Prevention of anaemia / weekly supplementation Veronique Priem 08.10.97
iron therapy David Brewster 13.10.97
Prevention of anaemia / weekly supplementation -Reply Rita Bhatia 14.10.97
Prevention of anaemia / weekly supplementation -Reply Penny Nestel 15.10.97
Re: Prevention of anaemia / weekly supplementation Ray Yip 15.10.97

Date: Wed, 8 Oct 1997 11:10:00 +0200

From: (Veronique PRIEM)

Subject: Prevention of anaemia / weekly supplementation


Dear All,

A question about Prevention of anaemia for pre school children and pregnant women.

Do you recommend Weekly supplementation in ferrous sulphate and folic acid.

I don't have a lot reference to justify this policy, very interesting in terms of

acceptability and treatment compliance.

My references are :

-Nutrition reviews, vol 53, N2 "Possible new developments in community control of iron deficiency anaemia" Lani-Stephenson, MNS, ph.D. (feb.95).

- "Iron deficiency in children, New possibilities for its control " Fernando E. Viteri.

I would like to know if you have other documents about weekly supplementation in

Iron and folic acid.

Also, your policy and recommendations about this protocol.

Thanks for your answers.




From: David Brewster

Date: Mon, 13 Oct 1997 08:23:58 +0930

Subject: iron therapy


In reply to Veronique's enquiry, I have recently completed a trial of iron therapy in Aboriginal Australian children, so have reviewed the many studies. It is still controversial, but my reading of the literature is that once weekly prophylactic iron (and presumably folate) in pregnancy is satisfactory, but does not have as prompt a response to treatment for iron deficiency anaemia cases. This was first studied in 1994, although the original idea of less frequent iron administration was derived from a 1990 study in rats. The theoretical basis for weekly dosing is that mucosal turnover occurs every 5-6 days in humans, and there is a transient refractory state of the intestine after a large dose of iron (`mucosal block'). This is different from the normal resistance of the intestine to unneeded iron or the ability of the intestine to adjust to the body's requirements. Although a recent American study found no significant absorptive advantage to giving iron less often than once daily, only a small proportion of those studied were iron deficient. But the mucosal block theory has been disputed from iron absorption studies using stable isotopes.

The only published trial we could find of less frequent than daily iron treatment in preschool children with low iron status was from Indonesia involving 8 weeks daily vs twice-weekly supplementation, which found no significant differences in treatment effect between the two groups. Doubts have been expressed about whether a weekly regime would really improve compliance over a daily regime, but the main advantage of weekly iron doses may be the feasibility of administering doses under supervision to ensure compliance. However, that may not be feasible in many settings, and poor compliance with a weekly dose may be more risky than with a daily regime.

Although most of the studies show a satisfactory response of iron deficiency anaemia to weekly or twice weekly iron, we found a slighly slower response than to IM iron.


Selected References

1. Berger J, Aguayo VM, Tellez W, Lujan C, Traissac P, San Miguel JL. Weekly iron supplementation is as effective as 5 day per week iron supplementation in Bolivian school children living at high altitude. Eur J Clin Nutr 1997; 51: 381-386.

2. Menendez C, Kahigwa E, Hirt R, et al. Randomised placebo-controlled trial of iron supplementation and malaria chemoprophylaxis for prevention of severe anaemia and malaria in Tanzanian infants. Lancet 1997; 350: 844-850.

3. Palupi L, Schultink W, Achadi E, Gross R. Effective community intervention to improve hemoglobin status in preschoolers receiving once-weekly iron supplementation. Am J Clin Nutr 1997; 65: 1057-1061.

4. Pappagallo S, Bull DL. Operational problems of an iron supplementation programme for pregnant women: an assessment of UNRWA experience. Bull World Health Organ 1996; 74: 25-33.

5. Ridwan E, Schultink W, Dillon D, Gross R. Effects of weekly iron supplementation on pregnant Indonesian women are similar to those of daily supplementation. Am J Clin Nutr 1996; 63: 884-890.

