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Recommendations Indian Pediatrics 2002; 640:647 |
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Technical Consultation on "Strategies for Prevention and Control of Iron Deficiency Anemia amongst Under Three Children in India" |
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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. Earlier studies from different centers during the last three decades have also reported a similar high prevalence. Anemia adversely affects the mental and motor development, and the behavior of infants. There is also evidence that developmental deficits that occur due to iron deficiency in infancy may be irreversible. Associations between hemoglobin concentration and psychomotor performance have been documented. Prevention of Iron Deficiency Anemia (IDA) in infants and growing children needs to be accorded a high priority for improving the quality of life of this vulnerable segment. A Technical Consultation was organized to discuss the Strategies for Prevention and Control of Iron Deficiency Anemia amongst under three children by the Human Nutrition Unit of the All India Institute of Medical Sciences, New Delhi on 17th March, 2002 . The consultation was sponsored by MOST-USAID Micro Nutrient Project, India. The list of invited participants is enclosed as Appendix I. The objectives of the consultation were: (i) to make recommendations for strengthening the child component of the National Nutritional Anemia Control Program (NNACP); and (ii) to identify important researchable areas in this context. The format of the consultation was to discuss the individual issues , after a status paper was presented , in a question and answer manner. After the deliberations and discussions on individual issues, the consensus statements were adopted on the issues on which sufficient data was available and it was agreed upon by majority of the participants. Conclusions and Recommendations 1. Issue: The age group to which IFA supplementation should be targeted Children between 6 to 35 months of age are highly vulnerable to develop iron deficiency. Since some of the adverse health consequences of iron deficiency in infancy may be irreversible, it is important to initiate preventive action at the earliest. It is recommended that iron supplementation in the NNACP should be targeted to children in the age group of 6 -35 months only. This age group also offers logistic advantages, as the target beneficiaries are identical to the National Program for Prevention and Control of Blindness due to Vitamin A Deficiency. 2. Issue: Type of iron salt Many iron compounds are available and have been used for the treatment and prevention of IDA. The comparative absorptive efficacy of iron amongst these is only marginally different. Available data indicates that ferrous iron is absorbed 4-10 times better than ferric iron. Ferrous sulfate is the least expensive iron compound. It is well absorbed, has reasonably good shelf life and has few side effects at dose levels used in the NNACP. Until such time that we have definitive validated data on Indian communities indicating better efficacy and cost-effectiveness of the newer forms of iron preparations, ferrous sulfate should be continued to be used in the NNACP. 3. Issue: What should be the preventive dose of iron? The iron requirements for different ages are often defined in terms of body weight. However, in a community setting, it is not feasible to use this approach. Thus a simple fixed dose strategy rather than an exact dose based on a body weight basis is more appropriate for young children under the NNACP. It is recommended that one dose should be used for all children 6 months -35 months of age. With due consideration to the safety issues, it is recommended that 20 mg Iron be used for anemia prophylaxis for all the children in this age group. The daily dosage of Iron Folic Acid (IFA) supplement (20mg elemental iron + 100 mcg folic acid) recommended for children in the current ongoing NNACP was considered appropriate. Children suffering from severe anemia should be referred to nearest health care facility for treatment 4. Issue: In which form Iron should be distributed? The present pediatric tablets of iron in the national program are difficult to administer to children between the ages of 6 to 35 months. The most practical iron supplement for children in this age group is an aqueous solution of a soluble ferrous salt. For logistic reasons, a concentrated iron solution dispensed as drops rather than syrup is recommended, as it would reduce the cost of packaging and transport. The following aspects should be considered while re-introducing the IFA liquid preparation in NNACP: i) IFA liquid preparation should have 20 mg/ml of elemental iron in the form of ferrous sulfate or equivalent; ii) There should be no deterioration in the composition, appearance and taste for at least 3 months after opening the bottle; iii) A shelf life of at least 2 years in unopened bottles; iv) Acceptable palatability; v) For safety reasons, the bottle should be so designed that 1 ml drops are directly dispensed into the child’s mouth by simply inverting the bottle. The plastic cap-cum-orifice that produces the drops must be firmly attached to the bottle so that it is impossible for the child to accidentally consume the entire contents. 