Iron interventions for women and children in low-income countries

Female rats consuming an iron and omega-3 fatty acid deficient diet preconception require combined iron and omega-3 fatty acid supplementation for the prevention of bone impairments in offspring

We previously showed in rats that pre- and postnatal deficiencies in iron and omega-3 (n-3) fatty acids can impair bone development, with additive and potentially irreversible effects when combined. This study aimed to investigate, in female rats consuming a combined iron and n-3 fatty acid deficient (ID + n-3 FAD) diet preconception, whether supplementation with iron and docosahexaenoic/eicosapentaenoic acid (DHA/EPA), alone and in combination, can prevent bone impairments in offspring. Using a 2 × 2 factorial design, female Wistar rats consuming an ID + n-3 FAD diet preconception were randomised to receive an: 1) iron supplemented (Fe + n-3 FAD), 2) DHA/EPA supplemented (ID + DHA/EPA), 3) Fe + DHA/EPA, or 4) ID + n-3 FAD diet from gestational day 10 throughout pregnancy and lactation. Post-weaning, offspring (n = 24/group; male:female = 1:1) remained on the respective experimental diets for three weeks until postnatal day 42-45. Offspring born to female rats consuming a control diet preconception and an Fe+DHA/EPA diet throughout pregnancy and lactation served as non-deficient reference group (Control+Fe+DHA/EPA). Bone mineral density (BMD) was measured using dual-energy X-ray absorptiometry and bone strength using three-point bending tests. Only offspring in the Fe+DHA/EPA group had significantly higher spine and femur BMD, and higher femur stiffness than offspring in the ID + n-3 FAD group, and had similar spine BMD and femur stiffness as the Control + Fe + DHA/EPA group. Offspring in the Fe + DHA/EPA group further had significantly higher femur strength (ultimate load) than the other experimental groups, and a similar femur strength as the Control + Fe + DHA/EPA group. This study shows that only combined iron and DHA/EPA supplementation can prevent bone impairments in offspring of female rats consuming an iron and n-3 FA deficient diet preconception.

Effectiveness of intermittent iron and high-dose vitamin A supplementation on cognitive development of school children in southern Ethiopia: a randomized placebo-controlled trial

BACKGROUND

Iron is an essential mineral whose deficiency results in cognitive alteration, impaired emotional behaviors, and altered myelination and neurotransmission. In animal models, it has been shown that vitamin A (VA) could affect cognition.

OBJECTIVES

The study aimed to evaluate the effectiveness of intermittent iron and VA supplementation on cognitive development of schoolchildren, and to assess the interaction between these supplementations.

METHODS

Considering a 2 × 2 factorial design, 504 children were randomly assigned to 1 of the 4 arms: placebo VA and placebo iron supplement; high-dose vitamin VA and placebo iron supplement; iron supplement and placebo VA; and iron and high-dose vitamin VA supplements. Cognitive development was assessed using Raven's Coloured Progressive Matrices, digit span, Tower of London, and visual search tasks.

RESULTS

The mean [± standard deviation (SD)] age of the enrolled children was 9.6 (±1.6) y. One-fifth of the children had iron deficiency or anemia, whereas 2.9%, 3.9%, and 12.1% of children had low iron stores, iron deficiency anemia, and VA deficiency, respectively. Intermittent iron supplementation did not result in any significant improvement of children's cognitive development and had a negative effect on the performance index of the visual search task compared with placebo (-0.17 SD, 95% confidence interval: -0.32, -0.02). Effects were evident among children with stunting, thinness, or children coming from understimulating home environments. High-dose VA supplementation resulted in a significant improvement of digit span z-score with a mean difference of 0.30 SD (95% confidence interval: 0.14, 0.46) compared with placebo VA. VA had a more beneficial impact for girls, children infected with helminths, and those from food secure households.

CONCLUSION

In a population where the prevalence of iron deficiency is low, intermittent iron supplementation did not have any or negative effect on the child's cognitive development outcomes. Conversely, VA supplementation improved the child's working memory.

TRIAL REGISTRATION NUMBER

The study is registered at clinicaltrials.gov as NCT04137354 (https://clinicaltrials.gov/study/NCT04137354).

Iron status and cardiometabolic risk in children

AIM

We aimed to evaluate associations between serum ferritin and transferrin and variables related to the metabolic syndrome (MetS) in children.

METHODS

Cross-sectional and longitudinal study in prepubertal children(n=832) aged 3-14 years. A subset(n=203) were re-examined after a mean follow-up of 3.7±0.8 years[range 2-6]. Outcomes were MetS and MetS components scores, glycosylated haemoglobin (HbA1c), and their follow-up change.

RESULTS

Children with low ferritin had increased HbA1c Z scores (ANCOVA,P=0.003). Ferritin was inversely associated with glycaemia [fully adjusted β (95% confidence interval): -2.35(-4.36 to -0.34)]. Transferrin was associated with diastolic blood pressure[β: 0.02(0.01-0.04)] and log-HOMA-IR [β:0.001(0.0005-0.002)]. MetS risk score worsened during follow-up in children with the lowest baseline ferritin levels. In contrast, at baseline ferritin was positively associated with all (except glycaemia) the MetS-related variables but adjustments for inflammatory, hepatic function, and body mass markers attenuated those associations(P>0.05).

CONCLUSIONS

Lower iron status was independently associated with glycaemic markers and MetS in children, whereas higher ferritin levels were related to other cardiometabolic risk markers under the influence of inflammation, hepatic injury and body mass. Research is required to study whether this mixed pattern is part of an early risk or would be explained by a normal transition during growth and development.

Global profile of anemia during pregnancy versus country income overview: 19 years estimative (2000-2019)

Anemia is a worldwide public health problem that is worst in low- and middle-income countries (LMICs), reaching 60% of prevalence. The etiology of anemia is diverse and multifactorial, with iron deficiency being the most prevalent, and often found in pregnant women. Iron is indispensable for the production of red blood cells and approximately 80% of the available heme iron is used for hemoglobin synthesis in mature erythroblasts. Iron deficiency affects oxygen transport, compromising energy and muscle metabolism and can occur with depletion of iron storage, defective erythropoiesis, and low hemoglobin levels. We analyzed anemia prevalence in pregnant women from 2000 to 2019 worldwide correlating them with current (2022) country income, with especial attention to LMICs using WHO dataset. Our analysis indicates that pregnant women from LMICs had a higher probability (40%) of anemia during pregnancy especially those from Africa and South Asia. Africa and the Americas showed a higher decrease in the prevalence of anemia from 2000 to 2019. The Americas and Europe have a lower prevalence, concentrated in 57% of most upper-middle- and high-income countries. Black women are also more prone to develop anemia during pregnancy, especially if they are from LMICs. However, the prevalence of anemia appears to decrease with an increase in educational level. In conclusion, anemia prevalence fluctuated from 5.2 to 65.7% worldwide in 2019, validating it as a public health problem.

Risks of Anaemia Among Pre-School Children Following Maternal Nutrition Education and Counselling in Urban Informal Settlements of Nairobi, Kenya

Slum environment may pose risk to child health and nutrition. This study assessed the risks of anemia among under five-year-old children, five years after implementing a nutrition education and counseling intervention in two urban slums in Nairobi, Kenya. A cross-sectional study was conducted in May 2018 as a follow-up of a randomized controlled study carried out between 2012-2015. A trained nurse measured hemoglobin levels of 438 children from households which participated in the initial study. Multivariate logistic regression was conducted to identify risks of anemia. The mean (+SD) age of the children was 55.9 (5.3) months and mean (+SD) hemoglobin was 10.7 (1.5) g/dL. Anemia prevalence was 59.8%, 33.9% had mild, 24.7% moderate, and 1.2% severe anemia. Absence of home toilet (AOR = 3.31; 95% CI, 1.20-9.09), household which paid to use a toilet facility (AOR = 1.86; 95% CI, 1.12-3.08), child's frequency of eating colored fruits and vegetables (AOR = 0.28; 95% CI, 0.08-0.96), meat and meat products (AOR = 0.31; 95% CI, 0.23-6.01), number of meals a child aged <15years ate a day preceding the study (AOR = 1.49; 95% CI, 1.14-1.98), and a mother who had a history of anemia (AOR = 2.89; 95% CI, 1.22-12.01), were factors significantly associated with child's anemia status. The environment of urban informal settings influences child anemia status. Further studies with interventions are therefore required in order to improve sanitation facilities and access to meats, fruits, and vegetables in urban slums through innovative kitchen gardens and small animal husbandry.

Association of Maternal and Child Anemia With Brain Structure in Early Life in South Africa

Importance

Anemia affects millions of pregnant women and their children worldwide, particularly in low- and middle-income countries. Although anemia in pregnancy is a well-described risk factor for cognitive development, the association with child brain structure is poorly understood.

Objective

To explore the association of anemia during pregnancy and postnatal child anemia with brain structure in early life.

Design, Setting, and Participants

This neuroimaging nested cohort study was embedded within the Drakenstein Child Health Study (DCHS), a population-based birth cohort in South Africa. Pregnant individuals were enrolled into the DCHS between 2012 and 2015 from 2 clinics in a periurban setting. Mother-child pairs were assessed prospectively; follow-up is ongoing. A subgroup of children had brain magnetic resonance imaging (MRI) at age 2 to 3 years from 2015 to 2018. This study focused on the 147 pairs with structural neuroimaging and available hemoglobin data. Data analyses were conducted in 2021 and 2022.

