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Background: Children with underweight in the first 2 years have lower body mass index z‐score (zBMI) and height‐for‐age z‐score (HAZ) in later childhood. It is not known if underweight in the first 2 years is associated with nutrition risk in later childhood. Objective: (1) Determine the relationship between underweight (zBMI < −2) in the first 2 years and nutrition risk measured by the Nutrition Screening for Toddlers and Preschoolers (NutriSTEP) score from 18 months to 5 years. (2) Explore the relationship between underweight in the first 2 years and the NutriSTEP subscores for eating behaviours and dietary intake from 18 months to 5 years. Methods: This was a prospective study, including healthy full‐term children in Canada aged 0–5 years. zBMI was calculated using measured heights and weights and the WHO growth standards. NutriSTEP score was measured using a parent‐completed survey and ranged from 0 to 68. Nutrition risk was defined as a score ≥21. Linear mixed effects models were used. Results: Four thousand nine hundred twenty‐nine children were included in this study. At enrolment, 51.9% of participants were male. The prevalence of underweight children was 8.8%. Underweight in the first 2 years was associated with higher NutriSTEP (0.79, 95% CI: 0.29,1.29), higher eating behaviour subscore (0.24, 95% CI: 0.03, 0.46) at 3 years and higher odds of nutrition risk (OR: 1.39, 95% CI: 1.07,1.82) at 5 years. Conclusions: Children with underweight in the first 2 years had higher nutrition risk in later childhood. Further research is needed to understand the factors which influence these relationships. Key points: In this prospective cohort study of 4929 children aged 0–5 years, children with underweight in the first 2 years of life had higher odds of nutrition risk at 5 years of age compared to children without underweight in the first 2 years (p = 0.02). Further research is needed to understand the factors which influence these relationships. [ABSTRACT FROM AUTHOR]

Background: Invasive pneumococcal disease is a major cause of infant morbidity and death worldwide. Vitamin D promotes anti-pneumococcal immune responses in vitro, but whether improvements in infant vitamin D status modify risks of nasal pneumococcal acquisition in early life is not known.Methods: This is a secondary analysis of data collected in a trial cohort in Dhaka, Bangladesh. Acute respiratory infection (ARI) surveillance was conducted from 0 to 6 months of age among 1060 infants of women randomized to one of four pre/post-partum vitamin D dose combinations or placebo. Nasal swab samples were collected based on standardized ARI criteria, and pneumococcal DNA quantified by qPCR. Hazards ratios of pneumococcal acquisition and carriage dynamics were estimated using interval-censored survival and multi-state modelling.Results: Pneumococcal carriage was detected at least once in 90% of infants by 6 months of age; overall, 69% of swabs were positive (2616/3792). There were no differences between any vitamin D group and placebo in the hazards of pneumococcal acquisition, carriage dynamics, or carriage density (p > 0.05 for all comparisons).Conclusion: Despite in vitro data suggesting that vitamin D promoted immune responses against pneumococcus, improvements in postnatal vitamin D status did not reduce the rate, alter age of onset, or change dynamics of nasal pneumococcal colonization in early infancy. Trial registration Registered in ClinicalTrials.gov with the registration number of NCT02388516 and first posted on March 17, 2015. [ABSTRACT FROM AUTHOR]

Child growth standards are commonly used to derive age- and sex-standardized anthropometric indices but are often inappropriately applied to preterm-born children (<37 weeks of gestational age (GA)) in epidemiology studies. Using the 2004 Pelotas Birth Cohort, we examined the impact of correcting for GA in the application of child growth standards on the magnitude and direction of associations in 2 a priori–selected exposure-outcome scenarios: infant length-for-age z score (LAZ) and mid-childhood body mass index (scenario A), and infant LAZ and mid-childhood intelligence quotient (scenario B). GA was a confounder that had a strong (scenario A) or weak (scenario B) association with the outcome. Compared with uncorrected postnatal age, using GA-corrected postnatal age attenuated the magnitude of associations, particularly in early infancy, and changed inferences for associations at birth. Although differences in the magnitude of associations were small when GA was weakly associated with the outcome, model fit was meaningfully improved using corrected postnatal age. When estimating population-averaged associations with early childhood growth in studies where preterm- and term-born children are included, incorporating heterogeneity in GA at birth in the age scale used to standardize anthropometric indices postnatally provides a useful strategy to reduce standardization errors. [ABSTRACT FROM AUTHOR]

Objective: Millions of children suffer from severe acute malnutrition (SAM) in low- and middle- income countries. Much is known about the effectiveness of community treatment programmes (CMAM) but little is known about post-discharge outcomes after successful treatment. The present study aimed to evaluate post-discharge outcomes of children cured of SAM.Design: Prospective, observational cohort study. Children with SAM who were discharged as cured were followed monthly for 6 months or until they experienced relapse to SAM. 'Cure' was defined as a child achieving a mid-upper arm circumference (MUAC) of ≥115 mm with ≥15 % weight gain after loss of oedema. Relapse was defined as a child with MUAC<115 mm and/or oedema at any monthly visit.Setting: Save the Children CMAM programme in Swabi, Pakistan, from January 2012 to December 2014.Subjects: Children aged 6-59 months (n 117) discharged as cured from the CMAM programme were eligible for the study and followed for 6 months.Results: One hundred children (92·6 %) remained free of SAM, eight (7·4 %) relapsed to SAM, nine (8·3 %) were lost to follow-up and none died. Most relapses occurred within 3 months of discharge (mean time to relapse 73·4 (sd 36·2) d). At enrolment, 90 % had moderate acute malnutrition (MAM) and 10 % were not malnourished. By the end of 6 months, 35 % persisted with MAM and the remaining were not malnourished.Conclusions: In rural Pakistan, fewer than 10 % of children cured of SAM relapsed. The first 3 months is the most vulnerable time. [ABSTRACT FROM AUTHOR]

