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1.  Meat consumption is associated with less stunting among toddlers in four diverse low-income settings 
Food and nutrition bulletin  2011;32(3):185-191.
Early growth faltering is common but is difficult to reverse after the first 2 years of life.
To describe feeding practices and growth in infants and young children in diverse low-income settings prior to undertaking a complementary feeding trial.
This cross-sectional study was conducted through the Global Network for Women’s and Children’s Health Research in Guatemala, Democratic Republic of Congo, Zambia, and Pakistan. Feeding questionnaires were administered to convenience samples of mothers of 5- to 9-month old infants and 12- to 24-month-old toddlers. After standardized training, anthropometric measurements were obtained from the toddlers. Following the 2006 World Health Organization Growth Standards, stunting was defined as length-for-age < −2SD, and wasting as weight-for-length < −2SD. Logistic regression was applied to evaluate relationships between stunting and wasting and consumption of meat (including chicken and liver and not including fish).
Data were obtained from 1,500 infants with a mean (± SD) age of 6.9 ± 1.4 months and 1,658 toddlers with a mean age of 17.2 ± 3.5 months. The majority of the subjects in both age groups were breastfed. Less than 25% of the infants received meat regularly, whereas 62% of toddlers consumed these foods regularly, although the rates varied widely among sites. Stunting rate ranged from 44% to 66% among sites; wasting prevalence was less than 10% at all sites. After controlling for covariates, consumption of meat was associated with a reduced likelihood of stunting (OR = 0.64; 95% CI, 0.46 to 0.90).
The strikingly high stunting rates in these toddlers and the protective effect of meat consumption against stunting emphasize the need for interventions to improve complementary feeding practices, beginning in infancy.
PMCID: PMC3918945  PMID: 22073791
Complementary feeding; infant growth; infant nutrition; stunting
2.  Bioavailability of zinc oxide added to corn tortilla is similar to that of zinc sulfate and is not affected by simultaneous addition of iron 
Food and nutrition bulletin  2012;33(4):261-266.
Corn tortilla is the staple food of Mexico and its fortification with zinc, iron, and other micronutrients is intended to reduce micronutrient deficiencies. However, no studies have been performed to determine the relative amount of zinc absorbed from the fortified product and whether zinc absorption is affected by the simultaneous addition of iron.
To compare zinc absorption from corn tortilla fortified with zinc oxide versus zinc sulfate and to determine the effect of simultaneous addition of two doses of iron on zinc bioavailability.
A randomized, double-blind, crossover design was carried out in two phases. In the first phase, 10 adult women received corn tortillas with either 20 mg/kg of zinc oxide added, 20 mg/kg of zinc sulfate added, or no zinc added. In the second phase, 10 adult women received corn tortilla with 20 mg/kg of zinc oxide added and either with no iron added or with iron added at one of two different levels. Zinc absorption was measured by the stable isotope method.
The mean (± SEM) fractional zinc absorption from unfortified tortilla, tortilla fortified with zinc oxide, and tortilla fortified with zinc sulfate did not differ among treatments: 0.35 ± 0.07, 0.36 ± 0.05, and 0.37 ± 0.07, respectively. The three treatment groups with 0, 30, and 60 mg/kg of added iron had similar fractional zinc absorption (0.32 ± 0.04, 0.33 ± 0.02, and 0.32 ± 0.05, respectively) and similar amounts of zinc absorbed (4.8 ± 0.7, 4.5 ± 0.3, and 4.8 ± 0.7 mg/day, respectively).
Since zinc oxide is more stable and less expensive and was absorbed equally as well as zinc sulfate, we suggest its use for corn tortilla fortification. Simultaneous addition of zinc and iron to corn tortilla does not modify zinc bioavailability at iron doses of 30 and 60 mg/kg of corn flour.
PMCID: PMC3909684  PMID: 23424892
Corn tortillas; food fortification; stable isotopes; zinc absorption; zinc oxide
Nutrition reviews  2011;69(0 1):10.1111/j.1753-4887.2011.00434.x.
