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.4 ii J in Nutr 1 993 :58 :33 9-42 . P rin ted in U S A . 1993 A m erican S oc ie ty fo r C lin ica l N utrition
33 9
Dec reased ra te o f s tun ting am ong anem ic Indones ian
p re schoo l ch ild ren th rough iron supp lem en ta tio n
Im eld a T Ange les W ern er J Schu ltin k Pau l M atu le ss i R a ine r G ross and Soem ilah S astro am id jo jo
A B S T R A C T E ffec ts o f iron su pp lem en ta tion on gro w th and
h em ato log ica l s ta tu s o f Indones ian an em ic prescho o l ch ild ren
w ith low w eigh t-fo r-age w ere in vestiga ted . A trea tm en t g roup n
= 39) rece ived da ily supp lem en ts o f3O m g F e and 20 m g v itam in
C , w hereas a con tro l g ro up n = 37) rece ived 20 m g v itam in C
only fo r a p er io d of 2 m o. S upp lem en t a llo cation w as doub le
b lin d . A t the s ta rt an d fin ish of th e s tudy , body w eigh t, he igh t,
fo od in tak e. and hem oglob in and serum fem tin co ncen tra tion s
w ere de te rm ined . O nly the trea tm en t g rou p sho w ed a sign if ican t
inc rease in all hem ato log ica l v alues P < 0 .001). H e igh t and
w eigh t o f a ll ch ild ren increased P < 0 .01). Inc reases in he igh t
a nd h eig ht -f or -a ge
score in the trea tm en t g rou p w ere la rger
P = 0 .001 ) th an the increase in the con tro l g roup . T he pos itive
effec t o f iron su pp lem en tation on linear g row th w as no t caused
by in creased food in take , bu t seem s to be in fluenced by d ecreased
m o rb id ity . Iron supp lem en ta tio n m ay be a re la tive ly inexp en sive
w ay to he lp d ecrease the h igh p reva lence of s tun ting . A m J
C /in N u tr 1993:58 :339-42 .
KEY W ORDS Iron
supp lem en ta tion , an em ia , g row th ra te,
p rescho o lers, In dones ia
Introduction
Iron -defic iency anem ia and decreased grow th ra te a re tw o
m ajo r nu trition -re la ted prob lem s am o ng prescho o l ch ild ren in
deve lop ing coun tries 1 2). A nem ia in ch ild ren is assoc ia ted
w ith decreased p hys ica l capac ity and grow th , im p aired im m u ne
sys tem , and reduced lea rn ing capac ities (2 -5 ). A ch ild w h o h as
been iron-defic ien t anem ic in in fan cy risk s p ro trac ted deve l-
opm enta l d isadvan tages com pared w ith peers hav ing be tte r iron
sta tu s (6 ). D ecreased gro w th ra te in ch ild ren in deve lop ing
coun tries is asso cia ted w ith inc reased m orb id ity risk and redu ced
scho las tic ach ievem ent (7 ). G row th perfo rm ance in ch ild ren can
be assessed by m easuring w eigh t, he igh t, and ag e, and can b e
c lassified by co m bin ing the m easu rem en ts to fo rm the ind ica to rs
w eigh t- fo r-he igh t (W FH ), he igh t-fo r-age (H F A ), and w eigh t-fo r-
age (W FA ) (8) . A chro n ic lack of n u trien ts w ill lead to a low
H F A (stun ting ), w h ich is h ig h ly p reva len t in m any com m unitie s
in deve lop ing coun tries. S tun ting im plies tha t a ch ild s gene tic
po ten tia l is n o t fu lly exp ressed (9 ), and it m ay nega tive ly a ffec t
phy sica l w ork capac ity in la te r life becau se of sm aller b ody s ize
(10) . S tun ting u sua lly deve lop s f rom an early age onw ard , an d
ifle ft un trea ted afte r som e tim e , no ca tch ing up m ay be p oss ib le
(11 , 12 ).
