The Indian Journal of Pediatrics (June 2019) 86(6):523–531

https://doi.org/10.1007/s12098-019-02932-5

REVIEW ARTICLE

Prevention and Control of Anemia Amongst Children

and Adolescents: Theory and Practice in India
Umesh Kapil 1 & Radhika Kapil 2 & Aakriti Gupta 1

Received: 14 January 2019 / Accepted: 14 March 2019 / Published online: 11 May 2019
# Dr. K C Chaudhuri Foundation 2019

Abstract
Anemia is a major public health problem in India with prevalence of more than 50% amongst children and adolescents. The
decline in the burden of anemia has been insignificant over the past 5 decades. The present review assesses the National
Guidelines for Prevention and Control of Anemia in India, the current status of the program implementation and possible reasons
for the continued high prevalence of anemia in the country.

Keywords Anemia . Iron . Folic acid . Adolescents . Children

Introduction Prevalence of Anemia Amongst Children

and Adolescents
The World Health Organization (WHO) has estimated that
globally 1.9 billion people are anemic [1], with highest burden Under 5 y Children and Children 6–9 y of Age
of anemia existing among children (42.6%) [2].
Prevention and control of anemia in children is a public- Studies undertaken in 1980s documented more than 65%
health priority as it is associated with long-term negative ef- prevalence of anemia in pre-school children [5–7]. National
fects on cognitive and psychomotor function [3, 4]. In India, Nutrition Monitoring Bureau (NNMB) conducted in 2003 [8]
efforts have been made during last 50 y to reduce the preva- reported pooled prevalence of anemia among under five chil-
lence of anemia mainly through iron supplementation. Recent dren as 67% (range: 34–92%).
evidence suggests that etiology of anemia is multifactorial and Clinical Anthropometric and Biochemical Survey
less than 50% are likely to be anemic due to iron deficiency (CAB), conducted as a part of Annual Health Survey
[2]. (AHS) in the year 2014, reported that the prevalence of
In the present communication, authors have reviewed the anemia in different states was in the range of 64–94%
existing program on prevention and control of anemia, its amongst under 5 y children and 81–95% amongst children
current status of implementation and possible reasons for con- in the age group 5–9 y [9].
tinued high prevalence of anemia in the country.

Adolescents (10–19 y)

The prevalence of anemia among adolescent girls is alarming-

ly high. NNMB (2003) reported pooled prevalence of anemia
* Radhika Kapil
drradhikapath@gmail.com amongst adolescent girls to be 70%, with state wise variation
in the range of 49–90% [8]. AHS CAB (2014) documented
1 the prevalence of anemia in the range of 74–91% amongst
Human Nutrition Unit, All India Institute of Medical Sciences,
New Delhi, India adolescent girls in different states [9]. A community-based
2 national study conducted in 16 districts in 2006, documented
Department of Pathology, Jawaharlal Nehru Medical College,
Belgaum, Karnataka, India high prevalence of anemia of 90% in adolescent girls [10].
524 Indian J Pediatr (June 2019) 86(6):523–531

Etiology of Anemia psychomotor development and decreased capacity for

physical exercise and work performance [16].
Anemia has a multifactorial etiology that requires a multi- There is increasing evidence that iron deficiency can cause
pronged approach for its prevention and treatment. Iron significant central nervous system damage even in the absence
deficiency was considered as the most prevalent etiological of anemia [17]. These alterations in the brain structure and
factor leading to anemia. However, recent evidence sug- function occur during pre and post natal periods and infancy
gests that the proportion of anemia due to iron deficiency when neurogenesis and differentiation of different brain re-
is less than 50% and varies in different populations in de- gions are occurring. This damage continues to adulthood
veloping countries depending on the local conditions [4]. and may be irreversible even when iron treatment is provided
The proportion of anemia associated with iron deficiency is to correct the iron stores in the early stages of iron deficiency
only 14% for pre-school children; 16% for non-pregnant [17]. Anemia has been independently associated with de-
women of reproductive age in countries where anemia creased cognition equivalent to a 5-10-point deficit in intelli-
prevalence is more than 40%, especially in rural popula- gence quotient, impaired coordination of language and motor
tions [11]. The other etiological factors include hemoglobin- skills, poor attentiveness, memory and learning ability and low-
opathies, worm infestations, deficiencies of micronutrients er school achievements amongst adolescent girls [3, 4, 18–25].
like zinc, copper, folic acid, vitamin B12 and vitamin A [2].
Anemia amongst children and adolescents is caused mainly
due to i) increased iron requirements during periods of rapid National Iron+ Initiative (NIPI) Programme
growth ii) low iron stores at birth, iii) non-exclusive
breastfeeding, iv) early introduction of inappropriate comple- Ministry of Health and Family Welfare (MoHFW) launched
mentary food resulting in decreased breast milk intake and the National Iron+ Initiative (NIPI) program in 2011 in which
higher risk of intestinal infections, v) feeding of plant based all the age groups were included for iron and folic acid sup-
diets with low quantity and poor bioavailablity of iron due to plementation [26]. The NIPI guidelines were intensified to
high content of inhibitors, vi) iron loss due to malaria and soil formulate Anemia Mukt Bharat Strategy in 2018 [27].
transmitted helminthes, vii) poor iron absorption due to inad- The doses, regime and role of different service providers
equate personal hygiene, environmental sanitation, unsafe for management of anemia through Iron folic acid (IFA) sup-
drinking water. plementation have been described in Tables 1 and 2 [27].