Background: Determining the spatial patterns of infection among young children living in a malaria-endemic area may provide a means of locating high-risk populations who could benefit from additional resources for treatment and improved access to healthcare. The objective of this secondary analysis of baseline data from a cluster-randomized trial among 1943 young Ghanaian children (6-35 months of age) was to determine the geo-spatial factors associated with malaria and non-malaria infection status. Methods: Spatial analyses were conducted using a generalized linear geostatistical model with a Matern spatial correlation function and four definitions of infection status using different combinations of inflammation (C-reactive protein, CRP > 5 mg/L) and malaria parasitaemia (with or without fever). Potentially informative variables were included in a final model through a series of modelling steps, including: individual-level variables (Model 1); household-level variables (Model 2); and, satellite-derived spatial variables (Model 3). A final (Model 4) and maximal model (Model 5) included a set of selected covariates from Models 1 to 3. Results: The final models indicated that children with inflammation (CRP > 5 mg/L) and/or any evidence of malaria parasitaemia at baseline were more likely to be under 2 years of age, stunted, wasted, live further from a health facility, live at a lower elevation, have less educated mothers, and higher ferritin concentrations (corrected for inflammation) compared to children without inflammation or parasitaemia. Similar results were found when infection was defined as clinical malaria or parasitaemia with/without fever (definitions 3 and 4). Conversely, when infection was defined using CRP only, all covariates were non-significant with the exception of baseline ferritin concentration. In Model 5, all infection definitions that included parasitaemia demonstrated a significant interaction between normalized difference vegetation index and land cover type. Maps of the predicted infection probabilities and spatial random effect showed defined high- and low-risk areas that tended to coincide with elevation and cluster around villages. Conclusions: The risk of infection among young children in a malaria-endemic area may have a predictable spatial pattern which is associated with geographical characteristics, such as elevation and distance to a health facility. Original trial registration clinicaltrials.gov (NCT01001871) [ABSTRACT FROM AUTHOR]

Background: The causes of stunting are complex but likely include prenatal effects, inadequate postnatal nutrient intake, and recurrent infections. Low-birth-weight (LBW) infants are at high risk of stunting. More than 25% of live births in low- and middle-income countries are at full term with low birth weight (FT-LBW). Evidence on the efficacy of specific interventions to enhance growth in this vulnerable group remains scant. Objective: We investigated the independent and combined effects of a directed use of a water-based hand sanitizer (HS) and a mineraland vitamin-enhanced micronutrient powder (MNP) (22 minerals and vitamins) to prevent infections and improve nutrient intake to reduce stunting in FT-LBW infants. Design: The study was a prospective 2 × 2 factorial, clusterrandomized trial in 467 FT-LBW infants during 2 periods: from 0 to 5 mo postpartum (0–180 d postpartum) and from 6 to 12 mo postpartum (181–360 d postpartum) with the use of 48 clusters. All groups received the same general nutrition, health, and hygiene education (NHHE) at enrollment and throughout the 12 mo. Group assignments initially included the following 2 groups: no HS (control) group or HS from 0 to 5 mo postpartum. These assignments were followed by further divisions into the following 4 groups from 6 to 12 mo postpartum: 1) no HS and no MNP (control), 2) HS only, 3) MNP only, and 4) HS and MNP. Results: When delivered in combination with NHHE, the use of an HS showed no additional benefit in reducing indicators of infection in the first or second half of infancy or the likelihood of stunting at 12 mo postpartum. FT-LBW infants who received the MNP (with or without the HS) were significantly less likely to be stunted at 12 mo than were controls (OR: 0.35; 95% CI: 0.15, 0.84; P = 0.017). Conclusions: The use of a mineral- and vitamin-enhanced MNP significantly reduced stunting in FT-LBW infants in this high-risk setting. The use of a water-based HS did not have an additive effect. This trial was registered at clinicaltrials.gov as NCT01455636. [ABSTRACT FROM AUTHOR]

Background: The OptEC trial aims to evaluate the effectiveness of oral iron in young children with non-anemic iron deficiency (NAID). The initial sample size calculated for the OptEC trial ranged from 112-198 subjects. Given the uncertainty regarding the parameters used to calculate the sample, an internal pilot study was conducted. The objectives of this internal pilot study were to obtain reliable estimate of parameters (standard deviation and design factor) to recalculate the sample size and to assess the adherence rate and reasons for non-adherence in children enrolled in the pilot study.Methods: The first 30 subjects enrolled into the OptEC trial constituted the internal pilot study. The primary outcome of the OptEC trial is the Early Learning Composite (ELC). For estimation of the SD of the ELC, descriptive statistics of the 4 month follow-up ELC scores were assessed within each intervention group. The observed SD within each group was then pooled to obtain an estimated SD (S2) of the ELC. Correlation (ρ) between the ELC measured at baseline and follow-up was assessed. Recalculation of the sample size was performed using analysis of covariance (ANCOVA) method which uses the design factor (1- ρ(2)). Adherence rate was calculated using a parent reported rate of missed doses of the study intervention.Conclusion: The new estimate of the SD of the ELC was found to be 17.40 (S2). The design factor was (1- ρ2) = 0.21. Using a significance level of 5%, power of 80%, S2 = 17.40 and effect estimate (Δ) ranging from 6-8 points, the new sample size based on ANCOVA method ranged from 32-56 subjects (16-28 per group). Adherence ranged between 14% and 100% with 44% of the children having an adherence rate ≥ 86%. Information generated from our internal pilot study was used to update the design of the full and definitive trial, including recalculation of sample size, determination of the adequacy of adherence, and application of strategies to improve adherence.Trial Registration: ClinicalTrials.gov Identifier: NCT01481766 (date of registration: November 22, 2011). [ABSTRACT FROM AUTHOR]