The rationale is considered for promoting the availability of local, affordable, non-fortified food sources of bioavailable iron in developing countries. Intakes of iron from the regular consumption of meat from the age of six months are evaluated with respect to physiological requirements. The paper includes a description of two major randomized controlled trials of meat as a first and regular complementary food that are currently in progress. These trials involve poor communities in Guatemala, Pakistan, Zambia, Democratic Republic of the Congo and China.
PMCID: PMC3875190  PMID: 22043884
iron; meat; complementary feeding
4.  Implementing a Pediatric Obesity Care Guideline in a Freestanding Children’s Hospital to Improve Child Safety and Hospital Preparedness1 
Journal of pediatric nursing  2012;27(6):707-714.
Medical and surgical care of children with severe obesity is complicated and requires recognition of the problem, appropriate equipment, and safe management. There is little literature describing patient, provider, and institutional needs for the severely obese pediatric patient. Nonetheless, the limited data suggest 3 broad categories of needs unique to this population: (a) airway management, (b) drug dosing and pharmacology, and (c) equipment and infrastructure. We describe an opportunity at the Children’s Hospital Colorado to better prepare and optimize care for this patient population by creation of a Pediatric Obesity Care Guideline that focused on key areas of quality and safety.
PMCID: PMC3607510  PMID: 22178030
Pediatric obesity; Pediatric safety; Care guideline; Severe obesity
5.  Mathematical model of zinc absorption: effects of dietary calcium, protein and iron on zinc absorption 
The British journal of nutrition  2012;109(4):695-700.
A previously described mathematical model of Zn absorption as a function of total daily dietary Zn and phytate was fitted to data from studies in which dietary Ca, Fe and protein were also measured. An analysis of regression residuals indicated statistically significant positive relationships between the residuals and Ca, Fe and protein, suggesting that the presence of any of these dietary components enhances Zn absorption. Based on the hypotheses that (1) Ca and Fe both promote Zn absorption by binding with phytate and thereby making it unavailable for binding Zn and (2) protein enhances the availability of Zn for transporter binding, the model was modified to incorporate these effects. The new model of Zn absorption as a function of dietary Zn, phytate, Ca, Fe and protein was then fitted to the data. The proportion of variation in absorbed Zn explained by the new model was 0·88, an increase from 0·82 with the original model. A reduced version of the model without Fe produced an equally good fit to the data and an improved value for the model selection criterion, demonstrating that when dietary Ca and protein are controlled for, there is no evidence that dietary Fe influences Zn absorption. Regression residuals and testing with additional data supported the validity of the new model. It was concluded that dietary Ca and protein modestly enhanced Zn absorption and Fe had no statistically discernable effect. Furthermore, the model provides a meaningful foundation for efforts to model nutrient interactions in mineral absorption.
PMCID: PMC3683099  PMID: 22617116
Mathematical models; Zinc absorption; Calcium; Iron; Protein
6.  Efficacy and Safety of a High Protein, Low Carbohydrate Diet for Weight Loss in Severely Obese Adolescents 
The Journal of pediatrics  2010;157(2):252-258.
To evaluate the efficacy and safety of a carbohydrate restricted versus a low fat diet on weight loss, metabolic markers, body composition, and cardiac function tests in severely obese adolescents.
Study design
Subjects were randomized to one of two diets: a high protein, low carbohydrate (20 g/day) diet (HPLC) or low fat (30% of calories) (LF) regimen for 13 weeks; close monitoring was maintained to evaluate safety. After the intervention, no clinical contact was made until follow-up measurements were obtained at 24 and 36 weeks from baseline. The primary outcome was change in BMI-Z-score at 13, 24, and 36 weeks.
Forty-six subjects (24 HPLC, 22 in LF) initiated and 33 subjects completed the intervention; follow-up data were available on approximately half of the subjects. Significant reduction in BMI-Z-score (BMI-Z) was achieved in both groups during intervention, and was significantly greater for the HPLC group (p=0.03). Both groups maintained significant BMI-Z reduction at follow-up; changes were not significantly different between groups. Loss of lean body mass was not spared in the HPLC group. No serious adverse effects were observed related to metabolic profiles, cardiac function, or subjective complaints.