Implementation of Program for Children (6–59 mo)

Health Consequences A liquid formulation containing 20 mg elemental iron and 100

microgram (mcg) folic acid is administered bi-weekly to chil-
Anemia has adverse effects on growth and development dren in the age group of 6–59 mo. IFA supplements are sup-
amongst school age children. The health consequences plied in bottles of 50/100 ml. The bottles have an auto-
are known to occur even at mild levels of anemia or prior dispenser so that only 1 ml of syrup is dispensed at a time to
to onset of clinical stage of anemia [12]. Anemia causes the beneficiary [27]. Accredited social health activist (ASHA)
marked impairment in oxidative energy production in skel- provides IFA syrup bi-weekly for the first week under her
etal muscle [13–15]. This leads to delayed physical and supervision through home visits.

Table 1 IFA supplementation programme for prophylaxis of anemia in children [27]

Age group Intervention/Dose Regime Service delivery

Children (6–59 mo) 1 ml of IFA syrup containing 20 mg Biweekly supplementation throughout Through ASHA
of elemental iron and 100 mcg the period 6–59 mo of age and Inclusion of doses administrated to the child in
of folic acid de-worming for children 12 mo and Mother Child Protection card
above.
Children (5–9 y) 45 mg elemental iron Weekly supplementation throughout In school children, through teachers and for
and 400 mcg of folic acid the period 5–9 y of age and biannual out-of-school children, through ASHA
de-worming during home visits
Adolescents (10–19 y) 60 mg elemental iron and 500 mcg of Weekly supplementation throughout In school children, through teachers and in
folic acid the period 10–19 y of age and out-of-school children, through quarterly
biannual de-worming Adolescent Health Day component of
RKSK programme at AWC

ASHA Accredited Social Health Activist; AWC Anganwadi centre; IFA Iron folic acid; RKSK Rashtriya Kishore Swasthya Karyakram
Table 2 Therapeutic supplementation of IFA on the basis of hemoglobin levels in children and adolescents [27]

Target group Who will screen and place Periodicity Treatment Follow-up Referral
of screening

Children 6–59 mo • ANM: VHND/sub-centre/ • RBSK/ANM: as per Mild and Moderate Anemia • Every month by ANM at VHND In case the child has not
session site scheduled microplan (7–10.9 g/dl): • Hb estimation after responded to the
• RBSK team: AWC/school • MO: opportunistic 3 mg of iron/kg/d for 2 mo: completing 2 mo of treatment treatment of anemia
• MO: health facility • For children 6–12 mo (6–10.9 kg): • Monitoring by ASHA for with daily dose of iron
1 ml IFA syrup, once a day compliance of IFA syrup every for 2 mo, refer the
• For children >1–3 y (11–14.9 kg): 14 d for a period of 2 mo child to the FRU/DH
1.5 ml IFA syrup, once a day If hemoglobin levels improve to MO/Pediatrician/Physician
• For children >3–5 y (15–19.9 kg): normal levels, the treatment is for further investigations.
Indian J Pediatr (June 2019) 86(6):523–531

2 ml IFA syrup, once a day discontinued, but the

prophylactic IFA dose is
continued.
Severe Anemia (<7 g/dl):
• Refer urgently to DH/FRU
• Management of severe anemia
in children of 6–59 mo is to be
done by the MO at the FRU/DH
based on investigations.

