The effects of prenatal and postnatal high-dose vitamin B-12 supplementation on human milk vitamin B-12: a randomized, double-blind, placebo-controlled trial in Tanzania

BACKGROUND

Vitamin B-12 status in human milk (HM) has critical implications for infant growth and development. Few studies have separately evaluated the effects of prenatal and postnatal maternal high-dose vitamin B-12 supplementation on HM vitamin B-12 concentration.

OBJECTIVES

This randomized controlled trial aimed to assess the effects of prenatal and postnatal vitamin B-12 supplementation on HM vitamin B-12 at 6 wk and 7 mo postpartum.

METHODS

Pregnant women were enrolled in Dar es Salaam, Tanzania, between 2001 and 2004. From recruitment (12-27 weeks of gestation) through 6 wk postpartum, participants were randomly assigned to daily oral multiple micronutrient supplementation or placebo. From 6 wk to 18 mo postpartum, a subset of participants was randomly assigned to a postnatal supplement or placebo. The supplement included 50 μg/d of vitamin B-12 and various other vitamins. HM vitamin B-12 concentrations were analyzed at 6 wk and 7 mo postpartum for 412 participants.

RESULTS

The prevalence of HM vitamin B-12 of <310 pmol/L was 73.3% and 68.4% at 6 wk and 7 mo postpartum, respectively. Prenatal supplementation increased HM vitamin B-12 concentration (percent difference: 34.4; 95% CI: 17.0, 54.5; P < 0.001) at 6 wk; this effect was not present at 7 mo. Postnatal supplementation increased HM vitamin B-12 concentration (percent difference: 15.9; 95% CI: 1.91, 31.9; P = 0.025) at 7 mo. Effect modification between prenatal and postnatal supplementation on HM vitamin B-12 status at 7 mo was found, with the effects of prenatal and postnatal supplements more pronounced among those receiving control during the other period; the prenatal supplement had a greater effect with postnatal control, and the postnatal supplement had a greater effect with prenatal control.

CONCLUSIONS

Prenatal maternal vitamin B-12 supplementation has benefits on short-term HM status, and postnatal maternal vitamin B-12 supplementation has benefits on long-term HM status. This trial was registered at clinicaltrials.gov as NCT00197548. https://clinicaltrials.gov/ct2/show/NCT00197548.

A Predictive Model for Thiamine Responsive Disorders among Infants and Young Children: Results from a Prospective Cohort Study in Lao People's Democratic Republic

OBJECTIVE

To develop a predictive model for thiamine responsive disorders (TRD) among infants and young children hospitalized with signs or symptoms suggestive of thiamine deficiency disorders (TDD) based on response to therapeutic thiamine in a high-risk setting.

STUDY DESIGN

Children aged 21 days to <18 months hospitalized with signs or symptoms suggestive of TDD in northern Lao PDR were treated with parenteral thiamine (100mg daily) for ≥3 days in addition to routine care. Physical examinations and recovery assessments were conducted frequently for 72 hours after thiamine was initiated. Individual case reports were independently reviewed by three pediatricians who assigned a TRD status (TRD or non-TRD), which served as the dependent variable in logistic regression models to identify predictors of TRD. Model performance was quantified by empirical area under the receiver operating characteristic curve (AUROC).

RESULTS

449 children (median [Q1, Q3] 2.9 [1.7, 5.7] months old; 70.3% exclusively/predominantly breastfed) were enrolled; 60.8% had a TRD. Among 52 candidate variables, those most predictive of TRD were exclusive/predominant breastfeeding, hoarse voice/loss of voice, cyanosis, no eye contact and no diarrhea in the previous 2 weeks. The AUROC (95% CI) was 0.82 (0.78, 0.86).

CONCLUSIONS

In this study, the majority of children with signs or symptoms of TDD responded favorably to thiamine. While five specific features were predictive of TRD, the high prevalence of TRD suggests that thiamine should be administered to all infants and children presenting with any signs or symptoms consistent with TDD in similar high-risk settings. The usefulness of the predictive model in other contexts warrants further exploration and refinement.

Effects of vitamin B12 supplementation on oxidative stress markers and pro-inflammatory cytokines during pregnancy and postpartum among Bangladeshi mother-child pairs

BACKGROUND

There is limited research to determine whether vitamin B12 (B12) supplementation during pregnancy and lactation is protective against oxidative stress and pro-inflammatory cytokines and whether this effect is transferred to breastfed infants via milk. In addition, associations among maternal plasma/ milk and infant B12 status and immune function markers are poorly characterized.

OBJECTIVES

To evaluate effects of oral B12 supplementation during pregnancy and postpartum on maternal and infant 8-hydroxy-2'-deoxyguanosine (8-OH-dG, an oxidative stress marker) and proinflammatory cytokine levels, and examine associations between maternal plasma, breastmilk and infant B12 status as well as immune function markers.

METHOD

In a blinded, placebo-controlled trial, Bangladeshi women (n = 68, 18-35 years, hemoglobin < 11 g/dL, gestational weeks 11-14) received either 250 μg/day B12 or placebo throughout pregnancy up to 3-months postpartum. Samples were collected from mothers at baseline and 3-months postpartum and from infants at 3-months to measure B12 status indicators, 8-OH-dG and proinflammatory cytokines.

RESULTS

Maternal postpartum B12 was positively associated with infant plasma B12. Higher milk B12 concentrations were associated with increased infant B12 (beta (β) = 277, 95% confidence interval (CI) = (132, 423), p<0.001) and lower total homocysteine (β = -7.63, 95% CI = (-12.40, -2.86), p = 0.002) levels. Maternal B12 supplementation reduced plasma 8-OH-dG concentrations among postpartum mothers and infants compared to the placebo group. Supplementation increased plasma TNF-α and IL-6 levels among mothers and IL-10 and IFN-γ levels among infants.

CONCLUSION

Milk and maternal plasma B12 at 3 months were associated with infant B12. Maternal B12 supplementation modulates 8-OH-dG and several cytokines which may protect against immune response-induced oxidative stress.

TRIAL REGISTRATION

(clinicaltrials.gov: NCT01795131- 1st posted on 20/02/2013).

Human Milk Micronutrients and Child Growth and Body Composition in the First 2 years: A Systematic Review

Human milk (HM) provides a plethora of nutritional and non-nutritional compounds that support infant development. For many compounds, concentrations vary substantially among mothers and across lactation, and their impact on infant growth is poorly understood. We systematically searched MEDLINE, Embase, the Cochrane Library, Scopus, and Web of Science to synthesize evidence published between 1980 and 2022 on HM components and anthropometry through 2 y of age among term-born infants. Outcomes included weight-for-length, length-for-age, weight-for-age, body mass index (in kg/m2)-for-age, and growth velocity. From 9992 abstracts screened, 144 articles were included and categorized based on their reporting of HM micronutrients, macronutrients, or bioactive components. Micronutrients (vitamins and minerals) are reported here, based on 28 articles involving 2526 mother-infant dyads. Studies varied markedly in their designs, sampling times, geographic and socioeconomic settings, reporting practices, and the HM analytes and infant anthropometrics measured. Meta-analysis was not possible because data were sparse for most micronutrients. The most-studied minerals were zinc (15 articles, 1423 dyads) and calcium (7 articles, 714 dyads). HM iodine, manganese, calcium, and zinc concentrations were positively associated with several outcomes (each in ≥2 studies), whereas magnesium (in a single study) was negatively associated with linear growth during early lactation. However, few studies measured HM intake, adjusted for confounders, provided adequate information about complementary and formula feeding, or adequately described HM collection protocols. Only 4 studies (17%) had high overall quality scores. The biological functions of individual HM micronutrients are likely influenced by other HM components; yet, only 1 study analyzed data from multiple micronutrients simultaneously, and few addressed other HM components. Thus, available evidence on this topic is largely inconclusive and fails to address the complex composition of HM. High-quality research employing chronobiology and systems biology approaches is required to understand how HM components work independently and together to influence infant growth and to identify new avenues for future maternal, newborn, or infant nutritional interventions.

Human Milk Macronutrients and Child Growth and Body Composition in the First Two Years: A Systematic Review

Among exclusively breastfed infants, human milk (HM) provides complete nutrition in the first mo of life and remains an important energy source as long as breastfeeding continues. Consisting of digestible carbohydrates, proteins, and amino acids, as well as fats and fatty acids, macronutrients in human milk have been well studied; however, many aspects related to their relationship to growth in early life are still not well understood. We systematically searched Medline, EMBASE, the Cochrane Library, Scopus, and Web of Science to synthesize evidence published between 1980 and 2022 on HM components and anthropometry through 2 y of age among term-born healthy infants. From 9992 abstracts screened, 57 articles reporting observations from 5979 dyads were included and categorized based on their reporting of HM macronutrients and infant growth. There was substantial heterogeneity in anthropometric outcome measurement, milk collection timelines, and HM sampling strategies; thus, meta-analysis was not possible. In general, digestible carbohydrates were positively associated with infant weight outcomes. Protein was positively associated with infant length, but no associations were reported for infant weight. Finally, HM fat was not consistently associated with any infant growth metrics, though various associations were reported in single studies. Fatty acid intakes were generally positively associated with head circumference, except for docosahexaenoic acid. Our synthesis of the literature was limited by differences in milk collection strategies, heterogeneity in anthropometric outcomes and analytical methodologies, and by insufficient reporting of results. Moving forward, HM researchers should accurately record and account for breastfeeding exclusivity, use consistent sampling protocols that account for the temporal variation in HM macronutrients, and use reliable, sensitive, and accurate techniques for HM macronutrient analysis.