Exposures

Mothers had hemoglobin measurements during pregnancy, and a subgroup of children had hemoglobin measurements during early life. Anemia was classified as hemoglobin levels less than 11 g/dL based on World Health Organization guidelines; children younger than 6 months were classified using local guidelines.

Main Outcomes and Measures

Child brain volumes of global, subcortical, and corpus callosum structures were quantified using T1-weighted MRI. Linear regression models were used to analyze the associations between maternal and child anemia with child brain volumes, accounting for potential confounders.

Results

Of 147 children (mean [SD] age at MRI, 34 [2] months; 83 [56.5%] male) with high-resolution MRI scans, prevalence of maternal anemia in pregnancy was 31.3% (46 of 147; median [IQR] gestation of measurement: 13 [9-20] weeks). Maternal anemia during pregnancy was significantly associated with smaller volumes of the child caudate bilaterally (adjusted percentage difference, -5.30% [95% CI, -7.01 to -3.59]), putamen (left hemisphere: -4.33% [95% CI, -5.74 to -2.92]), and corpus callosum (-7.75% [95% CI, -11.24 to -4.26]). Furthermore, antenatal maternal hemoglobin levels were also associated with brain volumes in the caudate (left hemisphere: standardized β = 0.15 [95% CI, 0.02 to 0.28]; right hemisphere: β = 0.15 [95% CI, 0.02 to 0.27]), putamen left hemisphere (β = 0.21 [95% CI, 0.07 to 0.35]), and corpus callosum (β = 0.24 [95% CI, 0.09 to 0.39]). Prevalence of child anemia was 52.5% (42 of 80; median [IQR] age of measurement: 8.0 [2.7 to 14.8] months). Child anemia was not associated with brain volumes, nor did it mediate the association of maternal anemia during pregnancy with brain volumes.

Conclusions and Relevance

In this cohort study, anemia in pregnancy was associated with altered child brain structural development. Given the high prevalence of antenatal maternal anemia worldwide, these findings suggest that optimizing interventions during pregnancy may improve child brain outcomes.

The Influence of Intensive Nutritional Education on the Iron Status in Infants

Iron is an essential nutrient for a child’s proper development at every growth stage. It is crucial for the production of red blood and muscle cells, DNA replication, and the development of the brain, nervous and immune systems. Iron deficiency is the most common micronutrient deficiency in children worldwide. Despite widespread access to nutritional information for children, parents continue to make many feeding mistakes. This study aimed to assess whether any nutritional intervention would affect the iron status in children. The parents of 203 children were randomly assigned to one of two groups: the study group received intensive mobile nutritional education for a year, while the control group received no intervention. Blood tests were performed on both groups at the beginning of the study and one year later. The educational intervention resulted in statistically significantly higher levels of RBC (red blood cells; p = 0.020), HGB (haemoglobin; p = 0.039), HCT (haematocrit; p = 0.036), MCV (mean cell volume; p = 0.018) parameters and iron dietary intake (p ≤ 0.001). Even a non-targeted dietary intervention improves the iron status in children. As iron management is insufficient in most children, an iron-targeted nutritional intervention appears necessary.

Coverage of Iron and Folic Acid Supplementation in India: Progress Under the Anemia Mukt Bharat Strategy 2017-2020

High prevalence of anemia is a severe public health problem in India. In 2018, India launched the Anemia Mukt Bharat (AMB) strategy that focuses on six beneficiary groups for coverage, six institutional mechanisms for health system strengthening and six programmatic interventions to accelerate reductions in anemia prevalence. This paper uses the Health Management Information System (HMIS) data (2017-18 to 2019-20) to examine gains in IFA coverage across Indian states. A coverage based AMB index is computed to review performance across states. After the launch of AMB strategy, the IFA supplementation coverage between 2017-18 and 2019-20 has increased for all beneficiary groups (pregnant women from 78% to 90%; lactating mothers from 34% to 49%; school going adolescent girls (boys) from 23% to 40% (21% to 42%); out-of-school adolescent girls from 6% to 23%; children 5-9 years from 8% to 3%; and, children 6-59 months from 7% to 15%). Coverage was relatively low for target groups being served through a multi-departmental convergence mechanism (health and other departments such as education department for schools or women and child development department for anganwadi centres) than compared to those served by health department alone. However, no major gender disparities are noted in the coverage of IFA supplementation among school-going girls and boys. Bulk of the variations in coverage is attributable to state-specific differences. Training and sensitization workshops for state and district officials are found to be associated with increased coverage across beneficiary groups. The paper argues that despite following international best practices in the field it is important to harness synergy in program implementation across line departments to eliminate coverage inefficiencies.

Effects and Reversibility of Pre- and Post-natal Iron and Omega-3 Fatty Acid Deficiency, Alone and in Combination, on Bone Development in Rats

Both iron and omega-3 (n-3) polyunsaturated fatty acids may play an important role in bone development. The aim of this study was to investigate the effects of pre- and post-natal iron and n-3 fatty acid deficiency (FAD), alone and in combination, on bone development in rats, and to determine whether effects are reversible when a sufficient diet is provided post-weaning. Using a 2×2-factorial design, 56 female Wistar rats were allocated to one of four diets: (1) control, (2) iron deficient (ID), (3) n-3 FAD or (4) ID and n-3 FAD, and were maintained on the respective diets throughout gestation and lactation. At weaning (post-natal day [PND] 21), offspring (n = 24/group; male:female=1:1) were randomly allocated to either continue with their respective diets or to switch to the control diet until PND 42-45. Bone mineral density (BMD) and bone strength were determined using dual X-ray absorptiometry and three-point bending tests, respectively. Pre- and post-natal ID resulted in significantly lower BMD in the spine and bone strength in the left femur. Both ID and n-3 FAD resulted in lower BMD in the right femur, with an additive reduction in the combined ID and n-3 FAD group vs. controls. While negative effects of pre- and post-natal ID alone were reversed in offspring switched to a control diet post-weaning, lower BMD and bone strength persisted in offspring with combined ID and n-3 FAD during the prenatal and early post-natal period. Effects were not sex-specific. These results indicate that ID during early life may negatively influence bone development, with potential additive effects of n-3 FAD. While the effects of ID alone seem reversible, a combined ID and n-3 FAD may result in irreversible deficits in bone development.

Prevalence and approaches to manage iron deficiency anemia (IDA)

Iron is a vital micronutrient required for growth and development at all stages of human life. Its deficiency is the primary cause of anemia that poses a significant global health problem and challenge for developing countries. Various risks are involved during iron deficiency anemia (IDA), such as premature delivery, low birth weight, etc. Further, it affects children's cognitive functioning, delays motor development, hampers physical performance and quality of life. It also speeds up the morbidity and mortality rate among women. The major reasons accountable are elevated iron demand in diet, socio-economic status, and disease condition. Various strategies have been adopted to reduce the IDA occurrence, such as iron supplementation, iron fortificants salts, agronomic practices, dietary diversification, biofortification, disease control measures, and nutritional education. Usually, the staple food groups for fortification are considered, but the selection of food fortificants and their combination must be safe for the consumers and not alter the finished product's stability and acceptability. Genetically modified breeding practices also increase the micronutrient levels of cereal crops. Therefore, multiple strategies could be relied on to combat IDA.

A community-based randomized controlled trial providing weekly iron-folic acid supplementation increased serum- ferritin, -folate and hemoglobin concentration of adolescent girls in southern Ethiopia

Adequate micronutrient status during adolescence can break the inter-generational cycle of malnutrition. This study evaluated the effect of community-based weekly iron-folic acid supplementation (WIFAS) on serum ferritin (SF), serum folate (SFol) and hemoglobin concentration (Hb) among adolescent girls. A community-based, individually randomized-controlled trial (RCT) was conducted in four villages of Wolaita and Hadiya zones. Adolescent girls (n = 226) aged 10-19 years were recruited and randomly assigned (n = 113/group) into: (i) WIFAS and (ii) control (no intervention) groups. Anthropometry, Hb concentration, and serum ferritin (SF), SFol, and C-reactive protein (CRP) was analyzed at baseline and endline. Baseline Hb, SF, SFol and CRP concentrations were similar in both groups (P > 0.05). About 47-49% of adolescents had marginal iron store (< 50 µg/l). Hb, SF, and SFol concentrations increased in the intervention group, but not in the control group (P < 0.05). Marginal iron store decreased from 49 to 12% after 3-months of WIFAS; whereas, the proportion of adolescents with elevated SF (> 15 µg/l) was slightly higher in the WIFAS than in the control group (P = 0.06). After adjusting for confounding factors in the multiple linear regression model, a three-months WIFAS intervention was associated with an improvement of 4.10 ng/ml in serum folate, 39.1 μg/l in serum ferritin, and 1.2 g/dl in hemoglobin concentration relative to the control group (P < 0.001). WIFAS intervention for three-months was effective in reducing iron and folate deficiency in adolescent girls. Future studies should evaluate the long-term impact of intermittent WIFAS.

Adherence to prenatal iron–folic acid supplementation and associated factors among pregnant women attending antenatal care services in Dilla town, South Ethiopia

Background:

During pregnancy, due to the physiological and hormonal change, the requirement of iron–folic acid is enhanced. Therefore, the occurrence of iron/folic acid deficiency is relatively high and it is responsible for 95% of anemia during pregnancy.

Objectives:

The aim of this study was to assess adherence to prenatal iron–folic acid supplementation (IFAS) and associated factors among pregnant women attending antenatal care services at public health facilities of Dilla town.

