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Editorial

Indian Pediatrics 2003; 40:293-295 

Prevention and Control of Iron Deficiency Anemia Amongst Young Children


Iron deficiency remains a major nutritional problem among infants and young children in India. The National Family Health Survey II, conducted in 1998-99, documented that about 74 per cent children between the ages of 6-35 months were anemic(1). Earlier studies from different regions in the country during the last three decades have also reported a similar high prevalence(2-7).

Since 1990, outstanding progress has been made towards eliminating iodine deficiency through universal salt iodization. Vitamin A deficiency is being aggressively addressed through nationwide biannual distribution of vitamin A solution to infants, young children and fortification of foods. However, during this same period, little progress has been made towards elimination of iron deficiency. Iodine and vitamin A deficiencies receive far greater attention and support due to more intense advocacy efforts by international and bilateral organizations. Simultaneously, an erroneous perception exists amongst the health adminis-trators and planners that effective and practi-cal interventions are not available for prevent-ing iron deficiency. Iron thus continues to remain the most "neglected micronutrient" in spite of it’s greater burden on health.

Evidence indicates that iron deficiency anemia is associated with impaired performance on a range of mental and physical functions in children including physical coordination and capacity, mental development, cognitive abilities, and social and emotional development(8). Other health consequences include reduced immunity, increased morbidity, increased susceptibility to heavy metal (including lead) poisoning. The precise effects vary with the age groups studied. Recent studies have documented that the iron supplementation at a later age may not reverse the effects of moderate to severe iron deficiency anemia that occured during the first 18 months of life(9-12).

It is true that National Nutrition Anemia Control Program (NACP) was launched in the country in 1970. It was supposed to cater to children between 1-5 years of age. Under this program, fifty per cent of children were to be given 100 tablets of iron and folic acid (IFA) per year for prophylaxis against nutritional anemia(13). However, the children below 24 months can not swallow the tablets and there is no provision of IFA liquid preparation in the program. Consequently, the children in this age group largely remained uncovered.

The health consequence of iron deficiency during first two years of life are not only serious but also irreversible. Paradoxically, during this critical "window" no effectively functioning supplementation program is in place to prevent iron deficiency. It is evident that strong concerted efforts need to be undertaken to improve the scenario(14). Some of the possibilities in this context are enumerated below (i) inclusion of IFA liquid under the NACP and targeting iron supplementation to children in the age group of 6-35 months on a priority basis (ii) initiating iron supplementation of all anemic and non anemic women/adolescent girls in the community so that they can enter pregnancy with adequate iron stores, (iii) promotion of exclusive breast feeding for all infants as it plays a significant role in preventing iron deficiency in both infants and their mothers, (iv) full term infants (of mothers with adequate iron stores), who are exclusively breastfed do not need supplemental iron until they are 6 months of age. After this age, breastfed infants should be given extra iron in the form of iron-fortified home made complementary foods. Where iron-fortified complementary foods are not widely or regularly consumed by young children, all infants should receive iron and folic acid supplements after six months of age.

It is often argued that the liquid iron supplements are costly to transport and store, and require packaging to enable caregivers to provide it in an effective, correct, and safe manner. However, no attempt has been undertaken to prove this assumption. Even if this approach is costly, there is a strong need to experiment with it on a pilot basis.

IFA supplementation should be done through the peripheral health and Integrated Child Development Services Scheme functionaries at the village level. Home visit once in a month is a part of the routine responsibilities of Anaganwadi Worker and Auxiliary Nurse Midwife, which can be utilized for distribution of the IFA. Various contact points like measles immunization (9 months), DPT booster (16 months) and take home ration day in ICDS scheme (where ever followed) should be utilized for distribution of IFA. Other village level developmental functionaires/voluntary persons available in the community may also be utilized for IFA supplementation, monitoring the compliance and side effects and for counseling the mother about the benefits of IFA. An effective step would be to make the IFA available at the village level through the net work of health sub-centers and anganwadi centers.

In conclusion, there is an urgent need to initiate specific public health action to prevent iron deficiency in young children. The time for meticulous planning is over, what is needed is immediate action.

Umesh Kapil,
Professor,
Department of Human Nutrition,
All India Institute of Medical Sciences,
New Delhi, 110 029,
India.
E-mail: [email protected]

 References


1. National family Health Survey-India (NFHS-II) 1998-99, International Institute of Population Sciences. Measures International, Demographic Health Survey, 2000.

2. Seshadri S, Hirode K, Naik P, Shah A, Gupta N. An effective intervention to reduce the prevalence of anemia in children. Indian J Med Res, 1984, 80: 164-173.

3. Indian Council of Medical Research. Studies on preschool children. ICMR Tech Rep Ser No 26. National Institute of Nurition. Hyderabad, 1977.

4. Raman L, Pawashe AB, Vasanthi G, Parvati CH, Vasumathi N, Rawal A. Plasma ferritin in the assessment of iron status on Indian infants. Indian Pediatr 1990; 27: 705-713.

5. Gomber S, Kumar S, Rusia U, Gupta P, Agarwal KN, Sharma S. Prevalence and etiology of nutritional anemias in early childhood in an urban slum. Indian J Med Res 1998; 107: 269-273.

6. Singla PN, Agarwal KN, Singh RM, Reddy ECG, Tripathi AM, Agarwal DK. Deficiency anemia in pre-school children - Estimation of prevalence based on response to hematinic supplementation. J Trop Pediatr 1982; 26: 239-242.

7. Choudhury P, Vir S. Prevention and strategies for control of iron deficiency anemia. In: Nutrition in Children, Developing Country Concerns. Eds. Sachdev HPS and Choudhury P, NewDelhi, 1st edition 1994, pp 492-524.

8. Preventing Iron defieincy in women and children technical consensus on Key Issues. 7-9 October 1998, UNICEF, UNU, WHO, MI, Technical Group International Nutrition Foundation, USA 1998.

9. Zlotkin S. Current issues for the prevention and treatment of iron deficiency anemia. Indian Pediatr 2002; 39: 125-128.

10. Scrimashaw N. 1990. Functional Significance of Iron Deficiency. In: Functional Significance of Iron Deficiency. Third Annual Nutrition Workshop. Eds. Enwonwu, C, Meharry Medical College, Nashville, TN, USA, 1990, pp 1-14.

11. Drapper A. Child development and Iron Defi-ciency: Early Action is Critical for Healthy Mental, Physical and Social Development. Oxford Brief, I The Inter-national Nutritional Anemia Consultative Group. Washington, D.C., USA, 1997.

12. Stoltzfus R, Dreyfuss M. Guidelines for the Use of Iron Supplements to Prevent and Treat Iron Deficiency Anemia. The International Nuritional Anemia Consultative Group Washington, D.C., USA, 1998.

13. Kapil U. National nutrition supplementation programmes. Indian Pediatr 1992; 29: 1601-1613.

14. Recommendations of Technical Consultation on Strategies for Prevention and Control of Iron Deficiency Anemia amongst Under Three Children in India. Indian Pediatr 2002; 39: 640-647.

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