Anthelminthic treatment and haemoglobin concentrations during pregnancy.

A longitudinal study was conducted in Sierra Leone to measure the impact of a single dose anthelminthic (400 mg albendazole) and daily iron-folate supplements (36 g iron and 5 mg folate) on haemoglobin (HG) concentration during pregnancy. After controlling for baseline Hb concentration and season, anthelmintic treatment reduced the decline in haemoglobin concentration between the first and third trimesters by 6.6 g/L (p=0.0034) relative to the control. The corresponding value for iron-folate supplements was 13.7 g/L(p<0.0001) [corrected]. These findings indicate that anthelminthic treatment should be included in strategies to control maternal anaemia in Sierra Leone.

The effect of 1-year use of the CuT 380A and oral contraceptive pills on hemoglobin and ferritin levels.

This is a longitudinal study of the effect of 1 year of use of Cu-T 380A intrauterine device (IUD) and oral hormonal contraceptives (OC) on the hemoglobin (Hb) content, serum ferritin, and percent iron saturation (serum iron/total iron binding capacity) of women with initial Hb level of 9-12 g/dL. It was carried out by the Egyptian Fertility Care Society in collaboration with seven University and Ministry of Health Teaching Hospitals. Women were followed-up at fixed intervals when laboratory tests conducted at admission were repeated. The use of Cu-T380A IUD produced a statistically significant drop in the Hb content and percent iron saturation levels after 12 months of use, as compared to the use of OC for the same period. The drop was greater with longer IUD use, initial high Hb levels, and among urban and semiurban residents. It is recommended that iron supplementation be part of the IUD services provided in family planning units in view of the high prevalence of anemia among women in the childbearing age in Egypt.

PIP: This longitudinal study examined the effect of 1 year of use of the Cu-T 380A IUD and of oral contraceptives (OCs) on the hemoglobin (Hb) content, serum ferritin, and percent iron concentration of women with an initial Hb level of 9-12 g/dl. A total of 256 IUD initiators and 202 contraceptive pill initiators in seven participating centers in Egypt comprised the study population. Hb content was measured after 3, 6, 9, and 12 months, and the serum ferritin, serum iron, and total iron binding capacity after 6 and 12 months of contraceptive use. Findings revealed that the use of Cu-T 380A IUD produced a statistically significant drop in the Hb content and percent iron saturation levels after 12 months of use, as compared with the use of OCs for the same period. The drop was greater with longer IUD use, initial high Hb levels, and among urban and semiurban residents. It is recommended that iron supplementation be part of the IUD services provided in family planning units in view of the high prevalence of anemia among women of childbearing age in Egypt. Moreover, mass media campaigns should be carried out to improve the nutritional status of women, especially in the poorer population.

Effectiveness of primary level antenatal care in decreasing anemia at term in Tanzania.

BACKGROUND: In Tanzania the prevalence of anemia in pregnancy is high inspite of a high antenatal attendance and an established national policy of routine hematinic supplementation and malaria chemosuppression to all pregnant women, free of cost in all antenatal clinics. OBJECTIVES: To assess the effectiveness of reinforcing existing antenatal clinic routines for prevention and treatment of anemia in pregnancy, combined with individual and community health education. METHODS: A prospective controlled intervention study in two antenatal clinics at primary level. At booking (median 24 weeks), 1045 women were screened for anemia and followed-up to late pregnancy (gestational age > or =34 weeks). In addition to hematinic and malaria prophylaxis, extra interventions at the study clinic included retraining of staff, group and individual counselling of women and community health education in the area. RESULTS: There was a significant overall increase in median Hb from 10.1 g/dl at booking to 10.6 g/dl in late pregnancy, and prevalence of anemia (Hb < or =10.5 g/dl) was reduced from 60% at booking to 47%, at both clinics, with 57% reduction in the proportion with severe anemia (Hb <7.0 g/dl). Severely anemic women increased their median Hb by 3.2 g/dl during antenatal care. No additional effect was observed from an individual and community information program. CONCLUSION: Ensuring an adequate supply of drugs seems to be the most important activity to achieve safe hemoglobin levels in pregnant women, but even an active antenatal program has a limited effect when anemia is highly prevalent and booking is late.

PIP: This study assesses the effectiveness of primary level antenatal care in decreasing anemia among pregnant women in Tanzania. The sample included 1045 women screened for anemia and followed-up to late pregnancy. Extra interventions at the study clinic included retraining of staff, group and individual counseling of women, and community health education in the area. Results showed a significant overall increase in median Hb from 10.1 g/dl at booking to 10.6 g/dl in late pregnancy. Prevalence of anemia was reduced from 60% at booking to 47% at both clinics, with a 57% reduction in the proportion having severe anemia. Severely anemic women increased their median Hb by 3.2 g/dl during antenatal care. This study concludes that ensuring an adequate supply of drugs seems to be the most important activity to achieve safe hemoglobin levels in pregnant women, but even an active antenatal program has a limited effect when anemia is highly prevalent and booking is late.

Iron status in 268 Danish women aged 18-30 years: influence of menstruation, contraceptive method, and iron supplementation.