Methods:

Facility-based cross-sectional study design was employed selecting 403 pregnant women attending antenatal care services in three public health institutions of Dilla town. The women were included in the study by simple random sampling. Data were collected by interview and document review. Then it was entered into EPI Data version 3.1 and exported to SPSS version 20 for analysis. Bivariate and multivariate binary logistic regression techniques were used to identify independent predictors. A p-value <0.05 was taken as indication of statistical significance.

Results:

From the total of planned 403 pregnant women, 396 participated in the study, with a response rate of 98.2%. Of these, 172 (43.4%) pregnant women were adhered to IFAS. The study also revealed that history of previous anemia (adjusted odds ratio (AOR) = 1.87; 95% confidence interval (CI): (1.01–3.47); p = 0.04), frequency of antenatal care center (ANC) visits (AOR = 2.51; 95% CI: (1.17–5.37); p = 0.01), knowledge of IFA supplement (AOR = 2.28; 95% CI: (1.36–3.82); p = 0.002), and knowledge of anemia (AOR = 2.30; 95% CI: (1.40–3.77); p = 0.001) were independent predictors of adherence to IFAS.

Conclusion:

The finding of this study showed that less than half of the pregnant women were adhered to IFAS. History of previous anemia, frequency of ANC visits, knowledge of IFA supplement, and knowledge of anemia were the factors associated with adherence to IFA supplement.

Prevalence and Predictors of Anemia Among Children Aged 6-23 Months in Dodota District, Southeast Ethiopia: A Community-Based Cross-Sectional Study

Background

Globally, anemia is a public health problem affecting children living in both developed and developing countries with bad consequences on children’s cognitive, social, and economic development.

Objective

To assess the prevalence and predictors of anemia among children aged 6–23 months residing at Dodota district, Southeast Ethiopia.

Methods

A community-based cross-sectional study was conducted from January–July 2019, at Dodota district, in Southeast Ethiopia. Multistage, random, and systematic sampling techniques were employed to recruit households and study participants. Trained community health extension workers were involved in the data collection. Data were entered into Epi_info 7.2.2 for clean-up and exported to SPSS 21 for analysis. Frequency and proportion were used to describe nominal and ordinal variables. Mean with SD were used to describe continuous variables. Pearson correlation coefficient was used to assess correlation between numeric variables. Regressional analysis was used to assess factors predicting the occurrence of anemia. P<0.05 with 95% CI was considered significant.

Results

A total of 917 children were included and the prevalence of anemia was found to be 407 (44.4%, 95% CI=41.1–47.4). When stratified to age category, the prevalence of anemia was highest among the age group of 6–12 months. Lack of ANC visits, lack of iron supplementation during pregnancy, untimely initiation of complementary feeding, and initiation of cow’s milk before 1 year of age were factors associated with anemia.

Conclusion

The prevalence of anemia was at the level of major public health problems. Antenatal and obstetric factors as well as child feeding practices were risk factors associated with anemia; and utilizing obstetric and childcare practices is highly recommended to mitigate this public health problem.

Maternal Compliance to Recommended Iron and Folic Acid Supplementation in Pregnancy, Sri Lanka: A Hospital-Based Cross-Sectional Study

Iron deficiency anaemia during pregnancy is a common public health problem that negatively affects maternal and newborn health. This study aims to identify the rate of maternal compliance with the recommended iron and folic acid (IFA) supplementation during pregnancy and to identify factors associated with maternal compliance and non-compliance. A hospital-based cross-sectional study was conducted among 703 women at 0-4 days postpartum. The prevalence of anaemia at the initial antenatal clinic (ANC) visit and at the third trimester were 20.8% and 44.9%, respectively. The rate of IFA supplementation compliance during pregnancy was 80.1%. Forgetfulness (66.9%) was the major reason for non-compliance, followed by side effects (15.7%). Maternal employment [OR (95%CI): 1.7 (1.00-2.89)], history of a low birth weight infant [OR (95%CI): 0.4 (0.19-0.9)] and history of anaemia [OR (95%CI): 0.4 (0.12-0.98] were significantly associated with maternal compliance with IFA supplementation. Only 26.6% of the participants adhered to dietary recommendations during the period when IFA supplements were provided. The rate of maternal compliance with IFA supplementation was high. However, the prevalence of maternal anaemia during pregnancy was also high, which was presumably due to poor dietary compliance despite high IFA supplementation compliance.

Integrating Calcium Into Antenatal Iron-Folic Acid Supplementation in Ethiopia: Women's Experiences, Perceptions of Acceptability, and Strategies to Support Calcium Supplement Adherence

Recommendations for antenatal calcium supplementation to prevent preeclampsia could substantially reduce maternal mortality, but adherence to multiple daily doses may constrain effectiveness. World Health Organization guidelines recommend 3 daily calcium supplements (1.5-2 g/d), taken separately from 1 iron-folic acid (IFA) supplement; however, limited data suggest lower calcium doses may also be effective. We conducted mixed-methods household trials to identify strategies for supporting adherence and integrating calcium into antenatal IFA supplementation programming in Ethiopia. Participants were randomly assigned to 3 regimens varying in dose and timing and were later given a choice of regimens. Semistructured interviews conducted over 6 weeks explored acceptability, barriers, and facilitators and offered opportunities to choose calcium pill type. Interviews were transcribed, translated, and analyzed thematically. Calcium adherence was measured using medication event monitoring. All participants (N=48) agreed to try supplementation. Adherence barriers included forgetting to take pills when busy or travelling and perceived side effects. Midday doses were the most challenging because of farming, market, and social events; women avoided taking supplements in public due to fear of being perceived as HIV positive. Social support from families, visual reminders, and anticipated benefits motivated adherence. More participants (75%) selected chewable versus conventional supplements due to organoleptic properties, but this preference declined over time. Adherence rates did not substantially differ across regimens with 2 (81.1%), 3 (83.4%), or 4 (77.1%) pill-taking events. Women indicated that the 2-event regimen was more acceptable than 3- and 4-event regimens, but this acceptability was not associated with higher adherence. Consequently, mean daily calcium consumption (811.3 mg) was lower than for 3-event (1,251.1 mg) and 4-event (1,156.4 mg) regimens. Integrating calcium into antenatal IFA supplementation is acceptable to Ethiopian women, with a 3-event regimen yielding the highest consumption rates. Despite women experiencing challenges with midday dosing and stigma, using simple home-based strategies and being counseled on the purpose of supplementation were more effective than reducing dosage for mitigating barriers and improving adherence.

Home fortification of foods with multiple micronutrient powders for health and nutrition in children under two years of age

BACKGROUND

Vitamin and mineral deficiencies, particularly those of iron, vitamin A, and zinc, affect more than two billion people worldwide. Young children are highly vulnerable because of rapid growth and inadequate dietary practices. Multiple micronutrient powders (MNPs) are single-dose packets containing multiple vitamins and minerals in powder form, which are mixed into any semi-solid food for children six months of age or older. The use of MNPs for home or point-of-use fortification of complementary foods has been proposed as an intervention for improving micronutrient intake in children under two years of age. In 2014, MNP interventions were implemented in 43 countries and reached over three million children. This review updates a previous Cochrane Review, which has become out-of-date.

OBJECTIVES

To assess the effects and safety of home (point-of-use) fortification of foods with MNPs on nutrition, health, and developmental outcomes in children under two years of age. For the purposes of this review, home fortification with MNP refers to the addition of powders containing vitamins and minerals to semi-solid foods immediately before consumption. This can be done at home or at any other place that meals are consumed (e.g. schools, refugee camps). For this reason, MNPs are also referred to as point-of-use fortification.

SEARCH METHODS

We searched the following databases up to July 2019: CENTRAL, MEDLINE, Embase, and eight other databases. We also searched four trials registers, contacted relevant organisations and authors of included studies to identify any ongoing or unpublished studies, and searched the reference lists of included studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs with individual randomisation or cluster-randomisation. Participants were infants and young children aged 6 to 23 months at the time of intervention, with no identified specific health problems. The intervention consisted of consumption of food fortified at the point of use with MNP formulated with at least iron, zinc, and vitamin A, compared with placebo, no intervention, or use of iron-containing supplements, which is standard practice.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the eligibility of studies against the inclusion criteria, extracted data from included studies, and assessed the risk of bias of included studies. We reported categorical outcomes as risk ratios (RRs) or odds ratios (ORs), with 95% confidence intervals (CIs), and continuous outcomes as mean differences (MDs) and 95% CIs. We used the GRADE approach to assess the certainty of evidence.

