Effect of iron supplementation on development of iron deficiency anemia in breastfed infants

Effect of Low-Dose Iron Supplementation on Early Development in Breastfed Infants: A Randomized Clinical Trial

Importance

Breastfed infants are at risk of iron deficiency, which is associated with suboptimal development. There is a paucity of evidence on the effects of iron supplementation on child development, and current guidelines are divergent.

Objective

To assess whether daily iron supplementation, 1 mg/kg, between 4 and 9 months in exclusively or predominantly breastfed infants improves psychomotor development at 12 months.

Design, Setting, and Participants

This was a randomized, double-blind, placebo-controlled trial conducted between December 2015 and May 2020 with follow-up through May 2023 in an outpatient setting in Poland and Sweden. Participants were healthy singleton infants born at term with birth weight greater than 2500 g who were exclusively or predominantly breastfed (>50%) and did not have anemia (hemoglobin >10.5 g/dL) at age 4 months. Exclusion criteria included major illness, congenital anomaly, food allergy, and difficulty communicating with caregivers.

Interventions

Iron (micronized microencapsulated ferric pyrophosphate), 1 mg/kg, or placebo (maltodextrin) once daily from age 4 to 9 months.

Main Outcomes and Measures

The primary outcome was psychomotor development assessed by motor score of Bayley Scales of Infant and Toddler Development III at 12 months, adjusted for gestational age, sex, and maternal education. Secondary outcomes included cognitive and language scores at 12 months; motor, cognitive, and language scores at 24 and 36 months; iron deficiency (serum ferritin <12 ng/mL), and iron deficiency anemia (iron deficiency and hemoglobin <10.5 g/dL) at 12 months.

Results

Of 221 randomized infants (111 female), 200 (90%) were included in the intention-to-treat analysis (mean [SD] age, 12.4 [0.8] months). Iron supplementation (n = 104) compared to placebo (n = 96) had no effect on psychomotor development (mean difference [MD] for motor score, -1.07 points; 95% CI, -4.69 to 2.55), cognitive score (MD, -1.14; 95% CI, -4.26 to 1.99), or language score (MD, 0.75; 95% CI, -2.31 to 3.82) at 12 months. There were no significant differences at 24 and 36 months. The intervention did not reduce the risk for iron deficiency (relative risk [RR], 0.46; 95% CI, 0.16 to 1.30) or iron deficiency anemia (RR, 0.78; 95% CI, 0.05 to 12.46) at 12 months.

Conclusion and Relevance

No benefit was found with daily low-dose iron supplementation between 4 and 9 months with respect to psychomotor development, risk of iron deficiency, or iron deficiency anemia among breastfed infants in a setting of low risk of anemia.

Trial Registration

ClinicalTrials.gov Identifier: NCT02242188.

Comparison of the effect of ferrous sulfate and ferrous gluconate on prophylaxis of iron deficiency in toddlers 6-24 months old: A randomized clinical trial

BACKGROUND

Iron deficiency anemia (IDA) is one of the most common anemias, especially in children 4-23 months. Therefore, prophylaxis is necessary to improve iron status as well as reduce IDA in Toddlers. The aim of this study was to compare the efficacy of daily supplementation with ferrous gluconate (FG) and ferrous sulfate (FS) on iron status in toddlers.

MATERIALS AND METHODS

A total of 120 healthy toddlers were divided randomly into 2 groups at the Amir-Kabir Hospital, Arak, Iran and received FS and FG from March 2020 to December 2020. Iron status was evaluated at baseline and after 6 months of supplementation. The statistical significance of the differences in iron status between FS and FG groups was calculated using Student's t-test and the Pearson' s Chi-square test for qualitative variables. SPSS software (version 16, Chicago, IL, USA) was used for statistical analysis.

RESULTS

Comparison of iron status of FS and FG groups toddlers at baseline and after 6 months of supplementation showed that there was a significant difference in hemoglobin (Hb) (10.46 vs. 12.45, P = 0.001) and ferritin level (28.08 vs. 59.63, P = 0.001).

CONCLUSIONS

Although prophylaxis with FG led to a higher Hb and ferritin levels, our study recommended that both FG and FS supplements were effective for prophylactic use in the prevention of IDA. However, FG was more effective than FS because FG group that received FG supplementation indicated a higher Hb and ferritin levels in comparison to the FS group that received FS supplementation.

