Approaches for Reducing the Risk of Early-Life Iron Deficiency-Induced Brain Dysfunction in Children

Assessment of Dietary Iron Intake and Sources in Early Childhood in a Nationally Representative Cross-Sectional Survey

BACKGROUND

Iron deficiency has particular importance in early childhood because of its impact on growth and development. Preventive food-based strategies of iron deficiency require knowledge of intakes and sources of iron.

OBJECTIVE

This study aimed to assess daily iron intakes (DIIs) in 2013, to compare them with the dietary reference values, to assess their evolution since 1981, and to identify iron food sources among nonbreastfed French children younger than 3 years.

DESIGN

This was a nationwide cross-sectional survey conducted in 2013 in France to assess DIIs by means of comparing them with the dietary reference values. Parents' reported diet diaries were collected for 3 nonconsecutive days.

PARTICIPANTS/SETTING

Of the 1,184 children enrolled in the study, 1,035 nonbreastfed healthy children aged 0.5 to 35 months stratified into 11 age groups were included after informed consent was obtained from parents and according to a weighted quota sampling method.

MAIN OUTCOME MEASURES

DII from the different food sources and trends in their evolution from 1981 to 2013 was assessed.

STATISTICAL ANALYSES PERFORMED

Results are expressed as median with interquartile range and range and mean ± SD. Student t test was used with the 2-sided α level of significance set at 5%.

RESULTS

Mean ± SD DII was 6.7 ± 2.3 mg/d before 6 months, 8.2 ± 2.7 mg/d from 6 months to 1 year, and 7.0 ± 3.2 mg/d from 1 to 3 years. The prevalence of infants older than 7 months with a DII less than the dietary reference values was 52.5%, and that of young children was 30%. After slightly increasing until 2005, DIIs decreased thereafter. Formulas contributed to most of the DIIs up to 2 years of age. Cereals were the second largest contributor to DIIs, and meat accounted for a small part of iron intake.

CONCLUSIONS

A substantial number of children between 6 months and 3 years of age were at risk of insufficient iron intake. This risk increased from 2005 to 2013. The role of formula in ensuring iron intake is highlighted. More research on health outcomes of low iron intakes is needed.

Combined intervention strategy for reversing iron-deficiency anaemia and deficiency in psychomotor development in chronic malnutrition

BACKGROUND

chronic iron-deficiency anaemia in children has a negative impact on neuronal and cognitive development. Despite current knowledge on this subject, in Bolivia iron intake along the psychomotor development stimulation as part of a comprehensive rehabilitation process for children with severe chronic malnutrition is not yet used.

OBJECTIVE

to evaluate the effect of a neurorestorative diet, consisting of iron supplements and other micronutrients, along with psychomotor stimulation in preschool children with chronic malnutrition, iron-deficiency anaemia and severe psychomotor delay.

PATIENTS AND METHODS

twenty-four children between 1 and 56 months of age admitted to the integral nutritional recovery centre (INRC), Paediatric Hospital of Cochabamba, Bolivia were included. A strategy of intervention was applied consisting of nutritional replenishment through the administration of elaborated meals prepared from local foods with high heme and non-heme iron concentration, added with vegetables plus the administration of micronutrient´s supplementation and the psychomotor stimulation. Anthropometric indices, psychomotor and biochemical parameters were measured at four times points, during the hospitalisation period.

RESULTS

at the beginning, the anthropometric and psychomotor parameters were decreased (between -2 and -3 z score and below 50 % respectively). Combined strategy intervention with iron and other micronutrients together photons produced significant changes between the evaluated time points, both in anthropometric and psychomotor parameters, although these changes were less than expected.

CONCLUSIONS

the combined strategy used in this study allowed recovery from the anaemia and minimal growth due to the low birth weight or chronic malnutrition. However, the intervention was insufficient to achieve a complete recovery.

Prognostic Performance of Hematological and Serum Iron and Metabolite Indices for Detection of Early Iron Deficiency Induced Metabolic Brain Dysfunction in Infant Rhesus Monkeys

BACKGROUND

The current pediatric practice of monitoring for infantile iron deficiency (ID) via hemoglobin (Hgb) screening at one y of age does not identify preanemic ID nor protect against later neurocognitive deficits.

OBJECTIVES

To identify biomarkers of iron-related metabolic alterations in the serum and brain and determine the sensitivity of conventional iron and heme indices for predicting risk of brain metabolic dysfunction using a nonhuman primate model of infantile ID.

METHODS

Simultaneous serum iron and RBC indices, and serum and cerebrospinal fluid (CSF) metabolomic profiles were determined in 20 rhesus infants, comparing iron sufficient (IS; N = 10) and ID (N = 10) infants at 2 and 4 mo of age.

RESULTS

Reticulocyte hemoglobin (RET-He) was lower at 2 wk in the ID group. Significant IS compared with ID differences in serum iron indices were present at 2 mo, but Hgb and RBC indices differed only at 4 mo (P < 0.05). Serum and CSF metabolomic profiles of the ID and IS groups differed at 2 and 4 mo (P < 0.05). Key metabolites, including homostachydrine and stachydrine (4-5-fold lower at 4 mo in ID group, P < 0.05), were altered in both serum and CSF. Iron indices and RET-He at 2 mo, but not Hgb or other RBC indices, were correlated with altered CSF metabolic profile at 4 mo and had comparable predictive accuracy (area under the receiver operating characteristic curve scores, 0.75-0.80).

CONCLUSIONS

Preanemic ID at 2 mo was associated with metabolic alterations in serum and CSF in infant monkeys. Among the RBC indices, only RET-He predicted the future risk of abnormal CSF metabolic profile with a predictive accuracy comparable to serum iron indices. The concordance of homostachydrine and stachydrine changes in serum and CSF indicates their potential use as early biomarkers of brain metabolic dysfunction in infantile ID.

Serum ferritin values in neonates <29 weeks' gestation are highly variable and do not correlate with reticulocyte hemoglobin content

OBJECTIVES

To compare serum ferritin and RET-He values among extremely low gestational age neonates ELGANs with other markers of iron-deficient erythropoiesis.

STUDY DESIGN

This is a secondary analysis of the NICHD Darbepoetin Trial. Study data from placebo recipients who had a serum ferritin, a RET-He, and a mean corpuscular volume (MCV) measurement within a 24-hour period were analyzed for correlation.

RESULTS

Mixed linear regression models showed no association between ferritin and RET-He at both early (β = 0.0016, p = 0.40) and late (β = -0.0001, p = 0.96) time points. Positive associations were observed between RET-He and MCV at baseline, early, and late time points (p < 0.01, =0.01, <0.001, respectively), while ferritin was not associated with MCV at any time point.

CONCLUSIONS

Our study shows that RET-He is better correlated with MCV as a marker of iron-limited erythropoiesis than ferritin. The results suggest that ferritin is limited as a marker of iron sufficiency in premature infants.

STUDY IDENTIFICATION

FDA IND Number 100138; ClinicalTrials.gov number NCT03169881; NRN ID number NICHD-NRN-0058 (Darbe).

Neonatal outcomes from a randomized controlled trial of maternal treatment of iron deficiency anemia with intravenous ferumoxytol vs oral ferrous sulfate

BACKGROUND

Anemia in pregnancy is common worldwide and has known maternal risks. The relationship between the types of treatment offered for maternal anemia and the effects on the fetus and newborn are largely uninvestigated.

OBJECTIVE

This study aimed to investigate whether maternal treatment with intravenous ferumoxytol compared to oral ferrous sulfate results in an increase in neonatal hematologic and iron indices. These analyses were planned secondary outcomes and post hoc analysis from the trial with a primary outcome of change in maternal hemoglobin.