The HPLC diet is a safe and effective option for medically supervised weight loss in severely obese adolescents.
PMCID: PMC2892194  PMID: 20304413
Obesity; obesity treatment; body composition; hyperlipidemia; insulin resistance; satiety
7.  Biological Determinants Linking Infant Weight Gain and Child Obesity: Current Knowledge and Future Directions12 
Advances in Nutrition  2012;3(5):675-686.
Childhood obesity rates have reached epidemic proportions. Excessive weight gain in infancy is associated with persistence of elevated weight status and later obesity. In this review, we make the case that weight gain in the first 6 mo is especially predictive of later obesity risk due to the metabolic programming that can occur early postpartum. The current state of knowledge regarding the biological determinants of excess infant weight gain is reviewed, with particular focus on infant feeding choice. Potential mechanisms by which different feeding approaches may program the metabolic profile of the infant, causing the link between early weight gain and later obesity are proposed. These mechanisms are likely highly complex and involve synergistic interactions between endocrine effects and factors that alter the inflammatory and oxidative stress status of the infant. Gaps in current knowledge are highlighted. These include a lack of data describing 1) what type of infant body fat distribution may impart risk and 2) how maternal metabolic dysfunction (obesity and/or diabetes) may affect milk composition and exert downstream effects on infant metabolism. Improved understanding and management of these early postnatal determinants of childhood obesity may have great impact on reducing its prevalence.
PMCID: PMC3648749  PMID: 22983846
8.  Biofortification of Pearl Millet with Iron and Zinc in a Randomized Controlled Trial Increases Absorption of These Minerals above Physiologic Requirements in Young Children123 
The Journal of Nutrition  2013;143(9):1489-1493.
Millet is unusually drought resistant and consequently there is a progressive increase in the use of these grains as a human food staple, especially in large areas of India and sub-Saharan Africa. The purpose of this study was to determine the absorption of iron and zinc from pearl millet biofortified with 2 micronutrients that are typically deficient in nonfortified, plant-based diets globally. The study was undertaken in 40 children aged 2 y in Karnataka, India (n = 21 test/19 controls). Three test meals providing ∼84 ± 17 g dry pearl millet flour were fed on a single day for zinc and 2 d for iron between 0900 and 1600 h. The quantities of zinc and iron absorbed were measured with established stable isotope extrinsic labeling techniques and analyses of duplicate diets. The mean (± SD) quantities of iron absorbed from test and control groups were 0.67 ± 0.48 and 0.23 ± 0.15 mg/d, respectively (P < 0.001). The quantities of zinc absorbed were 0.95 ± 0.47 and 0.67 ± 0.24 mg/d, respectively (P = 0.03). These data did not include absorption of the modest quantities of iron and zinc contained in snacks eaten before and after the 3 test meals. In conclusion, quantities of both iron and zinc absorbed when iron and zinc biofortified pearl millet is fed to children aged 2 y as the major food staple is more than adequate to meet the physiological requirements for these micronutrients.
PMCID: PMC3743277  PMID: 23843474
9.  Overweight and Obesity Are Increased in Childhood-Onset Cerebrovascular Disease 
Journal of child neurology  2012;28(4):517-519.
The objective of this work was to determine whether overweight/obesity is a risk factor for cerebrovascular disease in children. The study included 53 children with non–neonatal-onset cerebral sinovenous thrombosis or arterial ischemic stroke. The prevalence of overweight/obesity was compared between this cohort and healthy children from the National Health and Nutrition Examination Survey. In addition, cerebral sinovenous thrombosis patients were compared to a group of matched hospitalized controls. The prevalence of overweight/obesity was significantly higher in the cerebral sinovenous thrombosis cohort (55%), but not the arterial ischemic stroke cohort (36%), relative to national controls (32%; P = .04 and P = .81, respectively). Similarly, the prevalence of overweight/obesity was significantly higher in the cerebral sinovenous thrombosis cohort than in Colorado controls (25%; P = .02). In conclusion, the prevalence of overweight/obese was significantly increased in cerebral sinovenous thrombosis patients as compared to both national and local controls. Results should be evaluated in a larger multi-institutional cohort.