Children 5–9 y RBSK team: in-school and • Once a year Mild and Moderate Anemia • Class teacher/ Nodal teacher at In case the child has not
out-of-school children • Opportunistic screening (8–11.4 g/dl): school to orient parents during responded to the
All children with clinical of Hb of children 3 mg of iron/kg/d for 2 mo Parent Teacher Meeting (PTM) treatment of anemia
signs and symptoms of visiting the health Line listing of all anemic cases is for compliance of treatment. with daily dose of iron
anemia are referred to facility. to be maintained in the school • Parents to ensure follow-up of for 2 mo, refer the
SC/PHC for Hb register for IFA supplementation child after 30 d and 60 d at the child to the FRU/DH
estimation and further and given to the ANM/LHV/Multiple nearest SC/health facility MO/Pediatrician/Physician
management. purpose health worker for • Follow-up by ANM/LHV/MPHW for further investigation.
designated area. of designated area, as feasible.
• Hb estimation after completing
2 mo of treatment
• If hemoglobin levels improve to
normal levels, the treatment is
discontinued, but the prophylactic
IFA dose is continued
Severe Anemia (<8 g/dl):
• Refer urgently to DH/FRU
• Management of severe anemia in
children of 5–9 y is to be done
by the MO at the FRU/DH based
on investigations.
525
 526

Table 2 (continued)

Target group Who will screen and place Periodicity Treatment Follow-up Referral
of screening

All school-going adolescents In school premises Annually Mild and Moderate Anemia • Line listing of all anemic cases If no improvement after
10–19 y in government/ by RBSK team (8–11.9 g/dl): is to be maintained in the three mo of treatment,
government-aided Two IFA tablets (each with 60 mg school register for IFA ANM/MO of nearest
schools elemental iron and 500 mcg supplementation and given to facility to refer the
folic acid), once daily, for 3 mo, the ANM/LHV/MPHW of adolescent to FRU/DH
orally after meals designated area
• Follow-up by ANM/LHV/MPHW
of designated area, as feasible
• Parents to ensure follow-up of
adolescent after 45 d to 90 d at
the nearest sub-centre/ health facility
• If hemoglobin levels improve to
normal levels, the treatment is
discontinued, but the prophylactic
IFA dose is continued
Severe Anemia (<8 g/dl):
Management of severe anemia in
adolescents (10–19 y) is to be
done by the MO at FRU/DH
based on investigations.

ANM Auxiliary Nurse Midwifery; ASHA Accredited Social Health Activist; AWC Anganwadi centre; DH District hospital; FRU First referral units; Hb Hemoglobin; IFA Iron folic acid; LHV Lady Health
Visitor; MO Medical Officer; MPHW Multi Purpose Health Worker; PHC Primary health centre; RBSK Rashtriya Bal Swasthya Karyakram; SC Sub-centre; VHND Village Health Nutrition Day
Indian J Pediatr (June 2019) 86(6):523–531
Indian J Pediatr (June 2019) 86(6):523–531 527

