JOURNAL OF TROPICAL PEDIATRICS, VOL. 60, NO. 1, 2014
Assessment of Drinking Water Fortification with Iron Plus
Ascorbic Acid or Ascorbic Acid Alone in Daycare Centers as
a Strategy to Control Iron-Deficiency Anemia and Iron
Deficiency: A Randomized Blind Clinical Study
by Carlos A. N. de Almeida,1 Elza D. De Mello,2 Adriana P. R. Ramos,3 Camila A. João,4 Carolina R. João,5 and
José E. Dutra-de-Oliveira6
1
University of Ribeirão Preto, Eugeˆnio Ferrante, 170, Ribeirão Preto - SP - Brazil, CEP 14027-150
2
Federal University of Rio Grande do Sul (UFRGS) and Head of the Nutrology Service at Hospital de Clinicas de Porto
Alegre, Brazil
3
Director of the Clinical Analysis Laboratory of Ribeirão Preto University, Brazil
4
Nutritionist of CESNI, University of Ribeirão Preto, Brazil
5
Nutritionist of CESNI, University of Ribeirão Preto, Brazil
6
Medical Department of the School of Medicine of Ribeirão Preto of the University of São Paulo (USP), Brazil
Correspondence: Carlos de Almeida. R. University of Ribeirão Preto, Eugeˆnio Ferrante, 170, Ribeirão Preto - SP - Brazil, CEP
14027-150, E-mail <[email protected]>.
Summary
Objective: Assess drinking water fortification with iron and/or ascorbic acid as a strategy to control
iron-deficiency anemia and iron deficiency.
Methods: Randomized blind clinical study, fortifying drinking water to 153 pre-school children during
3 months, with iron and ascorbic acid (A), ascorbic acid (B) or plain water (C). Hemoglobin (Hb), mean
corpuscular volume (MCV) and ferritin were measured.
Results: Within the groups, Hb raised in all three groups, MCV in A and B and ferritin in A. The
difference between time points 0 and 1 was significant between A and B for Hb, when A and B were
compared with C for MCV and when A was compared with either B or C for ferritin.
Conclusions: Water fortification is efficient in controlling iron deficiency and anemia. Iron stores’
recovery depends on a more effective offer of iron. Water fortification must be preceded by a careful
assessment of the previous nutritional status.
Key words: anemia, iron deficiency, nutrition assessment, health education.
Introduction
Iron-deficiency anemia (IDA) and iron deficiency
(ID) may be considered the most prevalent nutritional
problems in the world [1]. Recent data from the World
Health Organization show that there are around 1.6
billion people with these disorders, and the prevalence
in pre-school children is of 41.8% [2]. In Brazil, due to
the absence of national studies, the scenario has been
presented by regional studies, which together demonstrate the magnitude of the problem. A systematic
review published in 2009 evaluated data from 53 publications and concluded that the national prevalence
Funding
This work was supported by the International
Atomic Energy Agency (IAEA) [grant RLA 6053].
among pre-school children was of 53% [3]. A metaanalysis published in 2010, also reviewing regional
studies from the whole country, demonstrated prevalences ranging from 35 to 68.8% among pre-school
children [4]. The possible severe consequences of
IDA for child development [5–8] justify the constant
search for strategies to control it. Our research group
has conducted in the southeastern part of Brazil, projects to investigate prevalence along the same lines, as
well as developed control strategies by means of fortification programs. In Pontal, in the State of São
Paulo, a project with iron-fortified orange juice was
conducted, attaining significant reduction in the
prevalence of anemia, from 60 to 20% after 4
months of intervention [9]. In Monte Alto, also in
São Paulo, a project of water fortification in daycare centers was implemented during 6 months, with
iron salts and ascorbic acid, also obtaining a decrease
ß The Author [2013]. Published by Oxford University Press. All rights reserved. For Permissions, please email: [email protected]
doi:10.1093/tropej/fmt071
Advance Access published on 20 August 2013
40
C. A. N. DE ALMEIDA ET AL.
from 45.9 to 31.1% in the prevalence of anemia [10].
In Belo Horizonte, State of Minas Gerais, also by
means of iron and ascorbic acid-fortified water in
day-care centers, a change in the prevalence of
anemia was attained with a drop from 29.3 to 7.9%
after 5 months of intervention [11].
