Routine Iron Supplementation Research Articles

Gaps in evidence regarding iron deficiency anemia in pregnant women and young children: summary of US Preventive Services Task Force recommendations

The US Preventive Services Task Force (USPSTF) makes recommendations to primary care providers regarding preventive services for asymptomatic patients. Recommendations are based on the scientific evidence that the delivery of the preventive service leads to improvements in meaningful patient outcomes. After a review of the available evidence, the USPSTF found insufficient evidence to recommend routine iron supplementation for pregnant women or routine screening for iron deficiency anemia in pregnant women or young children. The USPSTF identified a critical evidence gap that is related to whether changing hematologic indexes in otherwise asymptomatic pregnant women or in infants within populations who are reflective of the United States leads to an improvement in maternal or child health outcomes. Future research opportunities are described to address these important evidence gaps.

Effects of long-term weekly iron and folic acid supplementation on lower genital tract infection \u2013 a double blind, randomised controlled trial in Burkina Faso

BackgroundProvision of routine iron supplements to prevent anaemia could increase the risk for lower genital tract infections as virulence of some pathogens depends on iron availability. This trial in Burkina Faso assessed whether weekly periconceptional iron supplementation increased the risk of lower genital tract infection in young non-pregnant and pregnant women.MethodsGenital tract infections were assessed within a double blind, controlled, non-inferiority trial of malaria risk among nulliparous women, randomised to receive either iron and folic acid or folic acid alone, weekly, under direct observation for 18 months. Women conceiving during this period entered the pregnancy cohort. End assessment (FIN) for women remaining non-pregnant was at 18 months. For the pregnancy cohort, end assessment was at the first scheduled antenatal visit (ANC1). Infection markers included Nugent scores for abnormal flora and bacterial vaginosis (BV), T. vaginalis PCR, vaginal microbiota, reported signs and symptoms, and antibiotic and anti-fungal prescriptions. Iron biomarkers were assessed at baseline, FIN and ANC1. Analysis compared outcomes by intention to treat and in iron replete/deficient categories.ResultsA total of 1954 women (mean 16.8 years) were followed and 478 (24.5%) became pregnant. Median supplement adherence was 79% (IQR 59–90%). Baseline BV prevalence was 12.3%. At FIN and ANC1 prevalence was 12.8% and 7.0%, respectively (P < 0.011). T. vaginalis prevalence was 4.9% at FIN and 12.9% at ANC1 (P < 0.001). BV and T. vaginalis prevalence and microbiota profiles did not differ at trial end-points. Iron-supplemented non-pregnant women received more antibiotic treatments for non-genital infections (P = 0.014; mainly gastrointestinal infections (P = 0.005), anti-fungal treatments for genital infections (P = 0.014) and analgesics (P = 0.008). Weekly iron did not significantly reduce iron deficiency prevalence. At baseline, iron-deficient women were more likely to have normal vaginal flora (P = 0.016).ConclusionsPericonceptional weekly iron supplementation of young women did not increase the risk of lower genital tract infections but did increase general morbidity in the non-pregnant cohort. Unabsorbed gut iron due to malaria could induce enteric infections, accounting for the increased administration of antibiotics and antifungals in the iron-supplemented arm. This finding reinforces concerns about routine iron supplementation in highly malarious areas.Trial registrationTrial registration number NCT01210040. Registered with Clinicaltrials.gov on 27 September 2010

Iron deficiency among blood donors: experience from the Danish Blood Donor Study and from the Copenhagen ferritin monitoring scheme.

