Research needed to strengthen science and programs for the control of iron deficiency and its consequences in young children

Association of Iron Supplementation Programs with Iron-Deficiency Anemia Outcomes among Children in Brazil

Anemia remains a condition with high prevalence in populations worldwide, and the prevalence of anemia among children under five years old in Brazil is approximately 40%, being higher in communities marked by social inequities. Diverse government programs during recent decades targeted iron-deficiency anemia, considering its impacts throughout the lifetime. The objective of this study was to investigate the effects of two government iron supplementation programs on health outcomes related to iron-deficiency anemia among children up to 4 years old in Brazilian municipalities. A longitudinal panel encompassing data from 5570 municipalities from 1998 to 2019 was investigated using a difference-in-differences framework with multiple interventions and distinct times of adhesion, and fixed-effects models were estimated to control for invariant municipal characteristics throughout the period in order to ensure comparability. The results indicate significant effects of the federal programs in reducing hospitalizations and lengths of stay due to iron-deficiency anemia, especially in non-poor municipalities. There was complementarity in the effects of the programs; however, neither of the programs influenced mortality rates. Thus, it is important to consider possible improvements in the operationalization of the programs, in order to achieve better results in the reduction of severe iron-deficiency anemia among children up to 4 years old.

Importance of coverage and quality for impact of nutrition interventions delivered through an existing health programme in Bangladesh

Understanding implementation of interventions is critical to illuminate if, how, and why the interventions achieve impact. Alive & Thrive integrated a nutrition intervention into an existing maternal, neonatal, and child health (MNCH) programme in Bangladesh, documenting improvements in women's micronutrient supplement intake and dietary diversity. Here, we examined how well the nutrition intervention was implemented and which elements of implementation explained intervention impact. Survey data were collected in 2015 and 2016 from frontline health workers (FLW) and households in areas randomized to nutrition‐focused MNCH (intensified interpersonal counselling, community mobilization, distribution of free micronutrient supplements, and weight‐gain monitoring) or standard MNCH (antenatal care with standard nutrition counselling). Seven intervention elements were measured: time commitment, training quality, knowledge, coverage, counselling quality, supervision, and incentives. Multiple regression was used to derive difference‐in‐differences (DID) estimates. Using village‐level endline data, path analysis was used to determine which elements most explained intervention impacts. FLWs in both areas were highly committed and well supervised. Coverage was high (>90%) for counselling, supplement provision, and weight‐gain monitoring. Improvements were significantly greater for nutrition‐focused MNCH, versus standard MNCH, for training quality (DID: 2.42 points of 10), knowledge (DID: 1.20 points), delivery coverage (DID: 4.16 points), and counselling quality (DID: 1.60 points). Impact was substantially explained by coverage and delivery quality. In conclusion, integration nutrition intervention into the MNCH programme was feasible and well‐implemented. Although differences in coverage and counselling quality most explained impacts, all intervention elements—particularly FLW training and performance—were likely important to achieving impact.

Childhood anemia in Rural Haiti: the potential role of community health workers

BACKGROUND

Childhood iron deficiency anemia (IDA) is an important contributor to under-five mortality in the developing world. There is evidence that Community Health Worker (CHW) delivered programs to increase maternal knowledge of child health practices may decrease childhood IDA. This study reports findings on the association between a long standing CHW intervention and childhood anemia status in rural Haiti.

METHODS

Using structural equations and mediation analyses on data from a household-based survey of 621 mother/child dyads, we tested the hypothesis that CHW would have a direct positive effect on maternal knowledge and an indirect effect on childhood anemia in rural Haiti.

RESULTS

CHW contact was significantly associated with maternal knowledge of key child health practices (β = 0.193, SE = 0.058, p = 0.001). However, knowledge was not associated with childhood anemia (β = -0.008, SE = 0.009, p = 0.382). Maternal knowledge categories significantly affected by CHW contact included diarrheal prevention knowledge (β = 0.111, SE = 0.045, p = 0.013) and signs of malnutrition (β = 0.217, SE = 0.071, p = 0.002). There was no significant association with knowledge of vitamin A and iron rich foods (β = 0.057, SE = 0.032, p = 0.074), which is the intervention most likely to impact childhood anemia. In all path models tested, we identified the control variables low household socio-economic status, mothers' anemia status, and child's age less than 24 months as significant predictors of childhood anemia.

CONCLUSIONS

CHWs delivered interventions are associated with improved maternal knowledge of child health practices in rural Haiti; however, this knowledge is not associated with improved childhood anemia. Concurrently with CHW-delivered programs, interventions household poverty are implied to impact childhood health outcomes in resource poor settings.

Maternal HIV status affects the infant hemoglobin level: A comparative cross-sectional study