Albendazole tablets (400 mg) are also provided to children clinical pallor are referred to Primary health care (PHC)/
every 6 mo for de-worming. Half tablet is administered to Mobile Medical/Health Teams for estimation of hemoglobin
children between 1 and 2 y age and 1 full tablet is adminis- and treatment of anemia.
tered to children in the age group of 2 y and above [27].
IFA syrup bottles are kept with mothers for administration
of IFA to their children. ASHA demonstrates the mothers/ Reasons for Continued High Prevalence
caregivers regarding the procedure to provide IFA syrup of Anemia
through the autodispenser bottle and instructions for storage
of IFA bottle in a cool and dark place, away from the reach of Impact of Iron Supplementation on Hemoglobin
children and for closing the lid of the bottle tightly each time Levels
after administration etc. ASHA educates the mothers about the
following: i) benefits of IFA syrup on physical and cognitive Recent scientific evidence suggests that iron supplementation
development of the child, ii) methods for improving iron and could lead to increase in the mean blood hemoglobin (Hb)
folate content of the diets, iii) importance of sanitation and concentration by 8.0 g/L [95% Confidence Interval (CI):
hygienic practices for preventing worm infestation in the child 5.0—11.0] in children, 10.2 g/L (95% CI: 6.1—14.2) in preg-
and iv) possible side-effects associated with IFA administra- nant women and 8.6 g/L (95% CI: 3.9—13.4) in non-pregnant
tion such as black discoloration of stools [27]. women [4]. After applying these shifts to blood hemoglobin
ASHA undertakes fortnightly home visits and encourages (Hb) concentrations, it is estimated that about 42% of anemia
the mother to administer IFA syrup to their child themselves in in children and about 50% of anemia in women would be
ASHA's presence to build confidence of the mother [27]. All amenable to iron supplementation [4]. Another recent scien-
doses of IFA administered to the child are recorded in the tific evidence suggests that the response of iron therapy on Hb
Mother and Child Protection (MCP) card [27]. ASHA records levels in anemic subjects in the age group of 6 to 59 mo is low
compliance in the IFA compliance card attached with the in malarial non-hyperendemic region (37.9-62.3%) and hy-
MCP card and teaches the mothers to record the consumption perendemic regions (5.8-31.8%) [28]. However, in India, iron
of IFA after administering every dose in the MCP card. supplementation is the only major intervention which is being
The nutritional status of children assessed by Mid-upper implemented for combating anemia and hence the prevalence
arm circumference (MUAC) is also undertaken to ensure that continues to be high.
IFA syrup is not administered to children with Severe acute
malnutrition. Prophylactic iron supplementation is not given Administration of Prophylactic Doses to Anemic
to children who have known hemoglobinopathy or acute ill- Subjects
ness like fever, acute diarrhea, pneumonia etc [27].
In India, more than 50% children are presently suffering from
Implementation of Program for Children (5–9 y) anemia [8, 9]. However, only prophylaxis doses of iron are
and Adolescents (10–19 y) being supplemented to these children instead of therapeutic
doses. The prophylactic doses could possibly result in Hb
Children in the age group of 5–9 y are provided with weekly level to be maintained at the same level instead of improving.
supplementation of 45 mg elemental iron and 400 mcg folic
acid by teachers in government and government-aided schools Poor Bioavailability of Iron from Indian Diets
using spot feeding approach of IFA after the mid-day meal or
lunch break. Out-of-school children between 5 and 9 y are The Indian diets are primarily derived from cereals, pulses and
provided IFA tablets through ASHA during home visits. vegetables and contain approximately 7 mg of iron per
Biannual de-worming with Albendazole (400 mg) is also giv- 1000 kcal. Bioavailability of iron from the plant based sources
en to all children [27]. is low (5% in men and children and 8% in women) due to
Adolescents (10–19 y) are administered with weekly IFA presence of inhibitory factors such as phytates, polyphenols,
supplementation (WIFS) containing 60 mg elemental iron and tannins and oxalates [29].
500 mcg of folic acid throughout the period of 10–19 y of age
through a Bfixed day^ approach. Biannual de-worming with Role of Environmental Enteropathy
Albendazole (400 mg) is also given to all children [27].
Rashtriya Bal Swasthya Karyakram (RBSK) team under- Anemia in chronic diseases may be triggered by chronic
takes screening for anemia among children and adolescents inflammation of the gut and atrophy of the intestinal
studying in schools and Rashtriya Kishore Swasthya villi due to poor quality of water, sanitation and hygiene
Karyakram (RKSK) programme at Anganwadi centres for (WASH) conditions, characterized as environmental enter-
out-of-school children. All children and adolescents with opathy (EE). Inflammation leads to malabsorption of
528 Indian J Pediatr (June 2019) 86(6):523–531