Blood components collected from blood donors are an invaluable part of modern-day medicine. A healthy blood donor population is therefore of paramount importance. The results from the Danish Blood Donor Study (DBDS) indicate that gender, number of previous donations, time since last donation and menopausal status are the strongest predictors of iron deficiency. Only little information on the health effects of iron deficiency in blood donors exits. Possibly, after a standard full blood donation, a temporarily reduced physical performance for women is observed. However, iron deficiency among blood donors is not reflected in a reduced self-perceived mental and physical health. In general, the high proportion of iron-deficient donors can be alleviated either by extending the inter-donation intervals or by guided iron supplementation. The experience from Copenhagen, the Capital Region of Denmark, is that routine ferritin measurements and iron supplementation are feasible and effective ways of reducing the proportion of donors with low haemoglobin levels.

Factors Influencing Antenatal Haematinics Prescription Behaviour of Physicians in Calabar, Nigeria.

BACKGROUND:Routine iron and folic acid supplementation in pregnancy have been proved to be effective in reducing the prevalence and morbidities of anaemia. However, there is limited data regarding the prescription habits of physician obstetric care givers.AIM:This study set to investigate the attitudes and factors which influence the practice among physicians in University of Calabar Teaching Hospital (UCTH).MATERIAL AND METHODS:A questionnaire based cross-sectional survey was conducted among randomly recruited physician offering antenatal services between August and September 2015. Systemic sampling was used to select 70 doctors in the departmental duty roster. Data were presented in percentages and proportion. Chi-square test was used to test the association between variables. Statistical significance was set at p < 0.05.RESULTS:The response rate was 100%. The mean age of the respondents was 30.26 ± 6.67 years. All the respondents routinely prescribed haematinics to pregnant women but 34.3% of them did not prescribe to apparently healthy clients in their first trimester. Only 30% and 11.4% of them prescribed it in the postnatal and preconception periods respectively. Brands that contained iron, folate and vitamins as a single capsule were mostly favoured, and information about brands of drugs was mostly provided by the pharmaceutical sales representatives. Younger doctors were more likely to offer haematinics with nutritional counselling compared to older respondents. However, there was no significant relationship between haematinics prescription and sex (p = 0.3560), Age (p = 0.839), current professional status (p = 0.783), and client complaint of side effect of medication (p = 0.23). Oral medication was mostly utilised.CONCLUSION:Effort to effectively control anaemia in pregnancy should involve re-orientation of physician obstetric care providers especially about prenatal and postnatal medication and counselling.

Prophylactic Iron Supplementation in Pregnancy: A Controversial Issue.

In our world today, iron deficiency (ID) is the most frequent nutritional deficiency and it is being considered as an epidemic public health crisis. Women of reproductive age and infants are at particular risk of ID, especially in underdeveloped countries. During pregnancy, iron deficiency anemia is a specific risk factor associated with negative maternal and perinatal outcomes. Many countries have iron supplementation (IS) programs—as recommended by the World Health Organization—during pregnancy; however, IS clinical benefits and risks are unclear. This review aims to discuss the threats and benefits of routine IS on maternal and infant outcomes.

A longitudinal study of iron status during pregnancy and the risk of gestational diabetes: findings from a prospective, multiracial cohort.

The aim of this study was to prospectively and longitudinally investigate maternal iron status during early to mid-pregnancy, and subsequent risk of gestational diabetes mellitus (GDM), using a comprehensive panel of conventional and novel iron biomarkers. A case-control study of 107 women with GDM and 214 controls (matched on age, race/ethnicity and gestational week during blood collection) was conducted within the the Eunice Kennedy Shriver National Institute of Child Health and Human Development Fetal Growth Studies-Singleton Cohort (2009-2013), a prospective and multiracial pregnancy cohort. Plasma hepcidin, ferritin and soluble transferrin receptor (sTfR) were measured and sTfR:ferritin ratio was derived, twice before GDM diagnosis (gestational weeks 10-14 and 15-26) and at weeks 23-31 and 33-39. GDM diagnosis was ascertained from medical records. Adjusted ORs (aORs) for GDM were estimated using conditional logistic regression analysis, adjusting for demographics, prepregnancy BMI and other major risk factors. Hepcidin concentrations during weeks 15-26 were 16% higher among women with GDM vs controls (median 6.4 vs 5.5ng/ml; p = 0.02 ), and were positively associated with GDM risk; the aOR (95% CI) for highest vs lowest quartile was 2.61 (1.07, 6.36). Ferritin levels were also positively associated with GDM risk; the aOR (95% CI) for highest vs lowest quartile was 2.43 (1.12, 5.28) at weeks 10-14 and 3.95 (1.38, 11.30) at weeks 15-26. The sTfR:ferritin ratio was inversely related to GDM risk; the aOR (95% CI) for highest vs lowest quartile was 0.33 (0.14, 0.80) at weeks 10-14 and 0.15 (0.05, 0.48) at weeks 15-26. Our findings suggest that elevated iron stores may be involved in the development of GDM from as early as the first trimester. This raises potential concerns for the recommendation of routine iron supplementation among iron-replete pregnant women.

