among nonpregnant women of reproductive age, ∼40% have plasma ferritin ≤30 μg/l, i.e. an unfavorable iron status with respect to pregnancy. An adequate iron status during pregnancy implies body iron reserves ≥500 mg at conception, but only 15-20% of women have iron reserves of such a magnitude. Iron supplements during pregnancy reduce the prevalence of IDA. In Europe, IDA can be prevented by a general low-dose iron prophylaxis of 30-40 mg ferrous iron taken between meals from early pregnancy to delivery. In affluent societies, individual iron prophylaxis tailored by the ferritin concentration should be preferred to general prophylaxis. Suggested guidelines are: ferritin >70 μg/l, no iron supplements; ferritin 31-70 μg/l, 30-40 mg ferrous iron per day, and ferritin ≤30 μg/l, 60-80 mg ferrous iron per day. In women with ferritin <15 μg/l, i.e. depleted iron reserves and possible IDA, therapeutic doses of 100 mg ferrous iron per day should be advised.

Relationship between maternal DHA and iron status and infants' cognitive performance

PURPOSE

The dietary nutrients iron and long-chain polyunsaturated fatty acids are believed to play an important role in early brain development. We investigated the relationship between pregnant women's iron and docosahexaenoic acid (DHA) status and their infants' cognitive performance at age six months.

METHODS

Blood iron and DHA status were analyzed in pregnant women at 28 to 32 weeks of gestation. The women's dietary habits, sociodemographic background, and cognitive performance were assessed using questionnaires. At age six months, infants' blood hemoglobin was analyzed, feeding practices assessed, and weight, length, and head circumference recorded. Each infant's cognitive performance was assessed using the Brunet-Lézine Scale of Psychomotor Development of Early Childhood and the Bayley Scales of Infant Development. Sixty-three mother-infant dyads completed the study.

RESULTS

During pregnancy, 9.5% of pregnant women were anemic, 34.9% had low iron stores, and 3.2% suffered from iron deficiency anemia. The DHA represented 4.36% and 2.15% in erythrocyte and plasma total fatty acids, respectively. These levels were considered adequate. No significant relationship was observed between gestational iron or DHA status and infants' cognitive performance.

CONCLUSIONS

In this small group of infants born to mothers with relatively good feeding practices and a privileged socioeconomic background, cognitive testing with the instruments above was not associated with maternal iron and DHA levels at age six months.

Identifying a window of vulnerability during fetal development in a maternal iron restriction model

It is well acknowledged from observations in humans that iron deficiency during pregnancy can be associated with a number of developmental problems in the newborn and developing child. Due to the obvious limitations of human studies, the stage during gestation at which maternal iron deficiency causes an apparent impairment in the offspring remains elusive. In order to begin to understand the time window(s) during pregnancy that is/are especially susceptible to suboptimal iron levels, which may result in negative effects on the development of the fetus, we developed a rat model in which we were able to manipulate and monitor the dietary iron intake during specific stages of pregnancy and analyzed the developing fetuses. We established four different dietary-feeding protocols that were designed to render the fetuses iron deficient at different gestational stages. Based on a functional analysis that employed Auditory Brainstem Response measurements, we found that maternal iron restriction initiated prior to conception and during the first trimester were associated with profound changes in the developing fetus compared to iron restriction initiated later in pregnancy. We also showed that the presence of iron deficiency anemia, low body weight, and changes in core body temperature were not defining factors in the establishment of neural impairment in the rodent offspring.Our data may have significant relevance for understanding the impact of suboptimal iron levels during pregnancy not only on the mother but also on the developing fetus and hence might lead to a more informed timing of iron supplementation during pregnancy.

Iron deficiency: beyond anemia

Iron deficiency is the most common nutritional disorder affecting at least one third of world's population. Though anemia is common manifestation of iron deficiency, other effects of iron deficiency on various tissues, organs and systems are usually under recognized. Impaired brain development and cognitive, behavioural and psychomotor impairment are most worrisome manifestations of iron deficiency. Studies have demonstrated that some of these changes occurring during period of brain growth spurt (<2 years age) may be irreversible. Association of iron deficiency with febrile seizures, pica, breath holding spells, restless leg syndrome and thrombosis is increasingly being recognized. Impaired cell-mediated immunity and bactericidal function are generally noted in iron-deficient persons; however, the findings are inconsistent. Despite proven reversible functional immunological defects in vitro studies, a clinically important relationship between states of iron deficiency and susceptibility to infections remains controversial. Studies from malaria endemic regions have reported increased incidence of malaria in association with iron supplementation. These and some other aspects of iron deficiency are reviewed in this article.

