Home fortification with calcium reduces Hb response to iron among anaemic Bangladeshi infants consuming a new multi-micronutrient powder formulation.

OBJECTIVE: To 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). DESIGN: A 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. SETTING: Twenty-six rural villages in the Kaliganj sub-district of Gazipur, Bangladesh. SUBJECTS: One hundred infants aged 6-11 months. RESULTS: A 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. CONCLUSIONS: Although 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.

Folate and synthetic folic acid content in Canadian fortified foods two decades after mandatory fortification.

In 1998, Health Canada mandated folic acid fortification of white flour and enriched grain products to prevent neural tube defects. At the time, neither the Canadian Nutrient File (CNF) nor product labels reflected the actual folate content of foods. We aimed to assess if 20 years post-fortification, the CNF values for total folate and synthetic folic acid accurately reflect amounts determined by direct analysis. Using the 2001 Food Expenditure Survey and ACNielsen Company data, we identified 10-15 of the most purchased fortified foods across seven food categories in Canada. Total folate concentrations were determined by tri-enzyme digestion and microbial assay. Folic acid concentrations were determined using liquid chromatography-tandem mass spectrometry. Except for "cooked pastas", mean total folate content of foods (n = 89) were significantly higher than CNF values across categories (p < 0.05), reflecting 167% ± 54% of CNF values. Similarly, mean folic acid content of foods was higher than CNF values for all categories except "cooked pastas" (p < 0.05), with a mean of 188% ± 94% of CNF values; the latter CNF values included uncooked pasta. In sum, 20 years post-fortification, and 10 years since the last direct measurement, CNF and product label values still underestimate actual total folate and the folic acid content of foods. These findings emphasize that dietary estimates established using the CNF may significantly underestimate actual intakes and thus caution should be exercised when interpreting estimates of nutritional adequacy based on these values.

A comparison of micronutrient inadequacy and risk of high micronutrient intakes among vitamin and mineral supplement users and nonusers in Canada.

Although supplement use is prevalent in North America, there is little information on how supplements affect the prevalence of nutrient adequacy or risk of intakes greater than the tolerable upper intake level (UL). The objectives of this study were to compare the prevalence of nutrient adequacy and percent of intakes greater than the UL from diet alone between supplement users and nonusers and determine the contribution of supplements to nutrient intakes. Dietary intakes (24-h recall) and supplement use (previous 30 d) from respondents ≥1 y in the Canadian Community Health Survey 2.2 (n = 34,381) were used to estimate the prevalence of nutrient adequacy and intakes greater than the UL. Software for Intake Distribution Evaluation was used to estimate usual intakes. The prevalence of nutrient adequacy from diet alone was not significantly higher among supplement users than nonusers for any nutrient. Based on diet alone, children 1-13 y had a low prevalence of nutrient adequacy (<30%) except for vitamin D and calcium. Among respondents ≥14 y, inadequacies of vitamins A and D, calcium, and magnesium were >30%. For other nutrients, there was a low prevalence of nutrient adequacy. There were no nutrient intakes greater than the UL from diet alone, except zinc in children. When supplements were included, ≥10% of users in some age/sex groups had intakes of vitamins A and C, niacin, folic acid, iron, zinc, and magnesium greater than the UL, reaching >80% for vitamin A and niacin in children. In conclusion, from diet alone, the prevalence of nutrient adequacy was low for most nutrients except for calcium, magnesium, and vitamins A and D. For most nutrients, supplement users were not at greater risk of inadequacy than nonusers; supplement use sometimes led to intakes greater than the UL.

Effect of nitrous oxide exposure during surgery on the homocysteine concentrations of children.