Iron deficiency anemia: like mother, like child

Iron deficiency remains a leading cause of anemia worldwide. The prevalence among infants and toddlers in the US remains close to 10% despite widespread adoption of iron-fortified formulas and the recommendation to delay the introduction of cow’s milk until 1 year of age; in developing countries the frequency is often much higher. In addition to anemia, there is evidence that iron deficiency causes long-term neurocognitive deficits that can persist despite iron replacement therapy. Although the most recent US Preventive Services Task Force guidelines recommend iron supplements for high-risk infants (low birth weight or premature), there is a surprising paucity of high-quality data regarding the value of routine screening or iron supplementation for low-risk infants. In this volume of The Journal, Zhang et al report on a retrospective review of mother-infant pairs in northern China who had enrolled in a large prospective study of iron and vitamin supplementation during pregnancy. Although they did not directly measure iron status in their subjects, this population has very low frequencies of hemoglobinopathies and infections that might cause anemia; thus, it is logical to conclude that nutritional factors (eg, iron deficiency) were a major cause for anemia when it was observed. The investigators found that infants born to women with mild anemia at the end of the second trimester (hemoglobin levels 100-109 g/L, approximately 6% of the total population) had almost double the risk of overt anemia at 5-7 and 11-13 months of age, compared with infants born to women with hemoglobin levels ≥ 110 g/L. These results suggest that maternal anemia during late pregnancy could reasonably be used as an additional risk factor to identify infants who are at increased risk of nutritional anemia and who might benefit from targeted efforts at detection and prevention, especially among resource-limited populations for whom the relative ease and low cost of hemoglobin/hematocrit measurements would be an important consideration. Article page 106▶ Maternal Hemoglobin Concentration during Gestation and Risk of Anemia in Infancy: Secondary Analysis of a Randomized Controlled TrialThe Journal of PediatricsVol. 175PreviewThis study examined the relationship between maternal hemoglobin (Hb) concentration and the risk of anemia in infancy. Full-Text PDF

Is Routine Iron Supplementation Necessary in Pregnant Women With High Hemoglobin?

Background:Iron supplementation is a chief component in prenatal care, with the aim of preventing anemia; however, extreme maternal iron status may adversely affect the birth outcome. Given the negative consequences of high maternal iron concentrations on pregnancy outcomes, it seems that iron supplementation in women with high hemoglobin (Hb) should be limited.Objectives:The aim of this study was to examine the effect of iron supplementation on iron status markers in pregnant women with high Hb.Patients and Methods:In a randomized, double-blind, placebo-controlled trial, 86 pregnant women with Hb > 13.2 g/dL and ferritin > 15 μg/l in the 16th - 20th week of pregnancy were randomized into experimental and control groups. From the 20th week until the end of pregnancy, the experimental group received one ferrous sulfate tablet containing 50 mg of elemental iron daily, while the control group received a placebo. Hb and ferritin levels at 37 - 39 weeks of pregnancy were evaluated and compared. In addition, after delivery the birth weight was measured in two groups and compared.Results:There were statistically significant differences between the two groups in Hb (p = 0/03) and ferritin (p = 0/04) levels at the end of pregnancy, but the incidence of anemia exhibited no difference in either group (p < 0/001). In addition, the mean of birth weight in experimental group and control group were 3391/56 ± 422, 3314/06 ± 341, respectively and it was not significant difference (p = 0.2).Conclusions:Not using iron supplementation did not cause of anemia in women with Hb concentrations greater than 13.2 g/dL during pregnancy; thus, the systematic care and control of iron status markers without iron supplementation is recommended for these women.

