{"paper_id":"11a8b9a4-abf0-4509-9a47-6346472884e5","body_text":"Prevalence and factors associated with iron deficiency anaemia \namong preterm infants attending clinics in Dodoma, Tanzania: A \nfacility- based cross sectional study.   \nChrister R Mchwampaka1, MD, Dina C. Mahamba1, , MD, Shubi Matovelo 2,  \nMD,Shakilu Jumanne1,  \n \n \n \nAuthors’ institutional affiliations  \n1Department of Paediatrics & Child Health, University of Dodoma Tanzania \n2Department of Biochemisrty and Physiology, University of Dodoma, Dodoma,  \n \nCorrespondence:  Dina Mahamba,M.D \nE-mail: +255755788427, dinamahamba@gmail.com \nDepartment of Paediatrics & Child Health ;College of Health Sciences- University of \nDodoma,Box395,Dodoma- Tanzania \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted October 28, 2024. ; https://doi.org/10.1101/2024.10.25.24316098doi: medRxiv preprint \nNOTE: This preprint reports new research that has not been certified by peer review and should not be used to guide clinical practice.\n\nAbstract \nAim: Iron deficiency anemia (IDA) among preterm infants is a global public health \nproblem due to its effects on development, immunity and general growth that may be \nirreversible. Despite the high burden of preterm births in Tanzania the prevalence and \nfactors associated with IDA among preterm infants remains relatively understudied \nand this constituted of the aim of this study. \nMethods: A cross-sectional analytical study design was conducted among 190 preterm \ninfants who attended p ediatric clinic in Dodoma  City from December 2022 to May \n2023. Socio-demographic, clinical information, and laboratory markers of hemoglobin \nand iron status were obtained. Logistic regression analysis was applied to determine \nfactors associated with the outcome (Iron Deficiency Anaemia). \nResults: A total of 190 preterm infants were enrolled in the study and the mean age \nwas 4.01 months (SD ±0.99 month. The prevalence of IDA among preterm infants was \n11.58%. Factors associated with IDA were very low birth weight (AOR 6.906, CI: \n1.4774-32.359, p value < 0.0142), preterm infant not supplemented with Iron (AOR \n6.282, CI:1.045 -37.763, p value< 0.0446, multiple pregnancies (AOR 6.848, \nCI:1.692-27.708, p value < 0.0006) and severe anaemia during pregnancy (AOR \n11.998, CI:5.068-40.197, p value< 0.0001).  \nConclusion: Iron deficiency anemia was found to be 11.58% which fall under public \nhealth problem under WHO classification.  To reduce IDA among preterm infants, \nthere has to be an emphasis on iron supplementation to all preterm infants, and those \nwith very low birth weight, born from mother who had multiple pregnancy and severe \nanaemia during pregnancy need close follow up and improved postnatal  \nKeynotes \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted October 28, 2024. ; https://doi.org/10.1101/2024.10.25.24316098doi: medRxiv preprint \n\n• This study enrolled 190 preterm infants attending p ediatric clinic in Dodoma \ncity to determine factors associated with iron deficiency anaemia (IDA)  \n•  Globally IDA in preterm infants   range between 25 to 80, which   complicates \ntheir prematurity by causing poor growth, poor functioning of multiple organ \nsystems, poor neurological development and contributes to death and \ndisability  \n• Iron supplementation to all preterm infants is highly recommended  \n \nKey words: Iron deficiency anaemia, Preterm infants \nBackground \nIron deficiency anemia (IDA) develops  when the body's iron reserves are insufficient \nto maintain the regular synthesis of red blood cells (RBCs) , inadequate dietary iron, \nimpaired iron absorption, bleeding, or loss of body iron in the urine may be the cause  \n(Hempel & Bollard, 2016)  IDA among preterm  infants is d ocumented as a  global \npublic health problem, with prevalence  ranging from 25% to 80%(Ferri et al., 2014)This \nis consistent with world health organization (WHO)’s standard, revealing that when the \nIDA prevalence is 5% it is considered a public health burden (Paulley & Duff, 2022). \nPreterm infants in the first week of life had   26.4 times  likely to develop iron depletion  \nwhich can lead to IDA compared to  term infants with normal birth weights ,  the high \nprevalence of IDA among preterm infants has been associated with low iron stores at \nbirth, early onset of erythropoiesis, rapid catch -up growth, iatrogenic blo od loss , \nlimited dietary sources of iron, (Moreno-Fernandez et al., 2019) . IDA in preterm \ninfants  complicates their prematurity by causing poor growth, poor functioning of \nmultiple organ systems, and poor neurological development (McCarthy et al., \n2019a).This leads to the increase of infant mortality rates (Moreno-Fernandez et al., 2019)  \nIn  sub-Saharan Africa, IDA is not well reported especially for preterm  infants  ,  most \nof the studies have reported the prevalence of IDA for under five children accounting \nto 60%   (Lemoine & Tounian, 2020)  ,In East Africa according to a study done by \nHellen in Kenya to assess the prevalence of iron deficiency and iron deficiency anaemia \nin low-birth-weight infants on follow -up at Kenyatta National Hospital was 14.5% \n(Hellen G, 2019).  