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With safeguards, iron may not raise kids' malaria risk

By Genevra Pittman

NEW YORK (Reuters Health) - Despite concerns that iron supplements may increase children's risk of malaria in regions where it is common, a new study found kids in Ghana who received nutrient powder with iron were no more likely to get the disease than their peers.

According the World Health Organization (WHO), there were approximately 660,000 deaths from malaria in 2010. About 90 percent of those occurred in Africa, most in children under five years old.

Some studies have suggested giving children iron might increase their risk of malaria - including one trial that was halted early due to more hospitalizations for malaria and other infections among children receiving iron.

The theory is that malaria-causing parasites can take up extra iron in the body before it binds to proteins, hastening parasites' growth and giving malaria a "head start," Dr. Stanley Zlotkin, from the Hospital for Sick Children in Toronto, said.

"Many governments were left in the situation where if there was malaria in the country, they really didn't know what to do with children with iron-deficiency anemia," Zlotkin, who worked on the study with colleagues from Canada and Ghana, told Reuters Health.

Iron deficiency is common in poor regions and can cause delays in motor skill development and thinking and memory problems as children get older. It is closely linked with anemia - when the body doesn't have enough red blood cells.

In the past, the WHO has said that with iron supplementation, "caution should be exercised in settings where the prevalence of malaria and other infectious diseases is high" and supplementation should be targeted to kids who are anemic and at risk of iron deficiency.

Recently, following a separate analysis of multiple trials, the organization recommended iron programs be implemented alongside malaria prevention, diagnosis and treatment strategies where malaria is common - in which case supplementation may not increase risks.

The new study included close to 2,000 children under three years old in rural Ghana. The families of all children were given a nutrient powder to sprinkle on their child's food every day for five months; half received powder fortified with 12.5 milligrams of iron and the others received iron-free powder.

All children were also given insecticide-treated bed nets to help prevent malaria and treated if they developed the disease.

During the study period, there were 338 cases of malaria among the 966 children given extra iron and 392 cases among 989 kids who received the iron-free nutrient powder.

After taking into account children's iron levels at the start of the study, there was no difference in malaria rates between the two groups, the researchers report in the Journal of the American Medical Association.

However, more children receiving iron were admitted to the hospital: 156, compared to 128 not getting extra iron.

"This can't be ignored, because it actually adds to the concerns," said Andrew Prentice, from the London School of Hygiene and Tropical Medicine, who co-authored an editorial published with the study.

Zlotkin said the reason behind the extra hospitalizations wasn't clear, but that "we will have to continue to observe children who are getting the micronutrient powder."

He said providing iron in powder form rather than as drops or tablets may mean there's less time between when the mineral is absorbed and when it binds to proteins, giving parasites less of a chance to snatch it for their own use.

But Prentice proposed another explanation - that children in the study weren't getting enough iron to cure their anemia, and malaria parasites feed most aggressively on iron in new red blood cells that form when anemia is successfully treated.

"If you want to move from a position of being anemic to being non-anemic, you're almost certainly going to go through a period of being susceptible to malaria," he told Reuters Health.

Prentice thinks a possible solution is to give iron along with anti-malarial drugs or to develop blood or urine tests showing when it is safe to give children iron.

Still, Zlotkin said his group's findings support the most recent WHO recommendations.

"Where people are paying attention to the prevention and treatment of malaria, it is safe to use micronutrient powders with iron," he said.

SOURCE: http://bit.ly/14q8ksM Journal of the American Medical Association, online September 3, 2013.

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