Heamoglobin response to routine iron and folate supplementation during pregnancy in an HIV-endemic rural area roma, Lesotho

Iron deficiency is the leading cause of anaemia during pregnancy in African settings. Pregnancy and HIV are important risk factors for iron deficiency anaemia. The study assessed the occurrence of anaemia during pregnancy, the response to iron and folate supplements and the associated factors. The assessment was based on quantitative retrospective data of 126 pregnant women who attended antenatal care (ANC) between February and April 2014 in Roma, Lesotho and had haemoglobin (Hb) values taken at first ANC visit (baseline) and at term of gestation. Forty (31.8%) women were HIV-positive and 23 (57.5%) of them were anaemic at baseline. In total, 50 (39.5%) women had anaemia at baseline. The mean Hb at term was significantly higher (p<0.001) than that at baseline. Overall, 26 (20.6%) women had sub-optimal Hb response to iron and folate supplements, fifty-percent of whom were HIV-positive. Notably, 3 (2.4%) women developed anaemia while on supplements. Late first ANC visit (p=0.01), anaemia at baseline (p<0.001) and HIV-positive status (p=0.024) were significantly associated with sub-optimal Hb response. There is need to encourage early reporting for ANC and closely monitor women with HIV and/or anaemia at first ANC visit.

Screening for Iron Deficiency Anemia and Iron Supplementation in Pregnant Women to Improve Maternal Health and Birth Outcomes: U.S. Preventive Services Task Force Recommendation Statement.

Update of the 2006 U.S. Preventive Services Task Force (USPSTF) recommendation on screening for iron deficiency anemia. The USPSTF reviewed the evidence on the association between change in iron status as a result of intervention (oral supplementation or treatment) in pregnant women and adolescents and improvement in maternal and infant health outcomes. This recommendation applies to pregnant women and adolescents living in the United States who do not have symptoms of iron deficiency anemia. It does not address pregnant women who are malnourished, have symptoms of iron deficiency anemia, or have special hematologic conditions or nutritional needs that may increase their need for iron. The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for iron deficiency anemia in pregnant women to prevent adverse maternal health and birth outcomes. (I statement). The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of routine iron supplementation for pregnant women to prevent adverse maternal health and birth outcomes. (I statement).

Routine Iron Supplementation and Screening for Iron Deficiency Anemia in Pregnancy: A Systematic Review for the U.S. Preventive Services Task Force

Routine screening and supplementation for iron deficiency anemia (IDA) in asymptomatic, nonanemic pregnant women could improve maternal and infant health outcomes. Update of a 2006 systematic review by the U.S. Preventive Services Task Force on screening and supplementation for IDA in pregnancy. MEDLINE and the Cochrane Library (1996 to August 2014) and reference lists of relevant systematic reviews to identify studies published since 1996. English-language trials and controlled observational studies about effectiveness of screening and routine supplementation for IDA in developed countries. Data extraction and quality assessment confirmed and dual-rated by a second investigator using prespecified criteria. No study directly compared clinical outcomes or harms of screening or not screening pregnant women for IDA. Twelve supplementation trials were included, and no controlled observational studies met inclusion criteria. On the basis of 11 trials, routine maternal iron supplementation had inconsistent effects on rates of cesarean delivery, small size for gestational age, and low birthweight and no effect on maternal quality of life, gestational age, Apgar scores, preterm birth, or infant mortality. Twelve trials reported improvements in maternal hematologic indices, although not all were statistically significant. Pooled analysis of 4 trials resulted in a statistically significant difference in IDA incidence at term, favoring supplementation (risk ratio, 0.29 [95% CI, 0.17 to 0.49]; I2= 0%). Maternal iron supplementation did not affect infant iron status at 6 months. Harms, none of which were serious or had long-term consequences, were inconsistently reported in 10 of the trials, with most finding no difference between groups. Data from trials in countries with limited generalizability to U.S. populations were included. Studies were methodologically heterogeneous, and some were small and underpowered. There is inconclusive evidence that routine prenatal supplementation for IDA improves maternal or infant clinical health outcomes, but supplementation may improve maternal hematologic indices. Agency for Healthcare Research and Quality.

