Association between total duration of breastfeeding and iron deficiency

Examining the Double Burden of Underweight, Overweight/Obesity and Iron Deficiency among Young Children in a Canadian Primary Care Setting

There is little evidence on the prevalence of the double burden and association between body mass index (BMI) and iron deficiency among young children living in high-income countries. We conducted a cross-sectional study of healthy children, 12-29 months of age, recruited during health supervision visits in Toronto, Canada, and concurrently measured BMI and serum ferritin. The prevalence of a double burden of underweight (zBMI < -2) and iron deficiency or overweight/obesity (zBMI > 2) and iron deficiency was calculated. Regression models examined BMI and serum ferritin as continuous and categorical variables, adjusted for covariates. We found the following in terms of prevalence among 1953 children (mean age 18.3 months): underweight 2.6%, overweight/obesity 4.9%, iron deficiency 13.8%, iron-deficiency anemia 5.4%, underweight and iron deficiency 0.4%, overweight/obesity and iron deficiency 1.0%. The change in median serum ferritin for each unit of zBMI was -1.31 µg/L (95% CI -1.93, -0.68, p < 0.001). Compared with normal weight, we found no association between underweight and iron deficiency; meanwhile, overweight/obesity was associated with a higher odds of iron deficiency (OR 2.15, 95% CI 1.22, 3.78, p = 0.008). A double burden of overweight/obesity and iron deficiency occurs in about 1.0% of young children in this high-income setting. For risk stratification and targeted screening in young children, overweight/obesity should be added to the list of important risk factors.

Factors associated with syndemic anemia and stunting among children in Myanmar: A cross-sectional study from a positive deviance approach

BACKGROUND

Anemia and stunting in children are detrimental to the prospects of a normal, healthy upbringing. Having similar risk factors and serious consequences, the syndemic aspect of these two ailments is mostly underrated, and positive deviant (PD) factors that ensure non-anemic status in stunted children have not been studied to date.

METHODS

This study aimed to identify PD factors that have potential to prevent syndemic anemia among stunted children aged 6-59 months in Myanmar. This was a cross-sectional secondary analysis of the Myanmar Demographic and Health Survey (DHS) data conducted in 2016, applying the PD concept, where children who were stunted without anemia were considered as PDs.

RESULTS

Among 1248 stunted children, those who had the syndemic condition were compared with their PD peers in terms of maternal characteristics as well as socioeconomic and health-related factors. Multivariable logistic regression analyses were used to identify the determinants of syndemic state. The results showed that three out of every five stunted children were anemic. The syndemic risk was decreased among children of maternal age groups 20-34 years and 35-44 years: [aOR] = 0.19, 95% CI = 0.05-0.69; p = 0.012, and aOR = 0.19, 95% CI = 0.05-0.75; p = 0.018, respectively. Moderately stunted children (aOR = 0.53, 95% CI = 0.34-0.81; p = 0.004) and children who were not currently breastfed (aOR = 1.56, 95% CI = 1.01-2.41; p = 0.044) were less likely to develop the syndemic condition.

CONCLUSION

Maternal age, stunting severity, breastfeeding duration, and maternal anemic status are strong predictors in determining hemoglobin concentrations among stunted children. This study suggests that nutritional interventions targeting PD factors could represent syndemic action in improving child health.

Growth, Nutritional Status, and Dietary Intake Patterns Associated With Prolonged Breastfeeding in Young Korean Children: A Nationwide Cross-Sectional Study

BACKGROUND

Although the optimal duration of breastfeeding remains unclear, breastfeeding is generally recommended exclusively for the first 6 months of life, which continues into late infancy. However, the awareness regarding the effects of long-term breastfeeding is relatively low compared with that of breastfeeding in early infancy. We aimed to investigate the growth and nutritional characteristics of the children with prolonged breastfeeding (PBF) over 1 year.

METHODS

This cross-sectional study was based on the data of children aged 12 to 23 months from the National Health and Nutrition Examination Survey (2010-2020) conducted by the Korean Center for Disease Control and Prevention. Data on anthropometric measurements, dietary behavior, and food and nutrient intake were extracted, and the association between PBF and growth, nutritional status, and dietary patterns were analyzed.

RESULTS

Of the 872 children with a birth weight of ≥ 2.5 kg in the final analysis, 34.2% continued breastfeeding over 12 months of age, and their median breastfeeding duration was 14.2 months. Children with PBF were more likely to have lower current body weight (P < 0.001) and weight gain (P < 0.001), lower daily protein (P = 0.012), calcium (P < 0.001), and iron (P < 0.001) intake per calorie compared with children weaned by 12 months of age or those who were never breastfed. Furthermore, they were started on complementary food at 6 months or later rather than 4-5 months (P < 0.001), consumed cow's milk earlier (P = 0.012), and consumed probiotics as dietary supplements (P < 0.001) significantly less commonly. When comparing the intake of food groups, children with PBF had a significantly higher intake of cereals and grains (P = 0.023) and fruits (P = 0.020) and a significantly lower intake of bean products (P = 0.020) and milk and dairy products (P = 0.003).

CONCLUSION

Korean children who continued breastfeeding over 12 months of age showed distinct characteristics in terms of growth, nutritional status, and dietary patterns in the second year of life compared to children who did not. Long-term additional research on their growth and nutritional status may be needed; however, these findings are significant as important fundamental data for nutritional counseling to establish healthy PBF.

Chronic Iron Deficiency and Cognitive Function in Early Childhood

BACKGROUND AND OBJECTIVES

A landmark longitudinal study, conducted in Costa Rica in the 1980s, found that children with chronic iron deficiency compared with good iron status in infancy had 8 to 9 points lower cognitive scores, up to 19 years of age. Our objective was to examine this association in a contemporary, high-resource setting.

METHODS

This was a prospective observational study of children aged 12 to 40 months screened with hemoglobin and serum ferritin. All parents received diet advice; children received oral iron according to iron status. After 4 months, children were grouped as: chronic iron deficiency (iron deficiency anemia at baseline or persistent nonanemic iron deficiency) or iron sufficiency (IS) (IS at baseline or resolved nonanemic iron deficiency). Outcomes measured at 4 and 12 months included the Early Learning Composite (from the Mullen Scales of Early Learning) and serum ferritin.

RESULTS

Of 1478 children screened, 116 were included (41 chronic, 75 sufficient). Using multivariable analyses, the mean between-group differences in the Early Learning Composite at 4 months was -6.4 points (95% confidence interval [CI]: -12.4 to -0.3, P = .04) and at 12 months was -7.4 points (95% CI: -14.0 to -0.8, P = .03). The mean between-group differences in serum ferritin at 4 months was 14.3 μg/L (95% CI: 1.3-27.4, P = .03) and was not significantly different at 12 months.

CONCLUSIONS

Children with chronic iron deficiency, compared with children with IS, demonstrated improved iron status, but cognitive scores 6 to 7 points lower 4 and 12 months after intervention. Future research may examine outcomes of a screening strategy on the basis of early detection of iron deficiency using serum ferritin.