Micronutrient Supplementation and Fortification Interventions on Health and Development Outcomes among Children Under-Five in Low- and Middle-Income Countries: A Systematic Review and Meta-Analysis

Micronutrient deficiencies continue to be widespread among children under-five in low- and middle-income countries (LMICs), despite the fact that several effective strategies now exist to prevent them. This kind of malnutrition can have several immediate and long-term consequences, including stunted growth, a higher risk of acquiring infections, and poor development outcomes, all of which may lead to a child not achieving his or her full potential. This review systematically synthesizes the available evidence on the strategies used to prevent micronutrient malnutrition among children under-five in LMICs, including single and multiple micronutrient (MMN) supplementation, lipid-based nutrient supplementation (LNS), targeted and large-scale fortification, and point-of-use-fortification with micronutrient powders (MNPs). We searched relevant databases and grey literature, retrieving 35,924 papers. After application of eligibility criteria, we included 197 unique studies. Of note, we examined the efficacy and effectiveness of interventions. We found that certain outcomes, such as anemia, responded to several intervention types. The risk of anemia was reduced with iron alone, iron-folic acid, MMN supplementation, MNPs, targeted fortification, and large-scale fortification. Stunting and underweight, however, were improved only among children who were provided with LNS, though MMN supplementation also slightly increased length-for-age z-scores. Vitamin A supplementation likely reduced all-cause mortality, while zinc supplementation decreased the incidence of diarrhea. Importantly, many effects of LNS and MNPs held when pooling data from effectiveness studies. Taken together, this evidence further supports the importance of these strategies for reducing the burden of micronutrient malnutrition in children. Population and context should be considered when selecting one or more appropriate interventions for programming.

Comparison of Different Iron Preparations in the Prophylaxis of Iron-deficiency Anemia

We compared the efficacy of ferrous sulfate (divalent) and ferric polymaltose (trivalent) compounds for the prophylaxis of iron-deficiency anemia (IDA). Study infants included exclusively breast milk-fed term infants. Subjects were divided randomly into 2 groups at 4 months of age and group 1 (n=56) received divalent and group 2 (n=56) received trivalent iron (Fe) preparation at a dose of 2 mg/kg/d for 5 months. At 9 months of age, after a 5-month prophylaxis, a significant increase was observed in hemoglobin (Hb), hematocrit, serum Fe levels, and transferrin saturation in both groups. However, group 1 had significantly higher Hb, hematocrit, mean corpuscular volume, Fe, and transferrin saturation than group 2 (11.7±0.6 g/dL, 34.6%±1.7%, 76.2±2.9 fL, 55.5±1.8 mcg, 20.8±3.9 g/L, respectively in group 1 vs. 11.3±0.5 g/dL, 33.5%±1.5%, 74.7±3.2 fL, 42.5±1.8 mcg, 14.1±7.5 g/L, respectively in group 2). No significant difference was found in ferritin values between the groups. Fe deficiency was found in 17 (30.3%) of the subjects in group 1, and 23 (41%) of subjects in group 2 whereas 5 (8.9%) subjects had IDA in group 1 and 12 (12%) in group 2 which were insignificant between groups. No significant difference was found with regard to side effects between 2 Fe preparations. Although divalent Fe therapy led to a higher Hb and serum Fe level, both ferrous and ferric Fe preparations were effective for prophylactic use in the prevention of Fe deficiency and IDA with comparable side effects.

Iron deficiency anemia from diagnosis to treatment in children

Iron deficiency is the most common nutritional deficiency worldwide and an important public health problem especially in developing countries. Since the most important indicator of iron deficieny is anemia, the terms "iron deficiency" and "iron deficiency anemia" are often used interchangeably. However, iron deficiency may develop in the absence of anemia and the tissues may be affected from this condition. The most common causes of iron deficiency in children include insufficient intake together with rapid growth, low birth weight and gastrointestinal losses related to excessive intake of cow's milk. If insufficient intake can be excluded and there is insufficient response to oral iron treatment in patients with iron deficiency especially in older children, blood loss should be considered as the underlying cause. The main principles in management of iron deficiency anemia include investigation and elimination of the cause leading to iron deficiency, replacement of deficiency, improvement of nutrition and education of the patient and family. In this article, the practical approaches in the diagnosis and treatment of iron deficiency and the experience of our center have been reviewed.

Meeting iron needs for infants and children

PURPOSE OF REVIEW

Iron deficiency early in life is associated with impaired neurological development. This study reviews the latest research on how to best meet iron requirements in infants and children.

RECENT FINDINGS

There is concurrent evidence that delayed cord clamping is well tolerated and improves infant iron stores. Iron supplements or enriched complementary foods starting before 6 months of life do not reduce iron deficiency prevalence in low-risk populations. However, for low birth weight infants, iron supplements before 6 months of life have long-term benefits. Iron deficiency anaemia (IDA) during the second half year of life is rare in countries with high compliance to iron-rich complementary foods, but remains a major problem globally. In high-risk populations, iron supplementation reduces IDA and possibly improves growth. However, increased risk of infections is a concern and optimal preventive strategies have not yet been determined. Finally, there is concurrent evidence that iron supplementation of anaemic school-aged children reduces IDA and possibly improves neuropsychological outcomes.

SUMMARY

Interventions for prevention of iron deficiency should be prioritized in risk groups. However, the unclear long-term benefits and possible risk of adverse effects, particularly increased infections in developing countries, prompt further large-scale, double-blinded trials.