How much Antenatal Supplemental Iron is Required to Preserve Maternal Iron Status? The MINIMat Intervention trial in Bangladesh.

Objectives: To prevent iron deficiency in pregnancy universal iron folic acid supplementation is recommended by WHO. We aimed to compare the effect of multiple micronutrients supplements with two different dosages of iron/folic acid supplements on maternal iron status. Methods: In the MINIMat intervention trial in Bangladesh, pregnant women were randomized into three micronutrient supplementation groups: 30 mg iron/400 ugfolic acid (Fe30 F), 60 mg iron/400 ugfolic acid (Fe 60 F) and multiple micronutrients +30 mg iron/400 ugfolic acid (MM). Adherence was electronically monitored by use of eDEM-pillbottles. Plasma-ferritin (p-Ft) was assessed at start of supplementation (week 14) and at week 30 at gestation in random subset. Intent to treat and multivariate regression analyses were performed (n=561). Results: Iron deficiency (ID) was 7% at start of supplementation. At wk 30 ID was 29% and mean p-Ft 20.0 ug/L with no differences according to supplementation type. Within each type there was a significant dose-effect per capsule on p-Ft that did not differ between types when amount of iron in the supplements was taken into consideration. There was no further dose-effect on p-Ft of iron intake exceeding 4 g. Using lowest tertile of iron intake as reference, middle and highest intake tertile increased p-Ft and showed a protective effect on ID at wk30 but did not differ between each other. Conclusions: Despite no further effect on p-Ft of higher iron intake than 4 g, ID developed to become prevalent at wk 30 suggesting that iron intake exceeding 4 g contributes to limited extent to reduce ID in pregnancy. Supplement with multiple micronutrients did not provide any additional effect.

Anemia Varies with Season and is not Related to Iron Deficiency in Pre-school Children in Rural Bangladesh.

Objectives: To examine the prevalence of anemia, iron deficiency and iron deficiency anemia in pre-school children and potential seasonal variations. Methods: As part of a community-based trial in rural Bangladesh (the MINIMat-trial) children were assessed for hemoglobin and ferritin concentrations at 4.5 years. Season of blood collection were divided into 2 months categories starting with cool-and-dry season (15 Dec-14 Feb), followed by mild-temperature, hot-and-dry, monsoon-rains, hot-and-humid, and main-harvest season. We used logistic regression for associations between anemia and iron deficiency and chi-square test for seasonal differences. Results: Anemia was found in 7% of the children. Iron deficiency was low, only 3%, and consequently iron deficiency anemia was found in less than 1%. Iron deficiency was not associated with anemia, either in crude or adjusted analyses (SES, maternal education, height). Anemia varied significantly with season (p < 0.001) with the lowest prevalence found in the hot-and-humid season (4%) while anemia prevalence was about threefold in the hot-and-dry season (13%). Iron deficiency did not vary with season. Conclusions: In pre-school children in rural Bangladesh, anemia was relatively uncommon found in less than 10% of the children. A potential reason may be a relatively high iron content of drinking groundwater. The observed anemia was not associated with iron deficiency indicating the importance of other determinants. We found seasonal variations in anemia prevalence suggesting seasonal differences in diet, infections etc. as potential mechanisms in developing anemia. This also illustrates the risk of over- or under-estimating anemia if data are collected in a limited time period.

A Framework for Addressing Implementation Gap in Global Drowning Prevention Interventions: Experiences from Bangladesh.

Drowning is the commonest cause of injury-related deaths among under-five children worldwide, and 95% of deaths occur in low- and middle-income countries (LMICs) where there are implementation gaps in the drowning prevention interventions. This article reviews common interventions for drowning prevention, introduces a framework for effective implementation of such interventions, and describes the Saving of Lives from Drowning (SoLiD) Project in Bangladesh, which is based on this framework. A review of the systematic reviews on drowning interventions was conducted, and original research articles were pulled and summarized into broad prevention categories. The implementation framework builds upon two existing frameworks and categorizes the implementing process for drowning prevention interventions into four phases: planning, engaging, executing, and evaluating. Eleven key characteristics are mapped in these phases. The framework was applied to drowning prevention projects that have been undertaken in some LMICs to illustrate major challenges to implementation. The implementation process for the SoLiD Project in Bangladesh is used as an example to illustrate the practical utilization of the framework. Drowning interventions, such as pool fencing and covering of water hazards, are effective in high-income countries; however, most of these interventions have not been tested in LMICs. The critical components of the four phases of implementing drowning prevention interventions may include: (i) planning—global funding, political will, scale, sustainability, and capacity building; (ii) engaging—coordination, involvement of appropriate individuals; (iii) executing—focused action, multisectoral actions, quality of execution; and (iv) evaluating—rigorous monitoring and evaluation. Some of the challenges to implementing drowning prevention interventions in LMICs include insufficient funds, lack of technical capacity, and limited coordination among stakeholders and implementers. The SoLiD Project in Bangladesh incorporates some of these lessons and key features of the proposed framework. The framework presented in this paper was a useful tool for implementing drowning prevention interventions in Bangladesh and may be useful for adaptation in drowning and injury prevention programmes of other LMIC settings.

Body Composition of Bangladeshi Children: Comparison and Development of Leg-to-Leg Bioelectrical Impedance Equation.

The aim of this study was to investigate the validity of the Tanita TBF 300A leg-to-leg bioimpedance analyzer for estimating fat-free mass (FFM) in Bangladeshi children aged 4-10 years and to develop novel prediction equations for use in this population, using deuterium dilution as the reference method. Two hundred Bangladeshi children were enrolled. The isotope dilution technique with deuterium oxide was used for estimation of total body water (TBW). FFM estimated by Tanita was compared with results of deuterium oxide dilution technique. Novel prediction equations were created for estimating FFM, using linear regression models, fitting child’s height and impedance as predictors. There was a significant difference in FFM and percentage of body fat (BF%) between methods (p<0.01), Tanita underestimating TBW in boys (p=0.001) and underestimating BF% in girls (p<0.001). A basic linear regression model with height and impedance explained 83% of the variance in FFM estimated by deuterium oxide dilution technique. The best-fit equation to predict FFM from linear regression modelling was achieved by adding weight, sex, and age to the basic model, bringing the adjusted R2 to 89% (standard error=0.90, p<0.001). These data suggest Tanita analyzer may be a valid field-assessment technique in Bangladeshi children when using populationspecific prediction equations, such as the ones developed here.

Community-based Health Workers Achieve High Coverage in Neonatal Intervention Trials: A Case Study from Sylhet, Bangladesh.

A large proportion of four million neonatal deaths occur each year during the first 24 hours of life. Research is particularly needed to determine the efficacy of interventions during the first 24 hours. Large cadres of community-based workers are required in newborn-care research both to deliver these interventions in a standardized manner in the home and to measure the outcomes of the study. In a large-scale community-based efficacy trial of chlorhexidine for cleansing the cord in north-eastern rural Bangladesh, a two-tiered system of community-based workers was established to deliver a package of essential maternal and newborn-care interventions and one of three umbilical cord-care regimens. At any given time, the trial employed approximately 133 community health workers—each responsible for 4-5 village health workers and a population of approximately 4,000. Over the entire trial period, 29,760 neonates were enrolled, and 87% of them received the intervention (their assigned cord-care regimen) within 24 hours of birth. Approaches to recruitment, training, and supervision in the study are described. Key lessons included the importance of supportive processes for community-based workers, including a strong training and field supervisory system, community acceptance of the study, consideration of the setting, study objectives, and human resources available.