BACKGROUND: Nitrous oxide converts vitamin B12 to its nonmetabolically active form, inhibits methionine synthase, and results in an elevation of plasma total homocysteine (tHcy). The authors investigated the effect of nitrous oxide anesthesia on the plasma tHcy concentrations in children the morning after surgery and whether blood concentrations of folate and vitamins B12 and B6 were associated with any potential increase. METHODS: The authors measured plasma tHcy concentrations in 32 children before and 24 h after initial exposure to nitrous oxide (≥ 2 h). Genotype for methylenetetrahydrofolate reductase C677T and blood concentrations of folate, vitamins B12 and B6, and methylmalonic acid were measured before surgery. RESULTS: The median age of participants was 11 months (3-126 months). The median (first, third quartile) postoperative plasma tHcy concentration was significantly higher than the preoperative concentration (6.4 [4.7, 8.9] vs. 5.1[4.1, 6.4] µM, P < 0.0001), a 25% (2%, 42%) relative increase. Six of 28 (21%) children with normal, age-appropriate, preexposure plasma tHcy concentrations had postoperative plasma tHcy concentrations greater than the cutoff values. The duration of nitrous oxide exposure was associated positively with the rise in plasma tHcy concentration (R2 = 0.696, P = < 0.001). CONCLUSION: Exposure to ≥ 2 h nitrous oxide is associated with a small, albeit statistically significant, increase in postoperative plasma tHcy concentrations the morning after surgery in young children. The clinical significance of this increase is unknown.

Unexpectedly high early prevalence of anaemia in 6-month-old breast-fed infants in rural Bangladesh.

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 mid-pregnancy) 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.

How much folate is in Canadian fortified products 10 years after mandated fortification?

OBJECTIVE: In 1998, the Canadian government mandated folic acid fortification of white flour and enriched grain products to lower the prevalence of neural tube defects. There is now growing concern over the potential harmful effects of too much folic acid on some segments of the population. Given that the actual amount of folate in Canadian foods is unknown, the objective of this study was to measure the folate content in selected fortified foods. METHODS: Using data from the 2001 Food Expenditure Survey and the ACNielsen Company, 95 of the most commonly purchased folic acid-fortified foods in Canada were identified. Folate concentrations in these foods were determined using tri-enzyme digestion followed by microbiological assay. Analyzed values were compared to those in the Canadian Nutrient File (2007b, CNF) and to label values. RESULTS: The analyzed folate content of foods was, on average, 151% +/- 63 of the CNF values. Analyzed values as a percent of CNF values ranged from 116% in the "rolls and buns" category to 188% in "ready-to-eat cereals". Analyzed values were higher than label values for "breads", "rolls and buns" and "ready-to-eat cereals" (141%, 118% and 237%, respectively [p < 0.05]). CONCLUSIONS: Ten years after folic acid fortification of the food supply, neither the CNF nor label values accurately reflect actual amounts of folate in foods. Further, overage differences by food category hinder the development of future strategies designed to strike the right balance between health benefits and risks; monitoring of fortified foods for their nutrient content is required.

Is it necessary to measure resting energy expenditure in clinical practice in children?

We compared measured resting energy expenditure (MREE) and predicted resting energy expenditure (PREE) in 398 chronically ill children and found a wide variability for %MREE/PREE (standard deviation +/- 27.2). Bland-Altman analysis also suggested poor agreement between MREE and PREE (mean bias, 43.2 kcal; range, -645 to 1118.1 kcal). Our findings suggest that resting energy expenditure should be measured in chronically ill children.

Examining the effects of increased vitamin D fortification on dietary inadequacy in Canada.

OBJECTIVES: Despite mandatory fortification of milk and margarine, most Canadians have inadequate vitamin D intake and consequently poor vitamin D status, especially in the winter. Increasing vitamin D fortification is one possible strategy to address this inadequacy. The purpose of our study was to examine the modelled effect of increased vitamin D fortification on the prevalence of inadequacy and the percentage of intakes greater than the Tolerable Upper Intake Level (UL) using different fortification scenarios. METHODS: Dietary intakes (24-h recall) from the 2004 Canadian Community Health Survey 2.2 (n=34,381) were used to model increased vitamin D levels in milk and the addition of vitamin D to cheese and yogurt at various levels to meet label claims of an "excellent source" based on the recommended dietary intakes. The Software for Intake Distribution Evaluation was used to estimate the prevalence of inadequacy and intakes >UL. RESULTS: Fortification of milk, yogurt and cheese at 6.75 µg (270 IU)/serving led to more than doubling of vitamin D intakes across all sex/age groups and a drop in the prevalence of dietary inadequacy from >80% to <50% in all groups. Furthermore, no intakes approached the UL under any fortification scenario in any sex/age group. CONCLUSION: There is a pressing need to improve vitamin D status among Canadians. Increasing vitamin D fortification of dairy products, consistent with their positioning in Canada's Food Guide, can lead to increased intake without a risk of excess. This is a population-wide public health strategy that should be given consideration in Canada.

