Iron supplementation improves iron status and reduces morbidity in 

children with or without upper respiratory tract infections: a randomized 

controlled study in Colombo, Sri Lanka1–3 
Angela de Silva, Sunethra Atukorala, Irangani Weerasinghe, and Namanjeet Ahluwalia 
ABSTRACT Background: Iron deficiency anemia and recurrent infections are common among children of low socioeconomic 
status. Objective: The objective was to evaluate the effects of iron sup- plementation on iron status and morbidity in children with 
or without infection. Design: Children aged 5–10 y were recruited for a randomized, controlled, double-blind study from 
outpatients attending the Chil- dren’s Hospital, Colombo, Sri Lanka. Clinical, inflammatory, nutritional, and iron statuses were 
determined at baseline and after the intervention. Children with a history of recurrent upper respi- ratory tract infections (URTIs) 
and with laboratory and clinical evidence of a current URTI constituted the infection group (n = 179), and children without 
infection constituted the control group (n = 184). Subjects in both groups were supplemented with ferrous sulfate (60 mg Fe) or 
placebo once daily for 8 wk. Mor- bidity from URTIs, the number of gastrointestinal infections, and compliance were recorded 
every 2 wk. Results: The overall prevalence of anemia was 52.6%. Iron sup- plementation significantly improved iron status by 
increasing hemoglobin (P < 0.001) and serum ferritin (P < 0.001) concen- trations from baseline values in the children with or 
without infec- tion. There was no significant improvement in iron status in the children who received placebo. In both the 
infection group and the control group, the mean number of URTI episodes and the total number of days sick with an URTI during 
the period of interven- tion were significantly lower (P < 0.005 and P < 0.001, respec- tively) in the children who received iron 
supplements than in those who received placebo. Conclusion: Iron supplementation significantly improves iron status and 
reduces morbidity from URTIs in children with or with- out infection. Am J Clin Nutr 2003;77:234–41. 
KEY  WORDS  Anemia,  iron  status, inflammatory indicators, upper respiratory tract infections, iron supplementation, 5–10-y-old 
children, Sri Lanka 
INTRODUCTION 
Iron  deficiency  anemia  is  a  major  public  health  problem  in  developing  countries  including  Sri Lanka. A National Health and 
Nutrition  Survey  in  1995  found  that  58%  of  primary  school  children  were anemic when a hemoglobin concentration cutoff of < 
12  g/dL  was  used  (1).  The  prevalence  of  anemia  was  found  to  be  espe-  cially  high  among  children  from  low  socioeconomic 
groups; such 
children live in crowded environments and are also prone to recur- rent infections. Iron deficiency is the major cause of anemia in 
Sri  Lanka  (Ministry  of  Health,  Sri  Lanka,  Policy  Document  2000).  Prevention  of  iron  deficiency  is  essential  because  previous 
studies  highlighted  the  adverse  effects of iron deficiency on cognitive development, attention, behavior, school performance, and 
phys-  ical  activity  in  children  (2–5).  Furthermore,  iron  deficiency  is  also  associated  with  impaired  immunocompetence  and 
therefore can lead to increased morbidity (6– 8). 
The  relation  between  iron  status  and  morbidity is controversial (9). Some longitudinal studies with oral iron therapy showed a 
reduced  prevalence  of  respiratory  and gastrointestinal infections (10–12). Other reports indicated that there was an increase or no 
change  in  the incidence of infectious disease (13–15). Difficulties in interpreting the conflicting results from these studies on iron 
therapy  and  infection  include  limitations  in  experimental design, such as the inclusion of severely malnourished subjects; lack of 
proper  controls;  and  the  presence  of  other confounding variables, such as other nutritional deficiencies (eg, of protein, folic acid, 
or  vitamin  B-12).  Furthermore,  many  of  the  above  studies  were  car-  ried out in countries or areas where malaria is endemic and 
becomes a complicating factor (15, 16). In addition, most studies on children were limited to infants or preschoolers. Hence, there 
is  a  need  for  carefully  designed  and  executed  studies  to  examine  the  effects  of  iron  supplementation  on  morbidity  in  primary 
school  children  of low socioeconomic status, because recurrent respira- tory and gastrointestinal infections affect their well-being 
and  lead  to  irregular  school  attendance.  It  is  possible that iron supplemen- tation could improve iron status and reduce morbidity 
from  upper  respiratory  tract  infections  (URTIs)  and  gastrointestinal  infections  in  children  of  this  age  group.  Therefore,  while 
taking into account 
1  From  the  Departments  of  Physiology  (AdS)  and  Biochemistry  and  Molecu-  lar  Biology  (SA),  Faculty  of  Medicine, 
University  of  Colombo,  Sri  Lanka;  the  Lady  Ridgeway  Children’s  Hospital,  Colombo,  Sri  Lanka  (IW);  and  the  Nutrition 
Department, College of Health and Human Development, The Pennsylvania State University, University Park (NA). 
2Supported  by  a  grant  to  NA  from  USAID (through the ILSI Research Foun- dation) that was subcontracted to the University 
of Colombo, Sri Lanka. Smith Kline Beecham Inc supplied ferrous sulfate tablets. 