The aim of the present study was to evaluate the influence of menstruation, method of contraception, and iron supplementation on iron status in young Danish women, and to assess whether iron deficiency could be predicted from the pattern of menstruation. Iron status was examined by measuring serum (S-) ferritin and hemoglobin (Hb) in 268 randomly selected, healthy, menstruating, nonpregnant Danish women aged 18-30 years. Iron deficiency (S-ferritin <16 microg/l) was observed in 9.7%, of the women, iron deficiency anemia (S-ferritin < 13 microg/l and Hb < 121 g/l) in 2.2%. Iron supplementation, predominantly as vitamin-mineral tablets containing 14-20 mg of ferrous iron was used by 35.1%. The median serum ferritin was similar in non-iron users and in iron users, whereas the prevalence of iron deficiency was 12.6% in nonusers vs. 4.3% in users, the prevalence of iron deficiency anemia 3.4% in nonusers vs. 0%, in users (p=0.17) In non-iron-supplemented women, S-ferritin levels were inversely correlated with the duration of menstrual bleeding (rs= -0.25, p<0.001) and with the women's assessment of the intensity of menstrual bleeding (r(s)= -0.27, p<0.001), whereas no such correlations were found in iron-supplemented women. The results demonstrate that even moderate daily doses of ferrous iron can influence iron status in women with small iron stores. Women using hormonal contraceptives had menstrual bleeding of significantly shorter duration than those using intrauterine devices (IUD) or other methods. There was a high prevalence of small and absent body iron stores in young women, suggesting that preventive measures should be focused on those women whose menstruation lasts 5 days or longer, who have menstrual bleeding of strong intensity, who use an IUD without gestagen, and who are blood donors.

PIP: The influence of menstruation, method of contraception, and low-dose iron supplementation on iron status was investigated in 268 randomly selected, healthy, nonpregnant women 18-30 years of age from Copenhagen, Denmark. In addition, risk factors for development of iron deficiency in fertile women were identified. Iron deficiency (serum ferritin 16 mcg/l) was present in 9.7% and iron deficiency anemia (serum ferritin 13 mcg/l and hemoglobin 121 g/l) in 2.2%. 94 women (35.1%) took iron supplements, generally as a vitamin-mineral tablet containing 14.20 mg of ferrous iron. Median serum ferritin was the same (39 mcg/l) in users and non-users of iron supplements; however, the prevalence of iron deficiency was 12.6% in non-users compared with 4.3% in users and that of iron deficiency anemia was 3.4% in non-users vs. 0% in users. In non-users of iron supplements, serum ferritin levels were inversely correlated with the duration of menstrual bleeding (p 0.001) and women's assessment of the intensity of their bleeding (p 0.001). No such associations were found in supplement users. Menstrual bleeding in women using hormonal contraception (mean, 4.8 days) was significantly shorter than in those using IUDs (mean, 5.7 days). Median ferritin levels were 40 mcg/l in oral contraceptive users and 38 mcg/l in IUD users. Median serum ferritin levels also were higher in women who were not blood donors than in the 40 women (14.9%) who were regular donors (40 mcg/l and 30 mcg/l, respectively). These findings suggest that preventive measures should focus on women whose menstruation lasts 5 days or more, who have menstrual bleeding of strong intensity, who use an IUD without gestagen, and who are blood donors. These women should be encouraged to consume a diet rich in iron with a high bioavailability and/or to take a daily tablet containing 14-20 mg of ferrous iron.

Survey of subfertility patients attending a community clinic over a two year span, before and after national folate campaigns.

PIP: Findings are presented from a retrospective survey of two cohorts of new patients seeking subfertility advice who presented to the subfertility and preconception service of the Croydon Community Health Trust. The first cohort of 40 women presented between April 1, 1995, and March 31, 1996, and the second cohort of 36 women presented between April 1, 1996, and March 31, 1997. The national folate supplementation campaign was conducted in March-April 1996, during which local activities were held to increase awareness among health professionals. The women in cohorts 1 and 2 were aged 21-42 and 19-43 years, respectively, and had been attempting to become pregnant for 2-96 months. 45% of women in the first cohort and 36% in the second cohort had never been pregnant, while 12.5% and 27% of women in the two cohorts, respectively, had a prior history of pregnancy termination. A low incidence was observed at the clinic of correct usage of folate at the time of first attendance throughout the entire period and although folate supplementation had been discussed with some of the women upon their referral to Croydon, 100% uptake of such supplementation had not been achieved. Family planning patients at community services in Croydon should be offered routine rubella testing within 1 year of first attendance if they have not previously given birth in the UK since 1980. Furthermore, couples who are attempting to conceive must be urged to stop smoking preconceptually.^ieng

Zinc supplementation, mental development and behaviour in low birth weight term infants in northeast Brazil.

OBJECTIVE: To test whether zinc supplementation reduces the deficits in mental development and behaviour that are found in term infants of low birth weight in the study population. DESIGN: A prospective double-blind, part-randomised efficacy trial. SETTING: A low-income population in Pernambuco, northeast Brazil, where the economy is largely dependent on sugar-cane production, and where over 90% of deliveries occur in health facilities. SUBJECTS: During a 20-month period, all singleton, term infants weighing 1500-2499 g born to families of low income ( < US $280/month) were enrolled at birth (n = 205). At 6 and 12-months, the numbers tested were 163 and 138 respectively. INTERVENTION: Infants born from January 1993-January 1994 were randomly assigned to receive daily, except Sundays, a placebo (n = 66) or 1 mg zinc (n = 68). Those born February-August 1994 were given 5 mg zinc (n = 71). Supplementation was for eight weeks, starting at birth. Field workers visited each infant at home to administer the supplement. RESULTS: At 6 and 12-months, mental and psychomotor development was assessed with the Bayley Scales of Infant Development and no significant differences in the scores of the three groups were found. At 12-months, behaviour was also assessed on 5 ratings. Ratings were highest in infants given 5 mg zinc (P = 0.042). CONCLUSIONS: Zinc supplementation (5 mg/d) for eight weeks may reverse some of the poor behaviours, particularly responsiveness, exhibited by low birth weight infants. No amelioration of their mental and psychomotor deficits was found.