nutrients and disturbs the iron homeostasis by reducing The request for procurement of IFA tablets is gener-
iron absorption and utilisation, suppressing hemoglobin ally made when these functionaries have nil stock. They
synthesis and red blood cell production [30, 31]. have not been trained to maintain buffer supplies of IFA.
Evidence suggests that the children who are exposed to The district and block level store officers have not been
poor WASH, open defecation have lower hemoglobin trained in minimum stock management system at the store
levels due to increased risk of intestinal infection and warehouses. The IFA stocks are generally procured by the
chronic gut inflammation [32–35]. In countries with high store in-charge when there is complete stock out. This
inflammation exposure, contribution of iron deficiency in leads to delay in indenting and procurement of new stock
anemia has been suggested to be low for pre-school chil- of IFA. IFA, at times, are supplied in bulk, with less shelf
dren (20%) and non-pregnant women of reproductive age life or near to expiry date, which are provided to the health
(25%) [11]. workers for further distribution. First in first out mecha-
nism for management of IFA stocks is not practised.
iv) Monitoring and record keeping mechanisms for track-
Current Status of Implementation of Anemia ing the coverage of iron supplementation by teachers
Programme and AWW/ASHA has not been fully established [38].
The registers to maintain records are not available with
Programmatic Issues Amongst Children (6 mo to 9 y) teachers, ASHAs and AWWs in most cases. This pos-
sibly leads to unreliable reporting of data on coverage
i) The strategies developed and advocated under NIPI of IFA amongst children [39].
programme have not been pilot tested in the field v) The procurement, storage, distribution and availability
before they were implemented in the country. The of IFA syrup/tablets to the beneficiaries continues to be
operational feasibility, roles and responsibilities of a major constraint.
health workers, the difficulties encountered by
them during implementation were not observed in Procurement There is an inadequate calculation of IFA
Breal life^ situation. However, these guidelines requirements at the state level and thereby low alloca-
have been issued to states for implementation, tion of financial budget for procurement of IFA tablets
resulting in difficulties in operationalization of the [38]. Forecasting of future requirements of IFA is usu-
program. ally done using a top-down approach and arbitrary
ii) The ASHA is a voluntary worker. She is being equal distribution to all health centres is done rather
given more and more responsibilities for imple- than based on population and actual needs.
mentation of activities under the different programs
of National Health Mission [36]. She has been Storage District and block level stores have inadequate
asked to participate in all the health and nutrition space for storage of IFA. Although procurement of IFA
related activities that are being implemented at the is similar to other medicines listed on the Essential drug
village level. IFA supplementation is accorded low list but there is low prioritization of IFA tablets for
priority by their supervisors, leading to poor work storage at the district and block level warehouses [38].
performance. The task of supervised administration
of IFA twice a week through homevisits, is not Distribution The mechanism for distribution of IFA
considered feasible by them. This could also lead tablets required at the district, block, PHC, sub centre
to fatigue in the health system and the health level is poor [37, 38]. The process and mechanism of
worker. transport of IFA tablets/ syrups from district warehouse
iii) Inadequate procurement and distribution of IFA sup- to block and further to subcentres/school has not been
plies: There is a lack of policy on procurement and established and is being undertaken on ad hoc basis.
distribution of IFA supplies at state, district, block and The large quantity of IFA syrups for health institutions
sub centre levels [37, 38]. Auxiliary nurse midwives consists of heavy weight, which needs to be carried by
(ANMs) receive IFA from PHC for distribution. At the AWW/ASHA workers from PHC to the sub centre.
the village level, ASHAs receive IFA independently There is a lack of transport facility and budget to carry
in their drug kits. Anganwadi workers (AWWs) do these heavy weight supplies with health functionaries.
not directly receive IFA for distribution of antenatal
mothers. However, all three (ASHA, ANM, AWW) vi) Availability of IFA Stocks: A poor communication ex-
are to coordinate and distribute IFA in the community. ists between sub centre workers, Medical Officer at the
Specific roles and responsibilities amongst them have PHC and District Health Officer on availability of IFA
not been clearly defined. tablets at the different levels.
Indian J Pediatr (June 2019) 86(6):523–531 529

