Socio-economic status and puberty are the main factors determining anaemia in adolescent girls and boys in East Java, Indonesia.

OBJECTIVE: To determine prevalence and contributing factors of anaemia in adolescents. DESIGN: Cross-sectional study of anaemia prevalence, socio-economic status and puberty. SETTING: Schools in East Java, Indonesia. SUBJECTS: Male and female adolescent pupils (age 12-15 y; n=6486). RESULTS: Anaemia prevalence was 25.8% among girls (n=3486), 24.5% among pre-pubertal boys (n=821), and 12.1% among pubertal boys (n=2179). Socio-economic status, indicated by type of school attended, was an important factor determining the risk of anaemia. Girls had a higher risk when they attended a poor school (OR poorest school, 1.00; other schools, 0.67-0.87), had reached puberty (OR, 1.25), had lower retinol intake (OR 1st-4th quartiles-1.00, 0.97, 0.89, 0.77) and higher vitamin A intake from plant sources (OR 1st-4th quartiles-1.00, 1.10, 1.31, 1.04). Boys had a higher risk of anaemia when they attended a poor school (OR poorest school 1.00, other schools 0.54-0.63), were younger (OR per year=0.79), had not yet reached puberty (OR not yet, 1.00; already, 0.78), were shorter (OR per cm 0.95), had smaller mid-upper-arm circumference (MUAC) (OR per mm 0.99) and lower retinol intake (OR 1st-4th quartile 1.00, 0.67, 0.74, 0.68). CONCLUSIONS: Anaemia in adolescents should be reported separately for pre-pubertal and pubertal subjects and for different ages, and the population's socio-economic status should be specified. The results of this survey call for treatment of anaemia in adolescents. Given Indonesia's current situation, micronutrient intake of adolescents should be increased using supplements for all girls and for pre-pubertal boys. SPONSORSHIP: This survey was funded by USAID through the OMNI project.

Continuation of the decline in prevalence of anemia in low-income infants and children in five states.

OBJECTIVE: To examine whether there is a continuation of the decline in prevalence of anemia among low-income infants and children 6.0 to 59.9 months old from the early 1980s to the mid-1990s. STUDY DESIGN: Cross-sectional trend analysis of data from the Centers for Disease Control and Prevention's Pediatric Nutrition Surveillance System from the 5 states (Colorado, New Mexico, Oklahoma, Utah, and Vermont) that have been using the same laboratory method for anemia screening since 1984 or earlier. RESULTS: The overall prevalence of anemia decreased substantially in each state from the early 1980s to the mid-1990s as follows: Colorado by 52%; New Mexico by 75%; Oklahoma by 67%; Utah by 57%; and Vermont by 48%. In each state, the prevalence of anemia declined for children of different age groups, birth weights, genders, type of pediatric care visit (screening or follow-up), and most race/ethnic groups. CONCLUSIONS: The decline in the prevalence of anemia initially observed in the 1980s continued well into the 1990s. This decline is likely attributable to better iron nutrition related to greater usage of iron-fortified products and possibly better iron bioavailability in some of the food products.

Significance of an abnormally low or high hemoglobin concentration during pregnancy: special consideration of iron nutrition.

An association between moderate anemia and poor perinatal outcomes has been found through epidemiologic studies, although available evidence cannot establish this relation as causal. Anemia may not be a direct cause of poor pregnancy outcomes, except in the case of maternal mortality resulting directly from severe anemia due to hypoxia and heart failure. Preventing or treating anemia, whether moderate or severe, is desirable. Because iron deficiency is a common cause of maternal anemia, iron supplementation is a common practice to reduce the incidence of maternal anemia. Nevertheless, the effectiveness of large-scale supplementation programs needs to be improved operationally and, where multiple micronutrient deficiencies are common, supplementation beyond iron and folate can be considered. High hemoglobin concentrations are often mistaken as adequate iron status; however, high hemoglobin is independent of iron status and is often associated with poor health outcomes. Very high hemoglobin concentrations cause high blood viscosity, which results in both compromised oxygen delivery to tissues and cerebrovascular complications. Epidemiologic studies have also found an association between high maternal hemoglobin concentrations and an increased risk of poor pregnancy outcomes. Evidence does not suggest that this association is causal; it could be better attributed to hypertensive disorders of pregnancy and to preeclampsia. The pathophysiologic mechanism of these conditions during pregnancy can produce higher hemoglobin concentrations because of reduced normal plasma expansion and cause fetal stress because of reduced placental-fetal perfusion. Accordingly, higher than normal hemoglobin concentrations should be regarded as an indicator of possible pregnancy complications, not necessarily as a sign of adequate iron nutrition, because iron supplementation does not increase hemoglobin higher than the optimal concentration needed for oxygen delivery.