3  Reprints  not  available.  Address  correspondence  to  S  Atukorala,  Depart-  ment  of  Biochemistry  and  Molecular  Biology, 
Faculty of Medicine, University of Colombo, PO Box 271, Colombo 8, Sri Lanka. E-mail: sunethra@eureka.lk. 
Received September 28, 2001. Accepted for publication April 3, 2002. 
234 Am J Clin Nutr 2003;77:234–41. Printed in USA. © 2003 American Society for Clinical Nutrition 
 
FIGURE 1. Study design. 
possible  confounding  factors,  we  carried  out  a  study to evaluate the effect of iron supplementation (iron compared with placebo) 
on iron status and morbidity from URTIs and gastrointestinal infections in 5–10-y-old children with or without infection. 
SUBJECTS AND METHODS 
Subjects 
Four  hundred  fifty-three  children  (251  boys  and  202  girls)  who  were  with  or  without  infection and were aged between 5 and 
10  y were recruited over a period of 2 y. The subjects were children seeking treatment at the Out Patients Department of the Lady 
Ridgeway Children’s Hospital, Colombo, Sri Lanka, which is a non-fee-levying, state-run hospital. 
The  study  was  approved by the Ethical Review Committee of the Faculty of Medicine, University of Colombo, Sri Lanka, and 
by  The  Pennsylvania  State  University,  University  Park.  Children  were  recruited  into  the  study  after  obtaining  written informed 
consent  from  their  parents  or  guardians.  Children  with  severe  anemia  at  baseline  were  excluded  from  the  study,  supplemented 
with  iron,  and  followed  up.  All  subjects (iron and placebo groups) who were anemic at the end of the study were supple- mented 
with iron. 
Inclusion criteria 
The infection group consisted of children with a past history of recurrent URTIs and clinical and laboratory evidence of a 
current 
IRON SUPPLEMENTATION AND MORBIDITY 235 
URTI.  The  operational  definition  of  recurrent  URTIs  was  ≥2  sepa-  rate  episodes/mo  over  the  preceding  6–12  mo  (17).  URTIs 
included  coryza,  rhinitis,  acute  sinusitis,  pharyngitis,  tonsillitis, laryngitis, and tracheitis (18). The symptoms elicited were runny 
nose,  cough,  sore  throat,  difficulty  in  breathing  or  wheeze, and earache or discharge, with or without fever. Laboratory evidence 
of infection consisted of ≥3 of the following indicators of inflammation: an erythrocyte sedimentation rate (ESR) > 20 mm/h, an 
1 
-acid  glycoprotein  con-  centration  >  1.1  g/L,  a  C-reactive  protein concentration > 10 
mg/L,  and  a  white  blood  cell  (WBC)  count  >9  103/mm3  (19–21).  Episodes  of  illness  were considered separate if there were ≥5 
symp-  tom-free  days  between  the  episodes.  The  group  without  infection  (ie,  the  control  group)  consisted  of  children  seeking 
treatment  for  minor  injuries  that  did  not  involve  infection  or  for  poor  vision.  These  chil-  dren  either  had  no elevated values for 
any of the 4 laboratory tests of inflammation or had an elevated value for only 1 of the tests. 
Exclusion criteria 
Children  with  severe  protein-energy  malnutrition,  a  history  of  other  systemic  diseases,  chronic  bronchial  asthma,  or  chronic 
diar-  rhea were excluded from the study. Children were also excluded if they had signs of an infection but had elevated values for 
≤  2  inflammatory  indicators,  if  hemoglobin  data  was  not  available,  or  if  the  children  had  a  hemoglobin concentration < 70 g/L, 
which indicated severe anemia at baseline (22). 
Methods 
The  study  was  a  longitudinal,  randomized,  controlled,  double-  blind  supplementation  trial,  and  the  study  design  is  shown  in 
Figure  1.  On  the  basis  of  the  estimated  prevalence  of  anemia in this age group in Sri Lanka (1), the sample size was calcu- lated 
to  be  420,  with  the  assumption  that  the  prevalence  of  anemia  in  children  with  infection  was similar to that in chil- dren without 
infection and with the assumption of a 20% dropout rate. 
Baseline (before supplementation) 
For  each  child,  a  detailed  medical  history  was  obtained  and  a  clinical  examination  was  carried  out  by the study pediatrician. 
Socioeconomic status and morbidity from respiratory and gas- trointestinal illnesses (> 3 loose stools/24 h) during the preced- ing 
2  wk  were  recorded  on  pretested,  interviewer-administered  questionnaires.  Height  to  the  nearest  0.5  cm  and  weight  to  an 
accuracy  of  0.5  kg  (Salter  Balance;  Salter  Scales,  London)  were  recorded.  A  venous  blood  sample  (5  mL)  was  obtained  from 
each  child  between  0900  and  1100  by  using  sterile  equip-  ment.  An  aliquot  (2.5  mL)  was  collected  in  tubes  containing  an 
anticoagulant  (EDTA),  placed  on  ice,  and  processed  within  3  h  of  collection.  The  remaining  blood  (2.5  mL)  was collected in a 
tube  without  anticoagulants,  serum  was  separated  by  cen-  trifugation  at  3000  rpm  (MSE  Soniprep  150;  MSE  Scientific 
Instruments,  Crawley,  Sussex,  United  Kingdom)  for  7  min  at  28  C,  and  aliquots  were  stored  at  20  C.  The  lag  period  between 
baseline measurements and the start of the interven- tion was 24–36 h. 
