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Anemia affects a third of the world's population and contributes to increased morbidity and mortality, decreased work productivity, and impaired neurological development. Understanding anemia's varied and complex etiology is crucial for developing effective interventions that address the context-specific causes of anemia and for monitoring anemia control programs. We outline definitions and classifications of anemia, describe the biological mechanisms through which anemia develops, and review the variety of conditions that contribute to anemia development. We emphasize the risk factors most prevalent in low- and middle-income countries, including nutritional deficiencies, infection/inflammation, and genetic hemoglobin disorders. Recent work has furthered our understanding of anemia's complex etiology, including the proportion of anemia caused by iron deficiency (ID) and the role of inflammation and infection. Accumulating evidence indicates that the proportion of anemia due to ID differs by population group, geographical setting, infectious disease burden, and the prevalence of other anemia causes. Further research is needed to explore the role of additional nutritional deficiencies, the contribution of infectious and chronic disease, as well as the importance of genetic hemoglobin disorders in certain populations.

The optimal timing of umbilical cord clamping has been debated in the scientific literature for at least the last century, when cord clamping practices shifted from delayed towards immediate clamping. Recent research provides evidence for the beneficial effect of delayed cord clamping on infant iron status. The present review describes the physiological basis for the impact of cord clamping time on total body iron at birth and the relationship between birth body iron, as affected by cord clamping time, and iron status later in infancy. This research is discussed in the context of current clamping practices, which tend towards early cord clamping in most settings, as well as the high levels of anemia present in young infants in many countries worldwide.

To understand the factors contributing to changes in breastfeeding duration, we analyzed data from seven countries in Latin America and from Haiti to document changes in breastfeeding duration between 1986 and 2005. We used a novel method that permits the overall change to be separated into the portion attributable to changing population characteristics (e.g., greater urban population or increased maternal employment) and the portion resulting from changing breastfeeding behaviors within population subgroups (e.g., more breastfeeding among urban women). Our results indicate that in the low-to-middle-income countries studied, which are experiencing socioeconomic and demographic changes, improvements in breastfeeding duration occurred. These improvements are explained almost entirely by changing breastfeeding behaviors, which were particularly evident in certain subgroups of women, such as those with higher levels of education, and very little by changing population characteristics. The socioeconomic and demographic changes we studied that were previously associated with less breastfeeding no longer appear to have a large negative effect. Our findings show that individual behaviors are amenable to change and that changes in individual behaviors collectively contribute to positive national trends in breastfeeding.

[Image: see text] [Table: see text] [Table: see text] [Table: see text] [Table: see text] ABSTRACT: The term ‘lipid‐based nutrient supplements’ (LNS) refers generically to a range of fortified, lipid‐based products, including products like Ready‐to‐Use Therapeutic Foods (RUTF) (a large daily ration with relatively low micronutrient concentration) as well as highly concentrated supplements (1–4 teaspoons/day, providing

Author(s): Mridha, Malay K; Matias, Susana L; Chaparro, Camila M; Paul, Rina R; Hussain, Sohrab; Vosti, Stephen A; Harding, Kassandra L; Cummins, Joseph R; Day, Louise T; Saha, Stacy L; Peerson, Janet M; Dewey, Kathryn G | Abstract: BackgroundMaternal undernutrition and newborn stunting [birth length-for-age z score (LAZ) l-2] are common in Bangladesh.ObjectiveThe objective was to evaluate the effect of lipid-based nutrient supplements for pregnant and lactating women (LNS-PLs) on birth outcomes.DesignWe conducted a cluster-randomized effectiveness trial (the Rang-Din Nutrition Study) within a community health program in rural Bangladesh. We enrolled 4011 pregnant women at ≤20 gestational weeks; 48 clusters received iron and folic acid (IFA; 60 mg Fe + 400 μg folic acid) and 16 clusters received LNS-PLs (20 g/d, 118 kcal) containing essential fatty acids and 22 vitamins and minerals. Both of the supplements were intended for daily consumption until delivery. Primary outcomes were birth weight and length.ResultsInfants in the LNS-PL group had higher birth weights (2629 ± 408 compared with 2588 ± 413 g; P = 0.007), weight-for-age z scores (-1.48 ± 1.01 compared with -1.59 ± 1.02; P = 0.006), head-circumference-for-age z scores (HCZs; -1.26 ± 1.08 compared with -1.34 ± 1.12; P = 0.028), and body mass index z scores (-1.57 ± 1.05 compared with -1.66 ± 1.03; P = 0.005) than those in the IFA group; in adjusted models, the differences in length (47.6 ± 0.07 compared with 47.4 ± 0.04 cm; P = 0.043) and LAZ (-1.15 ± 0.04 compared with -1.24 ± 0.02; P = 0.035) were also significant. LNS-PLs reduced the risk of newborn stunting (18.7% compared with 22.6%; RR: 0.83; 95% CI: 0.71, 0.97) and small head size (HCZ l-2) (20.7% compared with 24.9%; RR: 0.85; 95% CI: 0.73, 0.98). The effects of LNS-PL on newborn stunting were greatest in infants born before a 10-wk interruption in LNS-PL distribution (n = 1301; 15.7% compared with 23.6%; adjusted RR: 0.69; 95% CI: 0.53, 0.89) and in infants born to women ≤24 y of age or with household food insecurity.ConclusionPrenatal lipid-based nutrient supplements can improve birth outcomes in Bangladeshi women, especially those at higher risk of fetal growth restriction. This trial was registered at clinicaltrials.gov as NCT01715038.