Screening and routine supplementation for iron deficiency anemia: a systematic review.

Supplementation and screening for iron-deficiency anemia (IDA) in young children may improve growth and development outcomes. The goal of this study was to review the evidence regarding the benefits and harms of screening and routine supplementation for IDA for the US Preventive Services Task Force. We searched Medline and Cochrane databases (1996-August 2014), as well as reference lists of relevant systematic reviews. We included trials and controlled observational studies regarding the effectiveness and harms of routine iron supplementation and screening in children ages 6 to 24 months conducted in developed countries. One author extracted data, which were checked for accuracy by a second author. Dual quality assessment was performed. No studies of iron supplementation in young children reported on the diagnosis of neurodevelopmental delay. Five of 6 trials sparsely reporting various growth outcomes found no clear benefit of supplementation. After 3 to 12 months, Bayley Scales of Infant Development scores were not significantly different in 2 trials. Ten trials assessing iron supplementation in children reported inconsistent findings for hematologic measures. Evidence regarding the harms of supplementation was limited but did not indicate significant differences. No studies assessed the benefits or harms of screening or the association between improvement in impaired iron status and clinical outcomes. Studies may have been underpowered, and control factors varied and could have confounded results. Although some evidence on supplementation for IDA in young children indicates improvements in hematologic values, evidence on clinical outcomes is lacking. No randomized controlled screening studies are available.

Can routine screening and iron supplementation for iron deficiency anemia in nonsymptomatic pregnant women improve maternal and infant health outcomes?

CLINICAL SCENARIOPregnant women have an increased need for iron that might not be met with diet alone. Due to physiologic anemia and population differences, no set criteria for defining iron deficiency anemia (IDA) are available globally. Serum ferritin and transferrin levels are often used to guide therapy by clinicians. Studies have reported an association between poor iron status and negative health outcomes such as low birth weight, premature birth, and perinatal death for women and their infants, although the evidence is weak.

Concerning iron balance in blood donors.

Concerning iron balance in blood donors.

Influence of host iron status on Plasmodium falciparum infection.

Iron deficiency affects one quarter of the world's population and causes significant morbidity, including detrimental effects on immune function and cognitive development. Accordingly, the World Health Organization (WHO) recommends routine iron supplementation in children and adults in areas with a high prevalence of iron deficiency. However, a large body of clinical and epidemiological evidence has accumulated which clearly demonstrates that host iron deficiency is protective against falciparum malaria and that host iron supplementation may increase the risk of malaria. Although many effective antimalarial treatments and preventive measures are available, malaria remains a significant public health problem, in part because the mechanisms of malaria pathogenesis remain obscured by the complexity of the relationships that exist between parasite virulence factors, host susceptibility traits, and the immune responses that modulate disease. Here we review (i) the clinical and epidemiological data that describes the relationship between host iron status and malaria infection and (ii) the current understanding of the biological basis for these clinical and epidemiological observations.

