Frequently Asked Questions

Q: Should we be worried about giving iron to young children in African countries?

A: There are currently concerns about both giving iron and not giving it to young children where malaria is endemic. There is some evidence that giving iron to children who don’t need it may increase malaria and other infections. There is a body of literature about the role that iron plays in neurodevelopment. Giving iron may have implications for survival in young children while withholding it may have consequences for both individual and national development. The World Health Organization recommends giving iron to children living in malaria-endemic areas in the context of malaria prevention and treatment activities. Click here for a more extensive review of giving iron to young children in malaria areas.

Q: Does mass treatment for worms lead to drug resistance?

A: Repeated mass treatment of helminths can lead to drug resistance, which has been shown to develop as a result of repeated treatment (Albonico et al, 2003). To avoid or delay drug resistance, the World Health Organization (WHO, 2002) recommends alternating drugs and assessing the efficacy of treatment periodically at sentinel sites during mass treatment programs. The frequency of tracking drug resistance depends on the frequency of the mass campaigns (WHO, 2002).

Q: Shouldn’t all women be screened for anemia before they receive iron?

A: No. Where anemia prevalence is high, all pregnant women should receive iron-folic acid supplements whether they have had screening test or not. In malaria- and hookworm-endemic areas, pregnant women also should receive anthelminthic and malaria (IPTp) treatment without screening for anemia or these infections. While screening for anemia is a best practice and a policy in most developing countries, the supplies for anemia testing are not always available. Ideally, if resources allow, screening would identify women with anemia who would then receive additional iron and be tested for malaria and helminth infections. When screening supplies are not available, all health workers should be trained to check for clinical signs of anemia (e.g., pallor) which identifies about 70% of severe anemia cases. Pregnant women and young children with severe anemia can then be treated and, if they do not respond to treatment, referred. In low resource settings where anemia prevalence is high, the cost of screening needs to be balanced with the cost of getting the integrated package (IFA, IPTp, and deworming) to all pregnant women. If the budget does not allow for purchasing both screening supplies and commodities for the integrated package, the public health approach would be to put available resources into ensuring the commodities for the integrated package are available to 80% of women.

Q: Who is the target group for deworming? In many countries school-age children appear to be receiving deworming medication while other groups are not?

A: Pregnant women and young children are the most vulnerable groups to the iron deficiency anemia caused by hookworm infection. Anemia in school-children has effects on educational outcomes such as attention span and educability, so many Ministries of Education are implementing, often with the Ministries of Health, programs to deworm children in school. There is some evidence that decreasing the burden of hookworm disease in school-children reduces transmission and also benefits the rest of the population. Click here for more information on deworming (Components of the Integrated Package tab/Helminths sub-tab).

Q: Isn’t anemia prevalence high because women do not take their iron-folic acid pills? 

A: No. Available information from Demographic and Health Surveys show that coverage of the integrated package to control anemia (IFA supplements, IPTp, and deworming) is still low, suggesting that the commodities in the package, including IFA, are just not available. Because IPTp and deworming are administered only several times during ANC visits, it is unlikely that non-compliance is a problem for these interventions. The compliance literature, mainly from Western countries, shows that adherence to a daily regimen, like IFA, may be challenging. Side effects from taking iron (e.g., black stools, gastric upset) are often touted as the main reason women do not take IFA. However, from the literature about compliance with IFA, the evidence supports that lack of supplies is still the major reason women do not take all their 180 IFA supplements. Women take IFA supplements if they are counseled that side effects may occur and how to manage them. Click here for more information about how to improve IFA supplementation programs.

Q: Does folic acid increase malaria?

A: Large doses of folic acid interfere with the treatment of malaria using sulfadoxine-pyrimethamine (SP). WHO recommends that doses below 5 mg of folic acid are safe to use. Most iron-folic acid tablets, including those available through UNICEF, contain 60 mg of iron and 400 mcg of folic acid, which is a low dose of folic acid and safe to give with SP treatment. Click here for more information on the Malaria sub-tab.

Pregnancy, IFA supplementation, and anti-folate malaria treatment:

Several studies, including a 2008 study following 467 pregnant women in western Kenya, found that women receiving high-dose folate supplementation (5 mg/day) had an increased risk of sulfadoxine-pyrimethamine (SP) treatment failure for malaria. Low doses of 0.4 mg/day or even 1.5 mg/day were not shown to have a negative effect on SP treatment (Van Eijk et al, 2008). The 2009 WHO position statement regarding weekly iron-folic acid supplementation (WIFS) in women of reproductive age addresses that weekly iron alone may need provided in two situations: 1) where mandatory folic acid fortification of staple foods has been introduced and shown to be effective; and 2) in anti-folate malaria treatment regions (WHO position paper, 2009). Click here to learn more.  

Q: IFA and multi-micronutrients?

A: There have been studies comparing multi-micronutrients (MMNs) with iron and iron-folic acid supplements alone. In many developing countries, diets are not diverse, so giving an MMN to supplement these diets held promise for improving pregnancy and newborn outcomes. So far, these studies giving MMNs have not shown an overwhelming increase in benefits compared to IFA supplements alone. The 2013 Lancet Maternal and Child Nutrition series recommended “replacement of iron-folate with multiple micronutrient supplements in pregnancy might have additional benefits for reduction of SGA (small-for-gestational-age) in at-risk populations, although further evidence from effectiveness assessments might be needed to guide policy change.” If MMNs do prove to have a comparative advantage over IFA, the cost-benefit of providing MMN over IFA needs to be considered. The cost of MMN supplements is $16.37 per pregnancy compared with the cost of IFA supplements, which is $5.23 per pregnancy.