In Tanzania few conducted studies demonstrated  (44.2%) \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted October 28, 2024. ; https://doi.org/10.1101/2024.10.25.24316098doi: medRxiv preprint \n\nprevalence of IDA among infants in Dar es Salaam (Omar Lweno et al., 2022) and 50% \namong under-five age children  in Kilimanjaro (Urio et al. 2019). \nThe  factors that were documented to be  associated with IDA among preterm  infants \ninclude Birth weight and phlebotomy (Beard et al., 2007; Ganjigunta et al., 2021; \nStrauss, 2010) Gestation type (Ru et al., 2016; Shinar et al., 2017), Age (Hassan et al., \n2016) feeding practices  preterm infants and  mothers who are  not supplemented with \niron during pregnancy , Low hemoglobin level, maternal illness   (Gurung et al., 2020b:  \n(Q.Li et al.,2019) \n In Tanzania, only few studies have been conducted and the factors were generalised to \ninfants and under five year’s children not specific to preterm infants, the factors stated \nincluded; maternal hemoglobin, sex of the child, low income, low birth weight, small \nfor gestational age (SGA), preterm delivery, and dietary status of infants and women \n(Omar Lweno et al., 2022). This study aimed to determine the prevalence and factors \nassociated with iron deficiency anaemia in preterm infants attending premature clinic   \nin Dodoma city.  \nMethods \nThis was a hospital based analytical cross section study design conducted at pediatric \nclinic at Dodoma Region Referral Hospital (DRRH) and RCH clinic in Makole health \ncentre in Dodoma city, central Tanzania. Duration of study was six months starting \nfrom December 2022 to May 2023 .The average attendance of preterm per months at \npaediatric clinic is 88 at DRRH, and 32 per months at RCH clinic at Makole Health \ncentre. Paediatric clinic at DRRH serves infants who have been discharged from the \nDDRH and therefore infants from other facilities before reaching the target weight of \n2.5kg. At DRRH, each visit to the clinic, preterm infant’s weight and vital signs are \ncarefully monitored to track their progress.  Additionally, the pediatric clinic ensures \nthat the preterm infants receive appropriate supplementation by providing iron and \nmultivitamin supplements,blood investigations like full blood picture, blood grouping \nand cross matching are taken from infants whose assessment findings by attending \ndoctor dictate . RCH clinic at Makole Health Centre receive large population of \ninfants’ average of 40 for immunization  according to their age as   per Expanded \nProgramme on Immunization.  \n 3.7 The sample size \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted October 28, 2024. ; https://doi.org/10.1101/2024.10.25.24316098doi: medRxiv preprint \n\n The sample size was calculated using the Kish & Leslie  \n𝑁 = 𝑍2 𝑃(1 − 𝑃)\n𝑑2  \nWhereby: \no N = sample size \no Z = score for 95% Confidence Interval which is 1.96 \no P = prevalence in a previous study \no d = tolerable error set at 5%, \nP = Prevalence of IDA in preterm infants with low birth weight from previous study \nwhich was 14.5% was used according to study done in  Kenya at Kenyatta National \nHospital in 2019 (Hellen G, 2019)  \nThe study included preterm  infants aged 3 to 6 months , (infants born before < 37 \ncompleted weeks) Confirmed by RCH card 4 \nInfants with feeding difficulties due to different medical conditions example \ncongenital anomalies like cleft lip and palate, hydrocephalus, history of bleeding, who \nwere sick were, (eg high temperature ≥38C) were excluded  \nPreterm infants meeting the inclusion criteria were consecutively enrolled until the \nrequired sample size was attained \nEnrolment was done only after parents/guardians had signed a written informed \nconsent at admission in the neonatal ward. Ethical approval to conduct the study was \ngranted by the University of Dodoma research and ethical review board with ethical \nclearance reference number MA.84/261/59/154. Permission to conduct the study was \nsought from the DRRH and Makole Health centre administration. A pretested \nstructured data collection sheet was used to extract demographic , medical history,  \nclinical data of preterm inf ants and mothers,  enrolled in the study. Physical \nexamination   and   laboratory results was done on all preterm infants up component \nof the study. Social demographic data such as place of residence, age, sex, gestation \nage, weight, current feeding practices, phlebotomy and iron supplement status were \nrecorded, also parents' or guardians' Gestation type, last hemoglobin level before \ndelivery, any maternal illness like pregnancy induced hypertension, gestation diabetics \nand postpartum hemorrhage were collect ed.  Each participant was examined for \npaleness and any sign of iron deficiency anemia like brittle or spoon-shaped nails.  \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted October 28, 2024. ; https://doi.org/10.1101/2024.10.25.24316098doi: medRxiv preprint \n\nUnder aseptic technique peripheral vein was identified and tourniquet applied 4 -5 \ninches from the puncture site, by using a gauge needle, the skin was punctured to \naccess the vein. Approximately 6 milliliters of venous blood drawn. 