STUDY DESIGN

A randomized controlled trial including 124 participants with anemia by World Health Organization criteria was performed in which participants were allocated in a 1:1 ratio to either 2 infusions of 510 mg of intravenous ferumoxytol or 325 mg oral ferrous sulfate twice daily. Fetal monitoring was performed during each intravenous iron infusion. Standard univariable statistical techniques were used to compare groups and to investigate associations between maternal and neonatal hemoglobin and iron indices.

RESULTS

Cord blood hematological parameters were equivalent between groups. Hemoglobin was 15.7 g/dL vs 15.4 g/dL (P=.6) and hematocrit was 50.5% and 49.2% (P=.4) in those randomized to intravenous ferumoxytol and oral ferrous sulfate, respectively. Iron studies revealed higher cord blood ferritin concentrations in infants of participants treated with intravenous ferumoxytol (294 vs 186, P=.005). There were equivalent iron (158 vs 146, P=.4), transferrin (186 vs 196, P=.4) and total iron binding capacity (246 vs 244, P=1) in neonates of participants receiving intravenous vs oral treatment. There were no effects of the infusions observed on cardiotocography. Gestational age at birth was equivalent between groups. We noted a larger birthweight in neonates of participants treated with intravenous ferumoxytol (3215 g vs 3033 g, P=.09), which was not statistically significant. Post hoc analyses revealed a statistically significant correlation between neonatal ferritin and maternal hemoglobin (P=.006) and neonatal ferritin and maternal ferritin (P=.017) at admission for delivery.

CONCLUSION

Neonates of participants who received intravenous ferumoxytol were born with higher ferritin concentrations in cord blood, at the same gestation with the same birthweight. Participants with higher hemoglobin and ferritin indices delivered infants with higher ferritin concentrations in cord blood.

The Interaction between Psychological Stress and Iron Status on Early-Life Neurodevelopmental Outcomes

This review presents evidence from animal and human studies demonstrating the possible connection and significant impact of poor iron status and psychological distress on neurocognitive development during pregnancy and the neonatal period, with implications for long-term cognition. Stress and iron deficiency are independently prevalent and thus are frequently comorbid. While iron deficiency and early-life stress independently contribute to long-term neurodevelopmental alterations, their combined effects remain underexplored. Psychological stress responses may engage similar pathways as infectious stress, which alters fundamental iron metabolism processes and cause functional tissue-level iron deficiency. Psychological stress, analogous to but to a lesser degree than infectious stress, activates the hypothalamic-pituitary-adrenocortical (HPA) axis and increases proinflammatory cytokines. Chronic or severe stress is associated with dysregulated HPA axis functioning and a proinflammatory state. This dysregulation may disrupt iron absorption and utilization, likely mediated by the IL-6 activation of hepcidin, a molecule that impedes iron absorption and redistributes total body iron. This narrative review highlights suggestive studies investigating the relationship between psychological stress and iron status and outlines hypothesized mechanistic pathways connecting psychological stress exposure and iron metabolism. We examine findings regarding the overlapping impacts of early stress exposure to iron deficiency and children's neurocognitive development. We propose that studying the influence of psychological stress on iron metabolism is crucial for comprehending neurocognitive development in children exposed to prenatal and early postnatal stressors and for children at risk of early iron insufficiency. We recommend future directions for dual-exposure studies exploring iron as a potential mediating pathway between early stress and offspring neurodevelopment, offering opportunities for targeted interventions.

A novel nano-iron supplement versus standard treatment for iron deficiency anaemia in children 6-35 months (IHAT-GUT trial): a double-blind, randomised, placebo-controlled non-inferiority phase II trial in The Gambia

BACKGROUND

Iron deficiency anaemia (IDA) is the leading cause of years lost to disability in most sub-Saharan African countries and is especially common in young children. The IHAT-GUT trial assessed the efficacy and safety of a novel nano iron supplement, which is a dietary ferritin analogue termed iron hydroxide adipate tartrate (IHAT), for the treatment of IDA in children under 3 years of age.

METHODS

In this single-country, randomised, double-blind, parallel, placebo-controlled, non-inferiority Phase II study in The Gambia, children 6-35 months with IDA (7≤Hb < 11 g/dL and ferritin<30 μg/L) were randomly assigned (1:1:1) to receive either IHAT, ferrous sulphate (FeSO₄) or placebo daily for 3 months (85 days). The daily iron dose was 12.5 mg Fe equivalent for FeSO₄ and the estimated dose with comparable iron-bioavailability for IHAT (20 mg Fe). The primary efficacy endpoint was the composite of haemoglobin response at day 85 and correction of iron deficiency. The non-inferiority margin was 0.1 absolute difference in response probability. The primary safety endpoint was moderate-severe diarrhoea analysed as incidence density and prevalence over the 3 months intervention. Secondary endpoints reported herein include hospitalisation, acute respiratory infection, malaria, treatment failures, iron handling markers, inflammatory markers, longitudinal prevalence of diarrhoea and incidence density of bloody diarrhoea. Main analyses were per-protocol (PP) and intention-to-treat (ITT) analyses. This trial is registered with clinicaltrials.gov (NCT02941081).

FINDINGS

Between Nov 2017 and Nov 2018, 642 children were randomised into the study (214 per group) and included in the ITT analysis, the PP population included 582 children. A total of 50/177 (28.2%) children in the IHAT group achieved the primary efficacy endpoint, as compared with 42/190 (22.1%) in the FeSO₄ group (OR 1.39, 80% CI 1.01-1.91, PP population) and with 2/186 (1.1%) in the placebo group. Diarrhoea prevalence was similar between groups, with 40/189 (21.2%) children in the IHAT group developing at least one episode of moderate-severe diarrhoea over the 85 days intervention, compared with 47/198 (23.7%) in the FeSO₄ group (OR 1.18, 80% CI 0.86-1.62) and 40/195 (20.5%) in the placebo group (OR 0.96, 80% CI 0.7-1.33, PP population). Incidence density of moderate-severe diarrhoea was 2.66 in the IHAT group and 3.42 in the FeSO₄ group (RR 0.76, 80% CI 0.59-0.99, CC-ITT population).There were 143/211 (67.8%) children with adverse events (AEs) in the IHAT group, 146/212 (68.9%) in the FeSO₄ group and 143/214 (66.8%) in the placebo group. There were overall 213 diarrhoea-related AEs; 35 (28.5%) cases reported in the IHAT group compared with 51 (41.5%) cases in the FeSO₄ group and 37 (30.1%) cases in the placebo group.

INTERPRETATION

In this first Phase II study conducted in young children with IDA, IHAT showed sufficient non-inferiority compared to standard-of-care FeSO₄, in terms of ID correction and haemoglobin response, to warrant a definitive Phase III trial. In addition, IHAT had lower incidence of moderate-severe diarrhoea than FeSO₄, with no increased adverse events in comparison with placebo.

FUNDING

The Bill & Melinda Gates Foundation (OPP1140952).

Adapting prenatal iron supplementation to maternal needs results in optimal child neurodevelopment: a follow-up of the ECLIPSES Study

Background

Prenatal prescription of standard iron supplements to prevent iron deficiency appears not to be appropriate for all women and their children, as some women may be at risk of iron deficiency and others at risk of iron excess early in pregnancy. The present study aimed to assess whether prenatal iron supplementation adapted to the needs of each pregnant woman affects their child’s neurodevelopment.

Methods

Follow-up of a community-based RCT involving 503 mother–child pairs. Non-anaemic pregnant women recruited in Tarragona (Spain) early in pregnancy were prescribed a daily iron dose based on their initial haemoglobin levels: Stratum 1 (Hb = 110–130 g/L, 80 or 40 mg/d of iron) and Stratum 2 (Hb > 130 g/L, 40 or 20 mg/d of iron). Women receiving 40 mg/d were considered the control group in each Strata. The child’s neurodevelopment was assessed at 40 days of age using the Bayley Scales of Infant Development-III (BSID-III). Adjusted multiple regression models were used.