Human Milk Bioactive Components and Child Growth and Body Composition in the First 2 Years: A Systematic Review

Human milk (HM) contains macronutrients, micronutrients, and a multitude of other bioactive factors, which can have a long-term impact on infant growth and development. We systematically searched MEDLINE, EMBASE, Cochrane Library, Scopus, and Web of Science to synthesize evidence published between 1980 and 2022 on HM components and anthropometry through 2 y of age among term-born infants. From 9992 abstracts screened, 141 articles were included and categorized based on their reporting of HM micronutrients, macronutrients, or bioactive components. Bioactives including hormones, HM oligosaccharides (HMOs), and immunomodulatory components are reported here, based on 75 articles from 69 unique studies reporting observations from 9980 dyads. Research designs, milk collection strategies, sampling times, geographic and socioeconomic settings, reporting practices, and outcomes varied considerably. Meta-analyses were not possible because data collection times and reporting were inconsistent among the studies included. Few measured infant HM intake, adjusted for confounders, precisely captured breastfeeding exclusivity, or adequately described HM collection protocols. Only 5 studies (6%) had high overall quality scores. Hormones were the most extensively examined bioactive with 46 articles (n = 6773 dyads), compared with 13 (n = 2640 dyads) for HMOs and 12 (n = 1422 dyads) for immunomodulatory components. Two studies conducted untargeted metabolomics. Leptin and adiponectin demonstrated inverse associations with infant growth, although several studies found no associations. No consistent associations were found between individual HMOs and infant growth outcomes. Among immunomodulatory components in HM, IL-6 demonstrated inverse relationships with infant growth. Current research on HM bioactives is largely inconclusive and is insufficient to address the complex composition of HM. Future research should ideally capture HM intake, use biologically relevant anthropometrics, and integrate components across categories, embracing a systems biology approach to better understand how HM components work independently and synergistically to influence infant growth.

Improving Anemia Assessment in Clinical and Public Health Settings

We aim to provide a practical approach to assess anemia and its primary causes, both in clinical settings and in the context of public health programs. Anemia remains a global challenge; thus, to achieve goals for anemia reduction and assess progress, standardized approaches are required for the assessment of anemia and its causes. We first provide a brief review of how to assess anemia, based on hemoglobin concentrations and cutoffs that correspond to age, sex, and physiologic status. Next, we discuss how to assess the likely causes of anemia in different settings. The causes of anemia are classified as non-nutritional (for example, because of infection, inflammation, blood loss, or genetic disorders) or nutrition-specific (for example, because of deficiencies of iron, vitamin A, riboflavin, vitamin B12, or folate). There is an important overlap between these 2 categories, such as the increased likelihood of iron deficiency in the context of inflammation. Given the multifaceted nature of anemia etiology, we introduce a framework for anemia assessment based on the "ecology of anemia," which recognizes its many overlapping causes. This conceptual framework is meant to inform what data on anemia causes may need to be collected in population surveys. The framework has a supporting table with information on the diagnostic tests, biomarkers and proposed cutoffs, characteristics, and feasibility of collecting the myriad information that can help elucidate the anemia etiology. We also provide examples of how this framework can be applied to interpret the anemia risk factor data from population-based surveys that can inform decisions about context-specific interventions. Finally, we present research gaps and priorities related to anemia assessment.

Maternal inflammatory, lipid and metabolic markers and associations with birth and breastfeeding outcomes

Background

Conditions in utero influence intrauterine and postnatal infant growth and a few studies indicate that maternal inflammation and insulin resistance might affect birth and breastfeeding outcomes. Furthermore, hormones in human milk (HM) may influence infant appetite-regulation and thereby milk intake, but the associations are less understood.

Objective

(1) To investigate associations between maternal inflammatory, lipid and metabolic markers and birth and breastfeeding outcomes, and (2) to assess predictors of maternal inflammatory, lipid and metabolic markers in pregnancy.

Methods

Seventy-one mother-infant dyads participating in the Mothers, Infants and Lactation Quality (MILQ) study were included in the present study. Fasting blood samples were collected around 28th gestational week, and HM samples at three time points from 1.0 to 8.5 months, where milk intake was assessed using 24-h test weighing. Maternal plasma inflammatory, lipid and metabolic markers included high-sensitive C-reactive protein (hs-CRP), tumor-necrosis factor-α (TNFα), interferon-γ (IFNγ), Interleukin (IL)-6, IL-8, high-, low-, and very-low-density lipoprotein (HDL, LDL, VLDL), total-cholesterol, triglycerides, leptin, adiponectin, insulin, C-peptide, the homeostasis model assessment of insulin resistance (HOMA-IR) and glucose concentration at t = 120 min following an oral glucose tolerance test. Of these, TNFα, IFNγ, IL-6, IL-8, leptin, adiponectin and insulin were also measured in HM samples.

Results

HDL in pregnancy was inversely associated with gestational age (GA) at birth and GA-adjusted birthweight z-score, whereas triglycerides and glucose (t = 120) were positively associated with GA-adjusted birthweight z-score. Higher hs-CRP, VLDL and triglycerides were associated with a higher placental weight. Furthermore, higher HDL, insulin, leptin and HOMA-IR were associated with longer duration of exclusive breastfeeding (EBF). Higher pre-pregnancy BMI was the main predictor of higher levels of hs-CRP, log-TNFα, leptin, insulin, C-peptide, and HOMA-IR.

Conclusion

Maternal lipid and metabolic markers influenced birthweight z-score and placental weight as well as duration of EBF. Furthermore, pre-pregnancy BMI and maternal age predicted levels of several inflammatory and metabolic markers during pregnancy. Our findings indicate that maternal lipid and metabolic profiles in pregnancy may influence fetal growth and breastfeeding, possibly explained by overweight and/or higher placental weight.

Clinical trial registration

https://clinicaltrials.gov/, identifier NCT03254329.

Ecologies, synergies, and biological systems shaping human milk composition-a report from "Breastmilk Ecology: Genesis of Infant Nutrition (BEGIN)" Working Group 2

Human milk is universally recognized as the preferred food for infants during the first 6 mo of life because it provides not only essential and conditionally essential nutrients in necessary amounts but also other biologically active components that are instrumental in protecting, communicating important information to support, and promoting optimal development and growth in infants. Despite decades of research, however, the multifaceted impacts of human milk consumption on infant health are far from understood on a biological or physiological basis. Reasons for this lack of comprehensive knowledge of human milk functions are numerous, including the fact that milk components tend to be studied in isolation, although there is reason to believe that they interact. In addition, milk composition can vary greatly within an individual as well as within and among populations. The objective of this working group within the Breastmilk Ecology: Genesis of Infant Nutrition (BEGIN) Project was to provide an overview of human milk composition, factors impacting its variation, and how its components may function to coordinately nourish, protect, and communicate complex information to the recipient infant. Moreover, we discuss the ways whereby milk components might interact such that the benefits of an intact milk matrix are greater than the sum of its parts. We then apply several examples to illustrate how milk is better thought of as a biological system rather than a more simplistic "mixture" of independent components to synergistically support optimal infant health.

Investigating donor human milk composition globally to develop effective strategies for the nutritional care of preterm infants: Study protocol

BACKGROUND

Globally, almost 15 million infants are born prematurely each year, disproportionately affecting low and middle-income countries. In the absence of mother's milk, the World Health Organization recommends using donor human milk (DHM) due to its protective effect against necrotizing enterocolitis, a life-threatening intestinal disorder. The use of DHM is increasing globally, with many low and middle-income countries integrating donor milk banks into their public health strategies to reduce neonatal mortality, yet very little is known about the nutritional composition of DHM. Additional knowledge gaps include how DHM composition is influenced by milk banking practices, and whether preterm nutrient recommendations are achieved when DHM is used with commercially available fortifiers.

METHODS

We designed a multi-site study with eight geographically diverse milk bank partners in high, middle, and low-income settings that will examine and compare a broad range of nutrients and bioactive factors in human milk from 600 approved milk bank donors around the world to create comprehensive, geographically diverse nutrient profiles for DHM. We will then simulate the random pooling of 2 to 10 donors to evaluate the impact of pooling as a potential strategy for milk banks to manage nutrient variability in DHM. Finally, we will evaluate whether commercially available fortifiers meet nutrient recommendations when used with DHM.

DISCUSSION

We expect that results from this study will improve nutritional care globally for the growing number of preterm infants who receive donor human milk.

Associations between maternal adiposity and appetite-regulating hormones in human milk are mediated through maternal circulating concentrations and might affect infant outcomes

Background

Appetite-regulating hormones (ARH) in human milk (HM) are suggested to affect infants’ milk intake and possibly infant growth. Maternal adiposity might contribute to higher levels of ARH in HM, either from the mammary gland or from raised circulating levels due to higher adiposity. Counterfactual-based mediation analysis can define indirect and direct effects between HM ARH and maternal and infant factors, and might be an important tool when investigating the mother-milk-infant triad.

Objective

We aim to investigate whether potential associations between (1) maternal adiposity and HM ARH and (2) HM ARH and infant milk intake and growth are mediated through maternal and infant plasma ARH, respectively.

Materials and methods

Maternal and infant anthropometry and body composition, HM and blood samples were collected from 223 mother-infant dyads participating in the Mother, Infant and Lactation Quality study at three postpartum visits from 1 to 8.49 months. Leptin, insulin and adiponectin were analyzed using immunoassays. Mediation analyses using linear mixed-effect models were applied to investigate the direct and indirect effects through maternal and infant plasma hormone concentrations.

Results

A positive association between maternal body-mass-index (BMI) and HM leptin was mediated by maternal plasma leptin by 29% when fixing BMI to < 25 kg/m², and through 51% when fixing BMI to ≥ 25 kg/m² (p_interaction < 0.01). There was no mediated effect through plasma insulin in the association between BMI and HM insulin (p = 0.068). We found negative and positive associations between HM insulin and total milk intake and infant weight, respectively, however, these diminished in mediation analyses with reduced sample sizes.

Conclusion

Our main results suggest that the association between maternal adiposity and HM leptin was mediated through circulating leptin to a stronger degree for mothers with overweight compared to mothers with normal-weight. This indicates that excess maternal adiposity, and the resulting rise of circulating leptin and possible concomitant low-grade inflammation, may be reflected in HM composition.