Fecal Iron Measurement in Studies of the Human Intestinal Microbiome

Iron is an essential micronutrient for humans and their intestinal microbiota. Host intestinal cells and iron-dependent bacteria compete for intraluminal iron, so the composition and functions of the gut microbiota may influence iron availability. Studies of the effects of the microbiota or probiotic interventions on host iron absorption may be particularly relevant to settings with high burdens of iron deficiency and gastrointestinal infections, since inflammation reduces iron bioavailability and unabsorbed intraluminal iron may modify the composition of the microbiota. The quantification of stool iron content may serve as an indicator of the amount of intraluminal iron to which the intestinal microbiota is exposed, which is particularly relevant for studies of the effect of iron on the intestinal microbiome, where fecal samples collected for purposes of microbiome characterization can be leveraged for stool iron analysis. However, few studies are available to guide researchers in the selection and implementation of stool iron assays, particularly because cross-comparison of available methods is limited in literature. This review aims to describe the available stool iron quantification methods and highlight their potential application in studies of iron-microbiome relationships, with a focus on pediatric research. MS-based methods offer high sensitivity and precision, but the need for expensive equipment and the high per-sample and maintenance costs may limit their widespread use. Conversely, colorimetric assays offer lower cost, ease of use, and rapid turnaround times but have thus far been optimized primarily for blood-derived matrices rather than stool. Further research efforts are needed to validate and standardize methods for stool iron assessment and to determine if the incorporation of such analyses in human microbiome studies 1) yields insights into the interactions between intestinal microbiota and iron and 2) contributes to the development of interventions that mitigate iron deficiency and promote a healthy microbiome.

Dietary Approaches to Iron Deficiency Prevention in Childhood-A Critical Public Health Issue

Iron is an essential nutrient, and individual iron status is determined by the regulation of iron absorption, which is driven by iron requirements. Iron deficiency (ID) disproportionately affects infants, children, and adolescents, particularly those who live in areas with unfavorable socioeconomic conditions. The main reason for this is that diet provides insufficient bioavailable iron to meet their needs. The consequences of ID include poor immune function and response to vaccination, and moderate ID anemia is associated with depressed neurodevelopment and impaired cognitive and academic performances. The persistently high prevalence of ID worldwide leads to the need for effective measures of ID prevention. The main strategies include the dietary diversification of foods with more bioavailable iron and/or the use of iron-fortified staple foods such as formula or cereals. However, this strategy may be limited due to its cost, especially in low-income countries where biofortification is a promising approach. Another option is iron supplementation. In terms of health policy, the choice between mass and targeted ID prevention depends on local conditions. In any case, this remains a critical public health issue in many countries that must be taken into consideration, especially in children under 5 years of age.

Pregnancy anaemia, child health and development: a cohort study in rural India

OBJECTIVE

To assess how pregnancy anaemia affects the offspring's early childhood development, child haemoglobin (Hb) levels child growth and diseases incidence 2 years after birth in a low-income setting. Furthermore, we investigate the mediating role of childhood Hb levels with disease incidences and skills.

DESIGN

Prospective cohort study.

SETTING AND PARTICIPANTS

The study participants are 941-999 mother-child dyads from rural Madhepura in Bihar, India. In 2015, the women were recruited during pregnancy from registers in mother-child centres of 140 villages for the first wave of data collection. At the time of the second wave in 2017, the children were 22-32 months old.

PRIMARY AND SECONDARY OUTCOME MEASURES

The recruited women were visited at home for a household survey and the measurement of the women's and child's Hb level, child weight and height. Data on the incidence of diarrhoea and respiratory diseases or fever were collected from interviews with the mothers. To test motor, cognitive, language and socioemotional skills of the children, we used an adapted version of the child development assessment FREDI.

RESULTS

The average Hb during pregnancy was 10.2 g/dL and 69% of the women had pregnancy anaemia. At the age of 22-32 months, a 1 g/dL increase in Hb during pregnancy was associated with a 0.17 g/dL (95% CI: 0.11 to 0.23) increase in Hb levels of the child. Children of moderately or severely anaemic women during pregnancy showed 0.57 g/dL (95% CI: -0.78 to -0.36) lower Hb than children of non-anaemic women. We find no association between the maternal Hb during pregnancy and early skills, stunting, wasting, underweight or disease incidence. While childhood anaemia does not correlate with childhood diseases, we find an association of a 1 g/dl increase in the child's Hb with 0.04 SDs higher test scores.

CONCLUSIONS

While pregnancy anaemia is a risk factor for anaemia during childhood, we do not find evidence for an increased risk of infectious diseases or early childhood development delays.

Iron status of full-term infants in early infancy is not associated with maternal ferritin levels nor infant feeding practice

Iron deficiency (ID) in early life is associated with morbidities. Most fetal iron required for infant growth is acquired in the third trimester from maternal iron store. However, how prenatal iron level affects ferritin level in early infancy remains controversial. This study aimed to examine the associations between maternal ferritin levels and cord blood serum ferritin (CBSF) and to compare the ferritin levels between different feeding practices in early infancy. Healthy Chinese mothers with uncomplicated pregnancy and their infants were followed up at 3 months post-delivery for questionnaire completion and infant blood collection. Infants who were predominantly breastfed and those who were predominantly formula fed were included in this analysis. Serum ferritin levels were measured in maternal blood samples collected upon delivery, cord blood and infant blood samples at 3 months of age. Ninety-seven mother-baby dyads were included. Maternal ID is common (56 %) while the CBSF levels were significantly higher than maternal ferritin levels. Only three infants (3 %) had ID at 3 months of age. There were no significant correlations between maternal ferritin levels with CBSF (r 0·168, P = 0·108) nor with infant ferritin levels at 3 months of age (r 0·023, P = 0·828). Infant ferritin levels at 3 months were significantly and independently associated with CBSF (P = 0·007) and birth weight (P < 0·001) after adjusting for maternal age, parity, maternal education, infant sex and feeding practice. In conclusion, maternal ID was common upon delivery. However, maternal ferritin levels were not significantly associated with CBSF concentrations nor infant ferritin concentrations at 3 months of age.