PMCID: PMC3697108  PMID: 22647484
obesity; arterial ischemic; stroke; cerebral sinovenous thrombosis; overweight
10.  Infant Stunting Is Associated With Short Maternal Stature 
The objectives were to determine the range of maternal height associated with growth velocity of older infants and the magnitude of this association in an indigent population. Maternal height and infant length-for-age z scores (LAZ) were positively correlated at both 6 (n=412, r=0.324) and 12 (n=388, r=0.335) months (P<0.0001) and for maternal heights from 131 to 164 cm. Maternal height is independently associated with infant LAZ and stunting (LAZ <−2) at both 6 and 12 months (P<0.001) and with linear growth velocity from 6 to 12 months (P=0.0023).
PMCID: PMC3607506  PMID: 21866055
infant growth; maternal height; stunting
11.  Newborn Care Training and Perinatal Mortality in Communities in Developing Countries 
The New England journal of medicine  2010;362(7):614-623.
Ninety-eight percent of the 3.7 million neonatal deaths and 3.3 million stillbirths per year occur in developing countries, and evaluation of community-based interventions is needed.
Using a train-the-trainer model, local instructors trained birth attendants from rural communities in six countries (Argentina, Democratic Republic of Congo, Guatemala, India, Pakistan, and Zambia) in the World Health Organization Essential Newborn Care course (routine neonatal care, resuscitation, thermoregulation, breastfeeding, kangaroo care, care of the small baby, and common illnesses), and in a modified version of the American Academy of Pediatrics Neonatal Resuscitation Program (in depth basic resuscitation), except in Argentina.
The Essential Newborn Care intervention was assessed with a before and after design (N=57, 643). The Neonatal Resuscitation Program intervention was assessed as a cluster randomized controlled trial (N=62,366). The primary outcome was 7-day neonatal mortality.
The 7-day follow-up rate was 99.2%. Following Essential Newborn Care training, there was no significant reduction from baseline in all-cause 7-day neonatal (RR 0.99; CI 0.81, 1.22) or perinatal mortality; there was a significant reduction in the stillbirth rate (RR 0.69; CI 0.54, 0.88; p<0.01). Seven-day neonatal mortality, stillbirth, and perinatal mortality were not reduced in clusters randomized to Neonatal Resuscitation Program training as compared with control clusters.
Seven-day neonatal mortality did not decrease following the introduction of Essential Newborn Care training of community-based birth attendants, although the rate of stillbirths was reduced following this intervention. Subsequent training in the Neonatal Resuscitation Program did not significantly reduce the mortality rates. ( number, NCT00136708).
PMCID: PMC3565382  PMID: 20164485
neonatal mortality; perinatal mortality; developing countries; health systems; effectiveness
12.  Need for Early Interventions in the Prevention of Pediatric Overweight: A Review and Upcoming Directions 
Journal of Obesity  2012;2012:123023.
Childhood obesity is currently one of the most prevailing and challenging public health issues among industrialized countries and of international priority. The global prevalence of obesity poses such a serious concern that the World Health Organization (WHO) has described it as a “global epidemic.” Recent literature suggests that the genesis of the problem occurs in the first years of life as feeding patterns, dietary habits, and parental feeding practices are established. Obesity prevention evidence points to specific dietary factors, such as the promotion of breastfeeding and appropriate introduction of nutritious complementary foods, but also calls for attention to parental feeding practices, awareness of appropriate responses to infant hunger and satiety cues, physical activity/inactivity behaviors, infant sleep duration, and family meals. Interventions that begin at birth, targeting multiple factors related to healthy growth, have not been adequately studied. Due to the overwhelming importance and global significance of excess weight within pediatric populations, this narrative review was undertaken to summarize factors associated with overweight and obesity among infants and toddlers, with focus on potentially modifiable risk factors beginning at birth, and to address the need for early intervention prevention.
