Efficacy and acceptability of two iron supplementation schedules in adolescent school girls in Lima, Peru

Intestinal microbiota composition and efficacy of iron supplementation in Peruvian children

OBJECTIVE

Despite repeated public health interventions, anemia prevalence among children remains a concern. We use an evolutionary medicine perspective to examine the intestinal microbiome as a pathway underlying the efficacy of iron-sulfate treatment. This study explores whether gut microbiota composition differs between anemic children who respond and do not respond to treatment at baseline and posttreatment and if specific microbiota taxa remain associated with response to iron supplementation after controlling for relevant inflammatory and pathogenic variables.

METHODS

Data come from 49 pre-school-aged anemic children living in San Juan de Lurigancho, Lima, Peru. We tested for differences in alpha and beta diversity using QIIME 2 and performed differential abundance testing in DESeq2 in R. We ran multivariate regression models to assess associations between abundance of specific taxa and response while controlling for relevant variables in Stata 17.

RESULTS

While we found no evidence for gut microbiota diversity associated with child response to iron treatment, we observed several differential abundance patterns between responders and non-responders at both timepoints. Additionally, we present support for a nonzero relationship between lower relative abundance of Barnesiellaceae and response to iron supplementation in samples collected before and after treatment.

CONCLUSION

While larger studies and more specific approaches are needed to understand the relationship between microbes and anemia in an epidemiological context, this study suggests that investigating nutritional status and pathogen exposure is key to better understanding the gut microbiome and impact of iron fortification.

Child, caretaker, and community: Testing predictors of anemia and response to iron supplementation in Peruvian preschool-aged children

OBJECTIVES

Despite repeated governmental and nongovernmental interventions, anemia remains a widespread public health concern in Peru. This article examines nutritional and disease factors associated with the prevalence of anemia and response to iron supplementation in Peruvian children, with the aim of understanding the lack of success of national programs.

METHODS

Data come from children, aged 2-5 years (n = 102), living in peri-urban Lima. Predictors of anemia and response to iron supplementation were explored at the individual, maternal, household, and environmental levels using logistic regression models, adjusted for clustering by household.

RESULTS

Half of the children in this sample were anemic and 50% of the anemic children responded to iron supplementation. We identified several factors that were associated with child anemia status and response to iron supplementation. Lower weight-for-age z-scores and the winter season were strong predictors of child anemia status and nonresponse to iron supplementation. Living with paternal grandparents was protective against anemia and elevated C-reactive protein at the time of the final interview was associated with a lack of response to iron supplementation.

CONCLUSIONS

The findings of this study document an association between children's anemia status and their nutritional and ecological environment, highlighting the importance of examining anemia within a specific context to better understand the factors driving this important health problem.

Adiposity and pathogen exposure: An investigation of response to iron supplementation and hypothesized predictors in anemic pre-school-aged children living in a dual burden environment

OBJECTIVES

Peruvians are experiencing rapid dietary and lifestyle changes, resulting in a phenomenon known as the "dual burden of disease." A common manifestation of the dual burden in individuals is the co-occurrence of overweight and anemia. Despite recent initiatives introduced to address these concerns, rates continue to be public health concerns. This study investigates the relationship between immune activation and lack of response to iron supplementation after 1 month of treatment and explores variation in body fat stores as a potential moderator between immune function and response to treatment.

METHODS

Data come from children, aged 2-5 years (n = 50) from a peri-urban community in Lima, Peru. Multivariate logistic regression models were used to explore the associations between response to treatment (Hb > =11.0 g/dl) after 1 month of treatment), markers of immune activation (C-reactive protein [CRP] and reported morbidity symptoms), and measures of body fat (waist-to-height ratio, triceps skinfold thickness, and body mass index [BMI]).

RESULTS

We found that high CRP is associated with a lack of response to iron supplementation after 1 month of treatment and that BMI z-score may moderate this association. Generally, larger body size is associated with response to iron supplementation whether or not the children in this sample have high immune activation. However, the probability of anemic children responding to iron supplementation treatment differed across adiposity measures.

CONCLUSIONS

Our finding suggesting that adiposity and CRP influence response to iron supplementation, furthers our understanding of the relationship between inflammation and anemia treatment in children and has both theoretical and public health implications.

Effects of preconception care and periconception interventions on maternal nutritional status and birth outcomes in low- and middle-income countries: A systematic review

Background

The preconception period is an ideal time to introduce interventions relating to nutrition and other lifestyle factors to ensure good pregnancy preparedness, and to promote health of mothers and babies. In adolescents, malnutrition and early pregnancy are the common challenges, particularly among those who live in low- and middle-income countries (LMIC) where 99% of all maternal and newborn deaths occur. These girls receive little or no attention until their first pregnancy and often the interventions after pregnancy are too late to revert any detrimental health risks that may have occurred due to malnutrition and early pregnancy.

Objectives

To synthesise the evidence of the effectiveness of preconception care interventions relating to delayed age at first pregnancy, optimising inter-pregnancy intervals, periconception folic acid, and periconception iron-folic acid supplementation on maternal, pregnancy, birth and child outcomes.

Search Methods

Numerous electronic databases (e.g., CINAHL, ERIC) and databases of selected development agencies or research firms were systematically searched for all available years up to July 2019. In addition, we searched the reference lists of relevant articles and reviews, and asked experts in the area about ongoing and unpublished studies.

Selection Criteria

Primary studies, including large-scale programme evaluations that assessed the effectiveness of interventions using randomised controlled trials (RCTs) or quasi-experimental designs (natural experiments, controlled before-after studies, regression discontinuity designs, interrupted time series [ITS]), that targeted women of reproductive age (i.e., 10-49 years) during the pre- and periconceptional period in LMICs were included. Interventions were compared against no intervention, standard of care or placebo.

Data Collection and Analysis

Two or more review authors independently reviewed searches, selected studies for inclusion or exclusion, extracted data and assessed risk of bias. We used random-effects model to conduct meta-analyses, given the diverse contexts, participants, and interventions, and separate meta-analyses for the same outcome was performed with different study designs (ITS, RCTs and controlled before after studies). For each comparison, the findings were descriptively summarised in text which included detailing the contextual factors (e.g., setting) to assess their impact on the implementation and effectiveness of each intervention.

Main Results

We included a total of 43 studies; two of these were included in both delaying pregnancy and optimising interpregnancy intervals resulting in 26 studies for delaying the age at first pregnancy (14 RCTs, 12 quasi-experimental), four for optimising interpregnancy intervals (one RCT, three quasi-experimental), five on periconceptional folic acid supplementation (two RCTs, three quasi-experimental), and 10 on periconceptional iron-folic acid supplementation (nine RCTs, one quasi-experimental). Geographically, studies were predominantly conducted across Africa and Asia, with few studies from North and Central America and took place in a combination of settings including community, schools and clinical. The education on sexual health and contraception interventions to delay the age at first pregnancy may make little or no difference on risk of unintended pregnancy (risk ratio [RR], 0.42; 95% confidence internal [CI], 0.07-3.26; two studies, =490; random-effect; χ ² p .009; I ² = 85%; low certainty of evidence using GRADE assessment), however, it significantly improved the use of condom (ever) (RR, 1.54; 95% CI, 1.08-2.20; six studies, n = 1604; random-effect, heterogeneity: χ ² p .004; I ² = 71%). Education on sexual health and and provision of contraceptive along with involvement of male partneron optimising interpregnancy intervals probably makes little or no difference on the risk of unintended pregnancies when compared to education on sexual health only (RR, 0.32; 95% CI, 0.01-7.45; one study, n = 45; moderate certainty of evidence using GRADE assessments). However, education on sexual health and contraception intervention alone or with provision of contraceptive showed a significant improvement in the uptake of contraceptive method. We are uncertain whether periconceptional folic acid supplementation reduces the incidence of neural tube defects (NTDs) (RR, 0.53; 95% CI, 0.41-0.77; two studies, n = 248,056; random-effect; heterogeneity: χ ² p .36; I ² = 0%; very low certainty of evidence using GRADE assessment). We are uncertain whether preconception iron-folic acid supplementation reduces anaemia (RR, 0.66; 95% CI, 0.53-0.81; six studies; n = 3430, random-effect; heterogeneity: χ ² p < .001; I ² = 88%; very low certainty of evidence using GRADE assessment) even when supplemented weekly (RR, 0.70; 95% CI, 0.55-0.88; six studies; n = 2661; random-effect; heterogeneity: χ ² p < .001; I ² = 88%; very low certainty of evidence using GRADE assessments),and in school set-ups (RR, 0.66; 95% CI, 0.51-0.86; four studies; n = 3005; random-effect; heterogeneity: χ ² p < .0001; I ² = 87%; very low certainty of evidence using GRADE assessment). Data on adverse effects were reported on in five studies for iron-folic acid, with the main complaint relating to gastrointestinal side effects. The quality of evidence across the interventions of interest was variable (ranging from very low to moderate) which may be attributed to the different study designs included in this review. Concerning risk of bias, the most common concerns were related to blinding of participants and personnel (performance bias) and whether there were similar baseline characteristic across intervention and comparison groups.