Supplementation and follow-up 
Children  were  stratified  by  age  and  sex  and  were  randomly  assigned  to  receive  iron  or  placebo  on  a  3:1  basis  within  each 
stratum. Because variation in the response to the intervention was likely to be greater in the iron group than in the placebo 
 
SILVA 236 
DE 
ET AL 
group,  3  times  as  many  subjects  were  assigned  to  the  iron  group  as  were  assigned  to  the placebo group. The allocation of more 
children  to  the  iron  group  ensured  an  adequate  number  in  the  intervention  group  to examine the effects of the intervention. One 
child with severe anemia was treated with iron and followed up separately. 
The  intervention  consisted  of  iron  (ferrous  sulfate)  tablets  (Feosol;  Smith  Kline  Beecham  Inc,  Philadelphia)  containing  the 
recommended  daily  dose  of  60  mg  elemental Fe (23) or placebo capsules containing 0.5 g lactose (State Pharmaceuticals Corpo- 
ration,  Colombo,  Sri  Lanka).  The  parents  or  guardians  of  each  child  were  instructed  to  give  the child one tablet/d at night. Nei- 
ther  the  subjects nor the members of the field staff were aware of the nature of the supplement. During the follow-up period, field 
investigators  visited  the  homes  of  the  participants  every  2  wk  to  monitor  compliance  by  questioning  participants  and  counting 
unused  tablets.  The  parents  or  caregivers  were  requested  to  make  note  of  morbidity  from  URTIs  and gastrointestinal infections 
for  the  preceding  2 wk. Field investigators verified these data during home visits by questioning the parents or guardians with the 
use of interviewer-administered questionnaires. 
After the intervention 
After  8 wk of supplementation, the children were reassessed at the hospital. All assessments made before the intervention were 
repeated,  and  morbidity  and  compliance  data  were  recorded.  Sub-  jects  in  both  the  iron  and  placebo  groups  who  were  anemic 
[hemo-  globin  concentration  <  115 g/L (23)] after the intervention were supplemented with iron (60 mg elemental Fe/d) for 4 wk 
and referred to the Out Patients Department for follow-up. 
Laboratory methods 
A  complete  blood  count  including  hemoglobin,  hematocrit,  mean  cell  volume,  and  WBC  count  was  obtained  by  using  an 
automated  analyzer  (Cel-dyn  3500;  Abbott  Diagnostics,  Abbott Park, IL). ESR was measured by using a modified version of the 
Westergren  method  (Dispette  2;  Ulster  Medical  Products,  a  division  of Lukens Medical Corporation, Albuquerque, NM), serum 
C-reactive protein concentrations were measured by using latex agglutination (bioMérieux sa, Marcy-l’Etoile, France), and 
1 
after  the  intervention  were  analyzed  by  using  a  two-factor  analy-  sis  of  variance  that  included  treatment  and  infection  main 
effects  and  a  treatment  infection  interaction  effect.  The  effects  of  sup-  plementation (iron or placebo) on morbidity from URTIs 
and  gas-  trointestinal  infections  were  examined  by  using  a  two-factor  analysis  of  variance  that included treatment and infection 
main  effects  and  a  treatment  infection  interaction  effect.  If  interac-  tions  were  significant,  the data were analyzed separately for 
chil- dren with or without infection (24). Statistical significance was set at P < 0.05. 
RESULTS 
Baseline 
Three  hundred  sixty-three  children  completed  the  full  course  of  supplementation  and  follow-up,  and 71 children dropped out 
of  the  study.  Twelve  children  who  had  infections  but  had  elevated  values  for  only  2  inflammatory  indicators  at  baseline,  6 
children  who  lacked  baseline  hemoglobin  data,  and  1  child with a baseline hemoglobin concentration < 70 g/L did not fulfill the 
inclusion  cri-  teria  for  the  study.  Subjects  dropped  out  of  the  study  because  their  families  were  displaced due to floods (n = 26; 
36.6%)  or  migrated  to  other  areas  (n  =  20;  28.1%)  or  because  the  subjects  failed  to  show  up  at  the  hospital  or  provide a blood 
sample  after  the  inter-  vention  (n  =  25;  35.2%).  The  children who dropped out of the study were not significantly different from 
the  remaining  children  in  age,  body  mass  index (BMI; in kg/m2), or baseline hemoglobin concentration. The mean (±SD) age of 
the  children  in  the  study  was  6.7  ±  1.4  y  (Table  1).  Most of the children belonged to low socioeconomic groups, and there were 
no  significant  differences between the iron and placebo groups in socioeconomic indicators, such as mother’s education level and 
family income (Table 1) and housing and latrine facilities (data not shown). 