Botulinum toxin A for treatment of sialorrhea in children: an effective, minimally invasive approach.

OBJECTIVES: To report (1) our experience with botulinum toxin A injections into the salivary glands of pediatric patients with sialorrhea, (2) the clinical outcomes of these interventions, and (3) the associated complication rates. DESIGN: Retrospective cohort study. SETTING: Urban pediatric hospital and pediatric rehabilitation center. PATIENTS: Forty-five neurologically impaired children. INTERVENTIONS: Patients received botulinum toxin A intrasalivary injections between January 2004 and May 2008 at the Hospital for Sick Children in Toronto, Ontario, Canada. All patients received sedation or general anesthesia for their botulinum toxin A injections, which were performed using ultrasonographic guidance. MAIN OUTCOME MEASURES: Posttreatment assessments included the duration of effect, patient complications, saliva consistency, caregiver willingness to repeat the treatment, caregiver satisfaction with the treatment, and caregiver overall assessment of the child's posttreatment quality of life. RESULTS: Forty-five subjects received a total of 91 botulinum toxin A treatments. The mean (SD) duration of effect was 4.6 (5.2) months. Duration of effect (log transformed) was significantly negatively associated with saliva quantity (P = .02), and there was a positive association with both increasing age and female sex, although neither reached statistical significance (P = .08 for each). Seven of the 24 documented complications were major, according to the Society of Interventional Radiology Classification System for Complications by Outcome scale. Thirty-six of the caregivers reported that this treatment improved the child's quality of life (80%). CONCLUSION: Ultrasonographically guided botulinum toxin A injections into the salivary glands are safe and efficacious in the management of sialorrhea in children with neurologic disorders.

Folic acid fortification above mandated levels results in a low prevalence of folate inadequacy among Canadians.

BACKGROUND: Understanding folate intakes after folic acid fortification of the food supply will help to establish dietary and supplement recommendations that balance health benefits and risks. OBJECTIVES: The objectives were to estimate the prevalence of folate inadequacy (POFI) and intakes above the Tolerable Upper Intake Level (UL) among Canadians and to estimate the supplemental dose that, with diet, provides reproductive-aged women with 400 µg folic acid/d to prevent neural tube defects. DESIGN: Twenty-four-hour recall and supplement (prior 30 d) data from the 2004 Canadian Community Health Survey (n = 35,107) were used to calculate the POFI and intakes above the UL with and without adjustment for fortification overages. POFI was also estimated by risk factors thought to be related to low folate intake. The Software for Intake Distribution Evaluation (SIDE program; Department of Statistics and Center for Agricultural and Rural Development, Iowa State University) was used to estimate usual dietary intakes in all analyses. RESULTS: Except for women aged >70 y, POFI was <20% after adjustment for fortification overages. For children aged <14 y, POFI approached zero, even when supplement use was excluded. POFI among adults was unaffected by supplement use, except for women aged >70 y. Only 18% of reproductive-aged women consumed 400 µg folic acid/d from diet and supplements. Modeling showed that supplements containing 325-700 µg folic acid would provide adult women with 400 µg/d but not more than the UL. Diabetes was associated with POFI. CONCLUSIONS: Innovative strategies are needed to ensure that the subgroups of Canadians who could still benefit from improved folate intake are targeted. Consideration should be given to removing folic acid from supplements designed for young children and men.