Authors' Conclusions

There is evidence that education on sexual health and contraception interventions can improve contraceptive use and knowledge related to sexual health, this review also provides further support for the use of folic acid in pregnancy to reduce NTDs, and notes that weekly regimes of IFA are most effective in reducing anaemia. However the certainty of the evidence was very low and therefore more robust trials and research is required, including ensuring consistency for reporting unplanned pregnancies, and further studies to determine which intervention settings (school, community, clinic) are most effective. Although this review demonstrates promising findings, more robust evidence from RCTs are required from LMICs to further support the evidence.

A community-based randomized controlled trial providing weekly iron-folic acid supplementation increased serum- ferritin, -folate and hemoglobin concentration of adolescent girls in southern Ethiopia

Adequate micronutrient status during adolescence can break the inter-generational cycle of malnutrition. This study evaluated the effect of community-based weekly iron-folic acid supplementation (WIFAS) on serum ferritin (SF), serum folate (SFol) and hemoglobin concentration (Hb) among adolescent girls. A community-based, individually randomized-controlled trial (RCT) was conducted in four villages of Wolaita and Hadiya zones. Adolescent girls (n = 226) aged 10-19 years were recruited and randomly assigned (n = 113/group) into: (i) WIFAS and (ii) control (no intervention) groups. Anthropometry, Hb concentration, and serum ferritin (SF), SFol, and C-reactive protein (CRP) was analyzed at baseline and endline. Baseline Hb, SF, SFol and CRP concentrations were similar in both groups (P > 0.05). About 47-49% of adolescents had marginal iron store (< 50 µg/l). Hb, SF, and SFol concentrations increased in the intervention group, but not in the control group (P < 0.05). Marginal iron store decreased from 49 to 12% after 3-months of WIFAS; whereas, the proportion of adolescents with elevated SF (> 15 µg/l) was slightly higher in the WIFAS than in the control group (P = 0.06). After adjusting for confounding factors in the multiple linear regression model, a three-months WIFAS intervention was associated with an improvement of 4.10 ng/ml in serum folate, 39.1 μg/l in serum ferritin, and 1.2 g/dl in hemoglobin concentration relative to the control group (P < 0.001). WIFAS intervention for three-months was effective in reducing iron and folate deficiency in adolescent girls. Future studies should evaluate the long-term impact of intermittent WIFAS.

Gambaran Pengetahuan, Sikap, dan Perilaku Kader Palang Merah Remaja (PMR) di SMAN 2 Lamongan Terhadap Program Suplementasi Tablet Tambah Darah

ABSTRACT  Background: anemia prevention through iron-folic acid supplementation (IFA) for female adolescent has become goverment’s program priority. Although this programme have been running, several constrains including consumption compliance was frequently found. On the other hand, school have potential resources such as Junior of The Red Cross (PMR) which can be peer educator for health including anemia for other students. Objectives: this research was aimed to describe knowledge, practice, and attitude of PMR member toward IFA supplementation in SMAN 2 LamonganMethods: This research used cross sectional design. The population of this study was 100 members of the Red Cross Youth Teaching (PMR) SMAN 2 Lamongan. The sample of this study was 60 students who were selected by the simple random sampling method who met the inclusion criteria, such as were active members of the PMR and were willing to take part in the study. Data collection was carried out using self-administered questionnaires using an online questionnaire application consisting of 20 questions to measure knowledge; 20 questions to measure attitude; and 13 questions to measure behavior. Data were categorized and analyzed using descriptive tests.Results: Most respondents still have lack of knowledge related to the TTD program (56.7%) and its benefits (56.7%). 66% of PMR cadres have a positive attitude towards TTD, but not 100% of PMR cadres consume blood-added tablets regularly.Conclusions Strengthening of knowledge and attitudes towards TTD is needed to improve compliance of TTD consumption among PMR members so that later PMR cadres can become peer educators for other students.ABSTRAKLatar Belakang: penanggulangan anemia dengan pemberian Tablet Tambah Darah (TTD) dengan sasaran remaja putri menjadi fokus pemerintah saat ini. Walaupun sudah mulai berjalan, seringkali ditemukan beberapa kendala dalam pelaksanaan program, diantaranya ketidakpatuhan konsumsi TTD. Di sisi lain, sekolah memiliki potensi sumberdaya untuk meningkatkan optimalisasi program TTD, salah satunya adalah Palang Merah Remaja (PMR) yang dapat menjadi pendidik sebaya tentang masalah kesehatan termasuk anemia bagi siswi lainnya.Tujuan: Penelitian ini bertujuan melihat gambaran pengetahuan, sikap, dan perilaku kader PMR di SMA Negeri 2 Lamongan terhadap program pemberian TTDMetode: Penelitian ini merupakan menggunakan desain cross sectional. Populasi penelitian ini adalah anggota ekstrakurikuler Palang Merah Remaja (PMR) SMAN 2 Lamongan sejumlah 100 orang. Sampel dari penelitian ini adalah 60 siswa anggota PMR yang dipilih dengan metode simple random sampling dan memenuhi kriteria inklusi yaitu merupakan anggota aktif PMR dan bersedia mengikuti penelitian. Pengumpulan data dilakukan dengan menggunakan self-administered questionnaires dengan menggunakan aplikasi kuesioner online yang terdiri dari 20 pertanyaan untuk mengukur pengetahuan; 20 pertanyaan untuk mengukur sikap; dan 13 pertanyaan untuk mengukur perilaku. Data dikategorikan dan dianalisis menggunakan uji deskriptif.Hasil: Sebagian besar responden masih memiliki pengetahuan yang kurang terkait program TTD (56,7%) dan manfaatnya (56,7%). Sebesar 66% kader PMR memiliki sikap yang positif terhadap TTD, namun tidak 100% kader PMR mengonsumsi tablet tambah darah secara rutin.Kesimpulan: Perlu penguatan terhadap pengetahuan serta sikap terhadap TTD untuk meningkatkan kepatuhan konsumsi TTD di kalangan anggota PMR agar nantinya kader PMR dapat menjadi pendidik sebaya bagi siswi lainnya. 

Intermittent iron supplementation for reducing anaemia and its associated impairments in adolescent and adult menstruating women

BACKGROUND

Anaemia is a condition in which the number of red blood cells is insufficient to meet physiologic needs; it is caused by many conditions, particularly iron deficiency. Traditionally, daily iron supplementation has been a standard practice for preventing and treating anaemia. However, its long-term use has been limited, as it has been associated with adverse side effects such as nausea, constipation, and teeth staining. Intermittent iron supplementation has been suggested as an effective and safer alternative to daily iron supplementation for preventing and reducing anaemia at the population level, especially in areas where this condition is highly prevalent.