In all the aforementioned studies, the method used
was ‘before and after’, and the absence of a control
group might compromise the importance of the results. Recently, with the support of the International
Atomic Energy Agency, the project ‘Jardinopolis
without anemia’ was implemented in the city of
Jardinopolis (São Paulo). The results of the initial
assessment phase have already been published [12].
The second phase aimed at assessing the efficacy of
drinking water fortification with iron and ascorbic
acid, this time placebo-controlled.
Method
A detailed description of the population has been
published [12]. The study was developed in the five
day-care centers of Jardinopolis, a town with around
35 000 inhabitants in the southeastern part of Brazil.
It basically encompassed a program of drinking
water fortification in those institutions. No sample
size calculation was made because all the day-care
centers of the city were included, configuring a population-based study. Additionally, a community
awareness program was conducted concerning the
causes, consequences and ways of prevention and
treatment of ID and anemia. The children and their
parents were included, as well as the institutions’ staff
and stakeholders of the municipality. Meetings,
group dynamics and lectures were organized. The
objective of this program was raising awareness on
the importance of the study, as well as contributing,
in an ethical way, to improve the nutritional quality
of the diet of the children who attended those institutions in the town.
To be included in the study, the child had to attend
one of the day-care centers regularly and be between
12 and 59 months of age. Two hundred one children
were initially accrued. Those with chronic diseases
such as severe asthma (n ¼ 1), neoplasm (n ¼ 1) and
celiac disease (n ¼ 1); those whose parents refused to
sign the informed consent (n ¼ 6) and those in whom
laboratory examinations could not be performed or
harvested (n ¼ 8) were excluded from the study. Of
the 184 children included after the initial assessment,
31 were excluded during the intervention period because they were removed from the institution (n ¼ 23)
or received some type of oral supplementation with
iron or vitamins (n ¼ 8).
The inclusion and exclusion criteria having been
met, 153 children participated in the study.
Identical drinking water fountains were purchased
for each day-care center, having a base with a tap
and a 20-l container, which were sanitized and filled
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Vol. 60, No. 1
with filtered water every morning. At every container, a pre-mix prepared in the municipal pharmacy
was added. The bottles of pre-mix were identical for
all the day-care centers, and the content was only
known by the pharmacist responsible for the preparation and by the researchers. The other subjects
involved in the study were blind for the treated and
the control groups. The day-care center staff were
previously trained to guarantee the use of fortified
water and any faucet the children might use as an
alternative source of drinking water was blocked.
Besides the educational program previously
described, water fortification was the only nutritional
intervention conducted in the five day-care centers.
The intervention period lasted for 3 months.
Following the model already applied in previous
studies conducted by the group [10,11,13], every
child of the five institutions received water prepared
with one of the different pre-mixes.
The five institutions (I, II, III, IV and V) engaged
in the project were divided into three groups by drawing lots. For each group, a different water-fortification strategy was used, one of them being the control
group, as detailed in the following text:
Group A, n ¼ 37, institution I, water with 10 mg of
iron and 100 mg of ascorbic acid per liter (added to
the water container, the pre-mix containing
1000 mg of FeSO4-7H2O and 2000 mg of ascorbic
acid diluted in 20 ml of water).
Group B, n ¼ 60, institutions II and III, water with
no iron and with 100 mg of ascorbic acid per liter
(added to the water container, the pre-mix containing 2000 mg of ascorbic acid diluted in 20 ml
of water).
Group C, n ¼ 56, institutions IV and V, water of
the control group (added to the water container,
the pre-mix containing 20 ml of water).
Before starting the intervention, 7 ml of blood was
drawn from each child through phlebotomy in the
day-care center, in the morning and after a 12-hour
fasting time. Four milliliters of blood was transferred
to a polyethylene test tube with no iron and no anticoagulant, and 3 ml to a vial containing 50 ml of 10%
aqueous solution of potassium ethylenediaminetetraacetic acid. Initially, only hemoglobin (Hb) was
dosed, and the groups were compared as to whether
there was statistical difference with regard to this parameter, with the objective of guaranteeing initial
standardization between the three groups. The analysis with the Kruskal–Wallis test resulted in
p ¼ 0.6417, the groups been considered similar for
the variable Hb concentration at time point 0. The
study was subsequently continued with the following
parameters being measured:
Hb and mean corpuscular volume (MCV) conducted in the Automatic Cell Coulter T-890,
series 6704465, New York, EUA;
41
C. A. N. DE ALMEIDA ET AL.
Ferritin measurements by the enzyme-linked
fluorescent assay method, with the model
MiniVidas by BIO-MÉRIEUX, series SV
122 588, Missouri, EUA;
Sodium metabisulfite erythrocytes sickling test.
