Safety of universal provision of iron through home fortification of complementary foods in malaria-endemic areas

Abstract

Home fortification of complementary foods with iron and other micronutrients is a low-cost strategy for filling nutrient gaps in the diets of infants and young children, but there has been uncertainty about the safety of universal provision of iron via home fortification in malaria-endemic areas. Based on the current understanding of the potential mechanisms of adverse effects of iron, the risk can probably be minimized by using the lowest possible efficacious dose of iron, preferably delivered in small amounts throughout the day with food, to minimize spikes in plasma nontransferrin-bound iron and large amounts of unabsorbed iron in the gastrointestinal tract. Results from 6 home fortification studies in malaria-endemic areas showed no increased risk of morbidity (including malaria), but these studies were not powered to rule out a modest increase in the risk of severe adverse events. At present, the safest option is to implement home fortification in the context of comprehensive malaria control strategies, as recommended in recent WHO guidelines.

Figure 1

Postulated effect of NTBI on severity of malaria. ICAM-1, intercellular adhesion molecule; iRBC, infected red blood cell; NTBI, nontransferrin-bound iron; PfEMR-1, Plasmodium falciparum erythrocyte membrane protein 1; ROS, reactive oxygen species. Adapted from Reference with permission.

Figure 2

Postulated effect of supplemental iron on bacteremia. iRBC, infected red blood cell. Adapted from Reference 5 with permission.

Figure 3

Pathways that may jointly contribute to adverse effects of supplemental iron in malaria-endemic areas. NTBI, nontransferrin-bound iron; ROS, reactive oxygen species. Adapted from Reference 5 with permission.