T he occurren ce ofanem ia and red uced grow th ra te a re o ften
assoc iated am on g p reschoo l ch ild ren . A uke tt e t a l (3 ) and
C hw an g e t al ( 1 3) repo rted tha t iron supp lem en ta tion im pro ves
phy sica l g row th in anem ic ch ild ren . T here fo re , iron su pp le -
m en tation m ay have the du a l ef fect o f po sitiv e ly in flu en cing
bo th hem ato lo g ic sta tus and grow th ra te . H ow ever, the m ech-
an ism ofiron-en hanced grow th rem ain s e lusive . In theory , th is
inc rease in g row th m ay b e d ue to decreased m orb id ity , to in -
c reased food in take , o r to the d irec t e ffec t o f iron itse lf.
C ons idering the h igh preva lences of an em ia and reduced
g row th ra te in Sou th eas t A s ia , the presen t s tudy investiga ted
w hether iron supp lem en ta tion w ould sign if ican tly im prov e
p hysica l g row th , as w ell as hem ato log ica l s tatus , o fanem ic pre -
schoo l ch ild ren w ith a low W FA .
Sub jec ts and m ethod s
T he study w as carried ou t in Jakarta . In dones ia , a t tw o sub-
d istric t hea lth o ffices tha t cov ered n e ig hborh oods w ith a to ta l
p opu la tio n of 109 000 and a pop u lation d ensity o f 380 00 /
k m 2. T he s tudy group com pr ised the low er soc io eco nom ic c lass
(25-30 % have no s tab le jobs). an d env ironm enta l hyg iene in
the s tudy area w as poor.
T he se lec tion process sequen tia lly iden tif ied ch ild ren , ag ed 2-
5 y . as low W F A and then as anem ic . T he se lection criter ia w ere
as fo llow s: W FA Z sco re be tw een -2 and -3 . hem og lo b in con -
cen tra tion be tw een 80 and 1 10 g /L , and serum ferritin < 12 g/
L . T he upper lim its o f the hem ato log ica l m easu res a re usua l
v alues used to d ef in e anem ia (2 ). A ll sub jec ts w ere iden tified
from ex isting records a t the h ealth cen te rs , w h ich con ta in ed on ly
da ta on W F A . F rom the hea lth cen te rs lis t 2 1 6 ch ild ren w ere
se lected w ho m et the an th ro pom etrica l c rite ria . A ll 2 16 ch ild ren
cam e to the h ea lth cen ter a t the reques t o fhea lth cen ter s ta ff so
th at the ir h em o glob in concen tra tion cou ld be ana lyzed . F or th ose
w ith a low hem og lo b in con cen tra tion , se ru m fem tin concen-
tra tion w as m easu red . F ina lly . 84 ch ild ren m et th e hem ato log ica l
crite ria . T he paren ts o f 80 ch ild ren gave w ritten co nsen t fo r
th eir ch ild ren s partic ipa tion in the s tu dy . S too l sam ples o f the
sub jec ts w ere exam ined fo r the presence o f paras itic in fec tion s
(asca rias is and trich uriasis). C h ild ren w ith paras ite s rece iv ed an -
tihe lm in th ic trea tm en t (1 4) befo re sta rting iro n su pp lem en ta tion ,
F rom the S E A M E O -T R O PM E D C ente r Jakarta a t the U nivers ity
of Ind on esia , Jak arta , In do nes ia and G esellsch aft f { 252 }r echn ische
Z u sam menarbe it, E schbo rn , G erm any .
2 A dd ress rep rin t req uests to W J S chu ltink , S E A M E O /G T Z , P 0 B ox
3 852 , 10 038 Jakarta. Ind onesia .
R ece iv ed N o vem ber 20 . 1 992 .
A ccep ted fo r pub lica tion M arch 18 , 19 93 .
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34 0
A N G E L E S E T A L
so as to rem o v e h e lm in th ias is as a co n f o u n d er o f b o th g ro w th
an d h em ato lo g ical s tatu s . T h e 8 0 su b jects w ere assig n ed at ran -
d o m to a treatm en t g ro u p i i 4 0 ) an d a co n tro l g ro u p n 4 0 ) .
N o n e o f th e ch ild ren su f f e red f ro m o b v io u s, acu te in f ec tio u s
diseases.