Clinical trials registry number

NCT03254329.

Estimating national and subnational nutrient intake distributions of global diets

BACKGROUND

Access to high-quality dietary intake data is central to many nutrition, epidemiology, economic, environmental, and policy applications. When data on individual nutrient intakes are available, they have not been consistently disaggregated by sex and age groups, and their parameters and full distributions are often not publicly available.

OBJECTIVES

We sought to derive usual intake distributions for as many nutrients and population subgroups as possible, use these distributions to estimate nutrient intake inadequacy, compare these distributions and evaluate the implications of their shapes on the estimation of inadequacy, and make these distributions publicly available.

METHODS

We compiled dietary data sets from 31 geographically diverse countries, modeled usual intake distributions for 32 micronutrients and 21 macronutrients, and disaggregated these distributions by sex and age groups. We compared the variability and skewness of the distributions and evaluated their similarity across countries, sex, and age groups. We estimated intake inadequacy for 16 nutrients based on a harmonized set of nutrient requirements and bioavailability estimates. Last, we created an R package-nutriR-to make these distributions freely available for users to apply in their own analyses.

RESULTS

Usual intake distributions were rarely symmetric and differed widely in variability and skewness across nutrients and countries. Vitamin intake distributions were more variable and skewed and exhibited less similarity among countries than other nutrients. Inadequate intakes were high and geographically concentrated, as well as generally higher for females than males. We found that the shape of usual intake distributions strongly affects estimates of the prevalence of inadequate intakes.

CONCLUSIONS

The shape of nutrient intake distributions differs based on nutrient and subgroup and strongly influences estimates of nutrient intake inadequacy. This research represents an important contribution to the availability and application of dietary intake data for diverse subpopulations around the world.

Maternal Mental Health in Late Pregnancy and Longitudinal Changes in Postpartum Serum Vitamin B-12, Homocysteine, and Milk B-12 Concentration Among Brazilian Women

Background

Little is known regarding the association between mental health distress during pregnancy and postpartum maternal serum biomarkers of vitamin B-12 status and milk B-12 concentration.

Objective

To evaluate the association between depressive and anxiety symptoms in the third trimester of pregnancy and changes in postpartum serum B-12, homocysteine, and B-12 milk concentration.

Methods

A total of 101 women (18–40 years) were studied in a prospective cohort with data at the third trimester of pregnancy (baseline) and three postpartum time-points (TPs): 2–8 days (TP1), 28–50 days (TP2), and 88-119 days (TP3) postpartum. B-12 concentrations in milk were measured by competitive chemiluminescent enzyme immunoassay at TP1, TP2, and TP3. Serum B-12 and homocysteine concentrations were evaluated at baseline, TP1, TP2, and TP3 by chemiluminescent immunoassays. Depressive and anxiety symptoms were measured with the Edinburgh Postnatal Depression Scale and the State-Trait Anxiety Inventory at baseline. Spearman's correlation test and multiple linear mixed-effect models were performed.

Results

The prevalence of depressive and anxiety state symptoms was 35.6 and 39.6% at baseline. High prevalence of low milk B-12 concentration (<310 pmol/L) were observed at TP1 (53.2%), TP2 (71.4%), and TP3 (71.1%). Women with anxiety symptoms at baseline presented higher median concentrations of serum homocysteine at TP1 and lower concentrations of serum and milk B-12 at TP2 compared with women without anxiety symptoms [8 (7; 9) vs. 6 (5; 8) and 266 (188; 369) vs. 332 (272; 413)]. Milk B-12 concentrations were positively and significantly correlated with maternal serum B-12 concentrations at different TP. Women with anxiety symptoms at baseline exhibited a decrease in daily postpartum homocysteine concentrations compared to women without anxiety symptoms (β = −0.002, SE = 0.001, p = 0.024).

Conclusion

Anxiety symptoms at the end of pregnancy were associated with longitudinal changes in maternal serum homocysteine concentrations during the first 3 months postpartum.

Chicken liver and eggshell crackers as a safe and affordable animal source food for overcoming micronutrient deficits during pregnancy and lactation in Indonesia: a double-blind, randomised placebo-controlled trial (SISTIK Growth Study)

Background: Indonesia ranks fifth in terms of the number of stunted children and there has been little change in the stunting prevalence in the last decade. In earlier observational studies conducted in 2014-2015, we identified several key underlying problems with the potential to impact stunting in Sumedang district, West Java, Indonesia. Deficits in intakes of growth-limiting micronutrients were observed, most notably calcium, iron, zinc, and vitamin A, emphasizing the need for a food-based intervention to overcome these micronutrient deficits in the diets of mothers and their infants.

Methods: A double-blind placebo-controlled cluster randomised trial comparing the effect of daily consumption of 75 grams of locally produced micronutrient-enriched crackers (MEC) (intervention group) compared to placebo crackers (control group) by mothers at two-time intervals: (i) from the 8-14 weeks of pregnancy to delivery (i.e., 28-34 weeks of consumption of MEC) on birth length, and (ii) from the 8-14 weeks of pregnancy to 5 months post-partum on attained linear growth and linear growth velocity of breast-fed infants. A total of 324 pregnant women from 28 clusters (villages) located in 3 sub-districts in Sumedang district, West Java, Indonesia, will be randomly assigned to either intervention (n=14 villages) or control (n=14 villages).

Discussion: This will be the first study in Indonesia to use crackers based on powdered eggshells and chicken liver, in a form which is acceptable, safe, and has a long shelf life. If daily consumption of MEC for 6 months during pregnancy can enhance birth length, or their continued daily consumption for 5 months postpartum improves both attained and incremental linear growth at 5 months of age, then scaling-up in Indonesia may be considered.

Trial Registration: https://clinicaltrials.gov/ct2/show/NCT04564222; 25 ^th September 2020

Daily supplementation of a multiple micronutrient powder improves folate but not thiamine, riboflavin, or vitamin B12 status among young Laotian children: a randomized controlled trial

PURPOSE

To assess the effects of intervention with a daily multiple micronutrient powder (MNP) on thiamine, riboflavin, folate, and B₁₂ status among young Laotian children.

METHODS

Children (n = 1704) aged 6-23 mo, participating in a double-blind placebo-controlled randomized trial were individually randomized to receive daily either MNP (containing 0.5 mg of thiamine, 0.5 mg riboflavin, 150 μg folic acid, and 0.9 μg vitamin B₁₂ along with 11 other micronutrients) or placebo and followed for ~ 36 weeks. In a randomly selected sub-sample of 260 children, erythrocyte thiamine diphosphate (eThDP), plasma folate and B₁₂ concentrations, and erythrocyte glutathione reductase activation coefficient (EGRac; riboflavin biomarker) were assessed at baseline and endline.

RESULTS

There was no treatment effect on endline eThDP concentrations (110.6 ± 8.9 nmol/L in MNP vs. 109.4 ± 8.9 nmol/L in placebo group; p = 0.924), EGRac (1.46 ± 0.3 vs. 1.49 ± 0.3; p = 0.184) and B₁₂ concentrations (523.3 ± 24.6 pmol/L vs. 515.9 ± 24.8 pmol/L; p = 0.678). Likewise, the prevalence of thiamine, riboflavin, and B₁₂ deficiencies did not differ significantly between the two groups. However, endline folate concentration was significantly higher in the MNP compared to the placebo group (28.2 ± 0.8 nmol/L vs 19.9 ± 0.8 nmol/L, respectively; p < 0.001), and correspondingly, the prevalence of folate deficiency was significantly lower in the MNP group (1.6% vs 17.4%; p = 0.015).

CONCLUSIONS

Compared to a placebo, daily MNP for 9 months increased only folate but not thiamine, riboflavin, or B₁₂ status in young Laotian children.

TRIAL REGISTRATION

The trial was registered at www.

CLINICALTRIALS

gov (NCT02428647) on April 29 2015.

Improving LC-MS analysis of human milk B-vitamins by lactose removal

•

Lactose in human milk affects B-vitamin analysis by fouling the ion source.

•

Typical extraction methods are inefficient for lactose removal.

•

Chromatographic separation from analytes enables lactose mechanical removal.

Our previously reported, first validated, UPLC-MS/MS-based simultaneous analysis of five human milk B-vitamins revealed severe matrix effects. High levels of endogenous lactose fouled the electrospray ionization source affecting the analysis. We evaluated solid-phase extraction (SPE), liquid–solid extraction (LSE), protein precipitation (PPT), and liquid chromatography effluent diversion for lactose-removal. SPE failed to separate lactose from vitamins; LSE using 2-propanol reduced lactose and vitamin recoveries. PPT-solvent, milk volume, and reconstitution solvent influenced flavin adenine dinucleotide, pyridoxal and nicotinamide recoveries. Using an optimized LC-gradient enabled chromatographic separation of lactose from vitamins and its removal using a post-column switch-valve. Only 40 µL milk was subjected to methanol-PPT and non-polar matrix removal by methyl tert-butyl ether. B-vitamin recoveries were established (81.9–118.6%; CV ≤ 11.9%; precision: 4.9–13.7%) with greatly reduced matrix effects, and improved process efficiency, and recovery.

Factors associated with longitudinal changes in B-vitamin and choline concentrations of human milk

BACKGROUND

Little is known regarding the associations between maternal factors and B-vitamin and choline concentrations in early milk and the trajectories of these vitamins during lactation.

OBJECTIVES

In this hypothesis-generating study, we modeled the association between maternal and offspring factors and longitudinal changes in milk B-vitamin and choline concentrations throughout lactation.

METHODS

A hundred women were studied in a prospective birth cohort and milk samples from 52 women were collected at 2-8 d, 76 women at 28-50 d, and 42 women at 88-119 d postpartum. Maternal dietary intake during pregnancy and lactation was assessed by an FFQ. Linear mixed-effects models with interaction terms were used to evaluate changes in milk B-vitamin and choline concentrations over time based on maternal factors and the early postpartum concentrations of these micronutrients.

