Frederick K. Grant

Effect of Women's Nutrition before and during Early Pregnancy on Maternal and Infant Outcomes: A Systematic Review

Current understanding of biologic processes indicates that womens nutritional status before and during early pregnancy may play an important role in determining early developmental processes and ensuring successful pregnancy outcomes. We conducted a systematic review of the evidence for the impact of maternal nutrition before and during early pregnancy (<12 weeks gestation) on maternal, neonatal and child health outcomes and included 45 articles (nine intervention trials and 32 observational studies) that were identified through PubMed and EMBASE database searches and examining review articles. Intervention trials and observational studies show that periconceptional (<12 weeks gestation) folic acid supplementation significantly reduced the risk of neural tube defects. Observational studies suggest that preconceptional and periconceptional intake of vitamin and mineral supplements is associated with a reduced risk of delivering offspring who are low birthweight and/or small-for-gestational age (SGA) and preterm deliveries (PTD). Some studies report that indicators of maternal prepregnancy size, low stature, underweight and overweight are associated with increased risks of PTD and SGA. The available data indicate the importance of womens nutrition prior to and during the first trimester of pregnancy, but there is a need for well-designed prospective studies and controlled trials in developing country settings that examine relationships with low birthweight, SGA, PTD, stillbirth and maternal and neonatal mortality. The knowledge gaps that need to be addressed include the evaluation of periconceptional interventions such as food supplements, multivitamin-mineral supplements and/or specific micronutrients (iron, zinc, iodine, vitamin B-6 and B-12) as well as the relationship between measures of prepregnancy body size and composition and maternal, neonatal and child health outcomes.

25-hydroxyvitamin D status of healthy, low-income, minority children in Atlanta, Georgia.

OBJECTIVES: The goals were to determine the prevalence of vitamin D deficiency among minority children in a southern US city, to examine differences in serum 25-hydroxyvitamin D levels between non-Hispanic black and Hispanic children, and to determine dietary sources of vitamin D. METHODS: Low-income, minority children (N = 290; mean age: 2.5 ± 1.2 years) were recruited during well-child clinic visits. Serum 25-hydroxyvitamin D and calcium levels were measured and dietary information was assessed. RESULTS: The mean 25-hydroxyvitamin D3 level was 26.2 ± 7.6 ng/mL, whereas 25-hydroxyvitamin D2 was not detected. Overall, 22.3% of children had deficient serum 25-hydroxyvitamin D3 levels (≤20 ng/mL), 73.6% had less-than-optimal serum 25-hydroxyvitamin D levels (≤30 ng/mL), and 1.4% had low serum calcium levels (≤9 mg/dL). A significantly larger proportion of non-Hispanic black children, compared with Hispanic children, had vitamin D deficiency (26% vs 18%; P < .05). Age and season of recruitment were significantly associated with vitamin D deficiency and low serum calcium levels. Older children (≥3 years) were less likely to have vitamin D deficiency (odds ratio [OR]: 0.89 [95% confidence interval [CI]: 0.81–0.96]; P < .001). Study enrollment during spring and summer reduced the likelihood of vitamin D deficiency by ∼20% (spring, OR: 0.85 [95% CI: 0.73–0.98]; P = .03; summer, OR: 0.82 [95% CI: 0.73–0.92]; P < .01). Fortified milk provided most dietary vitamin D (62%), with Hispanic children reporting greater intake. CONCLUSIONS: Suboptimal vitamin D status was common among apparently healthy, low-income, minority children. Age and season were significant predictors of vitamin D deficiency.

Zinc and iron deficiency and their interrelations in low-income African American and Hispanic children in Atlanta

BACKGROUND Information about the zinc status of low-income minority children in the United States is lacking. OBJECTIVE The objective was to determine the prevalence of zinc deficiency and anemia and their interrelation among low-income African American and Hispanic preschool children. DESIGN This was a cross-sectional study in which a prospective 3-d food diary was completed, and hemoglobin, serum ferritin, zinc, copper, and C-reactive protein concentrations were measured. Children with elevated C-reactive protein concentrations were excluded from analysis. RESULTS Of 292 children recruited, 280 (mean +/- SD age: 2.5 +/- 1.2 y) qualified for analysis. One hundred forty-six (52%) children were African American and 134 (48%) were Hispanic; 202 (72%) were enrolled in the Women, Infants, and Children nutrition program. A low serum zinc concentration (<10.7 mumol/L) was present in 34 (12%) children, and 37 (13%) were anemic (hemoglobin < 110 g/L). African American (odds ratio: 3.47; 95% CI: 1.51, 7.96) and anemic (odds ratio: 2.92; 95% CI: 1.24, 6.90) children had an increased risk of zinc deficiency. Serum zinc correlated with hemoglobin (r = 0.24, P < 0.001). Children with a height/length less than the fifth percentile had significantly lower mean serum zinc concentrations than those with a height/length greater than the fifth percentile (12.4 +/- 1.8 compared with 13.0 +/- 2.2 micromol/L; P < 0.001). In a multiple logistic regression model, African American race-ethnicity was associated with zinc deficiency (odds ratio: 0.26; P = 0.02). The main sources of iron and zinc in the diets were meat products and cereals. CONCLUSIONS The prevalence of zinc deficiency and anemia was high in this population of low-income minority children, especially among African Americans. Further investigation of the incidence of zinc deficiency and the ability of anemia to screen for it is warranted.