Delayed clamping of the umbilical cord increases the infant's iron endowment at birth and haemoglobin concentration at 2 months of age. We aimed to assess whether a 2-minute delay in the clamping of the umbilical cord of normal-weight, full-term infants improved iron and haematological status up to 6 months of age.476 mother-infant pairs were recruited at a large obstetrics hospital in Mexico City, Mexico, randomly assigned to delayed clamping (2 min after delivery of the infant's shoulders) or early clamping (around 10 s after delivery), and followed up until 6 months postpartum. Primary outcomes were infant haematological status and iron status at 6 months of age, and analysis was by intention-to-treat. This study is registered with ClinicalTrials.gov, number NCT00298051.358 (75%) mother-infant pairs completed the trial. At 6 months of age, infants who had delayed clamping had significantly higher mean corpuscular volume (81.0 fL vs 79.5 fL 95% CI -2.5 to -0.6, p=0.001), ferritin (50.7 mug/L vs 34.4 mug/L 95% CI -30.7 to -1.9, p=0.0002), and total body iron. The effect of delayed clamping was significantly greater for infants born to mothers with low ferritin at delivery, breastfed infants not receiving iron-fortified milk or formula, and infants born with birthweight between 2500 g and 3000 g. A cord clamping delay of 2 minutes increased 6-month iron stores by about 27-47 mg.Delay in cord clamping of 2 minutes could help prevent iron deficiency from developing before 6 months of age, when iron-fortified complementary foods could be introduced.

Maternal undernutrition and newborn stunting (birth length-for-age z-score < -2) are common in Bangladesh. In the Rang-Din Nutrition Study, a cluster-randomized effectiveness trial underway in northwest Bangladesh, pregnant women received either a) iron & folic acid (IFA) or b) lipid-based nutrient supplement (LNS, 20 g/d, 118 kcal) designed to enrich local diets of pregnant women with essential fatty acids, high-quality protein and 22 micronutrients. Women (n=4011) were enrolled at 13.1 ± 3.4 wk gestation; 40% were nulliparous and 31% were underweight (BMI < 18.5 kg/m2). In the full sample, there were significant reductions in newborn stunting [18.6 vs. 22.5%, adjusted relative risk (ARR)=0.83 (0.70, 0.96)] and small head circumference (HC z-score < -2) [20.8 vs. 24.7%, ARR=0.82 (0.71, 0.95)] in the LNS vs. IFA group; the difference in low birth weight was marginally significant (36.8 vs. 39.1%, p=0.087). LNS distribution was interrupted for 10 wk in 2012; among women who gave birth before the interrupti...

