Preventing Childhood Anemia in India: Iron Supplementation and Beyond

REVIEW Preventing childhood anemia in India: iron supplementation and beyond

HPS Sachdev 1 and T Gera 2

Childhood anemia has major adverse consequences for health and development. It’s prevalence in India continues to range from 70 to 90%. Although anemia is multifactorial in etiology, preventative efforts have predominantly focused on increasing iron intake, primarily through supplementation in pregnant and lactating women. Policy thrust for childhood anemia is only recent. However, program implementation is dismal; only 3.8–4.7% of preschoolers receive iron–folate supplements. There is an urgent need for effective governance and implementation. Policy makers must distinguish anemia from iron deficiency, and introduce additional area-specific interventions as an integrated package. Increased iron intake may yield maximum benefit but will only address up to half the burden. In 6–59 months old children, instead of 100 days’ continuous dosing with iron–folate syrup in a year, a directly supervised intermittent supplementation (biweekly; B100 days per year) merits consideration. Multiple micronutrient powders for home fortification of foods in 6–23 months old infants do not appear viable. Additional interventions include delayed cord clamping, earlier supplementation in low birth weight infants, appropriate infant and young child feeding guidelines, and intermittent supervised supplementation in children and adolescents through school health programs. Use of double (iron–folate)-fortified salt in mid-day meal programs deserves piloting. Important area-specific, non-iron interventions include targeted deworming, and prevention and treatment of hemoglobinopathies, malaria and other common infections. Routine addition of multi-micronutrients to iron–folate supplementation appears unjustified currently. There is a pressing need to conduct relevant research, especially to inform etiology, additional interventions and implementation issues.

European Journal of Clinical Nutrition (2013) 67, 475–480; doi:10.1038/ejcn.2012.212; published online 6 February 2013 Keywords: anemia; hemoglobinopathies; micronutrient; infection; iron

Anemia, defined as hemoglobin concentration below the estab- conditions coexist; thus their individual contribution varies in lished cutoff levels,1 has major consequences for human health different settings and is difficult to ascertain at population level. and socio-economic development.2 Severe anemia increases In the absence of a simple, reliable and cheap indicator of iron the risk of maternal and child mortality. In addition, the status, anemia is invariably used to quantify the burden of this negative consequences of iron deficiency anemia on cognitive micronutrient deficiency in public health settings. This has led to development, school performance and physical development of unjustified confusion amongst some policy makers that anemia children, and work productivity of adults are of major concern.2–7 and iron deficiency are synonymous and therefore remedial If cognitive impairment occurs at an early age, it may be measures should solely focus on enhancing iron intake. However, irreversible.5,7 effective strategies can be established only by recognizing the Although anemia has been recognized as a public health complexity of anemia. Consequently, an integrated multifactorial problem for several decades, the global prevalence of anemia still and multifaceted approach is now being stressed globally.2 remains unacceptably high.2 Children are particularly vulnerable This manuscript evaluates the burden and major causes of to iron deficiency anemia due to their increased iron requirements childhood anemia in India in the context of ongoing public health in the periods of rapid growth, especially in the first 5 years of interventions, and offers potential possibilities to accelerate life.7,8 Recent estimates suggest that globally 600 million progress. preschool and school-age children are anemic.9 Anemia is multifactorial in etiology.2,7–9 It is generally assumed that at least half of these cases are attributable to iron BURDEN deficiency.2,7,9 A systematic review suggests that, on average, in Several small studies report on the prevalence of anemia in non-malarial regions 38–62% of baseline anemia in preschool selected groups or localized areas.9 We identified four large children is responsive to iron supplementation; the corresponding studies conducted at national or sub-national level.11–14 The range for malarial hyperendemic regions is 6–32%.10 Infectious prevalences of childhood anemia range from 70 to 90%; there has diseases, in particular malaria, helminthiasis, tuberculosis and HIV, been no perceptible improvement in comparable national surveys are also important contributory factors. Other micronutrient over a decade (NFHS-2 and NFHS-3).8 The District Level Health deficiencies including vitamin B12, folate and vitamin A, and Survey conducted in 2002–2004, categorized districts as having 2,7 hemoglobinopathies can also cause anemia. Often these low, medium or high anemia burden if o35, 35–50 and 450%