Children, especially infants, are highly vulnerable to iron-deficiency anemia because of their rapid growth of the brain and the rest of the body. The objectives of this study were to compare the prevalence of iron-deficiency anemia in infants born from HIV-positive mothers and HIV-negative mothers and to identify the determinants of iron-deficiency anemia in infants.A comparative cross-sectional study was conducted in Bahir Dar city. Simple random sampling technique was used to select the study participants. Mothers were interviewed; blood samples were collected from mothers and infants to measure the hemoglobin level and anthropometric indicators were obtained from the infants using world health organization standards. Descriptive statistics were used to estimate the prevalence of infantile anemia. Binary logistic regression and multiple linear regressions were used to identify the determinants of infant anemia.A total of 1459 infants born from HIV-positive and HIV-negative mothers were included. The prevalence of iron-deficiency anemia in infants born from HIV-positive and HIV-negative mothers was 41.9% (95% CI: 39-44). Infantile iron-deficiency anemia was associated with maternal HIV infection (adjusted odds ratio [AOR] 2.54 [95% CI: 1.65-3.9]), stunting (AOR 3.46 [95% CI: 2.41-4.97]), low income (AOR 2.72 [95% CI: 2-3.73]), maternal malaria during pregnancy (AOR 1.81 [95% CI: 1.33-2.47]), use of cow milk before 6 month (AOR 1.82 [95% CI: 1.35-2.45]), residence (AOR 0.09 [95% CI: 0.06-0.13]), history of cough or fever 7 days preceding the survey (AOR 2.71 [95% CI: 1.99-3.69]), maternal hemoglobin (B 0.65 [95% CI: 0.61-0.68]), educational status of mother (B 0.22 [95% CI: 0.2-0.23]), age of the mother (B -0.03 [95% CI: -0.03, -0.02]), and family size (B -0.14 [95% CI: -0.18,-0.11]).

Translating formative research findings into a behaviour change strategy to promote antenatal calcium and iron and folic acid supplementation in western Kenya

The World Health Organization now recommends integrating calcium supplements into antenatal micronutrient supplementation programmes to prevent pre-eclampsia, a leading cause of maternal mortality. As countries consider integrating calcium supplementation into antenatal care (ANC), it is important to identify context-specific barriers and facilitators to delivery and adherence. Such insights can be gained from women's and health workers' experiences with iron and folic acid (IFA) supplements. We conducted in-depth interviews with 22 pregnant and post-partum women and 20 community-based and facility-based health workers in Kenya to inform a calcium and IFA supplementation programme. Interviews assessed awareness of anaemia, pre-eclampsia and eclampsia; ANC attendance; and barriers and facilitators to IFA supplement delivery and adherence. We analyzed interviews inductively using the constant comparative method. Women and health workers identified poor diet quality in pregnancy as a major health concern. Neither women nor health workers identified pre-eclampsia, eclampsia, anaemia or related symptoms as serious health threats. Women and community-based health workers were unfamiliar with pre-eclampsia and eclampsia and considered anaemia symptoms normal. Most women had not received IFA supplements, and those who had received insufficient amounts and little information about supplement benefits. We then developed a multi-level (health facility, community, household and individual) behaviour change strategy to promote antenatal calcium and IFA supplementation. Formative research is an essential first step in guiding implementation of antenatal calcium supplementation programmes to reduce pre-eclampsia. Because evidence on how to implement successful calcium supplementation programmes is limited, experiences with antenatal IFA supplementation can be used to guide programme development.

The Karnataka Anemia Project 2--design and evaluation of a community-based parental intervention to improve childhood anemia cure rates: study protocol for a cluster randomized controlled trial

BACKGROUND

Childhood anemia is highly prevalent worldwide. Improving the hemoglobin level of preschool age children could yield substantial benefits in cognitive and psychosocial development and overall health. While evidence-based recommendations for reducing childhood anemia in high anemia prevalence countries are available, there is no experimental evidence of community centered education and counseling programs, as a route to improved acceptance of iron supplements, demonstrating beneficial effects on anemia outcomes. We report on the evaluation protocol of a complex educational intervention led by the community lay health worker (LHW) and delivered to mothers of 12-59-month-old anemic children living in and visiting village day care centers in a large district of southern India.

METHODS AND DESIGN

The study is designed as a cluster randomized controlled trial. The intervention is based on the social cognitive theory and aims to promote among mothers, anemia awareness, dietary modifications to increase iron intake in the child, and recognition of the need for enhanced adherence to supplemental iron in the anemic child. From 270 eligible villages in the study area, a sample of 60 villages will be randomized to intervention [n = 30] or to treatment as usual [n = 30] of the study. LHWs in the intervention arm will be trained to administer the following intervention components to mothers of anemic children: 1] monthly distribution of Iron and folic acid (IFA) supplements to mothers of anemic children, and 2] five monthly counseling sessions of mothers of anemic children covering: a] anemia awareness education b] IFA adherence counseling and assessment, c] dietary modification to improve iron intake, and d] hygiene and sanitation. LHWs in the control arm will distribute IFA to mothers of anemic children as in the intervention arm but will not provide monthly education and counseling support. The primary outcome is the difference between the two experimental groups in anemia cure rates of children found to be anemic at baseline. Secondary outcomes, assessed as differences between all participants in both experimental groups, are: change in mothers' knowledge regarding anemia; 24 hour dietary iron intake; net improvement in individual hemoglobin values; serum ferritin; and the difference in overall cluster level childhood anemia prevalence. All outcomes will be measured 6 months after the start of the intervention. Multilevel linear and logistic regression models will be used to analyze differences between intervention and control groups in outcome variables.

DISCUSSION

This trial is designed to evaluate the effectiveness of an intervention intended to improve anemia cure rates in anemic children living in villages of Chamarajnagar, Karnataka a large district in south India. The extensive study of secondary endpoints will be used to identify possible weak points in the compliance to intervention delivery and uptake. This evaluation is one of the few large randomized trials evaluating the impact of an education and counseling intervention to reduce childhood anemia prevalence.

TRIAL REGISTRATION

This trial was registered with ISRCTN.com (identifier: ISRCTN68413407) on 17 September 2013.

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

Objective

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

Design

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

Setting

Talin communities, Aragatsotn Province, Armenia.

Subjects

Children under 5 years of age in Talin region.

