Iron Deficiency Anemia and Psychosocial Stimulation
Condition: Iron Deficiency Anemia
MeSH terms: Anemia; Anemia, Iron-Deficiency; Iron Deficiencies
Study type: Interventional

Summary: 
      In developing countries, poor nutrition, high morbidity, poverty, poor parental education and
      stimulation in the home, all detrimentally affect children's development. These conditions
      frequently occur together increasing the risk of poor development. Iron deficiency anemia
      (IDA) affects large numbers of young children and is associated with poor child development.
      There is some question as to whether infants with IDA can catch up in mental development to
      non-IDA infants. We plan to examine the effect of psychosocial stimulation on IDA children's
      growth and development using a randomized controlled trial and compare them with non-anemic
      children. The study will be located in poor villages accessible to Dhaka. Villages will be
      randomized to either receive psychosocial stimulation or none. Children, aged 6-12 months,
      with IDA (hemoglobin (Hb) 80.0-109g/L, ferritin<12μg/L & Transferrin Recepter (TfR) >7)
      (n=212) or without anemia (Hb>109g/L, ferritin>12μg/L, C-reactive protein (CRP) <5 & TfR<7)
      (n=212) will be identified in those villages. Intervention will include weekly home visits
      for 9 months by a play leader, who will demonstrate play with home made toys and teach the
      mothers about child development. All IDA children will be given 30 mg ferrous-sulphate daily
      for 9 months. At the beginning and end of the study, the following measurements will be made:
      Bayley Scales of Infant Development (mental and motor indices), Wolke's behavior ratings, Hb,
      serum ferritin, CRP, Transferrin receptor, anthropometry, home stimulation, and mothers'
      knowledge and practices of child development. Stool microscopy, maternal-urinary iodine (as a
      proxy to assess children's iodine status), dietary history, child rearing practices
      (parenting) of mothers, perinatal history and socioeconomic conditions will be assessed at
      the beginning and children's language development at the end. Depending on availability of
      funds serum TSH will also be measured in children to exclude iodine deficiency. We will also
      measure mothers' nutritional and mental status to assess its relationship with children's
      development. The treatment effect will be examined by intention to treat analysis using
      multiple regression of the outcome variables controlling for initial measures and multilevel
      analysis will be conducted to control for differences at village level. The findings of this
      project will have implications both for international and national policies on early
      childhood development programs for IDA children.
    

Detailed description: 
      In developing countries, millions of young children have developmental deficits due to poor
      nutrition, lack of a stimulating environment, and poverty. In Bangladesh, where poor
      nutrition, poverty and poor parental education are highly prevalent, the implications are
      serious not only for the individuals' future but also for national development.

      Iron deficiency and child development There is increasing evidence that iron deficiency
      anemia detrimentally affects children's development (Grantham-McGregor and Ani 2001). Many
      cross sectional studies have shown that iron deficiency is associated with poor psychomotor
      development and behavioral deficits in young children, and poor cognition and school
      achievement in school-aged children. Furthermore, longitudinal studies have observed that
      children who are anemic in the first 3 years of life continue to have poorer cognition,
      school achievement and psychosocial well being than children who were not anemic
      (Grantham-McGregor and Ani 2001). However, anemia is associated with many adverse social and
      economic family circumstances (Lozoff et al. 1991;de Andraca et al. 1990), which may
      adversely affect children's development.

      Anemic children who were treated with iron, failed to catch up with non-anemic children in
      developmental levels in several studies (e.g. Walter et al. 1989;Lozoff et al. 1987;Lozoff et
      al. 1996). A few randomized, controlled trials of iron treatment have been conducted with
      anemic young children (Stoltzfus et al. 2001;Idjarinata and Pollitt 1993;Aukett et al.
      1986;Friel et al, 2001). In two of the trials, anemic children under four (Stoltzfus et al.
      2001) or two years (Idjarinata and Pollitt 1993) achieved better development from iron
      supplementation. One of these studies in Indonesia involved only 25 treated anemic children
      (Idjarinata and Pollitt 1993). The other study was in Zanzibar and included many children
      with malaria and some severely anemic children (Stoltzfus et al. 2001) and only children with
      Hb <80g/L showed significant benefits in motor development but improvement in language
      milestones occurred in children with all levels of Hb. Two other randomized trials failed to
      show clear benefits (Aukett et al. 1986;Friel et al, 2001). One of them (Aukett et al. 1986)
      used an insensitive screening test to measure developmental outcomes and the other (Friel et
      al, 2001) compared the effect of low and high iron formula on the development of low birth
      weight children and no benefit was found in the high iron group. The high iron children
      actually had more respiratory infections.

      A recent meta-analysis of randomised trials (Sachdev et al, 2005) found that while there is
      evidence that older anemic children benefit from iron in cognition there is no convincing
      evidence from children under 27 months. However, three more recent randomized trials of iron
      supplementation were not included (Black et al, 2004; Lind et al, 2004, Freil et al 2003).
      One in Bangladesh (Black et al, 2004) found a non significant benefit to motor development
      from iron alone however the power of the study was extremely limited and the group receiving
      iron and zinc benefited in motor development. Both the Indonesian (Lind et al, 2004) and
      Canadian studies (Freil et al 2003) found benefits from iron treatment to infants' motor
      development but not to mental development. It has been suggested that the poor level of
      mental development found in IDA infants may be irreversible in some circumstances (Lozoff et
      al 2000).