Background: Vitamin D regulates bone mineral metabolism and skeletal development. Some observational studies have suggested that prenatal vitamin D deficiency increases the risk of adverse pregnancy and/or birth outcomes; however, there is scant evidence from controlled trials, leading the World Health Organization to advise against routine vitamin D supplementation in pregnancy. Importantly, little is known about the effect of maternal vitamin D status on infant linear growth in communities in South Asia where stunting is highly prevalent and maternal-infant vitamin D status is commonly suboptimal.Methods/design: The Maternal Vitamin D for Infant Growth study is a randomized, placebo-controlled, dose-ranging trial of maternal vitamin D supplementation during pregnancy and lactation in Dhaka, Bangladesh. The primary aims are to estimate (1) the effect of maternal prenatal oral vitamin D3 supplementation (4200 IU/wk, 16,800 IU/wk, or 28,000 IU/wk, administered as weekly doses) versus placebo on infant length at 1 year of age and (2) the effect of maternal postpartum oral vitamin D3 supplementation (28,000 IU/wk) versus placebo on length at 1 year of age among infants born to women who received vitamin D 28,000 IU/wk during pregnancy. Generally healthy pregnant women (n = 1300) in the second trimester (17-24 weeks of gestation) are randomized to one of five parallel arms: placebo 4200 IU/wk, 16,800 IU/wk, or 28,000 IU/wk in the prenatal period and placebo in the postpartum period or 28,000 IU/wk in the prenatal period and 28,000 IU/wk in the postpartum period. Household- and clinic-based follow-up of mother-infant pairs is conducted weekly by trained personnel until 26 weeks postpartum and every 3 months thereafter. The primary trial outcome measure is length for age z-score at 1 year of age. Anthropometric measurements, clinical information, and biological specimens collected at scheduled intervals will enable the assessment of a range of maternal, perinatal, and infant outcomes.Discussion: The role of vitamin D in maternal and infant health remains unresolved. This trial is expected to contribute unique insights into the effects of improving maternal-infant vitamin D status in a low-income setting where stunting and adverse perinatal outcomes represent significant public health burdens.Trial Registration: ClinicalTrials.gov identifier: NCT01924013. Registered on 13 August 2013. [ABSTRACT FROM AUTHOR]

Background: Three decades of research suggests that prevention of iron deficiency anemia (IDA) in the primary care setting may be an unrealized and unique opportunity to prevent poor developmental outcomes in children. A longitudinal study of infants with IDA showed that the developmental disadvantage persists long term despite iron therapy. Early stages of iron deficiency, termed non-anemic iron deficiency (NAID), provide an opportunity for early detection and treatment before progression to IDA. There is little research regarding NAID, which may be associated with delayed development in young children. The aim of this study is to compare the effectiveness of four months of oral iron treatment plus dietary advice, with placebo plus dietary advice, in improving developmental outcomes in children with NAID and to conduct an internal pilot study. Methods/Design: From a screening cohort, those identified with NAID (hemoglobin ≥110 g/L and serum ferritin <14 μg/L) are invited to participate in a pragmatic, multi-site, placebo controlled, blinded, parallel group, superiority randomized trial. Participating physicians are part of a primary healthcare research network called TARGet Kids! Children between 12 and 40 months of age and identified with NAID are randomized to receive four months of oral iron treatment at 6 mg/kg/day plus dietary advice, or placebo plus dietary advice (75 per group). The primary outcome, child developmental score, is assessed using the Mullen Scales of Early Learning at baseline and at four months after randomization. Secondary outcomes include an age appropriate behavior measure (Children's Behavior Questionnaire) and two laboratory measures (hemoglobin and serum ferritin levels). Change in developmental and laboratory measures from baseline to the end of the four-month follow-up period will be analyzed using linear regression (analysis of covariance method). Discussion: This trial will provide evidence regarding the association between child development and NAID, and the effectiveness of oral iron to improve developmental outcomes in children with NAID. The sample size of the trial will be recalculated using estimates taken from an internal pilot study. [ABSTRACT FROM AUTHOR]

Background: Prenatal calcium and iron supplements are recommended in settings of low dietary calcium intake and high prevalence of anemia. However, calcium administration may inhibit iron absorption. To overcome calcium-iron interactions, we developed a multi-micronutrient powder containing iron (60 mg), folic acid (400 μg), and calcium carbonate granules microencapsulated with a pH-sensitive enteric coating to delay intestinal release. Objectives: We aimed to establish in vivo evidence that enteric-coated (EC) calcium is bioavailable in pregnant women and to explore the dose-responsiveness of fractional calcium absorption (FCA) in pregnancy. Design: This was a randomized crossover trial in pregnant women (26-28 wk of gestation) in Dhaka, Bangladesh. Participants were allocated to 1 of 3 dose groups (500, 1000, or 1500 mg elemental Ca). FCA was estimated in random order for EC and non-EC (control) granules by a dual-stable-isotope method (44Ca-labeled granules and intravenous 42Ca) on the basis of the relative recovery of 44Ca compared with 42Ca in urine over 48 h. Results: Forty-nine participants with FCA for both EC and non-EC granules were included in the primary analyses. FCA geometric means were as follows: 21.8% (500 mg), 9.2% (1000 mg), and 11.7% (1500 mg) for non-EC granules compared with 3.3% (500 mg), 1.2% (1000 mg), and 2.1% for EC granules. Cumulative 48-h FCA of EC calcium was 85% lower (P < 0.001) than that of non-EC calcium, after adjustment for dose. In comparison to 500 mg, the FCA for the 1000-mg dose was 61% lower (P < 0.001) and was 42% lower (P = 0.002) for the 1500-mg dose, after adjustment for formulation. Conclusions: A pH-sensitive enteric coating substantially reduced calcium absorption from a prenatal multi-micronutrient powder. In its current formulation, this novel supplement is not suitable for clinical use. FCA was highly dose-dependent, such that doses of 1000 and 1500 mg delivered only negligibly more bioavailable calcium than the 500-mg dose. This trial was registered at clinicaltrials.gov as NCT01678079. [ABSTRACT FROM AUTHOR]