OBJECTIVES

To assess the effects of intermittent oral iron supplementation, alone or in combination with other nutrients, on anaemia and its associated impairments among menstruating women, compared with no intervention, a placebo, or daily supplementation.

SEARCH METHODS

In February 2018, we searched CENTRAL, MEDLINE, Embase, nine other databases, and two trials registers. In March 2018, we also searched LILACS, IBECS and IMBIOMED. In addition, we examined reference lists, and contacted authors and known experts to identify additional studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-RCTs with either individual or cluster randomisation. Participants were menstruating women; that is, women beyond menarche and prior to menopause who were not pregnant or lactating and did not have a known condition that impeded the presence of menstrual periods. The intervention was the use of iron supplements intermittently (one, two or three times a week on non-consecutive days) compared with placebo, no intervention, or the same supplements provided on a daily basis.

DATA COLLECTION AND ANALYSIS

Both review authors independently assessed the eligibility of studies against the inclusion criteria, extracted data from included studies, checked data entry for accuracy, assessed the risk of bias of the included studies, and rated the quality of the evidence using GRADE.

MAIN RESULTS

We included 25 studies involving 10,996 women. Study methods were not well described in many of the included studies and thus assessing risk of bias was difficult. The main limitations of the studies were lack of blinding and high attrition. Studies were mainly funded by international organisations, universities, and ministries of health within the countries. Approximately one third of the included studies did not provide a funding source.Although quality across studies was variable, the results consistently showed that intermittent iron supplementation (alone or with any other vitamins and minerals) compared with no intervention or a placebo, reduced the risk of having anaemia (risk ratio (RR) 0.65, 95% confidence interval (CI) 0.49 to 0.87; 11 studies, 3135 participants; low-quality evidence), and improved the concentration of haemoglobin (mean difference (MD) 5.19 g/L, 95% CI 3.07 to 7.32; 15 studies, 2886 participants; moderate-quality evidence), and ferritin (MD 7.46 μg/L, 95% CI 5.02 to 9.90; 7 studies, 1067 participants; low-quality evidence). Intermittent regimens may also reduce the risk of having iron deficiency (RR 0.50, 95% CI 0.24 to 1.04; 3 studies, 624 participants; low-quality evidence), but evidence was inconclusive regarding iron deficiency anaemia (RR 0.07, 95% CI 0.00 to 1.16; 1 study, 97 participants; very low-quality evidence) and all-cause morbidity (RR 1.12, 95% CI 0.82 to 1.52; 1 study, 119 participants; very low-quality evidence). Women in the control group were less likely to have any adverse side effects than those receiving intermittent iron supplements (RR 1.98, 95% CI 0.31 to 12.72; 3 studies, 630 participants; moderate-quality evidence).In comparison with daily supplementation, results showed that intermittent supplementation (alone or with any other vitamins and minerals) produced similar effects to daily supplementation (alone or with any other vitamins and minerals) on anaemia (RR 1.09, 95% CI 0.93 to 1.29; 8 studies, 1749 participants; moderate-quality evidence). Intermittent supplementation may produce similar haemoglobin concentrations (MD 0.43 g/L, 95% CI -1.44 to 2.31; 10 studies, 2127 participants; low-quality evidence) but lower ferritin concentrations on average (MD -6.07 μg/L, 95% CI -10.66 to -1.48; 4 studies, 988 participants; low-quality evidence) compared to daily supplementation. Compared to daily regimens, intermittent regimens may also reduce the risk of having iron deficiency (RR 4.30, 95% CI 0.56 to 33.20; 1 study, 198 participants; very low-quality evidence). Women receiving iron supplements intermittently were less likely to have any adverse side effects than those receiving iron supplements daily (RR 0.41, 95% CI 0.21 to 0.82; 6 studies, 1166 participants; moderate-quality evidence). No studies reported on the effect of intermittent regimens versus daily regimens on iron deficiency anaemia and all-cause morbidity.Information on disease outcomes, adherence, economic productivity, and work performance was scarce, and evidence about the effects of intermittent supplementation on these outcomes unclear.Overall, whether the supplements were given once or twice weekly, for less or more than three months, contained less or more than 60 mg of elemental iron per week, or given to populations with different degrees of anaemia at baseline did not seem to affect the findings. Furthermore, the response did not differ in areas where malaria was frequent, although very few trials were conducted in these settings.

AUTHORS' CONCLUSIONS

Intermittent iron supplementation may reduce anaemia and may improve iron stores among menstruating women in populations with different anaemia and malaria backgrounds. In comparison with daily supplementation, the provision of iron supplements intermittently is probably as effective in preventing or controlling anaemia. More information is needed on morbidity (including malaria outcomes), side effects, work performance, economic productivity, depression, and adherence to the intervention. The quality of this evidence base ranged from very low to moderate quality, suggesting that we are uncertain about these effects.

Community approval required for periconceptional adolescent adherence to weekly iron and/or folic acid supplementation: a qualitative study in rural Burkina Faso

Background

Iron deficiency remains a prevalent adolescent health problem in low income countries. Iron supplementation is recommended but improvement of iron status requires good adherence.

Objectives

We explored factors affecting adolescent adherence to weekly iron and/or folic acid supplements in a setting of low secondary school attendance.

Methods

Taped in-depth interviews were conducted with participants in a randomised, controlled, periconceptional iron supplementation trial for young nulliparous women living in a rural, malaria endemic region of Burkina Faso. Participants with good, medium or poor adherence were selected. Interviews were transcribed and analysed thematically.

Results

Thirty-nine interviews were conducted. The community initially thought supplements were contraceptives. The potential benefits of giving iron supplementation to unmarried “girls” ahead of pregnancy were not recognised. Trial participation, which required parental consent, remained high but was not openly admitted because iron supplements were thought to be contraceptives. Unmarried non-school attenders, being mobile, were often sent to provide domestic labour in varied locations. This interrupted adherence - as did movement of school girls during vacations and at marriage. Field workers tracked participants and trial provision of free treatment encouraged adherence. Most interviewees did not identify health benefits from taking supplements.

Conclusions

For success, communities must be convinced of the value of an adolescent intervention. During this safety trial, benefits not routinely available in iron supplementation programmes were important to this low income community, ensuring adolescent participation. Nevertheless, adolescents were obliged to fulfil cultural duties and roles that interfered with regular adherence to the iron supplementation regime.

Trial Registration

Trial Registration at clinicaltrials.gov: NCT01210040.

Electronic supplementary material

The online version of this article (10.1186/s12978-018-0490-y) contains supplementary material, which is available to authorized users.

A double-blind, randomized, and active-controlled phase III study of Herbiron drink in the treatment of iron-deficiency anemia in premenopausal females in Taiwan

Background

About 468 million non-pregnant women are estimated to suffer from iron-deficiency anemia (IDA) worldwide. The highest prevalence of IDA occurs in the Taiwanese population.

Objective

To evaluate the effectiveness of Herbiron to increase iron absorption in women with IDA.

Design

Phase III double-blind, randomized, active-controlled, and parallel comparative study enrolled 124 patients with IDA and consisted of a 2-week run-in period, randomization, 12 weeks of supplementation, and 4 weeks of follow-up. The treatment group received Herbiron drink 50 mL p.o., b.i.d., before meals (daily iron intake: 21 mg/day) plus placebo tablets. The control group received a ferrous sulfate tablet, t.i.d., plus placebo 50-mL drink before meals (daily iron intake: 195 mg/day).

Results

Both treatments significantly improved hemoglobin and all secondary efficacy endpoints. Most IDA patients treated with Herbiron or ferrous sulfate finished the study in the normal range. Ferrous sulfate treatment induced a rapid rate of hemoglobin synthesis, which plateaued by week 8, whereas Herbiron treatment increased the rate of hemoglobin synthesis more slowly, likely due to its nine-fold lower iron content. Gastrointestinal adverse events (diarrhea, abdominal pain, dyspepsia, and nausea) but not infectious adverse events were significantly more common in the ferrous sulfate group (n=11, 18.3%) than those in the Herbiron group (n=1, 1.6%) (p=0.004).