4 milliliter was \nkept in the red top blood Collection tube for CRP and serum ferritin test, 2milliliter \nwere kept on an EDTA purple top blood collection tube for Full Blood Picture test. All \nsamples were kept in ice bag 2 -8 centigrade, then transported to the lab according to \nlaboratory instructions.  (FBP) was measured using CELL -DYN Ruby hematology \n(Genway Biotech, USA) whereas serum ferritin and CRP were measured using Snibe \nMaglumi 800 analyser (Genway Biotech, USA). From the FBP; Hb level. MCV, and \nMCH were determined. All the samples were tested at DRRH laboratory, samples \ncollected from Makole Health Center were collected and transported to DRRH \nLaboratory through Cool box temperature of 2C to 8C. IDA was defined if they met \nany of the following criteria: HB < 10, MCV < 80fl, MCHC <32 g/ dl, (Serum Ferritin \n< 12 ug/L and CRP < 5 mg/dL)  \nData analysis was done  using the Statistical Package for Social Science (SPSS) \nsoftware version 2 5. Categorical variables were summarized using percentages (%) \nand frequency distributions, whereas mean and median with their measures of \ndistributions were used to summarize continuous variables. Multinomial logistic \nregression was used to determine the as sociation between clinical and laboratory \nfactors and adverse outcomes for IDA. Variables with a p-value of < 0.2 for unadjusted \nmultinomial logistic analysis were included in the  adjusted multinomial logistic \nregression analysis to determine i ndependent factors associated with IDA poor \noutcomes. Odds ratios were reported with 95% confidence interval and variables with \np values of <0.05 were considered statistically significant. \n  \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted October 28, 2024. ; https://doi.org/10.1101/2024.10.25.24316098doi: medRxiv preprint \n\nResults  \nFrom December 2022 to May 2023, A total of 190 enrolled in this study 139 from DRRH and \n51 from Makole Health Centre   \n \n Figure 1: Flow chart of Enrolled in preterm infants  \n \n \nRESULTS \nA total of 190 preterm infant with response rate of were enrolled in this study. 139 \nfrom pediatric clinic at DRRH and 51 from Makole Health were enrolled in this study \n148 Infants attended at \nDRRH \n54 infants attended at \nMakole Health Centre \n9 infants were excluded \n-6 had fever \n-3 Transfused in the past 3 \nmonths \n \n3 infants were excluded \n2 had fever \n1 Transfused in the past 3 \nmonths \nEligible infants \n139(73.1%) \nEligible infants \n51(26.8%) \n      Total                                       \nrecruited infants \n 190 \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted October 28, 2024. ; https://doi.org/10.1101/2024.10.25.24316098doi: medRxiv preprint \n\n \n \nInfant and maternal demographic data and clinical characteristics  \nMajority of preterm infants 109, (57.37%) were females. Mean age was 4.01 months \n(SD 0.99 month). Majority of infants (157, (82.63%) were born as singletons, more \nthan half 123 (64.74%) had birth weight of 1.5 kg or more and 175 infants (92.11%) \nwere on iron supplements. Most 145(90.65%) of the mothers had no maternal illness \n(pregnancy induced hypertension, gestation diabetics and postpartum hemorrhage) \nduring pregnancy and 22(11.58) had severe anaemia. Table 1  summarizes the \ndemographic data characteristics of the infants and maternal  \nTable 1: Infant and maternal demographic and clinical characteristics by IDA  \n Frequency  Percent  \nAge (months) \n             3-4 131 68.95 \n             5-6 59 31.05 \nSex    \n             Female 109 57.37 \n              Male 81 42 \nBirth weight in kg \n   \n              <1.5 (Very low birth weight) 67 35.26 \n              1.5 ≤2.5 (Low birth weight) 123 64.74 \nGA at birth in weeks  \n              <32 (Very preterm) 76 40.00 \n              32-33(moderate preterm) 40 21.05 \n              34-37(Late preterm) 74 38.95 \nPhlebotomy since birth \n              None 66 34.74 \n              1-2 times 106 55.79 \n               >2 times 18 9.47 \nCurrent feeding practices  \n              Exclusive breastfeeding 146 76.84 \n              Mixed feeding 44 23.165 \n  Iron supplementation   \n             No 15 7.89 \n            Yes 175 92.11 \nPallor \n              Pale 75 39.47 \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted October 28, 2024. ; https://doi.org/10.1101/2024.10.25.24316098doi: medRxiv preprint \n\n             Not pale 115 60.53 \n \nGestation type \n             Single tone 157 82.63 \n             Multiple pregnancy 33 17.37 \nDuration of iron supplements (months)   \n            <3 44 23.16 \n            ≥ 3  146 76.84 \nLast hb before delivery   \n            <7g/dl severe anaemia 22 11.58 \n             ≥7g/dl mild and anaemia to \nnormal \n168 88.42 \nAny maternal illness during pregnancy  \n(PIH,gestationa ldiabetes ,antepartum \nhemorrhage and maralia) \n  \n            Yes 30 15.79 \n            No 160 84.21 \nLaboratory findings of the infants \nHemoglobin (hb)    \n           Normal (> 10g/dl) 125(65.79)  \n            Low (<10g/dl) 65(34.21)  \n \nPrevalence of IDA among infants born preterm \nThe total of twenty -two of the 190 study participants had IDA making overall \nprevalence of IDA among preterm unfants to be 11.58% \n \n \n \n \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted October 28, 2024. ; https://doi.org/10.1101/2024.10.25.24316098doi: medRxiv preprint \n\n \nFigure 1: Prevalence of Iron deficiency anaemia among preterm infants  \n \n \n \nFactors associateds with Iron deficiency anemia among preterm infants aged 3 to \n6 months.  \nChi-square test was used to assess the factors associated with iron deficiency anemia \n(IDA) among preterm infants (3 to 6 months). In this study the findings show, that \nIDA was associated with very low birth weight (p=<0.0001), preterm infants who are \nnot on iron supplementation (p=. <.0001), very preterm (gestation age at birth of less \nthan 32 weeks) (p= 0.0165), mul tiple pregnancy (p=0.007), duration of Iron \nsupplementation of maternal of less than 3 month (p=0.0084) and severe anemia \nduring pregnancy (p=0.0011). See table 2 for further observation of the findings \n \n \nTable 2: Chi-square test and results on the assessment of factors associated with \niron deficiency anemia (IDA) among preterm infants (aged 3 to 6 months)  \nVariables No IDA \nN (%) \nIDA \nN (%) \nChi-\nsquare \nP-Value \n                  Infant factors     \nAge (months)      \n             3-4 116(88.55) 15(11.45) 0.0068 0.9342 \n             5-6 52(88.14) 7(11.86)   \nSex      \nFemale 97(88.99) 12(11.01) 0.00811 0.7758 \nMale 71(87.650 10(12.35)   \nBirth weight(kg)       \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted October 28, 2024. ; https://doi.org/10.1101/2024.10.25.24316098doi: medRxiv preprint \n\n<1.5 (Very low birth weight) 54(80.60) 13(19.40) 15.8739 <.0001 \n1.5+ (Low birth weight) 114(92.68) 9(7.32)   \nGA at birth (weeks)     \n<32 (Very preterm) 62(81.58) 14(18.42) 8.2121 0.0165 \n32-33Early moderate) 37(92.50) 3(7.50)   \n34-37 (Late moderate preterm) 69(93.24) 5(6.76)   \nPhlebotomy since birth      \nZero 60(90.91) 6(9.09) 5.1619 0.0757 \n1-2 times 95(89.62) 11(10.38)   \n>2 times 13(72.22) 5(27.78)   \nFeeding practices      \n            Exclusive breastfeeding 130(89.04) 16(10.96) 0.2367 0.6266 \nMixed feeding (Breast feeding \nwith formular milk) \n38(86.36) 6(13.64)   \n Iron supplementation       \nNo 6(40.00) 9(60.00)  <.0001* \nYes 162(92.57) 13(7.43)   \nMaternal characteristics \nGestation type     \nSingleton 145(92.36)) 12(7.64)  0.0010* \nMultiple pregnant 23(69.70) 10(30.30)   \n    \nDuration of iron supplementation \n(months) \n   \n \n \n   <3  34(77.27) 10(22.73) 6.95510   0.0084 \n   ≥3 134(91.78) 12(8.22)   \nLast hb before delivery    <.0001* \n<7g/dl (severe anaemia) 11(50.00) 11(50.00)   \n>7g/dl no severe anaemia) 157(93.45) 11(6.55)   \nMaternal illness during \n pregnancy \n any of the maternal illness (PIH, \nMalaria, gestational diabetes, \nantepartum hemorrhage) \n   0.0547* \nYes 23(76.67) 7(23.33)   \nNo 145(90.63) 15(9.38)   \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted October 28, 2024. ; https://doi.org/10.1101/2024.10.25.24316098doi: medRxiv preprint \n\n   \n \n4.5 Factors associated with iron deficiency anemia and preterm infants aged 3 \nto 6 months.    \nBinary logistic regression was used to determine the factors association with  iron \ndeficiency anemia among preterm infants aged 3 to 6 months. which revealed that; \nVery low birth weight (OR6.80, p value <0.0003), Low gestation age (OR3.14, p value \n<0.0.028), having more phlebotomy (OR3.85, p value <0.047), Preterm Infant not \nsupplemented with Iron (OR18.69, p value <0.000),  mothers who had  multiple \npregnancy (OR5.26, p value <0.001), Less than  3 months on iron supplemented with \nIron during pregnancy (OR3.29, p value <0.011), Low Hb for mothers before delivery \n(OR14.27, p value <0.000), maternal illness during pregnancy (OR2.94, p value \n<0.034). All those factors with p value <0.25 at bivariate level were subjected to \nmultivariate model. \nUpon adjusted binary logistic regression; only four factors with p value <0.05 at 95% \nCI remained significant associated with IDA, the factors included: Very low birth \nweight (OR6.91, p value <0.014), preterm infant not supplemented with Iron (OR6.28, \np value <0.045), mothers who had multiple pregnancy (OR6.85, p value <0.007) and \nLow Hb for mothers before delivery (OR11.99, p value <0.001). \n \n \n \n \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted October 28, 2024. ; https://doi.org/10.1101/2024.10.25.24316098doi: medRxiv preprint \n\nTable 3 summarizes the factors associated with iron deficiency anaemia. \nTable 3: Logistic Regression for Factors Associated with Iron Deficiency Anaemia for Preterm Infants Aged 3 to 6 Months  \n No IDA \nN (%) \nIDA \nN (%) \nUNADJUSTED ADJUSTED \nInfant factors \nVariable 168(88.42) 22(11.58) OR [95% CI] P-Value AOR [95%CI] P-Value \nBirth weight(kg)       \n<1.5 54(80.60) 13(19.40) 6.800[2.386,19.383] 0.0003 6.906[1.474,32.359] 0.0142 \n1.5+ 114(92.68) 9(7.32) Ref  Ref  \nGA at birth(weeks)       \n<32 62(81.58) 14(18.42) 3.139[1.134,8.689] 0.0276 1.988[0.450,8.784] 0.3645 \n32-33 37(92.50) 3(7.50) 0.633[0.122,3.283] 0.5859 1.179[0.166,8.369] 0.8692 \n34-37 69(93.24) 5(6.76) Ref  Ref  \nPhlebotomy since birth       \nNo 60(90.91) 6(9.09) Ref  Ref  \n1-2 (times) 95(89.62) 11(10.38) 1.158[0.407,3.295] 0.7835 0.369[0.082,1.664] 0.1944 \n>2 (times) 13(72.22) 5(27.78) 3.847[1.018,14.541] 0.0470 1.843[0.200,16.941] 0.5892 \nIron supplementations        \nNo 6(40.00) 9(60.00) 18.692[5.759,60.674]  6.282[1.045,37.763]  \nYes 