Long-term neurodevelopment of children exposed in utero to ciclosporin after maternal renal transplant

BACKGROUND

Immunosuppressant therapy is essential in the prevention of organ transplant rejection.

OBJECTIVE

To evaluate the long-term neurodevelopmental outcomes of children following in utero ciclosporin (cyclosporine) exposure after maternal renal transplantation.

METHODS

A cohort study with matched controls using a prospectively collected database was conducted to assess neurocognitive and behavioral outcomes using standardized measures. Thirty-nine children exposed in utero to ciclosporin therapy following maternal renal transplantation were assessed (15 single pregnancies, 24 multiple pregnancies) and compared with 38 matched unexposed children. Intelligence, visuomotor abilities, and psychologic adjustment were measured using the Wechsler Preschool and Primary Scale of Intelligence-Revised (WPPSI-R), the Beery Developmental Test of Visual-Motor Integration (VMI-4) and the Wide Range Assessment of Visual Motor Abilities (WRAVMA), and the Child Behavior Checklist (CBCL), respectively. Statistical analysis, including regression, was performed to determine the significant predictors for the main outcome, full-scale IQ (FIQ).

RESULTS

There were no significant differences in FIQ, verbal IQ (VIQ), performance IQ (PIQ) or behavioral outcomes between exposed and unexposed children or between single and multiple delivery groups. Thirty-three percent of exposed children were premature versus 0.5% in unexposed controls (p < 0.01). Prematurity was associated with low birthweight, high rates of perinatal complications, and instrumental deliveries. Relative to full-term children, premature, low birthweight children in the ciclosporin-exposed group had significantly lower FIQ and VIQ scores (101.04 vs 111.31 [p = 0.008] and 102.31 vs 113.08 [p = 0.021], respectively). Maternal IQ and socioeconomic status were positive and significant predictors for children's IQ (p < 0.001 and p = 0.03, respectively). There were no statistically significant differences in exposed children's IQ who were and were not breastfed.

CONCLUSION

In this cohort, there was no association between in utero exposure to ciclosporin and long-term neurocognitive and behavioral development in children after maternal renal transplantation. Maternal IQ and socioeconomic status are positive predictors for children's intelligence. However, maternal renal transplantation and associated co-morbidity is associated with higher rates of premature delivery and consequent poorer neurocognitive and behavioral outcomes. Proper management of maternal morbidity and improved obstetric care may improve the child's profile.

In utero iron status and auditory neural maturation in premature infants as evaluated by auditory brainstem response

OBJECTIVE

To determine whether cord ferritin (CF) concentration, an index of in utero iron status, is associated with auditory neural maturation in premature infants.

STUDY DESIGN

A prospective cohort study was performed to compare auditory neural maturation in infants with latent iron deficiency (CF 11-75 ng/mL) and infants with normal iron status (CF > 75 ng/mL) at birth. Our inclusion criteria were infants of 27-33 weeks gestational age who were admitted to the neonatal intensive care unit between July 2007 and November 2008 within 12 hours after birth and had cord blood collected. Infants with TORCH infections (toxoplasmosis, other infections, rubella, cytomegalovirus infection, and herpes simplex), chromosomal disorders, craniofacial anomalies, culture-proven sepsis, and/or unstable conditions were excluded. CF level was measured using a chemiluminescence immunoassay method. Bilateral monaural auditory brainstem evoked response (ABR) was assessed using 80-dB nHL click stimuli at a repetition rate of 29.9/seconds within 48 hours after birth.

RESULTS

Of the 80 infants studied, 35 had latent iron deficiency. After controlling for confounders, the infants with latent iron deficiency had significantly prolonged absolute wave latencies I, III, and V and decreased frequency of mature ABR waveforms compared with the infants with normal iron status.

CONCLUSION

Premature infants with in utero latent iron deficiency have abnormal auditory neural maturation compared with infants with normal in utero iron status.

Effectiveness of a large-scale iron-fortified milk distribution program on anemia and iron deficiency in low-income young children in Mexico

BACKGROUND

Anemia during infancy impairs neurodevelopment. Little information has been published about the effectiveness of large-scale programs on anemia and iron-deficiency prevention.

