Global guidelines for iron and folic acid supplementation in children should be revised

EMBARGO: 00:01H (London time) Friday January 13, 2006. In North America the embargo lifts at 18:30H ET Thursday January 12, 2006.

Giving all young children iron and folic acid supplements in a population with high rates of malaria could result in an increased risk of severe illness and death, according to the results of a randomised trial in this week's issue of The Lancet.

Anaemia caused by iron deficiency is widespread in the developing world and is especially common in children younger than 5 years. International guidelines recommend supplementation with iron and folic acid in children younger than age 2 years in areas with a high prevalence of anaemia. However, there is concern that this policy might be harmful in areas of high malaria transmission.

To investigate this, Robert Black (Johns Hopkins University, Baltimore, USA) and colleagues randomly assigned over 24, 000 children aged 1-35 months from Pemba, Zanzibar, to receive iron and folic acid, or iron, folic acid and zinc, or placebo. The iron and folic-acid groups of the trial were stopped early because, during follow-up, the investigators found that those who received iron and folic acid with or without zinc had a 12% higher risk of hospitalisations for severe disease or death than those on placebo. The research team found that only children whose anaemia was associated with iron deficiency benefited from supplementation with iron and folic acid.

Professor Black concludes: "In the presence of an active programme to detect and treat malaria and other infections, iron deficient and anaemic children can benefit from supplementation. However, supplementation of those who are not iron deficient might be harmful. As such, current guidelines for universal supplementation with iron and folic acid should be revised."

In a parallel trial, also published in The Lancet this week, James Tielsch (Johns Hopkins University, Baltimore, USA), Robert Black and colleagues, randomly assigned over 25, 000 children aged 1-36 months in Nepal--an area of low malaria transmission--to receive iron and folic acid, or iron, folic acid and zinc, or placebo. They found that daily supplementation with iron and folic acid with or without zinc had no effect on their risk of death. The authors state that despite the lack of effect, universal supplementation with iron and folic acid might still be warranted for young children in areas with low malaria transmission because of their potential role in motor and cognitive development.

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See also accompanying Comment.

Contact: Robert E Black, Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, 615 North Wolfe Street, Room E8527, Baltimore MD 21205-2179, USA. T) 410-955-3934, rblack@jhsph.edu

James M Tielsch, Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Room W5009, Baltimore, MD 21205-2103,USA. jtielsch@jhsph.edu

Bloomberg School of Public Health Public Affairs Tim Parsons or Kenna Lowe T) 410-955-6878, paffairs@jhpsh.edu


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