1Sitaram Bhartia Institute of Science and Research, New Delhi, India and 2Department of Pediatrics, SL Jain Hospital, Delhi, India. Correspondence: Professor HPS Sachdev, Sitaram Bhartia Institute of Science and Research, B-16 Qutab Institutional Area, New Delhi 110016, India. E-mail: [email protected] Received 13 December 2012; accepted 13 December 2012; published online 6 February 2013 Preventing childhood anemia in India HPS Sachdev and T Gera 476 children below 6 years had moderate or severe anemia, multifactorial etiology of anemia; a special focus on preschool respectively.13 The anemia burden was categorized as low in children; inclusion of infants between the ages of 6 and 12 months 149, moderate in 181 and high in 213 districts. (when the prevalence of anemia starts peaking), school children Majority of the data is restricted to preschool children (above and adolescents; and introduction of IFA syrup instead of tablets 6 months of age) and adolescent girls. A higher prevalence of for subjects between 6 and 59 months of age. However, the anemia was documented between 6 and 23 months of age and in implementation logistics still lack clarity, for example, when, how adolescents, in central and northern states, in rural areas, in low and by whom the 100 days of IFA supplementation will be socio-economic strata, and with low maternal literacy; boys are as delivered. vulnerable as girls.

Ground reality MAJOR ETIOLOGIC FACTORS There is no regular monitoring and information surveillance There is paucity of studies comprehensively evaluating the precise system in place for anemia control in children.8 Scant published 15 etiological factors of childhood anemia in various settings. data confirms the belief that the implementation of NNACP Prevalence and severity of childhood anemia has been correlated including IFA supplementation is severely deficient. In rural with maternal anemia and nutritional status, child’s Ahmednagar (Maharashtra), the district headquarters did not anthropometry, and iron and energy intake (unpublished receive supplies of iron supplements during the entire year from review). However, their causal role is uncertain because of higher authorities. The iron supplements were available for 0, 1–4, residual confounding. Apart from iron deficiency, Vitamin B12 5–8 and 9–11 months in 3, 4, 3 and 4 of the evaluated 14 primary and folate deficiencies may be significant contributors in some health centers, respectively.44 In the NFHS-3 survey, only 4.7% of 15–19 settings. Surprisingly, there is little data on the contribution of 6–59 months old children received iron supplementation during malaria to anemia; however, analyses of statewise distributions preceding 7 days.11 In the National Nutrition Monitoring Bureau 20 suggests that both conditions often coexist. There is no national evaluation in rural areas of eight states, only 3.8% of 1–5 year old database on the prevalence of helminth infestation or estimates of children received IFA supplements.14 In general, providers have a its contribution to anemia. Three studies in areas with high passive attitude and lack of conceptual clarity about various prevalence of helminthiasis (50–80%) showed significant components of the program, and there is virtually no social 21–23 association with anemia prevalence. It is difficult to mobilization or active community participation (unpublished ascertain the role of other infections, particularly that of sub- data). clinical infections. Several studies indicate that hemoglobinopathies including thallassemia, G6PD deficiency and sickle cell disease are the significant contributors amongst certain populations (Sindhis in Gujarat and Maharashtra) and in POTENTIAL WAY FORWARD some regions (north-eastern states, tribal areas of Orissa and West Anemia in children is a major public health problem of long- Bengal).24–39 It is evident that apart from iron deficiency, other standing duration, which is not being addressed by NNACP. In