OBJECTIVE

The objective was to assess the effectiveness of a large-scale program that distributes subsidized iron-fortified milk in Mexico on anemia and iron deficiency in children aged 12-30 mo.

DESIGN

A double-blinded, group-randomized effectiveness trial was conducted in 12 milk distribution clusters assigned to consume iron-fortified (FM; n = 7) or nonfortified (NFM; n = 5) milk. A daily portion of FM contained 5.28 mg Fe (ferrous gluconate) and 48 mg sodium ascorbate.

RESULTS

Overall treatment effects were documented at 6 and 12 mo for anemia and for iron deficiency assessed by both serum ferritin (SF) and serum soluble transferrin receptor (sTfR) (interaction: P < 0.10). Differential effects at 6 mo (P = 0.004) and 12 mo (P = 0.664) were documented only for sTfR. Estimated prevalences (EPs) of anemia (hemoglobin < 110 g/L) from baseline to 6 and 12 mo decreased from 42.6% to 19.7% and 9.4%, respectively, in the NFM group (n = 210) and from 44.5% to 12.7% and 4.0%, respectively, in the FM group (n = 357). EPs of SF < 12 mug/L from baseline to 6 and 12 mo changed from 36.0% to 41.8% and 17.1%, respectively, in the NFM group (n = 43) and from 29.8% to 18.6% and 5.7%, respectively, in the FM group (n = 144). EPs of sTfR > 3.3 mg/L from baseline to 6 and 12 mo decreased from 16.2% to 8.3% and 2.0%, respectively, in the NFM group (n = 114) and from 15.5% to 0.7% and 1.1%, respectively, in the FM group.

CONCLUSION

A large-scale iron-fortified subsidized-milk program was effective at reducing the rates of anemia and iron deficiency in Mexican children during 12 mo of implementation. This trial was registered at clinicaltrials.gov as NCT00508131.

Food insecurity is associated with iron deficiency anemia in US adolescents

BACKGROUND

Food insecurity, a condition of low or very low food security, is associated with decreased nutrient intake and poor health, which can lead to nutrient deficiency in children, including iron deficiency and iron deficiency anemia.

OBJECTIVE

The purpose of this study was to formally investigate the current relation of iron status and food security status among children aged 3-19 y (n = 11,247).

DESIGN

Participants of the National Health and Nutrition Examination Survey 1999-2004 were classified for food security status by using the US Children's Food Security Scale and the US Household Food Security Scale. Iron deficiency was defined as > or =2 abnormal values for transferrin saturation, serum ferritin, and erythrocyte protoporphyrin, with the addition of abnormal hemoglobin to classify iron deficiency anemia.

RESULTS

The odds of iron deficiency anemia among children aged 12-15 y were 2.95 times (95% CI: 1.18, 7.37; P = 0.02) those for children in households with food insecurity among children compared with children in households with food security among children.

CONCLUSIONS

The results of this study indicate a continuing need for successful interventions to reduce iron deficiency anemia among food-insecure children and to improve food security among children.

Social mobilization and social marketing to promote NaFeEDTA-fortified soya sauce in an iron-deficient population through a public–private partnership

Objective

The present pilot project aimed to assess the effectiveness of social mobilization and social marketing in improving knowledge, attitudes and practices (KAP) and Fe status in an Fe-deficient population.

Design

In an uncontrolled, before–after, community-based study, social mobilization and social marketing strategies were applied. The main outcomes included KAP and Hb level and were measured at baseline, 1 year later and 2 years later.

Setting

One urban county and two rural counties in Shijiazhuang Municipality, Hebei Province, China.

Subjects

Adult women older than 20 years of age and young children aged from 3 to 7 years were selected from three counties to attend the evaluation protocol.

Results

After 1 year, most knowledge and attitudes had changed positively towards the prevention and control of anaemia. The percentage of women who had adopted NaFeEDTA-fortified soya sauce increased from 8·9 % to 36·6 % (P ≤ 0·001). After 2 years, Hb levels had increased substantially, by 9·0 g/l (P ≤ 0·001) in adult women and 7·7 g/l (P ≤ 0·001) in young children.

Conclusion

Social mobilization and social marketing activities had a positive impact on the KAP of adult women, and resulted in marked improvements in Hb levels in both adult women and young children. This should be recommended as a national preventive strategy to prevent and control Fe deficiency and Fe-deficiency anaemia.