Results

Multiple regression analyses showed no association between the intervention and control group within each Strata on the BSID-III scores on any of the developmental scales in children, including cognitive, language, and motor development: Stratum 1 (β 1.46, 95%CI -2.15, 5.07; β 1.30, 95%CI -1.99, 4.59; and β 2.04, 95%CI -3.88, 7.96, respectively) and Stratum 2 (β -4.04, 95%CI -7.27, 0.80; β -0.36, 95%CI -3.47, 2.75; and β -3.76, 95%CI -9.30, 1.78, respectively).

Conclusions

In non-anaemic women in early pregnancy, no differences were found in the cognitive, language and motor development of children at 40 days of age between the dose of iron tested in each case –adjusted to initial Hb levels– compared to the dose of the control group. Further studies are guaranteed to confirm our findings.

Trial registration

The ECLIPSES study was registered at www.clinicaltrialsregister.eu as EudraCT number 2012–005,480-28.

Association between Obesity and Anemia in a Nationally Representative Sample of South Korean Adolescents: A Cross-Sectional Study

Anemia is associated with physical, cognitive, and developmental problems. Given that there are limited studies on anemia prevalence among obese Asian adolescents and that past evidence is controversial, this study investigated the relationship between obesity and anemia in a nationally representative sample of South Korean adolescents. Data were obtained from the 2007–2019 Korea National Health and Nutrition Examination Survey. Overall, 10,231 subjects were included in the analysis. Multiple logistic regression was performed to determine the relationship between obesity and anemia. Compared with the non-obesity group, the adjusted odds ratio (OR; 95% confidence interval [CI]) of anemia was 1.00 (0.66–1.50) in the obesity group. However, in the early adolescent subgroup of 10–13 years (adjusted OR, 2.88; 95% CI, 1.20–6.95), the risk of anemia was significantly higher in the obese group than in the non-obese group. Obesity was associated with an increased risk of anemia in early adolescents. Obese adolescents aged 10–13 require special care, especially through regular examination and management for anemia.

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.

Iron supplementation of breastfed Gambian infants from 6 weeks to 6 months of age: protocol for a randomised controlled trial

Background: A recent analysis showed that plasma iron concentrations decline rapidly from birth in Gambian infants, irrespective of sex or birthweight, to concentrations well below normal expected values for iron-replete children older than two months of age (typically >10 μmol/L). The development and function of neural and immune cells may thus be compromised before the minimum age at which children should receive iron supplementation as per World Health Organisation recommendations. Methods: This study is a two-arm, double-blind, placebo-controlled, randomised superiority trial. Infants will be randomised to receive iron drops (7.5mg/day of iron as ferrous sulphate) or placebo daily for 98 days, to test the impact on serum iron concentrations in healthy, breastfed infants (n = 100) aged 6-10 weeks at enrolment. Participants will be visited daily and supplemented by the field team. Daily health and weekly breastfeeding questionnaires will be administered. Anthropometry, and venous blood and faecal samples will be collected at enrolment and after 98 days of supplementation with serum iron as the primary endpoint. Low birthweight (less than 2.5kg at birth) and infants born prematurely (< 37 weeks) will not be excluded. Formula-fed and infants with any illness will be excluded. An additional study exploring maternal stakeholder perspectives of the intervention will be conducted by means of maternal interviews and four focus group discussions with local stakeholders. Discussion: Most breast-fed Gambian infants have very low circulating iron levels by five months of age. This study will introduce iron supplements much earlier in infancy than has previously been attempted in a low-income setting with the primary aim of increasing serum iron concentration. Trial registration: Clincaltrials.gov ( NCT04751994); 12 th February 2021.

What does the evidence tell us? Revisiting optimal cord management at the time of birth

A newborn who receives a placental transfusion at birth from delayed cord clamping (DCC) obtains about 30% more blood volume than those with immediate cord clamping (ICC). Benefits for term neonates include higher hemoglobin levels, less iron deficiency in infancy, improved myelination out to 12 months, and better motor and social development at 4 years of age especially in boys. For preterm infants, benefits include less intraventricular hemorrhage, fewer gastrointestinal issues, lower transfusion requirements, and less mortality in the neonatal intensive care unit by 30%. Ventilation before clamping the umbilical cord can reduce large swings in cardiovascular function and help to stabilize the neonate. Hypovolemia, often associated with nuchal cord or shoulder dystocia, may lead to an inflammatory cascade and subsequent ischemic injury. A sudden unexpected neonatal asystole at birth may occur from severe hypovolemia. The restoration of blood volume is an important action to protect the hearts and brains of neonates. Currently, protocols for resuscitation call for ICC. However, receiving an adequate blood volume via placental transfusion may be protective for distressed neonates as it prevents hypovolemia and supports optimal perfusion to all organs. Bringing the resuscitation to the mother's bedside is a novel concept and supports an intact umbilical cord. When one cannot wait, cord milking several times can be done quickly within the resuscitation guidelines. Cord blood gases can be collected with optimal cord management.   Conclusion: Adopting a policy for resuscitation with an intact cord in a hospital setting takes a coordinated effort and requires teamwork by obstetrics, pediatrics, midwifery, and nursing.

The Effects of Delayed Cord Clamping on 12-Month Brain Myelin Content and Neurodevelopment: A Randomized Controlled Trial

OBJECTIVE

This study aimed to determine if delayed cord clamping (DCC) affected brain myelin water volume fraction (VFm) and neurodevelopment in term infants.

STUDY DESIGN

This was a single-blinded randomized controlled trial of healthy pregnant women with term singleton fetuses randomized at birth to either immediate cord clamping (ICC) (≤ 20 seconds) or DCC (≥ 5 minutes). Follow-up at 12 months of age consisted of blood work for serum iron indices and lead levels, a nonsedated magnetic resonance imaging (MRI), followed within the week by neurodevelopmental testing.

RESULTS

At birth, 73 women were randomized into one of two groups: ICC (the usual practice) or DCC (the intervention). At 12 months, among 58 active participants, 41 (80%) had usable MRIs. There were no differences between the two groups on maternal or infant demographic variables. At 12 months, infants who had DCC had increased white matter brain growth in regions localized within the right and left internal capsules, the right parietal, occipital, and prefrontal cortex. Gender exerted no difference on any variables. Developmental testing (Mullen Scales of Early Learning, nonverbal, and verbal composite scores) was not significantly different between the two groups.

CONCLUSION

At 12 months of age, infants who received DCC had greater myelin content in important brain regions involved in motor function, visual/spatial, and sensory processing. A placental transfusion at birth appeared to increase myelin content in the early developing brain.

KEY POINTS

· DCC resulted in higher hematocrits in newborn period.. · DCC appears to increase myelin at 12 months.. · Gender did not influence study outcomes..

Nutrition and Brain Development

All nutrients are essential for brain development, but pre-clinical and clinical studies have revealed sensitive periods of brain development during which key nutrients are critical. An understanding of these nutrient-specific sensitive periods and the accompanying brain regions or processes that are developing can guide effective nutrition interventions as well as the choice of meaningful circuit-specific neurobehavioral tests to best determine outcome. For several nutrients including protein, iron, iodine, and choline, pre-clinical and clinical studies align to identify the same sensitive periods, while for other nutrients, such as long-chain polyunsaturated fatty acids, zinc, and vitamin D, pre-clinical models demonstrate benefit which is not consistently shown in clinical studies. This discordance of pre-clinical and clinical results is potentially due to key differences in the timing, dose, and/or duration of the nutritional intervention as well as the pre-existing nutritional status of the target population. In general, however, the optimal window of success for nutritional intervention to best support brain development is in late fetal and early postnatal life. Lack of essential nutrients during these times can lead to long-lasting dysfunction and significant loss of developmental potential.

