Human milk is the subject of many studies, but procedures for representative sample collection have not been established. Our improved methods for milk micronutrient analysis now enable systematic ...study of factors that affect its concentrations.
We evaluated the effects of sample collection protocols, variations in circadian rhythms, subject variability, and acute maternal micronutrient supplementation on milk vitamin concentrations.
In the BMQ (Breast-Milk-Quality) study, we recruited 18 healthy women (aged 18-26 y) in Dhaka, Bangladesh, at 2-4 mo of lactation for a 3-d supplementation study. On day 1, no supplements were given; on days 2 and 3, participants consumed ∼1 time and 2 times, respectively, the US-Canadian Recommended Dietary Allowances for vitamins at breakfast (0800-0859). Milk was collected during every feeding from the same breast over 24 h. Milk expressed in the first 2 min (aliquot I) was collected separately from the remainder (aliquot II); a third aliquot (aliquot III) was saved by combining aliquots I and II. Thiamin, riboflavin, niacin, and vitamins B-6, B-12, A, and E and fat were measured in each sample.
Significant but small differences (14-18%) between aliquots were found for all vitamins except for vitamins B-6 and B-12. Circadian variance was significant except for fat-adjusted vitamins A and E, with a higher contribution to total variance with supplementation. Between-subject variability accounted for most of the total variance. Afternoon and evening samples best reflected daily vitamin concentrations for all study days. Acute supplementation effects were found for thiamin, riboflavin, and vitamins B-6 and A at 2-4 h postdosing, with 0.1-6.17% passing into milk. Supplementation was reflected in fasting, 24-h postdose samples for riboflavin and vitamin B-6. Maximum amounts of dose-responding vitamins in 1 feeding ranged from 4.7% to 21.8% (day 2) and 8.2% to 35.0% (day 3) of Adequate Intake.
In the milk of Bangladeshi mothers, differences in vitamin concentrations between aliquots within feedings and by circadian variance were significant but small. Afternoon and evening collection provided the most-representative samples. Supplementation acutely affects some breast-milk micronutrient concentrations. This trial was registered at clinicaltrials.gov as NCT02756026.
Bangladesh is one of the 20 countries with highest burden of stunting globally. A large portion (around 2.2 million) of the population dwells in the slum areas under severe vulnerable conditions. ...Children residing in the slums are disproportionately affected with higher burden of undernutrition particularly stunting. In this paper, findings of a prospective cohort study which is part of a larger multi-country study are presented.
Two hundred and sixty five children were enrolled and followed since their birth till 24 months of age. Anthropometric measurements, dietary intake and morbidity information were collected monthly. Data from 9 to 12, 15-18 and 21-24 months were collated to analyze and report findings for 12, 18 and 24 months of age. Generalized estimating equation models were constructed to determine risk factors of stunting between 12 and 24 months of age.
Approximately, 18% of children were already stunted (LAZ < -2SD) at birth and the proportion increased to 48% at 24 months of age. Exclusive breastfeeding prevalence was only 9.4% following the WHO definition at 6 months. Dietary energy intake as well as intakes of carbohydrate, fat and protein were suboptimal for majority of the children. However, in regression analysis, LAZ at birth (AOR = 0.40, 95% CI: 0.26, 0.61), household with poor asset index (AOR = 2.81, 95% CI: 1.43, 5.52; ref.: average asset index), being male children (AOR = 1.75, 95% CI: 1.04, 2.95; ref.: female) and age (AOR = 2.34, 95% CI: 1.56, 3.52 at 24 months, AOR = 2.13, 95% CI: 1.55, 2.92 at 18 months; ref.: 12 months of age) were the significant predictors of stunting among this population.
As the mechanism of stunting begins even before a child is born, strategies must be focused on life course approach and preventive measurement should be initiated during pregnancy. Alongside, government and policymakers have to develop sustainable strategies to improve various social and environmental factors those are closely interrelated with chronic undernutrition particularly concentrating on urban slum areas.
It is unclear whether maternal vitamin D supplementation during pregnancy and lactation improves fetal and infant growth in regions where vitamin D deficiency is common.