MAIN RESULTS

We included 29 studies (33,147 children) conducted in low- and middle-income countries in Asia, Africa, Latin America, and the Caribbean, where anaemia is a public health problem. Twenty-six studies with 27,051 children contributed data. The interventions lasted between 2 and 44 months, and the powder formulations contained between 5 and 22 nutrients. Among the 26 studies contributing data, 24 studies (26,486 children) compared the use of MNP versus no intervention or placebo; the two remaining studies compared the use of MNP versus an iron-only supplement (iron drops) given daily. The main outcomes of interest were related to anaemia and iron status. We assessed most of the included studies at low risk of selection and attrition bias. We considered some studies to be at high risk of performance and detection bias due to lack of blinding. Most studies were funded by government programmes or foundations; only two were funded by industry. Home fortification with MNP, compared with no intervention or placebo, reduced the risk of anaemia in infants and young children by 18% (RR 0.82, 95% CI 0.76 to 0.90; 16 studies; 9927 children; moderate-certainty evidence) and iron deficiency by 53% (RR 0.47, 95% CI 0.39 to 0.56; 7 studies; 1634 children; high-certainty evidence). Children receiving MNP had higher haemoglobin concentrations (MD 2.74 g/L, 95% CI 1.95 to 3.53; 20 studies; 10,509 children; low-certainty evidence) and higher iron status (MD 12.93 μg/L, 95% CI 7.41 to 18.45; 7 studies; 2612 children; moderate-certainty evidence) at follow-up compared with children receiving the control intervention. We did not find an effect on weight-for-age (MD 0.02, 95% CI -0.03 to 0.07; 10 studies; 9287 children; moderate-certainty evidence). Few studies reported morbidity outcomes (three to five studies each outcome) and definitions varied, but MNP did not increase diarrhoea, upper respiratory infection, malaria, or all-cause morbidity. In comparison with daily iron supplementation, the use of MNP produced similar results for anaemia (RR 0.89, 95% CI 0.58 to 1.39; 1 study; 145 children; low-certainty evidence) and haemoglobin concentrations (MD -2.81 g/L, 95% CI -10.84 to 5.22; 2 studies; 278 children; very low-certainty evidence) but less diarrhoea (RR 0.52, 95% CI 0.38 to 0.72; 1 study; 262 children; low-certainty of evidence). However, given the limited quantity of data, these results should be interpreted cautiously. Reporting of death was infrequent, although no trials reported deaths attributable to the intervention. Information on side effects and morbidity, including malaria and diarrhoea, was scarce. It appears that use of MNP is efficacious among infants and young children aged 6 to 23 months who are living in settings with different prevalences of anaemia and malaria endemicity, regardless of intervention duration. MNP intake adherence was variable and in some cases comparable to that achieved in infants and young children receiving standard iron supplements as drops or syrups.

AUTHORS' CONCLUSIONS

Home fortification of foods with MNP is an effective intervention for reducing anaemia and iron deficiency in children younger than two years of age. Providing MNP is better than providing no intervention or placebo and may be comparable to using daily iron supplementation. The benefits of this intervention as a child survival strategy or for developmental outcomes are unclear. Further investigation of morbidity outcomes, including malaria and diarrhoea, is needed. MNP intake adherence was variable and in some cases comparable to that achieved in infants and young children receiving standard iron supplements as drops or syrups.

Biofortification of Pulse Crops: Status and Future Perspectives

Biofortification through plant breeding is a sustainable approach to improve the nutritional profile of food crops. The majority of the world's population depends on staple food crops; however, most are low in key micronutrients. Biofortification to improve the nutritional profile of pulse crops has increased importance in many breeding programs in the past decade. The key micronutrients targeted have been iron, zinc, selenium, iodine, carotenoids, and folates. In recent years, several biofortified pulse crops including common beans and lentils have been released by HarvestPlus with global partners in developing countries, which has helped in overcoming micronutrient deficiency in the target population. This review will focus on recent research advances and future strategies for the biofortification of pulse crops.

Fortification of rice with vitamins and minerals for addressing micronutrient malnutrition

BACKGROUND

Rice fortification with vitamins and minerals has the potential to increase the nutrition in rice-consuming countries where micronutrient deficiencies exist. Globally, 490 million metric tonnes of rice are consumed annually. It is the dominant staple food crop of around three billion people.

OBJECTIVES

To determine the benefits and harms of rice fortification with vitamins and minerals (iron, vitamin A, zinc or folic acid) on micronutrient status and health-related outcomes in the general population.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL, and 16 other databases all up to 10 December 2018. We searched ClinicalTrials.gov, and World Health Organization International Clinical Trials Registry Platform (ICTRP) on 10 December 2018.

SELECTION CRITERIA

We included randomised and quasi-randomised trials (with either individual or cluster randomisation) and controlled before-and-after studies. Participants were populations older than two years of age (including pregnant women) from any country. The intervention was rice fortified with at least one micronutrient or a combination of several micronutrients (iron, folic acid, zinc, vitamin A or other vitamins and minerals) compared with unfortified rice or no intervention.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Two review authors independently screened studies and extracted data.

MAIN RESULTS

We included 17 studies (10,483 participants) and identified two ongoing studies. Twelve included studies were randomised-controlled trials (RCTs), with 2238 participants after adjusting for clustering in two cluster-RCTs, and five were non-randomised studies (NRS) with four controlled before-and-after studies and one cross-sectional study with a control (8245 participants). Four studies were conducted in India, three in Thailand, two in the Philippines, two in Brazil, one each in Bangladesh, Burundi, Cambodia, Indonesia, Mexico and the USA. Two studies involved non-pregnant, non-lactating women and 10 involved pre-school or school-age children. All 17 studies reported fortification with iron. Of these, six studies fortified rice with iron only; 11 studies had other micronutrients added (iron, zinc and vitamin A, and folic acid). One study had one arm each with vitamin A alone and carotenoid alone. Elemental iron content ranged from 0.2 to 112.8 mg/100 g uncooked rice given for a period varying from two weeks to 48 months. Thirteen studies did not clearly describe either sequence generation or allocation concealment. Eleven studies had a low attrition rate. There was no indication of selective reporting in the studies. We considered two RCTs at low overall risk of bias and 10 at high overall risk of bias. One RCT was at high or unclear risk of bias for most of the domains. All controlled before-and-after studies had a high risk or unclear risk of bias in most domains. The included studies were funded by Government, private and non-governmental organisations, along with other academic institutions. The source of funding does not appear to have altered the results. We used the NRS in the qualitative synthesis but we excluded them from the quantitative analysis and review conclusions since they provided mostly contextual information and limited quantitative information. Rice fortified with iron alone or in combination with other micronutrients versus unfortified rice (no micronutrients added) Fortification of rice with iron (alone or in combination with other micronutrients) may make little or no difference in the risk of having anaemia (risk ratio (RR) 0.72, 95% confidence interval (CI) 0.54 to 0.97; I² = 74%; 7 studies, 1634 participants; low-certainty evidence) and may reduce the risk of iron deficiency (RR 0.66, 95% CI 0.51 to 0.84; 8 studies, 1733 participants; low-certainty evidence). Rice fortification may increase mean haemoglobin (mean difference (MD) 1.83, 95% CI 0.66 to 3.00; I² = 54%; 11 studies, 2163 participants; low-certainty evidence) and it may make little or no difference to vitamin A deficiency (with vitamin A as one of the micronutrients in the fortification arm) (RR 0.68, 95% CI 0.36 to 1.29; I² = 37%; 4 studies, 927 participants; low-certainty evidence). One study reported that fortification of rice (with folic acid as one of the micronutrients) may improve serum or plasma folate (nmol/L) (MD 4.30, 95% CI 2.00 to 6.60; 215 participants; low-certainty evidence). One study reported that fortification of rice with iron alone or with other micronutrients may slightly increase hookworm infection (RR 1.78, 95% CI 1.18 to 2.70; 785 participants; low-certainty evidence). We are uncertain about the effect of fortified rice on diarrhoea (RR 3.52, 95% CI 0.18 to 67.39; 1 study, 258 participants; very low-certainty evidence). Rice fortified with vitamin A alone or in combination with other micronutrients versus unfortified rice (no micronutrients added) One study had one arm providing fortified rice with vitamin A only versus unfortified rice. Fortification of rice with vitamin A (in combination with other micronutrients) may increase mean haemoglobin (MD 10.00, 95% CI 8.79 to 11.21; 1 study, 74 participants; low-certainty evidence). Rice fortified with vitamin A may slightly improve serum retinol concentration (MD 0.17, 95% CI 0.13 to 0.21; 1 study, 74 participants; low-certainty evidence). No studies contributed data to the comparisons of rice fortification versus no intervention. The studies involving folic acid and zinc also involved iron in the fortification arms and hence we reported them as part of the first comparison.

AUTHORS' CONCLUSIONS

Fortification of rice with iron alone or in combination with other micronutrients may make little or no difference in the risk of having anaemia or presenting iron deficiency and we are uncertain about an increase in mean haemoglobin concentrations in the general population older than 2 years of age. Fortification of rice with iron and other micronutrients such as vitamin A or folic acid may make little or no difference in the risk of having vitamin A deficiency or on the serum folate concentration. There is limited evidence on any adverse effects of rice fortification.

Iron Fortification and Bioavailability of Chickpea (Cicer arietinum L.) Seeds and Flour

Iron (Fe) deficiency is one of the most common nutritional disorders, and is mainly due to insufficient intake of bioavailable Fe. Chickpea (Cicer arietinum L.) was examined as a potential vehicle for Fe fortification. Fortificants (FeSO₄·7H₂O (ferrous sulfate hepta-hydrate), FeSO₄·H₂O (ferrous sulfate mono-hydrate) and NaFeEDTA (ethylenediaminetetraacetic acid iron (iii) sodium salt)) were applied by a spraying and drying method. At 2000 µg g^-1 iron fortificant, the fortified split desi seeds (dal), desi flour and kabuli flour supplied 18-19 mg, 16-20 mg and 11-19 mg Fe per 100 g, respectively. The overall consumer acceptability using a nine-point hedonic scale for sensory evaluation demonstrated that NaFeEDTA-fortified cooked chickpea (soup and chapatti) scored the highest among the three fortificants. Lightness (L*), redness (a*) and yellowness (b*) of Fe-fortified products changed over time. However, no organoleptic changes occurred. Fe bioavailability was increased by 5.8-10.5, 15.3-25.0 and 4.8-9.0 ng ferritin mg^-1 protein for cooked split desi seeds (soup), desi chapatti and kabuli chapatti, respectively, when prepared using Fe-fortified chickpea. Desi chapatti showed significantly higher Fe bioavailability than the other two. The increase in Fe concentration and bioavailability in fortified chickpea products demonstrated that these products could provide a significant proportion of the recommended daily Fe requirement.