Timing of iron deficiency and recognition memory in infancy

Objective: To determine the relationship between iron deficiency (or iron-deficient, ID) and neural correlates of recognition memory depending on ID timing (gestation vs. infancy) and infant age at testing (9 vs. 18 months).Study design: Event-related potentials (ERP) were used in a visual recognition memory task (mother vs. stranger face) to compare healthy term infants according to iron status at birth and 9 months. Fetal-neonatal ID was defined as cord serum ferritin < 75 µg/l or zinc protoporphrin/heme ratio > 118 µmol/mol, postnatal ID as ≥ 2 abnormal iron measures at 9 months with normal cord-blood iron status, and iron-sufficient as not ID at birth or 9 months. Recognition of mother faces was measured by negative component (Nc) and late slow wave (LSW). These ERP components reflect attention and memory updating processes, respectively.Results: All groups showed differences in Nc amplitude elicited by mother and stranger faces at 9 months. At 18 months, only postnatal ID and iron-sufficient groups showed condition differences in Nc amplitude. However, the 2 groups were different in the involved brain regions. For LSW, only the 2 ID groups showed condition differences in amplitude at 9 months. At 18 months, condition differences were not observed in any group.Conclusions: This study indicates that the timing of ID in early life (fetal-neonatal vs. postnatal) modulates the impact of ID on recognition memory. Such impact also varies depending on the age of infants at testing (9 vs. 18 months).

Neonatal Reference Intervals for the Complete Blood Count Parameters MicroR and HYPO-He: Sensitivity Beyond the Red Cell Indices for Identifying Microcytic and Hypochromic Disorders

OBJECTIVE

To create neonatal reference intervals for the MicroR and HYPO-He complete blood count (CBC) parameters and to test whether these parameters are sensitive early markers of disease at early stages of microcytic/hypochromic disorders while the CBC indices are still normal.

STUDY DESIGN

We retrospectively collected the CBC parameters MicroR and HYPO-He, along with the standard CBC parameters, from infants aged 0-90 days at Intermountain Healthcare hospitals using Sysmex hematology analyzers. We created reference intervals for these parameters by excluding values from neonates with proven microcytic disorders (ie, iron deficiency or alpha thalassemia) from the dataset.

RESULT

From >11 000 CBCs analyzed, we created reference intervals for MicroR and HYPO-He in neonates aged 0-90 days. The upper intervals are considerably higher in neonates than in adults, validating increased anisocytosis and polychromasia among neonates. Overall, 52% of neonates with iron deficiency (defined by reticulocyte hemoglobin equivalent <25 pg) had a MicroR >90% upper interval (relative risk, 4.14; 95% CI, 3.80-4.53; P < .001), and 68% had an HYPO-He >90% upper interval (relative risk, 6.64; 95% CI, 6.03-7.32; P < .001). These 2 new parameters were more sensitive than the red blood cell (RBC) indices (P < .001) in identifying 24 neonates with iron deficiency at birth.

CONCLUSIONS

We created neonatal reference intervals for MicroR and HYPO-He. Although Sysmex currently designates these as research use only in the US, they can be measured as part of a neonate's CBC with no additional phlebotomy volume or run time and can identify microcytic and hypochromic disorders even when the RBC indices are normal.

The critical roles of iron during the journey from fetus to adolescent: Developmental aspects of iron homeostasis

Iron is indispensable for human life. However, it is also potentially toxic, since it catalyzes the formation of harmful oxidative radicals in unbound form and may facilitate pathogen growth. Therefore, iron homeostasis needs to be tightly regulated. Rapid growth and development require large amounts of iron, while (especially young) children are vulnerable to infections with iron-dependent pathogens due to an immature immune system. Moreover, unbalanced iron status early in life may have effects on the nervous system, immune system and gut microbiota that persist into adulthood. In this narrative review, we assess the critical roles of iron for growth and development and elaborate how the body adapts to physiologically high iron demands during the journey from fetus to adolescent. As a first step towards the development of clinical guidelines for the management of iron disorders in children, we summarize the unmet needs regarding the developmental aspects of iron homeostasis.

Urinary ferritin; a potential noninvasive way to screen NICU patients for iron deficiency

OBJECTIVE

Building on our previous study, showing a correlation between ferritin in serum and urine, we conducted a feasibility evaluation, measuring urinary ferritin as a potential noninvasive screening test for iron deficiency among NICU patients.

STUDY DESIGN

This was a prospective analysis of paired serum/urine ferritin levels. We defined iron-limited erythropoiesis by a RET-He <5th percentile lower reference interval (<28 pg).

RESULTS

We obtained 49 paired serum/urine samples from neonates judged as at-risk for iron deficiency. Urine ferritin ("corrected" for urine creatinine and specific gravity) correlated with serum ferritin (correlation coefficient of log₁₀-transformed values 0.44). A corrected urine ferritin <12 ng/mL had a sensitivity of 82% (95% CI, 67-93%) and a specificity of 100% (CI, 66-100%) for detecting iron-limited erythropoiesis, with a positive predictive value of 100% (CI, 89-100%).

CONCLUSIONS

Measuring urinary ferritin in NICU patients is feasible. Since low values identify iron-limitation, this could become a useful noninvasive screen.

Iron supplementation in anemic Zanzibari toddlers is associated with greater loss in erythrocyte iron isotope enrichment

BACKGROUND

Heavy parasitic loads increase the risk of iron (Fe) deficiency anemia, which remains prevalent globally. Where parasites are common, understanding the influence of parasitic infections on Fe incorporation and erythropoiesis in toddlers is especially important.

OBJECTIVES

The aim of this study was to identify the impacts of malarial and helminth infections on red blood cell (RBC) Fe incorporation and subsequent changes in RBC Fe isotope enrichment for 84 days postdosing in toddlers at high risk for parasitic infections.

METHODS

Fe incorporation was measured in a group of Zanzibari toddlers (n = 71; 16-25 months) using a stable Fe isotopic method. At study entry, an oral stable Fe isotope was administered. Blood was collected 14 (D14) and 84 (D84) days postdosing for the assessment of Fe status indicators and RBC isotopic enrichment. Blood and stool samples were collected and screened for malaria and helminth parasites. Factors associated with changes in RBC Fe isotope enrichment were identified using regression models.

RESULTS

Toddlers who had larger weight-for-age z-scores, lower total body Fe, and helminth infections (n = 26) exhibited higher RBC Fe incorporation. RBC Fe isotope enrichment decreased from D14 to D84 by -2.75 percentage points (P < 0.0001; n = 66). Greater loss in RBC Fe isotope enrichment from D14 to D84 was observed in those who received Fe supplementation, those with either helminths or both malarial and helminth infections, and in those with greater RBC Fe incorporation on D14.

CONCLUSIONS

Toddlers who received Fe supplementation exhibited significantly greater losses of RBC Fe isotope enrichment over time. We speculate this greater loss of RBC Fe enrichment is indicative of increased erythropoiesis due to the provision of Fe among anemic or helminth-infected toddlers.

Reconciling markedly discordant values of serum ferritin versus reticulocyte hemoglobin content

OBJECTIVE

To determine why serum ferritin and reticulocyte hemoglobin (RET-He), drawn to assess neonatal iron sufficiency, sometimes have markedly discordant results.

STUDY DESIGN

Retrospective records review of five NICUs over 28 months, identifying all patients with a ferritin and RET-He within 48 h. We examined records of all who had marked discordance (one value >95th % reference interval, the other <5th %).

