Weekly iron supplementation for the prevention of anemia in pre-school children: a randomized, double-blind, placebo-controlled trial

Iron Pots for the Prevention and Treatment of Anemia in Preschoolers

OBJECTIVE

To assess the effect of food cooked in iron pots for the prevention and treatment of iron deficiency anemia.

METHODS

In this cluster randomized clinical trial, authors evaluated preschoolers aged 4-5 y for 16 wk. Children were cluster randomized to either eating from iron pots (Group A) or aluminum pots (Group B). Primary outcome variables were change in hemoglobin concentration and anemia prevalence. Two biochemical evaluations were performed, to determine Hb concentrations, before and after intervention. This study was conducted in two public preschools, located in the municipality of Mucambo, Ceará, in the northeast of Brazil.

RESULTS

At baseline, for group A, mean hemoglobin concentration was 12.26 ± 1.02 g/dL and 12.29 ± 0.95 g/dL after intervention, p = 0.78. In group B, mean baseline hemoglobin was 12.34 ± 1.04 g/dL, and 12.13 ± 0.86 g/dL after intervention, p = 0.07. All ten participants, who were anemic at baseline, were no longer anemic after intervention.

CONCLUSIONS

Using iron cooking pots in developing countries could provide an innovative strategy to prevent and treat iron deficiency anemia.

Prevention and Treatment of Anemia in Infants through Supplementation, Assessing the Effectiveness of Using Iron Once or Twice Weekly

BACKGROUND

The objective of this study was to compare the effect of once weekly iron supplementation (IS) versus twice weekly, on hemoglobin (Hb) levels and anemia prevalence.

METHODS

In this cluster-randomized clinical trial study, we evaluated infants aged 6-18 months. Length of intervention: 16 weeks. Infants were cluster randomized to either 25 mg elemental iron once weekly (Group-A) or twice weekly (Group-B). Primary outcome variables were change in Hb concentration and anemia prevalence. Two biochemical evaluations were performed to determine Hb concentrations, before and after intervention.

RESULTS

For Group-A, at baseline, mean Hb concentration was 10.8 ± 1.18 g/dl and after intervention 11.2 ± 1.07 g/dl,p = 0.12; anemia prevalence was 52.5% at baseline and 37.5% after intervention,p = 0.18; Group-B, mean baseline Hb was 10.7 ± 1.04 g/dl, and 11.3 ± 0.91 g/dl after intervention,p = 0.002; anemia prevalence reduced from 57.9 to 36.8%.

CONCLUSIONS

Both once and twice weekly IS increased mean Hb concentration; however, twice weekly supplementation provided more significant results.

Use of iron-fortified rice reduces anemia in infants

Food fortification is advocated to tackle iron deficiency in anemic populations. Our objective was to evaluate the impact of iron-fortified rice (Ultrarice(®)) weekly on hemoglobin and anemia levels compared with standard rice (control). This cluster-randomized study deals with infants (10-23 months) from two public child day care centers in Brazil, n = 216, in an 18 week intervention. The intervention group received individual portions of fortified rice (50 g) provided 56.4 mg elemental/Fe. For intervention center: baseline mean hemoglobin was 11.44 ± 1.07 g/dl, and after intervention 11.67 ± 0.96 g/dl, p < 0.029; for control: baseline mean hemoglobin value was 11.35 ± 4.01 g/dl, and after intervention 11.36 ± 2.10 g/dl, p = 0.986. Anemia prevalence for intervention center was 31.25% at baseline, and 18.75% at end of study, p = 0.045; for control 43.50% were anemic at baseline, and 37.1% at the end of study, p = 0.22. Number Needed to Treat was 7. Iron-fortified rice was effective in increasing hemoglobin levels and reducing anemia in infants.

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.