T h e treatm en t g ro u p receiv ed su p erv ised d aily su p p lem en ts
f o r a p erio d o f 2 m o o f 3 0 m g e lem en tal iro n as 8 1 m g h y d rated
f erro u s su lf ate . co m b in ed w ith 2 0 m g v itam in C . b o th in p o w -
d ered f o rm . D u rin g th e sam e p erio d o f tim e, th e co n tro l g ro u p
rece iv ed d aily su p p lem en ts o f 2 0 m g v itam in C alo n e. w h ich
w as o f s im ilar ap p earan ce to th e su p p lem en t co n tain in g iro n
(su p p lem en ts p rep ared b y PT K im ia Farm a, Jak arta, In d o n es ia) .
D aily su p p lem en t in g estio n b y su b jec ts to o k p lace at cen tral
lo catio n s , b e tw een m eals f ro m 0 9 0 0 to 1 1 3 0 h , an d w as su p er-
v ised c lo se ly b y d istric t h ealth w o rk ers an d o n e o f th e re search ers
(IT A .). A llo catio n o f th e su p p lem en ts w as d o u b le b lin d b y u s in g
co d ed su p p lem en t p ack ag es .
A t th e s tart an d f in ish o f th e 2 -m o su p p lem en tatio n p erio d
w e ig h t. h e ig h t, an d f o o d in tak e w ere reco rd ed . Fu rth e rm o re ,
b lo o d sam p le s w ere co llec ted to d e te rm in e h em o g lo b in , m ean
co rp u scu lar v o lu m e (M C V ), an d seru m f erritin co n cen tratio n .
W h ite b lo o d ce ll co u n ts (W B C s) w ere carried o u t to d e term in e
th e p re sen ce o f o ccu lt in f ec tio n s. O v er th e en tire p erio d o f su p -
p lem en tatio n , th e in c id en ce an d d u ratio n o f f ev er (b o d y te rn -
perature
>
3 7 { 17 6 } C),e sp irato ry in f ec tio n s (1 5 ), an d d iarrh ea (f o u r
o r m o re lo o se , w ate ry s to o ls p er 2 4 h ) w ere ch eck ed an d reco rd ed
d aily b y th e research er (IT A .) o r th e d is tric t h ealth w o rk er.
T h e ch ild ren w ere w eig h ed w ith o u t c lo th in g b e tw een 0 9 0 0
an d 1 1 0 0 to th e n earest 0 . 1 k g b y u sin g an e lectro n ic , p latf o rm -
m o d el w e ig h in g scale (S E C A 7 7 0 alp h a: S E C A , H am b u rg ,
G erm an y ). H e ig h t w as m easu red to th e n eares t 0 . 1 cm b y u sin g
a m i cro to is e.
sco re s o f th e in d icato rs W FA , H FA , an d W FH
w ere calcu lated b y u s in g th e N atio n al C en te r f o r H ealth S tatis tics
(N C H S ) re f e ren ce d ata to co rrec t f o r e f f e c ts o f sex an d ag e o n
g ro w th (1 6 ).
Fo o d in tak e w as d e te rm in ed b y th e 2 4 -h recall m e th o d o v er
3 alte rn ate d ay s (o n e d ay b e tw een th e d ay s o f d ata co llec tio n )
b y u sin g g en eric f o o d m o d e ls d esig n ed to id en tif y p o rtio n s iz e .
E n erg y in tak es w ere calcu lated b y u s in g th e In d o n es ian f o o d -
co m p o sitio n tab le ( 1 7 ) . In tak e at th e s tart an d f in ish o f th e su p -
p lem en tatio n p erio d w as calcu lated as th e av erag e in tak e o f th e
3 d o f d ata co llec tio n .
B lo o d sam p le s (3 m L ) w ere co llec ted v ia v en ip u n c tu re b e tw een
0 8 3 0 an d 1 1 3 0 . H em o g lo b in co n cen tratio n , M C V , an d W B C s
w ere d e term in ed b y e lec tro n ic co u n te r (S y sm ex C C -l 8 0 : T O A
M ed ical E lec tro n ic s L td . K o b e . Jap an ). S e ru m f erritin w as d e -
te rm in ed b y rad io im m u n o assay p ro ced u re 1 8 ) b y u sin g a co rn -
m erc ial k it (R am co L ab o rato rie s, H o u sto n ). A ll h em ato lo g ical
an aly se s w ere carried o u t at th e D ep artm en t o f C lin ical Path o l-
o g y , M ed ical Facu lty , U n iv e rs ity o f In d o n es ia.