Mean BMI values in the children with infection did not dif- fer significantly between the iron and placebo groups (Table 1). In 
the children without infection, those who were supplemented with iron had a significantly lower BMI (P = 0.007) than did those 
who were supplemented with placebo. None of the chil- dren had severe protein-energy malnutrition as indicated by -acid 
glycoprotein concentrations were meas- ured by using radial immnodiffusion (Kent Laboratories Inc, Redmond, WA). Iron stores 
were assessed by serum ferritin determination (immunoradiometric assay; DPC Inc, Los Ange- les). Baseline concentrations of 
potential confounders, serum folic acid, and vitamin B-12 (SimulTRAC SNB Radioassay; ICN Pharmaceuticals, Orangeburg, 
NY) were also measured. All sam- ples were assayed in duplicate, and a pooled serum sample was 
BMI values below the 5th percentile (25). Serum folic acid and vitamin B-12 concentrations did not differ significantly between 
the children with or without infection or between the iron and placebo groups. Low serum folic acid concentrations [< 3 ng/ mL 
(26)] were observed in 20% and 24.8% of the children with and without infection, respectively, and low serum vitamin B-12 
concentrations [< 150 pg/mL (26)] were observed in 0.6% and 0.7% of the children with and without infection, respectively. used 
as an internal control. 
Compliance and side effects Statistical analysis 
A high compliance was noted in both the iron groups 
(with Completed questionnaires were checked before the data were 
infection: 95.1%; without infection: 95.5%) and the 
placebo entered into an IBM PC 300 GL, and the data were analyzed by 
groups (with infection: 97.3%; without infection: 96.9%). 
Only a using SPSS version 7.5 for WINDOWS (SPSS Inc, Chicago) and 
few children experienced side effects in either the iron 
group EPI-INFO version 6.04 (Centers for Disease Control and Pre- 
(constipation: 11.7%; vomiting: 1.6%) or the placebo 
group (con- vention, Atlanta). The baseline characteristics of the children with 
stipation: 1%; vomiting: 1.1%; skin rash: 1.9%). or 
without infection were examined by chi-square test and analy- sis of variance. Serum ferritin data were log transformed before 
statistical analysis because they had a skewed distribution. 
Effects of iron supplementation iron status, and morbidity 
on inflammatory indicators, 
Changes in iron status (hemoglobin and serum ferritin) and 
When tests of inflammation were considered at 
baseline, the inflammatory indicators (ESR, 
1 
-acid glycoprotein, and WBC) 
children with infection had significantly higher ESRs, 
1 
-acid 
 
IRON SUPPLEMENTATION AND MORBIDITY 237 
TABLE 1 Baseline characteristics of the study population 
Children with infection (n = 179) Children without infection (n = 184) Iron group (n = 127) Placebo group (n = 52) Iron group (n 
= 134) Placebo group (n = 50) 
Age (y) 6.5 ± 1.31 6.7 ± 1.3 6.9 ± 1.4 7.6 ± 1.52 BMI (kg/m2) 12.9 ± 2.1 12.9 ± 1.2 12.6 ± 1.6 13.2 ± 1.92 Folic acid (ng/mL) 
4.91 ± 2.7 5.79 ± 3.6 4.94 ± 2.8 4.85 ± 3.4 Vitamin B-12 (pg/mL) 622 ± 209 629 ± 232 571 ± 215 639 ± 205 Socioeconomic 
indicators (%)3 
Family income 
<3500 rupees/mo (<$40) 44.1 [56] 44.2 [23] 45.3 [59] 43.8 [21] ≥3500 rupees/mo (≥$40) 55.1 [70] 55.8 [29] 54.7 [71] 56.2 [27] 
Mother’s educational level 
No education 4.7 [6] 7.7 [4] 4.6 [6] 8.3 [4] Primary or secondary 64.6 [82] 67.3 [35] 66.2 [86] 64.6 [31] Tertiary 29.9 [38] 25.0 
[13] 29.2 [38] 27.1 [13] 
1x – 
± SD. 2Significantly different from the iron group, P < 0.01. 3n in brackets. Socioeconomic data were unavailable for 1 child 
with infection and 6 children without infection (iron group: n = 4; placebo group: n = 2). 
glycoprotein  concentrations,  and  WBC  counts  than  did  those  without  infection  (Table 2). Furthermore, among the children with 
infection,  there  were  no  significant  differences  in  the  con-  centrations  of  inflammatory  indicators  between  the iron and placebo 
groups.  After  the  intervention,  the  values  of  all  inflam-  matory  indicators  except  WBC  significantly decreased (P < 0.05) in the 
children  with  infection  but  not  in the children without infection. However, the effect of treatment (iron com- pared with placebo) 
on the change in inflammatory indicators was not significant. 