RESULTS

Of 190 paired ferritin and RET-He measurements, 16 (8%) were markedly discordant. Fifteen of the 16 discordant samples involved a high ferritin and a low RET-He. In these, low MCV and high %Micro-R, and low MCH and high %HYPO-He were present. In total, 8 of the 15 had laboratory or clinical evidence of an inflammatory process and five had suspicion of infection documented.

CONCLUSIONS

When ferritin and RET-He were discordant, erythrocyte microcytosis and hypochromasia suggested that the RET-He gave the more accurate interpretation; that iron deficiency was likely present.

Is the erythropoietin-erythroferrone-hepcidin axis intact in human neonates?

In a two-part process, we assessed elements of the principal hormonal pathway regulating iron homeostasis in human neonates. Part 1: Quantifying erythropoietin (Epo), erythroferrone (ERFE), hepcidin, and relevant serum and erythrocytic iron-related metrics in umbilical cord blood from term (n = 13) and preterm (n = 10) neonates, and from neonates born to mothers with diabetes and obesity (n = 13); Part 2: Quantifying serum Epo, ERFE, and hepcidin before and following darbepoetin administration. Part 1: We measured Epo, ERFE and hepcidin in all cord blood samples. Epo and ERFE levels did not differ between the three groups. Preterm neonates had the lowest hepcidin levels, while neonates born to diabetic women with a very high BMI had the lowest ferritin and RET-He levels. Part 2: Following darbepoetin dosing, ERFE levels generally increased (p < 0.05) and hepcidin levels generally fell (p < 0.05). Our observations suggest that the Epo/ERFE/hepcidin axis is intact in the newborn period.

Using formative research to design context-specific animal source food and multiple micronutrient powder interventions to improve the consumption of micronutrients by infants and young children in Tanzania, Kenya, Bangladesh and Pakistan

Optimal complementary feeding practices including consumption of multiple micronutrient powders (MNP) are recommended to improve micronutrient intake by infants and young children (IYC) 6-23 months. Formative research was used to design the behaviour change strategy to improve IYC micronutrient intake for the multicountry ENRICH project in rural impoverished areas of Tanzania, Kenya, Bangladesh and Pakistan. Employing a qualitative approach with multiple methods and guided by a social ecological framework, the study was conducted in several phases: data collection in the community, household and health facilities, initial analysis and household trials (HHT). Results found limited use of animal source foods (ASF) for feeding IYC and MNP largely unavailable. Although cost constrained access to ASF, potential more affordable context-specific ASF options were identified in each setting. Caregivers associated ASF with many positive attributes for IYC, but barriers to feeding them included lack of caregiver time and knowledge of specific preparation techniques, and limited advice from health workers. Feeding practices were identified that used time-efficient, specific preparations for eggs and other ASF, and demonstrated good initial acceptability and feasibility during HHT. Testing MNP in HHT found good initial feasibility and acceptability and provided an understanding of the facilitators and constraints for preparing, feeding and promoting MNP. In conclusion, formative research led to the design of context-specific ASF and MNP complementary feeding promotion strategies to improve IYC consumption of micronutrients by identifying the practices, benefits, motivations and alternative actions to overcome the barriers in each setting.

Serum iron deficiency was associated with lower cognitive development in the children of the Santal tribe of West Bengal

AIM

Poor cognitive scores and low serum iron have been reported among chronically undernourished children from the Santal tribe, West Bengal. Our aim was to investigate the association between iron status and non-verbal cognitive development.

METHODS

We randomly selected 170 children (52.9% boys) aged 5-12 years from the Purulia district of West Bengal during 2007-2008 and assessed their iron status: haemoglobin concentration, serum concentration of iron, ferritin, transferrin, total iron-binding capacity and transferrin saturation. Their non-verbal cognitive development was assessed using the Raven's Coloured Progressive Matrices.

RESULTS

The haemoglobin concentration, serum iron, serum ferritin and transferrin saturation levels of the 27 children with an intellectual deficit and the 32 who had a below average intelligence quotient (IQ) were significantly lower (P < .05) than the 65 children with an average IQ. A large number of boys (55.6%) and girls (41.7%) who have an intellectual deficit had stage III iron depletion. The cognitive scores of children with stage II and III iron depletion were significantly lower (P < .05) than those with a normal IQ.

CONCLUSION

The iron depletion stage was associated with the severity of non-verbal cognitive impairment and serum ferritin appeared to be a sensitive biomarker for predicting non-verbal cognitive development.

A Retrospective Case-Control Study of the Determinants of Iron Deficiency Anemia in Infants in an Urban Community in Shanghai, China Between 2010-2015

BACKGROUND Iron deficiency anemia (IDA) is a global public health problem. This study aimed to analyze the social determinants of IDA in infants living in Shanghai, China, between 2010-2015. MATERIAL AND METHODS Data were analyzed retrospectively from the Shanghai Children's Health Check Record system in the Tangqiao Community Health Service Center for infants aged <24 months between January 1, 2010, and December 31, 2015. A study group was identified with IDA, and an age-matched and gender-matched healthy control group was identified. RESULTS The five-year prevalence rate of IDA was 11.49% (150/1305). Infants with IDA had significantly lower birth weights (3228.720±456.200 gm vs. 3376.870±393.719 gm; P<0.01), a higher percentage of premature births (10.67% vs. 1.33%; P<0.001), a longer exclusive breastfeeding period (10.63±4.844 months vs. 7.08±5.039 months; P<0.001), a higher rate of exclusive breastfeeding within four months after birth (P<0.001), a later start for complementary feeding (7.32±1.633 months vs. 6.93±1.794 months; P<0.05), and a higher rate of starting complementary feeding after 6 months of age (P<0.05). There were no significant differences between the two groups for maternal child-bearing age, mode of delivery, infant birth height, and birth rank. CONCLUSIONS The introduction of an iron-fortified formula for exclusively breastfed infants at 4 months of age, starting complementary feeding promptly before 6 months of age, and improving perinatal care for pregnant women to avoid premature birth and reduce low birth weight may be effective measures to prevent IDA.

Nutritional Factors in Fetal and Infant Brain Development

Fetal and infant brain development determine the trajectory of the organism across the lifespan. Optimal maternal and infant nutrition during the period of rapid brain development is vital to the integrity of the neural substrate for subsequent lifelong functions. The goal of this review is to educate the reader on the effects of fetal and infant nutrition on the developing human brain. A review of the literature reveals 6 nutrients that have been studied with respect to maternal nutrition and subsequent offspring brain development: folate, iodine, iron, vitamin D, choline, and docosahexaenoic acid (DHA; 22:6n-3). The research is discussed with a focus on the timing of nutrient needs (preconception, prenatally, and postnatally) as well as potential confounding and unobserved variables.

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.

Early-Life Iron Deficiency and Its Natural Resolution Are Associated with Altered Serum Metabolomic Profiles in Infant Rhesus Monkeys

BACKGROUND

Iron deficiency is the most common nutrient deficiency in human infants aged 6 to 24 mo, and negatively affects many cellular metabolic processes, including energy production, electron transport, and oxidative degradation of toxins. There can be persistent influences on long-term metabolic health beyond its acute effects.

OBJECTIVES

The objective was to determine how iron deficiency in infancy alters the serum metabolomic profile and to test whether these effects persist after the resolution of iron deficiency in a nonhuman primate model of spontaneous iron deficiency.

METHODS

Blood was collected from naturally iron-sufficient (IS; n = 10) and iron-deficient (ID; n = 10) male and female infant rhesus monkeys (Macaca mulatta) at 6 mo of age. Iron deficiency resolved without intervention upon feeding of solid foods, and iron status was re-evaluated at 12 mo of age from the IS and formerly ID monkeys using hematological and other indices; sera were metabolically profiled using HPLC/MS and GC/MS with isobaric standards for identification and quantification at both time points.