D ata an aly s is w as carried o u t b y u sin g th e M A N O V A re -
p eated -m easu res d es ig n o f SPSS/PC+ 4 .0 (S PS S In c. C h icag o )
(1 9 ) w ith treatm en t (iro n an d v itam in C v s v itam in C ) as a
b e tw een -su b jec ts f ac to r an d tim e (b e f o re v s af te r) as a w ith in -
su b ject f acto r. W hen th ere w as a sig n if ican t in te ractio n P < 0 .0 5 ) ,
th e d if f e ren ces b e tw een an d w ith in treatm en t g ro u p s w ere f u rth e r
in v es tig ated b y u s in g u n p aired an d p aired I te sts , re sp ectiv e ly .
W hen v alu es w ere n o t n o rm ally d is trib u ted , as f o r se ru m f erritin ,
d if f e ren ces w ith in g ro u p s w ere te sted b y u sin g W ilco x o n s
m atch ed -p airs s ig n ed -ran k te s t, an d d if f e ren ces b e tw een g ro u p s
w ere te sted b y u s in g th e M an n -W h itn ey te st (2 0 ), b ecau se a lo g -
arith m ic tran s f o rm atio n f ailed to g iv e a n o rm al d istrib u tio n . T o
te s t th e d if f eren ce in p rev alen ce o f h e lm in th ias is b e tw een g ro u p s
at th e tim e o f en ro llm en t, th e ch i-sq u are te st w as u sed .
T h e research p ro p o sal w as ap p ro v ed b y th e E th ical R ev iew
C o m m ittee o f th e U n iv ers ity o f In d o n esia, Jak arta. A t th e en d
o f th e 2 -m o su p p lem en tatio n p erio d th e ch ild ren in th e co n tro l
g ro u p receiv ed iro n su p p lem en ts o v er a 2 -m o p erio d to treat
th eir an em ia.
T h e f in al d ata set in clu d ed 3 9 (2 0 m ale an d 1 9 f em ale ) su b jec ts
in th e iro n -treatm en t g ro u p an d 3 7 (1 9 m ale an d 1 8 f em ale )
su b jec ts in th e co n tro l g ro u p . Fo u r o f th e se lected 8 0 su b jec ts
d ro p p ed o u t af te r an Islam ic h o lid ay o n w h ich th e ir p aren ts
to o k th em to v is it re lativ es o u tsid e Jak arta. M ean (S D ) ag e in
iro n -treated an d co n tro l g ro u p s w ere , re sp ectiv e ly , 3 7 .4 9 .5
an d 3 7 .2 1 0 .5 m o .
Resul ts
S to o l ex am in atio n b ef o re th e start o f th e su p p lem en tatio n
p erio d sh o w ed th at 5 6 .5 % o f th e ch ild ren in th e treatm en t g ro u p
an d 7 0 .3 % o f th e ch ild ren in th e co n tro l g ro u p w ere in f ec ted
w ith p aras ites (n o s ig n if ican t d if f e ren ce b y ch i-sq u are te st). A t
th e start o f th e stu d y . n o s ig n if ican t d if f e ren ces ex isted in h e -
m ato lo g ical v alu es (T ab le 1 n o r in w e ig h t an d h e ig h t (T ab le 2 )
b etw een th e treatm en t an d co n tro l g ro u p s . D u rin g th e su p p le -
m en tatio n p erio d W BC s o f all ch ild ren w ere w ith in th e n o rm al
lim its, in d icatin g ab sen ce o f se rio u s in f ec tio u s d isease s th at m ig h t
h av e in f lu en ced th e se ru m f erritin co n cen tratio n .
A f te r th e su p p lem en tatio n p erio d th e m ean v alu es o f th e
treatm en t g ro u p f o r h em og lo b in P 0 .0 0 1 ), M CV P 0 .0 2 ) ,
an d seru m f erritin P 0 .0 0 1 ) w ere h ig h er th an th e v alu es f o r
th e co n tro l g ro u p (T ab le 1 , w h ereas th e re w as n o sig n if ican t
d if f e ren ce f o r th e m ean v alu es o f w e ig h t, h e ig h t, an d th e
scores
o f W FA , H FA , an d W FH (T ab le 2 ). W ith resp ec t to th e ch an g e
in th e v ariab le s, th e b e f o re -af te r d if f e ren ces f o r th e treatm en t
g ro u p w ere sig n if ican tly g reate r th an th o se f o r th e co n tro l g ro u p
f or h em o gl ob in P
0 .0 0 1 , se ru m f em tin P
0 .0 2 ), M CV P
0 .0 2 ), h eig h t P 0 .0 0 1
,
an d H FA score P 0 .0 0 1
.