In the year 2017–2018, the coverage of children 6–59 d) Monitoring and supervision of the WIFS program is poor
mo who were provided with IFA syrup, was only 6.6%. at the school level. There is lack of accountability of
The coverage of IFA syrup in different states was in the teachers. No incentive is provided for supervised admin-
range of 0.0 to 49.3%, with majority (22 states) of the states istration of IFA supplementation to them [27].
having a coverage of less than 3% [27]. A major factor for e) Teachers and AWWs have not been trained and have in-
low coverage of IFA was the low procurement and avail- adequate skills for correctly identifying the clinical signs
ability of IFA syrup. Only 5 states namely Daman and Diu, of anemia.
Meghalaya, Sikkim, Puducherry and Maharashtra procured f) Comprehensive counseling of children on the health benefits
about 50% of the required quantity of IFA syrup [27]. of IFA supplementation is not routinely undertaken by the
In the year 2017–2018, only 8% of children in the ASHA, ANM, AWW and teachers. The beneficiaries are not
age group of 6–10 y received complete doses of IFA. educated about the possible side-effects of IFA consumption.
Less than 2% coverage was found in 15 states [27]. There is lack of health care support system for management of
Low coverage was observed possibly due to the low side-effects faced due to IFA supplementation in the schools.
procurement of IFA supplements. Twelve states pro- g) A low coverage of IFA supplementation amongst adoles-
cured less than 1% of their total IFA requirement [27]. cents existed in 2017–18, inspite of a high priority accorded
vii) There is a need for computerization, timely reporting by Government of India. The coverage with complete
from the district, clear documentation of existing inven- doses of IFA tablets was only 21.7% amongst children
tory, stock requests, and expiry dates at different levels. who were attending government or non-government
schools. The coverage was below 10% in 12 states. Only
3 states namely Punjab, Puducherry and Tamil Nadu had
The Issues Faced in the Implementation of WIFS coverage of more than 50% with complete doses of IFA
[27]. During 2017–2018, the overall percentage of procure-
a) Under WIFS program, enteric coated Iron and Folic Acid ment of IFA tablets was 35% in the country. Six states/
(EC IFA) tablets were being given every week to adoles- Union Territories had nil IFA tablets and only 3 states pro-
cents, which may have led to inadequate decline in anemia cured more than 50% of the total IFA requirements [27].
prevalence [26]. The poor clinical response of EC IFA as
compared to the conventional sugar coated IFA has been
widely documented [39, 40]. Evidence suggests that there
is low absorption of iron from the EC IFA tablets as com- Way Forward
pared to sugar coated IFA [41, 42]. A clinical trial, using
state-of-the-art stable isotopic methods conducted in 2018 The total expenditure on health sector in the country has in-
documented that absorption of iron from EC tablets was creased from 0.9% to nearly 2% of the gross domestic product.
substantially lower than that from non-enteric coated tablets However, anemia indicators for children and adolescents have
(4.3% vs. 12.1%) [43] as the EC tablets are ‘gastro-resistant’ not improved correspondingly [46]. Issues with program imple-
[44]. Recently, a policy decision has been taken by MoHFW mentation, poor coverage due to low acceptability of IFA tablets
to replace EC IFA tablets with sugar coated tablets under the and long duration of supplementation may have possibly result-
Anemia Mukt Bharat Strategy. However, these changes are ed in insignificant decline in the burden of anemia in India.
yet to be implemented in the National programme. Recent World Health Organization global guidelines (2016)
b) Fifty two doses of IFA are required to be administered to [45] on prophylaxis doses of IFA recommends daily adminis-
adolescents every year under WIFS. However, only about 28 tration of lower dose of iron of 60 mg amongst adolescents (10–
doses can be distributed due to i) 8 wk of summer holidays, 19 y) [46] instead of weekly doses [28]. These guidelines are
ii) 4 wk of winter vacation, iii) 5 wk of annual examinations, based on the results from systematic review [47, 48] including
iv) 5 wk mid year examination and v) 2 wk of government data from 67 trials conducted in 24 countries. In view of the
holidays. Hence, this WIFS strategy needs to be modified. above, there is a need to urgently adopt daily supplementation of
The recent WHO recommendation for daily iron supplemen- a lower dose of iron of 60 mg recommended in WHO guidelines
tation amongst adolescent girls continuously for 90 d needs (2016) [45] instead of weekly IFA supplementation amongst
to be adopted [45]. Daily supplementation of IFA will im- children and adolescents. These guidelines are based on the
prove the coverage of IFA and reduce system fatigue. results from systematic review [47, 48] including data from 67
c) There is lack of convergence of functioning between the trials conducted in 24 countries.
Department of Education and Health. Iron supplementa- Immediate remedial measures are needed to strengthen the
tion is considered as an additional responsibility by school supply chain mechanism for IFA and achieve effective program
teachers, leading to poor motivation for undertaking IFA implementation through periodic trainings at all levels. Effective
supplementation. convergence of several governmental departments like health,
530 Indian J Pediatr (June 2019) 86(6):523–531

