National Iron Plus Initiative

Need for the initiative

India is one of the countries with very high prevalence of anaemia in the world. Nutritional anaemia is a major public health problem in India and is primarily due to iron deficiency.

The National Family Health Survey-3 (NFHS-3) data suggests that anaemia is widely prevalent among all age groups, and is particularly high among the most vulnerable - nearly 58 per cent among pregnant women, 50 per cent among non- pregnant non-lactating women, 56 per cent among adolescent girls (15–19 years), 30 per cent among adolescent boys and around 80 per cent among children under 3 years of age and 70% below 5 years of age.

In young children, iron deficiency is due to increased iron requirement during periods of rapid growth. In addition, infant and toddler diets are often poor in bio- available iron, particularly post weaning. Children who suffer from anaemia have delayed psychomotor development and impaired performance; in addition they have 5–10 point deficit in intelligence quotient. Iron deficiency can cause significant central nervous system (CNS) damage even in the absence of anaemia. There seems to be a vulnerable period for these damages particularly between 9 and 18 months of age.

Ministry of Health and Family Welfare in 2013 launched “National Iron Plus Initiative” as a comprehensive strategy to combat the public health challenge of Iron Deficiency Anaemia prevalent across the life cycle. There are age specific interventions with Iron and Folic Acid Supplementation and Deworming for improving the haemoglobin levels and reducing the prevalence of anaemia for all age groups, that is children 6-59 months, 5 – 10 years, adolescent girls and boys (11-19 years), pregnant and lactating women and women in reproductive age group (20 – 49 years).

Age groups covered and related interventions

Under National Iron+ Initiative, the following age groups are covered for lifelong supplementation of Iron from the age of 6 month onwards:

• Bi-weekly 20 mg elemental iron and 100 microgram (mcg) folic acid per ml of liquid formulation and age appropriate de-worming for preschool children of 6-59 months.
• Weekly supplementation of 45 mg elemental iron and 400 mcg folic acid per child per day for children from 1st to 5th grade in Govt. & Govt. Aided schools, and at AWC for out of school children (6 to 10 years).
• Weekly dose of 100 mg elemental iron and 500 mcg folic acid with biannual de-worming in adolescents (10–19 years) under Weekly Iron and Folic Acid Supplementation (WIFS) Programme.
• Weekly supplementation of 100mg elemental iron & 500mcg of folic acid for women in reproductive age
• Pregnant and lactating women - 100mg elemental iron & 500mcg of folic acid - 1 tablet daily for 180 days, starting after the first trimester, at 14 - 16 weeks of gestation. To be repeated for 180 days post - partum.

Supplementation for Children 6–60 months as per GoI guidelines

One ml of IFA syrup containing 20 mg of elemental iron and 100 mcg of folic acid biweekly for 100 doses in a year. Iron folic acid supplements be supplied in bottles of 100 ml each and composition, preparation, dose and duration of IFA supplementation will remain same as the existing guidelines. The bottles should have an auto-dispenser so that only 1 ml of syrup will be dispensed at a time. Albendazole tablets will be provided to children for biannual de-worming, with dose half tablet between 1-2 years age and full tablet from the age of 2 years onwards.

For implementation among all children aged 6 to 60 months it is proposed that IFA supplement will be administered under the direct supervision of ANM/ASHA on fixed days on a biweekly basis. The micro plan for reaching out to these children can be worked out at village level. It is recommended that a particular child should receive the supplement on the fixed day (Monday and Thursday), though it can vary for the groups of children depending on the home visits schedule prepared at block/district level. The nutritional status of children should be assessed by MUAC (Mid Upper Arm Circumference less than 11.5 cm) to ensure that IFA syrup is not given to children with Severe Acute Malnutrition (SAM). ANM/ASHA would give IFA syrup bottles to mothers for safe storage and to lessen the logistic hurdle of carrying bottles around, but the IFA syrup will be administered under her direct supervision only. During the visits, the ANM/ASHA will also advise/inform the caregiver about the following issues:

• Time of administration – half an hour after food if the child has been breastfed (in LBW infants)/fed semisolid/solid food
• Benefits of regular intake of IFA syrup in physical and cognitive development of the child e.g. improvement in well-being, attentiveness in studies and intelligence etc. Minor side effects associated with IFA administration such as black discolouration of stools.
• Preservation of IFA bottle – in a cool and dark place, away from reach of children, keeping the lid of the bottle tightly closed each time after administration, etc.

Details of IFA supplementation will be included in the Mother and Child Protection (MCP) Card.

IFA supplementation programme and service delivery

Source : Ministry of Health and Family Welfare