……………   weekly iron supplementation for 1 to 5 year-old children, an economical and effective intervention for anemia prevention.

 

Philippines, the overall prevalence of iron deficiency anemia (IDA) is 30.6%, with a prevalence of 29.6% among children aged 1-5 years. Iron supplementation and food fortification have been identified as impact programs to address IDA. However, the existing guidelines on iron supplementation contained in the Department of Health Administrative Order 3-A s. 2000 does not include universal iron supplementation of 1-5 year-old children although routine supplementation of 2-5 year old children daily for about 2 months is indicated. Food fortification, on the other hand, is still not fully implemented. In addition, when hookworm infection is one of the underlying causes of IDA, both iron supplementation and food fortification will be less effective. Thus, the strategy for IDA in hookworm-endemic areas should include addressing hookworm infection concurrently.

In 2000, the Early Childhood Development Project of the Department of Social Welfare and Development (ECD-DSWD) called for the conduct of the study on the "Cost-effectiveness of deworming and weekly iron supplementation in the reduction of anemia among preschoolers: a field test". The Nutrition Center of the Philippines (NCP) responded to this call and was subsequently selected to conduct the study. The project was In the conducted from September 2001 to May 2003. The study showed that weekly iron  supplementation for 4 months, with or without deworming, was effective in improving the iron status of 1-5 year-old children. Based on this finding, the Philippine Association of Nutrition recommends weekly iron supplementation for 1-5 year-old children. A summary of the study, taken from the final report by the NCP, is presented below.

Title:   Cost-effectiveness of deworming and weekly iron supplementation in the reduction of anemia among preschoolers: a field test 

Objective:   This study aimed to determine the cost-effectiveness of the combined strategy of deworming and weekly iron supplementation (DIS) versus weekly iron supplementation alone (IS) in reducing the prevalence of anemia among preschoolers. 

Methods:   This randomized field trial was conducted among 2,082 preschoolers (aged 12-71 months) in 

8 rural villages in the municipalities of Barili and Dalaguete in Cebu Province. After the baseline data collection, the children were randomized to DIS group (experimental) or the IS group (control). The children in the DIS group were dewormed before the iron supplements were given. Children aged 1-2 years old were given 200 mg of albendazole while those aged 3-5 years old were given 400 mg of albendazole. All the children were given iron supplements weekly for 4 months as follows: 1.2 ml of ferrous sulfate drops for age 1-2 years; 7.5 ml of ferrous sulfate syrup for age 3-4 years; and, 12.0 ml of ferrous sulfate syrup for age 5 years.

Results:   At baseline, the characteristics of the children in the DIS and IS groups did not differ significantly except for Trichuris infection and mixed infection. After the intervention, the hemoglobin, zinc protoporphyrin and serum ferritin levels increased in both groups, with no significant differences observed between groups. Overall, the prevalence of anemia was reduced by 43%, iron deficiency (using serum ferritin) by 65%, iron deficiency (using zinc protoporphyrin) by 50%, IDA (using hemoglobin and serum ferritin) by 73% and IDA (using hemoglobin and zinc protoporphyrin) by 70%. The prevalence of infection for all helminths was similar to baseline levels after 4 months, although the prevalence and intensity of infection was significantly lower in the DIS group. The prevalence of stunting decreased while that of underweight and wasting increased slightly but not significantly. The average cost of administering DIS to a child is PHP 77.57 and PHP 45.52 for IS. The cost of drugs comprised 68.2% of total costs for DIS and 62.5% for IS. Significant additional mild anemia cases prevented were observed for IS while for DIS, significant reductions in hookworm and Ascaris infections were noted. DIS prevented less number of mild anemia cases and is more costly than IS. DIS was effective in reducing hookworm, Ascaris and Trichuris infection. As expected, IS did not have any considerable effect on geohelminthic infections. 

