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Effective coverage of antenatal iron and folic acid (IFA) supplementation is important to prevent adverse maternal and newborn health outcomes. We interviewed 2572 women from two rural districts in Bangladesh who had a live birth in the preceding six months. We analysed the number of IFA tablets received and consumed during pregnancy and examined the factors influencing IFA consumption by multiple linear regression and user adherence-adjusted effective coverage of IFA (consuming ≥180 IFA tablets) by Poisson regression. Overall, about 80% of women consumed IFA supplements in any quantity. About 76% of women received antenatal care at least once, only 8% received ≥180 IFA tablets, and 6% had user adherence-adjusted coverage of antenatal IFA supplementation. Multivariable analysis showed a linear relationship between the number of antenatal care (ANC) visits and the number of IFA supplements consumed, which was modified by the timing of the first ANC visit. Women's education, free IFA, and advice on IFA were also associated with higher IFA consumption. Interventions targeting at least eight ANC contacts, starting early in pregnancy, providing advice on the importance of IFA, and providing IFA supplements in higher quantity at ANC contacts are likely to increase effective coverage of antenatal IFA supplementation.

Background: Iron-deficiency is the most common nutritional deficiency globally. Due to the high iron requirements for pregnancy, it is highly prevalent and severe in pregnant women. There is strong evidence that maternal iron deficiency anaemia increases the risk of adverse perinatal outcomes. However, most of the evidence is from observational epidemiological studies except for a very few randomised controlled trials. IFA supplements have also been found to reduce the preterm delivery rate and neonatal mortality attributable to prematurity and birth asphyxia. These results combined indicate that IFA supplements in populations of iron-deficient pregnant women could lead to a decrease in the number of neonatal deaths mediated by reduced rates of preterm delivery. In this paper, we describe the protocol of a community-based cluster randomised controlled trial that aims to evaluate the impact of maternal antenatal IFA supplements on perinatal outcomes., Methods/design: The effect of the early use of iron-folic acid supplements on neonatal mortality will be examined using a community based, cluster randomised controlled trial in five districts with 30,000 live births. In intervention clusters trained BRAC village volunteers will identify pregnant women & provide iron-folic acid supplements. Groundwater iron levels will be measured in all study households using a validated test kit. The analysis will follow the intention to treat principle. We will compare neonatal mortality rates & their 95% confidence intervals adjusted for clustering between treatment groups in each groundwater iron-level group. Cox proportional hazards mixed models will be used for mortality outcomes & will include groundwater iron level as an interaction term in the mortality model., Discussion: This paper aims to describe the study protocol of a community based randomised controlled trial evaluating the impact of the use of iron-folic acid supplements early in pregnancy on the risk of neonatal mortality. This study is critical because it will determine if antenatal IFA supplements commenced in the first trimester of pregnancy, rather than later, will significantly reduce neonatal deaths in the first month of life, and if this approach is cost-effective., Trial Registration: This trial has been registered with the Australian New Zealand Clinical Trials Registry (ANZCTR) on 31 May 2012. The registration ID is ACTRN12612000588897 .

Background: Fetal nutritional insults may alter the later metabolic phenotype. We hypothesized that early timing of prenatal food supplementation and multiple micronutrient supplementation (MMS) would favourably influence childhood metabolic phenotype., Methods: Pregnant women recruited 1 January to 31 December 2002 in Matlab, Bangladesh, were randomized into supplementation with capsules of either 30 mg of iron and 400 μg of folic acid, 60 mg of iron and 400 μg of folic acid, or MMS containing a daily allowance of 15 micronutrients, and randomized to food supplementation (608 kcal) either with early invitation (9 weeks' gestation) or usual invitation (at 20 weeks). Their children (n = 1667) were followed up at 4.5 years with assessment of biomarkers of lipid and glucose metabolism, inflammation and oxidative stress., Results: Children in the group with early timing of food supplementation had lower cholesterol (difference -0.079 mmol/l, 95% confidence interval (CI) -0.156; -0.003), low-density lipoprotein (LDL) (difference -0.068 mmol/l, 95% CI -0.126; -0.011) and ApoB levels (difference -0.017 g/l, 95% CL -0.033; -0.001). MMS supplementation resulted in lower high-density lipoprotein (HDL) (difference -0.028 mmol/l, 95% CL -0.053; -0.002), lower glucose (difference -0.099 mmol/l, 95% CL -0.179; -0.019) and lower insulin-like growth factor 1 (IGF-1) (difference on log scale -0.141 µg/l, 95% CL -0.254; -0.028) than 60 mg iron and 400 μg folic acid. There were no effects on markers of inflammation or oxidative stress., Conclusions: Findings suggest that in a population where malnutrition is prevalent, nutrition interventions during pregnancy may modify the metabolic phenotype in the young child that could have consequences for later chronic disease risks., (© The Author 2016; all rights reserved. Published by Oxford University Press on behalf of the International Epidemiological Association.)