After 3 months of intervention, all laboratorial
tests were repeated.
The prevalences of anemia and ID were assessed
considering the World Health Organization recommendation for this age-group [14], every child with
Hb <11 g/dl being considered anemic. Those with
serum ferritin <12 mg/dl were considered irondeficient.
The statistical analysis was done in two steps. In
the first one, using the paired T-test for the variables
with normal distribution, and the Wilcoxon test for
those considered as non-parametric, the values of the
different indicators at time points 0 and 1 were compared within each study group. In the second step,
using the Mann–Whitney test, the differences between time points 0 and 1 were analyzed (T1 T0)
comparing each two groups.
The diet analysis was done taking into account the
meals in the institution and at home. For that, 10
children were randomly drawn, and, for each one
of them, 1 day of the week, between Monday and
Friday, was randomly chosen. On that day, all the
food eaten by that child in the institution was previously weighted and after the meal the leftovers were
also weighted. At the end of the period, a standardized handout was delivered to the family with the
same objective and the family was asked to fill it in
detail with all the food eaten at home. The results
observed in those 10 children were consolidated and
assessed jointly, comparing them with the dietary
reference intakes [15].
Daily clinical observations were conducted by the
employees of the day-care centers under the supervision of the staff of the study.
The study was approved by the ethics committee of
the Ribeirão Preto University on 27 October 2005
(number 067/05).
Results
The amount of water consumed was monitored at all
day-care centers and corresponded to 524 156 ml
per day for Group A, 532 150 ml per day for
Group B and 526 159 ml per day for Group C,
with no significant difference between groups
(p < 0.0001). Considering this consumption, children
from Group A received, on average, 5.2 mg of iron
and 52.4 mg of ascorbic acid; children from Group B
received no iron and 53.2 mg of ascorbic acid and
children from Group C received no iron and no
ascorbic acid.
The sodium metabisulfite erythrocytes sickling test
was negative in all children.
42
Daily clinical observation at the day-care centers
showed no diarrhea, side effects or intolerance due to
the intervention.
The general prevalence initially observed in anemia
and ID was, respectively, 25.5% and 20.3%
(n ¼ 153). After the intervention period, the general
prevalence of anemia and ID dropped to 13.1% and
13.7%, respectively.
The prevalence of anemia initially observed in each
group was 24.3% for Group A, 21.7% for Group B
and 19.4% for Group C; the prevalence of ID was
24.3% for Group A, 20.0% for Group B and 19.6%
for Group C. After the intervention period, the
prevalence of anemia in each group was 10.8% for
Group A, 15% for Group B and 12.5% for Group C;
the prevalence of ID was 5.4% for Group A, 18.3%
for Group B and 13.3% for Group C.
The results of the other analysis are depicted in
Tables 1–3. Table 1 demonstrates the description of
the variables within the groups, comparing time
points 0 (T0) and 1 (T1), and describes the mean
values (means þ standard deviation) of the difference
T1 T0. Hb increased in all three groups, MCV
increased in Groups A and B and ferritin increased
only in Group A.
Table 2 compares the values of T1 T0 between
the three groups in the study. With regard to Hb, a
small statistical difference was found (p ¼ 0.0434)
between Groups A and B (difference of T1 T0 between Groups A and B was 0.5 g/dl). The differences
between T1 T0 for MCV were significant when
Groups A and B were compared with Group C (difference of T1 T0 between Groups A and C was 3.2
fl and between Groups B and C was 4.2 fl), but no
difference was observed when comparing Groups A
and B. For ferritin, there was statistical difference
when T1 T0 of Group A was compared with
Groups B and C (difference of T1 T0 between
Groups A and B was 21 mg/l and between Groups
A and C was 19.6 mg/l).
Table 3 depicts the diets analysis, comparing the
results obtained with the dietary reference intakes.