PIP: Severe zinc deficiency, widespread in developing countries, has been associated with cognitive and psychomotor impairment in animal studies. The capability of zinc supplementation, to reduce the deficits in mental development and behavior found in low-birth-weight term infants, was assessed in a prospective study conducted in a low-income community in Pernambuco, Brazil. All 205 singleton, term infants, delivered at the local hospital in a 20-month period and weighing 1500-2499 g at birth, were enrolled. Infants born from January 1993 to January 1994, were randomly assigned to receive either a placebo (n = 66) or 1 mg of zinc (n = 68) 6 days a week. The 71 low-birth-weight infants delivered from February to August 1994, were given 5 mg of zinc 6 days a week. Supplementation administered by local health workers was initiated at birth and lasted for 8 weeks. Mental and psychomotor development was measured at 6 and 12 months of age by the Bayley Scales of Infant Development. There were no significant differences between infants in the 3 study groups on this test. Also at 12 months, infant behavior was assessed on 5 scales. Ratings for one of these scales (responsiveness to tester) were significantly higher in infants who received 5 mg of zinc than in the 2 other groups, and the 5 mg zinc group also had the highest scores on the 4 other scales. Further studies are urged to investigate the effect of zinc provided later in life, and for longer periods of time, on the development of low-birth-weight infants.

Oral contraceptives did not affect biochemical folate indexes and homocysteine concentrations in adolescent females.

OBJECTIVE: The study was designed to determine the impact of currently available oral contraceptive agents (OCAs), smoking, and alcohol on biochemical indexes of folate and vitamin B-12 in adolescent females. DESIGN: Subjects completed a 3-day weighed food record along with a detailed lifestyle questionnaire that included questions on OCA, cigarette, and alcohol use. After subjects had fasted overnight, blood samples were collected and analyzed for levels of serum and red blood cell (RBC) folate and serum B-12 and homocysteine. SUBJECTS/SETTINGS: Two hundred twenty-nine adolescent females (aged 14 to 20 years) were recruited from southern Ontario, Canada, by advertisements in newspapers, high schools, universities, shopping malls, adolescent drop-in centers, and community groups. STATISTICAL ANALYSES PERFORMED: Multiple regression models were used to determine the effect of lifestyle factors and covariates (e.g., dietary folate intake, supplemental folate intake, and age) on biochemical indexes. RESULTS: OCA use, alcohol use, and smoking were not significantly associated with lower serum or RBC folate levels, after controlling for folate intake. Serum homocysteine levels were not associated with smoking or OCA use; however, we estimated a 13% higher concentration among alcohol users than nonusers. Smoking and alcohol use were not associated with serum B-12 levels, but OCA use was associated with an estimated 33% lower serum B-12 level than nonuse. APPLICATIONS: Our findings provide no evidence to suggest that currently available OCAs have a negative impact on the folate status of adolescent females; thus, dietary advice designed to specifically encourage an increase in folate intake among adolescents who use OCAs is not supported. In contrast, serum B-12 levels were lower among OCA users than nonusers, which suggests that an interaction between OCA and some vitamins may persist. The suboptimal biochemical folate indexes of smokers may have more to do with the dietary quality of smokers than previously appreciated. Thus, efforts to improve dietary folate intakes of adolescents who smoke may be an important strategy for improving the folate status of young women.

PIP: The impact of oral contraceptive (OC) use, smoking, and alcohol drinking on biochemical indexes of folate and vitamin B-12 was investigated in 229 adolescents 14-20 years old recruited from advertisements in Ontario, Canada. Subjects completed a life-style questionnaire and a 3-day, weighed food record, followed by overnight fasting and the collection of blood samples. Of the 48 participants (21%) who were OC users, 30 had used the pill for more than 12 months. Only 37 adolescents (16%) smoked, but 94 (60%) had consumed alcohol in the month preceding the study. Median daily intake of folate and vitamin B-12 (including intake from supplements) was 215 mcg and 1.9 mcg, respectively. OC use, smoking, and alcohol consumption were not significantly associated with lower serum or red blood cell folate levels, after controlling for folate intake. Serum homocysteine levels were not correlated with smoking or OC use, but were 13% higher among alcohol drinkers than nondrinkers. Finally, although smoking and alcohol use were not associated with serum B-12 levels, OC use was linked with an estimated 33% lower serum B-12 level than was nonuse. These findings fail to validate concerns that OC use has a negative impact on the folate status of adolescent females, but suggest a need to improve the dietary folate intake of young women who smoke.

Gossypol-induced hypokalemia and role of exogenous potassium salt supplementation when used as an antispermatogenic agent in male langur monkey.

In our earlier study, we have observed that hypokalemia in langur monkeys, following gossypol acetic acid (GAA) treatment (5 mg dose level) when used as an antispermatogenic agent, and potassium salt supplementation partially maintained body potassium level of the animals. The aims of the present investigation was to confirm further occurrence of hypokalemia in the monkey (comparatively at two higher dose levels) and the role of potassium salt in preventing occurrence of gossypol-induced hypokalemia. Highly purified gossypol acetic acid alone at two dose levels (7.5 and 10 mg/animal/day; oral) and in combination with potassium chloride (0.50 and 0.75 mg/animal/ day; oral) was given for 180 days. Treatment with gossypol alone as well as with the supplementation of potassium salt resulted in severe oligospermia and azoospermia. Animals receiving gossypol alone showed significant potassium deficiency with signs of fatigue at both dose levels. Enhanced potassium loss through urine was found in potassium-deficient animals, whereas animals receiving gossypol acetic acid plus potassium salt showed normal serum potassium with a less significant increase in urine potassium level during treatment phases. Other parameters of the body remained within normal range except gradual and significant elevation in serum transaminases activity. The animals gradually returned to normalcy following 150 and 180 days of termination of the treatment.

