The Impact of Maternal Iron Deficiency and IDA on Childhood - Essay Example

The Impact of Maternal Iron Deficiency and IDA on Childhood Abstract Iron deficiency during pregnancy is one of the leading causes of anaemia as highlighted by the WHO. Anaemia has been described as an epidemic in the developed world affecting mostly women and children. Medical and nutritional experts have defines the recommended levels of nutritional iron intake in people of different ages and gender. The prevalence of anaemia that results from iron deficiency has contributed to its being tagged as a global epidemic. During pregnancy, the iron requirement raises to a 100 mg. However, reports indicate that many women go through the entire pregnancy period with attaining this level. This leads to complication during pregnancy and may trigger post pregnancy complications to the mother and child. In a bid to determine the impact of maternal iron deficiency and IDA on childhood, an extensive literature review was conducted. The review identified sources that exhibited relevance to the research question and that were recent. After analysis of the sources, which were both primary and secondary sources, the findings were compiled and have been presented in the discussion. From this literature review, it emerges that children and women are the risk groups likely to develop anaemia. Iron deficiency has been described as the leading nutritional condition in the globe. Moreover, 52% of expectant mothers do not meet the recommended iron level. Deficiency of iron in expectant mothers presents several symptoms such as fatigue, paleness, faint feeling, sour mouth and tinnitus. The causes of iron deficiency will be described in depth in this paper. In pregnant women, lack of sufficient weight gain may present a higher risk to the development of iron deficiency. Iron deficiency has adverse effects on both the mother and the unborn baby. In some cases, effect on the unborn babies my progress to early childhood. Proper diet and iron supplementation are some of the leading interventions. Introduction Definitions The World Health Organization (1) states that anaemia is a haemoglobin level of less than 13 g/dL for males 15 years and above, less than 12 g/dL in non-expectant women 15 years and above, and less than 11 g/dL in women who have conceived. The criteria used to diagnose anaemia are not standardised. Moreover, there is a lack of clarity as to the differentiation between functional iron deficiency and absolute iron deficiency (2). Additionally, what is defined as the standard range for haemoglobin also differs within a given population. In the UK, such variations can occur within ethnic groups and from region to region. It is advised that any indication of anaemia ought to be further researched, whenever an iron deficiency is identified (3). Iron deficiency usually occurs over time and is frequently not clinically obvious until iron stores are completely depleted, and the iron accessibility to the tissues is inadequate, leading to iron-deficiency anaemia. Globally, anaemia is usually a consequence of iron deficiency (4). It is often diagnosed from a reduction in the red cell indices. A reduction in haemoglobin is a later aspect of iron deficiency (4). The Role of Iron in Metabolism Iron (Fe) is a crucial component in several metabolic processes, and the typical individual contains 3–5g of iron, of which 66% originates in the oxygen–carrying molecule, haemoglobin. A standard diet in industrialised countries supplies approximately 15mg of iron per day, of which 5–10% is taken into the body (~· 1·mg), primarily in the first and second parts of the small intestine, as the acidic environments aid iron absorption, especially in when it is in its bivalent iron compound state. Absorption is supported by additional lowering substances, for instance HCl and vitamin C. The body has the ability to elevate its iron absorption in response to heightened needs, for example, throughout pregnancy, for use in breast milk, to support bone development at key growth stages as well as iron deficiency (see Table 1). Having been taken in from the bowel, iron is sent through the inner-layer cell to the blood, whereupon it is transported by the protein transferring to the bone marrow through the evolving red cells (41). The stores of iron within the body are made up of ferritin, a labile and easily available provider of iron and haemosiderin, which is a non-soluble form located commonly in white blood cells. Approximately 1·mg of iron a day is utilised by the system through human waste products and sweat (4). At Risk Groups Those who are most likely to experience iron deficiency are premature infants; children of more than six months during the weaning period; toddlers and teenagers due to growth spurts; pregnant women as a result of the elevated iron requirements; the elderly and those taking foods high in iron-absorption inhibitors (leading to reduced absorption); and menstruating women or those with pathological blood reduction as a consequence of repeated and/prolonged blood loss (4). Those who take a vegetarian diet, particularly vegans, have a higher risk of developing anaemia (5). Prevalence Iron deficiency is globally the most prevalent nutritional condition, and indeed it is at epidemic levels (6). In addition to impacting primarily children and women in developing countries, it also is the singular nutrient deficiency that most commonly occur in the developed world. It is estimated that 2 billion individuals, just under a third of the global population, are