Prevalence of Undernutrition and Anemia among the Child Beneficiaries of Mid-Day Meal Program

Estimates suggest that over one third of the World’s population suffer from anemia; primarily due to iron deficiency and India is projected to be one of the countries with very high prevalence. The National Family Health Survey (NFHS-III) reveals that the prevalence of anemia is 70-80% among Indian children. Anemia is an indicator of gross under nutrition and it affects the physical growth, cognitive performance and behavior of children. The objective of Mid-Day Meal program (MDM) was to control under nutrition and the probable anemic state among school children. In this background the present study was undertaken to examine the prevalence of anemia among the child beneficiaries of 8 to 10 years of age. The Male and Female children (no: 776) attending the Urban municipal upper primary schools in Tirupati (AP) composed the subjects of the study. A general information survey revealed that all the children belonged to low socio economic status. The data on anthropometry indicate that 37.5 and 36.1% children belong to the stunted and stunted & wasted type of malnutrition. Only 26.4% children were in the normal category. Prevalence of anemia was assessed through Cyanmethaemoglobin method. The results were interpreted using WHO cut-off values for classification of anemia into different degrees. The data revealed that of the 776 children studied, 19.6, 40.6 and 0.2% were in mild, moderate and severe anemic states, respectively. About 40% children were in the normal category having Hb values > 11.5g/dl. While MDM program is satisfactory in terms its nutrition contribution, the low food intake of children during other meals appear to bring down the days nutrient intake resulting in under nutrition and anemia. The results thus focus on the need for routine iron supplementation for the school going children to decrease the very high prevalence of iron deficiency anemia, till the time the child’s daily nutritional needs are taken care-of.

Socio-Demographic Correlates of Anaemia among Adolescents in Urban Slum

Background : Adolescence - a period of transition between childhood and adulthood is a significant period of human growth and maturation. Adolescents represent about a fifth of India's population. Iron needs are highest in males during peak pubertal development because of a greater increase in blood volume, muscle mass and myoglobin. Many studies in recent times have highlighted the high prevalence of anaemia among adolescent girls in India, however, there is limited published literature on prevalence of anaemia among adolescent boys. Aims : 1. To find out the prevalence of anaemia among adolescent (10-19 years) boys and girls in the urban slum of Meerut. 2. To study socio-demographic co-relates of anaemia. Material and Method : A Community based cross sectional study was conducted in urban slum, Multan nagar, catchment area of Urban Health and Training Center, Department of Community Medicine, Subharti Medical College, Meerut. A total of 406 (216 females and 190 males) adolescents (10 -19 years of age) were included in this study. Haemoglobin estimation was done using Direct Cyanmethaemoglobin method. Statistical analysis were done using Microsoft excel 2007 and Epi info version 3.5.3. Results : The prevalence of anaemia among adolescent males and females was found to be 31.6% and 52.8% respectively. Statistical significant association (p< 0.05) of anaemia among boys were found with type of family, socio-economic status, educational status&academic performance. Among females, the statistical significant socio-demographic factors were socio-economic&educational status. Conclusions : A high prevalence of anaemia was found among adolescent males and females. Considering the possible implications of anaemia on adolescent growth and development, the nutritional status of adolescents should not be overlooked and suggests the need for routine iron supplementation even among adolescent boys.

Determinants of compliance to iron supplementation among pregnant women in Enugu, Southeastern Nigeria.