RESULTS

The women with higher early postpartum milk concentrations of niacin (βinteraction = -0.02; SE = 0.00; P < 0.001), pantothenic acid (βinteraction = -0.10; SE = 2.56; P < 0.001), vitamin B-12 (βinteraction= -0.10; SE = 0.03; P < 0.001), and choline (βinteraction= -0.90; SE = 0.18; P < 0.001) exhibited a decrease in their concentrations throughout lactation. The participants with overweight and obesity prepregnancy experienced an increase in milk vitamin B-12 concentrations over time (βinteraction = 0.04; SE = 0.02; P = 0.06). In contrast, a decrease in vitamin B-12 concentration was observed among women with vitamin B-12 intake below the RDA during pregnancy (βinteraction= -0.08; SE = 0.05; P = 0.07). The women with niacin intake below the RDA during lactation experienced an increase in milk concentrations over time (βinteraction = 0.01; SE = 0.01; P = 0.03). A gestational age at birth >40 wk was associated with an increase in milk choline concentration throughout lactation (βinteraction = 0.54; SE = 0.16; P< 0.01).

CONCLUSIONS

Changes in B-vitamin and choline concentrations in human milk over time may be associated with the early concentrations of these micronutrients in milk, maternal prepregnancy BMI, dietary intake, and gestational age at delivery.

The Mothers, Infants, and Lactation Quality (MILQ) Study: A Multi-Center Collaboration

Little valid information is available on human milk nutrient concentrations, especially for micronutrients (MNs), and there are no valid reference values (RVs) across lactation. In this multi-center collaborative study, RVs will be established for human milk nutrients across the first 8.5 mo postpartum. Well-nourished, unsupplemented women in Bangladesh, Brazil, Denmark, and The Gambia (n = 250/site) were recruited during the third trimester of pregnancy. Milk, blood, saliva, urine, and stool samples from mothers and their infants are collected identically at 3 visits (1-3.49, 3.5-5.99, 6.0-8.49 mo postpartum). Milk analyses include macronutrients, selected vitamins, trace elements and minerals, iodine, metabolomics, amino acids, human milk oligosaccharides, and bioactive peptides. We measure milk volume; maternal and infant diets, anthropometry, and morbidity; infant development, maternal genome, and the infant and maternal microbiome. RVs will be constructed based on methods for the WHO Child Growth Standards and the Intergrowth-21st Project. This trial was registered at clinical trials.gov as NCT03254329.

Thiamine supplementation holds neurocognitive benefits for breastfed infants during the first year of life

Women reliant on mostly rice‐based diets can have inadequate thiamine intake, placing breastfed infants at risk of thiamine deficiency and, in turn, physical and cognitive impairments. We investigated the impact of maternal thiamine supplementation doses on infants’ cognitive, motor, and language development across the first year. In this double‐blind, four‐parallel‐arm, randomized controlled trial, healthy mothers of exclusively breastfed newborn infants were recruited in Kampong Thom, Cambodia. At 2 weeks postnatal, women (n = 335) were randomized to one of four treatment groups to consume one capsule/day with varying amounts of thiamine for 22 weeks: 0, 1.2, 2.4, and 10 mg. At 2, 12, 24, and 52 weeks of age, infants were assessed with the Mullen Scales of Early Learning (MSEL) and the Caregiver Reported Early Development Instrument (CREDI). Multiple regression and mixed effects modeling suggest that by 6 months of age, the highest maternal thiamine dose (10 mg/day) held significant benefits for infants’ language development, but generally not for motor or visual reception development. Despite having achieved standardized scores on the MSEL that approximated U.S. norms by 6 months, infants showed a significant drop relative to these norms in both language domains following trial completion, indicating that nutritional interventions beyond 6 months may be necessary.

Low-dose thiamine supplementation of lactating Cambodian mothers improves human milk thiamine concentrations: a randomized controlled trial

BACKGROUND

Infantile beriberi-related mortality is still common in South and Southeast Asia. Interventions to increase maternal thiamine intakes, and thus human milk thiamine, are warranted; however, the required dose remains unknown.

OBJECTIVES

We sought to estimate the dose at which additional maternal intake of oral thiamine no longer meaningfully increased milk thiamine concentrations in infants at 24 wk postpartum, and to investigate the impact of 4 thiamine supplementation doses on milk and blood thiamine status biomarkers.

METHODS

In this double-blind, 4-parallel arm randomized controlled dose-response trial, healthy mothers were recruited in Kampong Thom, Cambodia. At 2 wk postpartum, women were randomly assigned to consume 1 capsule, containing 0, 1.2 (estimated average requirement), 2.4, or 10 mg of thiamine daily from 2 through 24 weeks postpartum. Human milk total thiamine concentrations were measured using HPLC. An Emax curve was plotted, which was estimated using a nonlinear least squares model in an intention-to-treat analysis. Linear mixed-effects models were used to test for differences between treatment groups. Maternal and infant blood thiamine biomarkers were also assessed.

RESULTS

In total, each of 335 women was randomly assigned to1 of the following thiamine-dose groups: placebo (n = 83), 1.2 mg (n = 86), 2.4 mg (n = 81), and 10 mg (n = 85). The estimated dose required to reach 90% of the maximum average total thiamine concentration in human milk (191 µg/L) is 2.35 (95% CI: 0.58, 7.01) mg/d. The mean ± SD milk thiamine concentrations were significantly higher in all intervention groups (183 ± 91, 190 ± 105, and 206 ± 89 µg/L for 1.2, 2.4, and 10 mg, respectively) compared with the placebo group (153 ± 85 µg/L; P < 0.0001) and did not significantly differ from each other.

CONCLUSIONS

A supplemental thiamine dose of 2.35 mg/d was required to achieve a milk total thiamine concentration of 191 µg/L. However, 1.2 mg/d for 22 wk was sufficient to increase milk thiamine concentrations to similar levels achieved by higher supplementation doses (2.4 and 10 mg/d), and comparable to those of healthy mothers in regions without beriberi. This trial was registered at clinicaltrials.gov as NCT03616288.

Maternal postpartum deworming and infant milk intake: Secondary outcomes from a trial

The World Health Organization recommends deworming to reduce soil-transmitted helminth (STH)-attributable morbidity in women of reproductive age, including pregnant and lactating women, to reduce blood loss, iron deficiency anaemia and nutrient malabsorption. This study assessed the impact of maternal postpartum deworming with albendazole approximately 1 day after delivery on infant milk intake among a subset of 216 randomly selected mother-infant pairs recruited into a large trial in Peru. Infant milk intake was measured using the deuterium-oxide method at 1- and 6-month postpartum. Maternal STH infection was measured at 6-month postpartum. At 1-month postpartum, mean intake was 756 ± 16 and 774 ± 18 mL day^-1 in the albendazole and placebo groups, respectively (mean difference: -18 mL day^-1 ; 95% CI: -65, 30). At 6-month postpartum, mean intake was 903 ± 16 and 908 ± 18 mL day^-1 in the albendazole and placebo groups, respectively (mean difference: -5 mL day^-1 ; 95% CI: -52, 43). There was no statistically significant difference in milk intake between groups at either time point. At 6-month postpartum, mothers infected with Trichuris trichiura had infants with higher milk intakes (adjusted mean difference: 70 mL day^-1 ; 95% CI: 20, 120) compared with uninfected mothers. However, there was no statistically significant difference in infant milk intake between mothers who had moderate-and-heavy intensity infection compared with the comparison group (mothers with no and light intensity infection). A lower prevalence and intensity of infection, and inclusion of uninfected mothers in both arms of the trial, resulting in effect dilution, may explain the null findings.

Small-Quantity Lipid-Based Nutrient Supplements Do Not Affect Plasma or Milk Retinol Concentrations Among Malawian Mothers, or Plasma Retinol Concentrations among Young Malawian or Ghanaian Children in Two Randomized Trials

BACKGROUND

Vitamin A (VA) deficiency is prevalent in preschool-aged children in sub-Saharan Africa.

OBJECTIVES

We assessed the effect of small-quantity lipid-based nutrient supplements (SQ-LNS) given to women during pregnancy and lactation and their children from 6 to 18 mo of age on women's plasma and milk retinol concentrations in Malawi, and children's plasma retinol concentration in Malawi and Ghana.

METHODS

Pregnant women (≤20 wk of gestation) were randomized to receive daily: 1) iron and folic acid (IFA) during pregnancy only; 2) multiple micronutrients (MMN; 800 μg retinol equivalent (RE)/capsule), or 3) SQ-LNS (800 μg RE/20g) during pregnancy and the first 6 mo postpartum. Children of mothers in the SQ-LNS group received SQ-LNS (400 μg RE/20 g) from 6 to 18 mo of age; children of mothers in the IFA and MMN groups received no supplement. Plasma retinol was measured in mothers at ≤20 and 36 wk of gestation and 6 mo postpartum, and in children at 6 and 18 mo of age. Milk retinol was measured at 6 mo postpartum. VA status indicators were compared by group.

RESULTS

Among Malawian mothers, geometric mean (95% CI) plasma retinol concentrations at 36 wk of gestation and 6 mo postpartum were 0.97 μmol/L (0.94, 1.01 μmol/L) and 1.35 μmol/L (1.31, 1.39 μmol/L), respectively; geometric mean (95% CI) milk retinol concentration at 6 mo postpartum was 1.04 μmol/L (0.97, 1.13 μmol/L); results did not differ by intervention group. Geometric mean (95% CI) plasma retinol concentrations for Malawian children at 6 and 18 mo of age were 0.78 μmol/L (0.75, 0.81 μmol/L) and 0.81 μmol/L (0.78, 0.85 μmol/L), respectively, and for Ghanaian children they were 0.85 μmol/L (0.82, 0.88 μmol/L) and 0.88 μmol/L (0.85, 0.91 μmol/L), respectively; results did not differ by intervention group in either setting.

