Iron with folic acid

Daily iron and folic acid supplementation during pregnancy

It is estimated that more than 40% of pregnant women worldwide are anaemic. At least half of this anaemia burden is assumed to be due to iron deficiency.

Pregnant women require additional iron and folic acid to meet their own nutritional needs as well as those of the developing fetus. Deficiencies in iron and folic acid during pregnancy can potentially negatively impact the health of the mother, her pregnancy, as well as fetal development.

Evidence has shown that the use of iron and folic acid supplements is associated with a reduced risk of iron deficiency and anaemia in pregnant women.

WHO recommendations

Daily oral iron and folic acid supplementation with 30 mg to 60 mg of elemental iron* and 400 µg (0.4 mg) folic acid** is recommended for pregnant women to prevent maternal anaemia, puerperal sepsis, low birth weight, and preterm birth.***

*The equivalent of 60 mg of elemental iron is 300 mg ferrous sulfate heptahydrate, 180 mg ferrous fumarate or 500 mg of ferrous gluconate.
** Folic acid should be commenced as early as possible (ideally before conception) to prevent neural tube defects.
*** This recommendation supercedes the previous recommendation found within the WHO guideline ‘Daily iron and folic acid supplementation in pregnant women’ (2012).

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Additional information for this recommendation can be found in the guidance summary and in the guideline, under ‘WHO documents’ below.

  • Guidance summary

This is one of several WHO recommendations on iron and folic acid supplementation. The full set of recommendations can be found in ‘Full set of recommendations’.

  • Full set of recommendations

WHO documents

GRC-approved guidelines
  • WHO recommendations on antenatal care for a positive pregnancy experience
    Publication date: 2016
  • Process for developing nutrition guidelines at WHO

Evidence

Systematic reviews used to develop the guidelines
  • Daily oral iron supplementation during pregnancy
    Peña-Rosas JP, De-Regil LM, Garcia-Casal MN, Dowswell T.
    Cochrane Database of Systematic Reviews. 2015; Issue 7. Art. No.: CD004736.
  • Summary of this review
Related systematic reviews
  • Maternal anemia and risk of adverse birth and health outcomes in low- and middle-income countries: systematic review and meta-analysis
    Rahman MM, Abe SK, Rahman MS, Kanda M, Narita S, Bilano V, et al.
    Am J Clin Nutr. 2016;103(2):495-504.
  • Anaemia, prenatal iron use, and risk of adverse pregnancy outcomes: systematic review and meta-analysis
    Haider BA, Olofin I, Wang M, Spiegelman D, Ezzati M, Fawzi WW.
    BMJ. 2013; 346:f3443.
  • Routine iron/folate supplementation during pregnancy: effect on maternal anaemia and birth outcomes
    Imdad A, Bhutta ZA.
    Paediatric and Perinatal Epidemiology. 2012; 26:168–177.
Clinical trials
  • Current and ongoing clinical trials relating to daily iron and folic acid supplementation during pregnancy

Cost-effectiveness

Cost-effectiveness analyses
  • Cost-effectiveness of prenatal food and micronutrient interventions on under-five mortality and stunting: Analysis of data from the MINIMat randomized trial, Bangladesh
    Svefors P, Selling KE, Shaheen R, Khan AI, Persson LÅ, Lindholm L.
    PLoS One. 2018; 13(2):e0191260.
  • Cost-effectiveness of invitation to food supplementation early in pregnancy combined with multiple micronutrients on infant survival: analysis of data from MINIMat randomized trial, Bangladesh
    Shaheen R, Persson LÅ, Ahmed S, Streatfield PK, Lindholm L.
    BMC Pregnancy Childbirth. 2015; 15:125.
  • Iron fortification and iron supplementation are cost-effective interventions to reduce iron deficiency in four subregions of the world
    Baltussen R, Knai C, Sharan M.
    J Nutr. 2004; 134(10):2678-84.
  • More about this feature

Taking iron supplements

ABOUT IRON SUPPLEMENTS

Iron supplements may be taken as capsules, tablets, chewable tablets, and liquids. The most common tablet size is 325 mg (ferrous sulfate). Other common chemical forms are ferrous gluconate and ferrous fumarate.

Have your health care provider tell you how many pills you should take each day and when you should take them. Taking more iron than your body needs can cause serious medical problems.