anaemic (6, 7), and about 50% of those are a result of an insufficient supply of iron to generate haemoglobin (Hb) (8). Moreover, it is believed that 52% of pregnant women in the developing world are anaemic (9). Consequences of Iron Deficiency and Iron Deficiency Anaemia Typical signs of iron deficiency are caused by lowering quantities of oxygen in the system. This can lead to: paleness of complexion, fatigue, apathy, feeling faint, and breathlessness (3, 5). In some instances, this may extend to headaches, palpitations, changes in taste sensitivity, sore mouth, and tinnitus. If the anaemia persists and is not addressed, this could also result in hair falling out and even cardiovascular difficulties. Long-term, the immune system is negatively impacted and so the risk of infection increases (5). At its extreme, iron deficiency anaemia develops and can result in death, maternal haemorrhage and poor pregnancy outcomes (7). Iron deficiency and ultimately anaemia lower the ability to work of people and societies resulting in a severe reduction of economic standards for families and barriers to development in poorer nations (8). In general, it is the uneducated and the most disadvantaged, especially women and children, who are most affected by iron deficiency and, at its extreme, iron deficiency anaemia (8). It should be noted that anaemia whilst pregnant elevates the possibility of health difficulties in both the expectant mother and child. For instance, this can lead to a heightened risk of: having a low birth-weight baby (LBW), a pre-term birth, growth retardation for the infant, post-natal depression, and poor iron storage within the body of the infant, which, in turn, could possibly result in anaemia in the newborn infant (3). Causes of Iron Deficiency and Iron Deficiency Anaemia In developing countries, a cause may be due dietary factors such as to the lack of consumption of foods with enough iron that can lead to iron deficiency anaemia. This is not usual in developed countries such as the UK, because iron is in green vegetables, flour, meat, eggs, liver, and other foods. Even so, a diet low in iron may be tipped over into anaemia by a combination of other factors, such as blood loss through menstruation, growth spurts in children, and pregnancy. In some regions of the world, apart from the dangers of a vegan diet (7), individuals may be at risk due to the presence of certain absorption-inhibiting chemicals. However, dietary factors are not the only causes of iron deficiency anaemia (refer to Table 2), with the gut infection, hookworm, being the number one cause outside of poor iron absorption from the diet (4). Discussion Nutrition and Deficiency The nutritional status of the mother is key to successful, healthy outcomes for both the mother and child, commencing from conception, as this is vital for foetal growth and development. Before conceiving and throughout the pregnancy, achieving a normal bodyweight [a body mass index (BMI) of 20-25] is also critical, as being outside the healthy weight range in either direction can influence the birth consequences. Thus, the mother's diet must cater to the mother's own needs in addition to the requirements of the developing child, whilst at the same time allows maternal iron stores to be developed for foetal development and for lactation. Thus, it is evident that a balanced, healthy diet is even more significant during pregnancy than usual. The total iron necessitated during pregnancy is approximately 1000mg, but most women do not achieve this requirement (9, 10). Indeed, Sato et al (9), in their Brazilian based study of 61 women of whom 30 were present, found that all the pregnant women were still found to be below recommended iron levels, despite taking fortified food and iron supplementation. In Britain, it is believed that up to half of all women of reproductive age have poor iron residual supplies and are therefore in danger of developing anaemia if they conceive (11). Further, it is estimated that 40% of females between 19 and 34 years, presently in the UK have iron levels, which fall under the lower reference nutrient intake (LRNI) (12). Whilst the food intake may be similar to those of other individuals, expectant mothers in Britain are advised to eat an abundance of foods high in folate and iron, in addition to taking a vitamin D supplement on a daily basis (10g/day) for the duration of the pregnancy (13). Additionally, for those with a healthy weight prior to conception, an average weight gain of 12 kg (within the range of 10–14 kg) is linked with the best chance of positive health outcomes during pregnancy and delivery and with a lesser risk of having a low birth weight (LBW) baby (14). However, in practice, healthy women of a normal body weight prior to conception tend to have a wide range of weight gain whilst carrying the infant. Poor maternal weight gain whilst pregnant raises the possibility of having an LBW child, while too much weight gain elevates the chances of the mother post-partum becoming overweight and obese (14), which can lead to further chronic health complications. An infant weight at birth of 3.1–3.6 kg is recommended for the best health outcomes for both mother and child (13, 14). In the United Kingdom, increased dietary reference values (DRVs) for specific nutrients for pregnant women are advised for riboflavin, thiamin, folate and vitamins A, C and D, as well as protein and energy. The latter costs of pregnancy are thought to be approximately 321 MJ (77 000 kcal), though these alter from woman to woman, dependent on the location