5. Issue: Should any other micronutrients (like zinc, vitamin B12) be added to the IFA preparation? Folic acid should be added to the iron supplements to prevent folic acid deficiency anemia. More scientific data is required on the magnitude of vitamin B12 and zinc deficiencies and the benefits of adding these micronutrients before their routine supplementation in conjunction with iron can be considered as public health intervention measure under NNACP. 6. Issue: What should be the frequency of administration - daily or weekly? At this time insufficient evidence supports the effectiveness of weekly supplementation to allow this approach to be recommended in the NNACP, but data from studies in other countries justifies undertaking further study to determine the appropriateness of the weekly approach in India. 7. Issue: What should be the duration of supplementation? It is recommended that IFA supplementation should be done daily for minimum of 100 days in the first year of life and for minimum of 100 days in the second year of life. Currently there is no data to suggest a fixed duration of supplementation that will work in all the community settings. 8. Issue: What should be the strategy of covering under three children with IFA supplementation? The IFA supplementation should be done through the peripheral village health and the ICDS functionaries. Home visit once in a month is a part of the routine responsibilities of AWW and ANM, which should be utilized for distribution of the IFA. Various contact points like measles immunization (9 months), DPT booster (16 months), and the take home ration day of ICDS (where ever followed) should be utilized for distribution of IFA. Other village level developmental functionaries / voluntary persons available in the community should also be utilized. Bottles of IFA (containing 50/100 doses) may be given to mothers at 9 months and at 14 to 16 months of age at the immunization contact points for measles and DPT booster, respectively. During the routine household visits the AWW and ANM should monitor compliance, side effects and provide counseling, etc. An effective step would be to make the IFA available at the village level through the network of sub centers and Anganwadi centers so that the same can be distributed to the beneficiaries. 9. Issue: What would be the role of iron fortified food in prevention / treatment of anemia? Promoting the consumption of iron-fortified foods is an important approach to preventing anemia and this should be pursued wherever feasible. However, currently, no cost-effective technologies for fortifying cereals or other foods have been identified for routine use in the NNACP program. The development of such a technology will likely have great potential in contributing to reducing anemia. Iron fortified foods by themselves are unlikely to be effective in treating existing cases of anemia. 10. Issue: Safety of Iron Supplementation to under three children From the public health perspective, iron supplementation in young children has no apparent deleterious effect on the incidence of infectious morbidity in children. However, there is a higher risk (11%) of developing diarrhea, which may or may not be infectious in origin. 11. Issue: Areas for future research for strengthening the existing strategies for prevention and control of iron deficiency anemia amongst under three children I. Basic Research Areas
Compiled by: Dr. Umesh Kapil, Additional Professor, Public Health Nutrition, Department of Human Nutrition, All India Institute of Medical Sciences, New Delhi 110 029, India, Email: [email protected] and Dr. HPS Sachdev, Professor and Incharge, Division of Clinical Epidemiology, Depart-ment of Pediatrics, Maulana Azad Medical College, New Delhi 110 002, India. E-mail: drhpssachdev @yahoo.com Correspondence to: Dr. Umesh Kapil, Additional Professor, Public Health Nutrition, Department of Human Nutrition, All India Institute of Medical Sciences, New Delhi 110 029, India.E-mail: kapil [email protected] APPENDIX List of participants I. Representatives from Government of India
III. Representative from International Organisations
59. Dr. Neena Dodd 60. Dr. Victor Barbiero 61. Dr.K. Suresh 62. Dr. Sheila Vir, 63. Dr.Abdullah
Dustagheer 64. Dr. Ashi Kathuria 65. Dr. Usha Kiran 66. Dr. Philip Harvey 67. Dr. Siddharth Nirupam 68. Dr. Tom Schatzel
(represented by Dr.R.Sankar) 69. Dr Massee Bateman, 70. Dr. Arvind Mathur, 71. Mr. P. Bardhan*, 72. Mr. Tim Martineau,* Ph: 6529123, Fax: 6529296 * invited but could not participate |