PIP: An earlier study conducted by the authors indicated that body potassium levels were partially maintained in male langur monkeys treated with gossypol acetic acid (5 mg) and potassium salt supplementation. The present study sought to confirm the persistence of hypokalemia at two higher dosage levels (7.5 and 10 mg/animal/day) and assess the role of exogenous potassium salt (0.50 and 0.75 mg/animal/day) in preventing gossypol-induced hypokalemia. The two dosages of highly purified gossypol acetic acid were administered alone and in combination with potassium chloride for 180 days. All regimens produced severe oligospermia and azoospermia. However, monkeys who received gossypol alone showed significant potassium deficiency with signs of fatigue at both doses. On the other hand, animals receiving gossypol acetic acid and potassium salt supplementation showed normal serum potassium with a less significant increase in urine potassium level during treatment. Also noted was a gradual but significant elevation in the activity of serum transaminases. All parameters returned to normal 150-180 days after treatment termination. The hypokalemic effect documented in this study with gossypol alone may be due to renal leakage and gastrointestinal disturbances.

Effective community intervention to improve hemoglobin status in preschoolers receiving once-weekly iron supplementation.

The effect of weekly iron supplementation with and without deworming on hemoglobin was investigated in a double-masked, placebo-controlled field trial. Subjects were 289 preschoolers who were randomly divided into three groups. Groups 1 and 2 received 30 mg Fe once weekly and group 3 received a placebo. Group 1 additionally received anthelminthic treatment. Supplements were administered by the mothers, who were educated about iron deficiency beforehand. In the iron-supplemented groups prevalence of anemia decreased from 37.2% to 16.2% (P < 0.001). Hemoglobin increased by an average of 6.9 +/- 9.8 g/L in the two iron-supplemented groups (n = 191), which was greater (P < 0.001) than the increase of 1.9 +/- 8.0 g/L in the placebo group. None of the subjects had hookworm, and anthelminthic treatment did not have an additional effect. Iron supplements administered once weekly by mothers reduced anemia without major involvement of health staff.

PIP: The authors investigated the effect of weekly iron supplementation with and without deworming upon hemoglobin in a double-blind, placebo-controlled field trial conducted in the West Javanese village of Setia Asih. 289 children aged 2-5 years were randomly divided into three equal-sized treatment groups for the study. Groups one and two received 30 mg iron once weekly, while group three received a placebo. Group one also received anthelminthic treatment. Supplements were administered by the mothers who were taught about iron deficiency beforehand. In the iron-supplemented groups, the prevalence of anemia decreased from 37.2% to 16.2% and hemoglobin increased by an average of 6.9 +or- 9.8 g/l. However, hemoglobin increased only 1.9 +or- 8.0 g/l in the placebo group. No subjects had hookworms, so anthelminthic treatment had no additional effect.

Basic care reduces neonatal hyperbilirubinaemia.

We studied the frequency of jaundice, bilirubin estimations, phototherapy administration and exchange transfusions performed at 5 year intervals (1981, 1986 and 1991) among babies admitted to special care unit and those managed in postnatal ward, showing a decline which was significant except for the number of exchange transfusions performed. The number of term babies with serum bilirubin > 15 mg/dl and preterm babies with serum bilirubin > 10 mg/dl also declined significantly without prophylactic phototherapy or pharmacotherapy.

PIP: An examination of the case records of infants admitted to the Institute of Child Health in Bombay, India, in 1981, 1986, and 1991 reveals a significant decline over time in the numbers of infants with jaundice and those requiring serum bilirubin estimation and phototherapy. Cases of jaundice totalled 341 in 1981, 156 in 1986, and 109 in 1991. Bilirubin estimations were required in 166, 13, and 27 infants, respectively, while phototherapy was administered in 125, 7, and 1 cases, respectively. Nine infants received exchange transfusion in 1981 compared with 2 in 1986 and none in 1991. Also recorded were significant declines in serum bilirubin values exceeding 15 mg/dl in term babies and 10 mg/dl in preterm infants. These changes, which occurred without prophylactic use of phototherapy or pharmacotherapy, are considered to reflect a renewed emphasis on provision of warmth, early institution of breast milk feeds, and improved care in the labor room. Although modest physiologic levels of bilirubin during the neonatal period may not be harmful, the bilirubin concentration at which the risk of brain damage exceeds the risk of treatment remains unclear.

The effect of long-term calcium supplementation on indices of iron, zinc and magnesium status in lactating Gambian women.

The effect of long-term supplementation with CaCO3 on indices of Fe, Zn and Mg status was investigated in a randomized, double-blind intervention study of sixty lactating Gambian women. The supplement contained 1000 mg Ca and was consumed between meals 5 d/week, for 1 year starting 1.5 weeks postpartum. Compliance was 100%. Plasma ferritin concentration, plasma Zn concentration and urinary Mg output were measured before, during and after supplementation at 1.5, 13, 52 and 78 weeks postpartum. No significant differences in mineral status were observed at any time between women in the supplement and placebo groups. Analysis of the longitudinal data series showed that plasma ferritin and Mg excretion were characteristic of the individual (P < 0.001). Within individuals, ferritin concentration was higher at 1.5 weeks postpartum than later in lactation (P = 0.002). Plasma Zn concentration was lower at 1.5 weeks postpartum than at other times (P < 0.001), an effect which disappeared after albumin correction. Low plasma concentrations of ferritin and Zn indicated that the Gambian women were at high risk of Fe and Zn deficiency. Measurements of alpha 1-antichymotrypsin suggested that the results were not confounded by acute-phase responses. The results of the present study indicate that 1000 mg Ca as CaCO3 given between meals does not deleteriously affect plasma ferritin and Zn concentrations or urinary Mg excretion in women who are at risk of Fe and Zn deficiency.