The  overall  prevalence  of  anemia  (hemoglobin  concentration  <  115  g/L)  in  the  study  population  was  52.6%  at baseline, and 
there was no significant difference in the prevalence of anemia between the children with or without infection or between the iron 
and placebo groups (Table 3). Children with infection had signi- ficantly higher (P < 0.001) serum ferritin concentrations than did 
those  without  infection.  Serum  ferritin  concentrations  did  not  dif- fer significantly between the iron and placebo groups either in 
the  children  with  infection  or  in  those  without  infection  (Table  3).  After  supplementation,  the  prevalence  of  anemia  in  the iron 
groups  was  significantly  lower  than  that  at  baseline.  The  effect  of  supplementation  was  examined  by  comparing the changes in 
hemoglobin  and  ferritin  concentrations  after  supplementation  in  the  iron  and  placebo  groups.  Iron  supplementation  had  a 
significant  (P  <  0.001)  effect  in  increasing  the  mean  change  in  hemoglobin  concentration  in  the  children  with  or  without 
infection.  The  pres-  ence  or  absence  of  infection  had  no  significant  influence  (P  =  0.415)  on  the  change  in  hemoglobin 
concentration.  Serum  ferritin  also  increased  significantly  from  baseline  in  the  children  with  or  with-  out  infection  who  were 
supplemented  with  iron.  The  change  in  serum  ferritin  was  influenced  by  iron  supplementation  (P  <  0.001)  and  the  presence  or 
absence of infection (P < 0.005). Infection 
TABLE 2 Baseline values of and changes in inflammatory indicators after supplementation with iron or placebo1 
CRP >10 mg/L5 ESR2 AGP3 WBC4 
A
fter Group Baseline Change Baseline Change Baseline Change Baseline supplementation 
mm/h g/L 103/mm3 % 
Children with infection 
Iron group (n = 127) 31.6 ± 15.2 15.4 ± 1.0 1.42 ± 0.3 0.44 ± 0.3 11.1 ± 4.1 1.16 ± 0.2 92.9 [118] 27.5 [35]6 Placebo group (n = 
52) 30.3 ± 14.3 12.9 ± 1.5 1.41 ± 0.4 0.08 ± 0.5 10.6 ± 2.6 1.58 ± 0.4 82.6 [43] 28.8 [15]6 Children without infection 
Iron (n = 134) 11.8 ± 4.5 0.029 ± 0.9 0.78 ± 0.22 0.44 ± 0.5 8.01 ± 2.2 0.69 ± 0.2 30.5 [41] 19.4 [26] Placebo (n = 50) 11.7 ± 3.5 
0.52 ± 1.5 0.68 ± 0.20 0.03 ± 0.3 7.34 ± 1.7 0.22 ± 0.4 38.0 [19] 20.0 [10] 
1Except for CRP, all baseline values are means ± SDs. All change values are means ± SEs. ESR, erythrocyte sedimentation rate; 
AGP, 
1 
-a
cid  glyco-  protein;  WBC,  white  blood  cell;  CRP,  C-reactive  protein.  All  baseline  values  in  the  children  with  infection  were 
significantly higher (P < 0.005) than those in the children without infection. 
2The effect of infection was significant (P < 0.001), but the effect of supplementation (P = 0.174) and the infection 
supplementation interaction effect (P = 0.24) were not significant. 
3The effect of infection was significant (P < 0.001), but the effect of supplementation (P = 0.925) and the infection 
supplementation interaction effect (P = 0.354) were not significant. 
4The effect of infection was significant (P < 0.001), but the effect of supplementation (P = 0.441) and the infection 
supplementation interaction effect (P = 0.942) were not significant. 
5n in brackets. Mean values were not available for CRP data because the CRP assay was semiquantitative. 6Significantly 
different from baseline, P < 0.005. 
 
238 
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SILVA ET AL 
TABLE 3 Baseline values of and changes in hemoglobin and serum ferritin concentrations after supplementation with iron or 
placebo 
Children with infection (n = 179) Children without infection (n = 184) Iron-status 
indicator Baseline Change Baseline Change 
Hemoglobin 
All subjects (g/L)1 
Iron 112.6 ± 10.4 6.44 ± 0.82 112.3 ± 10.1 6.01 ± 0.85 Placebo 115.8 ± 10.3 0.74 ± 1.05 115.2 ± 11.1 2.1 ± 1.32 <115 g/L (%)2 
Iron 59.1 [75/127] 32.3 [41/127]3 53.0 [71/134] 32.8 [44/134]3 Placebo 46.2 [24/52] 42.3 [22/52] 44.0 [22/50] 34.0 [17/50] 
Serum ferritin4 
All subjects ( g/L)5 
Iron 46.1 (23.9–88.9) 6.6 ± 3.9 27.8 (15.2–50.8) 27.4 ± 2.9 Placebo 52.4 (25.9–105.9) 14.9 ± 10.4 31.4 (16.9–58.3) 4.1 ± 4.2 <20 
g/L (%)6 
Iron 10.0 [12/120] 3.3 [4/120]3 27.9 [36/129] 7.7 [10/129]3 Placebo 5.9 [3/51] 21.5 [11/51] 17.0 [8/47] 21.3 [10/47] 1Baseline 
values are means ± SDs, and change values are means ± SEs. The effect of supplementation was significant (P < 0.001), but the 
effect of infec- tion (P = 0.415) and the infection supplementation interaction effect (P = 0.303) were not significant. 
2n anemic/total n in brackets. 3Significantly different from baseline, P < 0.05. 4Ferritin data were unavailable for 16 children 
(with infection: n = 8; without infection: n = 8). 5Baseline values are geometric means and ranges, and change values are means 
± SEs. The effects of infection (P < 0.005) and supplementation (P < 0.001) were significant, but the supplementation infection 
interaction effect was not significant (P = 0.783). 
