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is it cost effective?
- vijayashankara.c. nanjegowda (29 November 2006)
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Re: is it cost effective?
- Professor Pranab Kumar Bhattacharya, Bhattacharya Rupak, Bhattacharya Ritwik (21 December 2006)
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Iron supplementation is associated with an increased risk of complications of malaria in children without iron deficiency
- Michael Eisenhut (7 January 2007)
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Fortified milk may actually increase morbidity
- Anne L. Murphy (21 January 2007)
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vijayashankara.c. nanjegowda, senior specialist, pediatrics new sohar hospital, sohar, oman
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Sir, Sunil Sazawal et al have conducted a well designed study to look at the effect of micronutrients on morbidity pattern in preschool children. Many studies have looked at the effects of vitamin A , iron , and zinc supplementation in children and have shown beneficial effects in children. Now the authors have added vitamin E, selenium and copper. The usefulness of these additions have not been looked into and also the cost of supplementation has not been calculated. In developing countries the cost involved is important as most of the children who need the supplementation come from a poor socioecnomic background. And also one needs to look into how these micronutrient are given. 3 milk feedings a day definitely adds to the cost, because these preschool children are on or should be on the family diet. So overall cost burden on the individual family will be high. The local governments providing this free, particularly in developing countries, is too much to be expected. Competing interests: None declared |
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Professor Pranab Kumar Bhattacharya, Professor, department of Pathology Institute of Post Graduate Medical Education Research & Training, 244A, AJC Bose Road, Kolkata-70000, Bhattacharya Rupak, Bhattacharya Ritwik
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To the Editor, We have gone through the article "Effects of fortified milk on morbidity in young children in north India: community based, randomised, double masked placebo controlled trial" BMJ 2006; 0: bmj.39035.482396.55v1 [Abstract] By authors Sunil Sazawal, Usha Dhingra, Girish Hiremath, Jitendra Kumar, Pratibha Dhingra, Archana Sarkar, Venugopal P Menon, and Robert E Black We would like to inform you that in the set up of West Bengal state of India, the under five mortality of child is arround 30% [21% for rural and 13% for urban & city area] and majority of these death are due to under nutrition, ARI and diarrohea. According to the World Bank report, the population of India mostly live in poverty or bellow poverty line. According to the World Bank, there are two international absolute poverty lines-- i.e Us$1.08 and Us$ 2.15 per day per capita income. And the World Bank estimated that Indonessia, Bangladesh, Nepal had the poverty line population 40% for Nepal, India Next 30% and then Bangladesh (20%) then Philipines and China 15% each when percapita perday income is considered Us$ 1.08, and when perday percapita income considered as Us$ 2.15 then 2/3 of population in India live in poverty. In Indian Rupees Us$=46 Rupees. West Bengal is a state in India, with a population of about 8.2 cores (2001 census), having 28% urban and 72% rural, with population in working group 28% (both urban and rural) and 64% non- working (Children+disabled+Unemployed,66% in urban and 62% in rural set up) and 2% marginal working group and percentage of population below poverty line [i.e income < Us$1.08 per day per capita] is around 33% in 2000, at rural set up and 16% at urban Set Up] As a result of very poor pocket purchase capacity the majority of the population in the state of West Bengal cannot have two full meals in most of days of a month. The question of providing milk three times feeding to their children in state of West Bengal is question of luxury/immpossibility for majority population of low socioeconomic and of low middle socioeconomic population, whose children suffer mostly from diarrhoea and ARI and major burden of under 5 death figure in state of West Bengal, India. The problem of under five death, ARI, Diarrhoea or ARI is not of rich, upper socioeconomic and upper middle socioeconomic class. Their children mostly suffer from obesity due to high calory diet consumption in West Bengal. We think the situation is more or less same in most other states of India like Orrisa, Bihar MP etc as the authors experience and also in developing countries. A one litre packet of Milk [government dairy] in state of West Bengal is around Rs 10/= which contains Vit A. The conclusion of the study that consumption of milk fortified with Vitamin E, Fe, Zn specific micronutrients can significantly reduce the burden of common morbidities among preschool children, especially in the first two years of life is no-doubt correct. But it will definitely increase the cost of milk and the milk which ever the people of poverty line or below poverty line, can purchase for their pre-school children from out of their pocket, due to increase of cost for addition of micronutrients they will not be able to provide the present ammount of milk which they can provide now for their children. Competing interests: None declared |