T he
ch an g e in W FH
sco re in th e co n tro l g ro u p w as h ig h er th an
th e ch an g e in th e treatm en t g ro u p P 0 .0 2 ) .
A f te r su p p lem en tatio n all h e rn ato lo g ical v alu es o f th e treat-
m en t g ro u p w ere ab o v e th e cu to f f p o in t co n cen tratio n s th at in -
d icate an em ia. W ith in -g ro u p in crease s in b o d y w e ig h t an d h e ig h t
T A B L E
1
H em ato lo g ical v alu es b e f o re an d af ter 2 m o su p p lem en tatio n *
B ef o re A f te r D if f e ren ce
Iron
+
v itam in C
3 9
H em o g lo b in (g IL ) 1 0 2
9
1 12 9 t 1 0 l 0 t
S eru m f erritin ( g /L )
6. 2
1 .7 1 5 .0
lO .2 t 8 .8
9.5j
M CV (f t.)
7 8 .2
7 .2 8 2 .5
5.4 4.0
4 .9
V itam in C n 37 )
H em o g lo b in (g IL ) 1 0 3
8 1 0 4
I 1
12
S eru m f erritin ( g /L ) 7 .1
2. 5
1 0 .0
1 0 .9 2 .9
1 0 .7
M C V (if .) 7 7 .6 7 .0 7 7 .9 9 .2 0 .3 8. 0
S D . M CV , m ean co rp u scu lar v o lu m e .
t S ig n if ican tly g reate r th an th e related v alu e o f th e v itam in C g ro u p :
tP 0 .0 0 1 , P < 0 .0 2 .
S ig n if ican t d if f eren ce b e tw een start an d f in ish o f su p p lem en tatio n
period,
P
0 .0 0 1 (w ith in -g ro u p ch an g e ).
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G R O W T H A N D IR O N S T A T U S O F C H IL D R E N
34 1
D ef in ed as f o u r o r m o re lo o se , w ate ry s to o ls p er 2 4 h .
T A B L E 2
W eig h t, h e ig h t, an d Z sco res o f an th ro p o m etric in d icato rs b e f o re an d
af ter 2 m o s up ple m en tatio n*
B ef o re A f te r D if f e ren ce
Iron + v i t a mi n C
=
39 )
W e i g h t( k g )
1 0 .6 1 .2 1 1 .1 1 .4 0 .5 0 .5 t
H e ig h t (cm ) 8 6 .2
6 .5 8 8 .9
5 .9 2 .7
l .S t t
W e ig h t-f o r-ag e -2 .5 3 0 .4 2
-2 .3 7
0 .4 9 0 .1 7 0 .3 3
H e ig h t-f o r-ag e -2 .3 3 0 .8 3 -1 .9 6 0 .7 3
0 .3 7 0.4ltt
W e ig h t - fo r -h e ig h t
1 .4 8 0 .5 5
1 .5 7 0 .5 0 -0 .0 6 0 .4 6
V itam in C n
=
37 )
W e ig h t (k g ) 1 0 .6 1. 3
1 1 . 2 1 5 0. 6 6 t
H eig h t (cm ) 8 6 .6 6 .9 8 8 .1 6 .9 1 .5 0 .8 1
W e ig h t - fo r -ag e
-2 .5 4 0 .3 4 -2 .3 3 0 .5 4
0 .2 1 0 .3 6
He ig h t - fo r -a g e
-2 .1 8 0 .9 6 -2 .1 0 0 .9 2 0 .0 7 0 .2 3
W eig h t-f o r-h e ig h t -1 .5 6 0 .6 0
-1 .3 6 0 .6 8 0 .2 1 0.5l I
. S D .
t S ig n if ican t d if f e ren ce b e tw een s tart an d f in ish o f su p p lem en tatio n
p erio d (w ith in -g ro u p ch an g e ) tP < 0 .0 1 P < 0 .0 5 .