conditions can contribute substantially to the continuing high India’s tenth Five-year Plan’s45 nutritional goals, all children are prevalence of childhood anemia. recommended to be screened for anemia.8 Screening is intended primarily to detect severe anemia that may not be treated with the current program alone and would need additional specific PREVENTIVE EFFORTS investigations and therapy. However, universal preventative The Nutritional Anemia Prophylaxis program was introduced in intervention cannot wait until individual screening for anemia, 1970 and was re-designated as the National Nutritional and its specific treatment based on the cause(s) is in place through Anemia Control Program (NNACP) in 1991.8,40 It had the an effectively functioning primary health-care system. objective of decreasing anemia among vulnerable sections, Urgent remedial measures are imperative for effective oper- namely women in reproductive age group, especially pregnant ationalisation of the universal preventative program, which and lactating women, intrauterine device users and 1–5 year old include the following main strategic aspects: (i) Policy and children through the following strategies: (a) promotion of regular Governance thrust: the current state of lethargic acceptance consumption of foods rich in iron; (b) provision of iron and folate should be replaced by a war-footing approach with the Ministry of tablets and (c) identification and treatment of severely anemic Health and Family Welfare assuming total charge instead of cases. The Program is implemented through the Primary Health ‘shared responsibilities with effective convergence’ amongst Centers and its sub-centers. The multiple purpose worker (female) several governmental departments. (ii) Address multi-factorial and other paramedicals working in the Primary Health Centers are etiology: various stakeholders, especially policy makers, should responsible for the distribution of iron tablets (adult and pediatric explicitly realize and attempt to address the multifactorial etiology doses). The functionaries of Integrated Child Development of anemia, instead of solely focusing on increasing iron intake; the Services (ICDS) Program also assist in the distribution of iron other causes are traditionally ignored or recede into the tablets to children and mothers in the ICDS blocks, and for background. (iii) Life cycle approach: a life cycle approach with imparting education to mothers on the prevention of nutritional special focus on the vulnerable periods is important; it is anemia. The Department of Food (Ministry of Food and Civil important to simultaneously address anemia in pregnant and Supplies) is responsible for promoting the consumption of iron- lactating women, adolescents and school children. (iv) Effective rich food. In addition, services of other community level workers implementation: well-designed public health programs cannot and involvement of formal and non-formal education, media, succeed without effective implementation at the beneficiary level. Horticultural Departments and voluntary organizations is recom- The reasons and remedies for the severely deficient implementa- mended to be utilized. tion of NNACP need urgent attention, including through relevant In summary, NNACP had been predominantly concentrating on implementation research incorporating the supply side, provider efforts to increase iron intake, primarily through iron supplemen- issues and community participation. tation in pregnant and lactating women. In recent years, the On the basis of recent evidence and experience, the following importance of addressing anemia in children has been rea- specific aspects merit priority consideration for modification of lized41,42 and pertinent modifications were introduced at the NNACP with these broad principles: (i) least disruption of the policy level in 2007.43 These included the need to consider the existing program, (ii) factoring for the severely deficient