Knowledge about the impact of maternal food and micronutrient supplementation on infant micronutrient status is limited. We examined the effect of maternal food and micronutrient supplementation on infant micronutrient status in the Maternal and Infant Nutrition Interventions in Matlab Trial. Pregnant women (n = 4436) were randomized to Early or Usual promotion of enrollment in a food supplementation program. In addition, they were randomly allocated to 1 of the following 3 types of daily micronutrient supplements provided from wk 14 of gestation to 3 mo postpartum: 1) folic acid and 30 mg iron (Fe30Fol); 2) folic acid and 60 mg iron; or 3) a multiple micronutrient including folic acid and 30 mg iron (MMS). At 6 mo, infant blood samples (n = 1066) were collected and analyzed for hemoglobin and plasma ferritin, zinc, retinol, vitamin B-12, and folate. The vitamin B-12 concentration differed between the micronutrient supplementation groups (P = 0.049). The prevalence of vitamin B-12 deficiency was lower in the MMS group (26.1%) than in the Fe30Fol group (36.5%) (P = 0.003). The prevalence of zinc deficiency was lower in the Usual food supplementation group (54.1%) than in the Early group (60.2%) (P = 0.046). There were no other differential effects according to food or micronutrient supplementation groups. We conclude that maternal multiple micronutrient supplementation may have a beneficial effect on vitamin B-12 status in infancy.

Background/objectives: Many children have diets deficient in both iron and zinc, but there has been some evidence of negative interactions when they are supplemented together. The optimal delivery approach would maximize clinical benefits of both nutrients. We studied the effectiveness of different iron and zinc supplement delivery approaches to improve diarrhea and anemia in a rural Bangladesh population., Study Design: Randomized, double blind, placebo-controlled factorial community trial., Results: Iron supplementation alone increased diarrhea, but adding zinc, separately or together, attenuated these harmful effects. Combined zinc and iron was as effective as iron alone for iron outcomes. All supplements were vomited <1% of the time, but combined iron and zinc were vomited significantly more than any of the other supplements. Children receiving zinc and iron (together or separately) had fewer hospitalizations. Separating delivery of iron and zinc may have some additional benefit in stunted children., Conclusions: Separate and combined administration of iron and zinc are equally effective for reducing diarrhea, hospitalizations and improving iron outcomes. There may be some benefit in separate administration in stunted children.

There is a concern that exclusive breast-feeding (EBF) for 6 mo may lead to iron and zinc deficiency in low-birth weight (LBW) infants. We assessed the association between duration of EBF and infant iron and zinc status in the Maternal and Infant Nutrition Interventions in Matlab trial, Bangladesh, stratified for normal birth weigh (NBW) and LBW. Duration of EBF was classified into EBF <4 mo and EBF 4-6 mo based on monthly recalls of foods introduced to the infant. Blood samples collected at 6 mo were analyzed for plasma zinc (n = 1032), plasma ferritin (n = 1040), and hemoglobin (Hb) (n = 791). Infants EBF 4-6 mo had a higher mean plasma zinc concentration (9.9 +/- 2.3 micromol/L) than infants EBF <4mo (9.5 +/- 2.0 micromol/L) (P < 0.01). This association was apparent in only the NBW strata and was not reflected in a lower prevalence of zinc deficiency. Duration of EBF was not associated with concentration of plasma ferritin, Hb concentration, or prevalence of iron deficiency or anemia in any strata. Regardless of EBF duration, the prevalence of zinc deficiency, iron deficiency, and anemia was high in infants in this population and strategies to prevent deficiency are needed.