Maternal iron deficiency alters essential fatty acid and eicosanoid metabolism and increases locomotion in adult guinea pig offspring

Iron deficiency (ID) is the most prevalent worldwide nutritional deficiency. Groups at risk of developing ID anemia are infants and pregnant women, even in industrialized countries. Our goal in this study was to evaluate the long-term consequences of maternal ID on the offspring's fatty acid and eicosanoid metabolism, behavior, and spatial memory. Female guinea pigs consumed iron-sufficient (IS) and -deficient (ID) diets for 14 d before mating and throughout pregnancy and lactation. Dietary iron restriction resulted in ID in pregnant females. On postnatal d 9, all offspring (ID and IS) were weaned to the IS diet and at 42 d, all offspring were iron replete. Locomotion was tested in pups on postnatal d 24 and 40 and spatial memory from d 25 to 40. Pups from the ID group were significantly more active in the open field at both times of testing, whereas spatial memory, tested in a Morris water maze, was comparable in both groups. On postnatal d 42, liver, RBC, and brain fatty acid composition were measured. Dihomogammalinolenic [20:3(n-6)], docosapentaenoic [22:5(n-3)], and docosahexaenoic [22:6(n-3)] acid contents were significantly higher in brain phospholipids of offspring born to ID dams. Prostaglandin E(2) and F(2alpha) concentrations were also significantly higher in brains of offspring born to ID dams. This demonstrates that moderate ID during gestation and lactation results in alterations of brain fatty acid and eicosanoid metabolism and perturbation in behavior in adult offspring.

Increased hippocampal expression of the divalent metal transporter 1 (DMT1) mRNA variants 1B and +IRE and DMT1 protein after NMDA-receptor stimulation or spatial memory training

Iron is essential for crucial neuronal functions but is also highly toxic in excess. Neurons acquire iron through transferrin receptor-mediated endocytosis and via the divalent metal transporter 1 (DMT1). The N-terminus (1A, 1B) and C-terminus (+IRE, -IRE) splice variants of DMT1 originate four protein isoforms, all of which supply iron to cells. Diverse physiological or pathological conditions induce differential DMT1 variant expression, which are cell-type dependent. Hence, it becomes relevant to ascertain if activation of neuronal plasticity processes that require functional N-methyl D: -aspartate (NMDA) receptors, including in vitro stimulation of NMDA receptor-mediated signaling and spatial memory training, selectively modify DMT1 variant expression. Here, we report for the first time that brief (5 min) exposure of primary hippocampal cultures to NMDA (50 muM) increased 24 h later the expression of DMT1-1B and DMT1+IRE, but not of DMT1-IRE mRNA. In contrast, endogenous DMT1 mRNA levels remained unaffected following 6 h incubation with brain-derived nerve factor. NMDA (25-50 muM) also enhanced DMT1 protein expression 24-48 h later; this enhancement was abolished by the transcription inhibitor actinomycin D and by the NMDA receptor antagonist MK-801, implicating NMDA receptors in de novo DMT1 expression. Additionally, spatial memory training enhanced DMT1-1B and DMT1+IRE expression and increased DMT1 protein content in rat hippocampus, where the exon1A variant was not found. These results suggest that NMDA receptor-dependent plasticity processes stimulate expression of the iron transporter DMT1-1B+IRE isoform, which presumably plays a significant role in hippocampal spatial memory formation.

Facing malnutrition and poverty: evaluating the CONIN experience

The Undernutrition Prevention Center (UPC) of the Corporation for Childhood Nutrition (CONIN) assists children from 0-3 years of age who present with primary or secondary undernutrition. The aim of the retrospective study reported here was to complete a nutritional, cognitive, and social evaluation of UPC children in Mendoza, Argentina, from 1996 to 2005. During the study period, a total of 478 schoolchildren aged 5-17 years (186 in the CONIN group and 292 in the non-CONIN group) were evaluated. Although no differences in weight and height were found between the groups, the percentage of children below the cutoff level for the maturity test was significantly lower in the CONIN group (10.8% versus 17.6%; P = 0.043). CONIN provides important social support to families through work qualification programs and health education.