Investigation of Iron and Zinc Concentrations in Human Milk in Correlation to Maternal Factors: An Observational Pilot Study in Poland

The aim of this study was to evaluate iron and zinc concentrations in the mature human milk (HM) and to investigate the relationship between these concentrations and maternal factors. HM samples were collected between 4–6 weeks postpartum from 32 healthy, exclusively breastfeeding mothers. The assessment of dietary intake during breastfeeding was based on a food frequency questionnaire and three-day dietary records. Nutritional status of participants was assessed with body mass index and body composition analysis, measured with bioelectrical impedance. HM intake was assessed with infants’ weighting, whereas iron and zinc contents in HM were determined by inductively coupled plasma mass spectrometer. The median intake of HM was 492.5 mL (466–528.5) and the concentrations of HM iron and zinc were 0.33 mg/L (0.26–0.46) and 2.12 mg/L (1.97–2.45), respectively. Maternal total zinc and iron intake (diet + supplementation) was positively correlated with their concentrations in HM. Consumption frequency of meat, vegetables and legumes was revealed to be a significant factor influencing zinc concentration in HM. Regarding iron, it was the consumption frequency of meat, fish and seafood, vegetables and legumes, nuts and seeds. The intake of iron from HM was low, and after assuming a mean fractional iron absorption, it was only 0.038 mg/d. Our results show that maternal diet influences iron and zinc content in HM, suggesting that adequate intake of food rich in investigated minerals may be a positive factor for their concentrations in HM.

Dietary Intake and Milk Micronutrient Levels in Lactating Women with Full and Partial Breastfeeding

BACKGROUND

Micronutrient intake and status in lactating women may impact micronutrient levels in milk.

OBJECTIVES

This study aimed to determine the micronutrient intake and status in lactating women, and their association with micronutrient levels in human milk.

METHODS

Lactating women were enrolled at 4-6 months postpartum. A 24h food recall was examined and nutrient intakes were analyzed using INMUCAL software. Human milk samples were collected to analyze calcium, copper, iron, and zinc levels. Plasma zinc and serum ferritin levels were determined.

RESULTS

Thirty-four women participated; 19 were classified as full breastfeeding and 15 as partial breastfeeding. Mean levels of calcium, copper, iron, and zinc in human milk were 243, 0.2, 0.2, and 1.56 mg/L, respectively. The prevalence of zinc deficiency (plasma zinc < 10.7 µmol/L) was 11.8%. No lactating women had iron deficiency. Nutrient intakes were lower than the recommended amounts in 38%-70% of participants, and were not correlated with corresponding nutrient levels in human milk. Multiple linear regression showed significant association between zinc levels in human milk and plasma for lactating women with full breastfeeding (β = 0.034, 95% confidence interval [0.003, 0.067], p = 0.040).

CONCLUSIONS

Lactating women were at risk of micronutrient deficiency. There was an association between zinc levels in human milk and plasma of lactating women with full breastfeeding. As the nutritional status of lactating women influences the quality of human milk, we should encourage good nutrient intake for lactating women.

Determining the Actual Zinc and Iron Intakes in Breastfed Infants: Protocol for a Longitudinal Observational Study

BACKGROUND

Zinc and iron deficiencies among breastfed infants during the first 6 months of life have been reported in previous studies. The amounts of zinc and iron intakes from breast milk are factors that contribute to the zinc and iron status of breastfed infants.

OBJECTIVE

This study aims to quantitatively determine zinc and iron intakes by breastfed infants during the first 4 months of life and to investigate the factors that predict zinc and iron status in breastfed infants.

METHODS

Pregnant women at 28 to 34 weeks of gestation were enrolled. Zinc and iron status during pregnancy was assessed. At delivery, cord blood was analyzed for zinc and iron levels. Participants and their babies were followed at 2 and 4 months postpartum. Maternal dietary intakes and anthropometric measurements were performed. The amount of breast milk intake was assessed using the deuterium oxide dose-to-mother technique. Breast milk samples were collected for determination of zinc and iron levels. The amount of zinc and iron consumed by infants was calculated. Zinc and iron status was determined in mothers and infants at 4 months postpartum.

RESULTS

A total of 120 pregnant women were enrolled, and 80 mother-infant pairs completed the study (56 provided full breastfeeding, and 24 provided breast milk with infant formula). All data are being managed and cleaned. Statistical analysis will be done.

CONCLUSIONS

This study will provide information on zinc and iron intakes in exclusively breastfed infants during the first 4 months of life and explore predictive factors and the possible association of zinc and iron intakes with infant growth and nutrient status.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/19119.

Association of Family Income and Risk of Food Insecurity With Iron Status in Young Children

IMPORTANCE

Iron deficiency (ID) has the greatest prevalence in early childhood and has been associated with poor developmental outcomes. Previous research examining associations of income and food insecurity (FI) with ID is inconsistent.

OBJECTIVE

To examine the association of family income and family risk of FI with iron status in healthy young children attending primary care.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study included 1245 children aged 12 to 29 months who attended scheduled primary care supervision visits from 2008 to 2018 in Toronto, Canada, and the surrounding area.

EXPOSURES

Family income and risk of FI were collected from parent-reported questionnaires. Children whose parents provided an affirmative response to the 1-item FI screen on the Nutrition Screening Tool for Every Toddler or at least 1 item on the 2-item Hunger Vital Sign FI screening tool were categorized as having family risk of FI.

MAIN OUTCOMES AND MEASURES

Iron deficiency (serum ferritin level <12 ng/mL) and ID anemia (IDA; serum ferritin level <12 ng/mL and hemoglobin level <11.0 g/dL). All models were adjusted for age, sex, birth weight, body mass index z score, C-reactive protein level, maternal education, breastfeeding duration, bottle use, cow's milk intake, and formula feeding in the first year.

RESULTS

Of 1245 children (595 [47.8%] girls; median [interquartile range] age, 18.1 [13.3-24.0] months), 131 (10.5%) were from households with a family income of less than CAD $40 000 ($29 534), 77 (6.2%) were from families at risk of FI, 185 (14.9%) had ID, and 58 (5.3%) had IDA. The odds of children with a family income of less than CAD $40 000 having ID and IDA were 3 times higher than those of children in the highest family income group (ID: odds ratio [OR], 3.08; 95% CI, 1.66-5.72; P < .001; IDA: OR, 3.28; 95% CI, 1.22-8.87; P = .02). Being in a family at risk of FI, compared with all other children, was not associated with ID or IDA (ID: OR, 0.43; 95% CI, 0.18-1.02; P = .06; IDA: OR, 0.16; 95% CI, 0.02-1.23; P = .08).

CONCLUSIONS AND RELEVANCE

In this study, low family income was associated with increased risk of ID and IDA in young children. Risk of FI was not a risk factor for ID or IDA. These findings suggest that targeting income security may be more effective than targeting access to food to reduce health inequities in the prevention of iron deficiency.

Prevalence of iron deficiency in 62,685 women of seven race/ethnicity groups: The HEIRS Study

Background

Few cross-sectional studies report iron deficiency (ID) prevalence in women of different race/ethnicity and ages in US or Canada.

Materials and methods

We evaluated screening observations on women who participated between 2001–2003 in a cross-sectional, primary care-based sample of adults ages ≥25 y whose observations were complete: race/ethnicity; age; transferrin saturation; serum ferritin; and HFE p.C282Y and p.H63D alleles. We defined ID using a stringent criterion: combined transferrin saturation <10% and serum ferritin <33.7 pmol/L (<15 μg/L). We compared ID prevalence in women of different race/ethnicity subgrouped by age and determined associations of p.C282Y and p.H63D to ID overall, and to ID in women ages 25–44 y with or without self-reported pregnancy.