Protein, zinc and vitamins A and C were ingested
above expectation, whereas the intake of carbohydrates, iron, calcium, folic acid and fibers was
below recommendations. Based on what usually happens in Brazil, about 60% of the protein consumed
comes from the combination of rice and bean, which
are used in a Brazilian diet at lunch and dinner,
almost all days.
Discussion
A previous study conducted by our group, offering
water fortified with 10 mg of iron and 100 mg of ascorbic acid per liter, had proven to be efficient in
increasing Hb concentration in children [16].
Nevertheless, there remained the question about the
role of ascorbic acid in those results, as the control
Journal of Tropical Pediatrics
Vol. 60, No. 1
Journal of Tropical Pediatrics
Paired T-test.
Wilcoxon.
Group A: fortification with iron and ascorbic acid; Group B: fortification with ascorbic acid; Group C: control; Hb: hemoglobin; MCV: mean corpuscular volume;
FT: ferritin.
b
a
0.5 (0.6)
0.4 (2.8)
1.8 (18.5)
<0.0001a
0.2562a
0.1334b
11.9 (0.9)
81.9 (4.6)
31.2 (17.4)
11.5 (0.8)
82.3 (5.8)
29.4 (24.1)
0.3 (0.9)
3.8 (4.6)
0.4 (14.6)
0.0122a
<0.0001a
0.8457a
0.8 (1.1)
2.8 (3.1)
21.4 (26.6)
Hb (g/dl)
MCV (fl)
FT (mg/l)
11.4 (1.4)
80.2 (7.7)
24.3 (14.4)
12.2 (0.9)
83.0 (5.6)
45.7 (28.8)
<0.0001a
<0.0001b
<0.0001b
11.5 (1.3)
77.2 (7.7)
29.4 (18.2)
11.8 (1.0)
81.0 (7.2)
29.8 (17.8)
T1 vs. T0
p
T1
mean (dp)
T0
mean (dp)
T1 T0
mean (dp)
T1 vs. T0
p
T1 T0
mean (dp)
T0
mean (dp)
T1
mean (dp)
T1 vs. T0
p
T0
mean (dp)
T1
mean (dp)
Group C (n ¼ 56)
Group B (n ¼ 60)
Group A (n ¼ 37)
TABLE 1
Variables within the study groups for time points 0 (T0) and 1 (T1) and description of T1 T0
T1 T0
mean (dp)
C. A. N. DE ALMEIDA ET AL.
Vol. 60, No. 1
TABLE 2
Comparing the difference T1 – T0 between the groups
Parameter
Comparison
p
Hb
Group
Group
Group
Group
Group
Group
Group
Group
Group
0.0434
0.3382
0.1364
0.0976
<0.0001
<0.0001
<0.0001
<0.0001
0.3534
MCV
FT
A vs. Group B
A vs. Group C
B vs. Group C
A vs. Group B
A vs. Group C
B vs. Group C
A vs. Group B
A vs. Group C
B vs. Group C
Group A: fortification with iron and ascorbic acid;
Group B: fortification with ascorbic acid; Group C: control; Hb: hemoglobin; MCV: mean corpuscular volume;
FT: ferritin.
Mann–Whitney test.
TABLE 3
Percentage of nutritional adequacy of the 10 children
assessed as compared with the dietary reference intake
recommendations
Item assessed
Adequacy
percentage
Energy
Protein
Carbohydrate
Iron
Zinc
Calcium
Vitamin C
Vitamin A
Folic Acid
Fiber
92
171
81
65
111
55
387
289
39
7
groups of the first studies received water alone. We
could question whether the result obtained might be
a consequence of the increase in iron and ascorbic
acid intake added together, as the role of ascorbic
acid as an enhancer of non-heme iron absorption is
well recognized [17]. We know that a population that
receives a satisfactory offer of iron, basically nonheme iron, may benefit from the adequate amounts
of ascorbic acid present in its usual diet or through
fortified food. The last study published by our group
[10] intended to assess exactly this issue, as one of the
groups received only ascorbic acid, taking a regular
diet rich in non-heme iron, and this group could be
compared with the other, which received the combination iron and ascorbic acid. The result was a significant and similar increase in Hb levels for both
groups. For this population, stimulating non-heme
iron associated to ascorbic acid was sufficient to
43
C. A. N. DE ALMEIDA ET AL.
foster the increment in the mean values of Hb and the
decrease in the prevalence of IDA. This fact is of
great relevance once the fortification with ascorbic
acid alone has lower cost, does not imply risk of
iron intoxication and the organoleptic properties of
the water are preserved. Nevertheless, the constraining factor is the need for intake of dietary non-heme
iron in enough quantity. In studies conducted in the
rural area of Mexico, Garcia et al. [18] and Diaz et al.