6n with low ferritin/total n in brackets. 
iron supplementation interactions were not significant for hemo- globin (P = 0.303) or serum ferritin (P = 0.783) concentrations. 
The  severity  of  infection  at  baseline  (defined  by  the  presence  of  a  documented  fever accompanying an URTI) was compared 
between  the  iron  and  placebo  groups.  Fever  was  defined  as  an  axillary  temperature  ≥37.5  C  (27).  At baseline the percentage of 
children  who  had  URTIs  with  fever  in  the  iron  group  (51.5%)  was  not  significantly  different  from  that  in  the  placebo  group 
(51.9%).  During  follow-up,  the  iron-supplemented  children with infection had a significantly lower (P < 0.001) number of URTI 
episodes  and  a  significantly  lower  number  of  URTI  episodes  accompanied  by  fever  (P  <  0.005) than did the children who were 
given placebo; both documented and undocumented episodes of fever 
TABLE 4 Effects of supplementation with iron or placebo on morbidity1 
Indicator of morbidity Number of Number of URTI Total number of days Number of episodes of Group URTI episodes2 
episodes with fever3 sick with an URTI4 gastrointestinal infection5 
Children with infection 
Iron group (n = 127) 2.14 ± 1.1 0.58 ± 0.79 17.2 ± 11.5 0.19 ± 0.43 Placebo group (n = 52) 2.78 ± 0.9 0.92 ± 0.83 26.9 ± 9.7 0.10 
± 0.30 Children without infection 
Iron group (n = 134) 0.96 ± 0.70 0.12 ± 0.35 5.2 ± 4.5 0.06 ± 0.28 Placebo group (n = 50) 1.38 ± 0.94 0.24 ± 0.47 8.9 ± 6.9 0.04 
± 0.19 
1x 
were  included  in  this  analysis  (Table  4).  The  children  without  infection  who  were  supplemented  with  iron  also  had  a  signifi- 
cantly lower number of URTI episodes (P < 0.001) than did those who received placebo. 
A  significant  supplementation  infection  interaction  (P  =  0.003)  was  noted  for  duration  of illness (Table 4). The children with 
or  without  infection  who  were  supplemented  with  iron  had  a signi- ficantly (P < 0.001) lower number of days of illness than did 
the corresponding placebo groups (Table 4). The number of episodes of gastrointestinal infection was low in all groups. Although 
the  children  with  infection  in  the  iron  group  had  a significantly higher number of episodes of gastrointestinal infections than did 
those in the placebo group, the effect of iron supplementation was not 
– 
± SD. URTI, upper respiratory tract infection. 2The effects of infection (P < 0.001) and supplementation (P < 0.001) were 
significant, but the infection supplementation interaction effect was not significant (P = 0.318). 
3The effects of infection (P < 0.001) and supplementation (P < 0.005) were significant, but the infection supplementation 
interaction effect was not significant (P = 0.125). 
4The effects of infection (P < 0.001) and supplementation (P < 0.001) were significant, as was the infection supplementation 
interaction effect (P = 0.003). 
5The effect of infection was significant (P = 0.003), but the but the effect of supplementation (P = 0.102) and the 
supplementation infection interac- tion effect (P = 0.419) were not significant. 
 
TABLE 5 Percentage of children with infection who were treated with oral antibiotics by treatment group 
Iron group Placebo group Antibiotic treatment1 (n = 127) (n = 52) 
At  recruitment  (week  0)  56.7  [72]  67.3  [35]  During  weeks  1–4  of  follow  up 26.8 [34] 30.7 [16] During weeks 5–8 of follow up 
15.7 [20] 21.1 [11] 
1The  antibiotic  treatment  given  by  the  Out  Patient  Department  con-  sisted  of  125  mg  amoxycillin  every  8  h  for  3  d.  If  the 
child  did  not  show  improvement,  treatment  was  given  for  an  additional  3  d.  There  were  no  significant  differences  between  the 
iron and placebo groups at recruitment or during follow-up. 
significant.  Among  the  children  with  infection,  there  was  no  signi-  ficant  difference  between  the iron and placebo groups in the 
per- centage of children who were given oral antibiotics at recruitment or at different time points during follow-up (Table 5). 
The  numbers  of  episodes  of  URTI  morbidity  were compared between iron-deficient and iron-sufficient groups. Subjects were 
considered  iron  deficient if their increase in hemoglobin concen- tration after iron supplementation was ≥10 g/L and were consid- 
ered  iron  sufficient  if  their  increase  in  hemoglobin  concentration  after  iron  supplementation  was  <  10  g/L  (28).  Among  the 
children  with  infection,  there  was  no  significant  difference  in  the  mean  (±SD)  number  of  episodes  of  URTI morbidity between 
the  iron-  deficient  subjects  (2.17  ±  1.1;  n  =  45)  and the iron-sufficient sub- jects (2.16 ± 1.1; n = 81). A similar result was found 
for  the  children  without  infection:  the  number  of  episodes  of  URTI  morbidity  did  not  differ  significantly  between  the 
iron-deficient (1.03 ± 0.7; n = 45) and iron-sufficient subjects (1.05 ± 0.8; n = 89). 