RESULTS

A total of 413 metabolites were measured, with differences in 40 metabolites identified between IS and ID monkeys at 6 mo (P$\le $ 0.05). At 12 mo, iron-related hematological parameters had returned to normal, but the formerly ID infants remained metabolically distinct from the age-matched IS infants, with 48 metabolites differentially expressed between the groups. Metabolomic profiling indicated altered liver metabolites, differential fatty acid production, increased serum uridine release, and atypical bile acid production in the ID monkeys.

CONCLUSIONS

Pathway analyses of serum metabolites provided evidence of a hypometabolic state, altered liver function, differential essential fatty acid production, irregular uracil metabolism, and atypical bile acid production in ID infants. Many metabolites remained altered after the resolution of ID, suggesting long-term effects on metabolic health.

Iron Status and Cancer Risk in UK Biobank: A Two-Sample Mendelian Randomization Study

We conducted a two-sample Mendelian randomization study to explore the associations of iron status with overall cancer and 22 site-specific cancers. Single-nucleotide polymorphisms for iron status were obtained from a genome-wide association study of 48,972 European-descent individuals. Summary-level data for breast and other cancers were obtained from the Breast Cancer Association Consortium and UK Biobank. Genetically predicted iron status was positively associated with liver cancer and inversely associated with brain cancer but not associated with overall cancer or the other 20 studied cancer sites at p < 0.05. The odds ratios of liver cancer were 2.45 (95% CI, 0.81, 7.45; p = 0.11), 2.11 (1.16, 3.83; p = 0.02), 10.89 (2.44, 48.59; p = 0.002) and 0.30 (0.17, 0.53; p = 2 × 10-5) for one standard deviation increment of serum iron, transferrin saturation, ferritin and transferrin levels, respectively. For brain cancer, the corresponding odds ratios were 0.69 (0.48, 1.00; p = 0.05), 0.75 (0.59, 0.97; p = 0.03), 0.41 (0.20, 0.88; p = 0.02) and 1.49 (1.04, 2.14; p = 0.03). Genetically high iron status was positively associated with liver cancer and inversely associated with brain cancer.

Association of Iron Status and Intake During Pregnancy with Neuropsychological Outcomes in Children Aged 7 Years: The Prospective Birth Cohort Infancia y Medio Ambiente (INMA) Study

Early iron status plays an important role in prenatal neurodevelopment. Iron deficiency and high iron status have been related to alterations in child cognitive development; however, there are no data about iron intake during pregnancy with other environmental factors in relation to long term cognitive functioning of children. The aim of this study is to assess the relationship between maternal iron status and iron intake during pregnancy and child neuropsychological outcomes at 7 years of age. We used data from the INMA Cohort population-based study. Iron status during pregnancy was assessed according to serum ferritin levels, and iron intake was assessed with food frequency questionnaires. Working memory, attention, and executive function were assessed in children at 7 years old with the N-Back task, Attention Network Task, and the Trail Making Test, respectively. The results show that, after controlling for potential confounders, normal maternal serum ferritin levels (from 12 mg/L to 60 mg/L) and iron intake (from 14.5 mg/day to 30.0 mg/day), respectively, were related to better scores in working memory and executive functioning in offspring. Since these functions have been associated with better academic performance and adaptation to the environment, maintaining a good state of maternal iron from the beginning of pregnancy could be a valuable strategy for the community.

Nutritional Gaps and Supplementation in the First 1000 Days

Optimized nutrition during the first 1000 days (from conception through the 2nd birthday) is critical for healthy development and a healthy life for the newborn. Pregnancy and the postpartum period are accompanied by physiological changes, increased energy needs, and changing requirements in the nutrients critical for optimal growth and development. Infants and toddlers also experience physiological changes and have specific nutritional needs. Food and nutrition experts can provide women of childbearing age with adequate dietary advice to optimize nutrition, as well as guidance on selecting appropriate dietary supplements. Considering the approaching 2020-2025 Dietary Guidelines for Americans (DGA) will be making specific recommendations for children, it is important to provide accurate scientific information to support health influencers in the field of nutrition. The purpose of this review is to summarize the nutrition and supplementation literature for the first 1000 days; to highlight nutritional and knowledge gaps; and to educate nutrition influencers to provide thoughtful guidance to mothers and families. Optimal nutrition during pregnancy through early childhood is critical for supporting a healthy life. Nutrition influencers, such as dietitians, obstetricians/gynecologists, and other relevant health professionals, should continue guiding supplement and food intake and work closely with expectant families and nutrition gatekeepers.

Alférez M, Díaz-Castro J. Fermented Goat Milk Consumption Enhances Brain Molecular Functions during Iron Deficiency Anemia Recovery

Iron deficiency anemia (IDA) is one of the most prevalent nutritional deficiencies worldwide. Iron plays critical roles in nervous system development and cognition. Despite the known detrimental consequences of IDA on cognition, available studies do not provide molecular mechanisms elucidating the role of iron in brain functions during iron deficiency and recovery with dairy components. In this study, 100 male Wistar rats were placed on a pre-experimental period of 40 days and randomly divided in two groups: a control group receiving a normal-Fe diet, (45 mg/kg), and an Fe-deficient group receiving a low-Fe diet (5 mg/kg). At day 40, 10 rats per group were sacrificed to anemia control, and 80 rats were divided into eight experimental groups fed with fermented goat or cow milk-based diets, with normal Fe content or Fe overload (450 mg/kg) for 30 days. IDA decreased most of the parameters related to brain molecular functions, namely dopamine, irisin, MAO-A, oxytocin, β-endorphin, and α-MSH, while it increased synaptophysin. These alterations result in an impairment of brain molecular functions. In general, during anemia recovery, fermented goat milk diet consumption increased dopamine, oxytocin, serotonin, synaptophysin, and α-MSH, and decreased MAO-A and MAO-B, suggesting a potential neuroprotective effect in brain functions, which could enhance brain molecular functions.

Mineral and vitamin intake of infants and young children: the Nutri-Bébé 2013 survey

PURPOSE

Minerals and vitamins are essential for optimal growth and development, particularly during the first years of life. Therefore, regularly evaluating their intake makes sense. For this purpose, we report the data from the Nutri-Bébé 2013 survey in comparison with the European Food Safety Authority Adequate Intake (AI), or Average Requirement, (AR) according to age.

METHODS

This observational, nationally representative, cross-sectional survey was conducted in 1035 non-breastfed French children aged 0.5-35 months. Dietary intake was recorded using a food diary on three non-consecutive days, framed by two face-to-face interviews.

RESULTS

The intake of zinc, magnesium and water-soluble vitamins most of the time met the recommendations. From the first weeks of life, sodium intake exceeded the AI, with a maximum median intake of 1137 mg/day after the age of 30 months. However, it has decreased since 2005. Calcium median intake often exceeded the AI or AR, reaching a maximum of 780 mg/day between 18 and 23 months. Median vitamin A intake always exceeded the AI or AR but exceeded the recommended upper limit in only a few cases. After 2 years, median iron intake was clearly below the AR, i.e. lower than 6.0 mg/day. Dietary vitamin D intake was below the AI, thereby justifying adequate supplementation. Vitamin E intake was below the AI in 50-75% of toddlers.

CONCLUSION

This survey highlights excessive sodium intake as well as a shortfall of iron, vitamin D, and vitamin E intakes. The potential consequences of these discrepancies with respect to health outcomes remain to be assessed.