Anemia in pregnancy is highly prevalent among antenatal clinic attendees in Enugu, Nigeria despite the practice of routine iron supplementation in pregnancy. The major problem with iron supplementation in pregnancy is compliance, and this may be a potential driver to the persistent high prevalence of anemia in this population. To find out the compliance rate and determinants of compliance to iron supplementation among pregnant women in Enugu, southeastern Nigeria. This was a questionnaire-based cross-sectional study of eligible pregnant women receiving antenatal care at the University of Nigeria Teaching Hospital (UNTH), Ituku/Ozalla, Enugu, Nigeria between April 1, 2012 and January 31, 2013. The knowledge of iron supplementation was 76.3% ( n = 302), however, the compliance rate was 65.9% ( n = 261). Tertiary level of education and high social class were factors significantly associated with compliance to iron supplementation after adjusting for other factors in the binary logistic regression analysis ( P < 0.05). The major barriers to compliance to iron supplementation included gastrointestinal side effects of iron supplements (41.7%), non-affordability of iron supplements (28.3%), and forgetfulness (15.0%) among the antenatal mothers. The compliance rate of 65.9% for iron supplementation by pregnant mothers in Enugu can further be improved by providing the drug free of charge in the short term and improvement in education and socioeconomic class of the populace in the long run.

Can Iron Supplementation be Reconciled with Benefits and Risks in Areas Hyperendemic for Malaria?

Malaria is associated with about a million fatalities annually, largely among young children in zones of intense malarial transmission. The last thing needed would be measures that might increase the severity of clinical malaria. Thus, the finding in a field trial on Pemba Island, Tanzania, that routine oral iron supplementation produced adverse effects in iron-sufficient subjects had a ripple effect throughout the international public health community; it has effectively paralyzed efforts to redress iron-deficiency anemia in malaria-endemic regions. From a Hippocratic perspective, we consider the de facto moratorium on oral supplementation in such circumstance as a prudent interim measure. Public health programs to combat iron-deficiency anemia cannot be denied indefinitely to malaria-endemic populations, but the universal campaigns of iron provision cannot simply resume in the manner of the past. Contemporary biological and epidemiological understanding of the coevolution of humans and their pathogens should be able to provide guidance within the context of the essential and harmful aspects of iron. From these evolutionary standpoints, we identify a series of unresolved dilemmas. Toward a way forward, we highlight the pros and cons, as well as possible directions toward short-term strengthening, within three domains: tailored oral iron compounds, iron administration targeted only to iron-deficient individuals through screening, and prudent use of antimalarial prophylaxis. Although the tension between the essentiality of iron for humans and its role in pathogen virulence looms through every consideration, this recognition is a starting point toward the weighing of appropriate options balancing benefits and safety.

Positive association between dietary iron intake and iron status in HIV-infected children in Johannesburg, South Africa

Anemia is a common complication of pediatric HIV infection and is associated with suboptimal cognitive performance and growth failure. Routine iron supplementation is not provided to South African HIV-infected children. We hypothesized that dietary iron intake without supplementation is sufficient to protect against iron deficiency (ID) in HIV-infected children receiving highly active antiretroviral therapy. In this prospective study, the difference between dietary intakes of iron-deficient children (soluble transferrin receptor >9.4 mg/L) and iron-sufficient children after 18 months on highly active antiretroviral therapy was examined. The association between iron intake and hemoglobin (Hb) concentration was also assessed. Longitudinal data collected for 18 months from 58 HIV-infected African children were assessed by generalized estimation equations, with adjustment for demographic information, dietary intakes, growth parameters, and CD4%. After adjustment for covariates, the longitudinal association between dietary iron intake and Hb concentration remained significant. This association shows that for every 1-mg increase in iron intake per day, Hb increases by 1.1 g/L (P < .001). Mean Hb increased significantly after 18 months of follow-up (106 ± 14 to 129 ± 14 g/L, P < .01), but soluble transferrin receptor also increased (7.7 ± 2.7 to 8.9 ± 3.0 mg/L, P < .01). The incidence of ID increased from 15.2% at baseline to 37.2% after 18 months. Children with animal protein intakes greater than >20 g/d had significantly lower odds for ID at 18 months than did children with lower intakes (odds ratio, 0.40; 95% confidence interval, 0.21-0.77). Dietary iron intake was insufficient to protect against ID, pointing to a need for low-dose iron supplementation for iron-deficient HIV-infected children and interventions to increase the consumption of animal protein.