Maternal iron deficiency and its effect on essential fatty acid and eicosanoid metabolism and spatial memory in the guinea pig offspring

Iron deficiency is prevalent among infants and pregnant women in industrialized country. The goal of this study was to evaluate the impact of moderate maternal iron deficiency on the offspring's fatty acid and eicosanoid metabolism and spatial memory in guinea pigs. An iron-sufficient (IS) or iron-deficient (ID) diet was fed 14 days before mating and throughout pregnancy and lactation. The pups were tested for spatial memory on post-natal days 4-7. On post-natal day 9, the biochemical analysis included the pup's brain fatty acid profiles, prostaglandin (PGE(2) and PGF(2alpha)) concentrations and cyclooxygenase II protein levels. Spatial memory and indices of eicosanoid metabolism were comparable in both dietary groups. However, n-3 fatty acids were significantly higher (p<0.05) in brain of pups from the ID group. The data suggest that maternal iron deficiency results in a modification of the fatty acid profile of the offspring's brain that is not associated with any spatial memory deficits during early development.

Effect of sodium iron ethylenediaminetetra-acetate (NaFeEDTA) on haemoglobin and serum ferritin in iron-deficient populations: a systematic review and meta-analysis of randomised and quasi-randomised controlled trials

We aimed to synthesise evidence to assess the effect and safety of NaFeEDTA on Hb and serum ferritin in Fe-deficient populations. We performed a systematic review, identifying potential studies by searching the electronic databases of Medline, Cochrane Library, Embase, WHO Library and China National Knowledge Infrastructure. We also hand-searched relevant conference proceedings and reference lists. Finally, we contacted experts in the field. The selection criteria included randomised or quasi-randomised controlled trials of NaFeEDTA compared with placebo. Hb, serum ferritin and adverse effects were outcomes of interest. Inclusion decisions, quality assessment and data extraction were performed by two reviewers independently. Seven studies met the inclusion criteria. All included studies assessed the effect of NaFeEDTA on Hb concentration, four studies assessed the effect on serum ferritin concentration, and one study on serum Zn concentration. After the intervention, Hb concentration and serum ferritin concentration were both higher in the NaFeEDTA group compared with the control group. For Hb, data from six studies could be pooled and the pooled estimate (weighted mean difference) was 8·56 (95 % CI 2·21, 14·90) g/l (P = 0·008). For serum ferritin, data from four studies could be pooled and the pooled difference was 1·58 (95 % CI 1·20, 2·09) μg/l (P < 0·001). Subgroup analysis indicated that a lower baseline Hb level was associated with a greater increase in Hb concentration. No significant difference in serum Zn concentration was found. We concluded that NaFeEDTA increased both Hb concentration and serum ferritin concentration substantially in Fe-deficient populations, and could be an effective Fe preparation to combat Fe deficiency.

The importance of delayed cord clamping for Aboriginal babies: a life-enhancing advantage

Third stage management has typically focused on women and postpartum haemorrhage. Clamping and cutting the umbilical cord following the birth of the baby has continued to be a routine part of this focus. Active versus physiological management of third stage is generally accepted as an evidence-based plan for women to avoid excessive blood loss. Other considerations around this decision are rarely considered, including the baby's perspective. This paper provides a review of the literature regarding timing of clamping and cutting of the umbilical cord and related issues, and discusses the consequences for babies and in particular *Aboriginal babies. Iron stores in babies are improved (among other important advantages) if the cord is left to stop pulsating for 3 min before being clamped. Such a simple measure of patience and informed practice can make a long lasting difference to a baby's health and for Aboriginal babies this advantage can be critical in the short and the long term for their development and wellbeing. To achieve much needed reductions in infancy anaemia and essential increases in infant survival, delayed cord clamping and cutting is recommended for all Aboriginal babies.

Plasma biomarkers in pediatric patients undergoing cardiopulmonary bypass

It is critical to identify at-risk patients and minimize the deleterious effects of cardiopulmonary bypass (CPB) procedures in pediatric populations. The present study screened the plasma proteome of pediatric patients undergoing CPB procedures to identify potential clinical biomarkers related to tissue damage, inflammation, or other pathologies. Blood samples were collected at five different time points from 10 children undergoing a CPB procedure. Plasma was isolated and analyzed using two-dimensional differential in-gel electrophoresis and matrix-assisted laser desorption ionization time of flight mass spectrometry. Levels of differentially regulated proteins identified by two-dimensional differential in-gel electrophoresis, and related proteins were then measured in all time points and patients. As well, associated small molecules and ions were measured. The present study identified 13 proteins and protein isoforms altered in expression, including hemopexin, ceruloplasmin, inter-alpha inhibitor H4, and alpha-2-macroglobulin. Immunoblot analysis revealed significant decreases in each of these proteins during the CPB procedure. Significant changes in the levels of copper, iron, Hb, epinephrine, norepinephrine, and serotonin were observed. The potential markers of pathology (inflammation, oxidative stress) identified during this preliminary study may illuminate opportunities for preventative measures and/or treatments during and following CPB procedures in pediatric patients.