162(92.57) 13(7.43) Ref <.0001 Ref 0.0446 \nMaternal factors \nGestation type       \nSingle tone 145(92.36)) 12(7.64) Ref  Ref  \nMultiple pregnant 23(69.70) 10(30.30) 5.255[2.037,13.554] 0.0006 6.848[1.692,27.708] 0.0070 \nDuration of iron supplements during pregnancy (months)    \n<3 34(77.27) 10(22.73) 3.285[1.309,8.240] 0.0113 1.835[0.452,7.457] 0.3960 \n≥ 3 134(91.78) 12(8.22) Ref  Ref  \nLast hb before delivery        \n<7 g/dl (severe anemia) 11(50.00) 11(50.00) 14.273[5.068,40.197] <.0001 11.998[2.699,53.335] 0.0011 \n≥7g/dl (not severe anaemia) 157(93.45) 11(6.55) Ref  Ref  \nMaternal illness during pregnancy  \n(Any of maternal illness Malaria, PIH, gestational, diabetes and antepartum hemorrhage) \n  \nYes 23(76.67) 7(23.33) 2.942[1.083,7.992 0.0343 2.398[0.490,11.742] 0.2807 \nNo 145(90.63) 15(9.38) Ref  Ref  \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted October 28, 2024. ; https://doi.org/10.1101/2024.10.25.24316098doi: medRxiv preprint \n\nCHAPTER FIVE \nDISCUSSION \n \nIron deficiency anemia (IDA) leads to poor growth, poor functioning of multiple organ systems, \npoor neurological development, effects on memory, cognition and auditory brain responses and \nirreversible long-term complications such as bone diseases among preterm infants. In Tanza nia \nfew conducted studies demonstrated high   (44.2%) prevalence of IDA among infants in Dar es \nSalaam (Omar Lweno et al., 2022) .Prevention is achieved by early initiation of iron \nsupplementation of elemental iron for preterm infants as prophylaxis against IDA.  In this cross -\nsection study 190 preterm infants were enrolled. The study aimed to determine the prevalence and \nfactors associated with IDA in preterm infants aged 3 to 6 months. The prevalence of IDA was \nfound to be 11.58%. Very low birth weight, (birth weight less than 1.5kg, those who were not \nsupplemented by iron, and those mothers who had multiple gestation and severe an emia were \nstrongly associated with occurrence of IDA. \nThe overall prevalence of iron deficiency anemia (IDA) in this study was found to be 11.58%. This \nis a public health  problem as define by WHO that if  prevalence ≥5% (measuring by ferritine \nconcentrations below the recommended cut off values (Paulley & Duff, 2022).However it is  almost  \nsimilar  to  the study  that was conducted  in Sweden  at Umea University that found the prevalence \nof IDA  to be  9.9%(Berglund et al., 2010) . Similarity in findings may be attributed by age groups \nof preterm infants in both studies that were within 6 months following birth, all infants had low \nbirth weight and majority in both groups were exclusive breastfeeding.  The findings in this study \nwere also close to another study done in Kenya that revealed prevalence of 14.6% for IDA (Hellen \nW Githaiga, 2019). Similarity in the prevalence could be possibly due to the fact that both studies  \ninvolved children with low birth weight, same study design,  majority of infants  were on iron \nsupplements, similar culture setting, availability of health services  and majority of infants were 6 \nmonths and below  same as current study .  \nThe prevalence of this study was low compared to the study conducted in Turkey which found the \nprevalence of Iron deficiency anemia in late -preterm infants to be 42.8% ( Ozdemir et al., 2013). \nThis observed   differences in findings  can be  attributed by the fact that participants involved in \nTurkey  were not on iron supplement  unlike this study where by majority of participants (92.57%) \nwere  on iron supplementation, this might have led to the higher prevalence in the study conducted \nTurkey since the documented evidince indicate that    premature infants   who are not supplemented  \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted October 28, 2024. ; https://doi.org/10.1101/2024.10.25.24316098doi: medRxiv preprint \n\nare associate with IDA (Ozdemir et al., 2010) . In addition, the study in Turkey included,  lower \nage premature infants (2 to 4 months) that utilize and need  more Iron for their growth  compared \nto  3 to 6 months  age used in  our study.  Postnatal, iron stores can be rapidly depleted during the \nfirst  six to eight weeks, coinciding with the onset of erythropoiesis and rapid catch -up growth \n(Rao & Georgieff, 2009) . Additionally, another study conducted in Brazil reported a higher \nprevalence of 26.5% among preterm infants with very low birth weight  aged one year of corrected \nage (Ferri et al., 2014) .The difference may be attributed by difference in the birth weight for the \nstudy population where the study focused on infants with less than 1.5 kg  and gestation age of \n<34 weeks compared to the current study that considered infants with less than 2.5 kg and gestation \nage <37 weeks.  