Background: Low-birth-weight children are known to be at risk of both anemia and cognitive/language deficits in their early years. Objective: The aim of the current study was to examine the effects of a 22-element multiple micronutrient powder (MNP) on the cognitive and language development of full-term low-birth-weight (LBW-T) children in Bangladesh. Methods: The current study was a follow-up of children who were enrolled in a randomized cluster trial at 7-12 mo of age. Children in 12 intervention clusters (communities) were administered a daily 22-element MNP sachet with their food for 5 mo, and both intervention and control groups (also 12 clusters) received nutrition, health, and hygiene education. The current study involved the assessment of children at 16-22 mo of age (22-element MNP group: n = 96; control group: n = 82) on 3 subtests of the Bayley Scales of Infant and Toddler Development III test to measure cognitive, receptive language, and expressive language development. Results: There was a significant effect of the 22-element MNP on children's expressive language scores (d = 0.39), and stunting moderated the effect on receptive language scores; there was no effect on cognitive development (d = 0.08). Conclusion: An MNP may thus offer one feasible solution to improve language development of LBW-T children in low-resource community settings. This trial was registered at clinicaltrials.gov as NCT01455636. [ABSTRACT FROM AUTHOR]

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ObjectiveTo investigate whether the recommended dietary intake of Ca in anaemic infants compromises the expected Hb response, via home fortification with a new Ca- and Fe-containing Sprinkles™ micronutrient powder (MNP).DesignA double-blind, randomized controlled, 2-month trial was conducted in Bangladesh. Infants were randomized to one of two MNP intervention groups containing Fe and other micronutrients, with or without Ca. Hb, anthropometrics and dietary intake were measured pre- and post-intervention while family demographics were collected at baseline.SettingTwenty-six rural villages in the Kaliganj sub-district of Gazipur, Bangladesh.SubjectsOne hundred infants aged 6–11 months.ResultsA significant increase in Hb (MNP, 13·3 (sd 12·6) g/l v. Ca-MNP, 7·6 (sd 11·6) g/l; P < 0·0001) was noted in infants from both groups. However, infants receiving MNP without Ca had a significantly higher end-point Hb concentration (P = 0·024) and rate of anaemia recovery (P = 0·008). Infants receiving MNP with Ca were more likely to remain anaemic (OR 3·2; 95 % CI 1·4, 7·5). Groups did not differ in dietary intake or demographic and anthropometric indicators.ConclusionsAlthough both groups showed significant improvement in Hb status, the nutrient–nutrient interaction between Fe and Ca may have diminished the Hb response in infants receiving the Ca-containing MNP. [ABSTRACT FROM PUBLISHER]

Prenatal calcium supplementation is recommended by the WHO to decrease the risk of preeclampsia in women with low dietary calcium intake; yet, this recommendation has not been successfully implemented to date. One component of an effective population-based prenatal calcium intervention will be the selection of a widely accepted calcium vehicle to promote consistent, long-term consumption of the supplement. We aimed to evaluate preference and acceptability of 4 different options for delivering prenatal calcium (conventional tablets, chewable tablets, unflavored powder, and flavored powder) to pregnant women in urban Bangladesh. In a modified discrete-choice trial, pregnant women (n = 132) completed a 4-d "run-in period" in which each delivery vehicle was sampled once, followed by a 21-d "selection period" during which participants were instructed to freely select a single delivery vehicle of their choice each day. Preference was empirically defined as the probability that each delivery vehicle was selected on a given day, and measured from participants' daily delivery vehicle selections; acceptability was assessed by using mid- and post-trial questionnaires. Conventional tablets demonstrated the highest probability of selection (62%); the probability of selection of chewable tablets (19%), flavored powder (12%), and unflavored powder (5%) were all significantly lower than for conventional tablets (P < 0.001). The palatability and product characteristics of the conventional tablets were more acceptable than for the other 3 delivery vehicles. Our rigorous methodologic approach used both quantitative and self-reported measures that consistently identified the most preferred and accepted prenatal calcium delivery form. Through observation of pregnant women's actual supplement use, and perceptions of acceptability (i.e., ease of use, palatability), we demonstrated that conventional tablets are likely to be the most accepted and successful calcium delivery vehicle in future field studies and scale-up of the WHO recommendation in Bangladesh. This trial was registered at clinicaltrials.gov as NCT01676636. [ABSTRACT FROM AUTHOR]

Background. Hypertensive diseases of pregnancy are important causes of maternal and perinatal mortality. Based on meta-analyses of efficacy trials of prenatal calcium supplementation to reduce the risk of hypertensive diseases of pregnancy, the World Health Organization recommends 1.5 to 2.0 g of elemental calcium per day for pregnant women with low dietary calcium intakes (as well as 60 mg of iron and 400 µg of folic acid). However, implementation of this recommendation is challenged by the size and number of calcium tablets required and the need to avoid concurrent ingestion of calcium and iron due to intraintestinal interactions. Objective. We developed a novel micronutrient powder containing microencapsulated pH-sensitive calcium in addition to iron and folic acid, designed to facilitate early intestinal iron release and delayed calcium release. Methods. Two pharmaceutical companies were contracted to develop a prototype, one of which was chosen for clinical testing. Calcium carbonate granules were coated with a trilayer pH-sensitive enteric coating using a fluid-bed spray coater. Iron and folic acid granules were encapsulated with a time-release coating. Iron and calcium dissolution profiles were assessed during exposure to acidic (pH 1.2) and/or basic (pH 5.8) media using a modified USP apparatus 1 (basket) method. Results. At pH 1.2, calcium and iron release was ʹ 10% and > 90% after 120 minutes, respectively. At pH 5.8, > 80% of total calcium was released after 90 minutes. Conclusions. Based on in vitro criteria, the supplement may be a promising approach for delivering calcium, iron, and folic acid as a single daily dose to pregnant women in settings of low dietary intake of calcium. [ABSTRACT FROM AUTHOR]