Results

These 62,685 women included 27,079 whites, 17,272 blacks, 8,566 Hispanics, 7,615 Asians, 449 Pacific Islanders, 441 Native Americans, and 1,263 participants of other race/ethnicity. Proportions of women with ID were higher in Hispanics and blacks than whites and Asians. Prevalence of ID was significantly greater in women ages 25–54 y of all race/ethnicity groups than women ages ≥55 y of corresponding race/ethnicity. In women ages ≥55 y, ID prevalence did not differ significantly across race/ethnicity. p.C282Y and p.H63D prevalence did not differ significantly in women with or without ID, regardless of race/ethnicity, age subgroup, or pregnancy.

Conclusions

ID prevalence was greater in Hispanic and black than white and Asian women ages 25–54 y. p.C282Y and p.H63D prevalence did not differ significantly in women with or without ID, regardless of race/ethnicity, age subgroup, or pregnancy.

Safety of intravenous iron isomaltoside for iron deficiency and iron deficiency anemia in pregnancy

PURPOSE

To evaluate the efficacy and safety for mother and child of using intravenous iron isomaltoside (IV-IIM) during pregnancy.

METHODS

Using an appointment register, we retrospectively identified all pregnant women who received a single dose of 1000 or 1500 mg IV-IIM in the maternity ward of Falu Hospital and subsequently gave birth between August 6, 2013 and July 31, 2018. Women who received IV-IIM (case group) were individually matched with pregnant women who did not receive IV-IIM (control group) by delivery date, maternal age (± 2 years), and parity. Adverse drug reactions (ADRs), demographic characteristics, hemoglobin and s-ferritin counts, pregnancy and delivery complications, and infant data (APGAR score, pH at umbilical artery, birthweight, birth length, intrauterine growth restriction and neonatal ward admission). Data were obtained from electronic patient charts. SPSS was used for descriptive statistics.

RESULTS

During the 5-year period, 213 women each received a single administration of IV-IIM. Ten (4.7%) ADRs occurred during IV-IIM administration. All ADRs were mild hypersensitivity reactions, abated spontaneously within a few minutes, and did not recur on rechallenge. No association between IIM dose and ADR frequency was noted. Maternal and fetal outcomes, including hemoglobin counts at delivery and postpartum, were similar in the case and control groups.

CONCLUSION

These results support the convenience, safety, and efficacy of a single high-dose (up to 1500 mg) infusion of IV-IIM for iron deficiency or iron deficiency anemia during pregnancy.

Maternal ethnicity and iron status in early childhood in Toronto, Canada: a cross-sectional study

OBJECTIVES

This study aimed to evaluate the association between maternal ethnicity and iron deficiency (ID) in early childhood, and to evaluate whether infant feeding practices linked to ID differ between maternal ethnic groups.

METHODS

This was a cross-sectional study of healthy children 1-3 years of age. Adjusted multivariable logistic regression analyses were used to evaluate the association between maternal ethnicity and ID (serum ferritin <12 µg/L) and the association between maternal ethnicity and five infant feeding practices (breastfeeding duration; bottle use beyond 15 months; current formula use; daily cow's milk intake >2 cups; meat consumption).

RESULTS

Of 1851 children included, 12.2% had ID. Compared with the European referent group, we found higher odds of ID among children of South Asian and West Asian/North African maternal ethnicities, and lower odds of ID among children of East Asian maternal ethnicity. Statistically significant covariates associated with higher odds of ID included longer breastfeeding duration and daily cow's milk intake >2 cups. Current infant formula use was associated with lower odds of ID. Children of South Asian maternal ethnicity had higher odds of bottle use beyond 15 months of age and lower odds of meat consumption.

CONCLUSIONS

We found increased odds of ID among children of South Asian and West Asian/Northern African maternal ethnicities. We found a higher odds of feeding practices linked to ID in children of South Asian maternal ethnicity, but not in children of West Asian/North African maternal ethnicity. Culturally tailored approaches to providing guidance to parents on healthy infant feeding practices may be important to prevent ID in early childhood.

TRIAL REGISTRATION NUMBER

NCT01869530.

Trajectory of vitamin D, micronutrient status and childhood growth in exclusively breastfed children

This study aimed to compare the trajectory of serum 25(OH)D, micronutrient levels, and anthropometric measurements between exclusively breastfed and mixed-fed children. This is a prospective cohort study. Anthropometric measurements of the children were obtained during scheduled clinical visits. Tests for 25(OHD), ferritin, zinc and complete blood count were performed yearly until 3 years of age. Clinical records and questionnaires on dietary habits were obtained. The results showed that despite official recommendations on vitamin D/iron supplements for breastfed children, less than 10% of our exclusively breastfed children received regular supplements. Thus, after 1 year, the odds for having iron deficiency anemia and vitamin D insufficiency were 9 [95% CI, 4-19] and 6 [95% CI, 2-16], respectively. Longitudinal follow-up showed the prevalence of iron deficiency to decrease from 34% at 1 year to 2% at age 3 years. However, the prevalence of vitamin D insufficiency remained persistently high throughout the first three years of life (60% at 1 to 44% at 3 years). Very few children had zinc deficiency. Anthropometric measurements showed exclusively breastfed children to have lower mean z-scores for body weight and height when compared to mixed-fed children after 12 months. In conclusion, children who were exclusively breastfed for longer than 4 months without proper supplement were more likely to have transient iron deficiency anemia and persistent vitamin D insufficiency. Their growth became relatively slower after infancy. Whether this was associated with underlying inadequate serum vitamin D and iron level remains an important issue to be explored.

Iron deficiency screening for children at 18 months: a cost-utility analysis

BACKGROUND

The peak prevalence of iron deficiency is in children 6 months to 3 years of age, a sensitive period for neurodevelopment. Our study objective was to examine the cost-utility of a proposed iron deficiency screening program for 18-month-old children.

METHODS

We used a decision tree model to estimate the costs in 2019 Canadian dollars and quality-adjusted life years (QALYs) associated with 3 iron deficiency screening strategies: no screening, universal screening and targeted screening for a high-risk population. We used a societal perspective and assessed lifetime QALY gains. We derived outcomes from the literature and prospectively collected data. We performed one-way and probabilistic sensitivity analyses to assess parameter uncertainty.

RESULTS

The incremental costs to society of universal and targeted screening programs compared to no screening were $2286.06/QALY and $1676.94/QALY, respectively. With a willingness-to-pay threshold of $50 000/QALY, both programs were cost-effective. Compared to a targeted screening program, a universal screening program would cost an additional $2965.96 to gain 1 QALY, which renders it a cost-effective option. The study findings were robust to extensive sensitivity analyses.