The documented evidence indicate that  higher demand of Iron in infants with low \nbirth weight is  due to rapid growth, also most of the iron transfer to fetus do occurs during the third \ntrimester , therefore   the level of IDA  increase as gestation age decrease, (Jopling et al., 2014) \nFurthermore the finding in the current study was higher compared to the study conducted  in \nIndonesia which revealed  the prevalence of 6% (Puspitasari et al., 2017). This difference probably \nis due to involvement of participants born at very preterm (gestation age of 28 weeks to the current \nstudy compared that of Indonesia, which involve moderate to rate preterm (gestation age of 32 \n<37) as documented that there is associated between IDA and low gestation age  this is due to \nincrease of rapid growth,high iron needs and reduced iron store(Omar Lweno et al., 2022). \nBasing on the findings of the current study, preterm infants with very low birth weight (less than \n1.5kg) were six-fold more likely to have IDA compared to their counterparts (above 1.5kg) This \nresult is comparable to others studies conducted in Korea, India  and Brazil where  their results \nindicated a positive association  of low birth weight with IDA (Ganjigunta et al., 2021; Joo et al., \n2016; Ferri et al.,2014). Different studies demonstrated a correlation  between a lower birth weight  \nand IDA in infants, this is mainly attributed by  lower store of iron at birth and higher  iron \nrequirements due to increased postnatal growth (Moreno-Fernandez et al., 2019) .Iron is an \nessential element for the function of  growing and differentiating cells  so if there is in rapid growth  \nas seen in very low birth more iron is needed compare to low birth  weight  (Ferri et al., 2014)  \nIn this study we observed that preterm infants who had iron supplementation were less likely to \ndevelop IDA. This result is comparable to other studies conducted  in Indonesia and China which \nrevealed similar correlation (Berglund et al., 2010; Li et al., 2021) . Also a  systematic study that \nevaluated iron supplementation in preterm and low -birth-weight infants, confirmed that iron \nsupplementation  increased hemoglobin and ferritin concentrations and a reduction in iron \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted October 28, 2024. ; https://doi.org/10.1101/2024.10.25.24316098doi: medRxiv preprint \n\ndeficiency anemia (McCarthy et al., 2019b).  Another study conducted in Italy that found  similar \ncorrelation went further to explain the association  basing on the fact that the more the duration of \niron supplementation, the higher the possibility of increased hemoglobin and ferritin \nconcentrations and a reduction in iron deficiency anemia,  (Raffaeli et al., 2020). It  has also been \ndocumented that  maternal iron is transferred to fetus during the third trimester of gestation but \nonce the transfer is interrupted by preterm birth  iron stored  deprived, thus  preterm  infants that  \nare not supplemented with iron end up with IDA(Berglund et al., 2010).  \n. \nThe current study revealed that mothers who had   low hemoglobin level during pregnancy \nincreased the odds of having preterm infants with IDA. This finding is similar to the study done in \nPhilippines, of which the results indicated  that  at 6 months evidence from the 2015–16 TDHS-\nMIS cross-sectional household survey in Tanzania (Msaki et al., 2022) , which found a similar \nresult and is supported by other evidence that suggested that anemic pregnant women are more \nlikely to have preterm infant (Gurung et al., 2020) , and hence increased the risk for IDA. In \naddition other  research evidence conclude that preterm infants  are deprived of the significant iron \ndeposit that occurs in the third trimester of pregnancy and have reduced iron stores at birth \ncompared with term infants (McCarthy et al., 2019b). This effect is more severe when  the woman \nhad anemia in pregnancy especially  in the third trimester, the observed result and association \ncould be linked to maternal anemia during pregnancy which has correlation to having infant with \nLBW(Enawgaw et al., 2019; Figueiredo et al., 2019) . Another  study conducted at Era Lucknow \nMedical College in India  (Shukla et al., 2019) on effect of maternal anemia on the status of iron \nstores in infants, concluded that maternal IDA may have an effect on the iron stores of newborns.  \nDuring pregnancy,the mother’s body prioritizes transferring iron to the developing fetus.As a \nresult,mother with anemia may have lower iron stores herself,and this can affect the iron stores \nthat are transferred to the baby in utero.(Terefe et al., 2015) \nIt was also uncovered by this study that mothers who had multiple pregnancy were more likely to \nhave preterm infants with IDA compared to those who had a singleton pregnancy.  The current \nstudy  results concurs with what was reported  in the study conducted  at  the Ohio State University \nWexner Medical Center in USA   which concluded that twin babies born preterm (≤37 weeks) are \nat greater risk of low iron stores at birth and of ID later in infancy (Campbell et al., 2022). It could \nfurther be linked to the fact that iron deficiency and anemia are prevalent in women with multiple \npregnancy (Ru et al., 2016), so that for pre-term twin babies, the odds for IDA increases as found \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted October 28, 2024. ; https://doi.org/10.1101/2024.10.25.24316098doi: medRxiv preprint \n\nin our study. The maternal iron requirements are increased during twin pregnancies, estimated to \nbe 1.8 times more than during singleton pregnancies, due to increased foetal and placental needs \nas well as increased maternal plasma volume expansion and red blood cell mas s (Shinar et al., \n2017). Therefore, compared to singleton gestations, maternal hemoglobin (Hgb) in multiple \npregnancies is lower in all trimesters, with an estimated IDA rate of 2.4 to even 4 times (Shinar et \nal., 2017) \n6.1 Conclusion \nThis study revealed that Iron Deficiency Anaemia is prevalent among preterm infants aged 3 to 6 \nmonths at health facilities in Dodoma city despite majority of them being on haematinics \nsupplement. The prevalence was found to be 11.58%, the very low birth weight of the preterm \ninfants, preterm infant not supplemented with Iron,  mothers who had multiple pregnancy and \nmothers having low Hb before delivery  were associate with IDA.  