Guidelines for Iron Supplementation to Prevent Iron Deficiency Anemia

Although many of the recommended dosages for iron supplementation are derived from dose per body weight, the recommended dosages in these guidelines are given in absolute quantities of elemental iron. A number of different iron-containing compounds are used in iron supplements. A list of some commonly used iron compounds and the amount of elemental iron they contain are included as Appendix A.

Where parasitic infections are common, giving anthelminthic or antimalarial drugs along with iron supplements may increase the effectiveness of supplementation. Where appropriate, complementary parasite control measures are given along with the guidelines for iron supplementation.

Pregnant Women

The high physiological requirement for iron in pregnancy is difficult to meet with most diets. Therefore, pregnant women should routinely receive iron supplements in almost all contexts. Where the prevalence of anemia in pregnant women is high (40% or more), supplementation should continue into the postpartum period to enable women to acquire adequate iron stores (Table 3). Complementary parasite control measures in pregnancy are given in Table 4.

Table 3. Guidelines for Iron Supplementation to Pregnant Women

Prevalence of anemia in pregnancy	Dose	Duration
< 40%	60 mg iron acid daily + 400 µg folic	6 months in pregnancy
³ 40%	60 mg iron acid daily + 400 µg folic	6 months in pregnancy, and continuing to 3 months postpartum

Notes:

· If 6 months duration cannot be achieved in pregnancy, continue to supplement during the postpartum period for 6 months or increase the dose to 120 mg iron in pregnancy.

· Where iron supplements containing 400 µg of folic acid are not available, an iron supplement with less folic acid may be used. Supplementation with less folic acid should be used only if supplements containing 400 µg are not available.

Table 4. Complementary parasite control measures in pregnancy

· Where hookworms are endemic (prevalence 20-30% or more) give anthelminthic treatment once in the second trimester of pregnancy. If hookworms are highly endemic (prevalence more than 50%), repeat anthelminthic treatment in the third trimester of pregnancy. The following anthelminthic treatments are effective and safe outside of the first trimester of pregnancy:
Albendazole	400 mg single dose
Mebendazole	500 mg single dose or 100 mg twice daily for 3 days
Levamisole	2.5 mg/kg single dose, best if a second dose is repeated on next 2 consecutive days
Pyrantel	10 mg/kg single dose, best if dose is repeated on next 2 consecutive days
· If Plasmodium falciparum malaria is endemic and transmission of infection is high, women in their first or second pregnancies should be given curative antimalarials at the first prenatal visit, followed by antimalarial prophylaxis according to local recommendations.

Children 6-24 Months of Age

Infants need a relatively high iron intake because they are growing very rapidly. Infants are normally born with plenty of iron. However, beyond 6 months of age, iron content of milk is not sufficient to meet many infants' requirements and complementary foods are usually low in iron. Low-birth-weight infants (less than 2500 g) are born with fewer iron stores and are at high risk of deficiency after 2 months. Where iron-fortified complementary foods are not widely and regularly consumed by young children, infants should routinely receive iron supplements in the first year of life (Table 5). Where the prevalence of anemia in young children (6-24 months) is 40% or more, supplementation should continue through the second year of life.

Table 5. Guidelines for iron supplementation to children 6-24 months of age

Prevalence of anemia in children 6-24 months	Dosage	Birth-weight category	Duration
<40%	12.5 mg iron + 50 µg folic acid daily	Normal	6-12 months of age
		Low birth weight (<2500 g)	2-24 months of age
³40%	12.5 mg iron +50 µg folic acid daily	Normal	6-24 months of age
		Low birth weight (<2500 g)	2-24 months of age

Note:

· If the prevalence of anemia in children 6-24 months is not known, assume it is similar to the prevalence of anemia in pregnant women in the same population.

· Iron dosage is based on 2mg iron/kg body weight/day.

Other Population Groups

Although pregnant women and young children are at greatest risk of iron deficiency anemia, other population groups frequently suffer its consequences and may benefit from iron supplementation programs. In some contexts it may be feasible and cost effective to distribute iron supplements to other groups if the prevalence of anemia is high (Table 6). Complementary parasite control measures for other population groups are given in Table 7.

Table 6. Guidelines for iron supplementation to other population groups

Group	Dosage
Children 2-5 years	20-30 mg iron
Children 6-11 years	30-60 mg iron
Adolescents and adults	60 mg iron (see notes)

Notes:

· For children 2-5 years, iron dosage is based on 2mg/kg body weight/day.

· If the population group includes girls or women of reproductive age, 400 µg folic acid should be included with the iron supplementation for the prevention of birth defects in those who become pregnant.

· Research is ongoing to determine the most cost-effective dosing regimen for iron supplementation to these age groups in different contexts. The efficacy of once- or twice-weekly supplementation in these groups appears promising, and the operational efficiency of intermittent dosing regimens is being evaluated. While policy recommendations are being formulated, program planners should adopt the dosing regimen believed to be most feasible and sustainable in their communities.

Table 7. Complementary parasite control measures for other population groups

· Where hookworms are endemic (prevalence 20-30% or greater) it will be most effective to combine iron supplementation with anthelminthic treatment to adults and children above the age of 5 years. Universal anthelminthic treatment, irrespective of infection status, is recommended at least annually. High-risk groups, women and children, should be treated more intensively (2-3 times per year). The following single-dose treatments are recommended:
Albendazole	400 mg single dose
Mebendazole	500 mg single dose
Levamisole	2.5 mg/kg single dose
Pyrantel	10 mg/kg single dose
(Anthelminthic treatment can be given to pregnant and lactating women. However, as a general rule, no drug should be given in the first trimester.)
· Where urinary schistosomiasis is endemic, provide annual treatment for urinary schistosomiasis to school-age children who report having blood in their urine. Give the following treatment:
Praziquantel	40 mg/kg, single dose