:j: S ig n if ican tly h ig h er th an th e re lated v alu e o f th e v itam in C g ro u p ,
P =
0 .001 .
II S ig n if ican tly h ig h er th an th e re lated v alu e o f th e iro n + v itam in C
g ro u p ,
P
=
2
w ere sig n if ican t in b o th g ro u p s (T ab le 2 ). T h e h e ig h t in c rease
in th e treatm en t g ro u p w as 2 .7 1 .5 cm
P =
0 .0 0 1 ) w hereas
th e in c rease in th e co n tro l g ro u p w as 1 .5 1 .8 cm P
=
0 .0 0 1 ) .
In th e iro n -treated g ro u p th e
sco re s o f W FA an d H FA in -
c reased s ig n if ican tly w h ereas in th e v itam in C -o n ly g ro u p
sco re s o f W FA an d W FH in creased d u rin g th e su p p lem en tatio n
period.
E n erg y in tak e at th e s tart o f th e su p p lem en tatio n p erio d w as
4 5 0 1 1 0 4 5 k J/d f o r th e iro n -treated g ro u p an d 4 1 1 3 1 18 7
k J/d f o r th e co n tro l g ro u p . A t th e en d o f th e su p p lem en tatio n
p erio d th e in tak es f o r th e treatm en t an d co n tro l g ro u p s w ere
4 4 1 8 8 4 0 an d 4 3 6 8 9 9 1 k J/d , resp ec tiv e ly . T h ere w ere n o
sig n if ican t ch an g es in e ith e r o f th e tw o g ro u p s .
E p iso d es o f f ev e r, resp irato ry in f ectio n s , an d d iarrh ea in th e
co n tro l g ro u p o ccu rred 1 .7 , 2 .5 , an d 3 .0 tim es m o re f req u en tly ,
re sp ec tiv e ly , th an in th e iro n -su p p lem en ted g ro u p (T ab le 3 ).
A v erag e d u ratio n o f th e illn e sse s w as ab o u t th e sam e in b o th
g ro u p s : 1 .5 , 3 .5 , an d 1 . I d , re sp ec tiv e ly , f o r f ev e r, re sp irato ry
in f ec tio n s, an d d iarrh ea. N o d ata w ere av ailab le o n m o rb id ity
b e f o re th e start o f th e stu d y .
Discussion
B o th an em ia an d g ro w th re tard atio n are h ig h ly p rev alen t in
In d o n esia an d are co n sid e red p u b lic h ealth p ro b lem s. In th is
m ilieu o f m u ltip le co n d itio n s , th e aim o f th is s tu d y w as to in -
v e s tig ate th e e f f e c t o f iro n su p p lem en tatio n o n th e b lo o d v alu es
an d p h y sical g ro w th v ariab le s o f an ern ic , u n d erw e ig h t, p re sch o o l
children.
T h e iro n d o sag e, w h ich w as in lin e w ith W o rld H ealth O r-
g an iz atio n (W HO ) reco m m en d atio n s (2 ) , p ro v ed to b e e f f ec tiv e .
T h e su b stan tial in c rease s in h em ato lo g ical v alu es o v er th e 2 -m o
su p p lem en tatio n p erio d o f th e iro n -treated g ro u p w ere sig n if i-
can tly larg er th an th e sm all ch an g es th at o ccu rred in th e v itam in
C -o n ly g ro u p .
D u rin g th e su p p lem en tatio n p erio d th e w e ig h t an d h eig h t o f
b o th g ro u p s in c reased as w o u ld b e ex p ec ted f o r g ro w in g ch ild ren .