Results

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

Conclusions

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

Prevalence and Factors Associated with Anemia Among Children Under 5 Years of Age--Uganda, 2009

Anemia in children under 5 years of age, defined by the World Health Organization as a hemoglobin concentration < 11 g/dL, is a global public health problem. According to the 2006 Demographic Health Survey, the prevalence of anemia among children under five in Uganda was 72% in 2006. The 2009 Uganda Malaria Indicator Survey was conducted in late 2009 and revealed that over 60% of children less than 5 years of age were anemic and that over half of children tested positive for malaria via a rapid diagnostic test. Children with concomitant malaria infection, and in households without any type of mosquito net were more likely to be anemic, confirming that children under 5 years, are vulnerable to both the threat of malaria and anemia and the beneficial effect of malaria prevention tools. However, prevention and treatment of other factors associated with the etiology of anemia (e.g., iron deficiency) are likely necessary to combat the toll of anemia in Uganda.

Prevalence of Anemia in Latin America and the Caribbean

Background:

In Latin America and the Caribbean, anemia has been a public health problem that affects mainly women of childbearing age and children under 6 years of age. However, the current prevalence of anemia in this region is unknown.

Objective:

To examine the latest available prevalence data on anemia in Latin America and the Caribbean.

Methods:

A systematic review was conducted in 2011 and updated in 2014. Studies determining the prevalence of anemia conducted in apparently healthy populations with national or regional representativeness were included in the review.

Results:

The lowest prevalence rates of anemia among children under 6 years of age were found in Chile (4.0%), Costa Rica (4.0%), Argentina (7.6%), and Mexico (19.9%). In Nicaragua, Brazil, Ecuador, El Panama, and Honduras, anemia was a moderate public health problem, with prevalence ranging Salvador, Cuba, Colombia, the Dominican Republic, Peru, from 20.1% to 37.3%. Anemia was a severe public health problem in Guatemala, Haiti, and Bolivia. The prevalence of anemia among women of childbearing age was lowest in Chile (5.1%). In Colombia, El Salvador, Costa Rica, Nicaragua, Ecuador, Mexico, Peru, Honduras, and Argentina, anemia was a mild public health problem, with prevalence ranging from 7.6% to 18.7%. In Guatemala, Brazil, the Dominican Republic, and Bolivia, anemia was a moderate public health problem, with prevalence ranging from 21.4% to 38.3%. Panama and Haiti had the highest reported prevalence rates (40.0% and 45.5%, respectively), and anemia was considered a severe public health problem in those countries.

Conclusions:

Anemia remains a public health problem in children under 6 years of age and women of childbearing age in most Latin America and Caribbean countries for which data are available.

Strengthening implementation and utilization of nutrition interventions through research: a framework and research agenda

Undernutrition among women and children contributes to almost half the global burden of child mortality in developing countries. The impact of nutrition on economic development has highlighted the need for evidence-based solutions and yielded substantial global momentum. However, it is now recognized that the impact of evidence-based interventions is limited by the lack of evidence on the best operational strategies for scaling up nutrition interventions. With the goal of encouraging greater engagement in implementation research in nutrition and generating evidence on implementation and utilization of nutrition interventions, this paper brings together a framework and a broad analysis of literature to frame and highlight the crucial importance of research on the delivery and utilization of nutrition interventions. The paper draws on the deliberations of a high-level working group, an e-consultation, a conference, and the published literature. It proposes a framework and areas of research that have been quite neglected, and yet are critical to better understanding through careful research to enable better translation of global and national political momentum for nutrition into public health impact.

Chilean complementary feeding program reduces anemia and improves iron status in children aged 11 to 18 months

BACKGROUND

Iron deficiency is the most prevalent nutritional deficiency in the world, primarily affecting infants, young children, and women of childbearing age.

OBJECTIVE

To evaluate the impact of the National Complementary Feeding Program (NCFP) on anemia and iron status in Chilean children aged 11 to 18 months.

METHODS

Two studies were performed. The first study was performed at one public outpatient health center in Santiago, using data collected in 1999 (n = 128) and 2000 (n = 125), before and after the national introduction of iron-fortified milk. Subsequently, a study of a representative sample (n = 320) from the two most populated areas of the country was performed in 2009.

RESULTS

One year after fortification, the prevalence of anemia was 9%; significantly lower (p < .001) than the 27% prevalence observed 1 year before. Ten years after fortification, 14% of children were anemic and 77% of children with anemia (12% of all children) suffered from iron-deficiency anemia. In 2009, 11% of children consuming iron-fortified milk delivered by the NCFP (73%) were anemic, significantly lower (p = .028) than the 21% prevalence of anemia observed in children without consumption. Consumption of iron-fortified milk was positively associated with hemoglobin concentration (r = 0.28, p = .022) and was associated with a lower prevalence of anemia after adjusting for confounding factors (odds ratio, 0.50; 95% CI, 0.26 to 0.96).

CONCLUSIONS

In Chile, the NCFP has had an impact on the reduction of anemia and improved the iron status of children aged 11 to 18 months. Increasing the consumption of this iron-fortified milk could enhance the impact of the NCFP.

Equity in access to fortified maize flour and corn meal

Mass fortification of maize flour and corn meal with a single or multiple micronutrients is a public health intervention that aims to improve vitamin and mineral intake, micronutrient nutritional status, health, and development of the general population. Micronutrient malnutrition is unevenly distributed among population groups and is importantly determined by social factors, such as living conditions, socioeconomic position, gender, cultural norms, health systems, and the socioeconomic and political context in which people access food. Efforts trying to make fortified foods accessible to the population groups that most need them require acknowledgment of the role of these determinants. Using a perspective of social determinants of health, this article presents a conceptual framework to approach equity in access to fortified maize flour and corn meal, and provides nonexhaustive examples that illustrate the different levels included in the framework. Key monitoring areas and issues to consider in order to expand and guarantee a more equitable access to maize flour and corn meal are described.