and distribution of fat, rate of metabolism and level of physical activity. It has been suggested that women in their third trimester solely require an additional 200 kcal of energy daily. This is, however, contingent on the mother's physical activity levels and her weight status. Vegetarians and vegans may require additional support to deal with possible shortages from dietary intake of riboflavin, vitamin B12 calcium, iron, and zinc, which may even include fortified foods or supplements (13). An additional at-risk group who may require interventions are teenage mothers who commence with a greater nutritional requirement due to their own growth spurts and the resultant possibility of competition with the foetus for nutrients (15, 52). Additionally, as teenage pregnancies are frequently unplanned, these mothers-to-be may already experience a poor nutritional status pre-conception, especially in terms of iron, calcium and folic acid (15). Impact on Mother of Iron Deficiency and IDA Throughout pregnancy, IDA is adverse to maternal and foetal well-being, and is linked to an elevated danger of maternal and foetal morbidity and death (1, 13). In the mother, it may cause breathing difficulties, fainting, tiredness, tachycardia and palpitations, as well as sleep difficulties and restless-leg syndrome (16). It may also result in a poorer immune-response to infection and lead to possible pre-eclampsia and haemorrhage, either pre- or post-delivery (13). There is also evidence that adults, including mothers with post-partum iron deficiency, may also experience impaired cognitive functioning and subsequent behavioural difficulties as a result of IDA (17, 18, 50). Impact of the Child of Iron Deficiency and IDA The three main negative birth outcomes that can occur are: LBW, pre-term birth and intrauterine growth restriction (IUGR), all of which are the primary cause of death in children without congenital abnormalities (19, 20, 21). Essentially, the additional iron needed from the mother's dietary iron intake is insufficient to meet the needs of the pregnancy, and when maternal iron stores are subsequently utilised, maternal IDA will develop (20). There is evidence that this can also result in lowered iron stores within the child up to the first year of birth, which could result in IDA in the child (22). Longer-term chronic conditions in these infants may also result in adulthood, such as type 2 diabetes, hypertension, or cardiovascular issues (13, 20, 23). Indeed, the foetal origins theory argues that chronic conditions in adulthood may be a consequence of ‘foetal learning resultant with lasting impact on the form, function or development of the individual as a result of damage as a key, pivotal developmental stage’ (13). It has been found that iron deficiency, especially in the first trimester of pregnancy, may severely and negatively impact foetal growth and be even more adverse than IDA in the second or third stages of pregnancy (24, 49). It has been identified that, in the initial two trimesters of pregnancy, maternal IDA raises the chances of premature labour (25). Premature births, low birth weight, and IUGR are more common in developing nations than in developed nations and, within industrialised countries, are greater among those with poor socio-economic status (26). Socioeconomic status is thought to impact the quantity and quality through the bioavailability of dietary iron intake (24). In their review of observational studies, Abu-Saad and Fraser (24) determined that the nutritional status of the mother is a changeable risk factor which can be addressed by public health policies in order to prevent or reduce negative birth outcomes, especially for those of poor socioeconomic status or in developing nations. Additionally, it has been found that iron deficiency can impact on brain development, as children with iron deficiency have been identified as achieving poorer outcomes in cognitive, motor, social-emotional and Neuro-physiological development compared to healthy children (27, 48). Apart from higher death rates, children stemming from iron-deficient pregnancies are often significantly developmentally sub-normal and may, for instance, experience delay or restriction in language development as well as motor development (20, 52). Moreover, it has been found that the impaired cognitive function that occurs with iron deficient babies can result in subsequent behavioural difficulties in the infant which cannot be overcome by treatment, such as supplementation, after the weaning period (18, 28). Iron within the brain is essential for neural metabolism and functioning. The link between this mechanism in children with iron deficiency is not yet fully understood, but is definitely observed and could be due to changes in energy metabolism within the brain (18, 29) or deficiencies in neurotransmitter metabolism or reduced myelin formation (18). As yet, there is still limited evidence of a causal link between cognitive deficits and iron deficiency based on controlled studies, though it has been found in observational studies (30, 42). Children seem to be most susceptible to this cognitive damage in the development of the foetus and during infancy under two years of age (31). Breastfeeding mothers are commonly believed to avoid IDA in newborn infants, but this may not be the case if they themselves experience IDA (32, 47). Thus, IDA within the pregnant mother may continue to have an impact post-partum on the child. Indeed, there has been little correlation shown between the amount of iron consumed by the mother and the