No abstract

Vitamin A deficiency (VAD) is an important contributor to child morbidity and mortality. The prevalence of VAD, measured by retinol-binding protein (RBP) or retinol, is overestimated in populations with a high prevalence of inflammation. We aimed to quantify and adjust for the effect of inflammation on VAD prevalence in a nationally representative survey of Liberian children 6 to 35 months of age. We compared five approaches to adjust RBP for inflammation and estimate VAD prevalence (defined as RBP <0.7 μmol/L): (1) ignoring inflammation; (2) excluding individuals with inflammation (C-reactive protein (CRP) >5 mg/L or alpha1-acid glycoprotein (AGP) >1 g/)L; (3) multiplying each individual’s RBP by an internal correction factor; (4) by an external correction factor; and (5) using regression (corrected RBP = exp(InRBP – β1(lnCRPobs-lnCRPref) – β2(lnAGPobs-lnAGPref)). Corrected RBP was based on a regression model where reference lnCRP and lnAGP were set to the maximum of the lowest decile. The unadjusted prevalence of VAD was 24.7%. Children with elevated CRP and/or AGP had significantly lower RBP concentrations than their apparently healthy peers (geometric mean RBP 0.79 μmol/L (95% CI: 0.76, 0.82) vs. 0.95 μmol/L (95% CI: 0.92, 0.97), P <0.001). Using approaches 2–5 resulted in a prevalence of VAD of 11.6%, 14.3%, 13.5% and 7.3%, respectively. Depending on the approach, the VAD prevalence is reduced 10–17 percentage points when inflammation is taken into account. Further quantification of the influence of inflammation on biomarkers of vitamin A status from other national surveys is needed to compare and recommend the preferred adjustment approach across populations.

In Vietnam, nutrition interventions do not target school children despite a high prevalence of micronutrient deficiencies. The present randomised, placebo-controlled study evaluated the impact of providing school children (n 403) with daily multiple micronutrient-fortified biscuits (FB) or a weekly Fe supplement (SUP) on anaemia and Fe deficiency. Micronutrient status was assessed by concentrations of Hb, and plasma ferritin (PF), transferrin receptor (TfR), Zn and retinol. After 6 months of intervention, children receiving FB or SUP had a significantly better Fe status when compared with the control children (C), indicated by higher PF (FB: geometric mean 36·9 (95 % CI 28·0, 55·4) mg/l; SUP: geometric mean 46·0 (95 % CI 33·0, 71·7) mg/l; C: geometric mean 34·4 (95 % CI 15·2, 51·2) mg/l; P,0·001) and lower TfR concentrations (FB: geometric mean 5·7 (95 % CI 4·8, 6·52) mg/l; SUP: geometric mean 5·5 (95 % CI 4·9, 6·2) mg/l; C: geometric mean 5·9 (95 % CI 5·1, 7·1) mg/l; P¼ 0·007). Consequently, body Fe was higher in children receiving FB (mean 5·6 (SD 2·2) mg/kg body weight) and SUP (mean 6·1 (SD 2·5) mg/kg body weight) compared with the C group (mean 4·2 (SD 3·3) mg/kg body weight, P, 0·001). However, anaemia prevalence was significantly lower only in the FB group (1·0 %) compared with the C group (10·4 %, P¼ 0·006), with the SUP group being intermediate (7·4 %). Children receiving FB had better weight-for-height Z-scores after the intervention than children receiving the SUP (P¼0·009). Vitamin A deficiency at baseline modified the intervention effect, with higher Hb concentrations in vitamin A-deficient children receiving FB but not in those receiving the SUP. This indicates that vitamin A deficiency is implicated in the high prevalence of anaemia in Vietnamese school children, and that interventions should take other deficiencies besides Fe into account to improve Hb concentrations. Provision of biscuits fortified with multiple micronutrients is effective in reducing anaemia prevalence in school children.Key words: School-aged children: Anaemia: Iron: Vitamin A: Zinc: Fortification: Pharmaceutical supplementation Anaemia and Fe-deficiency anaemia (IDA) have a negative impact (1) on physical and cognitive development of children, on immune status and resistance to infection and on work capacity. Fe deficiency (ID) affects nearly 3·5 billion people throughout the world, mainly women of reproductive age, infants and young children (2) . It is estimated that in developing countries, more than 40 % of preschool children and women of reproductive age are affected by anaemia (3) .Vietnam has experienced considerable economic growth in the last 10 years (4) and the living standard of the population has gradually increased, mainly in urban areas (5) . Malnutrition including micronutrient deficiencies remains a serious problem among vulnerable groups, in particular those living in rural or mountainous zones. In 2000, 34 % of the children aged , 5 years were underweight, and this has fallen to , 20 % over the last...