DISCUSSION 
Anemia  and  upper  respiratory  tract  infections  are  common  prob-  lems  among  primary  school  children of low socioeconomic 
status,  and  a  complex  relation  exists  between  iron  status  and  infection.  Iron  deficiency and anemia are associated with impaired 
immunocom-  petence  and  increased  morbidity  (7,  8),  and  infections  can  affect  iron  metabolism  (29).  Thus,  our  interest  was  to 
examine  the  effects  of  iron  supplementation  on  iron  status  and  morbidity  in  children  with  or  without  infection.  The  study 
population  was  comprised  of  chil-  dren from low socioeconomic backgrounds with a high prevalence of anemia (52.7%), similar 
to  the  prevalence  reported  in  the  national  survey  (1).  In  this  randomized,  controlled,  double-blind  study,  high  compliance  was 
noted  in  both  the  iron  and  placebo  groups.  The  delivery  of  the  supplements  every  2  wk to the participants’ homes by field staff 
may  have enhanced the motivation of parents to provide supplements. Interestingly, the number of children who experienced side 
effects  was  low  in  both  the  iron  and  placebo groups, which may also have contributed to the high compliance. In this supervised 
trial,  iron  supplementation  was  associated  not only with an improvement in iron status but also with a reduction in morbidity due 
to URTIs in children with or without infection. 
The  magnitudes  of  the  reductions in the prevalence of anemia and of the mean changes in hemoglobin concentration after iron 
supplementation  were  similar  between  the  children  with and without infection. This indicates that children with recurrent URTIs 
and those without infection can increase their hemoglobin 
IRON SUPPLEMENTATION AND MORBIDITY 239 
concentrations  to  a  similar  extent,  suggesting  that  iron  supple-  mentation  may  be  beneficial  for  children  even  during  an  active 
URTI.  Other  studies  also  showed  that  hemoglobin  concentrations  improve  with  iron  supplementation  even  in  the  presence  of 
inflam-  matory  conditions  (14,  30,  31).  The  percentage  of  children  with  low  iron  stores,  as  indicated  by  a  serum  ferritin 
concentration  <  20  g/L  (32),  was only 8.7% in the infection group at baseline. This value probably underestimates the proportion 
with  low  body  iron  stores  because  ferritin  is  an  acute-phase  protein  that  increases  during  infections  (33,  34).  The  significant 
increase  in  serum  fer- ritin concentration that was observed in the iron-supplemented children with or without infection was to be 
expected in this com- munity with a high prevalence of iron deficiency. To our knowl- edge, the present study is one of the few to 
provide important information on changes in serum ferritin concentration after iron supplementation in children with infection. 
Iron  supplementation  had  no  significant  effect  on  changes  in  inflammatory  indicators.  This  was  probably  because  the 
magnitude  of  the  change  in  concentrations  of  these  indicators  was  not  large  enough.  The  record  of  incidence  of  morbidity  is  a 
more  important  and  direct  indicator  of  immune  function  in  vivo.  Interestingly,  in  this  cohort  of  school-aged  children  with  or 
without infection, iron supplementation was associated with reduced morbidity. 
Previous  studies  on  iron  supplementation  during  infections  yielded  conflicting  results,  with  few  studies  showing  beneficial 
effects  of  iron  on  the  prevalence  of  infections  (10–12).  A  lower  incidence  of  respiratory  infections was reported in term infants 
who  were  fed  an  iron-containing milk formula than in those who were fed an unfortified formula (11). The positive effect of iron 
supplementation  on  linear  growth  was  attributed  to  decreased  mor-  bidity  in  preschool  children  in  2  studies  (12,  35).  In  some 
stud-  ies,  iron  supplementation  did  not  change  the  incidence  of  mor-  bidity  (14,  36,  37).  In  comparison  with  morbidity  in  a 
control  group,  the  morbidity  of  Pakistani  infants  who  were  given  an  iron-  fortified  cereal  during  weaning  did not change, but a 
high  inci-  dence  of  malnutrition  was  a  confounding  factor  in  these  subjects  (14).  Heresi  et  al  (37)  found  that  morbidity  from 
respiratory  infec-  tions  and  diarrhea  did  not  increase  in  infants after they were given iron-fortified milk. Furthermore, in another 
study  in  Bangladesh,  the  incidence  of  diarrhea  or  respiratory  illness  in  preschoolers  did  not  change  after  supplementation  with 
iron for 1 y (36). 
In  contrast,  a  study  of  adult  Somali  nomads  who  were  supple-  mented  with iron showed an increased frequency of infections 
(13). However, this study lacked adequate controls, and the iron supplement dose that was provided (900 mg FeSO 
4 
/d)  was  much  greater  than  that  presently  recommended  (23).  In  the  present 
study,  infection  and  supplementation  were  both significant main effects in all aspects of morbidity that were examined. The chil- 
dren  with  infection  had  a  greater number of URTI episodes, more severe episodes, and episodes of a longer duration than did the 
children  without  infection.  In  comparison  with  placebo,  iron  sup-  plementation  significantly reduced morbidity due to URTIs in 
the  children  with  or  without  infection.  In  particular, among the chil- dren with infection, those who received iron had 29% fewer 
URTI  episodes  than  did  those  who  received  placebo  and  had  infectious  episodes  that  were  40%  less  severe  than  those  of  the 
children  who  received  placebo.  The  higher  mean  (±SD)  number  of  illness-free  days  in  the  children  who  received  iron  than  in 
those  who  received  placebo  (38.3  ±  11.8  compared with 29.0 ± 9.5 d, P < 0.001) sug- gests that iron supplementation is likely to 
improve the quality of life of these children and ensure better school attendance. 