Emphasis on iron \nsupplementation to all preterm infants, and those with very low birth weight, born from mother \nwho had multiple pregnancy and severe anaemia during pregnancy need close follow up and \nimproved postnatal to reduce IDA. \nAcknowledgements  \nWe cannot express enough gratitude to the women who consented to let their preterm infants to \nparticipate in the study. Special thanks to Dr Halima Kasimu in charge of pediatric clinic  from \nDRRH and  Sr Josephine Dikoko incharge from Makole health centre  and all the staff at the at \npremature clinicat  DRRH and RCH clinic . \nFunding  \nNo funding was obtained for this study. \nConflict of interest \nThe authors report no conflict of interest \nCRM: Conceptualization of the project, data collection and analysis and preparation of the \nmanuscript draft \nDM: Conceptualization of the project, data analysis and preparation of the final manuscript \nSM: Conceptualization of the project, data analysis and preparation of the final manuscript   \nSJ: Conceptualization of the project, data analysis and preparation of the final manuscript \n \n \n \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted October 28, 2024. ; https://doi.org/10.1101/2024.10.25.24316098doi: medRxiv preprint \n\nReferences \nBeard, J., deRegnier, R. A., Shaw, M. D., Rao, R., & Georgieff, M. (2007). Diagnosis of iron \ndeficiency in infants. Laboratory Medicine , 38(2), 103 –108. \nhttps://doi.org/10.1309/7KJ11RX758UKLXXM \nBerglund, S., Westrup, B., & Domellof, M. (2010). Iron Supplements Reduce the Risk of Iron \nDeficiency Anemia in Marginally Low Birth Weight Infants. PEDIATRICS, 126(4), e874–\ne883. https://doi.org/10.1542/peds.2009-3624 \nCampbell, R. K., Buhimschi, C. S., Zhao, G., Dela Rosa, C., Stetson, B. T., Backes, C. H., & \nBuhimschi, I. A. (2022). Prevalence of and risk factors for iron deficiency in twin and \nsingleton newborns. 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CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted October 28, 2024. ; https://doi.org/10.1101/2024.10.25.24316098doi: medRxiv preprint \n\nFBP Full Blood Picture \nRCH Reproductive and Child Health \nDRRH Dodoma Regional Referral Hospital \ng/dl Gram per Deciliters \nHb Hemoglobin \nVLBW Very Low Birth Weight \nWHO World Health Organization \n \nReferences \nBeard, J., deRegnier, R. A., Shaw, M. D., Rao, R., & Georgieff, M. (2007). Diagnosis of iron \ndeficiency in infants. Laboratory Medicine , 38(2), 103 –108. \nhttps://doi.org/10.1309/7KJ11RX758UKLXXM \nBerglund, S., Westrup, B., & Domellof, M. (2010). Iron Supplements Reduce the Risk of Iron \nDeficiency Anemia in Marginally Low Birth Weight Infants. PEDIATRICS, 126(4), e874–\ne883. https://doi.org/10.1542/peds.2009-3624 \nCampbell, R. K., Buhimschi, C. S., Zhao, G., Dela Rosa, C., Stetson, B. T., Backes, C. H., & \nBuhimschi, I. A. (2022). Prevalence of and risk factors for iron deficiency in twin and \nsingleton newborns. Nutrients, 14, 3854. https://doi.org/10.3390/nu14183854 \nEnawgaw, B., Birhanie, M., Terefe, B., & Asrie, F. (2019). Prevalence of anemia and iron \ndeficiency among pregnant women attending antenatal care service at University of Gondar \nHospital, Northwest Ethiopia. Clin Lab , 65(4). \nhttps://doi.org/10.7754/Clin.Lab.2018.180822. \nFerri, C., Procianoy, R. S., & Silveira, R. C. (2014). Prevalence and risk factors for iron-deficiency \nanemia in very -low-birth-weight preterm infants at 1 year of corrected age. Journal of \nTropical Pediatrics, 60(1), 53–60. https://doi.org/10.1093/tropej/fmt077 \nFigueiredo, A. C. M. G., Gomes -Filho, I. S., Batista, J. E. T., Orrico, G. S., Porto, E. C. L., Cruz \nPimenta, R. M., dos Santos Conceição, S., Brito, S. M., Ramos, M. de S. X., Sena, M. C. F., \nVilasboas, S. W. S. L., Seixas da Cruz, S., & Pereira, M. G. (2 019). Maternal anemia and \nbirth weight: A prospective cohort study. Plos One , 14(3), e0212817. \nhttps://doi.org/10.1371/journal.pone.0212817 \nGanjigunta, V., Ahirrao, V. S., R., P., & B., R. (2021). Study of iron deficiency anemia in infants \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted October 28, 2024. ; https://doi.org/10.1101/2024.10.25.24316098doi: medRxiv preprint \n\nof 3 to 6 months age group and its risk factors: a cross sectional study. International Journal \nof Contemporary Pediatrics, 8(7), 1183. https://doi.org/10.18203/2349-3291.ijcp20212469 \nGurung, A., Wrammert, J., Sunny, A. K., Gurung, R., Rana, N., Basaula, Y. N., Paudel, P., Pokhrel, \nA., & Kc, A. (2020). Incidence, risk factors and consequences of preterm birth - findings from \na