A Multi-country Analysis that Explores Approaches to Account for the Effects of Inflammation on Ferritin Interpretation in Young Children.

Objectives: Ferritin is considered the most suitable indicator of low iron stores in population-based surveys. Ferritin is an acute-phase protein (APP) and studies find this can impact on its use and interpretation. This study explores the relationship between ferritin and other APPs in an effort to identify approaches to account for this relationship in the assessment of iron status in young children. Methods: Using data from the Biomarkers Reflecting Inflammation and Nutrition Determinants of Anemia (BRINDA) project, the association between ferritin and specific APPs, C-reactive protein (CRP) and α1-acid-glyco-protein (AGP), was explored. The prevalence of low-iron stores were compared using approaches to account for inflammation: exclude individuals with inflammation, use a higher ferritin cutoff, internally generated correction factors or correction factors generated via meta-analysis, and regression methods. Results: The dataset includes approximately 30,000 children (6-59 months) and encompasses all 6 WHO geographic regions. Based on preliminary findings from 11 countries, the prevalences of CRP (14-40%) and AGP (21-61%) were high. The Kendall tau correlations between ferritin and CRP or AGP ranged from -0.02 to 0.42. There was considerable variation in the prevalence of unadjusted low iron stores (0.3-32%) and in the percentage change induced by adjusting for CRP and AGP (0-82%) Conclusions: Ignoring inflammation generally resulted in underestimates of low iron stores in young children. These findings should inform efforts to develop a harmonized approach to the use of ferritin as a biomarker of iron status, aiding in the interpretation of the effectiveness of interventions.

Micronutrient Deficiencies in Pre-school Age Children and Women of Reproductive Age in Jordan.

Objectives: Jordan's 2010 National Micronutrient Survey assessed the prevalence and severity of anemia and micronutrient deficiencies in Jordanian women and children. Methods: A stratified multistage cluster sampling was used to establish a nationally representative household-based sample of Jordanian children (12 - 59 months) and non-pregnant women of reproductive age (15-49 years). Weighted descriptive statistics were used to calculate national prevalence and multivariate analyses were undertaken for the determination of risk factors of vitamin D deficiency Results: Anemia in children (hemoglobin < 110g/L) and women (hemoglobin < 120g/L) was a mild (17.0%) and moderate (30.6%) public health problem, respectively. Vitamin A deficiency (serum retinol < 0.70 umol/L) was prevalent in 18.3% of children and 4.8% of women. Vitamin D deficiency (25(OH)D3 < 11.0 ng/mL and < 12.0 ng/mL in children and women, respectively) was prevalent in 19.8% of children and 60.3% of women. Vitamin D deficiency was significantly more likely in women who routinely cover themselves with a scarf compared to those women who do not cover. In urban areas, children whose mothers were vitamin D deficient were more likely to be vitamin D deficient than children whose mothers were not deficient. Conclusions: With the exception of vitamin A, a higher burden of micronutrient deficiencies is seen in Jordanian women than children. Vitamin D deficiency in women is the most prevalent micronutrient deficiency in Jordan with approximately 3 out of 5 women being deficient.

Refinements to Assessment of Iodine Nutrition.

Objectives: The main target groups of iodine programs are pregnant women (PW) and nonpregnant women of reproductive age (NPW), yet surveys frequently focus on school age children (SAC). It is unclear whether median urinary iodine concentration (mUIC) in SAC can be used as a surrogate for PW and NPW. It is also unclear what range of iodine intake is adequate in SAC. The objectives of this research were to: 1) Compare mUIC values in SAC with those in PW and NPW; and 2) determine if the current mUIC range for SAC is appropriate by assessing thyroglobulin (Tg), a functional biomarker of iodine status. Methods: 1) The Iodine Task Force (ITF) reviewed surveys where mUIC in SAC, PW, and NPW were available and compared iodine status across groups; and 2) for determining the adequate range of mUIC in SAC, the ITF analyzed and interpreted a multicenter study. Results: 1) When SAC had adequate or above adequate iodine status, PW were inadequate in 47% of the surveys. 2) In SAC, the two current WHO/UNICEF/ICCIDD mUIC categories for classification of iodine nutrition as "adequate" and "above adequate" could be combined into a single "adequate" range based on Tg results showing no negative effect on the thyroid at the current "above adequate" range. Conclusions: A number of refinements to the current global recommendations in assessing iodine status were identified, including the importance of including PW and/or NPW in population-based assessments, and reconsideration of current mUIC criteria for the classification of optimal iodine nutrition in SAC.

The Micronutrient Survey Manual: A Manual for Assessing Vitamin and Mineral Nutritional Status and Interventions Using Cross-sectional Surveys.

Objectives: An important component of public health nutrition programs is the periodic assessment of vitamin and mineral nutritional status and coverage of micronutrient interventions. Performing high quality cross-sectional surveys can be enhanced by the availability of guidance on steps in survey methods, sample size, sampling methods, data collection, analysis and interpretation, dissemination of results, and appropriate feedback to improve intervention programs. A manual to assist implementers is described. Methods: A previously published manual, "Indicators and Methods for Cross-Sectional Surveys of Vitamin and Mineral Status of Populations", by the Centers for Disease Control and Prevention (CDC) and the Micronutrient Initiative (MI) served as the basis for this newer manual. New technical partners, WHO and UNICEF, have collaborated in the development of this up-to-date "Micronutrient Survey Manual". Results: In addition to updated resources for the assessment of anemia and iodine, iron, and vitamin A deficiencies, the manual has added information on folate and zinc deficiencies. Program indicators for assessing fortification of staple foods, point-of-use fortification with micronutrient powders, micronutrient supplementation, and dietary counselling are included. The manual contains detailed information on biologic sample collection and processing, sample size calculations, and analysis of survey data. Quality assurance throughout the survey process is emphasized. The issues of ethics, confidentiality, and informed consent are addressed. Conclusions: The "Micronutrient Survey Manual" can assist survey managers to improve the validity, efficiency, and standardization of cross-sectional surveys to better serve public health practice.