Iron stores in low and normal birth weight infants at birth and in early infancy

Serum ferritin levels of low birth weight (LBW; BW < 2,500 g) and normal birth weight (NBW; BW ≥ 2,500 g) infants were evaluated at birth and at 3 mo using electrochemiluminescence immunoassay. At birth, levels were 318.6 (31.0-829.5) ng/mL in LBW (n = 217) and 366.2 (122.4-858.5) ng/mL in NBW infants (n = 116; p < 0.01), with 1.4 % of LBW and none of the NBW infants having levels <12 ng/mL (p = 0.20). At follow up, levels were 66.9 (4.5-567.7) ng/mL in LBW (n = 126) and 126.2 (6.8-553.7) ng/mL in NBW infants (n = 76; p = 0.27), with 11.9 % of LBW and 11.8 % of NBW infants having levels <12 ng/mL (p = 0.80).

"How often? How much? Where from?" knowledge, attitudes, and practices of mothers and health workers to iron supplementation program for children under five in rural Tamil Nadu, south India

Iron deficiency anemia (IDA) affects 70% of under-5 children in India. The primary prevention strategy is regular iron supplementation. Little is known about what helps families adhere to daily iron supplementation. Our study explored the knowledge, attitudes, and practices of mothers and village health workers (VHWs) involved in a community health program in one hill district of Tamil Nadu. We conducted 30 semistructured interviews and 3 group discussions involving mothers, VHWs, and community stakeholders. Knowledge of IDA was widespread, yet no children were receiving the iron supplementation as recommended. The main determinants to adherence included the perception of its need, the ease of access, and the activity of VHWs. Preventive care requiring daily supplements is challenging. Our study suggests that increasing community awareness of mild anemia, simplifying dosage instructions, and further strengthening the supportive environment for VHWs would help in reducing the prevalence of IDA.

Learning how programs achieve their impact: embedding theory-driven process evaluation and other program learning mechanisms in alive & thrive

BACKGROUND

Traditionally, impact evaluations have focused primarily on answering what impact programs or interventions have, with less attention to how or why impacts are achieved, or not achieved. The Alive & Thrive initiative, a 6-year program that aims to improve infant and young child feeding (IYCF) practices and reduce stunting in Bangladesh, Ethiopia, and Vietnam, has a specific objective to generate learning on how to achieve and replicate Alive & Thrive's impact.

OBJECTIVE

In Alive & Thrive, theory-driven process evaluation methods are the primary mechanism through which data are generated to address this objective. This paper focuses on the different methodological approaches that are being utilized, to answer the critical "how" questions, and to generate information on the many processes and pathways to program impact.

METHODS

We identify four key principles in our methodological approach that guides all process evaluation activities: (1) developing detailed program impact pathway (PIP) models, (2) linking data collection to PIPs utilizing mixed methods and multiple data sources, (3) linking evaluation activities with program implementation timelines, and (4) engaging with the program implementation and management teams.

RESULTS

Beginning with the launch of the program, we outline the steps that have been taken in the design and implementation of the process evaluations of Alive & Thrive, and provide examples of how these steps have been operationalized in different country contexts.

CONCLUSIONS

This theory-driven and country- and component-specific approach, centered on careful analysis of PIPs, is intended to generate information on implementation and utilization pathways of Alive & Thrive's interventions, thereby answering the questions of how impacts are achieved, or why not. This evaluation approach is not without challenges, and we highlight some of these key challenges.

The politics of reducing malnutrition: building commitment and accelerating progress

In the past 5 years, political discourse about the challenge of undernutrition has increased substantially at national and international levels and has led to stated commitments from many national governments, international organisations, and donors. The Scaling Up Nutrition movement has both driven, and been driven by, this developing momentum. Harmonisation has increased among stakeholders, with regard to their understanding of the main causes of malnutrition and to the various options for addressing it. The main challenges are to enhance and expand the quality and coverage of nutrition-specific interventions, and to maximise the nutrition sensitivity of more distal interventions, such as agriculture, social protection, and water and sanitation. But a crucial third level of action exists, which relates to the environments and processes that underpin and shape political and policy processes. We focus on this neglected level. We address several fundamental questions: how can enabling environments and processes be cultivated, sustained, and ultimately translated into results on the ground? How has high-level political momentum been generated? What needs to happen to turn this momentum into results? How can we ensure that high-quality, well-resourced interventions for nutrition are available to those who need them, and that agriculture, social protection, and water and sanitation systems and programmes are proactively reoriented to support nutrition goals? We use a six-cell framework to discuss the ways in which three domains (knowledge and evidence, politics and governance, and capacity and resources) are pivotal to create and sustain political momentum, and to translate momentum into results in high-burden countries.

Iron status biomarkers and C-reactive protein in children aged 19 to 72 months in Chile

BACKGROUND

The Chilean Ministry of Health has combated iron deficiency through the delivery of fortified milk by the National Complementary Feeding Program (NCFP).

OBJECTIVE

To assess iron status and associations between biomarkers of iron status and serum C-reactive protein (CRP) in 218 beneficiaries of the NCFP aged 19 to 72 months in Santiago and Valparaiso, Chile.

METHODS

Blood was collected from a cross-sectional representative sample. Iron status (measured by hemoglobin, zinc protoporphyrin, and serum ferritin levels) and inflammation (according to CRP level) were determined.