Nutrients’ and Antinutrients’ Seed Content in Common Bean (Phaseolus vulgaris L.) Lines Carrying Mutations Affecting Seed Composition

Lectins, phytic acid and condensed tannins exert major antinutritional effects in common bean when grains are consumed as a staple food. In addition, phaseolin, i.e., the major storage protein of the bean seed, is marginally digested when introduced in the raw form. Our breeding target was to adjust the nutrient/antinutrient balance of the bean seed for obtaining a plant food with improved nutritional value for human consumption. In this study, the seeds of twelve phytohaemagglutinin-E-free bean lines carrying the mutations low phytic acid, phytohaemagglutinin-L-free, α-Amylase inhibitors-free, phaseolin-free, and reduced amount of condensed tannins, introgressed and differently combined in seven genetic groups, were analyzed for their nutrient composition. Inedited characteristics, such as a strong positive correlation (+0.839**) between the genetic combination “Absence of phaseolin + Presence of the α-Amylase Inhibitors” and the amount of “accumulated iron and zinc”, were detected. Three lines carrying this genetic combination showed a much higher iron content than the baseline (+22.4%) and one of them in particular, achieved high level (+29.1%; 91.37 µg g−1) without any specific breeding intervention. If confirmed by scientific verification, the association of these genetic traits might be usefully exploited for raising iron and zinc seed content in a bean biofortification breeding program.

School Feeding Reduces Anemia Prevalence in Adolescent Girls and Other Vulnerable Household Members in a Cluster Randomized Controlled Trial in Uganda

BACKGROUND

Food for education (FFE) programs that include school meals are widely used to improve school participation and performance, but evidence on nutritional benefits is limited.

OBJECTIVE

This study tested whether food fortified with multiple micronutrients provided in FFE programs reduced anemia prevalence of primary-school-age adolescent girls, adult women, and preschool children.

METHODS

Through the use of a cluster randomized controlled trial with individual-level repeated cross-sectional data, we measured impacts on anemia prevalence from 2 FFE programs, a school feeding program (SFP) providing multiple-micronutrient-fortified meals and a nutritionally equivalent take-home ration (THR). Camps for internally displaced people (IDP) (n = 31) in Northern Uganda were randomly assigned to SFP, THR, or a control group with no FFE. Rations were provided for 15 mo at SFP and THR schools. A survey of households (n = 627) with children aged 6-17 y was conducted (baseline and 18 mo later). Analyses used difference-in-differences by intent to treat.

RESULTS

Adolescent girls aged 10-13 y in FFE schools experienced a significant (P < 0.05) 25.7 percentage point reduction (95% CI: -0.43, -0.08) in prevalence of any anemia [hemoglobin (Hb) <11.5 g/dL, age 10-11 y; Hb <12 g/dL, age 12-13 y] and a significant 19.5 percentage point reduction (95% CI: -0.35, -0.04) in moderate-to-severe anemia (Hb <11 g/dL) relative to the control group, with no difference in impact between SFP and THR. The THR reduced moderate-to-severe anemia prevalence (Hb <11g/dL) of adult women aged ≥18 y (12.8 percentage points, 95% CI: -0.24, -0.02). All IDP camps initially received micronutrient-fortified rations through a separate humanitarian program; in one district where most households stopped receiving these rations, SFP reduced moderate-to-severe anemia of children aged 6-59 mo by 22.1 percentage points (95% CI: -0.42, -0.02).

CONCLUSIONS

FFE programs reduced any anemia and moderate-to-severe anemia in primary-school-age adolescent girls and reduced moderate-to-severe anemia for adult women and preschool children. This study was registered with clinicaltrials.gov as NCT01261182.

Prevalence and risk factors of anemia in children aged from 6 to 59 months in Togo: analysis from Togo demographic and health survey data, 2013-2014

BACKGROUND

Anemia in children continues to be a major public health challenge in developing countries and particularly in Sub-Saharan Africa. Anemia has serious consequences on the growth and development of the children in the early stages of life. This study aimed to determine the prevalence and associated factors of anemia among children from 6 to 59 months in Togo.

METHODS

Data from the Togo Demographic and Health Survey 2013-2014 were used for this study. This nationally representative survey provided data on a wide range of indicators such as mother and child health, nutrition and other characteristics. Anemia status was determined using hemoglobin level (Hb < 11.0 g/dl), and the weighted prevalence of childhood anemia along with 95% confidence intervals were provided. Data were analyzed using logistic regression models to estimate odds ratios (OR) and their 95% confidence intervals (95% CI) for associated factors.

RESULTS

Two thousand eight hundred ninety children aged 6-59 months were included in this analysis. The weighted prevalence of anemia was 70.9% [95% CI = 68.8-73.1] with 2.6% [95% CI = 2.0-3.3] of severe anemia among these children. In the multivariate analysis, the adjusted odds ratio (aOR) for anemia was 0.33 [95% CI = 0.26-0.42] in children aged from 24 to 42 months and 0.22 [95% CI = 0.17-0.29] in children aged from 43 to 59 months. Children's malaria status was strongly associated to childhood anemia with an aOR of 3.03 [95% CI = 2.49-3.68]. The secondary level of education and more for the mother was associated to childhood anemia with an aOR of 0.67 [95% CI = 0.52-0.86]. The aOR for children whose mother had anemia was 1.62 [95% CI = 1.30-2.02].

CONCLUSION

This study has highlighted the high prevalence of childhood anemia in Togo and revealed that younger children and maternal anemia were positively associated to childhood anemia whereas age of children and high level of maternal education were negatively associated to childhood anemia.

Feasibility of integrating calcium and iron-folate supplementation to prevent preeclampsia and anemia in pregnancy in primary healthcare facilities in Kenya

Calcium (Ca) supplementation to prevent preeclampsia can save maternal and newborn lives, but there are no program models for integration into existing antenatal care platforms. We used a program impact pathway model to guide the design of integrated Ca and iron-folate (IFA) supplementation in Kenya. We provided healthcare providers with job aids (posters and counseling cards), trained them on counseling techniques and supplementation guidelines, and developed behavior change materials for pregnant women (pill-taking calendars). We allocated health facilities to prescribe either 1.0 or 1.5 g/day Ca, with standard IFA. We collected implementation data from 16 facilities and 990 women. We also explored effects of supplementation on percentage of the population meeting recommended daily allowance. Supplements and job aids were available during 90% of facility spot-check episodes; calendar availability was lower (78%). Over 98% of clients received Ca and IFA supplements, but only 76% received enough Ca supplements to last between antenatal care visits. Among clients that still had pills by return date, adherence was 77% and 83% for the IFA and Ca regimen, respectively. When 1.5 g/day of Ca supplements were prescribed, over 75% of participants met recommended daily allowance. Only 54% met the recommended daily allowance when 1.0 g was prescribed. This study illustrates a systematic approach for integrating Ca supplementation into primary healthcare and demonstrates that such integration is feasible when contextual bottlenecks are addressed. Policy makers and program planners should pay attention to supply chain, healthcare worker dispensing behavior, and appropriateness of regimen for their settings.

Integrating nutrition into health systems at community level: Impact evaluation of the community-based maternal and neonatal health and nutrition projects in Ethiopia, Kenya, and Senegal

Maternal undernutrition and mortality remain high in several African countries. Key nutrition and health interventions improve maternal and birth outcomes. Evidence is scarce on how to strengthen health systems to ensure pregnant women and newborns are reached with these interventions. We conducted three quasi-experimental nonrandomized Community Based Maternal and Neonatal Health and Nutrition projects in regions of Ethiopia, Senegal, and Kenya to demonstrate how proven nutrition interventions could be integrated into health programs to improve knowledge and practices during pregnancy, birth, and postpartum. We evaluated impact on knowledge and practices related to maternal and neonatal care using logistic regression and repeated-measures models with districts as a fixed variable and adjusted for covariates. Combined country analyses show significant positive effects of the intervention on women receiving first antenatal care visit (ANC) during first trimester (OR = 1.44; p < .001), those consuming any iron and folic acid supplement during their latest pregnancy (OR = 1.60; p = .005), those whose <6 months infants were exclusively breastfed (OR = 2.01; p=.003), those whose delivery was facility based (OR = 1.48; p=.031), and those whose postnatal care was facility based (OR = 2.15; p<.001). There was no significant differences between intervention and control groups regarding one or more and four or more ANC visits, women consuming iron and folic acid for ≥90 days, and early initiation of breastfeeding. We conclude that integrating proven nutrition interventions into health programs at community level improved components of access to and use of ANC, delivery services, and postnatal care by women in three African countries.

Factors associated with socio-demographic characteristics and antenatal care and iron supplement use in Ethiopia, Kenya, and Senegal

Antenatal care (ANC) offers remarkable opportunities to reach a large number of women with effective nutrition and health interventions, including iron (Fe) supplementation. However, all women do not equally seek nor benefit from ANC. We aimed to identify characteristics associated with ANC and Fe use among women in hard-to-reach areas in Afar, Ethiopia; Sedhiou and Kolda, Senegal; and Kakamega, Kenya. Women who gave birth within 1 year preceding the survey (n = 4,575) from 15 different sub-regions were randomly selected and surveyed. Multivariable logistic regression was used to identify associations of socio-demographic characteristics with ANC and Fe use. Factors that showed positive associations with ANC uptake included education, income, possession of a mobile phone, and the occupation of the mother or another household member. Beginning ANC in the first trimester associated positively with achievement of 4 or more ANC visits, and having any ANC visits related positively with Fe intake. Distance to the nearest health facility was negatively associated, and type of nearest facility and counselling and health education were positively associated with some outcomes. The results from these surveys demonstrate the need to ensure access of services across all population groups and can help identify ANC programming needs.