multi-centric observational study for 14 months in Nepal. Archives of Public Health, 78(1), \n1–9. https://doi.org/10.1186/S13690-020-00446-7/TABLES/2 \nHassan, F., El-Gendy, F., Badra, H., Kamal Eldin, S., & Elsayyad, D. . (2016). Evaluation of iron-\ndeficiency anemia in infancy. Menoufia Medical Journal , 29(2), 269. \nhttps://doi.org/10.4103/1110-2098.192412 \nHempel, E. V., & Bollard, E. R. (2016). The Evidence -Based Evaluation of Iron Deficiency \nAnemia. Medical Clinics of North America , 100(5), 1065 –1075. \nhttps://doi.org/10.1016/j.mcna.2016.04.015 \nI, Urio, G., Beyanga, G., Musyoka, A., Ndaro, A., Mwitalemi, R., Maro, M., Majaliwa, E., Kinabo, \nG., & Mmbaga, B. (2019). Iron Depletion, Iron Deficiency, and Iron Deficiency Anaemia \nAmong Children Under 5 Years Old in Kilimanjaro, Northern Tanzania: A Hos pital-Based \nCross-Sectional Study. East African Health Research Journal , 3(1), 42 –47. \nhttps://doi.org/10.24248/eahrj.v3i1.597 \nJoo, E. Y., Kim, K. Y., Kim, D. H., Lee, J. E., & Kim, S. K. (2016). Iron deficiency anemia in \ninfants and toddlers. Blood Research , 51(4), 268 –273. \nhttps://doi.org/10.5045/br.2016.51.4.268 \nJopling, J., Henry, E., Wiedmeier, S. E., & Christensen, R. D. (2014). Reference Ranges for \nHematocrit and Blood Hemoglobin Concentration During the Neonatal Period : Data From \na Multihospital Health. 123. https://doi.org/10.1542/peds.2008-2654 \nLemoine, A., & Tounian, P. (2020). Childhood anemia and iron deficiency in sub-Saharan Africa \n– risk factors and prevention: A review. Archives de Pediatrie , 27(8), 490 –496. \nhttps://doi.org/10.1016/j.arcped.2020.08.004 \nLi, M., Lv, Y., Ying, J., Xu, L., Chen, W., Zheng, Q., Ji, C., & Shao, J. (2021). Effect of Daily \nIron Supplementation on Infantile Iron Homeostasis in Preterm Infants. Frontiers in \nPediatrics, 9(May), 1–10. https://doi.org/10.3389/fped.2021.687119 \nMcCarthy, E. K., Dempsey, E. M., & Kiely, M. E. (2019a). Iron supplementation in preterm and \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted October 28, 2024. ; https://doi.org/10.1101/2024.10.25.24316098doi: medRxiv preprint \n\nlow-birth-weight infants: A systematic review of intervention studies. Nutrition Reviews , \n77(12), 865–877. https://doi.org/10.1093/nutrit/nuz051 \nMcCarthy, E. K., Dempsey, E. M., & Kiely, M. E. (2019b). Iron supplementation in preterm and \nlow-birth-weight infants: a systematic review of intervention studies. Nutrition Reviews , \n77(12), 865–877. https://doi.org/10.1093/NUTRIT/NUZ051 \nMoreno-Fernandez, J., Ochoa, J. J., Latunde -Dada, G. O., & Diaz -Castro, J. (2019). Iron \ndeficiency and iron homeostasis in low birth weight preterm infants: A systematic review. \nNutrients, 11(5), 1–20. https://doi.org/10.3390/nu11051090 \nMsaki, R. V., Lyimo, E., Masumo, R. M., Mwana, E., Katana, D., Julius, N., Munuo, A., Leyna, \nG., Issaka, A. I., Dhami, M. V., & Agho, K. E. (2022). Predictors of iron deficiency anaemia \namong children aged 6 –59 months in Tanzania: Evidence from the 2015 –16 TDHS-MIS \ncross-sectional household survey. PLOS Global Public Health , 2(11), e0001258. \nhttps://doi.org/10.1371/journal.pgph.0001258 \nOmar Lweno, Ellen Hertzmark, Anne Marie Darling, Ramadhani Noor, Leguma Bakari, \nChristopher Sudfeld, Karim Manji, & Wafaie Fawzi. (2022). 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CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted October 28, 2024. ; https://doi.org/10.1101/2024.10.25.24316098doi: medRxiv preprint \n\n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted October 28, 2024. ; https://doi.org/10.1101/2024.10.25.24316098doi: medRxiv preprint \n\n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted October 28, 2024. ; https://doi.org/10.1101/2024.10.25.24316098doi: medRxiv preprint \n\n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted October 28, 2024. ; https://doi.org/10.1101/2024.10.25.24316098doi: medRxiv preprint \n\n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted October 28, 2024. ; https://doi.org/10.1101/2024.10.25.24316098doi: medRxiv preprint \n\n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted October 28, 2024. ; https://doi.org/10.1101/2024.10.25.24316098doi: medRxiv preprint \n\n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted October 28, 2024. ; https://doi.org/10.1101/2024.10.25.24316098doi: medRxiv preprint \n\n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted October 28, 2024. ; https://doi.org/10.1101/2024.10.25.24316098doi: medRxiv preprint \n\n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted October 28, 2024. ; https://doi.org/10.1101/2024.10.25.24316098doi: medRxiv preprint \n\n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted October 28, 2024. ; https://doi.org/10.1101/2024.10.25.24316098doi: medRxiv preprint \n\n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted October 28, 2024. ; https://doi.org/10.1101/2024.10.25.24316098doi: medRxiv preprint \n\n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted October 28, 2024. ; https://doi.org/10.1101/2024.10.25.24316098doi: medRxiv preprint \n\n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted October 28, 2024. ; https://doi.org/10.1101/2024.10.25.24316098doi: medRxiv preprint","source_license":"CC-BY-4.0","license_restricted":false}