Effectiveness of Biweekly Versus Daily Iron–Folic Acid Administration on Anaemia Status in Preschool Children

Effectiveness of Biweekly Versus Daily Iron–Folic Acid Administration on Anaemia Status in Preschool Children by Shally Awasthi,a Tuhina Verma,a and Shiela Virb a The Department of Paediatrics and Institute of Clinical Epidemiology, King George’s Medical University (KGMU), Lucknow, India b UNICEF, India Summary Three-quarters of preschool children in India are anaemic. With the aim of identifying a cost-effective strategy for iron supplementation, the study objective was to assess the effectiveness of daily versus biweekly iron–folic acid (IFA: 20 mg elemental iron and 0.1 mg folic acid/tablet) on change in haemoglobin (Hb) levels of preschool children (3–6 years). This was a rural community-based effectiveness study in Uttar Pradesh, North India. IFA was given in two schedules: biweekly (2 tablets/dose) and daily (1 tablet/dose) for 1 year with fortnightly monitoring for adherence. A total of 400 and 403 children were enrolled in daily and biweekly regimes, respectively, of which 57.32 per cent and 50.25 per cent were anaemic (Hb 511 g/dl) in each group. Adherence in biweekly and daily regimes was 89.05 per cent vs. 63.5 per cent. After 1 year, the mean Hb rise in daily and biweekly regime was 1.063 g/dl (SD: 1.6; p ¼ 0.000) and 1.053 g/dl (SD: 1.73; p ¼ 0.001), respectively. Reduction in point prevalence of anaemia was 65.7 per cent daily vs. 56.1 per cent in biweekly regimen ( p ¼ 0.0047). We conclude that biweekly as well as daily IFA administration is effective in raising Hb levels and decreasing community prevalence of anaemia significantly. However, since there is better adherence and lower drug costs associated with biweekly IFA administration, this can be considered for programme use. Introduction Of all the nutritional deficiencies, iron deficiency anaemia (IDA) is a major public health problem with nearly 70 million, i.e., about 60–70 per cent of all children below 6 years, suffering from it.1 According to the National Family Health Survey-2 in India, 74 per cent of children between 6 and 35 months are anaemic.2 IDA in infants and children can cause impaired motor development and co-ordination, impaired language development and scholastic performance, psychological and behavioural effects (inattention, fatigue, insecurity etc.), decreased physical activity,3–5 and decreased resistance to infection.6,7 Prevention of IDA in young children, therefore, is of high priority from a public health perspective. While iron–folic acid (IFA) supplementation is a simple and feasible strategy, there is Acknowledgements The study was funded by UNICEF. Correspondence: Prof. Shally Awasthi, Department of Paediatrics and Institute of Clinical Epidemiology, King George’s Medical University (KGMU), Shahmina Road, Lucknow # 226003, Uttar Pradesh, India. E-mail 5sawasthi@sancharnet4. currently insufficient data in India on the frequency of, as well as duration of, IFA administration.8 The current study was undertaken to assess the effectiveness of 1-tablet daily versus 2-tablets biweekly IFA, given to children aged 3–6 years, on the change in haemoglobin levels. IFA was delivered either through an existing government infrastructure (Integrated Child Health Development Services (ICDS)) or by the mother. A secondary objective was to assess the effectiveness of both systems. Materials and Methods Setting This study was conducted in Nindura Block, Barabanki district, North India. Barabanki district has an area of 3825 km2 and has 16 administrative blocks. Nindura block has 132 villages. Each village has about 75–150 houses and an average population of 1000. The block is further divided into 28 subcentres, each with five to seven villages. For this study all sub-centres were listed alphabetically, serially numbered, and two were selected by random for assessment of the interventional strategies, one per sub-centre. Journal of Tropical Pediatrics, Vol. 51, No. 2 ß Oxford University Press 2005; all rights reserved doi: 10.1093/tropej/fmh065 Advance Access Published on 26 January 2005 67 S. AWASTHI ET AL. Integrated Child Development Scheme (ICDS) Under the ICDS services, there is an anganwadi centre (AWC) in each village with a population of about 1000. Each AWC has an anganwadi worker (AWW) who is responsible for running an informal school and a supplementary nutrition programme for preschool children. There are about 150 children aged 3–6 years per village, of which only about onethird are registered to obtain services of the AWC. Interventions The interventional drug was IFA. Each IFA tablet contained 20 mg elemental iron with 0.1 mg folic acid and was given in two schedules, either daily or biweekly for 1 year, and was intensively supervised. In the daily schedule, 1 tablet was given. In the biweekly schedule, 2 tablets of IFA were given twice a week on fixed days (Wednesday and Saturday). Sub-centres of Shahpur Baxolia and Sipa Hidayatpur were included in this study. Children of Shahpur Baxolia were given IFA tablets biweekly for 1 year and those of Sipa Hidayatpur were given daily tablets for 1 year. The Department of Health, State Government and UNICEF sponsored IFA for the study. IFA was stored at the block level ICDS office from where the AWWs collected supplies for 2 months. IFA was given to the children either by the AWW, if they were registered and used the ICDS informal education services, or by the mother for non-registered children. On one particular day of every month the mothers of non-registered children came to the AWC to receive a monthly supply of IFA for their children. Monitoring of intervention A monitoring in-charge was responsible for each intervention type. He visited each AWC every 15 days to take an account of the drugs distributed to registered children. The monitoring in-charge also visited 20 randomly selected houses of non-registered children and collected information about the IFA tablet intake, including the number of pills consumed. Adherence was calculated by reported intake of IFA by the AWW for registered children and by counting the pills consumed by visiting homes of non-registered children. The proportion of children with 100 per cent adherence to each intervention regimen is reported. Measurement of nutritional indices A baseline survey of weight, height, and haemoglobin was done. Weight was measured using Uniscale 890 machines that could measure to the nearest 0.1 g. The weighing scale was checked by daily measuring of standard weights. Heights were measured by stadiometer. The staff were trained to use the instruments prior to fieldwork to minimize inter- and intraobserver variations. The accuracy of the machine was tested daily using the standard strip provided with the equipment. Ten per cent of the measurements were validated within 48 h. Hemocue (B-Haemoglobin photometer, Sweden) was used to estimate the haemoglobin levels, using the procedure described in the manual. Participants All children aged 3–6 years living in the villa (...truncated)