CONCLUSIONS

SQ-LNS had no effect on VA status of mothers or children, possibly because of low responsiveness of the VA status indicators.

High-Throughput Analysis of Water-Soluble Forms of Choline and Related Metabolites in Human Milk by UPLC-MS/MS and Its Application

Choline and related metabolites are key factors in many metabolic processes, and insufficient supply can adversely affect reproduction and fetal development. Choline status is mainly regulated by intake, and human milk is the only choline source for exclusively breastfed infants. Further, maternal status, genotype, and phenotype, as well as infant outcomes, have been related to milk choline concentrations. In order to enable the rapid assessment of choline intake for exclusively breastfed infants and to further investigate the associations between milk choline and maternal and infant status and other outcomes, we have developed a simplified method for the simultaneous analysis of human milk choline, glycerophosphocholine, phosphocholine, and the less abundant related metabolites betaine, carnitine, creatinine, dimethylglycine (DMG), methionine, and trimethylamine N-oxide (TMAO) using ultraperformance liquid chromatography–tandem mass spectrometry (UPLC–MS/MS). These analytes have milk concentrations ranging over 3 orders of magnitude. Unlike other recently described LC-based methods, our approach does not require an ion-pairing reagent or high concentrations of solvent modifiers for successful analyte separation and thus avoid signal loss and potential permanent contamination. Milk samples (10 μl) were diluted (1:80) in water : methanol (1:4, v:v) and filtered prior to analysis with an optimized gradient of 0.1% propionic acid_aq and acetonitrile, allowing efficient separation and removal of contaminants. Recovery rates ranged from 108.0 to 130.9% (inter-day variation: 3.3–9.6%), and matrix effects (MEs) from 54.1 to 114.3%. MEs were greater for carnitine, creatinine, and TMAO at lower dilution (1:40, p < 0.035 for all), indicating concentration-dependent ion suppression. Milk from Brazilian women (2–8, 28–50, and 88–119 days postpartum, n_total = 53) revealed increasing concentration throughout lactation for glycerophosphocholine, DMG, and methionine, while carnitine decreased. Choline and phosphocholine were negatively correlated consistently at all three collection time intervals. The method is suitable for rapid analysis of human milk water-soluble forms of choline as well as previously not captured related metabolites with minimal sample volumes and preparation.

Maternal plasma folate concentration is positively associated with serum total cholesterol and low-density lipoprotein across the three trimesters of pregnancy

Increased first-trimester low-density lipoprotein (LDL-C) concentration has been associated with adverse pregnancy outcomes, such as gestational diabetes. The B vitamins folate, B-6, and total B-12 are key for the methyl group-dependent endogenous synthesis of phosphatidylcholine, which is needed for lipoprotein synthesis, e.g., very low-density lipoprotein (VLDL), the precursor of circulating LDL-C. Maternal B-vitamin concentration usually declines across trimesters. Whether changes in maternal B-vitamin concentrations are associated with total cholesterol (TC), triglycerides (TG), and lipoprotein concentrations is unknown. Therefore, we explored the association between plasma folate, vitamin B-6 in the form of pyridoxal 5′-phosphate (PLP), and total B-12 with serum TC, LDL-C, HDL-C, and TG concentrations across trimesters. This secondary analysis used data of a prospective pregnancy cohort study included apparently healthy adult women (n = 179) from Rio de Janeiro, Brazil. The biomarkers were measured in fasting blood samples collected at 5–13, 20–26, and 30–36 weeks of gestation. The associations between B vitamins and lipid concentrations across trimesters were explored using linear mixed-effect models. Among B vitamins, only plasma folate was positively associated with TC (β = 0.244, 95% CI 0.034–0.454) and LDL-C (β = 0.193, 95% CI 0.028–0.357) concentrations. The positive relationship of maternal folate and TC and LDL-C concentrations may indicate the importance of folate as a methyl donor for lipoprotein synthesis during pregnancy.

Association of maternal diet, micronutrient status, and milk volume with milk micronutrient concentrations in Indonesian mothers at 2 and 5 months postpartum

BACKGROUND

Maternal micronutrient deficits during preconception and pregnancy may persist during lactation and compromise human milk composition.

OBJECTIVE

We measured micronutrient concentrations in human milk and investigated their association with maternal micronutrient intakes, status, and milk volume.

METHODS

Infant milk intake (measured via a deuterium dose-to-mother technique), milk micronutrient and fat concentrations, and maternal micronutrient intakes were assessed at 2 and 5 mo postpartum in 212 Indonesian lactating mother-infant pairs. Maternal hemoglobin, ferritin, transferrin receptors, retinol binding protein (RBP), zinc, selenium, and vitamin B-12 were measured at 5 mo (n = 163). Multivariate or mixed effects regression examined associations of milk micronutrient concentrations with maternal micronutrient intakes, status, and milk volume.

RESULTS

Prevalence of anemia (15%), and iron (15% based on body iron), selenium (2.5%), and vitamin B-12 deficiency (0%) were low compared with deficiencies of zinc (60%) and vitamin A (34%). The prevalence of inadequate intakes was >50% for 7 micronutrients at 2 and 5 mo. Median milk concentrations for most micronutrients were below reference values, and nearly all declined between 2 and 5 mo postpartum and were not associated substantially with milk volume (except for β-carotene, α-carotene, and β-cryptoxanthin). At 5 mo postpartum, associations between maternal micronutrient status and corresponding milk concentrations reported as mean percentage difference in human milk concentration for each unit higher maternal biomarker were significant for hemoglobin (1.9%), iron biomarkers (ranging from 0.4 to 7%), RBP (35%), selenium (70%), and vitamin B-12 (0.1%), yet for maternal intakes only a positive association with β-carotene existed.

CONCLUSIONS

Most milk micronutrient concentrations declined during lactation, independent of changes in human milk production, and few were associated with maternal micronutrient intakes. The significant associations between maternal biomarkers and milk micronutrient concentrations at 5 mo warrant further study to investigate whether the declines in milk micronutrients are linked to shifts in maternal status.

Micronutrient supplementation of lactating Guatemalan women acutely increases infants' intake of riboflavin, thiamin, pyridoxal, and cobalamin, but not niacin, in a randomized crossover trial

BACKGROUND

Maternal supplementation during lactation could increase milk B-vitamin concentrations, but little is known about the kinetics of milk vitamin responses.

OBJECTIVES

We compared acute effects of maternal lipid-based nutrient supplement (LNS) consumption (n = 22 nutrients, 175%-212% of the RDA intake for the nutrients examined), as a single dose or at spaced intervals during 8 h, on milk concentrations and infant intake from milk of B-vitamins.

METHODS

This randomized crossover trial in Quetzaltenango, Guatemala included 26 mother-infant dyads 4-6 mo postpartum who were randomly assigned to receive 3 treatments in a random order: bolus 30-g dose of LNS (Bolus); 3 × 10-g doses of LNS (Divided); and no LNS (Control), with control meals. Mothers attended three 8-h visits during which infant milk consumption was measured and milk samples were collected at every feed. Infant intake was assessed as $\mathop \sum \nolimits_{i\ = \ 1}^n ( {{\rm{milk\ volum}}{{\rm{e}}_{{\rm{feed\ }}n}} \times \ {\rm{nutrient\ concentratio}}{{\rm{n}}_{{\rm{feed}}\ n}}} )$ over 8 h.

RESULTS

Maternal supplementation with the Bolus or Divided dose increased least-squares mean (95% CI) milk and infant intakes of riboflavin [milk: Bolus: 154.4 (138.2, 172.5) μg · min-1 · mL-1; Control: 84.5 (75.8, 94.3) μg · min-1 · mL-1; infant: Bolus: 64.5 (56.1, 74.3) μg; Control: 34.5 (30.0, 39.6) μg], thiamin [milk: Bolus: 10.9 (10.1, 11.7) μg · min-1 · mL-1; Control: 7.7 (7.2, 8.3) μg · min-1 · mL-1; infant: Bolus: 5.1 (4.4, 6.0) μg; Control: 3.4 (2.9, 4.0) μg], and pyridoxal [milk: Bolus: 90.5 (82.8, 98.9) μg · min-1 · mL-1; Control: 60.8 (55.8, 66.3) μg · min-1 · mL-1; infant: Bolus: 39.4 (33.5, 46.4) μg; Control: 25.0 (21.4, 29.2) μg] (all P < 0.001). Only the Bolus dose increased cobalamin in milk [Bolus: 0.054 (0.047, 0.061) μg · min-1 · mL-1; Control: 0.041 (0.035, 0.048) μg · min-1 · mL-1, P = 0.039] and infant cobalamin intake [Bolus: 0.023 (0.020, 0.027) μg; Control: 0.015 (0.013, 0.018) μg, P = 0.001] compared with Control. Niacin was unaffected.

CONCLUSIONS

Maternal supplementation with LNS as a Bolus or Divided dose was similarly effective at increasing milk riboflavin, thiamin, and pyridoxal and infant intakes, whereas only the Bolus dose increased cobalamin. Niacin was unaffected in 8 h. This trial was registered at clinicaltrials.gov as NCT02464111.

Understanding the Intersection of Climate/Environmental Change, Health, Agriculture, and Improved Nutrition: A Case Study on Micronutrient Nutrition and Animal Source Foods

With a growing global population, the demand for high-quality food to meet nutritional needs continues to increase. Our ability to meet those needs is challenged by a changing environment that includes constraints on land and water resources and growing concerns about the impact of human activity including agricultural practices on the changing climate. Adaptations that meet food/nutritional demands while avoiding unintended consequences including negatively affecting the environment are needed. This article covers a specific case study, the role of animal source foods (ASFs) in meeting micronutrient needs in a changing environment. The article covers our understanding of the role of ASFs in meeting micronutrient needs, evidence-based approaches to the development of nutrition guidance, the current issues associated with the relation between animal production practices and greenhouse gas emissions, and examples of how we might model the myriad sources of relevant data to better understand these complex interrelations.