RESULTS

Serum CRP level was positively associated with serum ferritin and zinc protoporphyrin levels (r = 0.16 and r = 0.15; p = .0168 and p = .0290, respectively). Serum ferritin was higher among children with high CRP (> 10 mg/dL) than among those with low CRP (< or = 10 mg/dL) (p = .003). After adjustment for 10, 6, and 5 mg/L CRP, the prevalence of low serum ferritin changed from 56.4% without adjustment to 60.6%, 61.5%, and 42.7%, respectively, and the prevalence of high zinc protoporphyrin changed from 22.9% to 21.6%, 17.4%, and 17.9%, respectively. There were no differences between regions in biomarkers of iron status. There was no association between consumption of fortified milk and the prevalence of abnormal serum ferritin (< 15 microg/L) after adjustment for sex, age, and breastfeeding (OR, 1.00; 95% CI, 0.99 to 1.01; p = .288). After adjustment for 10 mg/L CRP, 5.5% were classified as having iron-deficiency anemia, 42.7% as having iron-deficiency erythropoiesis, 17.9% as having depleted iron stores, and 35.8% as having normal iron status. CONCLUSIONS. CRP level was positively associated with: serum ferritin and zinc protoporphyrin levels. Chilean children aged 19 to 72 months from Santiago and Valparaiso who were beneficiaries of the NCFP had a low prevalence of iron-deficiency anemia, a high prevalence of iron-deficiency erythropoiesis, and a moderate prevalence of depleted iron stores.

Position of the academy of nutrition and dietetics: nutrition security in developing nations: sustainable food, water, and health

It is the position of the Academy of Nutrition and Dietetics that all people should have consistent access to an appropriately nutritious diet of food and water, coupled with a sanitary environment, adequate health services, and care that ensure a healthy and active life for all household members. The Academy supports policies, systems, programs, and practices that work with developing nations to achieve nutrition security and self-sufficiency while being environmentally and economically sustainable. For nations to achieve nutrition security, all people must have access to a variety of nutritious foods and potable drinking water; knowledge, resources, and skills for healthy living; prevention, treatment, and care for diseases affecting nutrition status; and safety-net systems during crisis situations, such as natural disasters or deleterious social and political systems. More than 2 billion people are micronutrient deficient; 1.5 billion people are overweight or obese; 870 million people have inadequate food energy intake; and 783 million people lack potable drinking water. Adequate nutrient intake is a concern, independent of weight status. Although this article focuses on nutritional deficiencies in developing nations, global solutions for excesses and deficiencies need to be addressed. In an effort to achieve nutrition security, lifestyles, policies, and systems (eg, food, water, health, energy, education/knowledge, and economic) contributing to sustainable resource use, environmental management, health promotion, economic stability, and positive social environments are required. Food and nutrition practitioners can get involved in promoting and implementing effective and sustainable policies, systems, programs, and practices that support individual, community, and national efforts.

Timing of umbilical cord-clamping and infant anaemia: the role of maternal anaemia

BACKGROUND

Evidence from randomized controlled trials has shown that delayed cord-clamping is beneficial to infant iron status. The role of maternal anaemia in this relationship, however, has not been established.

OBJECTIVE

To determine the effect of maternal anaemia at delivery on the association between timing of umbilical cord-clamping and infant anaemia at 4 and 8 months of age.

METHODS

A cohort of pregnant women admitted to the labour room of Hospital Iquitos (Iquitos, Peru) and their newborns were recruited into the study during two time periods (18 May to 3 June and 6-20 July 2009). Between the two recruitment periods, the hospital's policy changed from early to delayed umbilical cord-clamping. Maternal haemoglobin levels were measured before delivery, and the time between delivery and cord-clamping was recorded at delivery for the entire cohort. Mother-infant pairs were followed-up at 4 (n = 207) and 8 months (n = 184) post partum. Infant haemoglobin levels were measured at follow-up visits. Data were analysed using logistic regression models.

RESULTS

The prevalence of maternal anaemia (Hb <11.0 g/dl) at delivery was 22%. Infant haemoglobin levels at 4 and 8 months of age were 10.4 g/dl and 10.3 g/dl, respectively. Infant haemoglobin levels did not differ significantly between infants born to anaemic mothers and those born to non-anaemic mothers at either 4 or 8 months of age. However, the association between the timing of cord-clamping and infant anaemia was modified by the mother's anaemia status. Significant benefits of delayed cord-clamping in preventing anaemia were found in infants born to anaemic mothers at both 4 months (aOR = 0.59, 95% CI 0.36-0.99) and 8 months (aOR = 0.38, 95% CI 0.19-0.76) of age.

CONCLUSION

The study contributes additional evidence in support of delayed cord-clamping. This intervention is likely to have most public health impact in areas with a high prevalence of anaemia during pregnancy.

Control of iron deficiency anemia in low- and middle-income countries

Despite worldwide economic and scientific development, more than a quarter of the world’s population remains anemic, and about half of this burden is a result of iron deficiency anemia (IDA). IDA is most prevalent among preschool children and women. Among women, iron supplementation improves physical and cognitive performance, work productivity, and well-being, and iron during pregnancy improves maternal, neonatal, infant, and even long-term child outcomes. Among children, iron may improve cognitive, psychomotor, and physical development, but the evidence for this is more limited. Strategies to control IDA include daily and intermittent iron supplementation, home fortification with micronutrient powders, fortification of staple foods and condiments, and activities to improve food security and dietary diversity. The safety of routine iron supplementation in settings where infectious diseases, particularly malaria, are endemic remains uncertain. The World Health Organization is revising global guidelines for controlling IDA. Implementation of anemia control programs in developing countries requires careful baseline epidemiologic evaluation, selection of appropriate interventions that suit the population, and ongoing monitoring to ensure safety and effectiveness. This review provides an overview and an approach for the implementation of public health interventions for controlling IDA in low- and middle-income countries, with an emphasis on current evidence-based recommendations.