[19] did not observe any increment in the values of
Hb when lemonade containing 25 mg of ascorbic acid
was offered twice a day to women with ID, although
they did note an increase in iron absorption.
Nevertheless, we must emphasize that in the study
by Garcia et al. [18], the diet was also poor in heme
iron and rich in non-heme iron and in phytates.
In the present study, for the first time, three intervention groups were assessed simultaneously:
iron þ ascorbic acid, ascorbic acid and control
(water). The results demonstrated an increment in
the concentration of Hb in all three groups, increase
in functional iron (elevation in MCV) in both intervention groups and elevation in iron deposits (increase in ferritin) only in the group that received
iron-fortified water.
With regard to the intervention, children from
Group A received, on average, 5.2 mg of iron and
52.4 mg of ascorbic acid; children from Group B
received no iron and 53.2 mg of ascorbic acid; and
children from Group C received no iron and no ascorbic acid. It is expected that small increments in
iron offer and in its alimentary bioavailability may
increase Hb concentration, what must have occurred
in the present study in all three groups: in Group A,
due to the increment in the offer through water fortification; in Group B, through the increase in diet
iron absorption thanks to enhancement by ascorbic
acid; in Group C, due to the intervention of the
research team in the community.
It must be considered as a confounding factor that
the increment in Hb values for the three groups might
have happened, despite the short duration of the project, due to the physiological elevation of Hb, which
occurs with age [20].
It is likely that: (i) small changes such as offering
ascorbic acid may cause an increase in Hb [10], (ii)
the increment in functional iron be observed when
the offer of iron is increased (iron-fortified water)
and also when the absorption of diet iron is stimulated (ascorbic acid-fortified water) [10] and (iii) the
positive impact over Hb due to the insertion of a
research group in the community may occur
[21–23]. Aspects such as the sense of support and
care of the people from the institutions, associated
to more motivated staffs who were more aware of
the problem, led to an improvement in the alimentary
iron offer through more bioavailable sources, removal of absorption inhibitors and the inclusion of
stimulants [24].
44
According to the current model [25], the process of
negative iron balance, which culminates in IDA,
begins with the exhaustion of the stores, represented
by a drop in ferritin. In continuation, a reduction in
ferritin is observed, represented by a decrease in the
size of erythrocytes, with a drop in MCV. Finally,
maintaining the negative balance, there is a fall in
Hb and anemia. On the other hand, when positive
iron balance is established, the process occurs inversely, initially observing an elevation in the concentration of Hb followed by an increase in MCV and
only later the replenishing of the iron stores with the
elevation in ferritin.
Many studies have recently demonstrated that the
developmental adverse effects that were long accepted for IDA may also occur in ID without
anemia [26]. In fact, there are not many articles
about the developmental adverse effects of ID in
humans and almost all of them are not completely
controlled for all potential confounders [27].
Nevertheless, the American Committee on
Nutrition, in a recent publication [28], suggests
that, taking into account that iron is the world’s
most common single-nutrient deficiency, it is important to minimize ID and IDA among infants and toddlers, even if an unequivocal relationship between
them and neurodevelopmental outcomes has yet to
be established. In the present study, the diet analysis
demonstrated iron intake below requirements,
adding the period the children spent in the institution
to the one at home. Iron ingested was also from low
bioavailability sources, as already demonstrated in
studies in the same region [10,12,29], and offering
stimulating factors such as ascorbic acid may
render better absorption [30]. During the study
period, this effect could only increase MCV and Hb
concentration, but could not replenish stores. The
increase in iron stores was observed only in Group
A, where the children received water fortified with
iron and ascorbic acid, emphasizing the need for
iron supplementation, and not ascorbic acid only.
Like previous studies by our group [10,11,31], daily
clinical observation at the day-care centers showed
no side effects or intolerance due to the intervention.
Probably because of the low doses of iron used for
fortification, some possible side effects like diarrhea
or tooth impregnation were not observed.