Objectives. We examined trends in breastfeeding promotion investments, breastfeeding promotion activities, and breastfeeding duration in Latin America and the Caribbean from the 1980s to the 2000s. Methods. We obtained financial data from the United States Agency for International Development and the International Code Documentation Center, and we obtained breastfeeding promotion data from surveys of breastfeeding coordinators with ministries of health and with the International Baby Food Action Network. We obtained breastfeeding data from nationally representative surveys conducted between 1986 and 2008. Results. Investment in breastfeeding promotion declined in the 2000s relative to earlier years. For all countries, breastfeeding duration increased between the first and last survey. Of the 12 countries represented in the interval when investment in breastfeeding promotion was high, breastfeeding duration decreased in 1 country. Of the 12 countries represented in the interval when investment was low, breastfeeding duration decreased in 3 countries. Nonetheless, the average annual change in breastfeeding duration for the 2 intervals was positive and similar (0.16 months and 0.21 months). Conclusions. Breastfeeding promotion likely resulted in large improvements in breastfeeding. Investments in breastfeeding promotion have declined, but this does not appear to have adversely affected breastfeeding duration.

BACKGROUND: Breastfeeding has large benefits for mothers and infants. The short-term benefits for child survival and reduced morbidity differ by population subgroup because of differences in underlying risk factors. Although breastfeeding is more common among poor than well-off women how breastfeeding patterns change between these subgroups is important from a policy perspective as the poor will benefit more from increased duration of breastfeeding. METHODS: We use nationally representative data from eight countries in Latin America and the Caribbean to document changes in breastfeeding duration between 1986 and 2005 and separate the overall change into the portion attributable to changing population characteristics and the portion resulting from changing breastfeeding behaviour within population subgroups. RESULTS: Breastfeeding duration increased in six out of the eight countries and the changes observed are largely explained by changing behaviour within population subgroups rather than changing population characteristics. Changes in breastfeeding duration did not tend to be equitably distributed but in four countries (Bolivia Brazil Colombia and Peru) the population subgroups whose children are most at risk for mortality and increased morbidity from not being breastfed were least likely to show improvements in breastfeeding duration. Between 1986 and 2004 in Peru breastfeeding duration declined by 0.6 months among rural women while increasing by 9.7 months among urban women; it increased by 6.3 months among women with prenatal care but only by 3.7 months among women with no prenatal care. Changes in breastfeeding in Guatemala and Haiti tended to favour the well-off compared with the poor though not consistently. In Nicaragua changes in breastfeeding duration tended to favour the less well-off. DISCUSSION: While promoting breastfeeding is a must for all women to maximize its benefits for child survival and health additional efforts are needed to reach poorly educated and rural women with little access to health care.

Delayed umbilical cord clamping, immediate skin-to-skin contact, and early initiation of breastfeeding have been shown to be simple, safe, and effective and should be implemented in all deliveries, with very few exceptions. Although these practices can also prevent death, their importance extends beyond survival and optimizes both short-and long-term neonatal and maternal health and nutrition. Their implementation requires that they be integrated with one another and included with other standard lifesaving care practices. Leveraging knowledge of efficacious interventions into high-quality programs with broad coverage is often the main obstacle to improving neonatal and maternal health in low-income countries. To achieve results at-scale, attention must be given to increasing access to scientific information supporting evidence-based practices and addressing the skills needed to implement the recommended practices; establishing and communicating global, national, and local policies and guidelines for implementation in conjunction with advocacy and synchronization with other maternal and neonatal care efforts; reorganizing delivery care services; and monitoring and evaluation. This will require international investments similar to those being made for other lifesaving neonatal interventions. Neonatal vitamin A supplementation, recommended for implementation in Asia, is controversial, and the evidence for and against this recommendation is reviewed.

OBJECTIVE: To assess the effect of using stunting versus underweight as the indicator of child undernutrition for determining whether countries in Latin America and the Caribbean are on track to meet the component of Millennium Development Goal (MDG) 1 pertaining to the eradication of hunger, namely to reduce undernutrition by half between 1990 and 2015. METHODS: The prevalence of underweight and stunting among children less than 5 years of age was calculated for 13 countries in Latin America and the Caribbean by applying the WHO Child Growth Standards to nationally-representative, publicly available anthropometric data. The predicted trend (based on the trend in previous years) and the target trend (based on MDG 1) for stunting and underweight were estimated using linear regression. FINDINGS: The choice of indicator affects the conclusions regarding which countries are on track to reach MDG 1. All countries are on track when underweight is used to assess progress towards the target prevalence, but only 6 of them are on track when stunting is used instead. Another two countries come within 2 percentage points of the target prevalence of stunting. CONCLUSION: Whether countries are determined to be on track to meet the nutritional component of MDG 1 or not depends on the choice of stunting versus underweight as the indicator. Unfortunately, underweight is the indicator officially used to monitor progress towards MDG 1. In Latin America and the Caribbean, the use of underweight for this purpose will fail to take account of the large remaining burden of stunting.

