Can anyone provide some insight regarding this question I posted a few months ago? My organization is in the planning stage of an intermittent supplementation of iron/folic acid program for prevention of anemia in menstruating women. One of our physicians has asked how we will ensure that we don't give the iron/folic acid to undiagnosed sickle cell sufferers. Has anyone planned for this consideration before? Is it a concern? Is sickle cell anemia usually identified before adolescence?

Hi Ellen, Given that the situation you describe is so common, there's a surprising gap in any specific recommendations (as you have probably also found). I guess from your description of the planned intervention that you are basing it on the 2011 WHO guidelines for this population group, which do not highlight any specific issues of concern for sickle cell suffers. I also can't find any guidelines that advise against supplementation in this case, however most guidelines (including the latest Cochrane review) unfortunately do not specifically address supplementation in the context of haemoglobinopathies. If sickle cell anaemia is HbSS type then my understanding is that it will usually be diagnosed during the first year of life, however there are various types of heterozygous sickle cell, sickle cell trait: HbAS (which is often asymptomatic) as well as other combinations of this trait with other abnormal haemoglobin types. With regard to any negative effect of iron supplementation in HbAS sufferers, I can only find reference within the context of malaria. One study in The Gambia (TRANS R SOC TROP MED (1995) 89, 289-292) looking at supplementation in pregnant women found reduced birth weight among supplemented women, which was suggested to be a result of increased susceptibility to malaria during the pregnancy. Their conclusion was that these women may not benefit from supplementation, however the authors accepted the HbAS status may not be known for most women in the context of a public nutrition intervention. "Pregnant women resident in malaria endemic areas who are known to have the haemoglobin genotype AS should not routinely be given iron supplementation during pregnancy. Further, larger studies are needed to confirm our findings and to determine the balance of advantages and disadvantages of such supplements. However if iron is given to AS women, it should be accompanied by administration of effective malaria chemoprophylaxis regardless of maternal parity." In contrast, a study in Kenya (Am J Clin Nutr 2004;79:466–72) among pre-school children found "The benefits of iron supplementation are likely to outweigh possible risks associated with malaria in children with the HbAA or HbAS phenotype." So overall I'd probably advise as on page 5 of the WHO 2011 guideline that: "In malaria-endemic areas, the provision of iron and folic acid supplements should be made in conjunction with adequate measures to prevent, diagnose and treat malaria" It may be worthwhile contacting the WHO office in country to ask their advise also? And/or prompt them for the need for additional guidance on this issue. Hope this helps a little.

Jacky, this is very helpful so thank you so much for taking the time to write this.