Micronutrient Powders to Control Anemia in Children: Ghana’s Cautionary Tale

More than two thirds of Ghanaian children under five years of age have some form of anemia, ranging from mild to severe. Among children aged 9 to 11 months and 12 to 17 months, the rates are in excess of 80%.[1] These unacceptably high levels have remained virtually unchanged for the past two decades; this calls for decisive action to improve the situation.

Ghana’s anemia control strategy excluded supplementation of preschool-age children due to warnings from the World Health Organization (WHO) to avoid universal iron supplementation of children in malaria-endemic populations without first screening for anemia. The caution stemmed from the supplementation trial in Pemba, Zanzibar, in which there was increased malaria-related morbidity and mortality among the children receiving iron, particularly among those who were iron replete.[2] The WHO recommendation further derailed ongoing discussions to adopt such multiple micronutrient powders (MNPs) as Sprinkles® for home fortification as a component of Ghana’s strategy.

Although the 2006 joint WHO/UNICEF statement[3] acknowledged that conclusions based on the Zanzibar study “should not be extrapolated to fortification or food-based strategies for delivering iron, where the patterns of iron absorption and metabolism may be substantially different”—Ghana remained wary and MNPs were not immediately adopted.

Results of ongoing research on fortification of complementary foods with MNPs in Kintampo District, an area in central Ghana with high malaria rates, were keenly anticipated to provide in-country evidence that MNPs were safe for young children.

Conclusions presented at a 2012 Ghana Nutrition Association-sponsored seminar from the Kintampo study indicated that there were no significant safety concerns with respect to adverse effects with home fortification of children’s foods with MNPs, as malaria incidence and malaria-related hospitalizations did not differ between children receiving MNPs with iron and those not receiving iron. These conclusions added to the general sentiment among many in the nutrition community in the country that Ghana was being over-cautious in delaying adoption of MNPs for the control of anemia. However, leaders at the national level argued that that MNPs should not be viewed as a panacea for the country’s micronutrient malnutrition problems; instead, they stressed that on-going efforts through food-based strategies, emphasizing appropriate child feeding by caregivers, diet diversity, and improving iron bioavailability from plant-based diets, were equally or even more crucial and sustainable.

At a recent stakeholders’ meeting, the Nutrition Department of the Ghana Health Service indicated that a multi-stakeholder taskforce had been formed to review all WHO guidelines relative to MNPs, with agreement to adopt MNPs as an additional opportunity in the mix of anemia control efforts. The operational issues are being considered, including mechanisms for scale-up. Although it would appear that Ghana is a rather late starter when it comes to MNPs, it can now benefit from the lessons learned by countries that have already included them in their nutrition programs. Ghana’s experience with MNPs shows that adoption and scale-up of promising nutrition interventions is often not a straight path, but rather one that frequently involves judgments about competing risks and even differing opinions among stakeholders.

[1] 2008 Ghana DHS

[2] Sazawal et al., Lancet 2006, 367: 133-43

[3]http://www.who.int/malaria/publications/atoz/who_statement_iron/en/index.html