Effect of iron supplementation on development of iron deficiency anemia in breastfed infants

This trial aimed to investigate the effect of iron supplementation on the development of iron deficiency anemia. The study encompassed 6-month-old infants who had been exclusively breastfed in the first 4 months of life. Infants in the supplemented group were given 1 mg kg(-1 )day(-1) ferrous sulfate for 6 months starting at 6 months of age. Blood samples were taken at age 12 months. A 3-day-diet was evaluated at 1 year of age. Data of 51 infants in the supplemented and 54 infants in the control group were analyzed. Mean hemoglobin values were similar in the two groups at the age of 12 months. Mean ferritin level of the supplemented group was significantly higher than that of the control. There was a significant positive correlation between dietary iron intake and hemoglobin levels. Nutrition might be more important than iron supplementation in preventing iron deficiency anemia during infancy.

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

BACKGROUND

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

AIMS

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

STUDY DESIGN

Prospective cohort study.

SUBJECTS

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

OUTCOME MEASURES

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

RESULTS

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

CONCLUSION

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

Targeted provision of oral iron: the evolution of a practical screening option

Universal oral iron supplementation, undertaken according to 1998 WHO guidelines, produced adverse consequences among some children in malaria-endemic areas. Prompted by the Pemba trial, which revealed excessive hospitalizations and deaths, WHO advised that iron supplementation in such regions be accompanied by previous screening for iron deficiency. This agenda, however, poses issues of cost, benefit, acceptability, technical feasibility, and reliability of such screening. The cost of equipment and personnel is balanced against savings from iron supplements spared and treatment for morbidity averted. Costs aside, the most efficacious acceptable screening approach for avoiding hospitalization and deaths must be fielded. Screening before supplementation can be used to assess hematological, iron, and possible inflammatory status to differentiate the source of decreased hemoglobin concentration. Iron deficiency has often been inferred from hematological status markers. The need for extraction of blood, albeit capillary in origin, and high assay costs limit the use of validated methods in screening. Noninvasive methods, i.e., not requiring the extraction of blood, provide the most acceptable and potentially least expensive approach for determining hematological or iron status. Although a noninvasive technique for iron and inflammatory status would be the ideal, it is unattained. Field-friendly, skin-probe hemoglobin devices, derived from instruments for clinical settings, are being developed and tested for eventual rollout in malarial areas. Given a firm grounding for the theoretical requirements needed to advance the screening agenda, evaluation and monitoring of the performance of screening devices can proceed hand in hand.

Underlying factors associated with anemia in Amazonian children: a population-based, cross-sectional study

Background

Although iron deficiency is considered to be the main cause of anemia in children worldwide, other contributors to childhood anemia remain little studied in developing countries. We estimated the relative contributions of different factors to anemia in a population-based, cross-sectional survey.

Methodology

We obtained venous blood samples from 1111 children aged 6 months to 10 years living in the frontier town of Acrelândia, northwest Brazil, to estimate the prevalence of anemia and iron deficiency by measuring hemoglobin, erythrocyte indices, ferritin, soluble transferrin receptor, and C-reactive protein concentrations. Children were simultaneously screened for vitamin A, vitamin B₁₂, and folate deficiencies; intestinal parasite infections; glucose-6-phosphate dehydrogenase deficiency; and sickle cell trait carriage. Multiple Poisson regression and adjusted prevalence ratios (aPR) were used to describe associations between anemia and the independent variables.

Principal Findings

The prevalence of anemia, iron deficiency, and iron-deficiency anemia were 13.6%, 45.4%, and 10.3%, respectively. Children whose families were in the highest income quartile, compared with the lowest, had a lower risk of anemia (aPR, 0.60; 95%CI, 0.37–0.98). Child age (<24 months, 2.90; 2.01–4.20) and maternal parity (>2 pregnancies, 2.01; 1.40–2.87) were positively associated with anemia. Other associated correlates were iron deficiency (2.1; 1.4–3.0), vitamin B₁₂ (1.4; 1.0–2.2), and folate (2.0; 1.3–3.1) deficiencies, and C-reactive protein concentrations (>5 mg/L, 1.5; 1.1–2.2).

Conclusions

Addressing morbidities and multiple nutritional deficiencies in children and mothers and improving the purchasing power of poorer families are potentially important interventions to reduce the burden of anemia.

Scientific Opinion on the welfare of cattle kept for beef production and the welfare in intensive calf farming systems

Information given in previous Opinions "Welfare of cattle kept for beef production" (SCAHAW, 2001) and "The risks of poor welfare in intensive calf farming systems" (EFSA, 2006) is updated and recent scientific evidence on the topics reviewed. Risks of poor welfare are identified using a structured analysis, and issues not identified in the SCAHAW (2001) beef Opinion, especially effects of housing and management on enteric and respiratory diseases are reviewed. The Opinion covers all systems of beef production, although the welfare of suckler cows or breeding bulls is not considered. The Chapter on beef cattle presents new evidence and recommendations in relation to heat and cold stress, mutilations and pain management, digestive disorders linked to high concentrate feeds and respiratory disorders linked to overstocking, inadequate ventilation, mixing of animals and failure of early diagnosis and treatment. Major welfare problems in cattle kept for beef production, as identified by risk assessment, were respiratory diseases linked to overstocking, inadequate ventilation, mixing of animals and failure of early diagnosis and treatment, digestive disorders linked to intensive concentrate feeding, lack of physically effective fibre in the diet, and behavioural disorders linked to inadequate floor space, and co-mingling in the feedlot. Major hazards for white veal calves were considered to be iron-deficiency anaemia, a direct consequence of dietary iron restriction, enteric diseases linked to high intakes of liquid feed and inadequate intake of physically effective fibre, discomfort and behavioural disorders linked to inadequate floors and floor space.

