April 2003, Volume 53, Issue 4

Editorial

Iron Deficiency Anemia: Preventive Strategies and Controversies

S. N. Adil  ( Division of Haematology, Department of Pathology. The Aga Khan University, Karachi. )
M.U. Shaikh  ( Division of Haematology, Department of Pathology. The Aga Khan University, Karachi. )

Iron deficiency is the most common micronutrient deficiency affecting approximately 50% of the world population.1 Iron deficiency anemia during childhood is associated with impaired work performance and also with impaired development in behavior, cognition, psychomotor skills, stunted growth. decrease appetite, poor performance of the immune system and this together has a negative impact on social and economic development.2 Mild to moderate anemia is one of the factors for women who are at risk of dying from one of the five major causes of maternal mortality, namely. haemorrhage, eclampsia, abortion, obstructed labor and sepsis.3 Iron deficiency is mainly prevalent in pre school children, school children, adolescent females and pregnant women. What should be the strategies to prevent these groups from the consequences of iron deficiency? Enrichment and fortification of food, dietary modification, and iron supplementation are the well-established modalities for the prevention of iron deficiency. Fortification of infant formulas and consumption of fortified and iron rich products by lactating women and young infants have dramatically reduced the prevalence in the developed countries but the overall picture is dismal because of poverty, illiteracy and poor health care system.4 Another emerging field is the hiomanipulation of micronutrients by genetically deleting iron absorption inhibitors e.g. removal of phytic acid from maize and beans and thereby increasing the bioavailahility of micronutrient.4
Iron supplementation is one of the most effective way to prevent and treat iron deficiency however, there are controversies regarding frequency of administration of oral iron and the dosage formulation.5 Daily oral iron supplements are effective at reducing the prevalence of anemia but at the cost of variable gastrointestinal side effects leading to poor compliance. An alternate approach to daily versus weekly iron supplementation has been suggested based on the mucosal block in rats. It has been noted that iron absorption is reduced in rats in the days immediately after the initial administration of iron and this introduced the mucosal block theory. however, the studies in humans have clearly revealed that there is no such mucosal block during iron supplementation that is responsible for a reduction in iron absorption in rats. One of the main indications for iron supplementation is pregnancy and with weekly administration the total iron deficit in the body will be substantial and can seriously harm both mother and fetus.6
As far as the dose is concerned, a daily dose of 60 mg of ferrous iron throughout the second half of the pregnancy should be sufficient to prevent iron deficiency. A dose of 120mg daily will be required for non pregnant iron deficient females or in females who were unable to start supplementation therapy in second trimester.7 Adolescent females is another group which should be targeted because adolescent pregnancies are not uncommon in our country and the objective should he the preparation of potential mother’s nutritional status in anticipation of pregnancy that will reduce the likelihood of complications and would increase the overall survival of mothers and infants.2
The third group that should he targeted is preschool and school children. Recently. Human Nutrition Unit of the All india Institute of Medical Sciences published the recommendations on strategies for prevention and control of iron deficiency anemia amongst children below the age of three years. Issues like the age group for iron supplementation, type of iron compounds, dosage, daily versus weekly administration and duration of iron supplementation have been (liScuSsed. The recommendations for children of group of upto three years include the use of Ferrous sulphate 20mg once daily in the form of drops that should be administered for at least hundred days in the first year of life and the same schedule should be repeated in second year.8 Keeping in view the comparable social status of our country we can benefit from these guidelines that can be incorporated in our health care system. A large number of doctors are employed in school health scheme that can play an important role in their implementation to the targeted groups. Similarly iron supplementation can be inducted in extended programme of immunization.

References

1. Saloojee H. Pettifor JM. Iron deficiency and impaired child development (editorial). BMJ 2001; 323:1377-8.
2.Ahrncd F. Khan MR. Jackson AA. Concomitant supplemental vitamin A enhances the response to weekly supplemental iron and folk acid in anemic teenagers in urban Bangladesh. Am J Clin Nutr 2001:74:108-15.
3.Guidotti Ri. Anemta in pregnancy in developing countries: coninientary. Br J Obstet Gynaecoi 2000:107:437-8.
4.Beard JL. Effectiveness and strategies of iron supplementation (luring pregnancy. Am J Clin Nutr 2000;71 (Suppl):S1288-S94.
5.Beard JL. Weekly iron intervention: the case for intermittent iron supplementation. AmJ Clin Nutc 998:68:209-12.
6.Hallberg L. Combating iron deficiency: daily administration of iron is far superior to weekly administration. Am J Clin Nor 1998: 68:213-17.
7.Bothwell TH. Iron requirement in pregnancy and strategies to meet them. American Journal of Clinical Nutrition 2000: 72 (suppl): S257-S64.
8.Kapil U, Sachdev HPS. Technical consultation on strategies for prevention and control of iron derficiency anemia amongst tinder three children in India. Indian Pediatr 2002:39:640-4.130
 

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