Integrated point-of-care testing (POCT) of HIV, syphilis, malaria and anaemia in antenatal clinics in western Kenya: A longitudinal implementation study

Background

In sub-Saharan Africa, HIV, syphilis, malaria and anaemia are leading preventable causes of adverse pregnancy outcomes. In Kenya, policy states women should be tested for all four conditions (malaria only if febrile) at first antenatal care (ANC) visit. In practice, while HIV screening is conducted, coverage of screening for the others is suboptimal and early pregnancy management of illnesses is compromised. This is particularly evident at rural dispensaries that lack laboratories and have parallel programmes for HIV, reproductive health and malaria, resulting in fractured and inadequate care for women.

Methods

A longitudinal eight-month implementation study integrating point-of-care diagnostic tests for the four conditions into routine ANC was conducted in seven purposively selected dispensaries in western Kenya. Testing proficiency of healthcare workers was observed at initial training and at three monthly intervals thereafter. Adoption of testing was compared using ANC register data 8.5 months before and eight months during the intervention. Fidelity to clinical management guidelines was determined by client exit interviews with success defined as ≥90% adherence.

Findings

For first ANC visits at baseline (n = 529), testing rates were unavailable for malaria, low for syphilis (4.3%) and anaemia (27.8%), and near universal for HIV (99%). During intervention, over 95% of first attendees (n = 586) completed four tests and of those tested positive, 70.6% received penicillin or erythromycin for syphilis, 65.5% and 48.3% received cotrimoxazole and antiretrovirals respectively for HIV, and 76.4% received artemether/lumefantrine, quinine or dihydroartemisinin–piperaquine correctly for malaria. Iron and folic supplements were given to nearly 90% of women but often at incorrect doses.

Conclusions

Integrating point-of-care testing into ANC at dispensaries with established HIV testing programmes resulted in a significant increase in testing rates, without disturbing HIV testing rates. While more cases were detected and treated, treatment fidelity still requires strengthening and an integrated monitoring and evaluation system needs to be established.

Design and implementation of a health systems strengthening approach to improve health and nutrition of pregnant women and newborns in Ethiopia, Kenya, Niger, and Senegal

Maternal and neonatal mortality are unacceptably high in developing countries. Essential nutrition interventions contribute to reducing this mortality burden, although nutrition is poorly integrated into health systems. Universal health coverage is an essential prerequisite to decreasing mortality indices. However, provision and utilization of nutrition and health services for pregnant women and their newborns are poor and the potential for improvement is limited where health systems are weak. The Community-Based Maternal and Neonatal Health and Nutrition project was established as a set of demonstration projects in 4 countries in Africa with varied health system contexts where there were barriers to safe maternal health care at individual, community and facility levels. We selected project designs based on the need, context, and policies under consideration. A theory driven approach to programme implementation and evaluation was used involving developing of contextual project logic models that linked inputs to address gaps in quality and uptake of antenatal care; essential nutrition actions in antenatal care, delivery, and postnatal care; delivery with skilled and trained birth attendant; and postnatal care to outcomes related to improvements in maternal health service utilization and reduction in maternal and neonatal morbidity and mortality. Routine monitoring and impact evaluations were included in the design. The objective of this paper is to describe the rationale and methods used in setting up a multi-country study that aimed at designing the key maternal and neonatal health interventions and identifying indicators related to inputs, outcomes, and impact that were measured to track change associated with our interventions.

Barriers and enablers for iron folic acid (IFA) supplementation in pregnant women

In order to inform large scale supplementation programme design, we review and summarize the barriers and enablers for improved coverage and utilization of iron and folic acid (IFA) supplements by pregnant women in 7 countries in Africa and Asia. Mixed methods were used to analyse IFA supplementation programmes in Afghanistan, Bangladesh, Indonesia, Ethiopia, Kenya, Nigeria, and Senegal based on formative research conducted in 2012–2013. Qualitative data from focus‐group discussions and interviews with women and service providers were used for content analysis to elicit common themes on barriers and enablers at internal, external, and relational levels. Anaemia symptoms in pregnancy are well known among women and health care providers in all countries, yet many women do not feel personally at risk. Broad awareness and increased coverage of facility‐based antenatal care (ANC) make it an efficient delivery channel for IFA; however, first trimester access to IFA is hindered by beliefs about when to first attend ANC and preferences for disclosing pregnancy status. Variable access and poor quality ANC services, including insufficient IFA supplies and inadequate counselling to encourage consumption, are barriers to both coverage and adherence. Community‐based delivery of IFA and referral to ANC provides earlier and more frequent access and opportunities for follow‐up. Improving ANC access and quality is needed to facilitate IFA supplementation during pregnancy. Community‐based delivery and counselling can address problems of timely and continuous access to supplements. Renewed investment in training for service providers and effective behaviour change designs are urgently needed to achieve the desired impact.

Delivery of iron-fortified yoghurt, through a dairy value chain program, increases hemoglobin concentration among children 24 to 59 months old in Northern Senegal: A cluster-randomized control trial

Background

Innovative strategies are needed to enhance the nutritional impact of agriculture. Value chain approaches, which use supply chains to add value (usually economic) to products as they move from producers to consumers, can be used to increase access to nutritious foods and improve nutritional status. This study tested whether a dairy value chain could be used to distribute a micronutrient-fortified yoghurt (MNFY) (conditional upon the producer supplying a minimum amount of cow milk/day) to improve hemoglobin and reduce anemia among preschool children in a remote area in Northern Senegal.

Methods

A cluster randomized control trial was used to compare 204 children (24 to 59 months of age at baseline) from households who received the MNFY coupled to a behavior change communication (BCC) campaign focusing on anemia prevention to 245 children from a control group (receiving BCC only) after one year. Randomization was done at the level of the family concession (households from the same family) (n = 321). Eligible households had a child of the target age and were willing to deliver milk to the dairy factory. Changes in anemia and hemoglobin between groups were assessed using mixed regression models.

Key findings

Anemia prevalence was very high at baseline (80%) and dropped to close to 60% at endline, with no differences between intervention groups. Hemoglobin increased by 0.55 g/dL, 95%CI (0.27; 0.84) more in the intervention compared to the control group after one year, in models that controlled for potentially confounding factors. The impact was greater (0.72 g/dL, 95%CI (0.34; 1.12)) for boys, compared to girls (0.38 g/dL, 95%CI (-0.03; 0.80)).

Conclusion

The dairy value chain was a successful strategy to distribute MNFY among pastoralists in Northern Senegal, and increase Hb concentrations among their children. This study is one of the first proofs of concept showing that a nutrition-sensitive agriculture value chain approach can contribute to improved child nutrition in a remote pastoralist population.

Trial registration

ClinicalTrials.gov NCT02079961

Adherence partners are an acceptable behaviour change strategy to support calcium and iron-folic acid supplementation among pregnant women in Ethiopia and Kenya

Antenatal calcium and iron-folic acid (IFA) supplementation can reduce maternal mortality and morbidity. Yet, even when pregnant women have a stable supply of supplements, forgetting is often a barrier to adherence. We assessed the acceptability of adherence partners to support calcium and IFA supplementation among pregnant women in Kenya and Ethiopia. Adherence partners are a behaviour change strategy to improve adherence, where pregnant women are counselled to select a partner (e.g. spouse, relative) to remind them to take their supplements. We conducted trials of improved practices, a formative research method that follows participants over time as they try a new behaviour. We provided pregnant women in Ethiopia (n = 50) and Kenya (n = 35) with calcium and IFA supplements and counselling, and suggested selecting an adherence partner. For each participant, we conducted semi-structured interviews about acceptability and adherence during four interviews over six weeks. We analysed interview transcripts thematically and tallied numerical data. In Kenya, 28 of 35 women agreed to try an adherence partner; almost all selected their husbands. In Ethiopia, 42 of 50 women agreed to try an adherence partner; half asked their husbands, others asked children or relatives. Most women who did not select adherence partners reported not needing help or not having anyone to ask. Participants reported adherence partners reminded and encouraged them, brought supplements, provided food and helped address side-effects. Almost all women with adherence partners would recommend this strategy to others. Adherence partners are an acceptable, low-cost strategy with the potential to support antenatal micronutrient supplementation adherence.

Iron Supplementation Affects Hematologic Biomarker Concentrations and Pregnancy Outcomes among Iron-Deficient Tanzanian Women

BACKGROUND

Iron deficiency is a highly prevalent micronutrient abnormality and the most common cause of anemia globally, worsening the burden of adverse pregnancy and child outcomes.

OBJECTIVE

We sought to evaluate the response of hematologic biomarkers to iron supplementation and to examine the predictors of the response to iron supplementation among iron-deficient pregnant women.

METHODS

We identified 600 iron-deficient (serum ferritin ≤12 μg/L) pregnant women, aged 18-45 y, presenting to 2 antenatal clinics in Dar es Salaam, Tanzania using rapid ferritin screening tests, and prospectively followed them through delivery and postpartum. All women received 60 mg Fe and 0.25 mg folate daily from enrollment until delivery. Proportions meeting the thresholds representing deficient hematologic status including hemoglobin <110 g/L, ferritin ≤12 μg/L, serum soluble transferrin receptor (sTfR) >4.4 mg/L, zinc protoporphyrin (ZPP) >70 mmol/L, or hepcidin ≤13.3 μg/L at baseline and delivery were assessed. The prospective change in biomarker concentration and the influence of baseline hematologic status on the change in biomarker concentrations were assessed. Regression models were estimated to assess the relation of change in biomarker concentrations and pregnancy outcomes.