Correcting for Inflammation Changes Estimates of Iron Deficiency among Rural Kenyan Preschool Children

The assessment of iron status where infections are common is complicated by the effects of inflammation on iron indicators and in this study we compared approaches that adjust for this influence. Blood was collected in 680 children (aged 6-35 mo) and indicators of iron status [(hemoglobin (Hb), zinc protoporphyrin (ZP), ferritin, transferrin receptor (TfR), and TfR/ferritin index)] and subclinical inflammation [(the acute phase proteins (APP) C-reactive protein (CRP), and α-1-acid glycoprotein (AGP)] were determined. Malaria parasitemia was assessed. Subclinical inflammation was defined as CRP >5 mg/L and/or AGP >1 g/L). Four groups were defined based on APP levels: reference (normal CRP and AGP), incubation (raised CRP and normal AGP), early convalescence (raised CRP and AGP), and late convalescence (normal CRP and raised AGP). Correction factors (CF) were estimated as the ratios of geometric means of iron indicators to the reference group of those for each inflammation group. Corrected values of iron indicators within inflammation groups were obtained by multiplying values by their respective group CF. CRP correlated with AGP (r = 0.65; P < 0.001), ferritin (r = 0.38; P < 0.001), Hb (r = -0.27; P < 0.001), and ZP (r = 0.16; P < 0.001); AGP was correlated with ferritin (r = 0.39; P < 0.001), Hb (r = -0.29; P < 0.001), and ZP (r = 0.24; P < 0.001). Use of CF to adjust for inflammation increased the prevalence of ID based on ferritin < 12 μg/L by 34% (from 27 to 41%). Applying the CF strengthened the expected relationship between Hb and ferritin (r = 0.10; P = 0.013 vs. r = 0.20; P < 0.001, before and after adjustment, respectively). Although the use of CF to adjust for inflammation appears indicated, further work is needed to confirm that this approach improves the accuracy of assessment of ID.

Characterization of posthospital bloodstream infections in children requiring home parenteral nutrition.

BACKGROUND Home parenteral nutrition (HPN) is lifesaving for children with intestinal failure. Catheter-associated bloodstream infections (CA-BSI) are common in hospitalized patients receiving parenteral nutrition (PN), but data evaluating CA-BSI in children receiving HPN are limited. OBJECTIVE To determine the incidence and characteristics of CA-BSI in children receiving HPN. METHODS Medical records of 44 children receiving HPN during a 3-year period were reviewed. End points were CA-BSI during the initial 6 months after discharge. CA-BSI was defined as isolation of pathogens from blood requiring antimicrobial therapy. RESULTS The primary indication for HPN was short bowel syndrome (46%), and 59 BSI were documented during the initial 6 months of HPN in 29 (66%) children. Of CA-BSI, polymicrobial infections accounted for 52%; gram-positive, 29%; gram-negative, 17%; and fungal, 2%. CA-BSI incidence per 1000 catheter-days was highest during the first month posthospital discharge (72 episodes; 95% confidence interval [CI], 45.4-109.6). CA-BSI incidence density ratio for children receiving HPN for >90 days compared with those receiving HPN for <30 days was 2.2 (P < .05). Logistic regression revealed that Medicaid insurance and age <1 year were associated with increased risk for CA-BSI (odds ratio [OR], 4.4 [95% CI, 1.13-16.99] and 6.6 [1.50-28.49], respectively; P < .05). CONCLUSIONS The incidence of CA-BSI in children receiving HPN is highest during the first month posthospital discharge. Strategies to address care in the immediate posthospital discharge period may reduce the burden of infectious complications of HPN.

Effect of Multiple Micronutrient versus Iron-Folate Supplementation during Pregnancy on Intrauterine Growth

This review examines the effects of prenatal multiple micronutrient (MM) supplementation (≥5 micronutrients) on intrauterine growth. We identified publications from 16 randomized controlled trials through PubMed and EMBASE database searches. Meta-analyses were performed by pooling results, and sub-analyses by timing of intervention and amount of iron were also done. The primary outcome measures were birthweight, low birthweight (LBW; <2,500 g) and small for gestational age (SGA). Prenatal MM supplementation significantly reduced the incidence of LBW (risk ratio, RR: 0.86; 95% CI: 0.81-0.92) and SGA (RR: 0.83; 95% CI: 0.73-0.95) compared to iron-folate supplementation; mean birthweight was significantly higher by 55 g for MM with borderline increases in gestational age. MM supplementation was associated with larger decreases in the risk of LBW and SGA in the subgroup of trials that used supplements containing 60 mg of iron, but were not statistically significantly different from those for trials that used 30 mg iron. Prenatal MM supplementation improved intrauterine growth and can be recommended instead of prenatal IFA supplements in settings where micronutrient deficiencies are common.