INTERPRETATION

A proposed universal screening program for iron deficiency would be cost-effective over the lifespan compared to both no screening (current standard of care) and a targeted screening program for children at high risk. Policy-makers and physicians may consider expanding the recommended 18-month enhanced well-baby visit to include screening for iron deficiency.

Higher Body Mass Index Is Associated with Iron Deficiency in Children 1 to 3 Years of Age

OBJECTIVES

To examine the association between body mass index (BMI) and iron deficiency in early childhood, while considering the influence of low-grade systemic inflammation.

STUDY DESIGN

Healthy children ages 1-3 years were included in a cross-sectional analysis. Age- and sex-standardized World Health Organization BMI z score (zBMI) was calculated using height/length and weight measurements; iron status was assessed by serum ferritin; inflammation was assessed by C-reactive protein (CRP). Children with CRP ≥10 mg/L were excluded because this may indicate acute systemic inflammation. Adjusted multivariable regression analyses were used to investigate the association between zBMI and both serum ferritin (µg/L), and iron deficiency (serum ferritin <12 µg/L). We performed prespecified subgroup analyses according to CRP level (normal [≤1.0 mg/L] and low-grade inflammation [>1.0 mg/L to <10.0 mg/L]).

RESULTS

Of 1607 children included, 20% were categorized as with zBMI >1, 13% had iron deficiency, and 18% had low-grade inflammation. Higher zBMI was associated with lower serum ferritin (-1.51 µg/L, 95% CI -2.23, -0.76, P < .0001) and increased odds of iron deficiency (OR 1.28, 95% CI 1.10, 1.50, P = .002). Though there was no interaction between zBMI and CRP for the adjusted linear regression model (P = .79) or logistic regression model (P = .43), children with low-grade inflammation had a higher serum ferritin (P < .0001).

CONCLUSIONS

Higher zBMI is associated with increased risk for iron deficiency in children between 1 and 3 years, and should be considered as a risk factor in targeted screening. Further research is needed to better understand the relationship between serum ferritin and CRP for children in all weight categories.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT01869530.

Breastfeeding Versus Bottle Feeding on Malocclusion in Children: A Meta-Analysis Study

BACKGROUND

Breastfeeding plays an important role in child health. However, there are doubts about its influence on malocclusions. Systematic reviews have yielded contradictory results. Research aim: This study aimed to investigate whether the type and duration of breastfeeding are associated with malocclusions in primary teething.

METHODS

The review strategy included several electronic databases, lists of references, reviews, dissertation and thesis websites, experts, and other relevant documents. Published and unpublished observational studies ( N = 42) were reviewed using the Participants (children), Interventions (breastfeeding), Comparisons (bottle feeding), Outcomes (malocclusion), and Study design (observational) strategy, without restrictions on language or locale. Information about the authors, publication year, country of study, setting, study design, sample size, age, type and duration of exclusive and mixed breastfeeding, and malocclusions was recorded by two blinded evaluators. Quantitative meta-analysis ( N = 30) of the studies with available data was performed.

RESULTS

Breastfeeding was a protective factor against malocclusions. The odds of association increased with breastfeeding duration. Irrespective of duration, breastfeeding had a protective association with open bite. For those who were breastfed for up to 6 months, breastfeeding protected against overjet, open bite, posterior crossbite, and crowding. Breastfeeding for 12 months or longer was associated with lower odds of overjet, open bite, and posterior crossbite. Breastfeeding exclusively for 6 months was also a protective factor against malocclusions. However, studies on this subject presented low quality, statistical heterogeneity, and only unadjusted measures of association in most of the cases.

CONCLUSION

Breastfeeding beneficially affects primary occlusion when practiced for at least 6 months.

Iron deficiency among low income Canadian toddlers: a cross-sectional feasibility study in a Community Health Centre and non-Community Health Centre sites

BACKGROUND

Iron deficiency in early childhood has been associated with poor developmental outcomes. Little is known about the nutritional health of young children receiving care at Canadian Community Health Centres (CHCs). Our objectives were to describe iron deficiency among toddlers at an Ontario CHC, to compare young children attending CHCs and non-CHCs, and assess the feasibility of conducting research on children in CHC settings.

METHODS

One CHC, Kingston Community Health Centres (CHC) with two clinical sites and one community programming site was added to the nine non-CHC pediatric and primary care clinics in the existing TARGet Kids! research network. A cross-sectional feasibilitystudy was conducted.and. Healthy children, ages 12-36 months were Enrolled. iron deficiency without inflammation (ferritin< 14 μg/L and CRP < 10 mg/L) and serum ferritin were assessed. Adjusted multivariable regression analyses were used to evaluate an association between CHC enrolment and iron status.

RESULTS

The CHC cohort (n = 31) was older, had lower household income, lower maternal education, higher nutrition risk scores, higher cow's milk intake, shorter breastfeeding duration and higher prevalence of unhealthy weights compared with the non-CHC cohort (n = 875). There was no association between CHC status and serum ferritin (difference in median serum ferritin 4.78 μg/L, 95% confidence interval [CI] -2.5, 14.3, p = 0.22) or iron deficiency (OR 0.55, 95% CI 0.11, - 2.73, p = 0.46) using multivariable linear and logistic regression, respectively.

CONCLUSION

Despite differences in sociodemographic variables, we did not detect a difference in iron status between toddlers enrolled at CHCs compared to non-CHC settings. Further research is needed to understand the health effects of poverty generally, and iron deficiency specifically among children receiving care at CHCs.

Breastfeeding to 12 mo and beyond: nutrition outcomes at 3 to 5 y of age

Background

Little is known about nutrition outcomes in preschoolers associated with breastfeeding duration beyond 12 mo of age.

Objective

The aim was to examine the association between total breastfeeding duration and nutrition outcomes at 3 to 5 y of age.

Design

A cross-sectional study in healthy children, ages 3-5 y, recruited from 9 primary care practices in Toronto was conducted through the TARGet Kids! (The Applied Research Group for Kids) research network. Parents completed standardized surveys, including the Nutrition Screening for Every Preschooler (NutriSTEP) used to assess nutrition risk.

Results

A total of 2987 children were included. Ninety-two percent of children were breastfed, and the mean ± SD breastfeeding duration was 11.4 ± 8.4 mo. The prevalence of nutrition risk (score >20) was 17.0%. We examined breastfeeding duration as a continuous variable. With the use of restricted cubic spline modeling, we confirmed a nonlinear relation between breastfeeding duration and NutriSTEP score, dietary intake and eating behavior subscores, and sugar-sweetened beverage and sweet-savory snack consumption. Segmented linear regression was used to examine this nonlinear relation in a piecewise approach. We found a decreasing trend in NutriSTEP score for children who were breastfed for 0-6 mo (β = -0.14; 95% CI: -0.29, 0.004), a significant decrease in NutriSTEP score for children breastfed for 6-12 mo (β = -0.20; 95% CI: -0.33, -0.07), and no significant change after 12 mo (β = 0.09; 95% CI: -0.07, 0.24) and beyond. The mean ± SD NutriSTEP scores were 17.1 ± 7.4 for no breastfeeding, 15.9 ± 6.5 for breastfeeding >0-6 mo, 13.9 ± 6.2 for >6-12 mo, 13.7 ± 6.3 for >12-18 mo, 14.6 ± 6.7 for >18-24 mo, and 14.3 ± 6.8 for >24-36 mo.