Iron deficiency during pregnancy and lactation modifies the fatty acid composition of the brain of neonatal rats

Iron deficiency is common in pregnant and lactating women and is associated with reduced cognitive development of the offspring. Since iron affects lipid metabolism, the availability of fatty acids, particularly the polyunsaturated fatty acids required for early neural development, was investigated in the offspring of female rats fed iron-deficient diets during gestation and lactation. Subsequent to the dams giving birth, one group of iron-deficient dams was recuperated by feeding an iron-replete diet. Dams and neonates were killed on postnatal days 1, 3 and 10, and the fatty acid composition of brain and stomach contents was assessed by gas chromatography. Changes in the fatty acid profile on day 3 became more pronounced on day 10 with a decrease in the proportion of saturated fatty acids and a compensatory increase in monounsaturated fatty acids. Long-chain polyunsaturated fatty acids in the n-6 family were reduced, but there was no change in the n-3 family. The fatty acid profiles of neonatal brain and stomach contents were similar, suggesting that the change in milk composition may be related to the changes in the neonatal brain. When the dams were fed an iron-sufficient diet at birth, the effects of iron deficiency on the fatty acid composition of lipids in both dam's milk and neonates' brains were reduced. This study showed an interaction between maternal iron status and fatty acid composition of the offspring's brain and suggests that these effects can be reduced by iron repletion of the dam's diet at birth.

Nutritional Supplements During Gestation and Autism Spectrum Disorder: What Do We Really Know and How Far Have We Gone?

Nutritional interventions are gaining remarkable attention as complementary management options for autism. Our aim is to provide literature data about the impact of the administration of dietary supplements during pregnancy on the risk of autism spectrum disorder in the offspring. A comprehensive search was undertaken by 2 reviewers independently using PubMed as the medical database source. Prospective clinical and experimental studies were considered and no year-of-publication restriction was placed. We were able to identify 4 basic (conducted in rodents) and 3 clinical research papers fulfilling our selection criteria. Supplements studied included folic acid, iron, multivitamins, choline, vitamin D, and docosahexaenoic acid. Choline and folic acid had a significant impact on the expression of autism-related genes. However, from a clinical point of view, prenatal folate administration did not reduce the risk of autism. Similarly, iron had no significant impact, while the use of multivitamins in moderate frequency had a protective effect. The use of vitamin D and docosahexaenoic acid during gestation decreased the incidence of autism in animal models. In conclusion, available data are controversial and cannot change current routine practice. More large-scale prospective studies are needed to identify the real effect of nutritional supplements and also optimize their administration.Key teaching pointsMultivitamins use during pregnancy can exert a protective effect on the risk of autism, although depending on the frequency of use. Nevertheless, prenatal iron and folate were not shown to have any significant impact.Research based on animal models showed that choline and folic acid can have a significant impact on the expression of autism-related genes in a sex-specific manner.Furthermore, the use of vitamin D and docosahexaenoic acid during gestation seem to decrease the incidence of autism in animal offspring.In the future, more clinical, large-scale prospective and methodologically homogenous clinical studies are needed to further investigate the effect of the periconceptional use of nutritional supplements on autism risk.

Effect of iron supplementation from neonatal period on the iron status of6-month-old infants at-risk for early iron deficiency: a randomized interventional trial

OBJECTIVE

To investigate the effects of iron supplementation from the second day after birth on 6-month hemoglobin (Hb), serum ferritin and motor development in infants at risk of early iron deficiency.

STUDY DESIGN

Term (37-41 weeks) infants of anemic (Hb ≤ 100 g L^-1; N = 100) and non-anemic (Hb > 100 g L^-1; N = 100) mothers were randomized to daily iron supplementation at a dose of 2 mg kg^-1 from 36 h of age (N = 50, each of anemic and non-anemic mothers) or no iron-supplementation (N = 50 each of anemic and non-anemic mothers). Hb, serum ferritin and motor development at 6 months were compared in the two groups.

RESULTS

Iron-supplemented infants had higher Hb (103.7 ± 9.3 g L^-1 versus 97.0 ± 9.4 g L^-1, p < .0001) and serum ferritin (133.93 ± 52.41 ng mL^-1 versus 78.09 ± 42.03 ng mL^-1, p < .001) concentrations, compared with the no iron-supplementation group. Their motor development was closer to age-appropriate norms than the no iron-supplementation group (5.83 ± 0.69 versus 5.18 ± 1.35, p < .01).

CONCLUSION

Early Iron supplementation is effective for improving iron status and motor development at 6 months in infants at risk for early iron deficiency.

Interventions to prevent iron deficiency during the first 1000 days in low-income and middle-income countries: recent advances and challenges

PURPOSE OF REVIEW

Iron deficiency remains highly prevalent in women and young children in low-income and middle-income countries. To prevent the potentially life-long consequences of iron deficiency when occurring during early life, the WHO recommends iron supplementation of pregnant women and young children. However, increasing evidence of limited efficacy and risk of current iron intervention strategies are cause of concern. This review aims to highlight recent advances and challenges of established and novel intervention strategies for the prevention of iron deficiency during the first 1000 days in low-income and middle-income countries.

RECENT FINDINGS

Recent meta-analyses and trials challenged the WHO's current recommendation to provide iron-folic acid rather than multiple micronutrient supplements during routine antenatal care. Furthermore, several studies explored optimal windows for iron supplementation, such as prior to conception. Studies are demonstrating that infectious and noninfectious inflammation is compromising the efficacy of iron interventions in vulnerable groups. Therefore, strategies addressing iron deficiency should focus on targeting infection and inflammation while simultaneously providing additional iron. Furthermore, both iron deficiency and iron supplementation may promote an unfavourable gut microbiota. Recent trials in infants indicate that the provision of a prebiotic together with iron may alleviate the adverse effects of iron on the gut microbiome and gut inflammation, and may even enhance iron absorption.

SUMMARY

Recent studies highlight the need for and potential of novel intervention strategies that increase the efficacy and limit the potential harm of universal iron supplementation.

Iron Metabolism and Brain Development in Premature Infants

Iron is important for a remarkable array of essential functions during brain development, and it needs to be provided in adequate amounts, especially to preterm infants. In this review article, we provide an overview of iron metabolism and homeostasis at the cellular level, as well as its regulation at the mRNA translation level, and we emphasize the importance of iron for brain development in fetal and early life in preterm infants. We also review the risk factors for disrupted iron metabolism that lead to high risk of developing iron deficiency and subsequent adverse effects on neurodevelopment in preterm infants. At the other extreme, iron overload, which is usually caused by excess iron supplementation in iron-replete preterm infants, might negatively impact brain development or even induce brain injury. Maintaining the balance of iron during the fetal and neonatal periods is important, and thus iron status should be monitored routinely and evaluated thoroughly during the neonatal period or before discharge of preterm infants so that iron supplementation can be individualized.

The Importance of Iron Status for Young Children in Low- and Middle-Income Countries: A Narrative Review

Early childhood is characterised by high physiological iron demand to support processes including blood volume expansion, brain development and tissue growth. Iron is also required for other essential functions including the generation of effective immune responses. Adequate iron status is therefore a prerequisite for optimal child development, yet nutritional iron deficiency and inflammation-related iron restriction are widespread amongst young children in low- and middle-income countries (LMICs), meaning iron demands are frequently not met. Consequently, therapeutic iron interventions are commonly recommended. However, iron also influences infection pathogenesis: iron deficiency reduces the risk of malaria, while therapeutic iron may increase susceptibility to malaria, respiratory and gastrointestinal infections, besides reshaping the intestinal microbiome. This means caution should be employed in administering iron interventions to young children in LMIC settings with high infection burdens. In this narrative review, we first examine demand and supply of iron during early childhood, in relation to the molecular understanding of systemic iron control. We then evaluate the importance of iron for distinct aspects of physiology and development, particularly focusing on young LMIC children. We finally discuss the implications and potential for interventions aimed at improving iron status whilst minimising infection-related risks in such settings. Optimal iron intervention strategies will likely need to be individually or setting-specifically adapted according to iron deficiency, inflammation status and infection risk, while maximising iron bioavailability and considering the trade-offs between benefits and risks for different aspects of physiology. The effectiveness of alternative approaches not centred around nutritional iron interventions for children should also be thoroughly evaluated: these include direct targeting of common causes of infection/inflammation, and maternal iron administration during pregnancy.

