 |
|
Original Article Indian Pediatrics 2003; 40:296-301 |
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
Anemia Prophylaxis in Adolescent School Girls by Weekly or Daily |
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
RECENT data from the District Nutrition Project (Indian Council Medical Research) in 16 districts of 11 states, on pre-valence of anemia in non-pregnant adolescent girls (total 4337; 11-18 years of age) showed rates as high as 90.1% with severe anemia (hemoglobin <7.0 g/dL) in 7.1%, suggesting prevalence of moderate-severe anemia during the second spurt of growth(1). Anemia is the late manifestation of deficiency of nutrient(s) needed for hemoglobin synthesis; such states are associated with health consequences(2). There is a general agreement that many adolescent girls in India need iron supplementation, which in turn will improve pre-pregnancy hemoglobin status and iron stores(3). Possibly, it may be easier to build their iron and folate reserves by supplementation/dietary diversification and education through schools. The question remains whether weekly supplementation will meet the need for growth, menstruation and future reproductive process demand or they will need regular daily supplementation. There are observations that weekly iron-supplementation may have similar or better response compared to the daily administration in controlling anemia. If true, weekly administration may be easier, cost effective and practical to administer. Wright and Southern(4) and Viteri, et al.(5) demonstrated that biweekly/weekly iron administration in rats was equally or more effective than daily dose. This was possibly related to the time of mucosal turnover. Administration of iron with folate or other vitamins in pregnancy(6) and childhood(7) has shown rise in hemoglobin and iron stores. In a study on rural children, 6-72 months old, those Anganwadis receiving weekly/biweekly 20 mg iron showed better rise in hemoglobin than 10 mg daily(8). School teachers and balwadi set up have been successful in control of anemia by iron-folate administration (9,10). Studies in adolescents(11-17) showed that iron alone or in combination with folate and vitamin A and C was able to raise hemoglobin and plasma ferritin status. In the present study the efficacy of weekly and daily supplementation of iron and folate was investigated for control of anemia and building of iron stores among school girls. Subjects and Methods The study was carried out during August 1996 to February 1999 in four Government Senior Secondary Schools. All these schools cater to the middle socio-economic group population in North-East Delhi. The total number of girls in the age group 10-17 years in these four schools together was 2210. Girls with hemoglobin <7.0 g/dL (0.3%) were excluded from the analysis. The expected rise of hemoglobin level by 0.75 g/dL after 100 days of treatment with 100 mg elemental iron and 500 µg of folic acid was considered significant. Taking significance at 95%, power 80% and with 5% dropouts, the calculated number of subjects was 118 for control and experimental groups. As school teachers did not agree to randomization at the individual girl level, the randomization was done at the class section level for the 60 class sections (all class sections taken). The study groups were I control; II daily and III weekly iron-folate tablets administered. Girls with all three measures of hemoglobin in each of the three groups were listed. The upper 118 girls from the selected subjects in each group were taken for the repeated measure MANOVA. The girls, parents and the school officials (Delhi Government) gave their consent for the study. The study was approved by the Institutional Ethics Committee on a condition that the control group would also receive 100 tablets (one per day) though this may be given after completion of the study. Group I. Control did not receive any tablets for the first 100 days and hemoglobin was estimated at 115 ± 5 days. They were thereafter given 100 iron folate tablets (iron 100 mg and folate 500 µg) with advice to take 1 tablet daily for 100 days; distributed weekly as in group II. Group II. (Daily administered group) These girls received one tablet daily for 100 days. Compliance was monitored verbally on weekly visits when 7 tables in a blister pack were distributed. The used blisters were collected, each week. Group III. (Weekly administered group) These girls were advised to take one tablet, which was distributed weekly in blister pack. They received the weekly tablet until group I completed the study (230 days). As the control group received 100 tablets after 115 days, the study continued for another 115 days to estimate their hemoglobin. Thus, hemoglobin was estimated, initially, at 115 days and at 230±5 days in all the three study groups. Seven girls in the daily administered group during the second week of intervention complained of gastric side effects and requested not to continue in the study and were excluded. Anemia was defined as hemoglobin level <12.0 g/dL(18). Plasma ferittin and C-reactive proteins (CRP) were estimated in every tenth girl of the study groups. Hemoglobin was estimated by the cyanmethemoglobin method(19). Briefly, 20 µl blood was added to tubes containing 5 ml of Drabkin’s solution (Ranbaxy, New Delhi). The variation in hemoglobin level on 2 consecutive determinations (separate, finger prick sample) on every fifth girl by two laboratory staff was 2.9%. The intra-indivi-dual variation was 1.7%. Plasma ferritin was estimated on samples stored at –20ºC. The ferritin was estimated on 10 µL plasma by an enzyme immunoassay method (Spectro Ferri-tin Kit, Ramco Lab, Houston). The variability on every fifth sample was 3.2 µg/L. C-reactive protein (CRP) was semi-quantitated using Reptiex CRP kit (Behring, USA). Statistical analysis was done using repeated measures ANOVA and MANOVA, Z-test and Chi-square with SPSS/PC soft-ware. Tukey test was used for pairwise comparisons in order to control the type I error to 5% level. Sexual maturity rating was done using Tanner’s criteria(20). The time of menarche and regularity of menstrual periods was noted. Results No girl in three study groups had hemoglobin level <7.0 g/dL at 115 and 230 days. Initially 0.3, 0.6 and 0.5% girls had hemoblobin level of 7-8 g/dL in-groups I, II and III respectively. After 115 days of intervention the corresponding values were 0.9, 0 and 0.3%. No girl had hemoglobin <8.0 g/dL at 230 days. More than 45% of these girls were anemic (level <12.0 g/dL) at the initial stage in each group. When no supple-mentation was given (control group) the prevalence of anemia increased by 3.2% at 115 days. In the intervention groups at 115 days anemia prevalence declined significantly by 12.5% and 7.7% in daily monitored and weekly monitored respectively. The difference between groups II and III was significant (P <0.001). The mean hemoglobin prevalence of and plasma ferritin levels in different groups are given in Table I. The mean levels were not significantly different in the various groups at inclusion (P >0.05). Controls (group I) showed non-significant decline in the average hemoglobin level at 115 days, but mean hemoglobin at 230 days was significantly higher than the value at 115 days (P <0.05). Daily treatment (group II) showed the maximum rise (0.5 g/dL) at 115 days (P <0.01). These levels were sustained at the same level at 230 days. Weekly administered (group III) did not show a significant rise (P >0.05) at 115 days, but showed significant change similar to the daily group at 230 days (P <0.05). Girls with hemoglobin ³12 g/dL were also benefited by daily supplementation as 35% of them showed rise in hemoglobin, compared to 26.1% in the weekly supple-mented group at 115 days (Z = 2.62; P <0.05). TABLE I Mean±SD for Hemoglobin (Hb) g/dL, Plasma Ferritin (PF) µg/L and Prevalence of Anemia (%)
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
References | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