Macro- and Micronutrients in Milk from Healthy Cambodian Mothers: Status and Interrelations

BACKGROUND

Except for low thiamin content, little is known about vitamins or macronutrients in milk from Cambodian mothers, and associations among milk nutrients.

OBJECTIVES

We measured fat-soluble vitamins (FSVs) and water-soluble vitamins (WSVs), and macronutrients, and explored internutrient associations in milk from Cambodian mothers.

METHODS

Milk from women (aged 18-45 y, 3-27 wk postpartum, n = 68) who participated in a thiamin-fortification trial were analyzed for vitamins B-2 (riboflavin, FAD), B-3 (nicotinamide), B-5, B-6 (pyridoxal, pyridoxine), B-7, B-12, A, E [α-tocopherol and γ-tocopherol (γ-TPH)], carotenoids, carbohydrate (CHO), fat, and protein. Milk vitamin B-1 [thiamin, thiamin monophosphate (TMP), thiamin pyrophosphate (TPP)] was previously assessed for fortification effects. Milk nutrient concentrations were compared with the Adequate Intake (AI) values for infants aged 0-6 mo. Pearson correlation was used to examine internutrient associations after excluding nutrients affected by fortification.

RESULTS

Fortification increased thiamin and B-1 and decreased γ-TPH. Less than 40% of milk samples met the AIs for all vitamins, and 10 samples did not reach any AI values for the analyzed nutrients. CHO, fat, and energy values were met in 1.5-11.8%, and protein in 48.5%, of the samples. Whereas fat, protein, and energy were related (all r < 0.5; P < 0.001) and associated with FSVs and WSVs, CHO correlated only with some WSVs. TPP was not correlated with B-1 vitamers, but with other WSVs (r = 0.28-0.58; P < 0.019). All FSVs, except α-carotene, were correlated with each other (r = 0.42-0.98; P < 0.002). TPP, FAD, B-2, and B-3 were associated with almost all FSVs (r = 0.24-0.63; P < 0.044).

CONCLUSIONS

Cambodian women might not provide sufficient nutrients to their exclusively breastfeeding infants. Besides thiamin, all other vitamins measured were much lower than the AI. There were many strong correlations among macronutrients and vitamins; the extent to which these are explained by maternal diet, milk volume, maternal physiology, or genetics requires additional exploration.

Why the Derivation of Nutrient Reference Values Should be Harmonized and How It Can be Accomplished

The adoption of a panel of Nutrient Reference Values (NRVs) in place of a single recommended intake allowed for assessment of nutritional adequacy and safe upper intake levels for nutrients on a population level and for individuals. The Average Requirement (AR) and Tolerable Upper Intake Level (UL) comprise 2 core NRVs needed to obtain accurate, comparable estimates of population-level nutrient intakes, which are necessary to plan and evaluate nutrition support programs globally. Harmonizing the derivation of NRVs, particularly the AR and UL, is essential to ensure inclusion of all countries, whether high-, middle-, or low-income, in the process and to improve access for all users to the tools and data needed to carry it out. The NRV process today is more rigorous and transparent than the first derivation of DRIs because of adoption of systematic reviews and bias assessment methodologies, updated food and nutrient databases, data on cultural and context-specific dietary patterns, and better metabolic markers of nutritional status. A proposed framework for the derivation of NRVs builds on available methodologies to support the NRV process; however, this is not sufficient to achieve harmonization of the process. Fundamental to moving forward toward harmonization is removing existing barriers, including limited access to resources and databases and variance in terminology used to identify specific NRVs; adoption of more rigorous and transparent methodologies, including chronic disease endpoints, in the review process; and creating a central repository for easily accessible evidence. Chief among the barriers to harmonization is a willingness of global bodies to support an agreed-upon approach to the derivation process. Improving access to tools and data resources and providing guidance and support to encourage their adoption are critical to achieving harmonization of the NRV process. The factorial approach for calculating a nutrient requirement is described as the sum of total endogenous nutrient loss (endogenous fecal, urinary, integumental, seminal, menstrual) divided by its bioavailability or fractional absorption.

Amino Acid Digestibility of Extruded Chickpea and Yellow Pea Protein is High and Comparable in Moderately Stunted South Indian Children with Use of a Dual Stable Isotope Tracer Method

BACKGROUND

Legumes are an excellent plant source of the limiting indispensable amino acid (IAA) lysine in vegetarian, cereal-based diets. However, their digestibility is poor largely because of their antiprotease content. Extrusion can enhance digestibility by inactivating trypsin inhibitors and thus potentially improve the protein quality of legumes.

OBJECTIVE

We measured the digestibility of extruded chickpea and yellow pea protein with use of a dual stable isotope method in moderately stunted South Indian primary school children.

METHODS

Twenty-eight moderately stunted children (height-for-age z scores <-2.0 SD and >-3.0 SD) aged 6-11 y from low to middle socioeconomic status were randomly assigned to receive a test protein (extruded intrinsically [2H]-labeled chickpea or yellow pea) along with a standard of U-[13C]-spirulina protein to measure amino acid (AA) digestibility with use of a dual stable isotope method. Individual AA digestibility in the test protein was calculated by the ratios of AA enrichments in the test protein to the standard protein in the food and their appearance in blood plasma collected at 6 and 6.5 h during the experiment, representing a plateau state.

RESULTS

The mean AA digestibility of extruded chickpea and yellow pea protein in moderately stunted children (HAZ; -2.86 to -1.2) was high and similar in both extruded test proteins (89.0% and 88.0%, respectively, P = 0.83). However, lysine and proline digestibilities were higher in extruded chickpea than yellow pea (79.2% compared with 76.5% and 75.0% compared with 72.0%, respectively, P < 0.02).

CONCLUSION

Extruded chickpea and yellow pea protein had good IAA digestibility in moderately stunted children, which was 20% higher than an earlier report of their digestibility when pressure-cooked, measured by the same method in adults. Higher digestibility of lysine and proline highlights better retention of these AA in chickpea during extrusion-based processing. Extrusion might be useful for developing high-quality protein foods from legumes. This trial was registered at www.ctri.nic.in as CTRI/2018/03/012439.

Perspective: Proposed Harmonized Nutrient Reference Values for Populations

Two core nutrient intake reference values (NRVs) are required for assessing the adequacy and safety of nutrient intakes for population groups: the average requirement (AR) and the tolerable upper level of intake (UL). Applications of such assessments include providing advice to improve intakes, formulating complementary foods, estimating the amounts of nutrients to be added to fortified foods and monitoring changes in intake, and product labeling at the global, national, or regional level. However, there is a lack of unity across country-level organizations in the methodological approach used to derive NRVs, and ARs and ULs are lacking in many compilations, thus limiting the ability to assess nutrient intakes for their population groups. Because physiological requirements vary little across populations globally, and setting reference values requires determining an acceptable level of uncertainty, it is feasible to adapt current recommendations from different sources to harmonize these core reference values. The objective of this review is to demonstrate an approach for harmonizing the NRVs for ARs (here termed "H-ARs") and ULs ("H-ULs") that can be applied on a global scale to assessing intakes across populations. The approach incorporates the framework and terminology recommended by reports from the United Nations University, the National Academies of Sciences, Engineering, and Medicine (NASEM), the Institute of Medicine (IOM), and the European Food Safety Authority (EFSA). After reviewing available alternatives, the proposed harmonized values were selected from standards set by EFSA (for Europe) and the IOM (for the United States and Canada), giving priority to those published most recently. Justifications for the proposed values are presented, along with discussion of their limitations. Ideally, these methods should be further reviewed by an international group of experts. Meanwhile, the H-ARs and H-ULs suggested in this review can be used to assess intakes of populations for many applications in global and regional contexts.

Vitamin B12 is Low in Milk of Early Postpartum Women in Urban Tanzania, and was not Significantly Increased by High dose Supplementation

The effect of maternal multivitamin supplementation on breast milk vitamin B12 concentrations has not been examined in Tanzania, where the prevalence of maternal plasma B12 insufficiency is 25.6%. Multivitamins (containing 50 µg vitamin B12) or placebo were provided during pregnancy and in the postpartum period. Breast milk samples were collected at or around six weeks postpartum from 491 participants in a trial of multivitamins (NCT00197548). Linear and logistic regression models were used to examine the effect of supplements on vitamin B12 concentration in milk and its associations with other variables including potential confounders. Median vitamin B12 concentration in breast milk was 206 pmol/L and 70% of women had levels indicating inadequacy (<310 pmol/L). Multivitamin supplements did not significantly reduce the odds of inadequate vitamin B12 in breast milk, suggesting suboptimal absorption. A single unit increase in maternal hemoglobin at six weeks was associated with 18% lower odds of inadequate vitamin B12 in breast milk. Participants with higher BMI at baseline had double the odds of having inadequate vitamin B12 than the reference group (<22 kg/m2). Trials to determine the optimal dose, route, and duration of supplementation to improve maternal B12 status in Sub-Saharan Africa are of utmost importance.

Total Water-Soluble Choline Concentration Does Not Differ in Milk from Vegan, Vegetarian, and Nonvegetarian Lactating Women

BACKGROUND

Choline is an essential nutrient for brain growth and other processes in the developing neonate. The impact of a maternal plant-based diet on the choline composition of breast milk is unknown.

OBJECTIVE

We assessed the water-soluble choline content of milk from lactating women in the United States following 3 dietary patterns: vegan, vegetarian, and nonvegetarian.

METHODS

We conducted a cross-sectional study of 74 healthy lactating women who provided a single breast-milk sample using a standardized collection protocol. Participants completed a food-frequency screener and were classified as follows: nonvegetarians (NONVEG) consumed meat; vegetarians (VEGT) consumed milk, dairy, and/or fish; and vegans (VEGAN) consumed animal products less than monthly. Primary outcomes measured were the concentration (in milligrams per liter) and distribution (percentage) of choline from the following water-soluble forms: free choline, phosphocholine (PCho), and glycerophosphocholine (GPC). Differences between diet groups were evaluated with ANOVA.