PMCID: PMC3362946  PMID: 22675610
13.  Complementary feeding: a Global Network cluster randomized controlled trial 
BMC Pediatrics  2011;11:4.
Inadequate and inappropriate complementary feeding are major factors contributing to excess morbidity and mortality in young children in low resource settings. Animal source foods in particular are cited as essential to achieve micronutrient requirements. The efficacy of the recommendation for regular meat consumption, however, has not been systematically evaluated.
A cluster randomized efficacy trial was designed to test the hypothesis that 12 months of daily intake of beef added as a complementary food would result in greater linear growth velocity than a micronutrient fortified equi-caloric rice-soy cereal supplement. The study is being conducted in 4 sites of the Global Network for Women's and Children's Health Research located in Guatemala, Pakistan, Democratic Republic of the Congo (DRC) and Zambia in communities with toddler stunting rates of at least 20%. Five clusters per country were randomized to each of the food arms, with 30 infants in each cluster. The daily meat or cereal supplement was delivered to the home by community coordinators, starting when the infants were 6 months of age and continuing through 18 months. All participating mothers received nutrition education messages to enhance complementary feeding practices delivered by study coordinators and through posters at the local health center. Outcome measures, obtained at 6, 9, 12, and 18 months by a separate assessment team, included anthropometry; dietary variety and diversity scores; biomarkers of iron, zinc and Vitamin B12 status (18 months); neurocognitive development (12 and 18 months); and incidence of infectious morbidity throughout the trial. The trial was supervised by a trial steering committee, and an independent data monitoring committee provided oversight for the safety and conduct of the trial.
Findings from this trial will test the efficacy of daily intake of meat commencing at age 6 months and, if beneficial, will provide a strong rationale for global efforts to enhance local supplies of meat as a complementary food for young children.
Trial registration
PMCID: PMC3032692  PMID: 21232139
14.  Early growth faltering in healthy term infants predicts longitudinal growth 
Early human development  2009;85(9):583-588.
Early growth monitoring may not identify infants at-risk for later growth faltering because it is difficult for the provider to recognize how large of a negative shift might be problematic.
The aim of this study was to determine whether a slowing in early weight-for-age could be used to identify children at increased risk of later growth faltering.
Longitudinal data for infants aged birth to two years were analyzed for 1978 healthy, term infants born between 1999-2001. Logistic regression techniques were used to determine whether a negative change in weight-for-age, across well-child visit intervals, can identify infants at risk for growth faltering.
The period prevalence of underweight was 24%. The odds ratio (OR) for infants with a negative shift in z-scores ≥ -0.85 between four and six months was 2.4 (95% CI 1.5, 3.9) compared to those without this shift, holding birth weight constant. Sensitivity analyses revealed the model was significant when either the 2000 CDC growth charts (p<.0001) or the 2006 WHO growth charts (p<.0001) were used as the reference, although the prevalence of underweight was lower (14.7%) when the 2006 WHO growth charts were the reference.
The findings support the hypothesis that a downward shift in weight-for-age of this magnitude during early infancy when well-child visits are most frequent can be used to identify children at-risk of later poor growth.
PMCID: PMC2741018  PMID: 19608359
Early Intervention; Failure-to-thrive; Growth; Infant; Weight; Sensitivity
15.  Zinc, Gravida, Infection, and Iron, but Not Vitamin B-12 or Folate Status, Predict Hemoglobin during Pregnancy in Southern Ethiopia1,2 
The Journal of nutrition  2008;138(3):581-586.
