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ARTICLE: Betsy Lozoff, Isidora De Andraca, Marcela Castillo, Julia B. Smith, Tomas Walter, and Paulina Pino Behavioral and Developmental Effects of Preventing Iron-Deficiency Anemia in Healthy Full-Term Infants Pediatrics 2003; 112: 846-854 [Abstract] [Full text] [PDF]

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IRON SUPPLEMENTATION IN DEVELOPING COUNTRIES REVISITED: SOCIOECONOMICAL AND PRACTICAL IMPLICATIONS

Ahmet Karadag, Ozlem Kirmemis, Ahmet Karadag, Nurdan Uras, Arzu Ozsahin and Betul Tavil   (11 December 2003)

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Betsy Lozoff   (23 December 2003)

IRON SUPPLEMENTATION IN DEVELOPING COUNTRIES REVISITED: SOCIOECONOMICAL AND PRACTICAL IMPLICATIONS 11 December 2003
Ahmet Karadag, MD, Pediatrician Fatih University Faculty of Medicine, Department of Pediatrics, Ozlem Kirmemis, Ahmet Karadag, Nurdan Uras, Arzu Ozsahin and Betul Tavil Send letter to journal: Re: IRON SUPPLEMENTATION IN DEVELOPING COUNTRIES REVISITED: SOCIOECONOMICAL AND PRACTICAL IMPLICATIONS kara_dag{at}hotmail.com Ahmet Karadag, et al.	To the editor, We have taken an interest in a recently published article in your journal by Lozoff et al (1). In their study, they have concluded that healthy full -term infants may get developmental and behavioral benefits from iron supplementation in the first year of life. But we have several questions and doubts about their discussion. Lozoff et al. supplied the iron to the infants -that are older than six months- via iron fortified formula rather than oral iron supplementation. There are two important disadvantages for iron-fortified formulas. First is that the iron suplementation with formula cannot be standardized because the amount of the infant’s daily oral intake is variable. Secondly, the consumption of iron-supplemented formulas significantly increase the cost of iron supplementation. In our country, there is an average of $3.88 difference between one can (400 g) of non-iron supplemented formula and the iron supplemented one. This difference becomes $11.64 for an infant who consumes three cans a month. On the contrary, monthly iron supplementation cost of the same infant is $2.6 with oral iron preparations. Moreover, as previously reported in a study on Turkish children, iron therapy twice a week with oral iron administration has been more cost effective (2). In their study, the absence of another group -that would have constituted of infants who were still breastfed but also supplemented with oral iron preparations- might cause some misinterpretations as if the only way of iron supplementation could be via formulas. However we believe that such a group not only would have provided a reasonable control data but also would have avoided such a misunderstanding. Overall, we imply that, especially in developing countries, oral iron supplementation instead of iron fortified formulas, provide economical advantages. Besides the continuation of breastfeeding will definitely be promoted in accordance with the widespread international breastfeeding politics. References: 1.Lozoff B, De Andraca I, Castillo M, Smith JB, Walter T, Pino P. Behavioral and developmental effects of preventing iron-deficiency anemia in healthy full-term infants. Pediatrics 2003;112:846-54. 2.Tavil B, Sipahi T, Gokce H, Akar N. Effect of twice weekly versus daily iron treatment in Turkish children with iron deficiency anemia. Pediatr Hematol Oncol 2003:20;319-26.
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Betsy Lozoff, Behavioral/Developmental Pediatrician University of Michigan Send letter to journal: Re: this article blozoff{at}umich.edu Betsy Lozoff	The letter by Ahmet Karadag et al. gives us the opportunity to emphasize the purpose of our recent study in Chile. The purpose was to determine whether or not there are behavioral and developmental benefits of preventing iron-deficiency anemia in infancy. Determining the best way to prevent iron deficiency is a different research question, which would require a different study design, and the optimal approach is likely to vary by population and conditions. At the time our study was planned, Chilean infants were weaned quite early from the breast. As part of a legally-required national program, they were provided unmodified cow milk at every well-child visit. Therefore, we chose iron-fortified formula as the vehicle for supplementation among infants who had already started receiving at least 250 ml of cow milk or formula per day. The iron content of the formula was known, the amount the infant consumed was recorded weekly, and total intake was controlled for in all analyses. However, the study did include breastfed babies and iron supplements, as suggested by Ahmet Karadag et al. A highly effective program to promote breastfeeding was ongoing in Chile as the study progressed. Midway through, we therefore began to enroll breastfed babies even if they had not started any bottle feeding. These babies received vitamins with or without iron as the supplement. The Figure in the paper shows the several groups in the study. We agree that iron-fortified formula is unlikely to be the best solution for preventing iron deficiency among infants in many settings. Finding ways to prevent iron-deficiency anemia in developing countries without interfering with breastfeeding is a major challenge. Approaches relying on medicinal iron drops for prevention have been used for many years. Results have often been disappointing, since it is difficult for families to give such supplements consistently for months on end. This contrasts to the effectiveness of medicinal iron in treating iron- deficiency anemia, which entails a much shorter time. For these reasons, a variety of other approaches to prevention are currently being developed, ranging from sprinkles and spreads to strains of staple foods that allow for better iron absorption. The goal and hope is to have a variety of options for supplementation so that individual countries and regions can select the approach that makes most sense for their conditions and culture.