Background: Iron deficiency is a major cause of anemia and the most prevalent nutrient deficiency among pregnant women in developing countries. The use of iron and folic acid supplements to treat and prevent iron-deficiency anemia has limited effectiveness, mainly due to poor adherence. Home fortification with a micronutrient powder for pregnant women may be an effective and acceptable alternative to traditional drug models.Objective: To determine whether home fortification with micronutrient powders is at least as efficacious as iron and folic acid tablets for improving hemoglobin concentration in pregnant women.Methods: A cluster-randomized noninferiority trial was conducted in the rural subdistrict of Kaliganj in central Bangladesh. Pregnant women (gestational age 14-22 weeks, n=478), were recruited from 42 community-based Antenatal Care Centres. Each centre was randomly allocated to receive either a micronutrient powder (containing iron,folic acid, vitamin C, and zinc) or iron and folic acid tablets. Changes in hemoglobin from baseline were compared across groups using a linear mixed-effects regression model.Results: At enrolment, the overall prevalence of anemia was 45% (n = 213/478). After the intervention period, the mean hemoglobin concentrations among women receiving the micronutrient powder were not inferior to those among women receiving tablets (109.5 ± 12.9 vs. 112.0 ± 11.2 g/L; 95% CI, -0.757 to 5.716). Adherence to the micronutrient powder was lower than adherence to tablets (57.5 ± 22.5% vs. 76.0 ± 13.7%; 95% CI, -22.39 to -12.94); however, in both groups, increased adherence was positively correlated with hemoglobin concentration.Conclusions: The micronutrient powder was at least as efficacious as the iron and folic acid tablets in controlling moderate to severe anemia during pregnancy. [ABSTRACT FROM AUTHOR]

Background. Iron deficiency is a major cause of anemia and the most prevalent nutrient deficiency among pregnant women in developing countries. The use of iron and folic acid supplements to treat and prevent irondeficiency anemia has limited effectiveness, mainly due to poor adherence. Home fortification with a micronutrient powder for pregnant women may be an effective and acceptable alternative to traditional drug models. Objective. To determine whether home fortification with micronutrient powders is at least as efficacious as iron and folic acid tablets for improving hemoglobin concentration in pregnant women. Methods. A cluster-randomized noninferiority trial was conducted in the rural subdistrict of Kaliganj in central Bangladesh. Pregnant women (gestational age 14-22 weeks, n = 478), were recruited from 42 communitybased Antenatal Care Centres. Each centre was randomly allocated to receive either a micronutrient powder (containing iron, folic acid, vitamin C, and zinc) or iron and folic acid tablets. Changes in hemoglobin from baseline were compared across groups using a linear mixed-effects regression model. Results. At enrolment, the overall prevalence of anemia was 45% (n = 213/478). After the intervention period, the mean hemoglobin concentrations among women receiving the micronutrient powder were not inferior to those among women receiving tablets (109.5 ± 12.9 vs 112.0 ± 11.2 g/L; 95% CI, -0.757 to 5.716). Adherence to the micronutrient powder was lower than adherence to tablets (57.5 ± 22.5% vs 76.0 ± 13.7%; 95% CI, -22.39 to -12.94); however, in both groups, increased adherence was positively correlated with hemoglobin concentration. Conclusions. The micronutrient powder was at least as efficacious as the iron and folic acid tablets in controlling moderate to severe anemia during pregnancy [ABSTRACT FROM AUTHOR]

An international perspective of the magnitude of anemia in indigenous peoples is currently lacking. The present systematic review was performed to characterize the global prevalence, severity, and etiology of anemia in indigenous peoples by conducting a systematic search of original research published in English from 1996 to February 2010 using PubMed, Medline, and Embase. A total of 50 studies, representing the following 13 countries, met the inclusion criteria: Australia, Brazil, Canada, Guatemala, India, Kenya, Malaysia, Mexico, New Zealand, Sri Lanka, Tanzania, the United States, and Venezuela. Results indicate major deficiencies in the coverage and quality of anemia monitoring data for indigenous populations worldwide. The burden of anemia is overwhelmingly higher among indigenous groups compared to the general population and represents a moderate (20-39.9%) to severe (≥40%) public health problem. For the most part, the etiology of anemia is preventable and includes inadequate diet, poor living conditions, and high infection rates (i.e., malaria and intestinal parasites). A concerted global effort is needed to reduce the worldwide burden of anemia in these marginalized populations. [ABSTRACT FROM AUTHOR]

Background: A link between the provision of iron and infectious morbidity has been suggested, particularly in children with malnutrition. Two meta-analyses concluded that iron is not harmful, but malnourished children were underrepresented in most available studies. Objective: This study evaluated the effect of iron-containing micronutrient powder (iron MNP) on infectious morbidities when provided to children with moderate-to-severe malnutrition and anemia. Design: A randomized, double-blind, placebo-controlled, noninferiority safety trial using a 2-mo course of daily iron MNP or placebo powder (PP) was conducted in 268 Bangladeshi children aged 12-24 mo with moderate-to-severe malnutrition (weight-for-age z score ≤ -2) and a hemoglobin concentration between 70 and 110 g/L. The primary endpoint was a composite of diarrhea, dysentery, and lower respiratory tract infection episodes (DDL) recorded through home visits every 2 d during the intervention and then weekly for 4 mo. The noninferiority margin was 1.2. Secondary endpoints included hemoglobin and anthropometric changes at 2 and 6 mo. All deaths and hospitalizations were documented. To capture seasonal variation, the study was repeated in the winter and summer with 2 distinct groups. An intention-to-treat analysis of recurrent events was performed by using the univariate Anderson-Gill model. Results: The baseline characteristics of the subjects were similar. Analysis of phase-aggregated DDL data showed that iron MNP was not inferior to PP (relative risk: 0.81; 95% CI: 0.62, 1.04) and improved hemoglobin concentrations (P < 0.0001). We recorded no deaths, and hospitalizations were rare. Conclusion: Iron MNP is safe and efficacious when provided to children aged 12-24 mo with moderate-to-severe malnutrition and anemia. This trial is registered at clinicaltrials.gov as NCT00530374. [ABSTRACT FROM AUTHOR]