Iron deficiency (ID) can occur among exclusively breastfed infants before 6 mo of age.The objective was to determine which subgroups of fully breastfed infants are at highest risk of ID.We assessed the prevalence of ID (ferritin12 mug/L) and iron deficiency anemia (IDA; ferritin12 mug/L and hemoglobin105 g/L) and risk factors associated with ID and IDA at 6 mo among 404 fully breastfed infants with a birth weight2500 g from 6 studies in Ghana, Honduras, Mexico, and Sweden. Infants with an elevated C-reactive protein concentration (8%) were excluded.The percentages of infants with ID were 6% in Sweden, 17% in Mexico, 13-25% in Honduras, and 12-37% in Ghana. The percentages with IDA were 2% in Sweden, 4% in Mexico, 5-11% in Honduras, and 8-16% in Ghana. With data pooled, the key predictors of ID (20%) were male sex [adjusted odds ratio (AOR): 4.6; 95% CI: 2.5, 8.5] and birth weight 2500-2999 g (AOR: 2.4; 95% CI: 1.4, 4.3). The predictors of IDA (8%) were male sex (AOR: 7.6; 95% CI: 2.5, 23.0), birth weight of 2500-2999 g (AOR: 3.4; 1.5, 7.5), and weight gain above the median since birth (AOR: 3.4; 95% CI: 1.3, 8.6). The combination of birth weight 2500-2999 g or male sex had a sensitivity of 91% for identifying ID and of 97% for identifying IDA.Among fully breastfed infants with a birth weight2500 g, IDA is uncommon before 6 mo, but male infants and those with a birth weight of 2500-2999 g are at higher risk of ID and IDA.

Delayed umbilical cord clamping, early skin‐to‐skin contact and early initiation of exclusive breastfeeding are three simple and inexpensive delivery care practices which have the potential to improve short‐term and long‐term nutrition and health outcomes in mothers and infants. In preterm infants, delayed clamping prevents intraventricular haemorrhage and improves haematological status, and in full‐term infants, delayed clamping improves iron status through 6 months of age. Early skin‐to‐skin contact, in addition to regulating neonatal temperature, improves early breastfeeding behaviours, which has important implications for long‐term infant nutrition and health. Finally, early exclusive breastfeeding prevents neonatal mortality and morbidity and provides numerous health and nutritional benefits to the infant, throughout infancy and beyond, as well as to the mother. Though each practice has been the subject of controlled trials and systematic reviews, with evidence of benefit from their implementation, these practices are not common in many delivery settings, nor are their long‐term effects on infant and maternal nutrition and health status adequately recognized. We discuss the immediate and long‐term health and nutrition benefits of each practice, and identify the policy and programme changes needed for integration and implementation of these practices into standard delivery care.

Iron deficiency is estimated to be the most common nutritional deficiency worldwide and is particularly persistent among infants and children. The high prevalence of anemia in 6- to 9-mo-old children raises the concern that birth iron stores in some infants are inadequate to sustain growth and development through the first 6 mo of life, and postnatal factors are contributing to early depletion of iron stores and development of anemia. At the same time, there are concerns about negative effects of excess iron in infants. Maternal iron status, infant birth weight and gestational age, as well as the timing of umbilical cord clamping at birth all contribute to the establishment of adequate total body iron at birth. Postnatally, feeding practices and growth rate are factors that will affect how quickly birth iron is depleted during the first 6 mo of life. Under conditions in which maternal iron status, birth weight, gestational age, and umbilical cord clamping time are optimal, and exclusive breast-feeding is practiced, infants should have adequate iron stores for the first 6-8 mo of life. Under suboptimal conditions, infants may not reach this goal and may need to be targeted for iron supplementation before 6 mo of age.

