Intermittent iron supplementation in preschool and school-age children
Guidance summary*
WHO recommendations
In settings where the prevalence of anaemia in preschool (24–59 months) or school-age (5–12 years) children is 20% or higher, intermittent iron supplementation is recommended as a public health intervention in preschool and school-age children to improve iron status and reduce the risk of anaemia.
Suggested schemes for intermittent iron supplementation in preschool and school-age children
Target group
Preschool-age children (24–59 months)
School-age children (5-12 years)
Supplement composition
25 mg of elemental irona
45 mg of elemental ironb
Supplement form
Drops/syrups
Tablets/capsules
Frequency
One supplement per week
Duration and time interval between periods of supplementation
3 months of supplementation followed by 3 months of no supplementation after which the provision of supplements should restart. If feasible, intermittent supplements could be given throughout the school or calendar year
Settings
Where the prevalence of anaemia in preschool or schoolage children is 20% or higher
a. 25 mg of elemental iron equals 75 mg of ferrous fumarate, 125 mg of ferrous sulfate heptahydrate or 210 mg of ferrous gluconate.
b. 45 mg of elemental iron equals 135 mg of ferrous fumarate, 225 mg of ferrous sulfate heptahydrate or 375 mg of ferrous gluconate.
Remarks
- In malaria-endemic areas, the provision of iron supplements should be implemented in conjunction with adequate measures to prevent, diagnose and treat malaria (1, 2).
- Intermittent iron supplementation is a preventive strategy for implementation at population level. If a child is diagnosed with anaemia in a clinical setting, he or she should be treated with daily iron supplementation until the haemoglobin concentration rises to normal (3). He or she can then be switched to an intermittent regimen to prevent the recurrence of anaemia.
- As there is limited evidence for the effective dose of folic acid or other vitamins and minerals for intermittent supplementation, it is suggested providing two times the recommended nutrient intake in these age groups without exceeding the daily upper limit (4). Thus children 24–59 months of age may be given a dose of 300 μg (0.3 mg) of folic acid once a week, whereas older children may be given 400 μg (0.4 mg).
- Where infection with hookworm is endemic (prevalence 20% or greater) it may be more effective to combine iron supplementation with anthelminthic treatment in children above the age of 5 years. Universal anthelminthic treatment, irrespective of infection status, is recommended at least annually in these areas (3, 5).
- The provision of iron supplements on an intermittent basis may be integrated into school or community programmes to reach the target populations. These programmes should ensure that the daily nutritional needs of preschool or school-age children are met and not exceeded, through the evaluation of nutritional status and intake, as well as consideration of existing anaemia and micronutrient deficiency control measures (such as provision of vitamin A supplements, fortified foods and anthelminthic therapy).
- The intermittent provision of supplements may include a behaviour communication change strategy that promotes the awareness and correct use of this product along with other practices such as hand washing with soap, prompt attention to fever in malaria settings, and measures to manage diarrhoea, particularly among younger children (6).
- The establishment of a quality assurance process is important to ensure that supplements are manufactured, packaged and stored in a controlled and uncontaminated environment (7).
- The selection of the most appropriate delivery platform should be context specific, with the aim of ensuring that the most vulnerable members of the populations are reached. For example, if the education system is selected as delivery channel, efforts should be made to reach children who do not attend school.
- Oral supplements are available as drops or syrups for preschool-age children, and tablets or capsules for school-age children. Liquid preparations for oral use are usually supplied as solutions, emulsions or suspensions containing one or more of the active ingredients in a suitable vehicle. All these preparations are supplied either in the finished form or, with the exception of oral emulsions, may need to be prepared just before use by dissolving or dispersing the granules or powder in the vehicle as stated on the label. Tablets (soluble tablets, effervescent tablets, dissolvable tablets for use in the mouth and modified release tablets) are solid dosage forms containing one or more active ingredients. They are manufactured by single or multiple compression (in certain cases they are moulded) and may be uncoated or coated. Capsules are solid dosage forms with hard or soft shells, which are available in a variety of shapes and sizes, and contain a single dose of one or more of the active ingredients (8).
* This is an extract from the relevant guideline (10). Additional guidance information can be found in this document.
References
1. WHO. Global malaria report 2010. Geneva, World Health Organization; 2010 (http://whqlibdoc.who.int/publications/2010/9789241564106_eng.pdf).
2. Brooker S. Malaria control in schools. A toolkit on effective education sector responses to malaria in Africa. London, Partnership for Child Development; 2009.
3. Stoltzfus R, Dreyfuss M. Guidelines for the use of iron supplements to prevent and treat iron deficiency anaemia. Washington, DC, ILSI Press; 1998. (http://www.who.int/nutrition/publications/micronutrients/- guidelines_for_Iron_supplementation.pdf).
4. WHO, FAO. Vitamin and mineral requirements in human nutrition, 2nd ed. Geneva, World Health Organization; 2004 (http://www.who.int/nutrition/publications/micronutrients/9241546123/en/).
5. Hall A, Hewitt G, Tuffrey V, de Silva N. A review and meta-analysis of the impact of intestinal worms on child growth and nutrition. Maternal and Child Nutrition. 2008; 4(Suppl. 1):118–236.
6. WHO, UNICEF joint statement. Clinical management of acute diarrhoea. Geneva, World Health Organization; 2004 (http://www.who.int/child_adolescent_health/documents/who_fch_cah_04_7/en/index.html).
7. WHO, WHO Expert Committee on Specifications for Pharmaceutical Preparations. Quality assurance of pharmaceuticals: meeting a major public health challenge. Geneva, World Health Organization; 2007 (http://www.who.int/medicines/publications/brochure_pharma.pdf).
8. The international pharmacopoeia, 4th ed. Geneva, World Health Organization; 2008 (http://apps.who.int/phint/en/p/about).
10. WHO. Guideline: Intermittent iron supplementation in preschool and school-age children. Geneva, World Health Organization; 2011 (http://www.who.int/nutrition/publications/micronutrients/guidelines/guideline_iron_supplementation_children/en/).