Blood counts return to normal after 2 months of iron therapy for most people. You may need to continue taking supplements for another 6 to 12 months to build up the body’s iron stores in the bone marrow.

TIPS FOR TAKING IRON

Iron is best absorbed on an empty stomach. Yet, iron supplements can cause stomach cramps, nausea, and diarrhea in some people. You may need to take iron with a small amount of food to avoid this problem.

Milk, calcium and antacids should NOT be taken at the same time as iron supplements. You should wait at least 2 hours after having these foods before taking your iron supplements.

Foods that you should NOT eat at the same time as you take your iron include:

  • High fiber foods, such as whole grains, raw vegetables, and bran
  • Foods or drinks with caffeine

Some doctors suggest taking a vitamin C supplement or drinking orange juice with your iron pill. This can help the iron absorb into your body. Drinking 8 ounces (240 milliliters) of fluid with an iron pill is also OK.

Tell your provider about all the medicines you are taking.

  • Iron tablets may cause other drugs you are taking to not work as well. Some of these include tetracycline, penicillin, and ciprofloxacin and drugs used for hypothyroidism, Parkinson disease, and seizures.
  • Medicines that reduce stomach acid will impair iron absorption. Your provider may suggest changing these.
  • Wait at least 2 hours between doses of these drugs and iron supplements.

SIDE EFFECTS

Constipation and diarrhea are very common. If constipation becomes a problem, take a stool softener such as docusate sodium (Colace).

Nausea and vomiting may occur with higher doses, but they can be controlled by taking the iron in smaller amounts. Ask your provider about switching to another form of iron rather than just stopping.

Black stools are normal when taking iron tablets. In fact, this is felt to be a sign that the tablets are working correctly. Talk to your provider right away if:

  • The stools are tarry-looking as well as black
  • If they have red streaks
  • Cramps, sharp pains, or soreness in the stomach occur

Liquid forms of iron may stain your teeth.

  • Try mixing the iron with water or other liquids (such as fruit juice or tomato juice) and drinking the medicine with a straw.
  • Iron stains can be removed by brushing your teeth with baking soda or peroxide.

Keep tablets in a cool place. (Bathroom medicine cabinets may be too warm and humid, which may cause the pills to fall apart.)

Keep iron supplements out of the reach of children. If your child swallows an iron pill, contact a poison control center right away.

Iron–Folic Acid Supplementation in Women of Reproductive Age

Iron–folic acid (IFA) supplementation during or before pregnancy can effectively reduce the risk of iron deficiency and anemia and improve gestational outcomes (Peña-Rosas and Viteri 2009).

Pre-conception: IFA supplementation before pregnancy can improve birth outcomes, increasing the iron and folic acid status in women pre-pregnancy, while addressing the iron deficiency that affects some menstruating women and adolescents (WHO 2009; WHO 2016a). Women of reproductive age (including adolescents) can be given oral IFA supplementation for three consecutive months, either daily or weekly, depending on the anemia prevalence rates in the setting (Table 4). Always consider the intervention in the context of other interventions to avoid exceeding daily iron requirements (e.g., mass fortification of staple foods) (WHO 2009).

Table 4: IFA Supplementation Recommendations for Women of Reproductive Age

Anemia Prevalence Among Women of Reproductive Age Recommendation
20–40% 120 mg iron + 2,800 mcg folic acid weekly
>40% 30-60 mg iron + 400 mcg folic acid daily for three consecutive months

Source: WHO 2009; WHO 2016a

Pregnancy: Women face increased iron requirements during pregnancy, and folic acid is necessary for the healthy development of the fetus. In the antenatal care package most countries, daily IFA supplementation is a key intervention. The World Health Organization (WHO) recommends daily oral IFA supplementation in areas where anemia prevalence rates are above 20 percent and weekly IFA supplementation in areas where anemia is 20 or below (see Table 5).

Table 5: IFA Supplementation Recommendations for Pregnant Women

Anemia Prevalence among Pregnant Women Recommendation
<20% 120 mg iron + 2,800 mcg folic acid weekly
20-40% 30-60 mg iron + 40 mcg folic acid daily
>40% 60 mg iron + 40 mcg folic acid daily

Source: WHO 2016b

IFA supplementation should begin as early as possible in a pregnancy and continue throughout. If a woman is diagnosed with anemia during her pregnancy, her iron dose should be increased to 120 mg daily until her hemoglobin concentration is normal (110 g/L or higher).