Conclusion

Twelve weeks of Herbiron treatment delivering 21mg of iron or ferrous sulfate treatment delivering 195 mg of iron induced normal hemoglobin levels in 62 or 91% of non-pregnant women with IDA in Taiwan, respectively, suggesting dose-dependent and bioavailability effects.

Daily iron supplementation for improving anaemia, iron status and health in menstruating women

BACKGROUND

Iron-deficiency anaemia is highly prevalent among non-pregnant women of reproductive age (menstruating women) worldwide, although the prevalence is highest in lower-income settings. Iron-deficiency anaemia has been associated with a range of adverse health outcomes, which restitution of iron stores using iron supplementation has been considered likely to resolve. Although there have been many trials reporting effects of iron in non-pregnant women, these trials have never been synthesised in a systematic review.

OBJECTIVES

To establish the evidence for effects of daily supplementation with iron on anaemia and iron status, as well as on physical, psychological and neurocognitive health, in menstruating women.

SEARCH METHODS

In November 2015 we searched CENTRAL, Ovid MEDLINE, EMBASE, and nine other databases, as well as four digital thesis repositories. In addition, we searched the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) and reference lists of relevant reviews.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs comparing daily oral iron supplementation with or without a cointervention (folic acid or vitamin C), for at least five days per week at any dose, to control or placebo using either individual- or cluster-randomisation. Inclusion criteria were menstruating women (or women aged 12 to 50 years) reporting on predefined primary (anaemia, haemoglobin concentration, iron deficiency, iron-deficiency anaemia, all-cause mortality, adverse effects, and cognitive function) or secondary (iron status measured by iron indices, physical exercise performance, psychological health, adherence, anthropometric measures, serum/plasma zinc levels, vitamin A status, and red cell folate) outcomes.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures of Cochrane.

MAIN RESULTS

The search strategy identified 31,767 records; after screening, 90 full-text reports were assessed for eligibility. We included 67 trials (from 76 reports), recruiting 8506 women; the number of women included in analyses varied greatly between outcomes, with endpoint haemoglobin concentration being the outcome with the largest number of participants analysed (6861 women). Only 10 studies were considered at low overall risk of bias, with most studies presenting insufficient details about trial quality.Women receiving iron were significantly less likely to be anaemic at the end of intervention compared to women receiving control (risk ratio (RR) 0.39 (95% confidence interval (CI) 0.25 to 0.60, 10 studies, 3273 women, moderate quality evidence). Women receiving iron had a higher haemoglobin concentration at the end of intervention compared to women receiving control (mean difference (MD) 5.30, 95% CI 4.14 to 6.45, 51 studies, 6861 women, high quality evidence). Women receiving iron had a reduced risk of iron deficiency compared to women receiving control (RR 0.62, 95% CI 0.50 to 0.76, 7 studies, 1088 women, moderate quality evidence). Only one study (55 women) specifically reported iron-deficiency anaemia and no studies reported mortality. Seven trials recruiting 901 women reported on 'any side effect' and did not identify an overall increased prevalence of side effects from iron supplements (RR 2.14, 95% CI 0.94 to 4.86, low quality evidence). Five studies recruiting 521 women identified an increased prevalence of gastrointestinal side effects in women taking iron (RR 1.99, 95% CI 1.26 to 3.12, low quality evidence). Six studies recruiting 604 women identified an increased prevalence of loose stools/diarrhoea (RR 2.13, 95% CI 1.10, 4.11, high quality evidence); eight studies recruiting 1036 women identified an increased prevalence of hard stools/constipation (RR 2.07, 95% CI 1.35 to 3.17, high quality evidence). Seven studies recruiting 1190 women identified evidence of an increased prevalence of abdominal pain among women randomised to iron (RR 1.55, 95% CI 0.99 to 2.41, low quality evidence). Eight studies recruiting 1214 women did not find any evidence of an increased prevalence of nausea among women randomised to iron (RR 1.19, 95% CI 0.78 to 1.82). Evidence that iron supplementation improves cognitive performance in women is uncertain, as studies could not be meta-analysed and individual studies reported conflicting results. Iron supplementation improved maximal and submaximal exercise performance, and appears to reduce symptomatic fatigue. Although adherence could not be formally meta-analysed due to differences in reporting, there was no evident difference in adherence between women randomised to iron and control.

AUTHORS' CONCLUSIONS

Daily iron supplementation effectively reduces the prevalence of anaemia and iron deficiency, raises haemoglobin and iron stores, improves exercise performance and reduces symptomatic fatigue. These benefits come at the expense of increased gastrointestinal symptomatic side effects.

Deficiencies in the Management of Iron Deficiency Anemia During Childhood

Limited high-quality evidence supports the management of iron deficiency anemia (IDA). To assess our institutional performance in this area, we retrospectively reviewed IDA treatment practices in 195 consecutive children referred to our center from 2006 to mid-2010. The majority of children were ≤4 years old (64%) and had nutritional IDA (74%). In 11- to 18-year-old patients (31%), the primary etiology was menorrhagia (42%). Many were referred directly to the emergency department and/or prescribed iron doses outside the recommended range. Poor medication adherence and being lost-to-follow-up were common. Substantial improvements are required in the management of IDA.

Examining Means of Reaching Adolescent Girls for Iron Supplementation in Tigray, Northern Ethiopia

Background: Iron deficiency is the most prevalent nutritional deficiency in adolescent girls from the developing world. One of the recommended interventions to improve iron status in adolescent girls is iron supplementation. Yet the provision of iron supplements to adolescent girls proved to be a challenging task for the health systems across the developing world. Objective: The objective of the study was to examine means of reaching adolescent girls for iron supplementation in Northern Ethiopia. Methodology: Analytical cross-sectional study consisting of both quantitative and qualitative approaches to data collection and analysis was used in this study. Stratified multi-stage systematic random sampling technique was adopted and primary quantitative data were collected from 828 (578 school attending and 250 non school attending) adolescent girls recruited from nine districts of Tigray. The primary quantitative data were analyzed using SPSS version 20 software. The qualitative data collected through key informant interviews and focus group discussions were transcribed verbatim and qualitatively analyzed. Results: The mean (SD) age of the girls was 16.7 (1.4) years. Four hundred forty seven (54%), 355 (42.9%) and 26 (3.1%) of the adolescent girls had low, medium and high diet diversity scores, respectively. More than half, 467 (56%), of the adolescent girls believed that adolescent girls were overloaded with household jobs everyday compared to boys from their respective communities. Key informants said that, there is no adolescent nutrition message promoted in the study area. Low community awareness, perceiving iron tablet as a contraceptive, religious and cultural influences, and lack of confidence in supplementation value of iron tablets, are some of the potential barriers mentioned by the key informant and focus group discussion participants. Schools (45%), health centers (27%) and health posts (26%) were the preferred public facilities for provision of iron supplements to student adolescent girls whereas schools (11%), health centers (47%) and health posts (41%) were the preferred public facilities for provision of iron supplements to adolescent girls who were not attending schools from the study communities. Conclusion: The health posts and health centers were the preferred health facilities for iron supplementation to adolescent girls who were not attending schools while the school was the preferred facility for iron supplementation of student adolescent girls.

Factors associated with high compliance/feasibility during iron and folic acid supplementation in a tribal area of Madhya Pradesh, India

OBJECTIVE

To study the feasibility of iron and folic acid (IFA) supplementation among tribal adolescent girls and identify factors associated with high compliance.