PIP: During March 1990-March 1991, 60 lactating mothers were recruited into a randomized, placebo-controlled trial designed to examine the effect of calcium (Ca) supplementation on plasma zinc (Zn) and ferritin (Fe) concentrations and on magnesium (Mg) excretion during and after Ca supplementation. The women lived in Keneba and Manduar villages in rural Gambia. They consumed 1000 mg Ca or the placebo (2 tablets of dextrose) between meals 5 days/week for 12 months beginning 1-5 weeks postpartum. All women complied. At no time were there significant differences in the indices used to determine Zn, Fe, and Mg status between lactating women on Ca supplements and those receiving the placebo. In fact, the mean differences were less than 10% of the total value. Many women (33-50%), regardless of supplementation group, had a plasma Fe concentration lower than 12 mcg/l, indicating depleted Fe stores. Many women also had low plasma Zn levels. Within individuals, plasma Zn concentrations were 15% lower at day 9 than later in lactation (p 0.001), while plasma Fe levels were 10% higher (p = 0.002). Plasma Zn levels were associated with plasma albumin levels (p 0.001). When adjusted for albumin, the effect of lactation on Zn disappeared. When compared with British women, Gambian women had a lower plasma Zn concentration (p 0.001). Within individuals and after adjustment for lactation stage and for albumin, plasma Zn levels varied between seasons (i.e., hot season values higher than other seasons) (p = 0.004). Women were more likely to excrete Mg during the hot season (p 0.001). These findings indicate that ingestion of 1000 mg Ca between meals has no adverse effect on plasma Fe and Zn levels or urinary Mg excretion in women at risk of Zn and Fe deficiency.

Oral rehydration therapy.

PIP: Oral rehydration solution (ORS), the best treatment of dehydration due to acute diarrhea, is the most important medical advance of this century since it is key to reducing infant and child morbidity and mortality. Pathogens responsible for acute diarrhea include those which produce enterotoxin at the intestinal mucosal surface, inducing secretion but are not invasive (e.g., Vibrio cholerae); those which invade and disrupt the mucosal lining (e.g., shigella species); and rotavirus. The World Health Organization (WHO)/UNICEF ORS is considered a universal ORS. Much research has been done on the ideal composition of an ORS. An ORS must have sufficient sodium to replace losses on a volume to volume basis, a glucose concentration that matches that of sodium to ensure its delivery to the ileum, sufficient amounts of potassium and base (e.g., sodium bicarbonate or trisodium citrate dihydrate) to correct acidosis and to enhance sodium absorption, and sufficient amounts of liquid. The risk of hypernatremia with use of the WHO/UNICEF ORS is a concern since infants and young children have an immature renal concentrating capacity, increased insensible water losses, and an impaired natriuretic response. Neonates and young infants may be prone to relatively slow correction of acidosis. It appears that the potassium content (20 mmol/l) of WHO-ORS should be higher to promote a net positive potassium retention. Too much glucose in the ORS will induce reverse osmosis of water into the gut, effectively making the ORS a dehydrating solution rather than a hydrating solution. Some carbohydrates other than glucose have proven effective glucose substitutes (e.g., sucrose, rice starch and powder, other cereals). Cereals have higher acceptability levels in developing countries. Research is investigating the nutritional benefits of supplementing ORS with micronutrients (e.g., vitamin A, folic acid, and zinc). ORS use with early refeeding has a beneficial effect on nutritional status after an acute diarrhea episode.^ieng

[The effect of the use of milk fortified with iron and vitamin C on hemoglobin levels and nutritional status of children under 2]. / Efeito do uso de leite fortificado com ferro e vitamina C sobre os niveis de hemoglobina e condicao nutricional de criancas menores de 2 anos.

The impact of the use of fortified powdered whole milk (9 mg of iron and 65 mg of vitamin C/100 g of milk) on the hemoglobin levels of children under 2 years of age was evaluated, over a period of 6 months, in 107 children enrolled in municipal Day Care Centers (DCC) and in 228 seen at a Basic Health Care Unit (BHCU). Before the beginning of the intervention, 66.4% of the children in the DCC and 72.8% of those seen at the BHCU had hemoglobin levels under 11.0 g/dl. After 6 months of fortified milk intake, these percentages fell to 20.6% and 18.0% respectively. The average hemoglobin before the intervention was 10.3 g/dl in the DCC and 10.5 in the BHCU. After 6 months these increased to 11.6 g/dl in the populations studied. Concerning the nutritional condition, evaluated according to Gomez's criteria, 57% of the DCC children presented an improvement, 41.1% showed changes and only 1.9% became worse. In the BHCU, 11.4% presented better condition, 70.6% remained the same and 18% worsened, which demonstrated differences in response regarding improvement of nutritional condition, when fortified milk was used in closed and open environments. The authors conclude that the utilization of enriched foods is an excellent alternative in the treatment of iron deficiency in populations of children under 2 years of age.