6. Viteri FE. Weekly compared with daily iron supplementation [letter]. Am J Clin Nutr 1996; 63: 610-612.

7. Yip R. Iron supplementation during pregnancy: is it effective? Am J Clin Nutr 1996; 63: 853-855.

8. Cook JD. Iron supplementation: is less better? Lancet 1995; 346: 587

9. Cook JD, Reddy MB. Efficacy of weekly compared with daily iron supplementation. Am J Clin Nutr 1995; 62: 117-120.

10. Schultink W, Gross R, Gliwitzki M, Karyadi D, Matulessi P. Effect of daily vs twice weekly iron supplementation in Indonesian preschool children with low iron status. Am J Clin Nutr 1995; 61: 111-115.

11. Solomons NW. Weekly versus daily oral iron administration: are we asking the right questions? Nutr Rev 1995; 53: 326-327.

12. Viteri FE, Liu X, Tolomei K, Martin A. True absorption and retention of supplemental iron is more efficient when iron is administered every three days rather than daily to iron-normal and iron-deficient rats. J Nutr 1995; 125: 82-91.

13. Gross R, Schultink W, Juliawati. Treatment of anaemia with weekly iron supplementation [letter]. Lancet 1994; 344: 821

14. Yip R. Iron deficiency: contemporary scientific issues and international programmatic approaches. [Review]. J Nutr 1994; 124: 1479S-1490S.

Date: Tue, 14 Oct 1997 10:47:12 +0200

From: Rita Bhatia <>

Subject: Prevention of anaemia / weekly supplementation -Reply


This from UNHCR

I have a similar query. We have a case load of about 17,000 Southern Sudanese boys (10-20Years) in a camp in Turkana district in Kenya. A sample survey reports HB levels among this group as expressed below:

25% less than 8g

53% 8-11.9g

and 22% 12-16 g

The diet is mainly cereal, Beans , Salt and oil. No access to fresh food items . It is a deserted area. These boys main aim is to study. One cooked meal of CSB is planned for the group....

The diet is not only deficit in Micronutrient but in Kcal as well . The planned ration is about 1900 kcal , though the needs of this group is larger. Hence a cooked meal was proposed...The total camp population is 50,000.

My question is what level of Iron Supplements be given , how often etc. The ration level itself is very political due nature of this population.

I am going there this week to review the situation and experts advise and field experience would be useful.....

Many thnaks


Rita Bhatia

Date: Wed, 15 Oct 1997 11:36:56 -0400

From: Penny Nestel <>

Subject: Prevention of anaemia / weekly supplementation -Reply


Many of the studies on weekly/biweekly vs daily supplementation show similar improvements in Hb levels among individuals with mild to moderate anemia. There is an ongoing debate about whether less than daily supplementation is appropriate for pregnant women. As I understand it, higher dose (120 mg Fe) weekly supplements have been proposed as being appropriate from the time that pregnancy is recognized and through lactation (? 6 months). In contrast daily doses are generally only given in the 2nd and 3rd trimesters and rarely during lactation. George Beaton is leading a team doing a meta analysis on the trials. The results are due later this year/early next year.

The practical implications of changing the protocol will be as important as the scientific basis for making changes and we probably know less about the former than the latter. Issues that affect compliance and, perhaps more importantly, supply will determine the effectiveness of the program. Ray Yip has raised many of the issues in his paper.

USAID and UNICEF held a consultative meeting on iron/multimicronutrient supplements for young children. The recommendation was that children 6-24 months be given 12.5 mg Fe daily as a syrup/drops - which would cover 90% of total Fe requirements for children 6-18 months old. This would be equivalent to ingesting 10 drops of a solution containing 25 mg Fe/mL or 1 teaspoon of a syrup containing 2.5 mg Fe/mL. Because the period of greatest risk of IDA is between 12 and 18 months, Fe supplements should be initiated as close to 6 months as possible and the supplements should be given for 6 months. Further details including aspects related to safety, packaging, feasibility of including other minerals and vitamins, recommendations on iron supplements, and future directions are given in the meeting summary that is available form the International Nutrition Anemia Consultative Group, ILSI Human Nutrition Institute, 1126 16th Street NW, Washington DC 20036-4810, USA. The citation is Nestel, P and D. Alnwick. 1997. Iron/micronutrient supplements for young children. INACG, Washington DC.


Following are references that we have related to the daily/weekly question, some of which were cited by David Brewster. Let me know if you would like a copy, but are unable to get one, giving details of where they should be sent.


1. Angeles-Agdeppa, I; Schultink, W; Sastroamidjojo, S; Gross, R, and Karyadi, D. Weekly micronutrient supplementation to build iron stores in female Indonesian adolescents. AJCN. 1997; 66: 177-83.