Conclusions

Breastfeeding for ≤12 mo was associated with decreased nutrition risk and healthier eating behaviors and dietary intake at 3-5 y of age. We found insufficient evidence of additional benefit for breastfeeding beyond 12 mo of age. The TARGet Kids! practice-based research network is registered at www.clinicaltrials.gov as NCT01869530.

Effect of infant feeding practices on iron status in a cohort study of Bolivian infants

BACKGROUND

Iron deficiency (ID) is the most common micronutrient deficiency worldwide, with potentially severe consequences on child neurodevelopment. Though exclusive breastfeeding (EBF) is recommended for 6 months, breast milk has low iron content. This study aimed to estimate the effect of the length of EBF on iron status at 6 - 8 months of age among a cohort of Bolivian infants.

METHODS

Mother-infant pairs were recruited from 2 hospitals in El Alto, Bolivia, and followed from one through 6 - 8 months of age. Singleton infants > 34 weeks gestational age, iron-sufficient at baseline, and completing blood draws at 2 and 6 - 8 months of age were eligible for inclusion (N = 270). Ferritin was corrected for the effect of inflammation. ID was defined as inflammation-corrected ferritin < 12 μg/L, and anemia was defined as altitude-corrected hemoglobin < 11 g/dL; IDA was defined as ID plus anemia. The effect of length of EBF (infant received only breast milk with no other liquids or solids, categorized as < 4, 4 - 6, and > 6 months) was assessed for ID, IDA, and anemia (logistic regression) and ferritin (Fer) and hemoglobin (Hb, linear regression).

RESULTS

Low iron status was common among infants at 6 - 8 months: 56% of infants were ID, 76% were anemic, and 46% had IDA. EBF of 4 months and above was significantly associated with ID as compared with EBF <  4 months (4 - 6 months: OR 2.0 [1.1 - 3.4]; > 6 months: 3.3 [1.0 - 12.3]), but not with IDA (4 - 6 months: OR 1.4 [0.8 - 2.4]; > 6 months: 2.2 [0.7 - 7.4]), or anemia (4 - 6 months: OR 1.4 [0.7 - 2.5]; > 6 months: 1.5 [0.7 - 7.2]). Fer and Hb concentrations were significantly lower with increasing months of EBF.

CONCLUSIONS

Results suggest a relationship between prolonged EBF and ID, but are not sufficient to support changes to current breastfeeding recommendations. More research is needed in diverse populations, including exploration of early interventions to address infant IDA.

Breastfeeding and Red Meat Intake Are Associated with Iron Status in Healthy Korean Weaning-age Infants

The present study investigated risk factors for iron deficiency (ID) and iron deficiency anemia (IDA) during late infancy, including feeding type and complementary feeding (CF) practice. Healthy term Korean infants (8-15 months) were weighed, and questionnaires regarding delivery, feeding, and weaning were completed by their caregivers. We also examined levels of hemoglobin, serum iron/total iron-binding capacity, serum ferritin, and mean corpuscular volume (MCV). Among 619 infants, ID and IDA were present in 174 infants (28.1%) and 87 infants (14.0%), respectively. The 288 infants with exclusively/mostly breastfeeding until late infancy (BFL) were most likely to exhibit ID (53.1%) and IDA (28.1%). The risk of ID was independently associated with BFL (adjusted odds ratio [aOR], 47.5; 95% confidence interval [CI], 18.3-122.9), male sex (aOR, 1.9; 95% CI, 1.2-2.9), fold weight gain (aOR, 2.6; 95% CI, 1.5-4.6), and perceived inadequacy of red meat intake (aOR, 1.7; 95% CI, 1.0-2.7). In addition to the risk factors for ID, Cesarean section delivery (aOR, 1.9; 95% CI, 1.1-3.2) and low parental CF-related knowledge (aOR, 2.8; 95% CI, 1.5-5.2) were risk factors for IDA. In conclusion, prolonged breastfeeding and perceived inadequacy of red meat intake may be among the important feeding-related risk factors of ID and IDA. Therefore, more meticulous education and monitoring of iron-rich food intake, such as red meat, with iron supplementation or iron status testing during late infancy if necessary, should be considered for breastfed Korean infants, especially for those with additional risk factors for ID or IDA.

Iron status, body size, and growth in the first 2 years of life

Rapid growth in infancy has been shown to adversely affect iron status up to 1 year; however the effect of growth on iron status in the second year of life has been largely unexplored. We aimed to investigate the impact of growth and body size in the first 2 years on iron status at 2 years. In the prospective, maternal-infant Cork BASELINE Birth Cohort Study, infant weight and length were measured at birth, 2, 6, 12, and 24 months and absolute weight (kg) and length (cm) gain from 0 to 2, 0 to 6, 0 to 12, 6 to 12, 12 to 24, and 0 to 24 months were calculated. At 2 years (n = 704), haemoglobin, mean corpuscular volume, and serum ferritin (umbilical cord concentrations also) were measured. At 2 years, 5% had iron deficiency (ferritin < 12 μg/L) and 1% had iron deficiency anaemia (haemoglobin < 110 g/L + ferritin < 12 μg/L). Weight gain from 6 to 12, 0 to 24, and 12 to 24 months were all inversely associated with ferritin concentrations at 2 years but only the association with weight gain from 12 to 24 months was robust after adjustment for potential confounders including cord ferritin (adj. estimate 95% CI: -4.40 [-8.43, -0.37] μg/L, p = .033). Length gain from 0 to 24 months was positively associated with haemoglobin at 2 years (0.42 [0.07, 0.76] g/L, p = .019), only prior to further adjustment for cord ferritin. To conclude, weight gain in the second year was inversely associated with iron stores at 2 years, even after accounting for iron status at birth. Further examinations of iron requirements, dietary intakes, and growth patterns in children in the second year of life in high-resource settings are warranted.

Low-Level Toxic Metal Exposure in Healthy Weaning-Age Infants: Association with Growth, Dietary Intake, and Iron Deficiency

Even low levels of toxic metal exposure (As, Cd, Hg, and Pb) in infancy might be harmful to children's development. This study investigated toxic metal exposure on healthy weaning-age infants and its relationship with growth, diet, and iron/anemia status. The weight, height, head circumference, whole blood levels of four toxic metals, hemoglobin, and serum ferritin of healthy infants was measured. Among 210 infants with a median age of 11.4 months (interquartile range: 10.5-12.0), the median levels of As, Cd, Hg, and Pb were 1.2 μg/L, 0.05 μg/L, 0.8 μg/L, and 0.83 μg/dL, respectively. In adjusted linear regression models, post-birth weight gain (Pb) and current head circumference (As, Pb) were negatively associated with toxic metal levels. In multiple linear regression or logistic regression analysis, the duration of breastfeeding (all four metals), perceived adequacy of rice-based food intake (As), regular fish intake (As, Hg), and iron deficiency with/without anemia (Cd, Pb) were associated with increased toxic metal levels. Although levels of toxic metals may not usually be high in this population, individual exposure risk may need to be assessed after considering the type of feeding or intake of complementary foods and the iron/anemia status while evaluating growth status during late infancy.