Objective: To determine the prevalence of anaemia and maternal and infant factors associated with Hb values in infants at 6 months of age in rural Bangladesh. Design: Infants (born to mothers supplemented with Fe-folic acid from midpregnancy) were visited at birth and 6 months of age. Mothers' anthropometric status, and infants' birth weight, gestational age at birth, weight and Hb concentration at 6 months were measured. Household socio-economic and demographic data, infant feeding practices and health status were collected using a pre-tested structured questionnaire. Setting: Rural Bangladesh. Subjects: Four hundred and two infants. Results: For the total cohort (n 402), the range of anaemia prevalence values was from 30·6% using a cut-off value of Hb<95 g/l to 71·9% using a value of Hb<110 g/l. Birth weight and month of birth were the only factors positively associated with infant Hb in a linear regression model (P=0·008 and 0·011, respectively). Conclusions: There was an unexpectedly high prevalence of anaemia in infants at 6 months of age, before the assumed period of vulnerability. Hb at this age tended to be higher in those with higher birth weight. We also found a season effect on Hb, as it tended to be higher as the study progressed. The high prevalence of anaemia at such an early age needs to be addressed to minimize the disease's long-term consequences. [ABSTRACT FROM AUTHOR]

Background: Improving the nutritional status of an emergency-affected population is essential, because undernutrition increases infection risk and is linked to more than 50% of childhood deaths in developing countries. Emergency food aid addresses nutritional needs, including micronutrient deficiencies, but is provided only for a limited time and uses few items, so the needs of specific target groups are often not fully met.Objective: To describe the post-tsunami experience with distribution of Vitalita Sprinkles in Aceh and Nias and to analyze the monitoring data gathered for the emergency response.Methods: International agencies such as Helen Keller International and partners provided micronutrients in response to the tsunami emergency in Aceh and Nias and to analyze the monitoring data gathered for the emergency response.Results: In March and April 2006, the percentage of children aged 6 months to 59 months who had consumed Vitalita in the previous month was more than 70% in 5 of 11 districts evaluated, 40% to 70% in another five districts, and 32% in one district. An independent survey found 25% less anemia among recipients. Almost all mothers interviewed during March to April 2006 (96.3%) had heard about Vitalita and recognized its packaging, 69% said that Vitalita contained vitamins for under-fives, 86% knew the appropriate target group for Vitalita, and 83% said it had to be mixed with solid food. Of the 26% that reported not having given Vitalita to their child in the last month, 90.5% said that their child did not like it. CONCLUSIONS AND LESSONS LEARNED: Because the product, including its concept, was new, appropriate information and training was required as well as a thorough introduction to the beneficiaries, particularly on proper use, to ensure acceptance. This experience demonstrates that providing micronutrients as part of emergency relief and transition programming, as recently recommended by the World Health Organization/UNICEF/World Food Program, is feasible. [ABSTRACT FROM AUTHOR]

Background. The effectiveness of commonly suggested public health interventions to control childhood iron-deficiency anemia has been low. Objective. To determine whether iron provided in Sprinkles daily or in a higher dose once weekly affected hemoglobin, serum ferritin levels, and serum transferrin receptor levels, and to determine whether there were differences in the effects of the two regimens. Methods. In this cluster-randomized, community-based trial conducted in rural areas of Bangladesh, 136 children aged 12 to 24 months with mild to moderate anemia (hemoglobin 70-109 g/L) were randomly allocated to receive Sprinkles daily (12.5 mg of elemental iron, n = 79) or once weekly (30 mg of elemental iron, n = 73) for 8 weeks. Hemoglobin, serum ferritin, and serum transferrin receptor were assessed at the start and end of the intervention. Results. In both groups, there were significant increases in hemoglobin and serum ferritin and a significant decrease in serum transferrin receptor (p <). There were no significant differences between the groups in the increases in hemoglobin (16.1 ± 13.2 g/L for the group receiving Sprinkles daily and 12.3 ± 13.3 g/L for the group receiving Sprinkles once weekly) and serum ferritin (10.6 and 5.7 µg/L, respectively). The decrease in serum transferrin receptor also did not significantly differ between the groups (median, -2.5 and -1. 8 mg/L, respectively). The prevalence rates of iron-deficiency anemia, depleted iron stores, and tissue iron deficiency decreased significantly within each group (p < .01), with no significant differences between the groups. Conclusions. Home fortification of complementary foods with Sprinkles given either daily or once weekly improved iron-deficiency anemia and iron status among young children. [ABSTRACT FROM AUTHOR]

Nutrient-nutrient interactions are an important consideration for any multiple-micronutrient formulation, including Sprinkles, a home-fortification strategy to control anemia. The objectives of this randomized controlled trial were as follows: 1) to compare the absorption of zinc at 2 doses given as Sprinkles; and 2) to examine the effect of zinc and ascorbic acid (AA) on iron absorption from Sprinkles. Seventy-five children aged 12-24 mo were randomly assigned to the following groups: 1) 5 mg of labeled zinc (67Zn) with 50 mg AA (LoZn group); b) 10 mg of labeled zinc (67Zn) with 50 mg AA (HiZn group); or 3) 5 mg zinc with no AA (control). All groups contained 30 mg of labeled iron (57Fe). Intravenous infusions labeled with 70Zn (LoZn and HiZn groups) and 58Fe (control) were administered. Blood was drawn at baseline, 48 h and 14 d later. The percentage of zinc absorbed did not differ between LoZn (geometric mean = 6.4%; min-max: 1.7-14.6) and HiZn (geometric mean = 7.5%; min-max: 3.3-18.0) groups. However, total zinc absorbed was significantly different between the LoZn (geometric mean = 0.31 mg; min-max: 0.08-0.73) and HiZn (geometric mean = 0.82 mg; min-max: 0.33-1.82) groups (P = 0.0004). Geometric mean percentage iron absorption values did not differ between the LoZn (5.9%; min-max: 0.8-21) and HiZn (4.4%; min-max: 0.6-12.3) groups and between the LoZn and control groups (5.0%; min-max: 1.4-24). We conclude that zinc in the form of Sprinkles has a low bioavailability, yet provides adequate amounts of absorbed zinc in young children, and that there is no effect of zinc or AA on iron absorption from the given formulations of Sprinkles. [ABSTRACT FROM AUTHOR]

Presents information on the strategy to control and prevent iron-deficiency anaemia (IDA) through the use of Sprinkles, a micronutrient powder for home fortification of complementary foods. History of the formulation of Sprinkles; Assessment of the bioavailability of iron in Sprinkles; Information on the effectivity of Sprinkles in the prevention of IDA.