DESIGN

Intervention study with IFA supplementation among tribal adolescent girls of Bijadandi block, Mandla district, Madhya Pradesh, India. Girls (n 274) from twelve villages randomly selected out of 100 potential villages received daily tablets containing iron (iii) hydroxide polymaltose complex equivalent to 100 mg of elemental Fe and 350 μg of folic acid (commercially available as Feritas tablets, marketed by Intas Pharmaceutical Ltd, India). IFA was given for 100 d and supervised by school teachers and anganwadi workers. Compliance was measured using cards and interviews.

SETTING

Community-based iron supplementation programme.

SUBJECTS

Tribal adolescent girls aged 12-19 years.

RESULTS

In total 233 girls completed the study. Prevalence of anaemia was reduced from 94 % at baseline to 69 % after the intervention. Compliance rate (>80 tablets) was 89 %. Minor side-effects were reported by three girls, yet they consumed >80 tablets. Factors associated with compliance included fasting during the local festival (χ 2 = 72·74, df 3; P < 0·0001) and counselling (χ 2 = 72·74, df 3; P < 0·0001). Other qualitative factors like social mobilization, timely supply of tablets, quality of tablets (blister pack) and availability of teachers and anganwadi workers were also associated with the compliance and feasibility.

CONCLUSIONS

High compliance indicates that IFA supplementation with tablets is feasible among the tribal adolescent girls of Bijadandi block, Mandla district.

Community-led initiative for control of anemia among children 6 to 35 months of age and unmarried adolescent girls in rural Wardha, India

BACKGROUND

Studies in India have reported a high prevalence of nutritional anemia among children and adolescent girls. Nutritional anemia is associated with impaired mental, physical, and cognitive performance in children and is a significant risk factor for maternal mortality.

OBJECTIVE

To evaluate the effect of a community-led initiative for control of nutritional anemia among children 6 to 35 months of age and unmarried rural adolescent girls 12 to 19 years of age.

METHODS

This Participatory Action Research was done in 23 villages of the Primary Health Centre, Anji, in Wardha District of Maharashtra. In February and March 2008, needs assessment was undertaken by interviewing the mothers of 261 children and 260 adolescent girls. Hemoglobin levels of adolescent girls and children were measured with the use of the hemoglobin color scale. The girls were given weekly iron-folic acid tablets, and the children were given daily liquid iron prophylaxis for 100 days in a year through community participation. The adolescent girls and the mothers of the children and adolescent girls were also given nutritional education on the benefits and side effects of iron supplementation. In June and July 2008, follow-up assessment was performed by survey and force field analysis.

RESULTS

There was a significant reduction in the prevalence of nutritional anemia from 73.8% to 54.6% among the adolescent girls and from 78.2% to 64.2% among the children. There was improvement in awareness of iron-rich food items among the adolescent girls and the mothers of the children. The benefits to girls, such as increase in appetite and reduction in scanty menses, tiredness, and weakness, acted as positive factors leading to better compliance with weekly iron supplementation. The benefits to children perceived by the mothers, such as increase in appetite, weight gain, reduction in irritability, and reduction in mud-eating behavior, acted as a dominant positive force and generated demand for iron syrup.

CONCLUSIONS

The community-led initiative for once-weekly iron supplementation for adolescent girls and iron prophylaxis for children, in addition to nutritional education, improved the hemoglobin status of children 6 to 35 months of age and unmarried rural adolescent girls 12 to 19 years of age.

Intermittent iron supplementation for improving nutrition and development in children under 12 years of age

BACKGROUND

Approximately 600 million children of preschool and school age are anaemic worldwide. It is estimated that half of the cases are due to iron deficiency. Consequences of iron deficiency anaemia during childhood include growth retardation, reduced school achievement, impaired motor and cognitive development, and increased morbidity and mortality. The provision of daily iron supplements is a widely used strategy for improving iron status in children but its effectiveness has been limited due to its side effects, which can include nausea, constipation or staining of the teeth. As a consequence, intermittent iron supplementation (one, two or three times a week on non-consecutive days) has been proposed as an effective and safer alternative to daily supplementation.

OBJECTIVES

To assess the effects of intermittent iron supplementation, alone or in combination with other vitamins and minerals, on nutritional and developmental outcomes in children from birth to 12 years of age compared with a placebo, no intervention or daily supplementation.

SEARCH METHODS

We searched the following databases on 24 May 2011: CENTRAL (2011, Issue 2), MEDLINE (1948 to May week 2, 2011), EMBASE (1980 to 2011 Week 20), CINAHL (1937 to current), POPLINE (all available years) and WHO International Clinical Trials Registry Platform (ICTRP). On 29 June 2011 we searched all available years in the following databases: SCIELO, LILACS, IBECS and IMBIOMED. We also contacted relevant organisations (on 3 July 2011) to identify ongoing and unpublished studies.

SELECTION CRITERIA

Randomised and quasi-randomised trials with either individual or cluster randomisation. Participants were children under the age of 12 years at the time of intervention with no specific health problems. The intervention assessed was intermittent iron supplementation compared with a placebo, no intervention or daily supplementation.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed the eligibility of studies against the inclusion criteria, extracted data from included studies and assessed the risk of bias of the included studies.

MAIN RESULTS

We included 33 trials, involving 13,114 children (˜49% females) from 20 countries in Latin America, Africa and Asia. The methodological quality of the trials was mixed.Nineteen trials evaluated intermittent iron supplementation versus no intervention or a placebo and 21 studies evaluated intermittent versus daily iron supplementation. Some of these trials contributed data to both comparisons. Iron alone was provided in most of the trials.Fifteen studies included children younger than 60 months; 11 trials included children 60 months and older, and seven studies included children in both age categories. One trial included exclusively females. Seven trials included only anaemic children; three studies assessed only non-anaemic children, and in the rest the baseline prevalence of anaemia ranged from 15% to 90%.In comparison with receiving no intervention or a placebo, children receiving iron supplements intermittently have a lower risk of anaemia (average risk ratio (RR) 0.51, 95% confidence interval (CI) 0.37 to 0.72, ten studies) and iron deficiency (RR 0.24, 95% CI 0.06 to 0.91, three studies) and have higher haemoglobin (mean difference (MD) 5.20 g/L, 95% CI 2.51 to 7.88, 19 studies) and ferritin concentrations (MD 14.17 µg/L, 95% CI 3.53 to 24.81, five studies).Intermittent supplementation was as effective as daily supplementation in improving haemoglobin (MD -0.60 g/L, 95% CI -1.54 to 0.35, 19 studies) and ferritin concentrations (MD -4.19 µg/L, 95% CI -9.42 to 1.05, 10 studies), but increased the risk of anaemia in comparison with daily iron supplementation (RR 1.23, 95% CI 1.04 to1.47, six studies). Data on adherence were scarce and it tended to be higher among those children receiving intermittent supplementation, although this result was not statistically significant.We did not identify any differential effect of the type of intermittent supplementation regimen (one, two or three times a week), the total weekly dose of elemental iron, the nutrient composition, whether recipients were male or female or the length of the intervention.

AUTHORS' CONCLUSIONS

Intermittent iron supplementation is efficacious to improve haemoglobin concentrations and reduce the risk of having anaemia or iron deficiency in children younger than 12 years of age when compared with a placebo or no intervention, but it is less effective than daily supplementation to prevent or control anaemia. Intermittent supplementation may be a viable public health intervention in settings where daily supplementation has failed or has not been implemented. Information on mortality, morbidity, developmental outcomes and side effects, however, is still lacking.

Effect of daily versus weekly home fortification with multiple micronutrient powder on haemoglobin concentration of young children in a rural area, Lao People's Democratic Republic: a randomised trial

BACKGROUND

Multiple micronutrient deficiencies, in particular iron deficiency anaemia (IDA) is a severe public health problem in Lao People's Democratic Republic (Lao PDR). Because of the practical difficulties encountered in improving the nutritional adequacy of traditional complementary foods and the limitations associated with the use of liquid iron supplementation for the treatment and prevention of IDA in infants and young children, recently, home-fortification with multivitamins and minerals sprinkles was recommended. This study aims to compare the effect of twice weekly versus daily supplementation with multivitamins and minerals powder (MMP) on anaemia prevalence, haemoglobin concentration, and growth in infants and young children in a rural community in Lao PDR.