Risk factors for moderate to severe anemia among children in Benin and Mali: insights from a multilevel analysis

BACKGROUND

Anemia currently affects 2 billion people throughout the world. Although the immediate causes of anemia among children are known (including malnutrition and infections), the importance of contextual determinants and their relationships with individual effects have rarely been explored.

OBJECTIVE

To identify anemia risk factors at the individual, household, and community levels among Beninese and Malian children, using simple and multilevel regression methods.

METHODS

An analysis was undertaken of nationally representative data collected in 2001 in Benin (n = 2,284) and Mali (n = 2,826) by the Demographic and Health Surveys. Sixteen potential risk factors for anemia were considered at the individual, household, and community levels. Comparative analyses were carried out using simple and multilevel logistic regression models.

RESULTS

Simple and multilevel logistic regression analyses yielded broadly similar results. Risk factors for moderate to severe anemia included incomplete immunization, stunted growth, recent infection, absence of bednet, low household living standard, rural residency (Mali), low maternal education, and low community development index (Benin). In addition, multilevel analysis indicated a clustering level of anemia in communities (intraclass correlation) of 14% and 19% in Benin and Mali, respectively.

CONCLUSIONS

Risk factors for child anemia appeared at all three levels (individual, household and community). Community-level clustering seemed to be low. Therefore, interventions to address anemia need not be village- or region-specific. Identifying a successful and replicable program is now a priority in child survival endeavors. It is likely that such a program would include a focus on improving immunization coverage, increased bednet usage, and reduced protein-energy malnutrition.

Predictors of serum ferritin and serum soluble transferrin receptor in newborns and their associations with iron status during the first 2 y of life

BACKGROUND

Adequate iron status at birth may prevent iron deficiency in early childhood.

OBJECTIVES

We aimed to identify predictors of serum ferritin (SF) and serum soluble transferrin receptor (sTfR) in healthy newborns and to relate these iron indexes to iron status in the first 2 y of life.

DESIGN

Using bivariate correlations and linear regression, we related various factors in pregnancy to SF (n=363) and sTfR (n=350) in healthy, term infants. Measurements of cord SF and sTfR were compared with those of SF and sTfR at 6, 12, and 24 mo. All 4 measurements were available for 191 and 169 infants for SF and sTfR, respectively.

RESULTS

Geometric mean (and 95% CI) cord SF and sTfR measurements were 159 (148, 171) microg/L and 7.3 (7.0, 7.6) mg/L, respectively. Cord SF correlated with sTfR (rho=-0.21, P<0.001). In regression analysis, cord SF correlated with smoking and the use of iron supplements during pregnancy (partial r=-0.12 and 0.16; P<0.05 for both). Cord sTfR was associated with first trimester BMI, gestational age, and male sex (partial r=0.30, 0.24, and 0.19, respectively; P<0.01 for all). Cord SF correlated with SF at 6, 12, and 24 mo (rho=0.45, 0.31, and 0.16 respectively; P<0.05 for all). At age 6 mo, 16 of 17 infants with SF <15 mug/L were boys.

CONCLUSIONS

Cessation of smoking and adequate iron prophylaxis during pregnancy may improve iron status in infancy. Cord SF is a predictor of iron status in the first 2 y of life. Boys are at particular risk of low iron status in early infancy.

An overview of evidence for a causal relation between iron deficiency during development and deficits in cognitive or behavioral function

This review, intended for a broad scientific readership, summarizes evidence relevant to whether a causal relation exists between dietary iron deficiency with (ID+A) or without (ID-A) anemia during development and deficits in subsequent cognitive or behavioral performance. An overview of expert opinion and major evidence in humans and animals is provided. Cognitive and behavioral effects observed in humans with ID-A and in animals with ID+/-A are provided in tables. The degree to which 5 conditions of causality are satisfied and whether deleterious effects of ID-A might be expected to occur are discussed. On the basis of the existing literature, our major conclusions are as follows. Although most of the 5 conditions of causality (association, plausible biological mechanisms, dose response, ability to manipulate the effect, and specificity of cause and effect) are partially satisfied in humans, animals, or both, a causal connection has not been clearly established. In animals, deficits in motor activity are consistently associated with severe ID+A, but adverse effects on performance in tests that target cognitive function have not been clearly shown. Resistance to iron treatment was observed in most trials of children <2 y of age with ID+A, but not in older children. Similar observations were made in rodents when ID+A occurred before rather than after weaning. In children >2 y of age and in adolescents with ID-A, evidence suggests cognitive or behavioral deficits; however, the surprisingly small number of studies conducted in either humans or animals prevents a thorough assessment.