PIP: The impact of the use of fortified powdered whole milk (9 mg of iron and 65 mg of vitamin C per 100 g of milk) on the hemoglobin levels of children under 2 years of age was evaluated, over a period of 6 months, in 107 children enrolled in municipal day care centers (DCC) and in 228 seen at a Basic Health Care Unit (BHCU). Before the beginning of the intervention, 66.4% of the children in the DCC and 72.8% of those seen at the BHCU had hemoglobin levels under 11.0 g/dl. After 6 months of fortified milk intake, these percentages fell to 20.6% and 18.0%, respectively. The average hemoglobin level before the intervention was 10.3 g/dl in the DCC and 10.5 g/dl in the BHCU. After 6 months these increased to 11.6 g/dl in the populations studied. Concerning the nutritional condition, evaluated according to Gomez's criteria, 57% of the DCC children showed improvement, 41.1% showed no change, and only 1.9% grew worse. In the BHCU, 11.4% showed improvement, 70.6% remained the same, and 18% worsened, which demonstrated differences in response regarding improvement of nutritional condition when fortified milk was used in closed and open environments. The authors conclude that the utilization of enriched foods is an excellent alternative in the treatment of iron deficiency in populations of children under 2 years of age. (author's)

Childhood deaths from anaemia in Accra, Ghana.

Severe anaemia has remained a major cause of morbidity and mortality in children of Southern Ghana since the early 1960s. 71.1% of 15450 children attending the Korle Bu Teaching Hospital, Accra referred to the laboratory for haematological studies had haemoglobin (HB) levels below 11.0 Gm/dl while 27.7% of anaemic patients had Hb levels below 7.0 gm/dl. Indeed, 71.1% of children with severe anaemia had Hb levels below 5.0 gm/dl, thus requiring urgent blood transfusion. Though the Department of Child Health alone utilised 32.2% of total blood processed by the National Blood Transfusion Service at Korle Bu, as many as 259 (58.1%) of the 554 deaths in the emergency rooms per annum in children beyond the neonatal period were related to severe anaemia. Iron deficiency was the commonest cause of anaemia and contributed further to the anaemias of sickle cell disease and protein--energy malnutrition. In the light of the significant decline in the prevalence of childhood anaemia in the developed world following improved counseling in nutrition, fortification of foods with iron, and iron supplementation to infants and school children, and the documented attendant improvement in growth velocity and intellectual performance we support the planned national anaemia survey and recommend for early consideration iron supplementation to older infants and pre-school children at risk.

PIP: Severe anemia has remained a major cause of morbidity and mortality in children of Southern Ghana since the early 1960s. Cases of anemia and anemia-associated mortality in the Korle Bu Teaching Hospital (KBTH), Accra, that occurred from January to December 1991 were reviewed. Data on hemoglobin levels, hypochromia, and malaria parasitemia of children referred from January to December 1991 were collected and analyzed to determine the prevalence of moderate/severe malaria parasitemia, anemia, and severe anemia. 10,989 (71.1%) of 15,450 children attending KBTH referred to the laboratory for hematological studies had hemoglobin (Hb) levels below 11.0 g/dl; while 3049 children (27.7%) of anemic patients had Hb levels below 7.0 g/dl. Of these 3049 children with severe anemia, 2185 (71.7%) had Hb levels below 5.0 g/dl, thus requiring urgent blood transfusion. Though the Department of Child Health alone utilized 32.2% of total blood processed by the National Blood Transfusion Service at KBTH, as many as 259 (58.1%) of the 554 deaths (306 male and 248 female) in the emergency room in children beyond the neonatal period were related to severe anemia. The main causes were nutritional anemia (n = 135), anemia associated with severe malaria (n = 56), anemia associated with sickle cell disease (n = 28), anemia associated with protein-energy malnutrition (n = 22), and 18 cases of anemia complicating gastroenteritis, pneumonia, meningitis, and convulsions. 108 (19.5%) deaths occurred because of neonatal sepsis, severe neonatal hyperbilirubinemia, meningitis and bronchopneumonia, severe anemia secondary to hemorrhage of the newborn, and faulty cord ligation. A significant decline occurred in the prevalence of childhood anemia in the developed world following improved counseling in nutrition, fortification of foods with iron, and iron supplementation to infants and schoolchildren with the attendant improvement in growth velocity and intellectual performance. A planned national anemia survey and early consideration of iron supplementation to older infants and preschool children at risk are recommended.

Control of iron and other micronutrient deficiencies in the English-speaking Caribbean.

Most micronutrient deficiencies affect relatively few people in the Caribbean; however, many Caribbean residents are affected by anemia that appears due primarily to a lack of dietary iron. While generally substantial, the prevalences of such anemia have differed a good deal from place to place and study to study, observed rates ranging from 27% to 75% in pregnant women, 19% to 55% in lactating women, and 15% to 80% in young children. Severe anemia, defined by a blood hemoglobin concentration below 8 g/dl, has been found in approximately 6% of the pregnant women and 11% of the preschool children in some Caribbean countries. The principal ways of controlling iron deficiency anemia are through food fortification, control of intestinal parasites, direct oral supplementation, and dietary modification. Progress has been made in iron fortification of wheat flour and wheat products (the principal foodstuffs consumed by the general public in most of the English-speaking Caribbean). Data on control of relevant parasites in the Caribbean (primarily hookworm and to a lesser extent whipworm) are limited. Health services throughout the English-speaking Caribbean have been providing direct iron supplementation for pregnant women, but high levels of anemia during pregnancy still exist because of coverage, monitoring, and compliance problems. All the Caribbean countries also have education programs, which mainly advise pregnant women about iron-rich foods and iron absorption inhibitors and enhancers.

The effect of oral contraceptives on protein metabolism.