We conducted a randomized, ...double-blind, placebo-controlled trial in Bangladesh to assess the effects of weekly prenatal vitamin D supplementation (from 17 to 24 weeks of gestation until birth) and postpartum vitamin D supplementation on the primary outcome of infants' length-for-age z scores at 1 year according to World Health Organization (WHO) child growth standards. One group received neither prenatal nor postpartum vitamin D (placebo group). Three groups received prenatal supplementation only, in doses of 4200 IU (prenatal 4200 group), 16,800 IU (prenatal 16,800 group), and 28,000 IU (prenatal 28,000 group). The fifth group received prenatal supplementation as well as 26 weeks of postpartum supplementation in the amount of 28,000 IU (prenatal and postpartum 28,000 group).
Among 1164 infants assessed at 1 year of age (89.5% of 1300 pregnancies), there were no significant differences across groups in the mean (±SD) length-for-age z scores. Scores were as follows: placebo, -0.93±1.05; prenatal 4200, -1.11±1.12; prenatal 16,800, -0.97±0.97; prenatal 28,000, -1.06±1.07; and prenatal and postpartum 28,000, -0.94±1.00 (P=0.23 for a global test of differences across groups). Other anthropometric measures, birth outcomes, and morbidity did not differ significantly across groups. Vitamin D supplementation had expected effects on maternal and infant serum 25-hydroxyvitamin D and calcium concentrations, maternal urinary calcium excretion, and maternal parathyroid hormone concentrations. There were no significant differences in the frequencies of adverse events across groups, with the exception of a higher rate of possible hypercalciuria among the women receiving the highest dose.
In a population with widespread prenatal vitamin D deficiency and fetal and infant growth restriction, maternal vitamin D supplementation from midpregnancy until birth or until 6 months post partum did not improve fetal or infant growth. (Funded by the Bill and Melinda Gates Foundation; ClinicalTrials.gov number, NCT01924013 .).
Information on the association between stunting and child development is limited from low‐income settings including Bangladesh where 36% of children under‐ 5 are stunted. This study aimed to explore ...differences in early childhood development (ECD) between stunted (length‐for‐age z‐score LAZ < −2) and nonstunted (LAZ ≥ −2) children in Bangladesh. Children (n = 265) aged 6–24 months who participated in the MAL‐ED birth cohort study were evaluated by trained psychologists at 6, 15, and 24 months of age using the Bayley Scales of Infant and Toddler Development‐III; child length and weight were measured using standard procedures. ECD scores (z‐scores derived from cognitive, motor, language and socio‐emotional skills) were compared between stunted, underweight (weight‐for‐age z‐score < −2), and wasted (weight‐for‐length z‐score < −2) children, controlling for child age and sex and maternal age, education, body mass index (BMI), and depressive symptoms. Stunted children had significantly lower ECD scores than their nonstunted peers on cognitive (P = .049), motor (P < .001), language (P < .001) and social–emotional (P = .038) scales where boys had significantly lower fine motor skills compared with girls (P = .027). Mother's schooling and BMI were significant predictors of ECD. Similar to stunting, underweight children had developmental deficits in all domains (cognitive: P = .001; fine motor: P = .039, and P < .001 for both gross motor and total motor; expressive communication: P = .032; total language: P = .013; social–emotional development: P = .017). Wasted children had poor motor skills (P = .006 for the fine motor; P < .001 for both gross motor and total motor development) compared with the nonwasted peers. Early childhood stunting and underweight were associated with poor developmental outcomes in Bangladesh.
Although child and maternal malnutrition has been reduced in Bangladesh, the prevalence of underweight (weight-for-age z-score <-2) among children aged less than five years is still high (41%). ...Nearly one-third of women are undernourished with body mass index of <18.5 kg/m2. The prevalence of anaemia among young infants, adolescent girls, and pregnant women is still at unacceptable levels. Despite the successes in specific programmes, such as the Expanded Programme on Immunization and vitamin A supplementation, programmes for nutrition interventions are yet to be implemented at scale for reaching the entire population. Given the low annual rate of reduction in child undernutrition of 1.27 percentage points per year, it is unlikely that Bangladesh would be able to achieve the United Nations' Millennium Development Goal to address undernutrition. This warrants that the policy-makers and programme managers think urgently about the ways to accelerate the progress. The Government, development partners, non-government organizations, and the academia have to work in concert to improve the coverage of basic and effective nutrition interventions, including exclusive breastfeeding, appropriate complementary feeding, supplementation of micronutrients to children, adolescent girls, pregnant and lactating women, management of severe acute malnutrition and deworming, and hygiene interventions, coupled with those that address more structural causes and indirectly improve nutrition. The entire health system needs to be revitalized to overcome the constraints that exist at the levels of policy, governance, and service-delivery, and also for the creation of demand for the services at the household level. In addition, management of nutrition in the aftermath of natural disasters and stabilization of prices of foods should also be prioritized.