The data from the present study ratify the potential of water fortification as a community strategy for
the control of ID and anemia, especially when the
low adherence for the supplementation programs
has been demonstrated [32]. The data also demonstrate that the recovery of Hb may be obtained by
educational strategies, as has been previously demonstrated in other studies [33], but the same does not
seem to occur with regard to iron stores. Stores replenishing is also crucial, and this effect seems to
depend on a more effective increase in iron offer to
the bone marrow, which, in the present study, was
Journal of Tropical Pediatrics
Vol. 60, No. 1
C. A. N. DE ALMEIDA ET AL.
only noted when iron offer was effectively increased
by means of fortified water.
The methodological limitations of our study need
to be considered. First, ferritin and MCV were the
only measures of iron status. Second, serum ferritin
concentrations can increase secondary to infection or
inflammation and, although we excluded children
with inflammatory illness, it is difficult to evaluate
some possible cases of non-apparent inflammatory
process. Third, it is difficult to control the food
received at home and some child may have ingested
more or less iron than expected during weekends or
after the day-care center time.
The results that have been obtained by our group
demonstrate that in an ideal situation, water fortification must be preceded by a careful assessment of
the previous nutritional status found in the institution [31]. Data such as the assessment of the children
iron nutritional status and of the food offered may
determine whether water fortification with ascorbic
acid only may be sufficient for that community [10].
On the other hand, if the option is fortification with
iron and ascorbic acid, the previous assessment may
point to the best concentration to be used for fortification, taking into account the previous studies
in which doses of 5–20 mg/l elemental iron were
used [11].
References
1. Miller JL. Iron deficiency anemia: a common and curable disease. Cold Spring Harb Perspect Med 2013;3:
pii: a011866. http://www.ncbi.nlm.nih.gov/pubmed/
23613366.
2. McLean E, Cogswell M, Egli I, et al. Worldwide prevalence of anaemia, WHO Vitamin and Mineral Nutrition
Information System, 1993fflÄı̀2005. Public Health Nutr
2009;12:444–54.
3. Jordão R, Bernardi JLD, Filho AAB. Prevalence of
iron-deficiency anemia in Brazil: a systematic review.
Rev Paul Pediatr 2009;27:9.
4. Vieira RCS, Ferreira HS. Prevalência de anemia em
crianças brasileiras, segundo diferentes cenários epidemiológicos. Revista de Nutrição 2010;23:433–44.
5. Algarin C, Nelson CA, Peirano P, et al. Iron-deficiency
anemia in infancy and poorer cognitive inhibitory control at age 10 years. Dev Med Child Neurol 2013;55:
453–8.
6. Felt BT, Peirano P, Algarin C, et al. Long-term neuroendocrine effects of iron-deficiency anemia in infancy. Pediatric research 2012;71:707–12.
7. Congdon EL, Westerlund A, Algarin CR, et al. Iron
deficiency in infancy is associated with altered neural
correlates of recognition memory at 10 years. J Pediatr
2012;160:1027–33.
8. Lozoff B. Early iron deficiency has brain and behavior
effects consistent with dopaminergic dysfunction. J
Nutr 2011;141:740S–6S.
9. de Almeida CAN, Crott GC, Ricco RG, et al. Control
of iron-deficiency anaemia in Brazilian preschool children using iron-fortified orange juice. Nutr Res 2003;
23:27–33.
Journal of Tropical Pediatrics
Vol. 60, No. 1
10. de Almeida CA, Dutra-De-Oliveira JE, Crott GC, et al.
Effect of fortification of drinking water with iron plus
ascorbic acid or with ascorbic acid alone on hemoglobin
values and anthropometric indicators in preschool children in day-care centers in Southeast Brazil. Food Nutr
Bull 2005;26:259–65.
11. Rocha DS, Capanema FD, Netto MP, et al.
Effectiveness of fortification of drinking water with
iron and vitamin C in the reduction of anemia and improvement of nutritional status in children attending
day-care centers in Belo Horizonte, Brazil. Food
Nutr. Bull 2011;32:340–6.
12. Almeida CAN, Ramos APP, Joao CA, et al.
Jardinópolis sem anemia, primeira fase: avaliação
antropométrica e do estado nutricional de ferro. Rev
Paul Pediatr 2007;25:254–7.
13. Dutra de Oliveira JE, Marchini JS. Drinking water as
an iron carrier to control iron deficiency. Nutrition
2006;22:853.