RESULTS

There was significant improvement in maternal biomarker concentrations between baseline and delivery, with increases in the concentrations of hemoglobin (mean difference: 15.2 g/L; 95% CI: 13.2, 17.2 g/L), serum ferritin (51.6 μg/L; 95% CI: 49.5, 58.8 μg/L), and serum hepcidin (14.0 μg/L; 95% CI: 12.4, 15.6 μg/L) and decreases in sTfR (-1.7 mg/L; 95% CI: -2.0, -1.3 mg/L) and ZPP (-17.8 mmol/L; 95% CI: -32.1, 3.5 mmol/L). The proportions of participants with low hemoglobin, ferritin, and hepcidin were 73%, 93%, and 99%, respectively, at baseline and 34%, 12%, and 46%, respectively, at delivery. The improvements in biomarker concentrations were significantly greater among participants with poor hematologic status at baseline - up to 12.1 g/L and 14.5 μg/L for hemoglobin and ferritin concentrations, respectively. For every 10-g/L increase in hemoglobin concentration, there was a 24% reduced risk of perinatal mortality (RR = 0.76; 95% CI: 0.59, 0.99) and a 23% reduced risk of early infant mortality (RR = 0.77; 95% CI: 0.60, 0.99). The risk of anemia at delivery despite supplementation was predicted by baseline anemia (RR = 2.11; 95% CI: 1.39, 3.18) and improvements in ferritin concentration were more likely to be observed in participants who took iron supplements for up to 90 d (RR = 1.41; 95% CI: 1.13, 1.76).

CONCLUSION

Iron supplementation decreases the risk of maternal anemia and increases the likelihood of infant survival among iron-deficient Tanzanian pregnant women. Interventions to promote increased duration and adherence to iron supplements may also provide greater health benefits.

Low Prevalence of Iron and Vitamin A Deficiency among Cambodian Women of Reproductive Age

Nearly half of women of reproductive age (WRA) in Cambodia are anemic. To guide interventions, national data on nutritional causes of anemia, including iron deficiency and vitamin A deficiency, are needed. In 2012, a national household survey in WRA on antibodies to routine vaccine-preventable disease immunity was performed. We used serum samples from this survey to estimate the prevalence of iron and vitamin A deficiency in 2112 Cambodian WRA, aged 15 to 39 years. Iron deficiency was classified as low or marginal iron stores (ferritin concentrations corrected for inflammation <15 μg/L and <50 μg/L respectively; Fer), iron deficient erythropoiesis (soluble transferrin receptor concentrations >8.3 mg/L; sTfR), or low total body iron (TBI) derived from Fer and sTfR concentrations (<0 mg/kg). Vitamin A status was classified using retinol binding protein (RBP) concentrations corrected for inflammation as deficient (<0.70 μmol/L) or marginal (<1.05 μmol/L. Overall, the prevalence of low iron stores, low TBI and iron deficient erythropoiesis was 8.1%, 5.0% and 9.3% respectively. Almost 40% of the women had marginal iron stores. Iron status was better in women living in urban areas compared to rural areas (p < 0.05 for TBI and sTfR). The prevalence of vitamin A deficiency was <1%. These findings suggest that the contribution of iron and vitamin A deficiency to the high prevalence of anemia in Cambodian WRA may be limited. The etiology of anemia in Cambodia needs to be elucidated further to guide current policies on anemia.

Food Insecurity Is Associated with Undernutrition but Not Overnutrition in Ecuadorian Women from Low-Income Urban Neighborhoods

Household food insecurity (HFI) is becoming an increasingly important issue in Latin America and other regions undergoing rapid urbanization and nutrition transition. The survey investigated the association of HFI with the nutritional status of 794 adult women living in households with children in low-income neighborhoods in Quito, Ecuador. Data were collected on sociodemographic characteristics, household food security status, and nutritional status indicators (dietary intake, anthropometry, and blood hemoglobin). Data were analyzed using multivariate methods. The findings identified revealed a high HFI prevalence (81%) among the urban households that was associated with lower per capita income and maternal education; long-term neighborhood residency appeared protective. HFI was associated with lower dietary quality and diversity and an increased likelihood of anemia and short stature but not increased high-calorie food intake or generalized or abdominal obesity. Although significant progress has been made in recent years, low dietary diversity, anemia, and growth stunting/short stature in the Ecuadorian maternal-child population continue to be major public health challenges. The study findings suggest that improving urban food security may help to improve these nutritional outcomes. They also underscore the need for food security policies and targeted interventions for urban households and systematic surveillance to assess their impact.

Oral iron supplements for children in malaria-endemic areas

BACKGROUND

Iron-deficiency anaemia is common during childhood. Iron administration has been claimed to increase the risk of malaria.

OBJECTIVES

To evaluate the effects and safety of iron supplementation, with or without folic acid, in children living in areas with hyperendemic or holoendemic malaria transmission.

SEARCH METHODS

We searched the Cochrane Infectious Diseases Group Specialized Register; the Cochrane Central Register of Controlled Trials (CENTRAL), published in the Cochrane Library, MEDLINE (up to August 2015) and LILACS (up to February 2015). We also checked the metaRegister of Controlled Trials (mRCT) and World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) up to February 2015. We contacted the primary investigators of all included trials, ongoing trials, and those awaiting assessment to ask for unpublished data and further trials. We scanned references of included trials, pertinent reviews, and previous meta-analyses for additional references.

SELECTION CRITERIA

We included individually randomized controlled trials (RCTs) and cluster RCTs conducted in hyperendemic and holoendemic malaria regions or that reported on any malaria-related outcomes that included children younger than 18 years of age. We included trials that compared orally administered iron, iron with folic acid, and iron with antimalarial treatment versus placebo or no treatment. We included trials of iron supplementation or fortification interventions if they provided at least 80% of the Recommended Dietary Allowance (RDA) for prevention of anaemia by age. Antihelminthics could be administered to either group, and micronutrients had to be administered equally to both groups.

DATA COLLECTION AND ANALYSIS

The primary outcomes were clinical malaria, severe malaria, and death from any cause. We assessed the risk of bias in included trials with domain-based evaluation and assessed the quality of the evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. We performed a fixed-effect meta-analysis for all outcomes and random-effects meta-analysis for hematological outcomes, and adjusted analyses for cluster RCTs. We based the subgroup analyses for anaemia at baseline, age, and malaria prevention or management services on trial-level data.

MAIN RESULTS

Thirty-five trials (31,955 children) met the inclusion criteria. Overall, iron does not cause an excess of clinical malaria (risk ratio (RR) 0.93, 95% confidence intervals (CI) 0.87 to 1.00; 14 trials, 7168 children, high quality evidence). Iron probably does not cause an excess of clinical malaria in both populations where anaemia is common and those in which anaemia is uncommon. In areas where there are prevention and management services for malaria, iron (with or without folic acid) may reduce clinical malaria (RR 0.91, 95% CI 0.84 to 0.97; seven trials, 5586 participants, low quality evidence), while in areas where such services are unavailable, iron (with or without folic acid) may increase the incidence of malaria, although the lower CIs indicate no difference (RR 1.16, 95% CI 1.02 to 1.31; nine trials, 19,086 participants, low quality evidence). Iron supplementation does not cause an excess of severe malaria (RR 0.90, 95% CI 0.81 to 0.98; 6 trials, 3421 children, high quality evidence). We did not observe any differences for deaths (control event rate 1%, low quality evidence). Iron and antimalarial treatment reduced clinical malaria (RR 0.54, 95% CI 0.43 to 0.67; three trials, 728 children, high quality evidence). Overall, iron resulted in fewer anaemic children at follow up, and the end average change in haemoglobin from base line was higher with iron.

AUTHORS' CONCLUSIONS

Iron treatment does not increase the risk of clinical malaria when regular malaria prevention or management services are provided. Where resources are limited, iron can be administered without screening for anaemia or for iron deficiency, as long as malaria prevention or management services are provided efficiently.

Beyond Effectiveness--The Adversities of Implementing a Fortification Program. A Case Study on the Quality of Iron Fortification of Fish and Soy Sauce in Cambodia

Fortification of fish and soy sauces is a cost-effective strategy to deliver and increase iron intake in the Cambodian diet, as both are widely consumed by the entire population. In order to qualify as fortified sauces recognized by international regulations, iron content must be between 230 and 460 mg/L, whilst nitrogen and salt should contain no less than 10 g/L and 200 g/L respectively. This survey aims to analyze the progress of the fortification program. Through a better understanding of its obstacles and successes, the paper will then consider approaches to strengthen the program. Two hundred and fifty two samples were collected from 186 plants and 66 markets in various provinces. They were then analyzed for iron, nitrogen and salt content. The study demonstrates that 74% of fortified fish and soy sauces comply with Cambodian regulations on iron content. 87% and 53.6% of the collected samples do not have adequate level of nitrogen and salt content, respectively. The paper will discuss additional efforts that need to be implemented to ensure the sustainability of the project, including the need to: (i) comply with International Codex; (ii) adopt mandatory legislation; and (iii) ensure enforcement.