Accelerating improvements in nutritional and health status of young children in the Sahel region of Sub-Saharan Africa: review of international guidelines on infant and young child feeding and nutrition

The United Nations Convention on the Rights of the Child holds governments responsible to ensure children's right to the highest attainable standard of health by providing breastfeeding support, and access to nutritious foods, appropriate health care, and clean drinking water. International experts have identified key child care practices and programmatic activities that are proven to be effective at reducing infant and young child undernutrition, morbidity, and mortality. Nevertheless, progress towards reducing the prevalence of undernutrition has been sporadic across countries of the Sahel sub-region of Sub-Saharan Africa. In view of this uneven progress, a working group of international agencies was convened to 'Reposition children's right to adequate nutrition in the Sahel.' The first step towards this goal was to organize a situational analysis of the legislative, research, and programmatic activities related to infant and young child nutrition (IYCN) in six countries of the sub-region: Burkina Faso, Chad, Mali, Mauritania, Niger, and Senegal. The purposes of this introductory paper are to review current information concerning the nutritional and health status of infants and young children in the Sahel and to summarize international guidelines on optimal IYCN practices. These guidelines were used in completing the above-mentioned situational analyses and encompass specific recommendations on: (i) breastfeeding (introduction within the first hour after birth, exclusivity to 6 months, continuation to at least 24 months); (ii) complementary feeding (introduction at 6 months, use of nutrient dense foods, adequate frequency and consistency, and responsive feeding); (iii) prevention and/or treatment of micronutrient deficiencies (vitamin A, zinc, iron and anaemia, and iodine); (iv) prevention and/or treatment of acute malnutrition; (v) feeding practices adapted to the maternal situation to reduce mother-to-child transmission of HIV; (vi) activities to ensure food security; and (vii) the promotion of hygienic practices concerning food preparation and storage and environmental sanitation. The following papers in this issue will present results of the situational analyses for the individual countries.

Iron-fortified milk and noodle consumption is associated with lower risk of anemia among children aged 6-59 mo in Indonesia

BACKGROUND

Anemia is common among children in developing countries and is associated with decreased cognitive and physical development. Iron-fortified foods may decrease child anemia.

OBJECTIVE

The objective was to describe the association between iron-fortified milk and iron-fortified noodle consumption and anemia in children aged 6-59 mo.

DESIGN

Consumption of fortified milk and fortified noodles and child anemia were assessed in 81,885 families from rural and 26,653 families from urban slum areas in Indonesia.

RESULTS

The proportions of children who received fortified milk and noodles were 30.1% and 22.6%, respectively, in rural families and 40.1% and 48.9%, respectively, in urban families. The prevalence of anemia among children from rural families was 55.9% and from urban families was 60.8%. Children from rural and urban families were less likely to be anemic if they received fortified milk [odds ratio (OR): 0.76; 95% CI: 0.72, 0.80 (P < 0.0001) and OR: 0.79; 95% CI: 0.74, 0.86 (P < 0.0001), respectively] but not fortified noodles [OR: 0.98; 95% CI: 0.93, 1.09 (P = 0.56) and OR: 0.95; 95% CI: 0.88, 1.02 (P = 0.16), respectively] in multiple logistic regression models with adjustment for potential confounders. In rural families, the odds of anemia were lower when the child who consumed fortified milk also consumed fortified noodles or when the child who consumed fortified noodles also consumed fortified milk.

CONCLUSIONS

In Indonesia, consumption of fortified milk and noodles was associated with decreased odds of child anemia. Iron-fortified milk and noodles may be a strategy that could be applied more widely as an intervention to decrease child anemia.

Effects of iron supplementation in nonanemic pregnant women, infants, and young children on the mental performance and psychomotor development of children: a systematic review of randomized controlled trials

BACKGROUND

Uncertainty exists regarding the effects of iron supplementation on neurodevelopmental outcomes in the absence of anemia.

OBJECTIVE

Our objective was to evaluate the effects of iron supplementation in nonanemic pregnant women and in nonanemic healthy children aged <3 y on the mental performance and psychomotor development of children.

DESIGN

In this systematic review, MEDLINE, EMBASE, and The Cochrane Library were searched through December 2009 for randomized controlled trials (RCTs).

RESULTS

None of 5 RCTs individually showed a beneficial effect of iron supplementation during early life on the Mental Developmental Index of the Bayley Scales of Infant Development at different ages throughout the first 18 mo. Meta-analysis of 3 RCTs (n = 561) showed that, compared with placebo, supplementation with iron had no significant effect on children's Mental Developmental Index at approximately 12 mo of age (weighted mean difference: 1.66; 95% CI: -0.14, 3.47). Three of 5 RCTs showed a beneficial effect of iron supplementation on the Psychomotor Development Index at some time points, whereas 2 did not. Meta-analysis of 3 RCTs (n = 561) showed significant improvement on the Psychomotor Development Index at approximately 12 mo of age in the iron-supplemented group compared with the control group (weighted mean difference: 4.21; 95% CI: 2.31, 6.12). Two RCTs showed no effect of iron supplementation on behavior. Neither of the 2 RCTs that addressed the influence of prenatal iron supplementation showed an effect of iron on either the intelligence quotient or behavioral status of the children.