Nutrition Survey Toolkit for Improved Micronutrient Surveys.

Objectives: The Survey Toolkit, developed by the U.S. Centers for Disease Control and Prevention and hosted by the Micronutrient Initiative, provides epidemiological support and guidance through standardized tools to countries for the assessment and monitoring of population micronutrient status and interventions. An important component of micronutrient programs is periodic surveys of micronutrient status and coverage of interventions. Execution of such surveys can be improved through use of tools and materials for planning, organizing, training and educating, implementing, and reporting of results. Methods: The toolkit offers a web-based, publicly accessible compilation of over 200 qualitative and quantitative survey tools. Tools were collated from various sources such as subject-matter experts, relevant organizations, and journal articles pertinent to the assessment of micronutrient deficiencies in populations, or were specifically created for inclusion. A user-friendly interface and search function enable users to identify tools needed for their specific task. The toolkit is currently being revised and a second edition is expected to be publicly released in 2015. Results: Tools include sample size calculators; lists of equipment and supplies; budget templates; specimen collection, processing and storage procedures; training materials, data collection templates, and survey report outlines. Additionally, examples of how the tools have been used in real-world settings are included. Conclusions: The Nutrition Survey Toolkit can help improve the validity and efficiency of surveys of vitamin and mineral deficiency and related interventions.

Suporte farmacológico a lactentes e crianças com choque séptico / Pharmacologic support of infants and children in septic shock

OBJETIVOS: O choque séptico (CS) é uma causa freqüente de internação na unidade de tratamento intensivo pediátrica e requer reconhecimento e intervenção imediatos para que haja um desfecho favorável. Nosso objetivo é revisar a literatura relacionada ao diagnóstico e manejo do CS e apresentar um manejo seqüencial para seu tratamento. FONTES DOS DADOS: Revisão não-sistemática da literatura médica através de pesquisa na base de dados MEDLINE. Os artigos foram selecionados de acordo com sua relevância em termos do objetivo proposto e com base na opinião dos autores. SíNTESE DOS DADOS: O desfecho da sepse e do CS depende do reconhecimento precoce e da implementação de tratamentos sensíveis ao tempo e guiados por objetivos. Esses tratamentos incluem reanimação agressiva com fluidos seguida de tratamento medicamentoso bem elaborado. Os objetivos da reanimação são a restauração da microcirculação e a melhora da perfusão tecidual. Os marcadores clínicos e laboratoriais são importantes para avaliar a adequação dos tratamentos. Respostas farmacocinéticas e farmacodinâmicas alteradas indicam que os agentes vasoativos devem ser ajustados a fim de atingirem o objetivo pré-estabelecido. Na reanimação inicial com soluções isotônicas (> 60 mL/kg), é possível usar infusão tanto de cristalóides (solução salina normal) como de colóides. Apesar da reanimação adequada com fluidos, se: (a) uma pressão de pulso com grande amplitude, pressão arterial baixa, ou pulso oscilante (débito cardíaco alto, baixa resistência vascular sistêmica - RVS) estiverem presentes, o uso de noradrenalina deve ser considerado; (b) reenchimento capilar prolongado, pulso fraco e filiforme, pressão arterial normal (baixo débito cardíaco, alta RVS), deve-se considerar o uso de dopamina, adrenalina ou dobutamina. O tratamento concomitante com dose de estresse de corticosteróides é indicado em populações selecionadas. CONCLUSÕES: A resposta hemodinâmica do CS é um processo variável que...

OBJECTIVES: Septic shock (SS) is a frequent cause for admission to the pediatric intensive care unit, requiring prompt recognition and intervention to improve outcome. Our aim is to review the relevant literature related to the diagnosis and management of SS and present a sequential management for its treatment. SOURCES: Non-systematic review of medical literature using the MEDLINE database. Articles were selected according to their relevance to the objective and according to the authors’ opinions. SUMMARY OF THE FINDINGS: The outcome of sepsis and SS is dependent on the early recognition and implementation of time-sensitive goal-directed therapies. These include rapid aggressive fluid resuscitation followed by a well-designed pharmacotherapy. The goals of the resuscitation are the restoration of microcirculation and improved organ tissue perfusion. Clinical and laboratory markers are needed to assess the adequacy of the treatments. Altered pharmacokinetic and pharmacodynamic responses dictate that vasoactive agents should be adjusted to achieve the predetermined goals. In initial resuscitation with isotonic solutions (> 60 mL/kg), either crystalloid (normal saline) or colloid infusion could be used. Despite adequate fluid resuscitation, if: (a) wide pulse pressure, low blood pressure, or bounding pulses (high cardiac output, low systemic vascular resistance - SVR) are present, norepinephrine should be considered; (b) prolonged capillary refill, weak pulses, narrow pulse pressure, normotensive (low cardiac output, high SVR), dopamine, epinephrine or dobutamine should be considered. Adjunctive therapy with stress dose of corticosteroid is indicated in selected populations. CONCLUSIONS: Septic shock hemodynamics is a changing process that requires frequent assessment and therapeutic adjustments.