education, water supply and sanitation is needed [47]. Promotion 10. Toteja GS, Singh P, Dhillon BS, et al. Prevalence of anemia among
pregnant women and adolescent girls in 16 districts of India. Food
of adequate WASH practices, adoption of toilets [33] and control
Nutr Bull. 2006;27:311–5.
of diarrhea through use of oral rehydration solution (ORS) along 11. Petry N, Olofin I, Hurrell RF, et al. The proportion of anemia asso-
with zinc supplementation [49, 50] needs to be promoted for ciated with iron deficiency in low, medium, and high human devel-
reducing the prevalence of anemia due to chronic inflammation opment index countries: a systematic analysis of national surveys.
Nutrients. 2016;8:693.
and EE. Additional interventions include targeted deworming,
12. Nelson M, Bakaliou F, Trivedi A. Iron-deficiency anaemia and
prevention and treatment of hemoglobinopathies, malaria and physical performance in adolescent girls from different ethnic back-
other common infections, delayed cord clamping, earlier supple- grounds. Br J Nutr. 1994;72:427–33.
mentation in low birth weight infants and appropriate infant and 13. Spear BA. Adolescent growth and development. J Am Diet Assoc.
2002;102:S23–9.
young child feeding guidelines need to be undertaken.
14. Beard JL. Iron requirements in adolescent females. J Nutr.
In India, the efforts to promote the availability of 2000;130:440S–2.
micronutrient-rich vegetables at affordable cost throughout 15. World Health Organization. Adolescent nutrition: a review of the
the year have been undertaken but the coverage achieved un- situation in selected south-east Asian countries. New Delhi: Reg
Off South-East Asia; 2006. p. 1–96.
der such efforts is very low. Behavior Change Communication
16. Li R, Chen X, Yan H, Deurenberg P, Garby L, Hautvast JG.
(BCC) programmes should be prioritized to promote the con- Functional consequences of iron supplementation in iron-deficient
sumption of iron-rich food amongst children. female cotton mill workers in Beijing, China. Am J Clin Nutr.
Effective utilization of funds (Rs 109 lakhs per district) by 1994;59:908–13.
state government allocated under Anemia Mukt Bharat 17. Yehuda S, Rabinovitz S, Carasso RL, Mostofsky DI. The effects of
brain iron deficiency on cognitive and behavioral aspects. In:
Strategy is needed for management and treatment of anemia, Yehuda S, Mostofsky DI, editors. Iron Deficiency and Overload.
especially childhood anemia [27]. Totowa: Humana Press; 2009. p. 195–206.
18. Ramakrishnan U. Nutritional Anemias. USA: CRC Press; 2001.
Authors’ Contribution UK, RK and AG: Concept and design and prep- 19. Seshadri S, Gopaldas T. Impact of iron supplementation on cogni-
aration of the manuscript. UK is the guarantor for this article. tive functions in preschool and school-aged children: the Indian
experience. Am J Clin Nutr. 1989;50:675–84,85–6.
20. Soemantri AG, Pollitt E, Kim I. Iron deficiency anemia and educa-
Compliance with Ethical Standards tional achievement. Am J Clin Nutr. 1985;42:1221–8.
21. Pollitt E, Hathirat P, Kotchabhakdi NJ, Missell L, Valyasevi A. Iron
Conflict of Interest None. deficiency and educational achievement in Thailand. Am J Clin
Nutr. 1989;50:687–96,96–7.
22. Soekarjo DD, de Pee S, Kusin JA, Bloem MW. School-based sup-
plementation: lessons learned in Indonesia. SCN News. UK: United
Nations System; 2006. p. 14–8.
References 23. More S, Shivkumar VB, Gangane N, Shende S. Effects of iron
deficiency on cognitive function in school going adolescent females
1. GBD 2017 Disease and Injury Incidence and Prevalence in rural area of central India. Anemia. 2013;2013:819136.
Collaborators. Global, regional, and national incidence, prevalence, 24. Halterman JS, Kaczorowski JM, Aligne CA, Auinger P,
and years lived with disability for 354 diseases and injuries for 195 Szilagyi PG. Iron deficiency and cognitive achievement among
countries and territories, 1990–2017: a systematic analysis for the school-aged children and adolescents in the United States.
Global Burden of Disease Study 2017. Lancet. 2018;392:1789– Pediatrics. 2001;107:1381–6.
858. 25. UNICEF/UNU/WHO. Iron deficiency anaemia assessment, pre-
2. World Health Organization. The Global Prevalence of Anaemia in vention, and control: a guide for programme managers. 2001.
2011. WHO Report; 2015. Available at: https://www.who.int/nutrition/publications/
3. Lozoff B, Jimenez E, Wolf AW. Long-term developmental outcome micronutrients/anaemia_iron_deficiency/WHO_NHD_01.3/en/.
of infants with iron deficiency. N Engl J Med. 1991;325:687–94. Accessed 1 Jan 2019.
26. Ministry of Health and Family Welfare. Guidelines for Control of
4. Pollitt E. Iron Deficiency and Cognitive Function. Annu Rev Nutr.
Iron Deficiency Anaemia. National Iron Plus Initiative; 2013.
1993;13:521–37.
27. Ministry of Health and Family Welfare. Anemia Mukt Bharat:
5. National Institute of Nutrition; Indian Council of Medical Research. Intensified National Iron Plus Initiative; 2018. Available at:
Community studies using common salt fortified with iron. Annual https://anemiamuktbharat.info/dashboard/#/. Accessed 1 Jan 2019.
Report; 1978. 28. Gera T, Sachdev HPS, Nestel P, Sachdev SS. Effect of iron supple-
6. Rao KV, Radhaiah G, Raju SV. Association of growth status and the mentation on haemoglobin response in children: systematic review
prevalence of anaemia in preschool children. Indian J Med Res. of randomised controlled trials. J Pediatr Gastroenterol Nutr.
1980;71:237–46. 2007;44:468–86.
7. Singla PN, Gupta HP, Ahuja C, Agarwal KN. Deficiency anaemias 29. National Institute of Nutrition. Nutrient Requirements and
in preschool children-estimation of prevalence based on response to Recommended Dietary Allowances for Indians. Indian Council of
haematinic supplementation. J Trop Pediatr. 1982;28:77–80. Medical Research; 2010.
8. National Institute of Nutrition; Indian Council of Medical Research. 30. Watanabe K, Petri WA. Environmental enteropathy: elusive but
National Nutrition Monitoring Bureau: Prevalence of Micronutrient significant subclinical abnormalities in developing countries.
Deficiencies: NNMB Technical Report No. 22. 2003. EBioMedicine. 2016;10:25–32.
9. Government of India. Annual Health Survey: Clinical, 31. Ngure FM, Reid BM, Humphrey JH, Mbuya MN, Pelto G,
Anthropometric and Bio-chemical (CAB) Survey; 2014. Stoltzfus RJ. Water, sanitation, and hygiene (WASH),
Indian J Pediatr (June 2019) 86(6):523–531 531