 

Conclusions: The combined intervention of DIS did not significantly impact on IDA among preschoolers possibly due to the low prevalence of IDA and hookworm infection in this study population. 

IS alone for 4 months was effective in reducing anemia. IS alone has a potential of cost savings compared to the combined strategy in preventing cases of mild anemia, because of more cases of mild anemia prevented at a lower cost. 

Deworming alone is also cheaper than the combined strategy in preventing geohelminthic infections in this population of preschoolers.

Recommendations and Policy Implications: As weekly iron supplementation for 4 months was proven effective in reducing anemia, it is recommended that this be implemented as a national program of the government. However, the duration of the iron supplementation must be for at least 1 year to prevent iron deficiency, improve iron stores and consequently prevent anemia. If the resources of the government are limited, iron supplementation can be targeted only among preschoolers who are anemic. If assessment of anemia is not feasible due to budget constraints, the child's nutritional status can be used as surrogate indicator for anemia. As this study has shown, it is more likely that underweight, stunted or wasted children are anemic.

It is recommended that weekly iron supplementation for 1-5 year-old children should be considered as a policy. Although this study did not assess the effect of daily iron supplementation, studies conducted elsewhere has proven that daily and weekly iron supplementation produce the same effect on iron status.

While iron supplementation in itself is highly effective in reducing anemia, food-based strategies as food fortification and dietary diversification through nutrition education are still more recommended as long-term interventions to address the malnutrition problem in the country. The evident inadequate energy and nutrient intake of children in this population is expected to be found in other poor communities in the country. 

An effectiveness trial in other communities with higher prevalence and intensity of geohelminthiases and/or other areas with multiple parasitic infections (for example, soil-transmitted helminths plus malaria or schistosomiasis) should be conducted. An efficacy trial on a subset of preschool children diagnosed with anemia and helminthiases may also be done. It is important that the frequency, timing and duration of deworming children be studied and instituted as a national program.

 

Authors:

Florentino S. Solon, M.D., M.P.H.; Liberty Fajutrao, M.D., M.P.H.; Juan Antonio A. Solon, M.D., M.Sc.; Jesus N. Sarol, Jr., Ph.D.; Lorena S. Wambangco-Tengco, R.N.D.; and, Liza S. Fermin, M.Sc., R.N.D.

Funder: Early Childhood Development Project-Department of Social Welfare and Development

Studies on the efficacy of weekly iron supplementation

1. Beaton GH, McCabe GP (1999) Efficacy of intermittent iron supplementation in the control of iron deficiency anemia in developing countries. An analysis of experience: Final report to the Micronutrient Initiative. Canada: Micronutrient Initiative.

2. Monteiro CA, Szarfarc SC, Brunken GS, Gross R, Conde WL (2001) Long-term preventive mass prescription of weekly doses of iron sulfate may be highly effective to reduce endemic child anemia. Food Nutr Bull 1:53-61. 

3. Liu X-N, Kang J, Zhao L, Viteri FE (1995) Intermittent iron supplementation in Chinese children is efficient and safe. Food Nutr Bull 16:139-46.

4. Palupi L, Schultink W, Achadi E, Gross R (1997) Effective community intervention to improve hemoglobin status in preschoolers receiving once-weekly iron supplementation Am J Clin Nutr 65:1057-61. 

5. Schultink W, Gross R, Gliwitzki M, Karyadi D, Matulessi P (1995) Effect of daily vs. twice weekly iron supplementation in Indonesian preschool children with low iron status. Am J Clin Nutr 61:111-15.

6. Soemantri AG, Pollitt E, Kim I (1985) Iron deficiency anemia and educational achievement Am J Clin Nutr 42:1221-8.

7. Thu BD, Schultink W, Dillon D, Gross R, Leswara ND, Kha HH (1999) Effect of daily and weekly micronutrient supplementation on micronutrient deficiencies and growth in young Vietnamese children. Am J Clin Nutr 69:80-6.