CONCLUSION

Limited available evidence suggests that iron supplementation in infants may positively influence children's psychomotor development, whereas it does not seem to alter their mental development or behavior.

Perinatal nutrition and immunity to infection

Epidemiological data provide strong evidence for a relationship between undernutrition and life-threatening infection in infants and children. However, the mechanisms that underlie this relationship are poorly understood. Through foetal life, infancy and childhood, the immune system undergoes a process of functional maturation. The adequacy of this process is dependent on environmental factors, and there is accumulating evidence of the impact of pre- and post-natal nutrition in this regard. This review outlines the impact of nutrition during foetal and infant development on the capacity to mount immune responses to infection. It provides an overview of the epidemiologic evidence for such a role and discusses the possible mechanisms involved.

Interdisciplinary Translational Research in Anthropology, Nutrition, and Public Health

This review focuses on several human population health research topics that exemplify interdisciplinary concepts and approaches from anthropology, nutrition, and public health with an emphasis on applied or translational global health implications. First, a recent study on neonatal survival in a resource-poor region emphasizes how health can be markedly improved with detailed translation and implementation of evidence from all three disciplines. Second, schistosomiasis, a parasitic worm infection, is reviewed with an emphasis on developing a consensus of its nutritional health burdens and the next translational research steps needed to improve control of both infection transmission and disease. Last, the author's long-term Samoan nutrition and health studies are described with a focus on new translational research to improve diabetes. This selective review attempts to provide a rationale for the intersections of anthropology, nutrition, and public health to proceed with fundamental biological, cultural, and behavioral research to reduce health inequalities globally and domestically.

Iron metabolism, malaria, and other infections: what is all the fuss about?

This article briefly describes how iron lies at the center of a host-pathogen battle for nutrients and why there are many theoretical reasons to suspect that administration of supplemental iron might predispose to infection. This is supported by in vitro and small animal studies, but meta-analysis of human epidemiological and intervention studies has found little evidence for most disease outcomes. Supplemental iron does appear to increase susceptibility to malaria as measured by a variety of malariometric indices. However, even in malarious areas, iron appears beneficial in iron-deficient subjects. The concerns about iron supplementation programs for children seem to be confined to Sub-Saharan Africa and to areas of high malaria endemicity, where it will be necessary to adopt a cautious approach to supplementation based either on screening out iron-replete children or combining iron administration with effective disease-control strategies.

Why iron deficiency is important in infant development

Infants who experience iron deficiency during the first 6-12 mo of life are likely to experience persistent effects of the deficiency that alter functioning in adulthood. A lack of sufficient iron intake may significantly delay the development of the central nervous system as a result of alterations in morphology, neurochemistry, and bioenergetics. Depending on the stage of development at the time of iron deficiency, there may be an opportunity to reverse adverse effects, but the success of repletion efforts appear to be time dependent. Publications in the past several years describe the emerging picture of the consequences of iron deficiency in both human and animal studies. The mechanisms for iron accumulation in the brain and perhaps redistribution are being understood. The data in human infants are consistent with altered myelination of white matter, changes in monoamine metabolism in striatum, and functioning of the hippocampus. Rodent studies also show effects of iron deficiency during gestation and lactation that persist into adulthood despite restoration of iron status at weaning. These studies indicate that gestation and early lactation are likely critical periods when iron deficiency will result in long-lasting damage.

Setting the stage for child health and development: prevention of iron deficiency in early infancy

Iron deficiency is estimated to be the most common nutritional deficiency worldwide and is particularly persistent among infants and children. The high prevalence of anemia in 6- to 9-mo-old children raises the concern that birth iron stores in some infants are inadequate to sustain growth and development through the first 6 mo of life, and postnatal factors are contributing to early depletion of iron stores and development of anemia. At the same time, there are concerns about negative effects of excess iron in infants. Maternal iron status, infant birth weight and gestational age, as well as the timing of umbilical cord clamping at birth all contribute to the establishment of adequate total body iron at birth. Postnatally, feeding practices and growth rate are factors that will affect how quickly birth iron is depleted during the first 6 mo of life. Under conditions in which maternal iron status, birth weight, gestational age, and umbilical cord clamping time are optimal, and exclusive breast-feeding is practiced, infants should have adequate iron stores for the first 6-8 mo of life. Under suboptimal conditions, infants may not reach this goal and may need to be targeted for iron supplementation before 6 mo of age.

Iron deficiency in young children in low-income countries and new approaches for its prevention

Anemia resulting from severe iron deficiency (ID) is the most prevalent and widespread nutrition-related health problem in infants and young children in low-income countries and has proven very resistant to prevention through public health interventions. Accumulative evidence from animal and human studies suggests that such deficiencies are associated with large adverse effects on child cognitive and motor development. Therefore, effective interventions to improve iron status will have large health benefits. Action to reduce young child ID would benefit from overarching policy and programmatic guidance that informs decision makers about what to do, when to do it, and how to do it. The impetus for new approaches to prevent ID in young children reflects growing recognition of the need to intervene early and often and for better vehicles to deliver iron. Prevention of ID requires strong delivery systems that enhance consumer demand and promote compliance. When this occurs, the prevalence of anemia is greatly reduced.