The effect of iron-fortified complementary food and intermittent preventive treatment of malaria on anaemia in 12- to 36-month-old children: a cluster-randomised controlled trial

Dominik Glinz, Richard F Hurrell, Mamadou Ouattara, Michael B Zimmermann, Gary M Brittenham, Lukas G Adiossan, Aurélie A Righetti, Burkhardt Seifert, Victorine G Diakité, Jürg Utzinger, Eliézer K N'Goran, Rita Wegmüller, Dominik Glinz, Richard F Hurrell, Mamadou Ouattara, Michael B Zimmermann, Gary M Brittenham, Lukas G Adiossan, Aurélie A Righetti, Burkhardt Seifert, Victorine G Diakité, Jürg Utzinger, Eliézer K N'Goran, Rita Wegmüller

Abstract

Background: Iron deficiency (ID) and malaria co-exist in tropical regions and both contribute to high rates of anaemia in young children. It is unclear whether iron fortification combined with intermittent preventive treatment (IPT) of malaria would be an efficacious strategy for reducing anaemia in young children.

Methods: A 9-month cluster-randomised, single-blinded, placebo-controlled intervention trial was carried out in children aged 12-36 months in south-central Côte d'Ivoire, an area of intense and perennial malaria transmission. The study groups were: group 1: normal diet and IPT-placebo (n = 125); group 2: consumption of porridge, an iron-fortified complementary food (CF) with optimised composition providing 2 mg iron as NaFeEDTA and 3.8 mg iron as ferrous fumarate 6 days per week (CF-FeFum) and IPT-placebo (n = 126); group 3: IPT of malaria at 3-month intervals, using sulfadoxine-pyrimethamine and amodiaquine and no dietary intervention (n = 127); group 4: both CF-FeFum and IPT (n = 124); and group 5: consumption of porridge, an iron-fortified CF with the composition currently on the Ivorian market providing 2 mg iron as NaFeEDTA and 3.8 mg iron as ferric pyrophosphate 6 days per week (CF-FePP) and IPT-placebo (n = 127). The primary outcome was haemoglobin (Hb) concentration. Linear and logistic regression mixed-effect models were used for the comparison of the five study groups, and a 2 × 2 factorial analysis was used to assess treatment interactions of CF-FeFum and IPT (study groups 1-4).

Results: After 9 months, the Hb concentration increased in all groups to a similar extent with no statistically significant difference between groups. In the 2 × 2 factorial analysis after 9 months, no treatment interaction was found on Hb (P = 0.89). The adjusted differences in Hb were 0.24 g/dl (95 % CI -0.10 to 0.59; P = 0.16) in children receiving IPT and -0.08 g/dl (95 % CI -0.42 to 0.26; P = 0.65) in children receiving CF-FeFum. At baseline, anaemia (Hb <11.0 g/dl) was 82.1 %. After 9 months, IPT decreased the odds of anaemia (odds ratio [OR], 0.46 [95 % CI 0.23-0.91]; P = 0.023), whereas iron-fortified CF did not (OR, 0.85 [95 % CI 0.43-1.68]; P = 0.68), although ID (plasma ferritin <30 μg/l) was decreased markedly in children receiving iron fortified CF (OR, 0.19 [95 % CI 0.09-0.40]; P < 0.001).

Conclusions: IPT alone only modestly decreased anaemia, but neither IPT nor iron fortified CF significantly improved Hb concentration after 9 months. Additionally, IPT did not augment the effect of the iron fortified CF. CF fortified with highly bioavailable iron improved iron status but not Hb concentration, despite three-monthly IPT of malaria. Thus, further research is necessary to develop effective combination strategies to prevent and treat anaemia in malaria endemic regions.

Trial registration: http://www.clinicaltrials.gov ; identifier NCT01634945; registered on July 3, 2012.

Figures

Fig. 1
Fig. 1
Trial profile. CF-FeFum complementary food fortified with NaFeEDTA + ferrous fumarate; CF-FePP complementary food fortified with NaFeEDTA + ferric pyrophosphate, IPT intermittent preventive treatment of malaria, Hb haemoglobin, HDSS health and demographic surveillance system
Fig. 2
Fig. 2
Haemoglobin concentration at baseline, 6 and 9 months for each study group. CF-FeFum complementary food fortified with NaFeEDTA + ferrous fumarate, CF-FePP complementary food fortified with NaFeEDTA + ferric pyrophosphate, IPT intermittent preventive treatment of malaria, Hb haemoglobin
Fig. 3
Fig. 3
Prevalence of anaemia at baseline, 6 and 9 months for each study group. Anaemic children are separated into children with iron deficiency and no iron deficiency. Iron deficiency was reduced in anaemic children receiving CF-FeFum or CF-FePP. IPT modestly reduced anaemia, without affecting iron deficiency. CF-FeFum complementary food fortified with NaFeEDTA + ferrous fumarate, CF-FePP complementary food fortified with NaFeEDTA + ferric pyrophosphate, IPT intermittent preventive treatment of malaria

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