Recognition and Management of Malnutrition

Iron deficiency (ID) is the most common nutritional deficiency worldwide. In developing countries, most affected individuals are women and children. Risk factors for ID, in addition to a diet lacking animal products, include: pregnancy, prematurity, low birthweight, early umbilical cord clamping, rapid growth, cow’s milk feeding (intestinal microhemorrhages), reduced intestinal absorption of iron due to high phytate and phosphate intake (cola beverages), menstruation, and parasitic infections. ID is also the most frequent cause of anemia. The three major causes of anemia in the developing world are nutritional deficiencies, malaria, and intestinal parasites (hookworm). The prevalence of anemia has been used as a surrogate marker of ID prevalence in a certain population. It has been estimated that ID in a population is 2 to 3 times more prevalent than ID anemia (IDA).

Clinical findings associated with severe anemia include skin, mucus membranes, and nail beds pallor, as well as dyspnea or tachypnea at rest. Clinical examination is not a reliable method for diagnosing isolated iron deficiency or milder forms of anemia. If laboratory tests are available, the diagnosis of anemia can be documented with hemoglobin (Hb) or hematocrit determinations. Table 5 shows the age-specific cut-off values for Hb and hematocrit according to WHO guidelines. The reduction in tissue oxygen supply associated with anemia is responsible for the clinical manifestations and long-term consequences of iron deficiency. Anemia is associated with growth retardation, increased susceptibility to infections, and impaired cognitive and psychomotor development. Very severe anemia (Hb <5 g/mL) is associated with increased mortality. Iron therapy and multivitamin therapy have both been shown to reverse some of these effects, but long-term studies suggest that iron deficiency anemia in early childhood can lead to irreversible developmental damage.

Iron supplementation for prevention and treatment of anemia

Due to the high bioavailability (about 50%) of lactoferrin-linked iron in human milk, exclusive breastfeeding during the first 4 to 6 months guarantees an appropriate iron pool in healthy term infants. Preterm infants need early iron supplementation, because their iron pools at birth are insufficient. With the introduction of solids at 6 months of age, begin appropriate supplementary feeding including foods with highly bioavailable heme iron (see Table 8 on page 19). Iron absorption can be enhanced by adding animal protein to the food.

Adequate intake of vitamin C and reduction of iron absorption suppresors in the diet also help to increase iron bioavailability. Adequate dietary intake of folic acid is also important, since IDA is often associated with folate deficiency (see Table 8 on page 19).

Iron supplementation programs have been effective in preventing ID. Preventive iron supplementation beginning at 6 months of age is encouraged and should be made available to those at risk for ID, since risks associated with ID at this age are highly significant. Recommendations for iron combined with folic acid supplementation for the prevention of ID are found in Table 6; severe anemia management is outlined in Table 7.

Notes:

• ᵃ Folic acid supplementation is included with iron supplementation.
• ᵇ If supplementation begins late during pregnancy, continue into the postnatal period to complete the total recommended duration.

TABLE 7. Treatment for severe anemia