Preschool iron-folic acid and zinc supplementation in children exposed to iron-folic acid in utero confers no added cognitive benefit in early school-age

In Nepal, antenatal iron-folic acid supplementation improved aspects of intellectual, executive, and fine motor function among school-age children. We examined the impact of added zinc to the maternal antenatal supplement (M-IFAZn) and preschool supplementation from 12 to 36 mo with iron-folic acid (C-IFA) ± zinc (C-IFAZn) on cognitive outcomes compared to maternal iron-folic acid (M-IFA) alone. Children 7-9 y old (n = 780) who participated in early childhood micronutrient supplementation trial during 2001-2004 and whose mothers participated in an antenatal micronutrient supplementation between 1999 and 2001 were followed for cognitive assessments in 2007-2009. Using multivariate analysis of variance and adjusting for confounders, M-IFA with child supplementation (either C-IFA or C-IFAZn) did not impact scores on the tests of general intelligence (Universal Nonverbal Intelligence Test), and executive function (Stroop and go/no go tests) relative to the M-IFA alone. However, children in the C-IFAZn group had slightly lower scores on the backward digit span (-0.29, 95% CI: -0.55, -0.04) and Movement Assessment Battery for Children (1.33, 95% CI: 0.26, 2.40) relative to the referent group, whereas both C-IFA (-1.92, 95% CI: -3.12, -0.71) and C-IFAZn (-1.78, 95% CI: -2.63, -0.92) produced somewhat lower finger tapping test scores (fine motor skills). The combination of M-IFAZn and C-IFA or C-IFAZn did not lead to any outcome differences relative to M-IFA alone. Preschool iron-folic acid ± zinc to children exposed to iron-folic acid in utero or addition of zinc to maternal iron-folic acid conferred no additional benefit to cognitive outcomes assessed in early school age. The late timing of supplementation during preschool may explain the lack of impact of iron and/or zinc.     

Predictors for antenatal insulin requirement in gestational diabetes

The purpose of this study was to identify pre-gestational and gestational factors predicting subsequent insulin requirement in patients with gestational diabetes mellitus (GDM). Maternal parameters were compared between mothers achieving glycemic control with or without the addition of antenatal insulin therapy (AIT). Insulin was required only in 8/83 (10%) patients for glycemic control. Those who needed insulin had a stronger family history of diabetes and higher first hour plasma glucose along with multiple (>1) abnormal values during oral glucose tolerance test (OGTT) in univariate analysis (p?相似文献   

Effects of maternal micronutrient supplementation on fetal loss and infant mortality: a cluster-randomized trial in Nepal

BACKGROUND: We previously reported that maternal micronutrient supplementation in rural Nepal decreased low birth weight by approximately 15%. OBJECTIVE: We examined the effect of daily maternal micronutrient supplementation on fetal loss and infant mortality. DESIGN: The study was a double-blind, cluster-randomized, controlled trial among 4926 pregnant women and their 4130 infants in rural Nepal. In addition to vitamin A (1000 microg retinol equivalents), the intervention groups received either folic acid (FA; 400 microg), FA + iron (60 mg), FA + iron + zinc (30 mg), or multiple micronutrients (MNs; the foregoing plus 10 microg vitamin D, 10 mg vitamin E, 1.6 mg thiamine, 1.8 mg riboflavin, 2.2 mg vitamin B-6, 2.6 microg vitamin B-12, 100 mg vitamin C, 64 microg vitamin K, 20 mg niacin, 2 mg Cu, and 100 mg Mg). The control group received vitamin A only. RESULTS: None of the supplements reduced fetal loss. Compared with control infants, infants whose mothers received FA alone or with iron or iron + zinc had a consistent pattern of 15-20% lower 3-mo mortality; this pattern was not observed with MNs. The effect on mortality was restricted to preterm infants, among whom the relative risks (RRs) were 0.36 (95% CI: 0.18, 0.75) for FA, 0.53 (0.30, 0.92) for FA + iron, 0.77 (0.45, 1.32) for FA + iron + zinc, and 0.70 (0.41, 1.17) for MNs. Among term infants, the RR for mortality was close to 1 for all supplements except MNs (RR: 1.74; 95% CI: 1.00, 3.04). CONCLUSIONS: Maternal micronutrient supplementation failed to reduce overall fetal loss or early infant mortality. Among preterm infants, FA alone or with iron reduced mortality in the first 3 mo of life. MNs may increase mortality risk among term infants, but this effect needs further evaluation.     

Eating Down in Pregnancy: Exploring Food-Related Beliefs and Practices of Pregnancy in Rural Nepal

Adequate nutrition during pregnancy, vital for the health of the mother and the newborn, may be influenced by pregnancy-related food beliefs. This study explores food-related beliefs and practices specifically related to reducing food intake in pregnancy in a rural community in Nepal by combining ethnographic and quantitative data collected from pregnant Nepali women.

A large proportion (60%) of women reported reducing rice intake during pregnancy but the reduction was related to food aversions and being unwell (66%), rather than the desire to have smaller babies or other cultural beliefs (18%). Only 10-20% reported reducing intakes of other nutrient-rich foods during pregnancy. Such foods were generally consumed in inadequate amounts due to seasonal variation or because of their high cost. In a multivariate analysis, maternal characteristics that were associated with decreasing food intake during pregnancy included literacy, poor appetite, socio-economic status, and presence of night blindness, caused by vitamin A deficiency.

