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| |  Iron Supplementation Does Not Increase the Risk of Malaria in Children: Presented at ECCMID By Chris Berrie HELSINKI, Finland -- May 20, 2009 -- Iron supplementation should not be restricted in settings where iron deficiency and anaemia affect most children, as it does not increase the risk of malaria, other infections, or all-cause mortality for children living in malaria-endemic areas, researchers stated here at the 19th European Congress of Clinical Microbiology and Infectious Diseases (ECCMID). Coinvestigator Mical Paul, MD, Unit of Infectious Diseases, Rabin Medical Centre, Beilinson Hospital, Petah Tikva, Israel, presented this systematic review and meta-analysis of randomised, controlled clinical trials conducted in hypoendemic to holoendemic malaria regions. The results of the review were presented here on May 17, on behalf of the Cochrane Infectious Diseases Group. Associations have been shown between anaemia, iron deficiency, and impaired development in children, although it is imperative to know whether iron supplementation can cause harm, Dr. Paul stated. Indeed, as the erythrocytic form of the malaria parasite requires free iron, she pointed out, children living in malaria-endemic regions might be protected when suffering from iron-deficiency anaemia. Dr. Paul said, "There has been a very large trial that reported that iron increases malaria, severe malaria, and death in children."(1) This trial resulted in heightened global concern, she added, and the present World Health Organization guidelines recommend screening for iron deficiency prior to iron supplementation in malaria areas, despite the logistic impracticalities of this. Dr. Paul and colleagues oversaw a comprehensive search with no restrictions on publication status carried out by 2 independent reviewers. Initially, 68 studies were identified, with a total of 42,981 children who fulfilled the inclusion criteria. These children provided the pool of studies for extraction of the various aspects of the full analysis. From 14 trials providing relevant data, there was no increased risk of clinical malaria with iron (+- folate) supplementation: relative risk (RR) 1.00 (95% confidence interval [CI], 0.88-1.13). Similarly, 4 trials demonstrated no increased risk with iron (+- folate) supplementation for children who were anaemic at baseline: RR 0.96 (95% CI, 0.85-1.09). None of the subgroup analyses affected these relative risks, although a post hoc analysis showed that, while no effects of iron (+- folate) versus placebo were seen when there was regular surveillance for malaria at baseline and during the trials, and where treatment for malaria was provided (RR 0.93; 95% CI, 0.84-1.04), when these facilities were not available, there was a small, but significant, increase in malaria associated with iron (+- folate) supplementation (RR 1.16; 95% CI, 1.03-1.31). Similarly, the rate of parasitaemia was significantly higher with iron (+- folate) supplementation (RR 1.13; 95% CI, 1.01-1.26). From 25 relevant trials, there were no differences seen between iron (+- folate) and placebo for all-cause mortality: RR 1.11 (95% CI, 0.90-1.36). Dr. Paul noted that, where the stopped Sazawal and colleagues trial was concerned, "they had no facilities to diagnose and treat malaria within the trial methods ... and that trial is an outlier compared to all the other trials. ... The other trials treated the children if they had malaria. This trial did not." "The conclusion may be that if you supplement with iron, you need some basic ... community support to treat malaria," Dr. Paul added, thus giving children the iron that they need for growth, while treating them well for malaria. 1. Sazawal S et al. Lancet. 2006;367:133-143. Erratum in: Lancet. 2006;367:302.
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