Low doses of folic acid—40 mcg daily or 2,800 mcg weekly—combined with iron can be given in combination with sulfadoxine-pyrimethamine to prevent malaria during pregnancy (see Intermittent Preventive Treatment during Pregnancy section) (Roll Back Malaria Partnership 2015; Maternal and Child Survival Program 2015). It is important to note that when providing IFA supplementation in settings with endemic infections, such as malaria and hookworm, measures to prevent and treat these infections should be implemented (WHO 2016b).

Many countries provide IFA supplementation to pregnant women through facility-based antenatal care, but in several countries, especially where antenatal care coverage is low, IFA supplements may be provided through community-based programs (MCHIP 2011). IFA supplementation for women of reproductive age (including adolescents) often relies on a community-based or other non-facility-based distribution model.

A barrier analyses on IFA supplementation consumption, while usually not nationally representative, can provide important insight into a program’s strengths and weaknesses, such as difficulties with the supply chain or poor distributor counseling skills (Sununtnasuk, D’Agostino, and Fiedler 2015). Quality of interpersonal counseling, and how side effects are addressed by health care providers, can also affect the implementation and effectiveness of an IFA supplementation intervention. Concerns about side effects are one main reason for non-compliance with IFA supplements among pregnant women; this may point to possible programmatic solutions, such as increasing women’s and communities’ awareness of the importance of supplements (Sadore, Gebretsadik, and Hussen 2015).

Measurement and data sources

Population-based surveys typically report the percentage of women with a live birth in the two to five years before the survey who received and took IFA supplementation during their most recent pregnancy. Surveys usually report means and medians, in addition to categorizing responses by the number of supplements consumed: any IFA supplements, less than 60, 60–89, or more than 90. Because antenatal care is typically the main platform for IFA supplement distribution for pregnant women, survey questions on antenatal care attendance and timing of the first antenatal care visit can provide information on the use of this platform to deliver IFA supplementation. Also, some surveys now ask women of reproductive age about their consumption of IFA supplements.

Surveys that collect information related to coverage of IFA supplementation include—

  • Demographic and Health Surveys
  • Multiple Indicator Cluster Surveys
  • National Micronutrient Surveys
  • Knowledge, Practice, and Coverage Surveys
  • other research or evaluation activities.

Health monitoring information systems usually include information about the distribution of IFA supplements to pregnant women, because they are one service that is supposed to be provided during antenatal care (Dwivedi et al. 2014).

Methodological issues

  • Coverage of IFA supplementation is not the same as adherence—and adherence to the correct dosing regimen is necessary to reach the intended impact. Most data sources report on IFA distribution, but women may not adhere to the dosage recommendations after they receive the supplements. Adherence intake is a challenge to measure and it may not be easily captured by the data outside year-end reports or research studies aimed at assessing coverage and adherence.
  • Pregnant women are supposed to take the supplement daily, beginning early in the pregnancy, but it can be difficult to find information on timing. Usually, timing of the first antenatal care visit is used as a proxy for beginning IFA supplementation, but this assumes that women do not have access to IFA supplementation earlier in the pregnancy.
  • Current routine data systems probably only capture IFA supplementation for pregnant women, while most systems do not collect data on supplementation for women of reproductive age, including adolescents.
  • Understanding antenatal care visits is helpful for interpreting data regarding IFA supplementation for pregnant women. Many countries, however, do not consistently record or report these data, complicating efforts to explain coverage of antenatal care services (Dwivedi et al. 2014).

Iron with or without folic acid supplementation in women

Full set of recommendations*

Nonpregnant adult women and adolescent girls (1,2)

Daily iron supplementation is recommended as a public health intervention in menstruating adult women and adolescent girls living in settings where the prevalence of anaemia is 40% or higher in this age group, for the prevention of anaemia and iron deficiency.

In populations where the prevalence of anaemia among nonpregnant women of reproductive age is 20% or higher, intermittent iron and folic acid supplementation is recommended as a public health intervention in menstruating women, to improve their haemoglobin concentrations and iron status and reduce the risk of anaemia.

Pregnant women (3)

Daily oral iron and folic acid supplementation with 30 mg to 60 mg of elemental irona and 400 µg (0.4 mg) folic acidb is recommended for pregnant women to prevent maternal anaemia, puerperal sepsis, low birth weight, and preterm birth.