14. WHO. Assessing the iron status of populations: including literature reviews : report of a Joint World Health
Organization/Centers for Disease Control and
Prevention Technical Consultation on the Assessment
of Iron Status at the Population Level, Geneva,
Switzerland, 6–8 April 2004. 2nd edn Geneva: WHO
Library, 2007.
15. USDA. Dietary Reference Intakes. Food and Nutrition
Informations Center 2012. http://fnic.nal.usda.gov/diet
ary-guidance/dietary-reference-intakes. (cited 11 July
2012).
16. Dutra-de-Oliveira JE, de Almeida CA. Domestic drinking water—an effective way to prevent anemia among
low socioeconomic families in Brazil. Food Nutr Bull
2002;23(3 Suppl):213–6.
17. Chiu PF, Ko SY, Chang CC. Vitamin C affects the
expression of hepcidin and erythropoietin receptor in
HepG2 cells. J Renal Nutr 2012;22:373–6.
18. Garcia OP, Diaz M, Rosado JL, Allen LH. Ascorbic
acid from lime juice does not improve the iron status of
iron-deficient women in rural Mexico. Am J Clin Nutr
2003;78:267–73.
19. Diaz M, Rosado JL, Allen LH, et al. The efficacy of a
local ascorbic acid-rich food in improving iron absorption from Mexican diets: a field study using stable isotopes. Am J Clin Nutr 2003;78:436–40.
20. Lacher DA, Barletta J, Hughes JP. Biological variation
of hematology tests based on the 1999-2002 National
health and nutrition examination survey. Natl Health
Stat Report 2012;12:1–10.
21. Fisberg M, Lima AM, Rhein SO, et al. Feijão enriquecido com ferro na prevenção de anemia em pré-escolares. Nutr. Pauta 2003;59:9.
22. Kapur D, Sharma S, Agarwal KN. Effectiveness of nutrition education, iron supplementation or both on iron
status in children. Indian Pediatr 2003;40:1131–44.
23. Palupi L, Schultink W, Achadi E, Gross R. Effective
community intervention to improve hemoglobin status
in preschoolers receiving once-weekly iron supplementation. Am J Clin Nutr 1997;65:1057–61.
24. Vellozo EP. Impacto de uma nova proposta de fortificação alimentar na prevenção da anemia carencial ferropriva em crianças e adolescentes - uma intervenção
comunitária São Paulo: UNIFESP, 2012.
25. Janus J, Moerschel SK. Evaluation of anemia in children. Am Fam Physician 2010;81:1462–71.
45
C. A. N. DE ALMEIDA ET AL.
26. Li M, Zhu L, Mai X, et al. Sex and gestational age
effects on auditory brainstem responses in preterm
and term infants. Early Hum Dev 2013;89:43–8.
27. Alloway TP. What do we know about the long-term
cognitive effects of iron-deficiency anemia in infancy?
Dev Med Child Neurol 2013;55:401–2.
28. Baker RD, Greer FR, The Committee on Nutrition.
Diagnosis and prevention of iron deficiency and
iron-deficiency anemia in infants and young
children (0-3 years of age). Pediatrics 2010;126:
1040–50.
29. Nogueira-de-Almeida CA, Ricco RG, Del Ciampo LA,
et al. Growth and hematological studies on Brazilian
children of low socioeconomic level. Arch Latinoam
Nutr 2001;51:230–5.
46
30. Ballot D, Baynes RD, Bothwell TH, et al. The effects of
fruit juices and fruits on the absorption of iron from a
rice meal. Br J Nutr 1987;57:331–43.
31. Lamounier JA, Capanema FD, Rocha DS, et al. Iron
fortification strategies for the control of childhood
anemia in Brazil. J Trop Pediatr 2010;56:448–51.
32. Azeredo CM, Cotta RM, da Silva LS, et al. Problems of
adherence to the program of prevention of iron deficiency anemia and supplementation with iron salts in
the city of Vicosa, Minas Gerais, Brazil. Cien Saude
Colet 2013;18:827–36.
33. Sanou D, Turgeon-O’Brien H, Desrosiers Trs.
Nutrition intervention and adequate hygiene practices
to improve iron status of vulnerable preschool
Burkinabe children. Nutrition 2010;26:68–74.
Journal of Tropical Pediatrics
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