The effect on protein and amino acid metabolism of combined oral contraceptives (OC) containing 150 micrograms of laevonorgestrel and 30 micrograms of ethinyl oestradiol was studied in a group of 34 healthy non-lactating women. This was compared to an identical study conducted in another group of 19 subjects who used IUCDs for contraception, and also in two other groups of subjects who were given an additional multivitamin preparation on a daily basis (29 subjects) and on the days when OC was not taken (29 subjects). Assessments were made prior to, and during the third week of the 4th, 7th, and the 13th cycles of OC treatment. Results indicated that the ceruloplasmin and retinol binding protein underwent significant increases with OC usage, while sex hormone binding globulin concentration, on the other hand, remained unaffected. At the same time, a significant reduction of several of the plasma amino acid and plasma albumin concentrations was observed, suggesting that the increase in the visceral and other types of protein concentrations previously noted was due to increased hepatic protein synthesis rather than increased breakdown or excretion as result of OC intake. Interesting biochemical alterations and metabolic effects previously observed may well be related to this altered synthesis and release of proteins and/or protein binders as well as induction of certain metabolic enzymes from the liver.

PIP: To assess the effects of combined oral contraceptive (OC) use on protein and amino acid metabolism, measurements were obtained from four groups of women: Group 1 (29 women who took OCs for 21 days followed by 7 days of multivitamin administration); Group 2 (29 women who took OCs and multivitamins concurrently for 21 days); Group 3 (34 women who took OCs and a placebo for 21 days); and Group 4 (19 IUD users). The OC used in this study contained 30 mcg of ethinyl estradiol and 150 mcg of levonorgestrel; 13 cycles were evaluated in the one-year study period. The fasting concentrations of ceruloplasmin and retinol binding protein increased by an average of 155% and 178%, respectively, above baseline in OC users but not in IUD controls. Fasting plasma concentrations of sex hormone binding globulin showed no changes over baseline in any of the four groups. Free amino acid concentrations were depressed in OC users by 13-33%, with the largest decreases occurring for tyrosine, glycine, ornithine, and proline. Finally, mean concentrations of alpha-1 and beta-globulins increased in OC users, while albumin and total protein decreased significantly. Overall, there was a trend toward increased hepatic protein synthesis with a resultant reduction in concentrations of plasma amino acids and albumin. Multivitamin supplementation did not alter any of these patterns.

Iron deficiency: assessment during pregnancy and its importance in pregnant adolescents.

The assessment of iron deficiency in pregnancy requires the accurate determination of indicators that have significant within-subject variability. For instance, serum ferritin concentrations may vary by as much as 25% from one day to the next. Added to this uncertainty about biological variability is the influence of plasma volume expansion on concentration-dependent indexes such as ferritin, plasma iron, and hemoglobin. Multiple measurements of iron status are suggested, and, if this is not possible, within-subject variability needs to be included in the confidence of assigning individuals to iron-status groups. An example of this former approach is shown for a group of pregnant adolescents with a very high prevalence of iron deficiency. Although the assessment of iron status in human populations is advanced compared with that of other nutrients, there is still a large uncertainty about absolute diagnosis during pregnancy.

PIP: Precise determination of indicators that have considerable within-subject variability is needed to assess iron deficiency in pregnant women. Within-subject day-to-day variation of serum ferritin levels may fluctuate as much as 25%. The uncertainty of biological variability is accompanied by the uncertainty of concentration-dependent indexes (e.g., ferritin, plasma iron, and hemoglobin) caused by plasma volume expansion. Physicians should take several measurements to determine iron status in pregnant women. If they cannot do this, they should incorporate confidence limits around measurements of women assigned to iron-sufficient or iron-deficient groups. In central Pennsylvania, health workers determined the iron status of 88 pregnant adolescents attending the prenatal clinic at Altoona Hospital or the Allegheny Family Physicians Group in Altoona to examine within-subject variability of iron status and the prevalence of iron deficiency in this group. At entry into the pilot study, about 70% of the pregnant teenagers had depleted iron stores. Even though the women were prescribed an iron supplement, depleted iron stores continued throughout pregnancy. Iron deficiency anemia was found in 7.4% at the end of the 1st trimester of pregnancy. Another 3.6% had anemia but not iron deficiency. At 2 weeks postpartum, 55% had iron deficiency anemia. About 20% had anemia with no signs of iron deficiency. When the researchers considered daily variability, the prevalence of depleted iron stores rose to 80% from 69%. All low birth weight infants (born to 8% of subjects) were born to mothers who were iron deficient at 11-16 weeks of pregnancy. There is considerable doubt about an absolute diagnosis of iron status during pregnancy.

Combatting anemia in adolescent girls: a report from India.

PIP: In a study on anemia in adolescent girls living in slum areas, 105 girls, aged 10 to 18, participated in qualitative (focus group discussions; open ended, in depth interviews) and quantitative (structured survey and hemoglobin estimation) research activities before and after intervention. Perceptions of mothers were also surveyed. The qualitative methods were used on selected subsamples in order to represent all age and ethnic groups and geographic areas of the slum. Quantitative methods were used on all 105 girls. The prevalence of anemia was 98%. The patterns of responses were similar for the focus groups, interviews, and surveys. Mothers and their daughters believed the girls were healthy (" one who ate well, worked without tiring easily and did not fall sick often"). There was no major connection made between menstruation and health, or between present and future health. Most of the girls were unaware of the Gujarati term for anemia, pandurog, which is used in awareness campaigns. The girls described symptoms (weakness = kamshakti) associated with anemia and knew these could be remedied with green leafy vegetables, fruit, milk, meat, tonics from the doctor, and iron tablets (shakti ni goli). Based on these results, a puppet show, using local terms and events, was developed that covered the causes, symptoms, treatment, and prevention of anemia. The term, pandurog, was introduced and reinforced. The girls were encouraged to have their blood tested and to take iron tablets. The hemoglobin levels of the girls were taken after the show and after an iron supplement program lasting three months. Compliance with the supplementation program was monitored biweekly. Group discussions with flash cards reinforced the information in the puppet show. Results from the last hemoglobin level showed a significant increase; however, the prevalence of anemia was 87%. About half of the girls consumed at least 60% of the tablets; one-fifth consumed 80%. Forgetfulness and fasting during Ramzaan were cited as reasons for noncompliance. There was a significant increase in awareness of the term, pandurog; the symptoms of anemia; the importance of diet in preventing pandurog; and the role of menstruation in increasing iron needs and contributing to pandurog.^ieng

Iron status in Danish women aged 35-65 years. Relation to menstruation and method of contraception.