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Michael Eisenhut, Consultant Paediatrician Luton&Dunstable Hospital NHS Foundation Trust, Luton, LU4ODZ, United Kingdom
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Dear Editor, Sazawal et al. found that fortification of milk, which included 9.6mg of additional iron per day was associated with a reduced incidence of diarrhoea and acute respiratory illnesses in a peri-urban setting in north India [1]. The authors concluded that fortification can significantly reduce the burden of common morbidities among preschool children. This statement cannot be generalized to all infectious diseases and may not apply to children without iron deficiency anaemia: The biggest study on iron supplementation in children so far included 24076 children in Tanzania [2]. This randomised, placebo controlled trial had to be stopped early because children who received iron supplements (12.5mg iron/day) were 12% (95% CI 2-23, p=0.02) more likely to die or to need treatment in hospital. This was partly due to a significantly increased risk of malaria related complications. Only the subgroup of children with anaemia benefited with regards to hospital admission or death. A review by Oppenheimer [3] including controlled trials of iron supplementation in all age groups concluded that iron supplementation increased episodes of clinical malaria in six of seven trials. Iron can exacerbate Plasmodium (P.) falciparum infection due to the fact that it inhibits the expression of inducible nitric oxide synthase, which subsequently down-regulates the formation of nitric oxide in macrophages. Nitric oxide is a critical element in macrophage mediated antiplasmodial antibody mediated cellular inhibition, which is the key element of immunity against blood stages of P. falciparum [4]. On the basis of these data a general recommendation of iron supplementation or fortification of milk for all children in a population with a high prevalence of infectious diseases like malaria is not justifiable. If children without iron deficiency are given iron supplements they may not only suffer from more severe complications of malaria but also have reduced growth [5]. References: 1. Sazawal S, Dhingra U, Hiremath G, Kumar J, Dhingra P, Sarkar A, Menon VP, Black RE. Effects of fortified milk on morbidity in young children in north India: community based, randomised, double masked placebo controlled trial. BMJ 2006 Nov 28; [Epub ahead of print]. 2. Sazawal S, Black RE, Ramsan M, Chawaya HM, Stoltzfus RJ, Dutta A, Dhingra U, Kabole I, Deb S, Othman MK, Kabole FM. Effects of routine prophylactic supplementation with iron and folic acid on admission to hospital and mortality in preschool children in a high malaria transmission setting: community-based, randomised, placebo-controlled trial. Lancet 2006;367:133-143. 3. Oppenheimer SJ. Iron and its relation to immunity and infectious disease. J Nutr 2001;131:616-635. 4. Fritsche G, Larcher C, Schennach H, Weiss G. Regulatory interactions between iron and nitric oxide metabolism for immune defense against Plasmodium falciparum infection. J Infect Dis 2001;183:1388-1394. 5. Idjradinata P, Watkins WE, Pollitt E. Adverse effect of iron supplementation on weight gain of iron-replete young children. Lancet 1994;343:1252-54. Competing interests: None declared |
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Anne L. Murphy, General Practitioner HA9 9ER
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Dear Sir The study by S. Sazawal et al fails to address the potential impact of their intervention on breastfeeding, and this confounder invalidates their conclusion that micronutrient enriched milk reduces the burden of morbidity amongst pre-school children. Toddlers (children age 1-3 years) were given 3 extra feeds daily, of fortified or unfortified cows milk. The additional milk is described as a ‘complementary feed’ but powdered milk is likely to decrease breastmilk intake. The comparison is between two groups of children receiving different types of breastmilk substitute, and so a control group is lacking. The population is strictly vegetarian (no meat, no eggs nor fish). The usual weaning diet is likely to contain less iron and zinc, and in a less bioavailable form, than that of most other global populations. Full data on the composition of milks is unavailable since the volume of feeds is not stated. It is unclear whether ‘nutritive value’ relates to total content or to bioavailable nutrients. The data do show that the unfortified milk provided no iron at all, and only a very small quantity of zinc. It is not possible to compare the substitute milks with commercially available formulae, other commercial complementary foods, family foods or with breastmilk. The WHO recommends exclusive breastfeeding for 6 months, with continued frequent breastfeeding on demand up to at least two years of age or beyond. All breastmilk substitutes cause harms, e.g. higher risk of serious infection, a shorter birth interval and deprivation of an important source of nutrition. These are associated with increased mortality as well as morbidity. I propose an alternative conclusion: Where frequent breastfeeding on demand is not possible, and meat, eggs and fish are unacceptable, toddlers given unfortified cows milk have a higher rate of illness, and a poorer micronutrient status than toddlers given fortified milk. Competing interests: Mother of two young children |
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