METHODS

A randomized trial was conducted in six rural communities. Children aged 6 to 52 months (n = 336) were randomly assigned to a control group (n = 110) or to one of two intervention groups receiving either two sachets per week (n = 115) or a daily sachet (n = 111) of MMP for 24 weeks; 331 children completed the study. A finger prick of blood was taken at baseline, at week 12, and again at week 24 to determine haemoglobin concentration. Anthropometric measurements were taken every 4 weeks. The McNemar test was used to assess within group differences at three time points in the study subjects with anaemia and one-way ANOVA was used to assess changes in mean haemoglobin concentration in the treatment groups.

RESULTS

MMP supplementation resulted in significant improvements in haemoglobin concentration and in the reduction of anaemia prevalence in the two treatment groups compared with the control group (p <0.001). The severely to moderately anaemic children (Hb <100 g/L) on daily supplementation recovered faster than those on twice weekly supplementation. MMP was well accepted and compliance was high in both treatment groups. Overall, the improvement in the weight for age Z-score was very small and not statistically significant across the three study groups.

CONCLUSIONS

MMP supplementation had positive effects in reduction of anaemia prevalence and in improving haemoglobin concentration. For severely to moderately anaemic children, daily MMP supplementation was more effective in improving haemoglobin concentration and reducing anaemia prevalence. A longer intervention period is probably needed to have a positive effect on growth.

Oral iron supplements for children in malaria-endemic areas

BACKGROUND

Iron-deficiency anaemia is common during childhood. Iron supplementation has been claimed to increase the risk of malaria.

OBJECTIVES

To assess the effect of iron on malaria and deaths.

SEARCH STRATEGY

We searched The Cochrane Library, PUBMED, MEDLINE, LILACS; and trial registry databases, all up to June 2011. We scanned references of included trials.

SELECTION CRITERIA

Individually and cluster randomized controlled trials conducted in hypoendemic to holoendemic malaria regions and including children below 18 years of age. We included trials comparing orally administered iron, iron with antimalarial treatment, or iron with folic acid versus placebo or no treatment. Iron fortification was excluded. Antihelminthics could be administered to either group. Additional micronutrients had to be administered equally to both groups.

DATA COLLECTION AND ANALYSIS

The primary outcomes were clinical (symptomatic) malaria, severe malaria, and death. Two authors independently selected the studies and extracted the data. We assessed heterogeneity and conducted subgroup analyses by the presence of anaemia at baseline, age, and malaria endemicity. We assessed risk of bias using domain-based evaluation. We performed a fixed-effect meta-analysis for all outcomes and random-effects meta-analysis for hematological outcomes. We adjusted analyses for cluster randomized trials.

MAIN RESULTS

Seventy-one trials (45,353 children) were included. For clinical malaria, no significant difference between iron alone and placebo was detected, (risk ratio (RR) 0.99, 95% confidence intervals (CI) 0.90 to 1.09, 13 trials). The results were similar in the subgroups of non-anaemic children and children below 2 years of age. There was no significant difference in deaths in hyper- and holoendemic areas, risk difference +1.93 per 1000 children (95% CI -1.78 to 5.64, 13 trials, 17,898 children). Iron administered for treatment of anaemia resulted in a larger increase in haemoglobin than iron given for prevention, and the benefit was similar in hyper- or holoendemic and lower endemicity settings. Iron and folic acid supplementation resulted in mixed results for severe malaria. Overall, the risk for clinical malaria was higher with iron or with iron plus folic acid in trials where services did not provide for malaria surveillance and treatment. Iron with antimalarial treatment significantly reduced malaria. Iron supplementation during an acute attack of malaria did not increase the risk for parasitological failure, (RR 0.96, 95% CI 0.74 to 1.24, three trials) or deaths.

AUTHORS' CONCLUSIONS

Iron alone or with antimalaria treatment does not increase the risk of clinical malaria or death when regular malaria surveillance and treatment services are provided. There is no need to screen for anaemia prior to iron supplementation.

Adherence and side effects of three ferrous sulfate treatment regimens on anemic pregnant women in clinical trials

The objective of this study was to analyze adherence and side effects of three iron supplement regimens (ferrous sulfate) on anemic pregnant women. The clinical trial involved 150 women between the 16th and 20th gestational weeks, at low obstetric risk and with hemoglobin concentration of between 8.0 and 11.0 g/dL. Treatment was provided by ferrous sulfate with 60 mg of elemental iron during 16 (+/- 1) weeks, in three regimens: single tablet a week (n = 48); single tablet twice a week (n = 53) or single tablet a day (n = 49). The outcomes were adherence, assessed through interviews and by counting tablets, and side effects, according to patient information. The adherence showed a declining trend (92%, 83% and 71%; p = 0.010) and the side effects revealed a growing trend (40%, 45% and 71%; p = 0.002) as the dosage increased. Diarrhea and epigastric pain were significantly associated with the dose administered (p = 0.002). These results suggest that in anemic pregnant women, complaints are directly proportional and the compliance is inversely proportional to the amount of medicinal iron.

Oral iron supplementation for preventing or treating anaemia among children in malaria-endemic areas

BACKGROUND

Iron-deficiency anaemia is common during childhood. Iron supplementation has been claimed to increase the risk of malaria.

OBJECTIVES

To assess the effect of iron on malaria and deaths.

SEARCH STRATEGY

We searched The Cochrane Library (2009, issue 1); MEDLINE; EMBASE; LILACS and metaRegister of Controlled Trials, all up to March 2009. We scanned references of included trials.

SELECTION CRITERIA

Individually and cluster-randomized controlled trials conducted in hypoendemic to holoendemic malaria regions and including children < 18 years. We included trials comparing orally administered iron with or without folic acid vs. placebo or no treatment. Iron fortification was excluded. Antimalarials and/or antiparasitics could be administered to either group. Additional micronutrients could only be administered equally to both groups.

DATA COLLECTION AND ANALYSIS

The primary outcomes were malaria-related events and deaths. Secondary outcomes included haemoglobin, anaemia, other infections, growth, hospitalizations, and clinic visits. We assessed risk of bias using domain-based evaluation. Two authors independently selected studies and extracted data. We contacted authors for missing data. We assessed heterogeneity. We performed fixed-effect meta-analysis and presented random-effects results when heterogeneity was present. We present pooled risk ratios (RR) with 95% confidence intervals (CIs). We used adjusted analyses for cluster-randomized trials.

MAIN RESULTS

Sixty-eight trials (42,981 children) fulfilled the inclusion criteria. Iron supplementation did not increase the risk of clinical malaria (RR 1.00, 95% CI 0.88 to 1.13; 22,724 children, 14 trials, random-effects model). The risk was similar among children who were non-anaemic at baseline (RR 0.96, 95% CI 0.85 to 1.09). An increased risk of malaria with iron was observed in trials that did not provide malaria surveillance and treatment. The risk of malaria parasitaemia was higher with iron (RR 1.13, 95% CI 1.01 to 1.26), but there was no difference in adequately concealed trials. Iron + antimalarial was protective for malaria (four trials). Iron did not increase the risk of parasitological failure when given during malaria (three trials). There was no increased risk of death across all trials comparing iron versus placebo (RR 1.11, 95% CI 0.91 to 1.36; 21,272 children, 12 trials). Iron supplementation increased haemoglobin, with significant heterogeneity, and malaria endemicity did not affect this effect. Growth and other infections were mostly not affected by iron supplementation.

AUTHORS' CONCLUSIONS

Iron does not increase the risk of clinical malaria or death, when regular malaria surveillance and treatment services are provided. There is no need to screen for anaemia prior to iron supplementation.