2. Cook, J. D. and Reddy, M. Efficacy of weekly compared with daily iron supplementation. AJCN. 1995; 62: 117-20.

3. Galloway, R and McGuire, J. Daily versus weeklyHow many iron pills do pregnant women need? Nutr. Rev. 1996; 54(10)318-323.

4. Katelhut, A; Schultink, W; Angeles, I; Gross, R, and Pietrzik, K. The effects of weekly iron supplementation with folic acid, vitamin A, and vitamin C on iron status of Indonesian adolescents. Asia Pacific J. Clin. Nutr. 1996; 5(3)181-5.

5. Liu, X; Zhang, J.; Yen, H, and Viterie, F. Hemoglobin and serum ferritin levels in pregnant Chinese women in response to weekly iron supplements. Symposium. 1996; .

6. Palupi, L; Schultink, W; Achadi, E, and Gross, R. Effective community intervention to improve hemoglobin status in preschoolers receiving once-weekly iron supplementation. AJCN. 1997; 65: 1057-61.

7. Schultink, W; Gross, M. and others. Effect of daily vs twice weekly iron supplementation in Indonesian preschool children with low iron status. Am. Jnl. Clin. Nutr. 1995; 61: 111-115.

8. Solomons, N. Daily versus weeklywe still might not be asking the right questions. Nutr. Rev. 1997; 55(4)141-2.

9. Tee, E; Cavaili-Sforza, L. and others. A study of the effectiveness of weekly iron supplementation in adolescent secondary school girls in Malaysia. Inst. for Medical Research.

10. Thorand, B; Schultink, W; Gross, R and others. Efficiency of the iron supplementation programme for pregnant women in Jeneponto, Sulawesi, Indonesia. Asia Pacific J. Clin. Nutr. 1994; 3(2): 11-5.

11. Viteri, F. Iron supplementation for the control of iron deficiency in population at risk. Nutr. Rev. 1997; 55(6)195-209.

12. Viteri, F. A new concept in the control of iron deficiency (ID)community-based preventative supplementation (PS) of at-risk groups by weekly intake of iron supplements.

13. Viteri, F; Xunian, L. and others. True absorption and retention of supplemental iron is more efficient when iron is administered every three days rather than daily to iron-normal and iron-deficient rats. Jnl. Nutr. 1995; 12(5): 82-91

18. Yip, R. Iron supplementation during pregnancyis it effective? AJCN. 1996; 63: 853-855.

Date: Wed, 15 Oct 1997 23:39:12 -0500

From: Ray Yip <>

Subject: Re: Prevention of anaemia / weekly supplementation


This is my quick summary of the weekly iron issue based on published reports.

First, it is important to keep in mind of which part of life cycle because iron requirement is very different. There are two periods iron requirement is hard to meet: infancy and pregnancy. During these period iron need is about 3 times higher than other part of life cycle.

During the "low iron requirement" period: 2-5 yrs, school age, adult men and non-pregnant women, the relatively low requirement or limited deficit in case of iron deficiency, it does not take much iron supplement to make up the need. For this reason, all studies thus far found a few month of weekly iron supplement works just as well as daily iron for a shorter period in improving iron status or in correcting anemia. In such case, one attractive aspect of using weekly iron is the feasibility of administering the iron under supervision, such as in school or work sites.

In term of "higher iron requirement" period, thus far there are no data for infancy, a period of very high risk for iron deficiency anemia, and data for pregnancy is not conclusive at best. One study from Indonesia by Scultink et al. in AM J CLin Nutr is one of the best known one and represents the problem of showing both daily or weekly iron were not very effective (more than half of the subjects were anemic by the end of the trial, likely has to do with compliance problem). The fact that there is "no difference" , or weekly is as ineffective as daily is hard to justify the weekly iron for pregnancy. The greater issue at hand is how to make iron supplement effective during pregnancy. Based on everything we know on iron requirement, it would be very hard to meet this requirement by weekly dose during pregnancy, especially in many areas many women are deficient before pregnancy.

Based on existing information, I would sconclude that weekly iron can be effective for low iron requirement part of life cycle. However, the evidence for the high iron requirement period, it is premature to conclude weekly iron will work, and there is a good chance it may not.