A survey of 2,851 patients with hemochromatosis: symptoms and response to treatment.

PURPOSE: Hemochromatosis is a genetic disorder of iron absorption that affects 5 per 1,000 persons and is associated with reduced health and quality of life. We sought to determine the type and frequency of symptoms that patients experienced before the diagnosis and the treatments that they received. METHODS: We mailed a questionnaire to 3,562 patients with hemochromatosis who were located using patient advocacy groups, physicians, blood centers, newsletters, and the Internet. RESULTS: Of the 2,851 respondents, 99% were white and 62% were men. Circumstances that led to diagnosis of hemochromatosis included symptoms (35%), an abnormal laboratory test (45%), and diagnosis of a family member with hemochromatosis (20%). The mean (+/- SD) age of symptom onset was 41 +/- 14 years. Symptoms had been present for an average of 10 +/- 10 years before the diagnosis was made. Among the 58% of patients with symptoms, 65% had physician-diagnosed arthritis and 52% had liver disease. The most common and troublesome symptoms were extreme fatigue (46%), arthralgia (44%), and loss of libido (26%). Physician instructions to patients included treatment with phlebotomy (90%), testing family members (75%), and avoiding iron supplements (65%). CONCLUSIONS: The diagnosis of hemochromatosis in most patients was delayed. Physician education is needed to increase the detection of patients with the disease and to improve its management.

Impact of a social marketing campaign promoting dark-green leafy vegetables and eggs in central Java, Indonesia.

In order to work towards further reduction of vitamin A deficiency in central Java, Indonesia, a social marketing campaign promoting eggs and dark-green leafy vegetables was initiated in March 1996. The nutritional surveillance system (December 1995-December 1996) found the following. The campaign's messages were well noticed. Consumption of at least one egg in the past week increased from 80% to 92% in mothers and from 78% to 92% in children 12-36 months old. It increased in all socio-economic groups and was independent of ownership of chickens. Most eggs had been purchased. The quantity of vegetables prepared increased from 93 to 111 g/person daily and most was purchased. Vitamin A intake increased from 335 to 371 RE/d for mothers and from 130 to 160 RE/d for children. Serum retinol levels increased after the start of the campaign, and were related to egg consumption and vitamin A intake. Because 1. data were collected in such a way that respondents were not aware of the link between data collected and the campaign, and 2. vitamin A status increased and was related to increased consumption of eggs and vitamin A intake, we conclude that the social marketing campaign was successful.

Continuation of decline in prevalence of anemia in low-income children: the Vermont experience.

OBJECTIVE: To examine whether the prevalence of childhood anemia in white low-income children has continued to decline into the 1990s. DESIGN: An examination of 14 years of hematocrit data from the Centers for Disease Control and Prevention's Pediatric Nutrition Surveillance System in Vermont from 1981 through 1994. SETTING: Public health clinics for the Special Supplemental Nutrition Program for Women, Infants, and Children in Vermont. The same screening method and criteria for identifying and defining anemia and the same quality-assurance procedures were used during the 14 years. The program eligibility criteria were also consistent except for part of 1991 and 1992. MAIN OUTCOME MEASURE: The annual prevalence of anemia. RESULTS: Between 1981 and 1994, the prevalence of anemia halved (from 7.9% to 3.6%, P<.001). For children aged 6 to 24 months, this decline was from 7.8% to 4.6% (P<.001); for children aged 2 to 5 years, the decline was from 7.9% to 3.1% (P<.001). CONCLUSION: The decline in the prevalence of anemia among low-income children observed by the Centers for Disease Control and Prevention's Pediatric Nutrition Surveillance System up to the mid-1980s has continued into the 1990s in Vermont. This finding indicates that iron nutrition in infancy and early childhood is still improving.