Iron, copper and fetal development

Pregnancy is a period of rapid growth and cell differentiation for both the mother and fetus. Consequently, it is a period when both are vulnerable to changes in dietary supply, especially of those nutrients that are marginal under normal circumstances. In developed countries this vulnerability applies mainly to micronutrients. Even now, Fe deficiency is a common disorder, especially in pregnancy. Similarly, Cu intake in the UK population is rarely above adequate levels, which is a matter of some concern, both in terms of public health and possible clinical consequences. In early studies it was shown that lambs born to mothers on Cu-deficient pastures develop ‘swayback,’ with neurological and muscular symptoms that cannot be reversed by postnatal supplementation. More recently, rat studies have shown that responses such as the ‘startle’ response are lost in offspring of Cu-deficient mothers. Data have shown that prenatal Fe deficiency results in increased postnatal blood pressure, even though the offspring have normal dietary Fe levels from birth. These observations emphasise the importance of Fe and Cu in growth and development. In the present review the importance of these metals and the consequences, both short term and long term, of deficiency will be discussed and some possible mechanisms whereby these effects may be generated will be considered.

Early iron deficiency alters sensorimotor development and brain monoamines in rats

Iron deficiency in human infancy reportedly leads to developmental delays and changes in neurobiology that may be irreversible. Using a rodent model, the present study examined whether dietary iron deficiency late in pregnancy and during lactation alters sensorimotor development and brain monoaminergic systems. Rats were assigned to 1 of 4 dietary treatments during gestation and lactation: 1) iron sufficient control; 2) prenatal iron deficiency beginning on gestational d 15 (G15); 3) postnatal iron deficiency beginning on postnatal d 4 (P4); 4) iron deficiency beginning on G15 followed by an iron sufficient diet on P4. Developmental milestones, open field behavior, brain iron and proteins, monoamines, and their transporters were evaluated between P6 and P21. Only G15 iron deficient rats had greater dopaminergic activity than controls as indicated by increased tyrosine hydroxylase levels, phosphorylated tyrosine hydroxylase levels, and cellular dopamine in prefrontal cortex and striatum at P15. These rats also showed delayed eye opening, ear development, and reduced locomotor activity. Iron repletion at P4 returned most measures to control levels by the time of weaning. Postnatal iron deficiency reduced striatal and ventral midbrain iron as well as cellular dopamine levels in prefrontal cortex and striatum at P21. Developmental delays in ear development and achievement in bar holding and surface righting also resulted from postnatal iron deficiency. These results indicate that iron deficiency begun at G15 affects early dopamine neurobiology, the development of specific developmental milestones, and behavior in preweaned rats.

Preconception maternal iron status is a risk factor for iron deficiency in infant rhesus monkeys (Macaca mulatta)

Iron deficiency is the most common micronutrient deficiency during pregnancy, and maternal anemia has been associated with poor pregnancy outcomes. However, it is still not clear how directly maternal iron status is linked to the infant's iron status postpartum. We investigated the impact of maternal iron deficiency on the hematological status of infant rhesus monkeys. Two groups of females, 8 iron deficient and 8 iron sufficient were assessed through pregnancy and for 6 mo postpartum. At conception, 4 females in each group were provided an iron-enriched diet. Iron status of the infant at birth reflected the preconception status of the mother, regardless of diet. Serum ferritin (Ft) concentrations were significantly higher in infants born to iron-sufficient mothers and were correlated with maternal transferrin saturation at entrance to the study (r = 0.52, P < 0.04). Infant iron status continued to reflect prenatal conditions through 6 mo of age. Our study confirmed the importance of iron sufficiency in gravid female monkeys for ensuring their infants' normal hematological development postpartum. A dietary intervention during pregnancy with only a moderate addition of iron was not sufficient to prevent the offspring from developing iron deficiency. These findings stress the importance of improving iron nutriture prior to conception.