Community-wide lockdowns in response to COVID-19 influenced many families, but the developmental cascade for children with autism spectrum disorder (ASD) may be especially detrimental. Our objective ...was to evaluate behavioral patterns of risk and resilience for children with ASD across parent-report assessments before (from November 2019 to February 2020), during (March 2020 to May 2020), and after (June 2020 to November 2020) an extended COVID-19 lockdown. In 2020, our study Mobile-based care for children with ASD using remote experience sampling method (mCARE) was inactive data collection before COVID-19 emerged as a health crisis in Bangladesh. Here we deployed "Cohort Studies", where we had in total 300 children with ASD (150 test group and 150 control group) to collect behavioral data. Our data collection continued through an extended COVID-19 lockdown and captured parent reports of 30 different behavioral parameters (e.g., self-injurious behaviors, aggression, sleep problems, daily living skills, and communication) across 150 children with ASD (test group). Based on the children's condition, 4-6 behavioral parameters were assessed through the study. A total of 56,290 behavioral data points was collected (an average of 152.19 per week) from parent cell phones using the mCARE platform. Children and their families were exposed to an extended COVID-19 lockdown. The main outcomes used for this study were generated from parent reports child behaviors within the mCARE platform. Behaviors included of child social skills, communication use, problematic behaviors, sensory sensitivities, daily living, and play. COVID-19 lockdowns for children with autism and their families are not universally negative but supports in the areas of "Problematic Behavior" could serve to mitigate future risk.
Human milk oligosaccharides (HMOs) support the development of a healthy gut microbiome and the growth of infants. We aimed to determine the association of different HMOs with severe acute ...malnutrition (SAM) among Bangladeshi young infants. This study was nested within a single-blind, randomized, pilot clinical trial (NCT0366657). A total of 45 breastmilk samples from mothers of < 6 months old infants who had SAM (n = 26) or were non-malnourished (n = 19) and were analyzed for constituent HMOs. Of the infants with SAM, 14 (53.85%) had secretor mothers, and 11 (57.89%) of the non-malnourished infants had secretor mothers. A one-unit increase in the relative abundance of sialylated HMOs was associated with higher odds of SAM in age and sex adjusted model (aOR = 2.00, 90% CI 1.30, 3.06), in age, sex, and secretor status adjusted model (aOR = 1.96, 90% CI 1.29, 2.98), and also in age and sex adjusted model among non-secretor mothers (aOR = 2.86, 90% CI 1.07, 7.62). In adjusted models, there was no evidence of a statistically significant association between SAM and fucosylated or undecorated HMOs. Our study demonstrates that a higher relative abundance of sialylated HMOs in mothers' breastmilk may have a negative impact on young infants' nutritional status.
Elevated blood lead level (BLL) is known to cause cardiac, immune, and cognitive damage but had not been thoroughly studied in relation to stunting among children under two years of age. We primarily ...aimed to assess the relationship between elevated BLL, the accumulation of concerned amount of the metal lead in blood and stunting and secondarily-wasting and underweight amongst Bangladeshi children less than two years of age. For this cross-sectional study, BLL measurements, anthropometric data, and socioeconomic indicator information were collected and analyzed for 729 children under two years of age upon enrollment in the MAL-ED study conducted in a Bangladeshi slum area. Univariate, bivariate and multivariate analyses were carried out to observe the proportion and mean and contribution of elevated BLL and other relevant variables in explaining the occurrence of stunting. Of the enrolled subjects, 39.0% were stunted length-for-age z score (LAZ<-2), 50.3% were male, and 86.6% had an elevated BLL (≥5μg/dL). Mean BLL of stunted children was 8.47 ± 3·37 μg/dL and 8.10 ± 3·80 μg/dL for non-stunted children. Proportion of children with elevated BLL was not significantly different between the stunted and non-stunted groups (p>0.05). When adjusted for other variables, elevated BLL was found to be a significant predictor of stunting and underweight (p<0.05) but not wasting (p>0.05). Elevated BLL (p<0·01), child's gender and weight (p<0·001), maternal body mass index (BMI) (p<0.05) and severe household food insecurity (p<0·05) were all significantly associated with stunting in the multivariate model. Increased odds of stunting was also observed for increased BLL. The findings suggest that chronic lead poisoning is significantly associated with high level of stunting among child slum dwellers in Bangladesh. These findings strengthen the argument for improved lead reduction efforts in Bangladesh, where lead poisoning and stunting are both highly prevalent.