The etiology of anemia during pregnancy in rural Southern Ethiopia is uncertain. Intakes of animal-source foods are low and infections and bacterial overgrowth probably coexist. We therefore measured the dietary intakes of a convenience sample of Sidama women in late pregnancy who consumed either maize (n = 68) or fermented enset (Enset ventricosum) (n = 31) as their major energy source. Blood samples were analyzed for a complete blood count, vitamin B-12 and folate status, plasma ferritin, retinol, zinc, albumin, and C-reactive protein (CRP). The role of infection and gravida was also examined. Dietary intakes were calculated from 1-d weighed records. No cellular animal products were consumed. Of the women, 29% had anemia, 13% had iron deficiency anemia, 33% had depleted iron stores, and 74 and 27% had low plasma zinc and retinol, respectively. Only 2% had low plasma folate (<6.8 nmol/L) and 23% had low plasma vitamin B-12 (<150 pmol/L), even though 62% had elevated plasma methylmalonic acid (MMA) (> 271 nmol/L). None had elevated plasma cystathionine or total homocysteine (tHcys). Women with enset-based diets had higher (P = 0.052) plasma vitamin B-12 concentration and lower (P < 0.05) cell volume, plasma cystathionine, and retinol than women consuming maize-based diets, but mean hemoglobin, plasma ferritin, MMA, tHcys, and folate did not differ. Plasma zinc, followed by CRP (≤5 mg/L), gravida (≤4), and plasma ferritin (≥12 μmg/L) status were major positive predictors of hemoglobin. Despite some early functional vitamin B-12 deficiency, there was no macrocytic anemia. Consumption of fermented enset may have increased vitamin B-12 levels in diet and plasma.
PMCID: PMC2440679  PMID: 18287370
16.  Calcium Absorption from Tortilla Meals Prepared from Low-phytate Maize. 
Calcium fortification of maize has been achieved for millenia in Central America by the process of nixtamalization. Bioavailability of calcium is, however, compromised by phytate, present in large quantities in maize kernels and only modestly reduced by nixtamalization.
The objective of this study was to compare calcium absorption from tortilla meals prepared from low-phytate maize with that from maize with typical phytate content.
Five healthy adult women were fed two test meals of approximately 140g tortillas in lieu of breakfast at one month intervals. On one occasion the tortillas were prepared from maize with approximately 60% phytate reduction (lpa1-1) and on the other occasion from the matching isohybrid wild-type maize. 44Ca (0.3mg/kg body weight) was administered in water as an extrinsic label commencing midway through the test meal and 42Ca (0.06 mg/kg body weight) was administered intravenously immediately after the test meal. Isotope ratios of 42Ca/43Ca and 44Ca/43Ca were measured by inductively-coupled plasma mass spectrometry in urine collected as an eight-hr pool from 16-24 hrs after administration of the intravenous tracer and prepared by the oxalate precipitation method. Fractional absorption of calcium was determined by a dual isotope ratio technique.
Mean fractional absorption from tortillas prepared from the low-phytate maize was 0.50 ± 0.03 compared with a mean of 0.35 ± 0.07 from the control maize (p = 0.01).
The increase in quantity of calcium absorbed could be of practical importance for calcium nutriture when intake of dairy products is limited.
PMCID: PMC1592687  PMID: 16002804
maize; phytate; low-phytate maize alleles; tortillas; calcium absorption
17.  A Mathematical Model of Zinc Absorption in Humans As a Function of Dietary Zinc and Phytate1,2 
The Journal of nutrition  2007;137(1):135-141.
The quantities of zinc and phytate in the diet are the primary factors determining zinc absorption. A mathematical model of zinc absorption as a function of dietary zinc and phytate can be used to predict dietary zinc requirements and, potentially, enhance our understanding of zinc absorption. Our goal was to develop a model of practical and informative value based on fundamental knowledge of the zinc absorption process and then fit the model to selected published data to assess its validity and estimate parameter values. A model of moderate mathematical complexity relating total zinc absorption to total dietary zinc and total dietary phytate was derived and fit to 21 mean data from whole day absorption studies using nonlinear regression analysis. Model validity, goodness of fit, satisfaction of regression assumptions, and quality of the parameter estimates were evaluated using standard statistical criteria. The fit had an R2 of 0.82. The residuals were found to exhibit a normal distribution, constant variance, and independence. The parameters of the model, AMAX, KR, and KP, were estimated to have values of 0.13, 0.10, and 1.2 mmol/d, respectively. Several of these estimates had wide CI attributable in part to the small number and the scatter of the data. The model was judged to be valid and of immediate value for studying and predicting absorption. A version of the model incorporating a passive absorption mechanism was not supported by the available data.
