Nutrition News for Africa
Abstract - July 2008
Report of the World Health Organization Technical Consultation
on Prevention and Control of Iron Deficiency in Infants and
Young Children in Malaria-Endemic Areas (Lyon, France, 12-14
June 2006). Food and Nutrition Bulletin, volume 28, number
4, pages S489-S631, 2007.
Introduction
The World Health Organization (WHO) convened a Technical
Consultation to discuss the findings of two large, community-based,
randomized, controlled trials designed to evaluate the impact
of iron plus folic acid supplementation on morbidity and mortality
of young children (1, 2). One trial was conducted in Zanzibar,
where malaria transmission is intense and occurs year-around,
and the other in Nepal, where exposure to malaria is low.
Findings confirmed that the iron supplementation is effective
for reduction of iron deficiency and anemia in iron-deficient
children. However, in Zanzibar routine iron-folic acid supplements
given with or without zinc resulted in an increased rate of
severe adverse events (hospitalization and mortality) in children.
The objective of the Consultation was to review the scientific
evidence on the safety and efficacy of different ways of administering
iron to control iron deficiency and iron-deficiency anemia,
and to provide guidance on the safest, most feasible, and
most effective ways of delivering additional iron to control
iron deficiency in infants and young children in malaria-endemic
areas.
Conclusions of WHO Consultation
The Consultation reached consensus on several important issues
related to providing additional iron to infants and young
children in malaria-endemic areas. In particular, strategies
to control iron deficiency in malaria-endemic regions should
be carried out in the context of comprehensive and effective
health care, including the provision of insecticide-treated
bed nets and vector control for the prevention of malaria,
and prompt recognition and treatment of malaria and its complications
with effective antimalarial and antibiotic drug therapy. Measures
to control iron deficiency should also include the control
of other prevalent parasitic diseases and infections, delayed
cord clamping and the promotion of exclusive breastfeeding
for the first 6 months of life, followed by consumption of
nutrient-dense and/or processed, fortified complementary foods.
Universal iron supplementation (use of medicinal iron as
pills or syrups) should not be implemented without the screening
of individuals for iron deficiency, because this mode of iron
administration may cause severe adverse events in iron-sufficient
children.
The safety of iron preparations administered through point-of-use
fortification of complementary foods for infants and young
children, i.e. powders, crushable tablets, and fat-based spreads,
is uncertain in malaria-endemic regions. Although there is
reason to believe that these preparations may be safer than
iron supplements, they cannot be recommended until this assumption
has been confirmed.
One option would be to administer additional iron to infants
and young children as processed complementary foods fortified
with iron. Although the safety of their use has not been documented,
this approach would avoid the potential adverse effects of
a large bolus of iron taken in a single dose, since the iron
would be consumed in smaller amounts throughout the day and
therefore absorbed more slowly.
Because widespread folate deficiency is not known to be a
problem in infants and young children, and supplemental folic
acid may interfere with the efficacy of antifolate antimalarial
drug therapy, supplemental folic acid or food fortified with
folic acid should not be given to infants and young children
in areas where antifolate antimalarial drugs are used.
Program and Policy Implications
Iron deficiency and iron deficiency anemia are common in
young children, and provision of additional iron to infants
and young children who are iron deficient should be a public
health priority. However, in malaria-endemic regions, and
possibly other areas of the world as well, precautions are
required to ensure that: 1) iron supplements (including point-of-use
fortification products) are only given to iron deficient children,
or 2) iron is provided in small doses distributed over the
day in processed complementary foods. Any iron supplementation
program in malaria-endemic areas has to be well integrated
into health programs to prevent and treat malaria and other
common infectious diseases.
NNA Editors' comments*
The Lyon conference focused only on the issue of adverse
effects of iron in malaria-endemic regions, which includes
most of sub-Saharan Africa. There is also evidence from studies
in non-malaria endemic regions that iron supplementation of
iron-sufficient children can increase the risk of infections
and restrict children’s growth in such settings (3,
4). Thus, possible risks and benefits of iron supplementation
must be considered in relation to underlying iron status in
all settings, not just malaria-endemic regions. Furthermore,
it is important to note that the adverse effects of iron detected
in the Zanzibar study appeared to be specific to iron status,
and were not directly related to anemia. Thus, measurement
of hemoglobin concentration should not be used as a proxy
for assessing iron status for making decisions about the use
of iron supplements. Rather, iron status should be measured
directly, using indicators like serum ferritin or red blood
cell protoporphyrin.
*Note that the comments have been added by the editorial
team and are not part of the cited publication.
References
1. Sazawal S, Black RE, Ramsan M, et al. Effects of routine
prophylactic supplementation with iron and folic acid on admission
to hospital and mortality in preschool children in a high
malaria transmission setting: community-based, randomized,
placebo-controlled trial. Lancet 2006;367:133-43.
2. Tielsch JM, Khatry SK, Stoltzfus RJ, et al. Effect of
routine prophylactic supplementation with iron and folic acid
on preschool child mortality in southern Nepal: community-based,
cluster-randomised, placebo-controlled trial. Lancet 2006;367:144-52.
3. Dewey KG, Domellöf M, Cohen RJ, Landa Rivera L, Hernell
O, Lönnerdal B. Iron supplementation affects growth and
morbidity of breast-fed infants: results of a randomized trial
in Sweden and Honduras. J Nutr 2002;132:3249-55.
4. Mitra AK, Akramuzzaman SM, Fuchs GJ, Rahman MM, Mahalanabis
D. Long-term oral supplementation with iron is not harmful
for young children in a poor community of Bangladesh. J Nutr
1997;127:1451-5.
You can find the summarized article and more detailed information
on the Internet by opening the following link: www.foodandnutritionbulletin.org
(Search FNB Archives for: Vol 28, No 4 (2007) Supplement 1.
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