Intermittent oral iron and folic acid supplementation with 120 mg of elemental ironc and 2800 µg (2.8 mg) folic acid once weekly is recommended for pregnant women to improve maternal and neonatal outcomes if daily iron is not acceptable due to side-effects, and in populations with an anaemia prevalence among pregnant women of less than 20%.

a The equivalent of 60 mg of elemental iron is 300 mg ferrous sulfate heptahydrate, 180 mg ferrous fumarate or 500 mg of ferrous gluconate.
b Folic acid should be commenced as early as possible (ideally before conception) to prevent neural tube defects.
c The equivalent of 120 mg of elemental iron is 600 mg ferrous sulfate heptahydrate, 360 mg ferrous fumarate or 1000 mg ferrous gluconate.

Postpartum (4)

Oral iron supplementation, either alone or in combination with folic acid, may be provided to postpartum women for 6–12 weeks following delivery for reducing the risk of anaemia in settings where gestational anaemia is of public health concern.d

d WHO considers a 20% or higher population prevalence of gestational anaemia to be a moderate public health problem.

* This is an extract from the relevant guidelines (1-4). Additional guidance information can be found in these documents.

SIDE EFFECTS: Constipation, diarrhea, or upset stomach may occur. These effects are usually temporary and may disappear as your body adjusts to this medication. If any of these effects persist or worsen, contact your doctor or pharmacist promptly.Iron may cause your stools to turn black, which is not harmful.If your doctor has prescribed this medication, remember that he or she has judged that the benefit to you is greater than the risk of side effects. Many people using this medication do not have serious side effects.An allergic reaction to this drug is unlikely, but seek immediate medical attention if it occurs. Symptoms of an allergic reaction include: rash, itching/swelling (especially of the face/tongue/throat), severe dizziness, trouble breathing.This is not a complete list of possible side effects. If you notice other effects not listed above, contact your doctor or pharmacist.In the US -Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.In Canada – Call your doctor for medical advice about side effects. You may report side effects to Health Canada at 1-866-234-2345.

PRECAUTIONS: Before taking this medication, tell your doctor or pharmacist if you are allergic to any of its ingredients; or if you have any other allergies. This product may contain inactive ingredients, which can cause allergic reactions or other problems. Talk to your pharmacist for more details.This medication should not be used if you have certain medical conditions. Before using this medication, consult your doctor or pharmacist if you have: certain metabolic disorders (e.g., hemochromatosis, hemosiderosis).Before taking this medication, tell your doctor or pharmacist your medical history, especially of: use/abuse of alcohol, stomach/intestinal problems (e.g., ulcers, colitis), vitamin B12 deficiency (pernicious anemia).During pregnancy, this medication should be used only when clearly needed. Discuss the risks and benefits with your doctor.This medication passes into breast milk. Consult your doctor before breast-feeding.

DRUG INTERACTIONS: See also How To Use section.If this drug has been prescribed, your doctor or pharmacist may already be aware of any possible drug interactions and may be monitoring you for them. Do not start, stop, or change the dosage of any medicine before checking with your doctor or pharmacist first.Before using this medication, tell your doctor or pharmacist of all prescription and nonprescription/herbal products you may use, especially: certain anti-seizure drugs (e.g., phenytoin), chloramphenicol, methyldopa.This product can decrease the absorption of other drugs such as bisphosphonates (for example, alendronate), levodopa, penicillamine, quinolone antibiotics (for example, ciprofloxacin, levofloxacin), thyroid medications (for example, levothyroxine), and tetracycline antibiotics (for example, doxycycline, minocycline). Therefore, separate your doses of these medications as far as possible from your doses of this product. Ask your doctor or pharmacist about how long you should wait between doses and for help finding a dosing schedule that will work with all your medications.This medication may interfere with certain laboratory tests (e.g., tests for blood in the stools), possibly causing false test results. Make sure laboratory personnel and all your doctors know you use this drug.This document does not contain all possible interactions. Therefore, before using this product, tell your doctor or pharmacist of all the products you use. Keep a list of all your medications with you, and share the list with your doctor and pharmacist.

QUESTION

According to the USDA, there is no difference between a “portion” and a “serving.” See Answer

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