PMCID: PMC1995555  PMID: 17182814
18.  Zinc absorption during late pregnancy in rural southern Ethiopia2 
Little is yet known about zinc absorption in late pregnancy, and no information on absorption from the total diet is available.
The objective was to measure the fractional absorption of zinc (FAZ) and to estimate the total quantity of absorbed zinc (TAZ) each day during the third trimester of pregnancy in poor rural southern Ethiopian women.
The participants (n =17) were a convenience sample from a larger study population. The third stage of pregnancy was estimated from fundal height by the Bushulo Health Center prenatal outreach program. FAZ was determined with a dual-isotope tracer ratio technique that uses measurements of urine enrichment with zinc stable isotopes administered intravenously and orally, as an extrinsic label, with all meals in 1 d. Total dietary zinc (TDZ) was calculated from weighed diet records and Ethiopian food-composition tables supported by zinc and phytate analyses of major food items for individual meals. Plasma zinc and exchangeable zinc pool size were also estimated.
Mean (±SD) FAZ was 0.35 ± 0.11, TDZ was 6.0 ± 3.2 mg/d, TAZ was 2.1 ± 1.0 mg/d, phytate intake was 1033 ± 843 mg/d, plasma zinc was 44.1 ± 6.0 μg/dL, and the exchangeable zinc pool size was 142 ± 39 mg. The molar ratio of phytate to zinc was 17:1.
Women from a poor rural population who were dependent on a moderately high-phytate diet had low TDZ and low plasma zinc concentrations in the third trimester of pregnancy. TAZ was modestly higher than that predicted but did not meet physiologic requirements.
PMCID: PMC1987331  PMID: 17093163
Zinc; absorption; phytate; pregnancy; Ethiopia
19.  The Maternal and Newborn Health Registry Study of the Global Network for Women’s and Children’s Health Research 
To implement a vital statistics registry system to register pregnant women and document birth outcomes in the Global Network for Women’s and Children’s Health Research sites in Asia, Africa, and Latin America.
The Global Network sites began a prospective population-based pregnancy registry to identify all pregnant women and record pregnancy outcomes up to 42 days post-delivery in more than 100 defined low-resource geographic areas (clusters). Pregnant women were registered during pregnancy, with 42-day maternal and neonatal follow-up recorded—including care received during the pregnancy and postpartum periods. Recorded outcomes included stillbirth, neonatal mortality, and maternal mortality rates.
In 2010, 72 848 pregnant women were enrolled and 6-week follow-up was obtained for 97.8%. Across sites, 40.7%, 24.8%, and 34.5% of births occurred in a hospital, health center, and home setting, respectively. The mean neonatal mortality rate was 23 per 1000 live births, ranging from 8.2 to 48.5 per 1000 live births. The mean stillbirth rate ranged from 13.7 to 54.4 per 1000 births.
The registry is an ongoing study to assess the impact of interventions and trends regarding pregnancy outcomes and measures of care to inform public health.
PMCID: PMC3417109  PMID: 22738806
Maternal mortality; Neonatal mortality; Perinatal mortality; Pregnancy; Registry; Stillbirth
20.  Antenatal corticosteroids trial in preterm births to increase neonatal survival in developing countries: study protocol 
Reproductive Health  2012;9:22.
Preterm birth is a major cause of neonatal mortality, responsible for 28% of neonatal deaths overall. The administration of antenatal corticosteroids to women at high risk of preterm birth is a powerful perinatal intervention to reduce neonatal mortality in resource rich environments. The effect of antenatal steroids to reduce mortality and morbidity among preterm infants in hospital settings in developed countries with high utilization is well established, yet they are not routinely used in developing countries. The impact of increasing antenatal steroid use in hospital or community settings with low utilization rates and high infant mortality among premature infants due to lack of specialized services has not been well researched. There is currently no clear evidence about the safety of antenatal corticosteroid use for community-level births.
