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Iron supplementation does not increase malaria risk during pregnancy
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Recent data suggest daily iron supplementation during pregnancy does not increase the risk for maternal malaria infection and results in positive birth outcomes.
“A trial among children reinforced earlier concerns that iron supplementation can increase rates of infectious diseases, including malaria,” researcher Martin N. Mwangi, PhD, of Wageningen University, Netherlands, and colleagues wrote. “Antenatal supplementation nonetheless continues to be recommended, despite reports that iron deficiency is associated with protection against Plasmodium infection in placental blood.
“In highly endemic areas, [Plasmodium] falciparum infections in pregnancy are usually asymptomatic, but they increase the risk of adverse birth outcomes and adverse maternal outcomes.”
Researchers enrolled 470 pregnant Kenyan women aged 15 to 45 years into the double blind, randomized trial. Participants were administered either 60 mg elemental iron as ferrous fumarate (n = 237) or placebo (n = 233) until 1 month postpartum, and all women received intermittent malaria prevention treatment and 5.7 mg iron daily through flour fortification.
Primary outcome was maternal Plasmodium infection at birth, and secondary outcomes were birth weight, gestational age, intrauterine growth and iron status for mothers and infants at 1 month after birth. Dipstick tests, PCR and histological examination of placental biopsies were used to detect infection. Iron status was measured through plasma iron markers, and all birth information or samples were collected following birth, or at first presentation to the research clinic for home deliveries.
Among participants who were not lost at follow-up, excluded or were missing data, Plasmodium infection risk for the intervention and controls groups was 50.9% and 52.1%, respectively, resulting in a crude difference (CD) of –1.2% (95% CI, –11.8% to 9.5%). Serious adverse events were reported for nine women receiving iron and 12 assigned placebo.
At baseline, 59.7% of women were iron-deficient, while mean concentrations of plasma ferritin were greater both maternally (CD = 123.4%; 95% CI, 85.5%-169.1%) and neonatally (CD = 17.5%; 95% CI, 2.4%-34.8%). Positive outcomes also were seen among the intervention group for infant birth weight (CD = 150 g; 95% CI, 56-244), but there was no difference in birth weight for gestational age.
“In low-and middle-income countries, it is generally impractical to screen for iron status, and most countries have policies for universal iron supplementation for pregnant women,” the researchers wrote. “Based on our results, we believe that the benefits of universal supplementation outweigh possible risks.”
In a related editorial, Parul Christian, DrPH, MSc, and Robert E. Black, MD, MPH, both of Johns Hopkins Bloomberg School of Public Health, wrote that the promising data on iron supplementation and malaria interactions is welcome, but the small sample size and other confounding factors do not make the findings absolute.
“It is also possible that the lack of adverse effects may be related to use of [intermittent preventive treatment] that may have reduced the prevalence and intensity of malaria infection among women in the study,” they wrote. “Every effort should be made to increase the use of the malaria interventions, and until that happens, the safety of antenatal iron is not assured.” –by Dave Muoio
Disclosures: Mwangi, Christian and Black report no relevant financial disclosures. Please see the full study for a list of all other authors’ relevant financial disclosures.
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