Iron Absorption from Two Milk Formulas Fortified with Iron Sulfate Stabilized with Maltodextrin and Citric Acid

Background: Fortification of milk formulas with iron is a strategy widely used, but the absorption of non-heme iron is low. The purpose of this study was to measure the bioavailability of two iron fortified milk formulas designed to cover toddlers’ nutritional needs. These milks were fortified with iron sulfate stabilized with maltodextrin and citric acid. Methods: 15 women (33–47 years old) participated in study. They received on different days, after an overnight fast, 200 mL of Formula A; 200 mL of Formula B; 30 mL of a solution of iron and ascorbic acid as reference dose and 200 mL of full fat cow’s milk fortified with iron as ferrous sulfate. Milk formulas and reference dose were labeled with radioisotopes ⁵⁹Fe or ⁵⁵Fe, and the absorption of iron measured by erythrocyte incorporation of radioactive Fe. Results: The geometric mean iron absorption corrected to 40% of the reference dose was 20.6% for Formula A and 20.7% for Formula B, versus 7.5% of iron fortified cow’s milk (p < 0.001). The post hoc Sheffé indeed differences between the milk formulas and the cow’s milk (p < 0.001). Conclusion: Formulas A and B contain highly bioavailable iron, which contributes to covering toddlers’ requirements of this micronutrient.

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.

Factors associated with non-use of antenatal iron and folic acid supplements among Pakistani women: a cross sectional household survey

Background

World Health Organization recommends a standard daily oral dose of iron and folic acid (IFA) supplements throughout pregnancy to begin as early as possible. The aim of the present study was to determine the prevalence of use of antenatal IFA supplements, and the socio-demographic factors associated with the non-use of antenatal IFA supplements from 14 selected districts in Pakistan.

Methods

Data was derived from a cross sectional household survey conducted in 14 project districts across Pakistan. Trained female field workers conducted interviews with married women of reproductive age from December 2011 to March 2012. Women with the most recent live births in the preceding five years of the survey were selected for this study. Data was analysed by using STATA 13 and adjusted for the cluster sampling design. Multivariate logistic regression models were constructed to identify the independent factors associated with the non-use of antenatal IFA supplements.

Results

Of 6,266 women interviewed, 2,400 (38.3%, 95% CI, 36.6%, 40.1%) reported taking IFA supplements during their last pregnancy. Among IFA users, the most common source of supplements was doctors (49.4%) followed by community health workers (40.3%). The mean (±SE) number of supplements used was 76.9 (±51.6), and the mean (±SE) month of pregnancy at initiation of supplementation was 5.3 (±1.7) months. Socio-demographic factors significantly associated with the non-use of antenatal IFA supplements were living in Dera Ghazi Khan district (AdjOR: 1.72), maternal age 45 years and above (AdjOR: 1.97), no maternal education (AdjOR: 2.36), no paternal education (AdjOR: 1.58), belonging to the lowest household wealth index quartile (AdjOR: 1.47), and no use of antenatal care (ANC) services (AdjOR: 13.39).

Conclusions

The coverage of antenatal IFA supplements is very low in the surveyed districts of Pakistan, and the lack of parental education, older aged women, belonging to poorest households, residence in Dera Ghazi Khan district and no use of ANC services were all significantly associated with non-use of these supplements. These findings highlight the urgent need to develop interventions targeting all pregnant women by improving ANC coverage to increase the use of antenatal IFA supplements in Pakistan.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2393-14-305) contains supplementary material, which is available to authorized users.

Antenatal iron and folic acid supplementation use by pregnant women in Khartoum, Sudan

Background

Anaemia during pregnancy can lead to adverse maternal and perinatal outcomes. The WHO recommends that all pregnant women in areas where anaemia is prevalent receive supplements of iron and folic acid. However, due to many factors, the use of iron and folic acid supplementation is still low in many countries. This study was conducted to assess the rates of iron-folic supplementation and the associated factors during pregnancy and the effects of taking iron-folic acid supplementation on rates of maternal anaemia and low birth weight (LBW) infants.

Methods

A cross-sectional study was conducted at Khartoum Hospital, Sudan. Enrolled women answered a questionnaire on socio-demographics characteristics, their pregnancy and delivery.

Results

Of 856 women, 788 (92.1%) used iron-folic acid supplementation during pregnancy and 65.4% used folic acid. While place of residence, occupation and level of education were not associated with iron-folic acid usage, older age (OR = 3, CI = 1.4–6.3) and use of antenatal care (OR = 14.3, CI = 7.4–27.5) were associated with iron-folic acid use. Primiparity (OR = 3.8, CI = 1.9–7.6), maternal employment (OR = 3.9, CI = 2.25–6.77) and use of antenatal care (OR = 7.9, CI = 4.1–15) were the factors associated with folic acid. Using iron-folic acid was protective against anaemia (OR = 0.39, CI = 0.2–0.7) and LBW infants (OR = 0.3, CI = 0.17–0.68).

Conclusion

There was a high rate of iron-folic acid supplementation use among pregnant women in Khartoum, Sudan, which was beneficial in preventing anaemia in expectant mothers and infants of LBW.

Providing male rats deficient in iron and n-3 fatty acids with iron and alpha-linolenic acid alone affects brain serotonin and cognition differently from combined provision

Background

We recently showed that a combined deficiency of iron (ID) and n-3 fatty acids (n-3 FAD) in rats disrupts brain monoamine metabolism and produces greater memory deficits than ID or n-3 FAD alone. Providing these double-deficient rats with either iron (Fe) or preformed docosahexaenoic acid (DHA)/eicosapentaenoic acid (EPA) alone affected brain monoamine pathways differently from combined repletion and even exacerbated cognitive deficits associated with double-deficiency. Iron is a co-factor of the enzymes responsible for the conversion of alpha-linolenic acid (ALA) to EPA and DHA, thus, the provision of ALA with Fe might be more effective in restoring brain EPA and DHA and improving cognition in double-deficient rats than ALA alone.

Methods

In this study we examined whether providing double-deficient rats with ALA and Fe, alone or in combination, can correct deficits in monoamine metabolism and cognition associated with double-deficiency. Using a 2 × 2 design, male rats with concurrent ID and n-3 FAD were fed an Fe + ALA, Fe + n-3 FAD, ID + ALA, or ID + n-3 FAD diet for 5 weeks (postnatal day 56–91). Biochemical measures, and spatial working and reference memory (using the Morris water maze) were compared to age-matched controls.

Results

In the hippocampus, we found a significant Fe × ALA interaction on DHA: Compared to the group receiving ALA alone, DHA was significantly higher in the Fe + ALA group. In the brain, we found significant antagonistic Fe × ALA interactions on serotonin concentrations. Provision of ALA alone impaired working memory compared with age-matched controls, while in the reference memory task ALA provided with Fe significantly improved performance.

Conclusion

These results indicate that providing either iron or ALA alone to double-deficient rats affects serotonin pathways and cognitive performance differently from combined provision. This may be partly explained by the enhancing effect of Fe on the conversion of ALA to EPA and DHA.

The first 500 days of life: policies to support maternal nutrition

BACKGROUND

From conception to 6 months of age, an infant is entirely dependent for its nutrition on the mother: via the placenta and then ideally via exclusive breastfeeding. This period of 15 months--about 500 days--is the most important and vulnerable in a child's life: it must be protected through policies supporting maternal nutrition and health. Those addressing nutritional status are discussed here.

OBJECTIVE AND DESIGN

This paper aims to summarize research on policies and programs to protect women's nutrition in order to improve birth outcomes in low- and middle-income countries, based on studies of efficacy from the literature, and on effectiveness, globally and in selected countries involving in-depth data collection in communities in Ethiopia, India and Northern Nigeria. Results of this research have been published in the academic literature (more than 30 papers). The conclusions now need to be advocated to policy-makers.

RESULTS

The priority problems addressed are: intrauterine growth restriction (IUGR), women's anemia, thinness, and stunting. The priority interventions that need to be widely expanded for women before and during pregnancy, are: supplementation with iron-folic acid or multiple micronutrients; expanding coverage of iodine fortification of salt particularly to remote areas and the poorest populations; targeted provision of balanced protein energy supplements when significant resources are available; reducing teenage pregnancies; increasing interpregnancy intervals through family planning programs; and building on conditional cash transfer programs, both to provide resources and as a platform for public education. All these have known efficacy but are of inadequate coverage and resourcing. The next steps are to overcome barriers to wide implementation, without which targets for maternal and child health and nutrition (e.g. by WHO) are unlikely to be met, especially in the poorest countries.

CONCLUSIONS

This agenda requires policy decisions both at Ministry and donor levels, and throughout the administrative system. Evidence-based interventions are established as a basis for these decisions, there are clear advocacy messages, and there are no scientific reasons for delay.

Effect of simultaneous supplementation of vitamin A and iron on diarrheal and respiratory tract infection in preschool children in Chengdu City, China

OBJECTIVE

The goal of this study was to investigate whether vitamin A combined with iron supplementation for preschool children resulted in improved changes in children's infectious morbidity.

METHOD

In this randomized placebo-controlled and blinded field intervention trial, totally 445 preschoolers, ages 3 to 6 y old, were randomly selected. All children were randomly divided into four groups: vitamin A supplement-only group (group I), iron supplement-only group (group II), vitamin A and iron supplement group (group III), and no vitamin A and ferrous sulfate as placebo-control (group IV) for 6 mo. The morbidity of diarrhea and respiratory infections, were collected during supplementation.

RESULTS

There was evidence of the lowest incidence rate of respiratory-related illnesses and fewest symptoms of runny nose, cough, and fever for children in group III compared with children in groups I, II and IV (P < 0.05). Moreover, despite the undistinguished incidence rate of vomiting, nausea, and stomach pain, the rate of diarrhea-related illness was significantly lower for children in group III than for those in the other three groups.

CONCLUSION

The beneficial affects on infectious morbidity over 6 mo, highlight the potential of vitamin A plus an iron supplement for preschool-aged children.