We hypothesize that a multi country, two-arm, parallel cluster randomized controlled trial to evaluate whether a multifaceted intervention to increase the use of antenatal corticosteroids, including components to improve the identification of pregnancies at high risk of preterm birth and providing and facilitating the appropriate use of steroids, will reduce neonatal mortality at 28 days of life in preterm newborns, compared with the standard delivery of care in selected populations of six countries. 102 clusters in Argentina, Guatemala, Kenya, India, Pakistan, and Zambia will be randomized, and around 60,000 women and newborns will be enrolled. Kits containing vials of dexamethasone, syringes, gloves, and instructions for administration will be distributed. Improving the identification of women at high risk of preterm birth will be done by (1) diffusing recommendations for antenatal corticosteroids use to health providers, (2) training health providers on identification of women at high risk of preterm birth, (3) providing reminders to health providers on the use of the kits, and (4) using a color-coded tape to measure uterine height to estimate gestational age in women with unknown gestational age. In both intervention and control clusters, health providers will be trained in essential newborn care for low birth weight babies. The primary outcome is neonatal mortality at 28 days of life in preterm infants.
Trial registration Identifier: NCT01084096
PMCID: PMC3477119  PMID: 22992312
Neonatal mortality; Antenatal corticosteroids; Implementation research; Preterm birth
21.  Fecal calprotectin levels are higher in rural than in urban Chinese infants and negatively associated with growth 
BMC Pediatrics  2012;12:129.
Fecal calprotectin (FC) is an established simple biomarker of gut inflammation. To examine a possible relationship between linear growth and gut inflammation, we compared fecal calprotectin levels in 6 month old infants from poor rural vs affluent urban families.
The project was a cross-sectional comparison of FC from rural and urban populations in China. The relationship between length-for-age Z-score (LAZ) and FC concentrations were also compared. Single fecal samples were assayed for FC using EK-CAL ELISA kits.
The age of subjects for both locations was 6.1 ± 0.2 mo; all were apparently healthy. The mean ± SD of the LAZ for the rural and urban infants were −0.6 ± 0.9 and 0.4 ± 0.9, respectively. FC had a non-normal distribution. The median FC of 420.9 and 140.1 μg/g for rural and urban infants, respectively, were significantly different (P < 0.0001). For the rural group, linear regression analysis showed that an increase in FC of 100 μg/g was associated with a decrease of 0.06 in LAZ.
FC levels were significantly elevated in the rural infants and high concentrations accounted for approximately one-third of the low LAZ scores of these infants.
PMCID: PMC3504525  PMID: 22917269
Fecal calprotectin; Infants; Children; Gut inflammation; Growth
22.  Lactation and Neonatal Nutrition: Defining and Refining the Critical Questions 
This paper resulted from a conference entitled “Lactation and Milk: Defining and refining the critical questions” held at the University of Colorado School of Medicine from January 18–20, 2012. The mission of the conference was to identify unresolved questions and set future goals for research into human milk composition, mammary development and lactation. We first outline the unanswered questions regarding the composition of human milk (Section I) and the mechanisms by which milk components affect neonatal development, growth and health and recommend models for future research. Emerging questions about how milk components affect cognitive development and behavioral phenotype of the offspring are presented in Section II. In Section III we outline the important unanswered questions about regulation of mammary gland development, the heritability of defects, the effects of maternal nutrition, disease, metabolic status, and therapeutic drugs upon the subsequent lactation. Questions surrounding breastfeeding practice are also highlighted. In Section IV we describe the specific nutritional challenges faced by three different populations, namely preterm infants, infants born to obese mothers who may or may not have gestational diabetes, and infants born to undernourished mothers. The recognition that multidisciplinary training is critical to advancing the field led us to formulate specific training recommendations in Section V. Our recommendations for research emphasis are summarized in Section VI. In sum, we present a roadmap for multidisciplinary research into all aspects of human lactation, milk and its role in infant nutrition for the next decade and beyond.
PMCID: PMC3428522  PMID: 22752723
Lactation; Infant nutrition; Human milk; Breastfeeding; Mammary gland development; Human nutrition; Preterm birth; Obesity; Undernutrition; Lactational programming; Milk

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