Iron status was assessed by serum (S-) ferritin and hemoglobin (Hb) in a population survey comprising 883 non-gravid Danish women in age cohorts of 35, 45, 55, and 65 years. Premenopausal women (n = 676) had lower S-ferritin, median 42 micrograms/l, than postmenopausal women (n = 207), median 80 micrograms/l (p < 0.0001). Of premenopausal women, 12.1% had S-ferritin < or = 20 micrograms/l (i.e. depleted iron stores), and 35.6% S-ferritin of 21-40 micrograms/l (i.e. small iron stores). Corresponding figures in postmenopausal women were 0.5% and 13.2%. Premenopausal blood donors (n = 88) had lower S-ferritin than non-donors (p < 0.001). In premenopausal women, S-ferritin levels were strongly dependent on the duration of menstrual bleeding (p < 0.0001), which in turn was related to the method of contraception. Women (n = 64) using hormonal contraceptives (the pill) had menstrual bleeding of shorter duration than those (n = 511) not using pills or intrauterine devices (IUD), who in turn had bleeding of shorter duration than those (n = 101) using IUD. Median S-ferritin in pill users was 62 micrograms/l, in those not using pills or IUD 42 micrograms/l, and in IUD users 36 micrograms/l. S-ferritin values < 40 micrograms/l (i.e. small and depleted iron stores) were seen in 25% of pill users, in 48% of those not using pills or IUD, and in 61% of IUD users.(ABSTRACT TRUNCATED AT 250 WORDS)

PIP: A sampling study was undertaken to evaluate the effect of menstruation and method of contraception on iron status, especially iron deficiency, in 883 randomly selected Danish women aged 35, 45, 55, and 65 years old. The women underwent clinical examination and related detailed medical histories, including blood donation activities within the past 5 years, method of contraception, duration of menstrual bleeding, and menopausal status. Fasting blood samples were frozen and analyzed by radioimmunoassay within 6 months. Iron depletion was defined as serum ferritin levels or=20mcg/l; iron stores were considered small or reduced at 21-40mcg/l and normal or replete at values 40mcg/l. When serum ferritin was depleted and hemoglobin was 121g/l, iron deficiency anemia was diagnosed. Median serum ferritin was 42mcg/l in premenopausal vs. 80mcg/l in postmenopausal (p0.0001). 88 premenopausal women were blood donors, and their serum ferritin (33mcg/l) was significantly lower than in nondonors (43mcg/l, p0.001). 12.1% of premenopausal women vs. 0.5% of postmenopausal women and 18.2% of premenopausal blood donors vs. 11.3% of nondonors had serum ferritin or=20mcg/l. Hemoglobin values were similar for donors and nondonors. Premenopausal women, however, had slightly, but significantly, lower hemoglobin levels than postmenopausal women. (p0.001), a difference which persisted even between women with identical ferritin levels. 30 (7.4%) premenopausal and 6 (4.8%) postmenopausal women had hemoglobin values 121g/l. Iron deficiency anemia was found in 12 (3%) premenopausal women who had a longer duration of menstrual bleeding than the nonanemic women. None of these deficient women currently used oral contraceptives or an IUD. 639 women provided information on duration of menstrual bleeding; oral contraceptive users had the shortest duration and IUD users the longest. In addition, ferritin levels were highest in present and former users of oral contraceptives, lower in those who currently used other methods, and lowest in current IUD users. Iron stores can be quickly exhausted in a large majority of premenopausal women, which means that guidelines for dietary iron intake and supplementation should take the special needs of members of a population into consideration.

Supplementation with vitamin A and iron for nutritional anaemia in pregnant women in West Java, Indonesia.

Nutritional anaemia, thought to be caused by iron deficiency, affects 50-70% of pregnant women in the developing world. The influence of vitamin A and iron supplementation was studied in anaemic pregnant women in West Java, in a randomised, double-masked, placebo-controlled field trial. 251 women aged 17-35 years, parity 0-4, gestation 16-24 weeks, and haemoglobin between 80 and 109 g/L were randomly allocated to four groups: vitamin A (2.4 mg retinol) and placebo iron tablets; iron (60 mg elemental iron) and placebo vitamin A; vitamin A and iron; or both placebos, all daily for 8 weeks. Maximum haemoglobin was achieved with both vitamin A and iron supplementation (12.78 g/L, 95% Cl 10.86 to 14.70), with one-third of the response attributable to vitamin A (3.68 g/L, 2.03 to 5.33) and two-thirds to iron (7.71 g/L, 5.97 to 9.45). After supplementation, the proportion of women who became non-anaemic was 35% in the vitamin-A-supplemented group, 68% in the iron-supplemented group, 97% in the group supplemented with both, and 16% in the placebo group. Improvement in vitamin A status may contribute to the control of anaemic pregnant women.