Objectives: To determine the effect of low-dose weekly supplementation with iron, zinc or both on growth of infants from 6 to 12 months of age., Subjects/methods: A total of 645 breastfed infants age 6 months who were not severely anemic (Hb> or = 90 g l(-1)) or severely malnourished (weight-for-age > or = 60% median) were randomized to receive 20 mg iron and 1 mg riboflavin; 20 mg zinc and 1 mg riboflavin; 20 mg iron, 20 mg zinc and 1 mg riboflavin; or riboflavin alone (control) weekly for 6 months., Results: Baseline characteristics were similar among the four supplementation groups. Weight, length and mid-upper arm circumference were assessed at baseline, 8, 10 and 12 months of age. There was no interaction of iron and zinc when given in a combined supplement on either weight or length (P>0.05). There were no effects of either iron or zinc on the rate of length or weight gain for all infants or when stratified by baseline Hb concentration., Conclusions: Weekly supplementation of 20 mg Fe, 20 mg Zn, or both does not benefit growth among infants 6-12 months of age in rural Bangladesh, a region with high rates of anemia and zinc deficiency.

This article presents the results of an expert consultation meeting aimed at evaluating the safety and public health implications of administering supplemental iron to infants and young children in malaria-endemic areas. Participants at this meeting that took place in Lyon, France on June 12-14, 2006 reached consensus on several important issues related to iron supplementation for infants and young children in malaria-endemic areas. The conclusions in this report apply specifically to regions where malaria is endemic.

Because infants and young children in many developing countries are deficient in both iron and zinc, and zinc can affect iron metabolism, evaluation of optimum strategies to simultaneously supplement iron and zinc is an important public health priority. This study evaluated the efficacy of weekly supplementation of iron or zinc or both on iron, zinc, and copper status in Bangladeshi infants. In a double-blind, randomized, controlled community trial, 6-mo-old infants were assigned to receive weekly supplements of 1 mg riboflavin (control, n = 82) or 1 mg riboflavin + 20 mg iron (n = 83), 20 mg zinc (n = 83), or both (n = 85) for 6 mo. Hemoglobin, serum ferritin, transferrin receptor, zinc, and copper concentrations were measured at baseline and at the end of intervention. Serum Zn increased in both groups receiving zinc; the increase was greatest among children with low baseline serum zinc concentration. Iron status indicators did not differ among the groups before or after 6 mo of supplementation. Supplementation with either zinc or iron decreased serum copper after 6 mo. Joint supplementation did not alter the individual effects of iron or zinc supplementation in these Bangladeshi children. However, the dosing regimen may not have been adequate to achieve the desired biochemical effects.

Given the high prevalence of micronutrient deficiencies and infectious diseases in infants in developing countries, an evaluation of the efficacy of different micronutrient formulations on infant morbidity is a priority. The efficacy of weekly supplementation of four different micronutrient formulations on diarrhea and acute lower respiratory infection (ALRI) morbidity was evaluated in Bangladeshi infants. In a double-blind, randomized, controlled community trial, 799 infants aged 6 mo were randomly assigned to one of the following 5 groups: 1) 20 mg elemental iron with 1 mg riboflavin, 2) 20 mg elemental zinc with 1 mg riboflavin, 3) 20 mg iron and 20 mg zinc with 1 mg riboflavin, 4) a micronutrient mix (MM) containing 20 mg iron, 20 mg zinc, 1 mg riboflavin along with other minerals and vitamins and 5) a control treatment, 1 mg riboflavin only. Health workers visited each infant weekly until age 12 mo to feed the supplement and to collect data on diarrhea and ALRI morbidity. Hemoglobin, serum ferritin and serum zinc levels of a sample of infants were measured at 6 and 12 mo. Compared with the control group, at 12 mo, serum ferritin levels were higher in the iron + zinc group, and serum zinc levels were higher in the zinc and iron + zinc groups. Simultaneous supplementation with iron + zinc was associated with lower risk of severe diarrhea, 19% lower in all infants and 30% lower in less well-nourished infants with weight-for-age Z-score below -1. Iron + zinc supplementation was also associated with 40% lower risk of severe ALRI in less well-nourished infants. MM supplementation was associated with a 15% higher risk of diarrhea in all infants and 22% higher risk in less well-nourished infants. Intermittent simultaneous supplementation with iron + zinc seems promising; it will be useful to determine whether higher doses would provide greater benefits.