Changes in Iron Status Are Related to Changes in Brain Activity and Behavior in Rwandan Female University Students: Results from a Randomized Controlled Efficacy Trial Involving Iron-Biofortified Beans

BACKGROUND

Evidence suggests that iron deficiency (ID) affects cognitive performance, as measured in behavior. Although such effects must be mediated by changes in the brain, very few studies have included measures of brain activity to assess this relation.

OBJECTIVE

We tested the hypothesis that provision of iron-biofortified beans would result in improvements in measures of iron status, brain dynamics, and behavior.

METHODS

A double-blind, randomized, intervention study was conducted in 55 women aged 18-27 y with low iron status (serum ferritin <20 µg/L). Women were randomly assigned to consume iron-biofortified (86.1 ppm iron) or comparison beans (50.1 ppm iron) daily for 18 wk. Iron status was assessed by hemoglobin, ferritin, transferrin receptor, and body iron; cognitive performance with 5 computerized tasks; and brain dynamics by concurrent electroencephalography (EEG). All measures were taken at baseline and endline.

RESULTS

The groups did not differ on any measures at baseline. Intention-to-treat analyses revealed significant (all P < 0.05) improvements in hemoglobin (partial effect size attributable to the independent variable, η2 = 0.16), ferritin (η2 = 0.17), and body iron (η2 = 0.10), speed of responding in attentional and mnemonic tasks (η2 = 0.04-0.29), sensitivity and efficiency of memory retrieval (η2 = 0.12-0.55), and measures of EEG amplitude and spectral power (η2 = 0.08 to 0.49). Mediation models provided evidence in support of the hypothesis that changes in iron status produce changes in behavior by way of changes in brain activity.

CONCLUSIONS

Behavioral performance and brain activity, as measured by EEG, are sensitive to iron status, and the consumption of iron-biofortified beans for 18 wk resulted in improvements in measures of both, relative to what was obtained with a comparison bean, in a sample of female university students. Furthermore, the results support the conclusion that changes in brain activity resulting from consumption of biofortified beans mediate the relations between changes in iron biomarkers and changes in cognition. Clinical trial registry: ClinicalTrials.gov Reg No. NCT01594359.

Frequent blood donation and offspring scholastic attainment: an assessment of long-term consequences of prenatal iron deficiency

BACKGROUND

Due to physiological demands, children and premenopausal women are at risk of developing iron deficiency. In premenopausal women, the risk may be further increased by repeated whole blood donations. Short-term consequences of iron deficiency in infancy include impaired cognitive development and lower IQ scores. This prompts concern that maternal iron deficiency before or during pregnancy may have long-term consequences for the offspring, for example, by affecting scholastic attainment. The aim of this study was to evaluate if prepregnancy donation intensity is associated with offspring scholastic attainment measured as grade averages in standardized national written examinations in Denmark.

STUDY DESIGN AND METHODS

By using the Danish personal identification number as key, we obtained information on donation intensity before pregnancy, school grade, year of graduation, age of the students, students' sex, and parental length of education and income from various nationwide registers. Linear regression analyses were performed, with grade average as outcome and maternal donation status as explanatory variable (nondonor, n = 177,078; low-frequency donor, n = 4995 [one to five donations in the 3 years before pregnancy]; high-frequency donor, n = 414 [six or more donations in the 3 years before pregnancy), and further adjusted for the covariates listed above.

RESULTS

Adjusted normalized (mean, 0; standard deviation [SD], 1) test scores were statistically significantly higher for children of active female donors compared with children of nondonors (SD, 0.104; 95% confidence interval, 0.079-0.129). We observed no differences in scholastic attainment between children of low-frequency donors and high-frequency donors.

CONCLUSION

Prepregnancy donation intensity, as a proxy of iron stores, is not associated with subsequent offspring scholastic attainment.

Ferritin in serum and urine: A pilot study

Serum ferritin reflects total body iron stores, thus a low serum ferritin is used as a parameter of iron deficiency. In healthy adults in Japan, urine ferritin levels were about 5% of serum ferritin levels, with a correlation coefficient of 0.79. It is not known whether a low urine ferritin could serve as a non-invasive screen for iron deficiency. If so, this might be useful for neonates and young children, avoiding phlebotomy to screen for iron deficiency. However, for urinary ferritin screening to be feasible, ferritin must be measurable in the urine and correlate with serum ferritin. Testing should also clarify whether the iron content of ferritin in serum and urine are similar. In this pilot feasibility study we measured ferritin in paired serum and urine samples of healthy adult males, healthy term neonates, growing preterm neonates, and children who had very high serum ferritin levels from liver disorders or iron overload. We detected ferritin in every urine sample, and found a correlation with paired serum ferritin (Spearman correlation coefficient 0.78 of log₁₀-transformed values). These findings suggest merit in further studying urinary ferritin in select populations, as a potential non-invasive screen to assess iron stores.

Perinatal Iron Deficiency: Implications for Mothers and Infants

Iron deficiency, with or without anemia, is common in pregnant women. In fact, nearly 30% of reproductive-age women are anemic worldwide, and anemia in pregnancy has an estimated global prevalence of 38%. Severe anemia can substantially increase the risk of maternal mortality, and can adversely affect fetal development. In this review, we examine the available data regarding epidemiology and consequences of iron deficiency in mothers and infants, current treatment strategies, and make recommendations for screening and treatment of iron deficiency anemia in gravidas and neonates.

[Association between iron deficiency and brain developmental disorder in children]

Iron deficiency (ID) is the most common trace element deficiency in childhood. Recent studies have shown that late fetus period, neonatal period, and infancy are important periods for brain development, and ID during these periods may cause irreversible damage to brain development, including abnormal emotion and behavior, cognitive decline, and attention deficit, which may still be present in adulthood. Therefore, it should be taken seriously. This article summarizes the research advances in major mechanisms involved in brain developmental disorder due to ID in the early stage of life and related intervention measures.

Prevalence and knowledge of anemia among pregnant women enrolled in Women, Infants and Children supplemental food program

Purpose

Although anemia during pregnancy is common in the USA, socio-demographic factors make pregnant women enrolled in Women, Infants and Children (WIC) program more vulnerable than the general population. The purpose of this study was to examine the socio-demographic characteristics, blood hemoglobin concentrations, nutrition knowledge and potential associations among these factors in a sample of pregnant women participating in the WIC program.

Design/methodology/approach

A cross-sectional study using survey methodology was conducted. In total, 60 pregnant women who were between 12 and 24 weeks of gestation and were carrying a single fetus were recruited from two WIC clinics. Overall nutrition knowledge was assessed with 42 questions arranged into three subscales. Participants’ scores were transformed into tertiles. WIC program records were used to record blood hemoglobin values. Principal component analysis was used to validate the knowledge subscales. Correlational and multivariate regression analyses were conducted to examine the relationship among variables.

Findings

Prevalence of anemia among the participants was higher than the national averages. Only 10 per cent of participants scored in the high tertile for nutrition knowledge. Anemia-during-pregnancy knowledge score was positively correlated with blood hemoglobin concentrations (r = 0.23, p < 0.05), and it was also a predictor of blood hemoglobin levels (R2 = 0.364, p = 0.02).

Originality/value

This is the first study to report on the knowledge of anemia, anemia during pregnancy and preventive measures among pregnant women enrolled in the WIC program.