Efforts to develop global programs for the control of iron deficiency require simple, low-cost, and accurate indicators of iron status.We aimed to compare estimates of body iron (BI) stores, as calculated from either plasma ferritin concentration alone (BI-ferritin) or the ratio of plasma transferrin receptor (TfR) to ferritin (BI-TfR/ferritin).Data were analyzed from 4 previously completed, randomized intervention trials that enrolled infants, schoolchildren, or pregnant women (total n = 1189, after excluding subjects with elevated C-reactive protein).The correlation coefficients between BI-ferritin and BI-TfR/ferritin were0.95 for all studies. The kappa index ranged from 0.5 to 1.0. All of the sensitivities of BI-ferritin for identifying persons with low iron stores (defined as BI-TfR/ferritin0 mg/kg body wt) were0.90. All of the specificities were0.90 except the study of pregnant women (specificity = 0.66). The effect sizes of iron intervention trials were significantly greater for change in iron reserves estimated by BI-TfR/ferritin than by BI-ferritin in 2 studies with larger effect sizes (1.11 compared with 1.00 and 1.56 compared with 1.44, respectively; P0.05) and 1 study with medium effect size (0.70 compared with 0.57; P0.05). However, there were no significant differences between estimates of these effect sizes for 1 study with a medium effect size and 1 study with a smaller effect size (0.78 compared with 0.83 and 0.37 compared with 0.35, respectively; P0.2).Plasma ferritin concentration alone provides a good approximation of total BI reserves, as estimated by BI-TfR/ferritin, on the basis of high correlation, sensitivity, and specificity among nonpregnant persons with unelevated C-reactive protein.

Fe deficiency is a common nutritional disorder during infancy, particularly in low-income countries. The Fe status of a breast-fed infant is strongly influenced by the body Fe content at birth, which is determined by factors that operate before birth (maternal Fe status before and during pregnancy; infant gestational age and birth weight) and at the time of delivery (the timing of umbilical cord clamping). Delaying the clamping of the umbilical cord for 2 min can increase body Fe content by approximately 33% (75 mg), and results in greater Fe stores at 6 months of age. After birth, male gender and a rapid rate of weight gain are associated with lower Fe status. During the first half of infancy dietary Fe requirements depend on Fe stores at birth. For an exclusively-breast-fed full-term normal-birth-weight infant with delayed umbilical cord clamping, whose mother had adequate Fe status during pregnancy, the Fe provided from stores and breast milk is sufficient for/=6 months, but before this time higher-risk infants may become Fe deficient. Fe supplementation can be beneficial for high-risk infants, but can have adverse effects on growth and morbidity of Fe-replete infants. After 6 months most breast-fed infants will require complementary foods that are rich in Fe.

Objective To investigate whether infant iron status, modified by umbilical cord clamping time and infant feeding mode, affected infant blood lead concentration at 6 months of age. Study design Participants were a subset of women and their infants randomized to receive early (10 seconds) or delayed (2 minutes) umbilical cord clamping and were monitored to 6 months postpartum in Mexico City. Iron and lead status was analyzed in maternal, placental, and 6-month infant blood samples. Baseline maternal lead exposure data and infant feeding data at 2, 4, and 6 months were collected. Results In the total sample, maternal blood lead concentration, infant ferritin, and breast-feeding practices predicted infant blood lead concentration. Among infants with higher placental blood lead concentration and breast-fed infants not receiving any iron-fortified formula or milk at 6 months, early clamping increased infant blood lead concentration, an effect mediated in part via decreased infant iron status. Conclusions Early cord clamping, by decreasing infant iron status, contributes to higher blood lead concentrations at 6 months of age among infants at high risk.

www.thelancet.com Vol 368 September 2, 2006 839 studies on the prevalence of mental disorders in children were completed in Baghdad, Mosul, and Dohuk. This was part of a group of 15 research studies. In the fi rst study we found that, of 600 primary school children from 16 schools in Baghdad (mean age 10·3 years), 283 (47%) reported exposure to a major traumatic event during the previous 2 years. 84 (14%) had post-traumatic stress disorder (PTSD; 21 of 225 boys [9%], 63 of 375 girls [17%]). In the second study in Mosul, 1090 adolescents from eight secondary schools were screened for mental disorders. 323 (30%) had symptoms of PTSD (127 of 481 boys [26%], 196 of 609 girls [32%]). There was a higher rate of PTSD in the older adolescents. 301 (92%) of the ill adolescents had not received any treatment. The third study, in Dohuk, involved 120 working street children and 120 school children. The prevalence of mental disorders was higher in the working children than the school children (42 [36%] vs 16 [13%]). There is an urgent need to address the needs of all children by means of preventive programmes such as life skills education and care programmes within the school setting.