Iron deficiency anemia (IDA) is more common in South Asian countries including India, Bangladesh and Pakistan than anywhere else in the world. During infancy and early childhood, IDA is associated with impaired psycho-motor development and cognitive function that may be irreversible. As a consequence, there is a growing awareness that IDA is one of many factors impeding socio-economic prosperity of developing nations. The combination of unacceptably high prevalence rates and inadequate preventative programs highlights the need for new effective sustainable strategies to control IDA. The burden of iron deficiency can be reduced by taking a more holistic approach that would include promotion of healthy weaning practices and use of appropriate complementary foods, together with improving the nutritional value of such foods. There is an increasing body of peer-reviewed literature to support the contention that "micronutrient Sprinkles" is an effective strategy to improve the nutritional value of home-prepared complementary foods and thus to reduce the burden of iron deficiency among children. By combining data from recently conducted randomised control trials, Sprinkles were shown to be as efficacious as iron drops for treating childhood anemia. The iron in Sprinkles is well absorbed, and Sprinkles are easy to use and well accepted by young children and their caregivers. Integrated into existing public health programs, Sprinkles has the potential to improve the effectiveness of such programs. [ABSTRACT FROM AUTHOR]

Background: The use of microencapsulated ferrous fumarate sprinkles is a new approach for home fortification. Iron and hematologic status may affect the absorption of iron from sprinkles. Objective: The objective was to measure the absorption (corrected erythrocyte incorporation of 57Fe) of 2 different doses of iron from sprinkles added to a maize-based complementary food provided to infants with different iron and hematologic status. Design: Infants aged 6-18 mo were randomly assigned to receive either 30 (n = 45) or 45 (n = 45) mg elemental Fe as 57Fe-labeled sprinkles added to a maize-based porridge on 3 consecutive days. A 58Fe tracer (0.2 mg as ferrous citrate) was also infused intravenously (n = 46). Blood was drawn at baseline and 14 d later to determine erythrocyte incorporation of 57Fe and 58Fe by using inductively coupled plasma mass spectrometry. On the basis of hemoglobin and soluble transferrin receptor concentrations, subjects were classified as having iron deficiency anemia (IDA), iron deficiency (ID), or sufficient iron status. Results: There was no significant effect of dose on iron absorption (P > 0.05). Geometric mean iron absorption was 8.25% (range: 2.9 -17.8%) in infants with IDA (n = 32), 4.48% (range: 1.1-10.6%) in infants with ID (n = 20), and 4.65% (range: 1.5-12.3%) in iron-sufficient infants (n = 20). Geometric mean iron absorption was significantly higher in infants with IDA than in infants with ID or iron-sufficient infants (P = 0.0004); however, there were no significant differences between infants with ID and iron-sufficient infants. Conclusion: During infancy, iron absorption from sprinkles in a maize-based porridge meets and surpasses requirements for absorbed iron and is up-regulated in infants with IDA. [ABSTRACT FROM AUTHOR]

This article discusses the process by which a country can effectively solve health problems through recommended changes in the nutrient content of the diet. Each country must consider not only the development of scientific guidelines suitable for its population, but also strategies for effective food-based dietary guidance to achieve the goal. This is best done by integrating health and dietary goals when forming scientific guidelines and by developing effective partnerships among the many sectors that influence the food supply and food selection. Using fat intake in children as an example, this article describes the determinants of success in achieving the goals of science-based dietary guidelines through food-based dietary guidance. [ABSTRACT FROM AUTHOR]

Severe deficiencies of iron (Fe) and iodine (I) affect more than one third of the world's population. A table salt, fortified with I and Fe, would be useful in areas in which anemia and goiter coexist. However, interactions between the two minerals have prevented their simultaneous use as fortificants. A method has been developed to coat I with dextran such that after spraying onto table salt, Fe and I do not interact. Our objective was to determine the absorption of Fe and the urinary excretion of I from table salt when provided in meals designed to significantly inhibit or enhance Fe absorption. Subjects (n = 16) ingested Fe-enhancing and Fe-inhibiting meals containing 5 g of table salt with 0.39 micromol dextran-coated I as potassium iodide and 1 mg of Fe (ferrous fumarate labeled with 59Fe) per gram of salt. Subjects also received a reference dose of 3 mg of ferrous fumarate labeled with 59Fe to "correct" for interindividual variation in iron absorption at a later date. Measured by whole-body counting, Fe-absorption from the Fe-enhancing meal (36.2 +/- 12.0%, corrected; 13.5 +/- 13.8% uncorrected) was significantly higher than that from the Fe-inhibiting meal (7.4 +/- 11.3%, corrected; 4.0 +/- 8.4%, uncorrected) (P < 0.0001). Urinary excretion of iodine at baseline and postingestion were not significantly different (0.89 +/- 0.5 vs. 1.06 +/- 0.39 micromol/L, P < 0.47) and were within the normal range. We conclude that Fe was well absorbed but influenced by the composition of the meal and that urinary excretion of iodine was maintained in the normal range with dextran-coated iodine. [ABSTRACT FROM AUTHOR]

The article presents the author's comments on the hair analysis, used as a diagnostic aid in chronic health problems. Although chemical analysis of the hair, including simultaneous multi-element analyses, have a legitimate use as a research tool, because of difficulties in interpretation it is not routinely used in hospital laboratories. The results of hair mineral determinations are used for a variety of purposes, including the detection of trace element deficiencies. The objective of hair analysis is the measurement of hair elements of endogenous origin. Interpretation of hair analysis is also dependent on the assumption of a normal rate of growth of scalp hair.