RESULTS

There was a wide range in breast-milk total water-soluble choline (4-301 mg/L), with no significant difference (P > 0.05) by maternal diet pattern. There were differences in choline forms, with VEGAN having a greater mean ± SD concentration and distribution of choline derived from GPC (62.7 ± 25.3 mg/L) than VEGT (47.7 ± 21.2 mg/L) and NONVEG (42.4 ± 14.9 mg/L) (P = 0.0052). There was a lower mean ± SD percentage of choline from PCho (P = 0.0106) in VEGAN (32.5% ± 18.3%) than in VEGT (46.1% ± 18.3%) and NONVEG (44.8% ± 15.7%). Lactation stage and maternal BMI were significantly associated with some choline forms.

CONCLUSIONS

There was a wide range of water-soluble choline concentrations in the milk of healthy lactating women following vegan, vegetarian, and nonvegetarian diets, with no observed difference in total water-soluble choline concentration by maternal diet. This suggests that maternal plant-based diet by itself is not a risk factor for low breast-milk choline.

Challenges in Designing and Delivering Diets and Assessing Adherence: A Randomized Controlled Trial Evaluating the 2010 Dietary Guidelines for Americans

BACKGROUND

Controlled-feeding trials are challenging to design and administer in a free-living setting. There is a need to share methods and best practices for diet design, delivery, and standard adherence metrics.

OBJECTIVES

This report describes menu planning, implementing, and monitoring of controlled diets for an 8-wk free-living trial comparing a diet pattern based on the Dietary Guidelines for Americans (DGA) and a more typical American diet (TAD) pattern based on NHANES 2009-2010. The objectives were to 1) provide meals that were acceptable, portable, and simple to assemble at home; 2) blind the intervention diets to the greatest extent possible; and 3) use tools measuring adherence to determine the success of the planned and implemented menu.

METHODS

Menus were blinded by placing similar dishes on the 2 intervention diets but changing recipes. Adherence was monitored using daily food checklists, a real-time dashboard of scores from daily checklists, weigh-backs of containers returned, and 24-h urinary nitrogen recoveries. Proximate analyses of diet composites were used to compare the macronutrient composition of the composite and planned menu.

RESULTS

Meeting nutrient intake recommendations while scaling menus for individual energy intake amounts and food portions was most challenging for vitamins D and E, the sodium-to-potassium ratio, dietary fiber, and fatty acid composition. Dietary adherence for provided foods was >95%, with no differences between groups. Urinary nitrogen recoveries were ∼80% relative to nitrogen intake and not different between groups. Composite proximate analysis matched the plan for dietary fat, protein, and carbohydrates. Dietary fiber was ∼2.5 g higher in the TAD composite compared with the planned menu, but ∼7.4 g lower than the DGA composite.

CONCLUSIONS

Both DGA and TAD diets were acceptable to most participants. This conclusion was supported by self-reported consumption, quantitative weigh-backs of provided food, and urinary nitrogen recovery. Dietary adherence measures in controlled-feeding trials would benefit from standard protocols to promote uniformity across studies. The trial is registered at clinicaltrials.gov as NCT02298725.

Human Milk as the First Source of Micronutrients

Well-nourished mothers are assumed to produce adequate concentrations of nutrients in their milk for optimal infant growth and development and infants should be exclusively breastfed during the first 6 months. It is important to know the nutrient content of human milk as this information is used to set recommended adequate intakes (AIs) for infants. Our review of existing information reveals that the AI recommendations are based on poor data. The milk content of a few nutrients may not be adequate to provide requirements for 6 months even in well-nourished mothers. Importantly, the concentrations of many micronutrients in milk are low when the mother consumes a poor quality diet. Our new efficient methods for milk nutrient analysis have enabled us to illuminate the large differences in milk micronutrient concentrations across populations, to examine the effects of milk collection protocols on nutrient concentrations, and to study the effects of maternal supplementation in pregnancy and/or lactation on milk micronutrient and infant status. The ongoing Mothers, Infants and Lactation Quality study proposes to answer some of these uncertainties. Two hundred and fifty healthy, well-nourished, unsupplemented mother-infant dyads in each of the 4 countries are being studied. The range of milk nutrient concentrations across the first 9 months postpartum will provide "Reference Values" against which other studies and surveys can evaluate the quality of milk and possibly target nutrients for treatment with supplements or fortification.

Low Serum B12 Concentrations Are Associated with Low B12 Dietary Intake But Not with Helicobacter pylori Infection or Abnormal Gastric Function in Rural Mexican Women

Background: Gastric function, Helicobacter pylori infection, and vitamin B12 (B12) dietary intake were assessed as predictors of serum B12. Methods: H. pylori antibodies, gastric function, B12 dietary intake, and biochemical/hematological parameters were measured in 191 adult women from two rural communities in Querétaro, Mexico. Results: The overall mean serum B12 concentration was 211 ± 117 pmol/L. The prevalences of low (≤ 148 pmol/L), marginal (148 to 221 pmol/L), and adequate (> 221 pmol/L) serum B12 were 28.4%, 31.1%, and 40.5%, respectively. Seventy-one percent of women tested positive for H. pylori antibodies. The prevalence of gastric function categories did not differ by serum B12 categories. The odds ratio for having low serum B12 was 2.7 (p = 0.01) for women with an intake below the estimated average requirement, 3.6 (p = 0.01) for those in the lowest tertile of total B12 intake, and 3.0 (p = 0.02) for those in the lowest tertile of B12 intake from animal source foods. Age and B12 intake were predictors of serum B12 concentrations [serum B12 (pmol/L) = 90.060 + 5.208 (B12 intake, µg/day) + 2.989 (age, years). Conclusions: Low serum B12 concentrations were associated with low B12 dietary intake but not with H. pylori infection or abnormal gastric function in rural Mexican women.

Methods to assess vitamin B12 bioavailability and technologies to enhance its absorption

Vitamin B12 (B-12) deficiency is still relatively common in low-, medium-, and high-income countries, mainly because of dietary inadequacy and, to a lesser extent, malabsorption. This narrative review is based on a systematic search of evidence on methods to assess B-12 bioavailability and technologies to enhance its absorption. A total of 2523 scientific articles identified in PubMed and 1572 patents identified in Orbit Intelligence were prescreened. Among the reviewed methods, Schilling's test and/or its food-based version (using cobalamin-labeled egg yolk) were used for decades but have been discontinued, largely because they required radioactive cobalt. The qualitative CobaSorb test, based on changes in circulating holo-transcobalamin before and after B-12 administration, and the 14C-labeled B-12 test for quantitative measurement of absorption of a low-dose radioactive tracer are currently the best available methods. Various forms of B-12 co-formulated with chemical enhancers (ie, salcaprozate sodium, 8-amino caprylate) or supplied via biotechnological methods (ie, microbiological techniques, plant cells expressing cobalamin binding proteins), encapsulation techniques (ie, emulsions, use of chitosan particles), and alternative routes of administration (ie, intranasal, transdermal administration) were identified as potential technologies to enhance B-12 absorption in humans. However, in most cases the evidence of absorption enhancement is limited.

14C-Cobalamin Absorption from Endogenously Labeled Chicken Eggs Assessed in Humans Using Accelerator Mass Spectrometry

Traditionally, the bioavailability of vitamin B-12 (B12) from in vivo labeled foods was determined by labeling the vitamin with radiocobalt (⁵⁷Co, ⁵⁸Co or ⁶⁰Co). This required use of penetrating radioactivity and sometimes used higher doses of B12 than the physiological limit of B12 absorption. The aim of this study was to determine the bioavailability and absorbed B12 from chicken eggs endogenously labeled with ¹⁴C-B12 using accelerator mass spectrometry (AMS). ¹⁴C-B12 was injected intramuscularly into hens to produce eggs enriched in vivo with the ¹⁴C labeled vitamin. The eggs, which provided 1.4 to 2.6 μg of B12 (~1.1 kBq) per serving, were scrambled, cooked and fed to 10 human volunteers. Baseline and post-ingestion blood, urine and stool samples were collected over a one-week period and assessed for ¹⁴C-B12 content using AMS. Bioavailability ranged from 13.2 to 57.7% (mean 30.2 ± 16.4%). Difference among subjects was explained by dose of B12, with percent bioavailability from 2.6 μg only half that from 1.4 μg. The total amount of B12 absorbed was limited to 0.5–0.8 μg (mean 0.55 ± 0.19 μg B12) and was relatively unaffected by the amount consumed. The use of ¹⁴C-B12 offers the only currently available method for quantifying B12 absorption in humans, including food cobalamin absorption. An egg is confirmed as a good source of B12, supplying approximately 20% of the average adult daily requirement (RDA for adults = 2.4 μg/day).

Micronutrient intakes of lactating mothers and their association with breast milk concentrations and micronutrient adequacy of exclusively breastfed Indonesian infants

BACKGROUND

Breast milk is the sole source of nutrition for exclusively breastfed infants in the first 6 mo of life, yet few studies have measured micronutrient concentrations in breast milk in light of maternal diet and subsequent infant micronutrient intakes.

OBJECTIVES

We evaluated the adequacy of micronutrient intakes of exclusively breastfed Indonesian infants by measuring milk volume and micronutrient concentrations and assessed maternal micronutrient intakes and their relationship with milk concentrations.

METHODS

Mother-infant (2-5.3 mo) dyads (n = 113) were recruited for this cross-sectional study. Volume of breast-milk intake via the deuterium dose-to-mother technique over 14 d and analyzed micronutrient concentrations were used to calculate micronutrient intakes of exclusively breastfed infants. Maternal 3-d weighed food records were collected to assess median (IQR) micronutrient intakes. Multivariate regression analyses examined the association of usual maternal micronutrient intakes with milk micronutrient concentrations after adjustment for confounding variables.

