Effectiveness of iron-fortified infant cereals on prevalence of anemia among children.

Dear Editor,

We read with great interest the article by Fotedar et al.[1] in the recent issue of your journal. I would like to commend the authors for their endeavor, but at the same time have the following comments to offer, explanation to which will benefit the readership of the journal.

The authors enrolled apparently healthy children between 12 and 24 months visiting the outpatient department (OPD) who were already on complementary feeds. The exclusion criteria virtually exclude all possible medical indications for which one visits OPD. So, what was the purpose of the visit to the hospital? Whether it was for vaccination or routine checkup is not clearly defined. The clear description of the inclusion criteria will improve the generalizability and the external validity of the study

Here, neither the duration of intake of the iron-fortified infant cereal (IFIC), amount of feed, and so on nor the time point of the assessment is mentioned. For an intervention, it is necessary to have defined time point for starting, the amount prescribed, and compliance with the intervention, along with the measures and time point of the outcome assessment

The dietary intake and socioeconomic status have a strong influence on the prevalence of the iron deficiency anemia.[23] Did authors recorded these and were they comparable between the two groups?

The baseline characteristics of the study subjects are not described. In the absence of baseline comparable value of hemoglobin, boys, and low-birth-weight infants among two groups, the results lose its validity. It might be possible that these two groups were different at the enrollment itself and the intervention did not make any difference. Also, the authors did not define the method of classifying the participants into two groups. As it was not a randomized trial, so there is a very high chance of bias, and in such cases, accepted method is the use of age and weight-matched controls

In Table 1, the comparison of weight and height between two groups shows that the IFIC group has significantly higher values. However, at the same time, the children in IFIC group were significantly older than the control group. So, it is natural to have larger weight and height and may not be related to the intervention. In such cases, the best way will be a comparison of the prevalence of underweight/stunting and wasting which will take age into the account

There is no mention regarding routine iron supplementation of iron in the study population. As per the “National Iron+ Initiative guidelines” by Ministry of Health and Family Welfare, all the children between 6 and 60 months should receive 1 mL of IFA syrup containing 20 mg of elemental iron and 100 μg of folic acid, biweekly, that is, 100 doses per year, along with biannual deworming.[4] So, it will be prudent to know the compliance of such programme in private clinical setup. It will be unethical to devoid the intervention group from iron supplementation.

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Conflicts of interest

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