environmental enteropathy, nutrition, and early child development: 42. Jacobs A, Miles PM. Role of gastric secretion in iron absorption.
making the links. Ann N Y Acad Sci. 2014;1308:118–28. Gut. 1969;10:226–9.
32. Coffey D. Working Paper: Sanitation Externalities, Disease, and 43. Sachdev HPS, Kurpad A, Saxena R, Kapil U. National expert group
Children’s Anemia. 2014. Available at: https://paa2014.princeton. technical consultation on prevention and treatment of iron deficien-
edu/papers/140309. Accessed 1 Jan 2019. cy anemia. Indian J Comm Health. 2018;30:1–11.
33. Coffey D, Spears D, Vyas S. Switching to sanitation: understanding 44. Singh HS, Roychowdhury S, Verma P, Bhandari V. A review on
latrine adoption in a representative panel of rural Indian households. recent advances of enteric coating. IOSR J Pharm. 2012;2:5–11.
Soc Sci Med. 2017;188:41–50. 45. World Health Organization. Guideline: Daily Iron Supplementation
34. Coffey D, Spears D. Implications of WASH benefits trials for water in Adult Women and Adolescent Girls; 2016. Available at: https://
and sanitation. Lancet Glob Health. 2018;6:e615. apps.who.int/iris/bitstream/handle/10665/204712/
35. Coffey D, Geruso M, Spears D. Sanitation, disease externalities and 9789241549523_eng.pdf?sequence=1. Accessed 1 Jan 2019.
anaemia: evidence from Nepal. Econ J. 2018;128:1395–432. 46. Hota P. National rural health mission. Indian J Pediatr. 2006;73:193–5.
36. National Health Mission. Government of India. Accredited Social 47. Low MS, Speedy J, Styles CE, De-Regil LM, Pasricha SR. Daily
Health Activist (ASHA) [Internet]. Available at: http://nhm.gov.in/ iron supplementation for improving anaemia, iron status and health
communitisation/asha/about-asha.html. Accessed 18 Feb 2019. in menstruating women (review). Cochrane Database Syst Rev.
37. Varghese JS, Swaminathan S, Kurpad AV, Thomas T. Demand 2016;4:CD009747.
and supply factors of iron-folic acid supplementation and its 48. Higgins JPT, Green S. Cochrane handbook for systematic reviews
association with anaemia in north Indian pregnant women. of interventions. Cochrane Collab. John Wiley & Sons, Ltd; 2011.
PLoS One. 2019;14:e0210634. Available at: https://training.cochrane.org/handbook. Accessed 1
38. Wendt AS, Stephenson R, Young MF, et al. Identifying bottlenecks Jan 2019.
in the iron and folic acid supply chain in Bihar, India: a mixed- 49. Liberato SC, Singh G, Mulholland K. Zinc supplementation in
methods study. BMC Health Serv Res. 2018;18:281 p. 1–12. young children: a review of the literature focusing on diarrhoea
39. Baird IM, Walters RL, Sutton DR. Absorption of slow-release iron prevention and treatment. Clin Nutr. 2015;34:181–8.
and effects of ascorbic acid in normal subjects and after partial 50. Lazzerini M, Wanzira H. Oral zinc for treating diarrhoea in children.
gastrectomy. Br Med J. 1974;4:505–8. Cochrane Database Syst Rev. 2016;12:CD005436.
40. Rudinskas L, Paton TW, Walker SE, Dotten DA, Cowan DH. Poor
clinical response to enteric-coated iron preparations. CMAJ.
1989;141:565–6.
41. Jacobs A, Rhodes J, Peters DK, Campbell H, Eakins JD. Gastric Publisher’s Note Springer Nature remains neutral with regard to
acidity and iron absorption. Br J Haematol. 1966;12:728–36. jurisdictional claims in published maps and institutional affiliations.