European Journal of Clinical Nutrition (2013) 475 – 480 & 2013 Macmillan Publishers Limited Preventing childhood anemia in India HPS Sachdev and T Gera 477 implementation and (iii) attempting novel interventions on pilot Food fortification scale with inbuilt research to guide future course. Consumption of iron-fortified foods reduces the risk of anemia.62 Salt fortification appears to be more effective, whereas cereals are less efficient, unless fortified with NaFeEDTA.62,63 Thus wheat-flour ENHANCING IRON CONTENT fortification initiatives, as in Gujarat state, will not yield substantial Amongst all potential interventions, enhancing iron intake is likely dividends unless fortification salt and dosage are appropriate. The to yield the maximum benefit because iron deficiency is widely most attractive option therefore is to use double-fortified (iodine– prevalent. However, even in the best case scenario, only half of the iron) salt instead of iodized salt in mid-day meal program in anemia burden will be addressed. schools. This strategy has government support and may not Evidence-based guidelines have been recently issued by WHO arouse activism because of minor modification in the salt- for increasing iron intake in preschool and school-age children,46 iodization program using national product(s). A comparative and infants between 6 and 23 months of age47 on the basis of research evaluation can explore the apparently costlier option of relevant Cochrane reviews.48,49 The use of multiple micronutrient NaFeEDTA fortification of cereals. powders for home fortification of foods in 6–23 months old 47 infants does not appear viable because of: (i) stiff resistance from Safety activists to ‘prevent commercialization of malnutrition and Evidence suggests that iron supplementation has no apparent multinational corporate benefits’; (ii) lack of government support harmful effect on the overall incidence of infectious illnesses in for this strategy; (iii) uncertainty about the amount of powder children, though it slightly increases the risk of diarrhea.64 In consumed with the offered food; (iv) anticipated poor malaria endemic areas also, iron alone or with antimalaria implementation for daily consumption through NNACP supply treatment does not increase the risk of clinical malaria or death chain and (v) potential for confusion and additional training needs when regular malaria surveillance and treatment services are for introducing a separate strategy for younger preschoolers. provided.65 It would therefore be prudent to ensure adequate As envisaged in the NNACP, a uniform IFA supplementation measures for prevention, diagnosis and treatment of malaria46 in strategy between 6 and 59 months of age (20 mg elemental iron such areas in the country. Prophylactic iron supplementation and 100 mcg folic acid as 1 ml syrup) has operational advantages. should preferably be withheld in diagnosed hemoglobinopathies, However, instead of loosely recommending 100 days of contin- severe acute malnutrition and acute infectious illnesses. Successful uous dosing in a year, a directly supervised intermittent iron supplementation efforts, especially over prolonged periods 46 B supplementation (biweekly; 100 days per year) may be more and through multiple sources, may theoretically result in iron effective. The Accredited Social Health Activist (ASHA) could overload, particularly in susceptible individuals. The prospect of perform this role, perhaps for a small incentive. It would be such iron overload escalating the ongoing epidemic of diabetes, prudent to pilot test this strategy before scaling it up. Operational coronary artery disease and metabolic syndrome66 will need research should also compare supervised weekly, partially thorough evaluation, if the preliminary evidence gets validated. supervised and flexible strategies for delivery of IFA supplements in diverse settings. In Uttar Pradesh and Jharkhand at block level, system support (including uninterrupted supply and NON-IRON INTERVENTIONS training) with unsupervised biweekly supplementation increased Additional micronutrients IFA syrup intake (B50%). In combination with co-interventions, Addition of multiple micronutrients to iron may result in no or anemia prevalence became 11 and 5% lower, respectively than marginal improvement in hemoglobin response.49,67 There is the control areas.50 scant, comparable data for iron–folate combination; routine addition of multi-micronutrients to IFA supplement cannot Low birth weight infants therefore be justified currently. Low birth weight babies are most vulnerable to early iron depletion postnatally,51,52 and iron supplementation decreases Deworming 53,54 the risk of anemia. In view of high low birth weight prevalence Periodic community deworming seems to have little or no effect 55 (B30%), IFA supplementation from 2 months of age with on hemoglobin response.68–70 For programmes that treat only reduced dose deserves exploration in such infants. children detected as infected (by screening), a single dose of deworming drugs probably increases hemoglobin;70 and this Delayed cord clamping strategy deserves implementation. In the interim, to overcome logistic constraints, community deworming can be attempted Delaying umbilical cord clamping for 2–3 min after birth improves above 2 years of age in regions with high (420%) hookworm iron nutriture and reduces the risk of developing anemia in prevalence. infants,56–58 particularly in those born to anemic mothers.59 Efforts are required to operationalize this practice as a central recommendation in neonatal health initiatives. Malaria Effective control, diagnosis and treatment of malarial infections are important in endemic regions. Control measures like Complementary foods intermittent preventive treatment, targeted treatment and house Infant and young child feeding recommendations should also screening may be effective in areas that are hyper- or holo- emphasize local innovations to enhance iron intake. endemic for malaria.71–75 However, the benefits of intermittent preventive treatment are short-lived and should be used only in Children and adolescents season of intense transmission. In our context, it would be IFA supplementation in this target group is virtually non-existent. meaningful to focus on vector control, and effective diagnosis and Vertical initiatives of intermittent IFA supplementation have been treatment. associated with decreased anemia in school-going adolescent girls in Gujarat60 and Uttar Pradesh.61 Incorporation of directly Hemoglobinopathies supervised, biweekly IFA supplementation in the school health Treatment and control of hemoglobinopathies should become an program (adolescents included) deserves urgent exploration. integral component of childhood anemia prevention efforts.

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