We conclude that eating down to prevent difficult deliveries may not be very common in rural Nepal but women may reduce food intake for reasons of aversion to food, lack of appetite, or feeling unwell. A decline in the consumption of foods rich in protein and micronutrients was not evident; such foods appear to be chronically low in the diets of poor women in this setting.     

Risk factors for umbilical cord infection among newborns of southern Nepal

Although umbilical cord infection contributes to neonatal mortality and morbidity and risk can be reduced with topical chlorhexidine, behavioral or other factors associated with cord infection in low-resource settings have not been examined. Data on potential risk factors for omphalitis were collected during a community-based, umbilical cord care trial in Nepal during 2002-2005. Newborns were evaluated in the home for signs of umbilical cord infection (pus, redness, and swelling). Omphalitis was defined as either pus discharge with erythema of the abdominal skin or severe redness (>2 cm extension from the cord stump) with or without pus. Multivariable regression modeling was used to examine associations between omphalitis and maternal, newborn, and household variables. Omphalitis was identified in 954 of 17,198 newborns (5.5%). Infection risk was 29% and 62% higher in infants receiving topical cord applications of mustard oil and other potentially unclean substances, respectively. Skin-to-skin contact (relative risk (RR) = 0.64, 95% confidence interval (CI): 0.43, 0.95) and hand washing by birth attendants (RR = 0.73, 95% CI: 0.64, 0.84) and caretakers (RR = 0.76, 95% CI: 0.60, 0.95) were associated with fewer infections. In this community, unhygienic newborn-care practices lead to continued high risk for omphalitis. In addition to topical antiseptics, simple, low-cost interventions such as hand washing, skin-to-skin contact, and avoiding unclean cord applications should be promoted by community-based health workers.     

Economic analyses of venous thromboembolism prevention strategies in hospitalized patients: a systematic review

ABSTRACT: INTRODUCTION: Despite evidence-based guidelines for venous thromboembolism prevention, substantial variability is found in practice. Many economic evaluations of new drugs for thromboembolism prevention do not occur prospectively with efficacy studies and are sponsored by the manufacturers, raising the possibility of bias. We performed a systematic review of economic analyses of venous thromboembolism prevention in hospitalized patients to inform clinicians and policy makers about cost-effectiveness and the potential influence of sponsorship. METHODS: We searched MEDLINE, EMBASE, Cochrane Databases, ACP Journal Club, and Database of Abstracts of Reviews of Effects, from 1946 to September 2011. We extracted data on study characteristics, quality, costs, and efficacy. RESULTS: From 5,180 identified studies, 39 met eligibility and quality criteria. Each addressed pharmacologic prevention: low-molecular-weight heparins versus placebo (five), unfractionated heparin (12), warfarin (eight), one or another agents (five); fondaparinux versus enoxaparin (11); and rivaroxaban and dabigatran versus enoxaparin (two). Low-molecular-weight heparins were most economically attractive among most medical and surgical patients, whereas fondaparinux was favored for orthopedic patients. Fondaparinux was associated with increased bleeding events. Newer agents rivaroxaban and dabigatran may offer additional value. Of all economic evaluations, 64% were supported by manufacturers of a "new" agent. The new agent had a favorable outcome in 38 (97.4%) of 39 evaluations [95% confidence interval [CI] (86.5 to 99.9)]. Among studies supported by a pharmaceutical company, the sponsored medication was economically attractive in 24 (96.0%) of 25 [95% CI, 80.0 to 99.9)]. We could not detect a consistent bias in outcome based on sponsorship; however, only a minority of studies were unsponsored. CONCLUSION: Low-molecular-weight heparins and fondaparinux are the most economically attractive drugs for venous thromboembolism prevention in hospitalized patients. Approximately two thirds of evaluations were supported by the manufacturer of the new agent; such drugs were likely to be reported as economically favorable.     

Rapid emergence of third-generation cephalosporin resistance in Shigella sp. isolated in Andaman and Nicobar Islands, India

Shigellosis is a major cause of diarrheal diseases among children in Andaman & Nicobar Islands, India, which have a population of 350,000 people, including settlers from mainland India and 6 indigenous tribes. From the last one-and-half decade, we have been monitoring the species distribution and emergence of antibiotic resistance among the isolates of Shigella. The circulating Shigella strains have been found rapidly acquiring resistance to a wide spectrum of antibiotics. The recent data indicate that a significant proportion of Shigella isolates have been resistant to newer generation of cephalosporins, which are used as an alternative of quinolones to treat the patients with shigellosis. In this communication, we report the antibiotic-resistant pattern of Shigella isolates that are recently isolated from these islands. From January 2008 to December 2009, 311 stool samples were processed and 44 (14%) Shigella isolates were recovered. Out of these 44 Shigella isolates, 6 (14%) were found to be resistant to all the three third-generation cephalosporins tested. The minimum inhibitory concentrations of the resistant isolates were all above the breakpoint for reduced susceptibility as per the Clinical and Laboratory Standards Institute guidelines. All of the cephalosporin-resistant Shigella strains were confirmed to produce extended-spectrum β-lactamases. By analyzing trends in the resistance patterns of the various Shigella species, we found that Shigella dysenteriae (40%) is currently more resistant, followed by Shigella flexneri (14%), than the other Shigella species in these islands of India, especially to the third-generation cephalosporins. The acquisition of resistance by enteric pathogens to the increasing number of antibacterial drugs is becoming a grave concern, particularly in developing countries where shigellosis is of a common occurrence.