The effect of weekly iron and vitamin A supplementation on hemoglobin levels and iron status in adolescent schoolgirls in western Kenya

BACKGROUND/OBJECTIVES

Iron deficiency anemia is a major public health problem in developing countries and may affect school performance and physical work capacity in nonpregnant adolescents, and may increase the risk of anemia during subsequent teenage pregnancies. We assessed the effect of weekly iron (120 mg elemental iron) and vitamin A (25 000 IU) supplementation on hemoglobin, iron status and malaria and nonmalaria morbidity in adolescent schoolgirls.

SUBJECTS/METHODS

A total of 279 schoolgirls aged 12-18 years from public primary schools in Kisumu, western Kenya. Double-blind randomized placebo-controlled trial using a factorial design.

RESULTS

Five months of iron supplementation was associated with a 0.52 g dl(-1) (0.21, 0.82) greater increase in hemoglobin relative to iron placebo. The effect was only observed in girls with iron deficiency on enrollment (1.34 g dl(-1) (0.79, 1.88)), but not in iron-replete girls (-0.20 g dl(-1) (-0.59, 0.18)). Similar differences in treatment effect were seen between menstruating and nonmenstruating girls. The effect of iron was independent of vitamin A. The baseline prevalence of vitamin A deficiency was low (6.7%) and no sustained increase in hemoglobin was seen with weekly vitamin A (-0.07 g dl(-1) (-0.38, 0.25)). Incidence of malaria parasitemia was higher in the iron than iron-placebo groups (Rate ratio 1.33 (0.94, 1.88)).

CONCLUSIONS

Weekly iron supplementation results in substantial increases in hemoglobin concentration in adolescent schoolgirls in western Kenya, which may outweigh possible risks caused by malaria, but only in iron-deficient or menstruating girls and not in iron-replete and nonmenstruating girls.

Nutrition education alone improves dietary practices but not hematologic indices of adolescent girls in Iran

BACKGROUND

Iron-deficiency anemia is the most prevalent nutritional deficiency worldwide. Iron-deficiency anemia has particular negative consequences on women in their childbearing years, and its prevention is a high priority in most health systems.

OBJECTIVE

This interventional study assessed the effect of nutrition education on hematologic indices, iron status, nutritional knowledge, and nutritional practices of high-school girls in Iran.

METHODS

Sixty healthy 16- to 18-year-old girls were randomly selected from two high schools in the city of Ahvaz and divided into two equally matched groups, one that received nutrition education, and one that did not. The education group received instruction in face-to-face sessions, group discussions, and pamphlets for 2 months. The control group did not receive any information during the study. Hematologic tests, corpuscular indices, and serum ferritin levels were measured at baseline and after 2 months. Food-frequency questionnaires were administered and histories taken, clinical signs of nutritional deficiencies observed, anthropometric measurements taken, nutritional knowledge tested, practices determined, and lifestyle questionnaires administered to all subjects.

RESULTS

There were no statistically significant differences in any baseline characteristics between the two groups. Scores for nutritional knowledge and practices of the education group were significantly higher after two months compared with the baseline (31.4 +/- 6 vs. 24.3 +/- 5.9 points, p < .001, and 31.2 +/- 5 vs. 28.4 +/- 5.7 points, p < .05, respectively). The scores in the control group showed no significant changes from baseline to 2 months. Mean corpuscular volume values were elevated in the education group (p < .001) but not in the control group. However, in the control group, serum ferritin concentrations showed about a 17% drop at the end of the study (p < .004). There were no changes in other hematologic, lifestyle, clinical, or anthropometric data compared with baseline after completion of the study in both groups.

CONCLUSION

These findings indicate that nutritional education can improve knowledge of healthy nutrition and lifestyle choices. Focused nutritional education using available resources and correcting current dietary habits in a vulnerable group of young women may result in dietary changes that can ultimately improve iron intake.

Effect of iron supplementation on haemoglobin response in children: systematic review of randomised controlled trials

OBJECTIVE

To evaluate the effect of iron supplementation on haemoglobin (Hb) in children through a systematic review of randomised controlled trials.

MATERIALS AND METHODS

Electronic databases, personal files, hand search of reviews, bibliographies of books, and abstracts and proceedings of international conferences were reviewed. Randomised controlled trials evaluating change in Hb levels with interventions that included oral or parenteral iron supplementation or iron-fortified formula milk or cereals were analysed.

RESULTS

A total of 55 trials (56 cohorts) provided relevant information. Publication bias was evident (P < 0.001). The pooled estimate (random-effects model) for change in Hb with iron supplementation (weighted mean difference) was 0.74 g/dL (95% CI, 0.61-0.87; P < 0.001; P < 0.001 for heterogeneity). Lower baseline Hb level, oral medicinal iron supplementation, and malarial nonhyperendemic region were significant predictors of greater Hb response and heterogeneity. Projections suggested that, on average, between 37.9% and 62.3% of baseline anaemia (Hb <11 g/dL) was responsive to iron supplementation among children under 6 years of age; the corresponding range for malarial hyperendemic regions was 5.8% to 31.8%.

CONCLUSIONS

This systematic review indicates that iron supplementation increases Hb levels in children significantly but modestly. The increase is greater in subjects who are anaemic at the start of the trial and lower in malarial hyperendemic areas and in those consuming iron-fortified food. The projected reductions in prevalence of anaemia with iron supplementation alone highlight the need for additional area-specific interventions, particularly in malaria-prone regions.

School-Based Iron and Folic Acid Supplementation for Adolescent Girls: Findings from Manica Province, Mozambique

Background

The 1997 Demographic and Health Survey in Mozambique shows that 47% of girls 15 to 19 years old living in Manica province (west-central Mozambique) are pregnant or have already had a child. A recent survey also shows that 45% of girls 10 to 18 years old attending school are anemic. Strategies are needed to build iron stores before pregnancy and to control seasonal and chronic iron deficiency and anemia in school-aged girls.

Objective

To assess the program effectiveness of two school-based weekly iron and folic acid (IFA) supplementation regimes (5-month supplementation vs. 8-month supplementation) in girls 10 to 18 years old attending school in Manica province.

Methods

Twelve schools were included in the study. Schools were ordered by descending mean hemoglobin concentration, and assigned alternately to study group 5 (six schools; 5-month supplementation) or study group 8 (six schools; 8-month supplementation). In both study groups, the weekly supplement contained 60 mg of elemental iron and 400 μg of folic acid. All girls received a single dose of mebendazol (500 mg) twice—once at the beginning of the study (T0) and once six months later (T6). Supplementation was implemented and supervised by the teachers of the schools included in the study. Between T0 and T3, girls in study group 8 received IFA supplements weekly whereas girls in study group 5 did not. Between T3 and T8, all girls in both groups received weekly IFA supplements.

Results

At T0, mean hemoglobin concentration and anemia prevalence were comparable in study groups 8 and 5 (125.3 ± 12.6 g/L vs. 123.8 ± 12.8 g/L; 28% vs. 29%, respectively). At T3, the mean hemoglobin concentration in study group 8 was significantly higher (126.3 ± 14.3 g/L vs. 121.5 g/dL ± 11.9 g/L p < .001) and the prevalence of anemia was lower (28% vs. 35%, p = .076) than in study group 5. At T8, after an additional 5-month supplementation period in both study groups, mean hemoglobin concentration and anemia prevalence in study groups 8 and 5 were not significantly different (126.5 ± 12.6 g/L vs. 124.9 ± 12.3 g/L; 23% vs. 27%, respectively).

Conclusion

In Manica Province, school-based weekly IFA supplementation is a feasible and effective intervention to prevent seasonal drops in hemoglobin concentration and increases in anemia prevalence. Short supplementation periods can have an important impact on girls' hematological status. However, the size of girls' hematological response in this study was significantly lower that that observed in studies with similar population groups, initial anemia prevalence, supplement dosing, and/or supplementation regime.