Risk of diarrhea related to iron content of infant formula: lack of evidence to support the use of low-iron formula as a supplement for breastfed infants.

BACKGROUND: Concern has been raised by infant feeding experts that supplementing breastfed infants with iron-fortified formula rather than low-iron formula may have an undesirable impact on their gastrointestinal flora. Thus far, there have been no clinical studies to address this issue directly. We compared the reported frequency of diarrhea for breastfed infants given iron-fortified formula with those fed low-iron formula. METHODS: Mothers participating in a mail panel provided feeding and diarrhea information on their infants at 2, 3, 4, 5, 6, 7, 9, and 12 months (n = 1743). Infants were grouped into five feeding categories: (1) breast milk only, (2) breast milk and low-iron formula, (3) breast milk and iron-fortified formula, (4) low-iron formula only, and (5) iron-fortified formula only. We calculated the number of diarrheal episodes per week for each feeding category and used rate ratios to estimate the relative impact of low-iron and iron-fortified formulas. RESULTS: Among infants who received both breast milk and formula, the rate ratio for iron-fortified formula versus low-iron formula was 1.06 (confidence interval, 0.84 to 1.34), indicating that the type of formula a breastfed infant receives does not significantly affect the frequency of diarrhea. CONCLUSIONS: We found no evidence to support the hypothesis that breastfed infants given iron-fortified formula are at greater risk of having diarrhea. This, in addition to the fact that iron-fortified formula has played a major role in preventing childhood iron deficiency anemia, supports the current recommendation that any formula given to infants be fortified with iron.

The challenge of improving iron nutrition: limitations and potentials of major intervention approaches.

Various approaches to improving iron status are discussed. Success in controlling iron deficiency worldwide will require the exploration and demonstration of all possible options. The approaches, which are not mutually exclusive, include iron supplementation, nutrition education, reducing intestinal parasites (particularly hookworm), expanding fortification of processed foods, and developing crops that are more iron bioavailable. Coordination with existing health and nutrition programs can enhance progress toward better overall nutrition. For example, in the development of food fortification or of crops with higher nutritional value, the combination of multiple micronutrients can be considered. Within the primary health care system, iron supplementation and deworming can be coordinated with other health care activities. The ultimate success in control of iron deficiency will depend on how well the various intervention approaches can be integrated within the current framework of public health, food processing, and agriculture development.

Prevention and control of iron deficiency in developing countries.

PIP: Iron deficiency is a global nutritional problem which mainly affects infants, children, and women of childbearing age. Using anemia as an indicator of iron deficiency, an estimated 30-60% of women and children in developing countries are iron deficient. Even in developed countries, iron deficiency warrants significant public health concern. This paper examines iron deficiency and strategies for its control, with an emphasis upon situations commonly found in developing countries. Sections address anemia and mortality, the effect of iron deficit upon child development and behavior, reduced work performance and productivity, meeting the nutritional requirements for iron in young children and women, general issues in the prevention and control of iron deficiency, nutrition promotion and an education-based approach, iron supplementation programs, the elimination of intestinal helminth infections, food fortification-based interventions for infants and younger children as well as adults, concerns about iron overload related to iron fortification, and an agriculture-based approach.^ieng

Lateral femoral cutaneous nerve block revisited. A nerve stimulator technique.

BACKGROUND AND OBJECTIVES: Regional block of the lateral femoral cutaneous nerve (LFCN) often has disappointing success rates despite the large volumes of local anesthetic used. This study was undertaken to investigate the utility of using a nerve stimulator (NS) to localize and block the LFCN. METHODS: After obtaining institutional approval and informed consent, the authors proceeded with a two-stage study. In stage 1, 20 ASA 1 volunteers underwent LFCN block by both a fan and a NS technique in a prospective, randomized, crossover study utilizing strict criteria for success and extent of block. To predict clinical utility, 20 patients underwent LFCN block by the NS technique using the same assessment criteria (stage 2). Statistical analysis for the comparisons was completed employing the Fisher's exact or paired t-test as appropriate. P < .05 was considered significant. RESULTS: The NS technique significantly improved the success of LFCN block over the fan technique (100% vs. 40%, P = .00002). The extent of successful blocks was no different with the two techniques. Success in stage 2 was similar to that in stage 1 (85%) predicting clinical utility. CONCLUSIONS: A NS can be used to localize a purely sensory nerve; such as the LFCN, and improve success rates in regional anesthesia.