T h is in c rease m ay h av e b een p o s itiv ely in f lu en ced b y th e d e -
w o rm in g treatm en t (2 1 ), b u t th e ex ten t to w h ich th is m ay b e
tru e can n o t b e es tim ated in th is stu d y . T h e w e ig h t g ain w as
sim ilar in b o th g ro u p s an d w as re f le c ted in a h ig h er W FA
sco re . T h e m ark ed ch an g e in h e ig h t in th e treatm en t g ro u p w as
1 .8 tim es g reate r th an th e h e ig h t ch an g e in th e co n tro l g ro u p ,
lead in g to a sig n if ican t rise in H FA
sco re f o r th e treatm en t
g ro u p o n ly . T h e f ac t th at th e W FA
sco re ch an g ed in th e co n tro l
g ro u p w h ile H FA
sco re d id n o t ch an g e re su lted in an in crease
in W FH
sco re in th e co n tro l g ro u p . B ef o re th e start o f th e
su p p lem en tatio n p erio d m o re ch ild ren in th e co n tro l g ro u p th an
in th e treatm en t g ro u p w ere in f ec ted w ith p aras ite s . T h e ch ild ren
in b o th g ro u p s rece iv ed an tih elm in th ic treatm en t, b u t n o rech eck
f o r p arasite in f ec tio n w as m ad e at th e en d o f th e su p p lem en tatio n
p erio d . If th e w o rm treatm en t g iv en b e f o re su p p lem en tatio n
h ad b een in e f f ec tiv e , th e re w o u ld h av e b een esp ec ially n eg ativ e
in f lu en ces o n g ro w th in th e co n tro l g ro u p . H o w ev er, su ch in f lu -
en ces are u n lik ely to h av e h ap p en ed co n s id e rin g th e su f f ic ien t
co m p arab le in c rease s in w e ig h t in b o th g ro u p s.
T h e en h an c in g e f f ec ts o f iro n su p p lem en tatio n o n g ro w th o f
an em ic ch ild ren h av e b een rep o rted e lsew h ere (3 . 1 3 ). T h e ch il-
d ren in th o se s tu d ie s h ad in itial H FA sco re s o f -0 . 1 4 (3 ) an d
I .6 6 1 3 ), w h ich d o es n o t c lass if y th em as b e in g s tu n ted , an d
th ey w ere n o t u n d erw e ig h t as o p p o sed to th e ch ild ren in th e
p resen t s tu d y . T w o stu d ie s am o n g T h ai ch ild ren d id n o t sh o w
an e f f ec t o f iro n su p p lem en tatio n o n g ro w th , b u t th is m ay b e
d u e to th e lo w am o u n t o f su p p lem en ted iro n o r to d if f e ren ces
in m e th o d o lo g y (2 2 , 2 3 ). N o rm ally , a ch ild 3 7 m o o f ag e w ith
a h e ig h t s im ilar to th e m ed ian o f th e N C H S re f e ren ce (1 6 ) w o u ld
n eed to g ro w 1 .4 cm in 2 m o to rem ain eq u al to th e m ed ian .
A n av erag e in crease in h e ig h t o f th e treatm en t g ro u p in th e p re s-
en t s tu d y w as 2 .6 cm . o r 1 8 6 % o f th e m ed ian g ro w th rate , in -
d icatin g a m ark ed acce le ratio n . In a stu d y in w h ich d aily f o o d
su p p lem en ts w ere p ro v id ed to stu n ted In d o n esian p resch o o l
ch ild ren f o r a p erio d o f 9 0 d (2 4 ), H FA
sco re s ch an g ed f ro m
-2 .3 4 to -2 .2 4 . w h ich re f le c ts a sm aller in c rease th an th e o n e
f o u n d in th is s tu d y . E f f ects o f f o o d su p p lem en tatio n o n p h y sical
g ro w th are rep o rted to b e m o s t ef f e ctiv e w h en ch ild ren are ag ed
< 1 y (2 5 , 2 6 ). In th e p re sen t stu d y , in w h ich n o f o o d su p p lem en ts
b u t o n ly iro n w ere d is trib u ted an d all ch ild ren w ere ag ed > 2 y ,
it is in te re stin g to n o te th at th e treatm en t g ro u p sh o w ed a m ark ed
im p ro v em en t in lin ear g ro w th .