Efficacy of multiple micronutrient supplementation for improving anemia, micronutrient status, growth, and morbidity of Peruvian infants

Anemia, micronutrient deficiencies, and growth faltering are still common in Peru. The study objective was to determine the efficacy of different micronutrient supplements in preventing growth failure, anemia, and micronutrient deficiencies in Peruvian infants. Three hundred and thirteen infants aged 6 to 12 mo participated in a double-blind, masked, controlled trial in which they were randomly assigned to receive either a daily dose of iron (DI), a daily dose of multiple micronutrients (DMM), a weekly dose of multiple micronutrients, or a placebo (P) for 6 mo. None of the supplements tested prevented growth faltering or the morbidities common during infancy. Anemia and plasma homocysteine concentrations fell significantly in all groups during the study, but the mean change of plasma homocysteine during the trial period was significantly smaller in the DI group than in other groups, and the increase in hemoglobin concentrations was smaller in the P group than the micronutrient treatment groups. Plasma ferritin concentrations decreased least in the groups taking daily micronutrient supplements containing iron (DI and DMM). There were no significant differences among groups in mean final values or changes in plasma zinc, retinol, tocopherol, or riboflavin. Although the DMM intervention was the most efficacious for preventing anemia, iron, and zinc deficiencies, 15%, 20%, and 50% of this group still remained anemic, zinc deficient, and iron deficient, respectively, at the end of the study. Further research thus should investigate whether higher doses of iron and zinc, together with infection control measures, are more efficacious.

Daily iron supplementation is more efficacious than twice weekly iron supplementation for the treatment of childhood anemia in western Kenya

A recent meta-analysis of 14 clinical trials indicated that daily compared with intermittent iron supplementation resulted in significantly greater hematological improvement in pregnant women. No such definitive beneficial effect was demonstrated in preschool children. We compared the efficacy of daily and twice weekly iron supplementation for 6 wk under supervised and unsupervised conditions in the treatment of mild and moderate anemia [hemoglobin (Hb) 50-109 g/L] in children aged 2-59 mo living in a malaria-endemic area of western Kenya. The study was a cluster-randomized trial using a factorial design; participants were aware of the treatment assigned. All children (n = 1049) were administered a single dose of sulfadoxine-pyrimethamine at enrollment followed by 6 wk of daily supervised iron supplementation [3-6 mg/(kg.d)], twice weekly supervised iron supplementation [6-12 mg/(kg.wk)], daily unsupervised iron supplementation, or twice weekly unsupervised iron supplementation. In the supervised groups, Hb concentrations at 6 and 12 wk (6 wk postsupplementation) were significantly higher in children given iron daily rather than twice weekly [mean (95% CI) difference at 6-wk: 4.2 g/L (2.1, 6.4); 12-wk: 4.4 g/L (1.8, 7.0)]. Among the unsupervised groups, Hb concentrations were not different at 6 wk [mean (95% CI) difference: 0.86 g/L (-1.4, 3.1)], but significantly higher at 12 wk for those assigned daily iron [mean (95% CI) difference: 3.4 g/L (0.79, 6.0), P = 0.02]. In this malarious area and after initial antimalarial treatment, 6 wk of daily iron supplementation results in better hematological responses than twice weekly iron supplementation in the treatment of anemia in preschool children, regardless of whether adherence can be ensured.

Formative Research to Develop a Nutrition Education Intervention to Improve Dietary Iron Intake among Women and Adolescent Girls through Community Kitchens in Lima, Peru

Formative research was conducted with 26 women and 16 adolescent girls to develop an education intervention through community kitchens (CK) in Lima, to increase their dietary iron intake and improve their iron status. A combination of qualitative research methods was used to explore perceptions about foods, nutrition, health, anemia and body image. The women recognized that there was a close association among eating well, "alimentarse bien", their health and prevention and treatment of anemia. They perceived that the nutritive value of a meal is determined primarily by its content of "nutritious" foods and by its being "balanced". Using this information the conceptual model of the education intervention was developed. The vulnerability of women to anemia was presented with the relationship between anemia and diet as the central focus. Feasible ways of achieving a nutritious diet were introduced to the community kitchens through promoting local heme iron sources and the consumption of beans with a vitamin C source. Animal source foods were amongst those considered to be nutritious and were "best buys" for iron content. CK searched for ways of assuring accessibility to these foods. The use of animal source foods in the community kitchen menus increased during the intervention.

Prevention of iron deficiency anemia in adolescent and adult pregnancies

OBJECTIVE

Worldwide attention over iron deficiency anemia (IDA) in pregnancy has shifted recently from providing supplements during pregnancy to attempting to ensure that women, especially adolescents, have adequate iron stores prior to conception. We sought to determine whether adolescent and/or adult women still need supplements during pregnancy to avoid IDA, even if iron stores are adequate, and whether the IDA translates into maternal and/or infant morbidity and mortality.

DESIGN

Randomized, double-blind clinical trial with placebo control.

SETTING

Multicenter clinic setting in central Wisconsin.

PARTICIPANTS

Adolescent women 18 years or less in their first pregnancy, and adult women 19 years or older, who were found to be healthy and iron sufficient at their first prenatal visit.

METHODS

Participants were randomized to receive iron supplementation (60 mg/day elemental iron) or placebo. Serum ferritin of 12 ng/mL or less with simultaneous hemoglobin of 11 g/dL or less defined IDA. When IDA occurred at the second trimester, a therapeutic supplement of 180 mg of elemental iron per day was initiated.

RESULTS

Forty-seven percent of all placebo-supplemented and 16% of all iron-supplemented patients exhibited IDA (p<0.001); 59% of adolescent placebo-supplemented and 20% of adolescent iron-supplemented patients exhibited IDA (p=0.021). Nausea, vomiting, diarrhea, and constipation were not significantly different in the iron supplemented group compared to the placebo group, and no significant differences were seen in maternal or neonatal health, but the number of women studied was limiting for analysis of these adverse events.

CONCLUSION

IDA is common in healthy, iron-sufficient adolescent pregnant women during the second trimester, and body stores of iron decline in both adolescent and adult pregnancies. The incidence of IDA during adolescent and adult pregnancies is substantially reduced with 60 mg of elemental iron per day. However, there remains no clear evidence that maternal or neonatal health will benefit from correcting these deficits.

Once weekly is superior to daily iron supplementation on height gain but not on hematological improvement among schoolchildren in Thailand

Intermittent iron supplementation has been suggested as a replacement for daily iron supplements for reducing anemia in developing countries. The effects of once weekly and daily iron supplementation on hemoglobin (Hb), serum ferritin (SF), prevalence of anemia, weight and height are compared in this study. Primary schoolchildren (n = 397) from two selected schools in the Hat Yai rural area, southern Thailand, were recruited in 1999. All children received Albendazole and then randomly received ferrous sulfate (300 mg/tablet) either daily or weekly, or a placebo for 16 wk. The average increase in Hb was not significantly different between the daily (mean +/- SD; 6.5 +/- 6.0 g/L) and weekly (5.7 +/- 6.3 g/L) groups. However, the average increase in SF was greater (P < 0.01) in the daily (mean +/- SD; 39.8 +/- 30.3 microg/L) than the weekly (13.4 +/- 17.3 microg/L) group. All cases of iron deficiency anemia were abolished in both daily and weekly groups, whereas no reduction in prevalence occurred in the placebo group. Height gain was greater in children who received weekly (mean +/- SD; 2.6 +/- 0.9 cm) than in those who received daily iron (mean +/- SD; 2.3 +/- 0.8 cm), (P < 0.01). Weight gain, weight-for-age and height-for-age were not significantly different among the intervention groups. It is concluded that a weekly iron dose is more effective than a daily dose in height gain but not in hematological improvement over 16 wk of supplementation.