Iron deficiency: contemporary scientific issues and international programmatic approaches.

Iron deficiency is a common nutritional disorder in developing countries and contributes significantly to reduced work productivity and economic output as well as to increased morbidity and mortality. There are well established biochemical tests for assessing iron status in developed countries. However, cost and interference from infectious conditions make it difficult to assess iron status in many developing country settings. Examination of the hemoglobin distribution in the population and assessment of the hemoglobin response to supplementation are alternative approaches to defining iron status and the nature of anemia. Prevention and control of iron deficiency requires the combined approach of dietary improvement, fortification of a common staple food when feasible, and appropriate iron supplementation for infants and pregnant women. In all these intervention activities, operational research is needed to improve effectiveness. In addition, controlling iron deficiency requires coordination with other nutrition and primary health care programs as part of an integrated approach to improved health and nutrition of the population.

Iron status with different infant feeding regimens: relevance to screening and prevention of iron deficiency.

The objective of this study was to evaluate the benefit of screening for anemia in infants in relation to their previous diet. The iron status of 854 nine-month-old infants on three different feeding regimens and on a regimen including iron dextran injection was determined by analysis of hemoglobin, serum ferritin, and erythrocyte protoporphyrin levels and of serum transferrin saturation. Infants were categorized as having iron deficiency if two or three of the three biochemical test results were abnormal and as having iron deficiency anemia if, in addition, the hemoglobin level was less than 110 gm/L. The prevalence of iron deficiency was highest in infants fed cow milk formula without added iron (37.5%), intermediate in the group fed human milk (26.5%), much lower in those fed cow milk formula with added iron (8.0%), and virtually absent in those injected with iron dextran (1.3%). The corresponding values for iron deficiency anemia were 20.2%, 14.7%, 0.6%, and 0%, respectively. The use of iron supplements is therefore justified in infants fed cow milk formula without added iron, even when there is no biochemical evidence of iron deficiency. The low prevalence of iron deficiency in the group fed iron-fortified formula appears to make it unnecessary to screen routinely for anemia in such infants. These results also support the recommendation that infants who are exclusively fed human milk for 9 months need an additional source of iron after about 6 months of age.

PIP: The objective of this study was to evaluate the benefit of screening for anemia in infants in relation to their previous diet. The iron status of 854 9-month old infants on 3 different feeding regimens and on a regimen including iron dextran infection was determined by analysis of hemoglobin, serum ferritin, and erythrocyte protoporphyrin levels and of serum transferrin saturation. Infants were categorized as having iron deficiency if 2 or 3 of the 3 biochemical test results were abnormal; if the hemoglobin level was 110 gm/L, then a diagnosis of iron deficiency anemia was also made. The prevalence of iron deficiency was highest in infants who were fed cow's milk formula without added iron (37.5%), intermediate in the group fed human milk (26.5%), much lower in those fed cow's milk formula with added iron (8.0%), and virtually absent in those injected with iron dextran (1.3%). The corresponding values for iron deficiency anemia were 20.2%, 14.7%, 0.6% and 0%, respectively. The use of iron supplements is therefore justified in infants who received cow's milk formula without added iron, even when there is no biochemical evidence of iron deficiency. The low prevalence of iron deficiency in the group fed iron-fortified formula appears to make it unnecessary to screen routinely for anemia in such infants. These results also support the recommendation that infants who receive human milk exclusively for 9 months require an additional source of iron after about 6 months of age.

Does iron supplementation compromise zinc nutrition in healthy infants?

Iron supplements are commonly administered to infants in order to prevent iron deficiency. We wished to determine whether iron administration could compromise zinc nutrition as might be suspected from previous studies. Measures of iron nutrition, serum zinc, and serum copper were measured before and after randomization of 291 healthy 1-yr-old infants to a 3 mo course of placebo or iron treatment (30 mg iron as ferrous sulfate given before a meal). There was no significant difference in serum zinc or copper in the two groups before or after treatment; thus iron administration did not result in any evidence of zinc deficiency in a healthy, well-nourished group of T-yr-old infants.