Integrating small‐quantity lipid‐based nutrient supplements (SQ‐LNS) into infant and young child feeding (IYCF) programmes can increase consumption of essential nutrients among children in vulnerable populations; however, few studies have assessed the impact of integrated IYCF–SQ‐LNS programmes on IYCF practices. A 2‐year, enhanced IYCF intervention targeting pregnant women and infants (0–12 months) was implemented in a health zone in the Democratic Republic of Congo (DRC). The enhanced IYCF intervention included community‐ and facility‐based counselling for mothers on handwashing, SQ‐LNS, and IYCF practices, plus monthly SQ‐LNS distributions for children 6–12 months; a control zone received the national IYCF programme (facility‐based IYCF counselling with no SQ‐LNS distributions). Cross‐sectional preintervention and postintervention surveys ( n = 650 and 638 in intervention and control areas at baseline; n = 654 and 653 in each area at endline, respectively) were conducted in mothers of children 6–18 months representative of both zones. Difference in differences (DiD) analyses used mixed linear regression models. There were significantly greater increases in the proportion of mothers in the intervention (vs. control) zone who reported: initiating breastfeeding within 1 hr of birth (Adj. DiD [95% CI]: +56.4% [49.3, 63.4], P < 0.001), waiting until 6 months to introduce water (+66.9% [60.6, 73.2], P < 0.001) and complementary foods (+56.4% [49.3, 63.4], P < 0.001), feeding the minimum meal frequency the previous day (+9.2% [2.7, 15.7], P = 0.005); feeding the child in a separate bowl (+9.7% [2.2, 17.2], P = 0.01); awareness of anaemia (+16.9% [10.4, 23.3], P < 0.001); owning soap (+14.9% [8.3, 21.5], P < 0.001); and washing hands after defecating and before cooking and feeding the child the previous day (+10.5% [5.8, 15.2], +12.5% [9.3, 15.6] and +15.0% [11.2, 18.8], respectively, P < 0.001 for all). The enhanced IYCF intervention in the DRC was associated with an improvement in several important IYCF practices but was not associated with a change in dietary diversity (minimum dietary diversity and minimum acceptable diet remained below 10% in both zones without significant differences between zones). The provision of fortified complementary foods, such as SQ‐LNS, may be an important source of micronutrients and macronutrients for young children in areas with high rates of poverty and limited access to diverse foods. Future research should verify the potential of integrated IYCF–SQ‐LNS to improve IYCF practices, and ultimately children's nutritional status.

Inflammation and infections such as malaria affect estimates of micronutrient status. Medline, Embase, Web of Science, Scopus and the Cochrane library were searched to identify studies reporting mean concentrations of ferritin, hepcidin, retinol or retinol binding protein in individuals with asymptomatic or clinical malaria and healthy controls. Study quality was assessed using the United States National Institute of Health tool. Random-effects meta-analyses were used to generate summary mean differences. In total, 44 studies were included. Mean ferritin concentrations were elevated by: 28.2 µg/L (95%CI: 15.6, 40.9) in children with asymptomatic malaria, 28.5 µg/L (95%CI: 8.1, 48.8) in adults with asymptomatic malaria, and 366 µg/L (95%CI: 162, 570) in children with clinical malaria compared to individuals without malaria infection. Mean hepcidin concentrations were elevated by 1.52 nmol/L (95%CI: 0.92, 2.11) in children with asymptomatic malaria. Mean retinol concentrations were reduced by: 0.11 µmol/L (95%CI: −0.22, −0.01) in children with asymptomatic malaria, 0.43 µmol/L (95%CI: −0.71, −0.16) in children with clinical malaria and 0.73 µmol/L (95%CI: −1.11, −0.36) in adults with clinical malaria. Most of these results were stable in sensitivity analyses. In children with clinical malaria and pregnant women, difference in ferritin concentrations were greater in areas with higher transmission intensity. We conclude that biomarkers of iron and vitamin A status should be statistically adjusted for malaria and the severity of infection. Several studies analysing asymptomatic infections reported elevated ferritin concentrations without noticeable elevation of inflammation markers, indicating a need to adjust for malaria status in addition to inflammation adjustments.