Effect of Iron Supplements On Children Living in Malaria-Endemic Areas

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Children in a malaria-endemic community in Ghana who received a micronutrient powder with iron did not have an increased incidence of malaria, according to a study in the September 4 issue of JAMA. Previous research has suggested that iron supplementation for children with iron deficiency in malaria-endemic areas may increase the risk of malaria.

“In sub-Saharan Africa, malaria is a leading cause of childhood morbidity and mortality, and iron deficiency is among the most prevalent preventable nutritional deficiencies. The provision of iron to children with iron deficiency anemia can enhance motor and cognitive development and reduce the prevalence of severe anemia. However, studies have suggested that iron deficiency anemia may offer protection against malaria infection and that the provision of iron may increase malaria morbidity and mortality,” according to background information in the article. “In 2006, the World Health Organization and the United Nations Children’s Fund released a joint statement that recommended limiting use of iron supplements (tablets or liquids) among children in malaria-endemic areas because of concern about increased malaria risk. As a result, anemia control programs were either not initiated or stopped in these areas.”

Stanley Zlotkin, M.D., Ph.D., of the Hospital for Sick Children, Toronto, and colleagues conducted a study to determine the effect of providing micronutrient powder (MNP) with or without iron on the incidence of malaria among children living in a high malaria-burden area. The randomized trial, which included children 6 to 35 months of age (n = 1,958 living in 1,552 clusters), was conducted over 6 months in 2010 in a rural community setting in central Ghana, West Africa. A cluster was defined as a compound including 1 or more households. Children were excluded if iron supplement use occurred within the past 6 months, they had severe anemia, or severe wasting. Children were randomized by cluster to receive a MNP with or without iron for 5 months followed by 1-month of further monitoring. Insecticide-treated bed nets were provided at enrollment, as well as malaria treatment when indicated.

Throughout the intervention period, adherence to the use of MNP and insecticide-treated bed nets were similar between the iron group and the no iron group. The researchers found that the overall incidence of malaria was lower in the iron group compared with the no iron group, but after adjustment for baseline values for iron deficiency and moderate anemia, these differences were no longer statistically significant. “Similar associations were found during the 5-month intervention period only for both malaria and malaria with parasite counts greater than 5000/µL (severe malaria). A secondary analysis demonstrated that malaria risk was reduced among the subgroup of those in the iron group who had iron deficiency and anemia at baseline.”

Overall, hospital admission rates did not differ significantly between groups. However, during the 5-month intervention period, there were more children admitted to the hospital in the iron group vs. the no iron group (156 vs. 128, respectively).

“The findings from the current study not only address a gap in the literature, but also have potentially important policy implications for countries like Ghana that have not implemented iron supplementation or fortification as part of anemia control programs in part due to the joint recommendation from the WHO and UNICEF. For ethical reasons, we ensured that all participants were not denied existing malaria prevention (insecticide-treated bed nets) or malaria treatment. As such, our results most likely can be applied to other malaria-endemic settings in which similar malaria control measures are in place. Overall, given our findings and the new WHO guidelines recommending iron fortification for the prevention and treatment of anemia among children younger than 2 years (in whom the prevalence of anemia is ≥20 percent), there should be renewed interest and consideration for implementing iron fortification in Ghana as part of the national nutrition policy.”

Editorial: Iron Fortification and Malaria Risk in Children

In an accompanying editorial, Andrew M. Prentice, Ph.D., of the London School of Hygiene and Tropical Medicine, and colleagues write that the increase seen in this study in hospital admissions among the iron supplementation group, which by definition constitutes a potentially serious adverse event, adds to the concerns about the safety of iron administration in highly malaria-endemic environments.

“Participants in an expert panel convened by the World Health Organization in 2007 speculated that iron given with foods, either by centralized or point-of-use fortification, would be safe. However, the Ghanaian trial reported by Zlotkin et al in this issue of JAMA now becomes the fourth trial to question this suggestion, and leaves global health policy makers with an unresolved dilemma. Until a means of safely administering iron in infectious environments has been developed, there remains an imperative to reduce the infectious burden as a prerequisite to moving poor populations from their current state of widespread iron deficiency and anemia.”

Source: American Medical Association (AMA)

Malaria Drugs Side Effects

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QUESTION

I was affected by malaria 5 months back. I am feeling tiered and weakness and heart trembling symptoms.

Any suggestions to overcome weakness?

ANSWER

Your fatigue is probably not caused by the treatment—one of the potential residual effects of malaria infection is iron deficiency, which can lead to anaemia, and this can cause tiredness. Eating iron-rich foods or asking your doctor about iron supplements might help if indeed you find your iron levels are too low. Recovery from any illness can sometimes take a long time, and getting plenty of rest, eating well and keeping well hydrated will all help you to regain your strength.

If you have recently taken malaria medication, perhaps you would be willing to spend a few minutes to take our Malaria Medication Side Effects Survey? We are very interested in hearing about the experiences of people who have taken different types of malaria medication, and particularly any side effects they have experienced. The survey should only take a few minutes and will be anonymous; we will publish the results on the website for you to see. Many thanks for your assistance!

Is Malaria Related to Chronic Fatigue and Hair Loss?

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QUESTION

I was in Ghana one year ans 6 months ago when I contracted malaria. I was hospitalised for one day and treated with coartem for 3 days. I was treated with antibiotics for typhoid also however I had been vaccinated against this prior to my trip.

Since my return I began loosing significant amount of hair from my head and suffer fatigue after small amounts of exercise and work. I never suffered from these ailments before having malaria. I consulted my doctor who suggested multivitamins which have reduced the hair loss however the fatigue persists.

I wish to know is the fatigue related to malaria and is there anything I can do to improve this problem. Generally I am fit and healthy, eat well and engage in regular exercise.

ANSWER

It is very unusual for malaria to have any long term health effects once the infection has been successfully treated. It is possible that you are suffering from some residual anemia, which can be caused by malaria, though is more likely due to iron deficiency in your diet. Given that you clearly were deficient for other nutrients (as shown by the positive effects seen when you started taking multivitamins), I would think that if you do have anemia, it is more likely due to diet than anemia! Try asking for a blood test for anemia from your doctor, and if you are indeed anemic, you can look into taking iron supplements as well, or try to include iron-rich foods in your diet.