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]

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