amount of iron present in breast milk. Further, no relationship has been determined between iron consumed and iron within the breast milk (32, 53). Notably, it has been found that iron levels in mother's milk fall as lactation progresses over time, with one report stating there is a drop of 30% within the first month of lactation itself. Unfortunately, the reasons for this are still unclear. This suggests that the more sustained the breastfeeding period, the more at risk the infant may become of developing a deficiency (32, 56). Moreover, as mothers begin to wean children onto solid food, there is an additional risk of the child developing an iron deficiency if there is insufficient iron present within the dietary sources (32, 43). Iron Supplementation Iron supplementation is the most common means of addressing the global problem of iron deficiencies in pregnancy (25, 46). Whilst oral supplementation is most prevalent, it is possible to provide intramuscular injection or intravenous infusion. Despite the difficulties in diagnosing IDA accurately, many pregnant women are provided with supplementation even though it may result in nausea, or cause or exacerbate constipation. The latter may be alleviated by altering the kind of iron supplement offered (13). Scholl (33) recommends that iron supplementation commence before conception or in the first trimester of pregnancy to reduce the risk of premature birth or LBW, especially in women with poor iron stores. Additionally, Scholl (33) emphasises that commencing supplementation in mid- or late pregnancy is unlikely to limit premature births. Notably, it has also been observed that women with high iron stores along with raised ferritin levels (>41 ng/ml) (possibly due to intrauterine infection or alternatively to the restricted increment of the plasma in the mother's blood), especially in the third trimester, are also at elevated risk of premature delivery (33, 45). Furthermore, there is uncertainty as to the interrelationship of micronutrients, especially those of metals such as zinc, copper and iron, as well as antioxidants vitamin A and E, on the development and growth of the foetus (24, 54). Thus, further research is required in this area to clarify the appropriateness of supplementation, especially if more than one micronutrient is involved, as is increasingly the case in pre-natal vitamin supplementation (20, 24). Moreover, there are contradictory findings in terms of the impact of supplementation on cognitive performance on those who have experienced iron deficiency. In a systematic review by Martins et al. (34), seven randomised control trials found that oral supplementation in infants with anaemia or iron deficiency did not benefit significantly in psychomotor development. Further, a different review involving seventeen RCTs on children of varying ages and iron levels, found that iron supplementation was not linked with enhanced cognitive function in children under five years (35), or indeed with increased physical growth (36). However, another recent systematic review by Iannotti et al (37) explored a variety of health complications and possible advantages of iron supplementation in children below five years of age, and did, in this case, find that iron supplementation resulted in benefits to cognition and motor development in both anaemic and iron-deficient children, whilst at the same time being linked with a heightened risk of mortality in regions where malaria was common. In a more recent systematic review by Falkingham et al (30, 55), it was found that iron supplementation specifically aided attention and concentration in adolescents and adult women, irrespective of baseline amounts of iron status. Additionally, it also supported heightened intelligence assessment in both children and females who were anaemic at baseline, whilst not improving any other areas of cognitive function (30, 44). Conclusion Iron intake is key to the health of both mother and child. In an ideal world, diet and supplementation should reflect this in the pre-pregnancy planning stages. However, in a world of malnutrition linked to endemic obesity and high levels of unplanned teenage pregnancies in the developed world, and under-nutrition in the developing world due to food insecurity, this does not always occur. Thus, there is an increasing need for public health strategies that will publicise and educate the population as to the need for a healthy diet and iron supplementation before conception and at the start of pregnancy. This could include integrating information into school and college curricula on health; community initiatives on health; and even television campaigns. This message needs to be reinforced in primary care units so that a mother receives appropriate nutrition advice and supplementation at her first point of contact with healthcare professionals. 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Nutrition during pregnancy: Part I, weight gain : part II, nutrient supplements. Washington, D.C: National Academy Press. (54) Blackburn, S. T. (2013). Maternal, fetal, & neonatal physiology: A clinical perspective. Maryland Heights, MO: Elsevier Saunders. (55) Lauwers, J., & Swisher, A. (2011). Counseling the nursing mother: A lactation consultant's guide. Sudbury, MA: Jones & Bartlett Learning. (56) Duggan, C., Watkins, J. B., & Walker, W. A. (2008). Nutrition in pediatrics: Basic science, clinical application. Hamilton: BC Decker. Appendix Table 1: Dietary Iron Requirements per Day (4, adapted) Table 2: causes of iron deficiency anaemia( 4, adapted). Read More