      Stimulation and child development Iron deficient children show less activity, more apathy and
      are less likely to explore their environment than iron replete children and thus acquire
      skills only slowly (Grantham-McGregor and Ani 2001). One reason for the failure of some
      anemic children to catch up in mental development to non-anemic children following treatment
      may be that they have missed opportunities to explore their environment. Thus, they may
      require extra play experiences to catch up in development. In addition, many anemic children
      come from homes with low levels of stimulation and other psychosocial disadvantages
      (Grantham-McGregor and Ani 2001), which may exacerbate their poor level of development.

      In previous studies in poor populations, it has been shown that teaching mothers how to play
      with their children and be responsive to them improves the children's development (WHO 1999).
      It is clear that in order to reach their developmental potential, disadvantaged children
      require not only good health and nutrition but also supportive and caring environments. In
      Jamaica (Grantham-McGregor et al. 1991), stunted children needed extra stimulation as well as
      food supplementation to catch up with non-stunted children. We therefore plan to examine the
      benefits of adding psychosocial stimulation to iron treatment on IDA infants motor and mental
      development and determine if they catch up to non-anemic infants.

      Situation in Bangladesh The nutritional status of Bangladeshi children is extremely poor. Low
      birth weight is estimated to occur in 36% of births. It is estimated that among children
      under 5 years the prevalence of stunting (height-for-age <-2 z scores) is 43% and wasting
      (weight-for-height <-2 z scores) is 13% (UNICEF 2006). Iron deficiency anemia is a major
      public health problem in young children. A national rural survey found that 52.7% of children
      aged 6 to 59 months were anemic (Hb <110g/L). However, the prevalence of anemia was 78% among
      children 6-11 months of age and 64% among children 12- 23 months of age (IPHN/HKI 1999). A
      review of studies of prevalence of anemia in Bangladesh (Ahmed 2000) found levels ranging
      from 81 to 49% with a suggestion of rural children having higher levels of anemia than urban
      children in small studies. However, severe anemia (Hb < 70g/L) was rare.

      The main etiology of anemia in young children in Bangladesh is reported to be poor dietary
      iron intake especially during the period of rapid growth (Ahmed 2000). Vitamin A deficiency
      is common and may contribute to anemia (Ahmed et al. 2001). However, in Bangladesh there is a
      government policy of supplementing children under 5 years with vitamin A every 6 months and
      coverage is estimated to be good at 87% (UNICEF 2006). A national survey in 1995-6 (Jahan and
      Hossain 1998) found that the diets of children aged one to three years have marked deficits
      in energy, protein and iron. Approximately 60% of iron intake came from cereal. It is clear
      that poor iron intake is a major contributor to iron deficiency in this population. Low birth
      weight is also highly prevalent and low iron stores from birth are likely to be another
      important contributor to iron status.

      A representative survey of 14 rural districts (7,764 people of 0-60 years of age) found that
      anemia was associated with large families, poor sanitation and socioeconomic status, poor
      nutritional status and parasitic infection (Husain et al. 1997). Anemic children are
      therefore likely to be exposed to several risk factors associated with poverty that may
      detrimentally affect their development.

      Iodine deficiency was endemic in Bangladesh and national Iodine Deficiency Disorder (IDD)
      survey in 1993 found 47.1% of population suffered from some form of goiter and about 69% of
      people were biochemically iodine deficient (Yusuf et al. 1993). Following this survey, salt
      iodination program was started in 1993, which has improved the iodine status of the people in
      the country. In 1998 a nationwide survey found that 77% of households (in the whole country
      except in Cox's Bazar district) consumed iodized salt (BBS 1998). According to the UNICEF's
      report 70% of all households in Bangladesh consume iodized salt (UNICEF 2006). We will
      therefore assess whether iodine deficiency is a problem in the study population and if so, we
      will advice the families to use iodized salt.

      In addition most Bangladeshi mothers suffer from poor nutrition (The March of Dimes, 2002),
      anemia (Stallkamp et al. 2006), low education (Unicef 2006), and some are also depressed
      (Hamadani, personal communication). Maternal nutritional (Perez et al. 2005) and mental
      status (Black et al. 2007) has been found to affect children's development.
    

Intervention name(s): Stimulation
Intervention type(s): Behavioral
Intervention description(s): Stimulation given to the child by mother
Allocation: Randomized
Intervention model: Single Group Assignment
Masking: Single (Outcomes Assessor)
Primary purpose: Treatment
Keywords: Psychosocial stimulation in addition to iron supplementation will improve mental and psychomotor development, language, behavior and growth of IDA infants.; With the addition of stimulation IDA infants will catch up to the non-anemic infants.