Objectives:To determine the effect of low-dose weekly supplementation with iron, zinc or both on growth of infants from 6 to 12 months of age.Subjects/Methods:A total of 645 breastfed infants age 6 months who were not severely anemic (Hb90 g l−1) or severely malnourished (weight-for-age 60% median) were randomized to receive 20 mg iron and 1 mg riboflavin; 20 mg zinc and 1 mg riboflavin; 20 mg iron, 20 mg zinc and 1 mg riboflavin; or riboflavin alone (control) weekly for 6 months.Results:Baseline characteristics were similar among the four supplementation groups. Weight, length and mid-upper arm circumference were assessed at baseline, 8, 10 and 12 months of age. There was no interaction of iron and zinc when given in a combined supplement on either weight or length (P>0.05). There were no effects of either iron or zinc on the rate of length or weight gain for all infants or when stratified by baseline Hb concentration.Conclusions:Weekly supplementation of 20 mg Fe, 20 mg Zn, or both does not benefit growth among infants 6–12 months of age in rural Bangladesh, a region with high rates of anemia and zinc deficiency.European Journal of Clinical Nutrition (2009) 63, 87–92; doi:10.1038/sj.ejcn.1602905; published online 19 September 2007 [ABSTRACT FROM AUTHOR]

Background: Micronutrient malnutrition is a widespread problem in developing countries. Supplemental zinc has been shown to improve growth in undernourished children, but the effect in infants or when combined with iron is less known. We assessed the effect of low-dose weekly zinc and/or iron supplementation on growth among infants from 6-12 mo of age. Methods: Bangladeshi infants were randomized to receive 20 mg iron (Fe), 20 mg zinc (Zn), both (Fe + Zn), or riboflavin alone weekly from 6-12 mo of age. Weight and length were assessed fit baseline, 8, 10, and 12 mo of age. Changes in anthropometric indicators were compared using multiple linear regression analyses and 6-mo growth trajectories were compared by supplementation groups for all infants and in stratified analyses by baseline Hb concentration. Results: Baseline characteristics were similar among the 4 groups. Overall, z-scores declined over the 6 month period. There was no effect of Fe, Zn, or both on length. Fe + Zn had a negative effect on weight, yet supplementation with Fe or Zn alone had no effect. There was no differential effect by supplement type when stratified by Hb concentration. Fe or Zn alone decreased the rate of weight gain, but these small effects were not observed in the Fe + Zn group. Conclusions: Low-dose weekly supplementation with Fe and/or Zn does not benefit growth among infants 6-12 mo of age. [ABSTRACT FROM AUTHOR]

Abstract: Experimental studies indicate that zinc (Zn) and calcium (Ca) status, in addition to iron (Fe) status, affect gastrointestinal absorption of cadmium (Cd), an environmental pollutant that is toxic to kidneys, bone and endocrine systems. The aim of this study was to evaluate how various nutritional factors influence the uptake of Cd in women, particularly during pregnancy. The study was carried out in a rural area of Bangladesh, where malnutrition is prevalent and exposure to Cd via food appears elevated. The uptake of Cd was evaluated by associations between erythrocyte Cd concentrations (Ery-Cd), a marker of ongoing Cd exposure, and concentrations of nutritional markers. Blood samples, collected in early pregnancy and 6 months postpartum, were analyzed by inductively coupled plasma mass spectrometry (ICPMS). Ery-Cd varied considerably (range: 0.31–5.4μg/kg) with a median of 1.1μg/kg (approximately 0.5μg/L in whole blood) in early pregnancy. Ery-Cd was associated with erythrocyte manganese (Ery-Mn; positively), plasma ferritin (p-Ft; negatively), and erythrocyte Ca (Ery-Ca; negatively) in decreasing order, indicating common transporters for Cd, Fe and Mn. There was no evidence of Cd uptake via Zn transporters, but the association between Ery-Cd and p-Ft seemed to be dependent on adequate Zn status. On average, Ery-Cd increased significantly by 0.2μg/kg from early pregnancy to 6 months postpartum, apparently due to up-regulated divalent metal transporter 1 (DMT1). In conclusion, intestinal uptake of Cd appears to be influenced either directly or indirectly by several micronutrients, in particular Fe, Mn and Zn. The negative association with Ca may suggest that Cd inhibits the transport of Ca to blood. [Copyright &y& Elsevier]