Breastfeeding, Mixed, or Formula Feeding at 9 Months of Age and the Prevalence of Iron Deficiency and Iron Deficiency Anemia in Two Cohorts of Infants in China

OBJECTIVE

To assess associations between breastfeeding and iron status at 9 months of age in 2 samples of Chinese infants.

STUDY DESIGN

Associations between feeding at 9 months of age (breastfed as sole milk source, mixed fed, or formula fed) and iron deficiency anemia (IDA), iron deficiency, and iron sufficiency were determined in infants from Zhejiang (n = 142) and Hebei (n= 813) provinces. Iron deficiency was defined as body iron < 0 mg/kg, and IDA as iron deficiency + hemoglobin < 110 g/L. Multiple logistic regression assessed associations between feeding pattern and iron status.

RESULTS

Breastfeeding was associated with iron status (P < .001). In Zhejiang, 27.5% of breastfed infants had IDA compared with 0% of formula-fed infants. The odds of iron deficiency/IDA were increased in breastfed and mixed-fed infants compared with formula-fed infants: breastfed vs formula-fed OR, 28.8 (95% CI, 3.7-226.4) and mixed-fed vs formula-fed OR, 11.0 (95% CI, 1.2-103.2). In Hebei, 44.0% of breastfed infants had IDA compared with 2.8% of formula-fed infants. With covariable adjustment, odds of IDA were increased in breastfed and mixed-fed groups: breastfed vs formula-fed OR, 78.8 (95% CI, 27.2-228.1) and mixed-fed vs formula-fed OR, 21.0 (95% CI, 7.3-60.9).

CONCLUSIONS

In both cohorts, the odds of iron deficiency/IDA at 9 months of age were increased in breastfed and mixed-fed infants, and iron deficiency/IDA was common. Although the benefits of breastfeeding are indisputable, these findings add to the evidence that breastfeeding in later infancy identifies infants at risk for iron deficiency/IDA in many settings. Protocols for detecting and preventing iron deficiency/IDA in breastfed infants are needed.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT00642863 and NCT00613717.

Iron status of young children from immigrant families

OBJECTIVES

Children from immigrant families may be at risk for iron deficiency (ID) due to differences in pre-migration and post-migration exposures. Our objectives were to determine whether there is an association between family immigrant status and iron stores and to evaluate whether known dietary, environmental or biological determinants of low iron status influence this relationship.

DESIGN

This was a cross-sectional study of healthy urban preschool children (12-72 months) recruited from seven primary care practices in Toronto. Laboratory assessment of serum ferritin and haemoglobin and standardised parent-completed surveys were completed between 2008 and 2013 during routine health maintenance visits. Multiple regression analyses were used to evaluate the association between family immigrant status and serum ferritin, ID (ferritin <14 μg/L) and iron deficiency anaemia (IDA) (ferritin <14 μg/L and haemoglobin ≤110 g/L).

RESULTS

Of 2614 children included in the analysis, 47.6% had immigrant family status. The median serum ferritin was 30 μg/L and 10.4% of all children had ID and 1.9% had IDA. After adjusting for maternal ethnicity and education, age, sex, income quintile, cow's milk intake, breastfeeding duration and bottle use, there were no significant associations between immigrant status and ferritin, ID or IDA. Significant predictors of low iron status included age, sex, cow's milk intake and breastfeeding duration.

CONCLUSIONS

We found no association between family immigrant status and iron status after including clinically important covariates in the models. These data suggest immigrant children may not need enhanced screening for iron status or targeted interventions for iron supplementation.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Prevalence of Iron Deficiency and Anemia among Young Children with Acute Diarrhea in Bhaktapur, Nepal

Iron deficiency anemia is still common in children under five years of age and may impair their growth and cognitive development. Diarrhea is the second most common reason for seeking medical care for young children in Nepal. However, neither screening programs nor effective preventive measures for anemia and iron deficiencies are in place among children with diarrhea in many developing countries. The aims of this study were to determine the prevalence of anemia and iron deficiency and explore their associations with clinical, socioeconomic, and anthropometric parameters in Nepalese children. This was a cross-sectional study based on 1232 children, six to 35 months old, with acute diarrhea participating in a zinc supplementation trial. The mean (SD) hemoglobin was 11.2 g/dL (1.2). Anemia was found in 493 children (40%); this estimate increased to 641 (52%) when we adjusted for the altitude of the study area (hemoglobin <11.3 g/dL). One in every three children had depleted iron stores and 198 (16%) of the children had both depleted iron stores and anemia, indicating iron deficiency anemia. The prevalence of anemia among children presenting with acute diarrhea was high but the degree of severity was mainly mild or moderate. Iron deficiency explained less than half of the total anemia, indicating other nutritional deficiencies inducing anemia might be common in this population.

Severe iron-deficiency anaemia and feeding practices in young children

Objectives

Fe-deficiency anaemia (IDA) occurs in 1–2 % of infants in developed countries, peaks at 1–3 years of age and is associated with later cognitive deficits. The objectives of the present study were to describe the characteristics of young children with severe IDA and examine modifiable risk factors in a developed-country setting.

Design

Two prospective samples: a national surveillance programme sample and a regional longitudinal study sample.

Setting

Canada, 2009–2011.

Subjects

Two samples of young children recruited from community-based health-care practices: a national sample with severe anaemia (Hb<80 g/l) due to Fe deficiency and a regional sample with non-anaemic Fe sufficiency.

Results

Children with severe IDA (n201, mean Hb 55·1 g/l) experienced substantial morbidity (including developmental delay, heart failure, cerebral thrombosis) and health-care utilization (including a 42 % hospitalization rate). Compared with children with Fe sufficiency (n597, mean Hb 122·4 g/l), children with severe IDA consumed a larger volume of cow’s milk daily (median 1065 mlv. 500 ml,P<0·001) and were more likely to be using a bottle during the day (78 %v. 43 %, OR=6·0; 95 % CI 4·0, 8·9) and also in bed (60 %v. 21 %, OR=6·5; 95 % CI 4·4, 9·5).

Conclusions

Severe IDA is associated with substantial morbidity and may be preventable. Three potentially modifiable feeding practices are associated with IDA: (i) cow’s milk consumption greater than 500 ml/d; (ii) daytime bottle use beyond 12 months of age; and (iii) bottle use in bed. These feeding practices should be highlighted in future recommendations for public health and primary-care practitioners.