RESULTS

Mean ± SD intake of breast-milk volume was 787 ± 148 mL/d. Median daily infant intakes of iron, zinc, selenium, magnesium, sodium, and B-vitamins (thiamin, riboflavin, niacin, pantothenic acid, B-6, and B-12) were below their respective Adequate Intakes. Inadequacies in maternal intakes (as % < estimated average requirements) were >40% for calcium, niacin, and vitamins A, B-6, and B-12. Significant positive associations existed between maternal usual intakes of vitamin A, niacin and riboflavin and milk retinol, nicotinamide, and free riboflavin concentrations in both unadjusted and adjusted (for infant age, milk volume, and parity) analyses (all P < 0.05).

CONCLUSIONS

The majority of micronutrient intakes for these exclusively breastfed infants and their mothers fell below recommendations, with associations between maternal intakes and breast-milk concentrations for 3 nutrients. Data on nutrient requirements of exclusively breastfed infants are limited, and a better understanding of the influence of maternal nutritional status on milk nutrient concentrations and its impact on the breastfed infant is needed.

Validation and Application of Biocrates AbsoluteIDQ® p180 Targeted Metabolomics Kit Using Human Milk

Human-milk-targeted metabolomics analysis offers novel insights into milk composition and relationships with maternal and infant phenotypes and nutritional status. The Biocrates AbsoluteIDQ® p180 kit, targeting 40 acylcarnitines, 42 amino acids/biogenic amines, 91 phospholipids, 15 sphingolipids, and sum of hexoses, was evaluated for human milk using the AB Sciex 5500 QTRAP mass-spectrometer in liquid chromatography-tandem mass-spectrometry (LC-MS/MS) and flow-injection analysis (FIA) mode. Milk (<6 months lactation) from (A) Bangladeshi apparently healthy mothers (body mass index (BMI) > 18.5; n = 12) and (B) Bangladeshi mothers of stunted infants (height-for-age Z (HAZ)-score <-2; n = 13) was analyzed. Overall, 123 of the possible 188 metabolites were detected in milk. New internal standards and adjusted calibrator levels were used for improved precision and concentration ranges for milk metabolites. Recoveries ranged between 43% and 120% (coefficient of variation (CV): 2.4%-24.1%, 6 replicates). Milk consumed by stunted infants vs. that from mothers with BMI > 18.5 was lower in 6 amino acids/biogenic amines but higher in isovalerylcarnitine, two phospholipids, and one sphingomyelin (p < 0.05 for all). Associations between milk metabolites differed between groups. The AbsoluteIDQ® p180 kit is a rapid analysis tool suitable for human milk analysis and reduces analytical bias by allowing the same technique for different specimens. More research is needed to examine milk metabolite relationships with maternal and infant phenotypes.

Cohort Description of the Madagascar Health and Environmental Research-Antongil (MAHERY-Antongil) Study in Madagascar

The Madagascar Health and Environmental Research-Antongil (MAHERY-Antongil) study cohort was set up in September 2015 to assess the nutritional value of seafood for the coastal Malagasy population living along Antongil Bay in northeastern Madagascar. Over 28 months of surveillance, we aimed to understand the relationships among different marine resource governance models, local people's fish catch, the consumption of seafood, and nutritional status. In the Antongil Bay, fisheries governance takes three general forms: traditional management, marine national parks, and co-management. Traditional management involves little to no involvement by the national government or non-governmental organizations, and focuses on culturally accepted Malagasy community practices. Co-management and marine national parks involve management support from either an non-govermental organization (NGO) or the national government. Five communities of varying governance strategies were enrolled into the study including 225 households and 1031 individuals whose diets, resource acquisition strategies, fisheries and agricultural practices, and other social, demographic and economic indicators were measured over the span of 3 years. Clinical visits with each individual were conducted at two points during the study to measure disease and nutritional status. By analyzing differences in fish catch arising from variation in governance (in addition to intra-annual seasonal changes and minor inter-annual changes), the project will allow us to calculate the public health value of sustainable fisheries management approaches for local populations. There is hope that coastal zones that are managed sustainably can increase the productivity of fisheries, increasing the catch of seafood products for poor, undernourished populations.

Endocannabinoid Metabolome Characterization of Milk from Guatemalan Women Living in the Western Highlands

BACKGROUND

Recognized as the gold-standard ideal fare, human milk has a unique composition that meets infants' needs throughout development. Endocannabinoids and endocannabinoid-like compounds [endocannabinoid metabolome (ECM)] are endogenous lipid mediators derived from long-chain polyunsaturated fatty acids. Based on animal models, it has been proposed that endocannabinoid arachidonoyl glycerol (AG) plays a role in establishing the suckling response during lactation. In addition, endocannabinoid ethanolamides have been shown to stimulate food intake. The mechanisms of action and the role of the ECM in human milk are not fully understood.

OBJECTIVES

The present study aimed to characterize and quantify the ECM in human milk samples from an underserved population in Guatemala.

METHODS

Human milk samples were collected from lactating women (n = 26) for ECM characterization and quantification. Samples were taken at 3 different time points between 4 and 6 mo of lactation during maternal fasting. Human milk samples were analyzed by liquid chromatography-mass spectrometry. Identified members of the ECM were: arachidonoyl ethanolamide, palmitoyl ethanolamide (PEA), oleoyl ethanolamide, docosahexaenoyl ethanolamide, eicoapentaenoyl ethanolamide, eicosenoyl ethanolamide, AG, palmitoyl glycerol, oleoyl glycerol, docosahexaenoyl glycerol, eicosapentaenoyl glycerol, eicosenoyl glycerol, arachidonic acid (ARA), docosahexaenoic acid (DHA), and eicosapentaenoic acid (EPA).

RESULTS

Overall, concentrations in the ethanolamide group were lower than the glycerols. A time effect was observed for ARA, DHA, EPA, and PEA across the 3 time points (P ≤ 0.05).

CONCLUSIONS

Our study identified the ECM in mature human milk and provides the first report for a population with health disparities within a developing country. The few studies available have been conducted in developed countries. Hypotheses for future studies can be developed based on this study's data to help elucidate specific roles for members of the ECM and how this biological system modulates infant health and development.

Prevalence of low serum vitamin B12 in Mexican children and women: results from the first National Nutrition Survey (1999) as a basis for interventions and progress

Serum samples from the 1999 Mexico National Nutrition Survey (NNS) were analyzed to determine the prevalence of low serum B12 concentrations, identify factors related with low values including B12 intake, and importantly, to provide a baseline for monitoring progress in reducing deficiency. Samples for B12 were available from 488 children and 464 women, a sub-sample of the nationally representative 1999 NNS. The national overall prevalence of low (<200 pg/mL) and marginal (200 to 300 pg/mL) serum B12 was 25.6% and 21.0%, respectively. Adolescent girls had the lowest serum B12 concentrations (325 ± 308 pg/mL) and the prevalence of deficiency was 40% in pregnant women even using a lower cut-point (<135 pg/mL). Residents of rural areas and the South, population groups with poorest socioeconomic status, and illiterate and indigenous women had the lowest serum B12 Children and women who met dietary recommendations for B12 intake had higher serum B12 than those who did not. Overall 45.9% of intakes fell below the Estimated Adequate Requirement. Dietary B12 intake of children and women was directly correlated with serum B12 (r = 0.18, p < 0.001 and r = 0.11, p = 0.0304). The prevalence of marginal and deficient B12 status in 1999 was much higher than the most recently published national data suggesting the success of national policies to improve micronutrient status.

Breast milk provides inadequate amounts of vitamin B12 for predominantly breastfed Guatemalan infants

Vitamin B12 (B12) plays in an important role in the development and function of the brain and nervous system, and adequate B12 status is especially important for the normal development of infants. In previous research conducted in Guatemala City we reported a high prevalence of B12 deficiency in lactating women and their infants 3 and 12 months of age, and low B12 concentrations in breast milk. The objective of this study was to assess predictors of serum B12 concentration in predominantly breastfed Guatemalan infants including intake of B12 from breast milk and other foods. Serum B12, breast milk and other food intakes, anthropometry, morbidity and socioeconomic status were assessed in infants 6.7 ± 0.6 months of age (n = 127, 52% female) in peri-urban Guatemala City. Twenty-four percent of infants had deficient B12 status (serum B12 concentration < 148 pmol/L) and 37% had marginal B12 status (148-220 pmol/L). Serum B12 concentrations were negatively correlated with infants' consumption of energy from breast milk (r = -0.37, p = 0.001), and positively correlated with their total consumption of animal source foods, especially cow's milk (r = 0.40, p = 0.001). Based on previously analyzed breast milk B12 concentrations in a nearby community, breast milk provided < 10% of the recommended daily B12 intake for this age. We conclude that there was a high prevalence of B12 deficiency in these Guatemalan infants by 6 months of age. Serum B12 was higher in infants consuming more cow's milk and lower in those consuming more breast milk.

Water-Soluble Vitamins in Human Milk Factors Affecting Their Concentration and Their Physiological Significance

Most B vitamins and vitamin C are among the nutrients in milk most strongly affected by maternal status and/or dietary intake. Recent analytical methods are more efficient and valid, revealing major differences in water-soluble vitamins across population groups. An inadequate supply in milk can be detrimental to the breastfed infant's health and development although cutoff points below which risk is increased are often uncertain, and little attention has been paid to adverse effects of low milk water-soluble vitamins on infant health and function. Concentrations change during lactation: thiamine, niacin, and pantothenic acid increase; B6, B12, and ascorbic acid gradually decrease; while riboflavin concentrations are stable, as is choline after an initial increase. Folate fluctuates until stabilizing in late lactation. Water-soluble vitamin concentrations in milk are also influenced by maternal supplementation, and, for some, by parity, preterm delivery, smoking, and maternal illness. However, there is relatively little change in concentrations during a feed nor is diurnal variation a major influence. Reported concentrations are used to set adequate intakes for infants and incremental requirements for lactation. However, the status of available data is poor due to the small number of participants in most studies, uncertainties about maternal nutritional status, and variable times of milk collection postpartum.