In th e p re sen t stu d y , en erg y in tak e w as su f f ic ien t f o r th e ch il-
d ren s ac tu al w e ig h t acco rd in g to W H O d aily in tak e reco m -
m en d atio n s o f 3 9 7 k J/k g (9 5 k cal/k g ) (9 ) . T reatin g an em ia is
rep o rted to in crease ap p e tite in ad u lts (2 7 ). H o w ev er, th e treat-
T A B L E 3
E p iso d es o f f ev e r. re sp irato ry in f ectio n s, an d d iarrh ea d u rin g th e
su p p lem en tatio n p erio d in th e tw o g ro u p s
T yp e o f m orb id ity
Iron + v itam in C
n
=
39 )
V itam in C
n
=
37 )
%
Fev er 7 .7
1 3 .5
R esp irato ry in fe ctio ns
1 0 .3 2 7 .0
D iarrh ea* 5 .1 1 6 .2
-
7/26/2019 Decrease Rate of Stunting Among Anemic Indonesian Preschool Children Through Iron Supplementation
4/4
34 2
A N G E L E S E T A L
m en t g ro u p d id n o t h av e in creased en erg y in tak e af te r th e su p -
p lem en tatio n p erio d . T h is su g g ests th at th e in c reased lin ear
g ro w th rate in th e treatm en t g ro u p w as n o t cau sed b y h ig h er
f o o d in tak e . D u rin g th e su p p lem en tatio n p erio d th e in cid en ce
o f in f ec tio u s d isease s in th e treatm en t g ro u p w as le s s th an in th e
co n tro l g ro u p . T h is m ay h av e in f lu en ced th e in c reased g ro w th
rate in th e treatm en t g ro u p . Fu rth e rm o re th e d irec t ac tio n o f
iro n o n o x id ativ e p ro cesse s m ay h av e s tim u lated g ro w th rate .
T h e re su lts o f th is stu d y in d icate th at iro n su p p lem en tatio n
m ay p lay an im p o rtan t ro le in o v erco m in g b o th g ro w th re tar-
d atio n an d an em ia in p re sch o o l ch ild ren . It is reco m m en d ed ,
th e re f o re . th at co n s id e ratio n b e g iv en to p ro v id in g iro n su p p le-
m en tatio n n o t o n ly to ex is tin g targ et g ro u p s su ch as p reg n an t
w o m en , b u t also to p re sch o o l ch ild ren . T h ere f o re , f u rth er stu d y
o n e f f ec tiv e su p p lem en tatio n sy stem s f o r p re sch o o l ch ild ren
w o u ld n eed to b e co n d u c ted . It is im p o rtan t to n o te th at th e
co s t o f iro n treatm en t is re lativ e ly lo w . In th e p resen t stu d y , f o r
ex am p le , treatm en t f o r o n e ch ild f o r 1 m o co s t $ 0 .1 8 .
T rad itio n ally , it is b e lie v ed th at lo w W FA o r H FA is cau sed
b y a lack o f p ro te in an d /o r en erg y . T h is assu m p tio n is to o lim ited
an d sh o u ld b e rev iew ed , tak in g in to acco u n t th e e f f ec ts o f m i-
c ro n u trien ts . N o t o n ly sh o u ld iro n b e co n s id e red , b u t also z in c .
w h ich is rep o rted to en h an ce g ro w th (2 8 , 2 9 ) an d th e in te rac tio n
b e tw een m icro n u trien ts su ch as th e o n e b etw een iro n an d v i-
tam in A (3 0 ). Fu rth e rm o re , a W H O w o rk in g g ro u p co n c lu d ed
th at stu n tin g w as n o t an ap p ro p riate in d icato r o f m aln u tritio n
b ecau se in f ec tio u s d isease s m ay also co n trib u te to g ro w th re tar-
d atio n o f ch ild ren (3 1
.
H o w ev er, th is s tu d y d id co n f irm th at
lack o f m ic ro n u trien ts m ay cau se in creased m o rb id ity , w h ich
lead s to g ro w th d ep ressio n in ch ild ren , an d m ay th ere f o re lead
in d irec tly to s tu n tin g . It is n ecessary to reco n s id e r th e ex is tin g
b e lie f s ab o u t ch ro n ic m aln u tritio n , th e u se o f s tu n tin g as an
ap p ro p riate in d icato r, an d th e se lec tio n o f su itab le treatm en t.
In c reased k n o w led g e ab o u t th e ro le o f m icro n u trien ts is v ital in
th is asp ec t. {163}3
W e th an k Po p p y H en d raw an , d irec to r o f T eb e t C o m m u n ity H ealth
C en te r, f o r h er ex ce llen t co o p eratio n . T he v alu ab le reco m m en d atio n s
o f N oe l S o lo m on s an d G u s taaf S ev en h u y sen are h ig h ly ap p rec iated .
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