Excessive glucose absorption and dialysate amino acid and protein losses contribute to malnutrition in children on glucose-based continuous ambulatory peritoneal dialysis (CAPD). We used 2.5 and 4.25% glucose and 1.1 and 2.0% amino acid dialysates to assess short-term effectiveness and nutritional consequences of amino acid-based dialysis solutions. Plasma and effluent urea and creatinine concentrations were similar with amino acid and glucose dialysis although 16% less fluid was removed with amino acid dialysates. Absorption of 77.3 ± 5.3% of dialysate amino acids exceeded losses of amino acids and protein in glucose effluent. With amino acid dialysates, fasting plasma glucose concentrations were maintained while plasma amino acid levels rose, peaked at 1 h, and, excepting methionine, isoleucine, and phenylalanine with the 2.0% solution, returned to initial levels after 5 h. Compared with glucose, amino acid dialysates provide reduced but satisfactory fluid and waste removal, maintain normoglycemia, and more than compensate for effluent losses of amino acids and protein. [ABSTRACT FROM AUTHOR]

Measures percentile estimates for transferrin receptor in normal infants 9-15 months of age from Edmonton, Toronto, Montreal and Halifax. Information on the subjects and methods used in this study; Details on the results of the study.

Presents a study measuring the day-to-day intraindividual variation of transferrin receptor (TfR) compared with ferritin in healthy men and women. Clinical significance of TfR and transferrin in assessing iron status; Comparison of total individual variation of venous serum ferritin between younger and older women; Role of age in variability of ferritin concentrations in women.

Inorganic sulfate is an end product of sulfur amino acid metabolism but it is also the cosubstrate for the biosynthesis of a wide array of complex sulfoesters. In vitro studies have shown that SO4 availability may be the primary determinant of sulfoconjugation rates for specific substrates but the relationship between S intake and sulfoester formation in vivo is not known. By substituting MgCl2 for MgSO4 in an amino acid infusate for parenteral nutrition, we were able to examine prospectively the effect of an altered SO4 load on S metabolism. In comparing 21 low-birthweight infants on the experimental MgCl2 infusate with 14 subjects on the control MgSO4 infusate, we observed a 40% decrease in urinary excretion of free SO4 and a 31% decrease in excretion of total acid-labile sulfoesters. There was a significant correlation (r = 0.44; p < 0.02) between total S intake and sulfoester excretion, suggesting that S intake influences sulfoconjugation in the low-birthweight infant requiring total parenteral nutrition. [ABSTRACT FROM AUTHOR]

Reports on the meeting by a group from the Canadian Paediatric Society and Health Canada, in the 1990s, to consider the applicability of recommendations to restrict the total and saturated fat in children over two years. What the recommendations were intended for; Evidence for the efficacy of the recommended diet in reducing risk; Developmental considerations related to dietary fat; Adequacy of energy and nutrient intakes of children consuming a 30:10 diet.

The relative bioavailability (RBV) of iron and folic acid for a new powdered pregnancy supplement (SuppleFem containing 30rag of iron from micronized ferric pyrophosphate (FePP) [SunActive Fe®], and 600µg folic acid) and a traditional pregnancy supplement (Materna® containing 27 mg iron from ferrous fumerate and 1000µg folic acid) were compared using Area under the Curve (AUC). Eighteen healthy women between 24 to 32 weeks gestation with normal hemoglobin were randomized to receive both supplements in a crossover study with a one week washout period. Six blood samples were made over eight hours on each study day. Diurnal variation for serum iron was also measured and accounted for in the analysis. AUC measures and percentage absorption were compared using Proc Mixed. Figure 1. RBV for Materna (top- maximum concentration [Cmax] =6.6 µmol · h/L, time to reach maximum concentration [Tmax] =12 hrs) and SuppleFem (bottom- Cmax=1.6 µmol.h/L, Tmax=10hrs) These data show a borderline significant difference between the RBV of iron for Materna and Supplefem (p=0.05). The percentage of absorption (per mg) was greater with Materna (1.9±1.34) compared to SuppleFem (0.77±.99) (p=0.037). Preliminary analysis showed no significant difference (p=0.94) between the RBV for folic acid from both supplements. These results suggest that the RBV and the absorption kinetics of the FePP in SuppleFem are different than those of ferrous fumerate in Materna over the time period observed, whereas there was no difference for folic acid. [ABSTRACT FROM AUTHOR]

Presents a response by S. H. Zlotkin to a letter to the editor about his article "Micronutrient Sprinkles to Control Childhood Anaemia," in a 2005 issue of "PLoS Medicine."

Background: Three decades of research suggests that prevention of iron deficiency anemia (IDA) in the primary care setting may be an unrealized and unique opportunity to prevent poor developmental outcomes in children. A longitudinal study of infants with IDA showed that the developmental disadvantage persists long term despite iron therapy. Early stages of iron deficiency, termed non-anemic iron deficiency (NAID), provide an opportunity for early detection and treatment before progression to IDA. There is little research regarding NAID, which may be associated with delayed development in young children. The aim of this study is to compare the effectiveness of four months of oral iron treatment plus dietary advice, with placebo plus dietary advice, in improving developmental outcomes in children with NAID and to conduct an internal pilot study.Methods/design: From a screening cohort, those identified with NAID (hemoglobin ≥110 g/L and serum ferritin <14 μg/L) are invited to participate in a pragmatic, multi-site, placebo controlled, blinded, parallel group, superiority randomized trial. Participating physicians are part of a primary healthcare research network called TARGet Kids! Children between 12 and 40 months of age and identified with NAID are randomized to receive four months of oral iron treatment at 6 mg/kg/day plus dietary advice, or placebo plus dietary advice (75 per group). The primary outcome, child developmental score, is assessed using the Mullen Scales of Early Learning at baseline and at four months after randomization. Secondary outcomes include an age appropriate behavior measure (Children's Behavior Questionnaire) and two laboratory measures (hemoglobin and serum ferritin levels). Change in developmental and laboratory measures from baseline to the end of the four-month follow-up period will be analyzed using linear regression (analysis of covariance method).Discussion: This trial will provide evidence regarding the association between child development and NAID, and the effectiveness of oral iron to improve developmental outcomes in children with NAID. The sample size of the trial will be recalculated using estimates taken from an internal pilot study.Trial Registration: This trial was registered with Clinicaltrials.gov (identifier: NCT01481766 ) on 22 November 2011. [ABSTRACT FROM AUTHOR]