Nutrient intakes of infants with atopic dermatitis and relationship with feeding type

BACKGROUND/OBJECTIVES

The prevalence of atopic dermatitis in infants is increasing worldwide. However, the nutrient intake status of infants with atopic dermatitis has not been studied properly. This study was conducted to compare the nutrient intake status of infants in the weaning period with atopic dermatitis by feeding type.

MATERIALS/METHODS

Feeding types, nutrient intake status and growth status of 98 infants with atopic dermatitis from age 6 to 12 months were investigated. Feeding types were surveyed using questionnaires, and daily intakes were recorded by mothers using the 24-hour recall method. Growth and iron status were also measured.

RESULTS

The result showed that breastfed infants consumed less energy and 13 nutrients compared to formula-fed or mixed-fed infants (p < 0.001). The breastfed group showed a significantly lower intake rate to the Dietary Reference Intakes for Koreans than the other two groups (p < 0.001). In addition, they consumed less than 75% of the recommended intakes in all nutrients, except for protein and vitamin A, and in particular, iron intake was very low, showing just 18.7% of the recommended intake. There was no significant difference in growth by feeding type, but breastfed infants showed a significantly higher rate of iron deficiency anemia (p < 0.001).

CONCLUSIONS

Continuous management programs should be prepared for breastfed infants with atopic dermatitis, who are in a period when rapid growth takes place and proper nutrient intake is essential.

A two-and-a-half-year-old breastfed toddler presenting with anemia: a case report

BACKGROUND

Anemia is a common presentation in children but the differential diagnosis of iron deficiency and β-thalassemia remains a diagnostic challenge. Red blood cell indices have been shown to perform weakly in such scenarios. One potential cause is breastfeeding, but the evidence for unusually prolonged exclusive breastfeeding as a cause of iron deficiency anemia in older (>2 years) toddlers is sparse and the association of breastfeeding with iron deficiency in this age group of older toddlers is not unequivocally established. In this case we describe an unusual cause of nutritional iron deficiency anemia in the age group of 2-3 years.

CASE PRESENTATION

We describe a two-and-a-half-year-old Turkish boy who presented to our outpatient clinic with recurrent diarrhea and anemia. The patient was febrile (99.1°F) with pale skin and signs of mild dehydration. A reduced nutritional status with a weight of 11.5 kg between the 3rd and 10th percentile was noted. Nutritional evaluation revealed that the boy was still exclusively breastfed with more than 6 times breastfeedings per day. Iron supplementation ameliorated the anemia and reduced hypochromic red blood cells.

CONCLUSION

The case demonstrates that unusually prolonged (longer than two years) exclusive breastfeeding is a potential cause of iron deficiency anemia in older toddlers. We discuss a simple combination of laboratory tests with ferritin and red cell distribution width that together with a nutritional evaluation provide a quick diagnosis and show that even at such an advanced stage of nutritional iron deficiency oral iron supplementation is an effective treatment.

Identification, prevention and treatment of iron deficiency during the first 1000 days

Iron deficiency is a global problem across the life course, but infants and their mothers are especially vulnerable to both the development and the consequences of iron deficiency. Maternal iron deficiency during pregnancy can predispose offspring to the development of iron deficiency during infancy, with potentially lifelong sequelae. This review explores iron status throughout these "first 1000 days" from pregnancy through two years of age, covering the role of iron and the epidemiology of iron deficiency, as well as its consequences, identification, interventions and remaining research gaps.

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

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

Iron Deficiency is Not Associated with Increased Blood Cadmium in Infants

OBJECTIVES

To determine whether blood cadmium concentration is elevated in iron-deficient infants.

METHODS

Blood cadmium and serum ferritin concentrations, serum iron/total iron-binding capacity (Fe/TIBC) and complete blood counts were measured in 31 iron deficient and 36 control infants, aged 6-24 months. All 31 iron-deficient infants received iron supplementation for 1-6 months.

RESULTS

Blood cadmium concentrations were measured again in 19 of the iron deficient infants after their ferritin levels returned to the normal range. The mean blood cadmium concentration did not differ significantly in iron deficient and control infants. The mean blood cadmium concentration in the 19 iron-deficient infants was not significantly altered by ferric hydroxide treatment, while their hemoglobin, ferritin, and Fe/TIBC (%) concentrations were significantly higher after than before treatment.

CONCLUSION

These findings indicate that iron deficiency does not increase blood cadmium concentrations in infants, in contrast with the effects of iron deficiency on manganese and lead concentrations.

Effects of iron therapy on blood lead concentrations in infants

To determine whether blood lead concentration is elevated in iron-deficient infants, blood lead and serum ferritin concentrations, serum iron/transferring iron-binding capacity (Fe/TIBC) and complete blood counts were measured in 30 iron deficient and 35 control infants, aged 6-24 months. All 30 iron-deficient infants received iron supplementation (ferric hydroxide-polymaltose complex, 6mg/kg Fe(3+)/day) for 1-6 months. Blood lead concentrations were measured in 18 of the iron deficient infants after their ferritin levels returned to the normal range. The geometric mean blood lead concentration was higher in iron deficient than in control infants (1.846 vs. 1.416μg/dL). After iron therapy, the blood lead levels of iron-deficient infants decreased significantly compared with pre-treatment levels (1.785 vs. 2.386μg/dL), and the hemoglobin and ferritin concentrations increased significantly. These findings indicate that iron deficiency increases blood lead concentrations in infants with very low blood lead concentrations.

Blood manganese concentration is elevated in infants with iron deficiency

The present study was done to determine whether blood Mn concentration is elevated in iron-deficient infants. Thirty-one infants with iron deficiency and thirty-six control subjects (6-24 months of age) were tested for blood Mn concentration, complete blood counts, serum ferritin, and serum iron/transferring iron-binding capacity (Fe/TIBC). All the 31 iron-deficient infants were treated with iron supplement; however, 19 of them underwent blood Mn checkup again in compliance with follow-up schedule when their ferritin levels returned to the normal range. Iron therapies were done for 1-6 months (mean, 2.8; standard deviation, 1.6) using ferric hydroxide-polymaltose complex (6 mg/kg Fe(3+) daily). Infants with iron deficiency had a higher mean blood Mn concentration than controls (2.550 vs. 1.499 μg/dL, respectively). After iron therapy, the blood Mn levels of iron-deficient infants significantly decreased compared to their pre-therapy levels (2.045 vs. 2.971 μg/dL, respectively), and their hemoglobin and ferritin levels significantly increased. After adjustment for covariates (e.g., age and breast-feeding), multiple linear regression models showed that increased blood Mn levels were significantly associated with low serum ferritin and hemoglobin levels, whereas with Fe/TIBC there was only a tendency. Our results indicate that iron deficiency increases blood Mn levels in infants, presumably by increasing Mn absorption.