 
The  reduction  in  morbidity  observed  in  the  present  study  may  be due to iron supplementation or the resolution of the infections. 
The  results  of  statistical  analysis  indicated  that  iron  supplemen-  tation  had  a  significant  effect  apart  from  the  resolution  of  the 
infections.  Antibiotic  treatment  cannot  solely  account  for  the  lower  morbidity  seen  in  the  iron  group  than  in  the  placebo group 
because  the  number  of  children  who  received  antibiotics  was  sim-  ilar  in  both  the  iron  and  placebo  groups  at  recruitment  and 
during  follow-up.  Thus,  our  results  suggest  that  iron  supplementation  was  at  least  partly  responsible  for  the  reduction  in 
morbidity  due  to  URTIs.  Note  that  even  the  children  without  infection  who  received  iron  had  lower  morbidity  than  did  their 
counterparts  who  received  placebo,  although  the  number  of  URTI  episodes  and  the  number  of  days  of  illness  were  low.  The 
number  of  episodes  of  gastroin-  testinal  infection  was  low  in  the  children  with  or  without  infec-  tion.  This  may  be because the 
children  who  were  examined  in  the  present  study  were  older  than  those  in  previous  studies  (14,  36)  and  thus  were  not  as 
susceptible to frequent diarrhea as were infants and preschool children. 
Twenty percent of the children with infection in the present study had a low serum folate concentration; low folate status, how- 
ever,  was  not  associated  with  increased  morbidity  from URTIs because there was no significant difference in morbidity between 
folate-sufficient  (≥  3  ng/mL)  and  folate-deficient  children  (data  not  shown).  Because  a  low  serum  vitamin  B-12  concentration 
was  noted  in  <1%  of  the  children  with  or  without  infection,  it  is  unlikely  to  have  been  important  in  the etiology of anemia and 
infection in this study. 
One  may  speculate  that supplementation with iron may be harmful in children who are iron sufficient. However, our analy- sis 
in  the  present  study  indicates  that  iron  supplementation  of  iron-  sufficient  children  was  not  associated  with  adverse  effects  in 
terms  of  infectious  morbidity.  Previous  studies  showed  impairments  in  immune  function,  mainly  T  cell  function,  during  iron 
deficiency  (6,  7,  38).  Iron  supplementation  may  reduce  morbidity  by  improv-  ing  immune  function;  additional  studies  are 
necessary to establish the mechanisms responsible for the reduction in morbidity observed in the present study. 
The  strength  of  the  present  study  is  its  design,  which  not  only  ensured  the  absence  of  complications  such  as  malaria, severe 
protein-  energy  malnutrition,  and  other  nutrient  deficiencies  that  affect the utilization of iron, but also incorporated the inclusion 
of  an  appro- priate control group for infection and intervention effects. How- ever, note that in the present study the children with 
infection  were  ambulatory  outpatients  who  had  recurrent  URTIs  but  were  not  severely  ill.  Children  who  were  severely  ill  with 
chronic  inflam-  matory  conditions  and  were  on long-term treatment with steroids and other drugs were not included in the study. 
Further  studies  are  needed  to  determine  whether  similar  benefits  would  accrue  in  chil-  dren  who  have  more  chronic  or  severe 
inflammatory  conditions  than  those  in  the  present  study.  A  longer  duration  of  intervention  and  follow-up  is  also  indicated  to 
evaluate the long-term effects of iron supplementation on morbidity. 
In  conclusion,  the  results  of  our  study  showed  that  in  a  commu-  nity  where  the  prevalence  of  anemia  is  high, daily oral iron 
supple-  mentation  of  5–10-y-old  children  for  8  wk  improved  iron  status  in  children  with  or  without  infection.  Iron 
supplementation  was  also  associated  with  a  significant  reduction  in  morbidity  due  to  URTIs  and  with  a  greater  number  of 
illness-free  days.  Furthermore,  oral  iron  supplementation  did  not  increase  morbidity  in  iron-sufficient  chil-  dren.  Thus,  iron 
supplementation of children with recurrent URTIs 
240 
DE 
SILVA ET AL 
should be considered and is likely to be associated with improved iron status, reduced morbidity, and enhanced well-being. 
We  are  grateful  to  the  Ministry  of  Health,  Sri  Lanka,  for  permitting  us  to  carry  out this study and to the Director and staff of 
the  Children’s  Hospital,  Sri  Lanka,  for  their  help.  We  sincerely  thank  Rajitha  Wickremesinghe,  Department  of  Community 
Medicine,  Faculty  of  Medical  Sciences,  University  of  Sri  Jayawardanepura,  Sri  Lanka,  for  statistical  advice.  We are grateful to 
the  field  investigators  for  their  diligent  work  and  to  our  subjects  and  their  parents  for  their  participation  and  cooperation.  We 
thank Sean Lynch for insights and help- ful comments. 
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