Children in resource-limited settings remain vulnerable to zinc deficiency and its consequences.
To evaluate the effects of different doses, durations, and frequencies of zinc supplementation on the ...incidence of diarrhea and change in linear growth among young children.
We conducted a randomized, partially double-blind, controlled, 6-arm, community-based efficacy trial in Dhaka, Bangladesh. Children aged 9–11 mo were randomly assigned to receive 1 of the following interventions for 24 wk: 1) standard micronutrient powder (MNP) containing 4.1 mg zinc and 10 mg iron, daily; 2) high-zinc (10 mg), low-iron (6 mg) (HiZn LoFe) MNP, daily; 3) HiZn (10 mg) LoFe (6 mg)/HiZn (10 mg), no-iron MNPs on alternating days; 4) dispersible zinc tablet (10 mg), daily; 5) dispersible zinc tablet (10 mg), daily for 2 wk at enrollment and 12 wk; 6) placebo powder, daily. Primary outcomes were incidence of diarrhea and change in length-for-age z-score (LAZ) over the 24-wk intervention period. Home visits were conducted twice weekly to assess diarrhea and other morbidity. Incidence and prevalence outcomes were compared among groups with Poisson regression; continuous outcomes were compared using ANCOVA.
A total of 2886 children were enrolled between February 2018 and July 2019. The mean incidence and prevalence of diarrhea among all participants was 1.21 episodes per 100 d and 3.76 d per 100 d, respectively. There were no differences in the incidence or prevalence of diarrhea across intervention groups. The decline in LAZ was slightly smaller among children in the daily HiZn LoFe MNP group compared with the placebo powder group (P < 0.05).
The dose of zinc in MNPs as well as the duration and frequency of supplementation evaluated in this trial were not effective in reducing diarrhea; however, the daily HiZn LoFe MNP formulation offered modest improvements in linear growth among young children. This trial was registered at clinicaltrials.gov as NCT03406793.
The association of vitamin D with neuro-behavioral outcomes of young children is unclear, particularly of those who reside in tropical countries and are otherwise exposed to adequate sun light. To ...investigate this association, we analysed the existing data of poor infants, who participated in an observational, prospective-cohort (MalED) study, conducted in a slum of Dhaka-city. We assessed 265 infants aged 6-8 months for cognitive, motor, language and behavior development using Bayley-III. Information about infants' temperament and communicative skills were provided by the mothers through a culturally modified "temperament-scale" and a "communicative-developmental inventory". Serum concentration of vitamin D 25(OH)D was measured in 205 infants. Around 28.3% of infants in this community had low level vitamin D, with the cut-off at <50 nmol/L. After controlling for all possible covariates, a multivariable-adjusted linear regression showed that children with vitamin D levels <50 nmol/L had significantly lower scores in two dimensions of temperament: activity (B±SE 1.64±0.78; 95%CI 0.10, 3.18; p = 0.037; effect size 0.37 SDs) and soothabilty (2.02±0.70; 0.64, 3.41; p = 0.004; 0.53 SDs), compared to children with vitamin D levels of ≥50nmol/L. These infants also scored low in word comprehensions (1.28±0.62; 0.05, 2.51; p = 0.042; 0.23 SDs) and were less active during test-procedures (0.33±0.16; 0.02, 0.64; p = 0.035; 0.27 SDs). Both the groups tested similarly in cognitive and motor scores. This study found, despite adequate sunlight-exposure, one in four infants of this slum-community are suffering from a subclinical vitamin D deficiency. Higher levels of vitamin D in these infants showed a positive association with temperament, language and behavior but not with cognitive and motor development. Our findings highlight the early-detected extra-skeletal neuro-behavioral role of vitamin D. Future studies in this area will give more insight.
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