Iron and folic acid supplementation is not routinely provided in many CMAM programs. Fortified supplementary foods used for the treatment of MAM do contain iron and folic acid in prescribed doses varying between food products. The WHO/ UNICEF/ WFP do not have any current recommendation on the administration of these supplements in children undergoing treatment for MAM. However, there is a WHO recommendation for point-of-use fortification of complementary foods with iron-containing micronutrient powders in infants and young children in populations where anemia is a public health problem (WHO guideline: Use of multiple micronutrient powders for point-of-use fortification of foods consumed by infants and young children aged 6–23 months and children aged 2–12 years. Geneva: World Health Organization; 2016.) . These interventions may be included in national protocols for the management of all children in a community.

Hi Anonymous,

In an integrated CMAM programme reference would normally be made to national IMCI / IMNCI guidelines or their equivalent. As an example, IMNCI guidelines indicate the following doses to be given daily for a period of 14 days for "some palmar pallor":

For infants / children aged < 1 year using ferrous fumarate (20mg / 5ml)

< 2 months- 4 months (4-5kg) give 1 ml

4 months - 12 months (6 - 9.9kg) give 1.25ml

For children aged > 12 months using ferrous sulphate 200mg + Folate 250mcg tablets

12 months to 3 years (10 - 13.9kg) give 1/2 (half) tablet

3 years to 5 years (14 - 19 kg) give 1 (one) tablet

The guidelines state that this would not be given to children on RUTF, and severe anaemia would necessitate hospital admission.

WFP endorsed Philippine national guidelines on the management of MAM indicate the same doses to be given daily for a period of 3 months for iron deficiency anaemia (https://docs.wfp.org/api/documents/WFP-0000019825/download/?_ga=2.31184762.459941052.1561018056-1150098128.1561018056). 

WHO / UNICEF indicate that, in emergency contexts, the recommended nutrient intake (RNI) per day for children 6-59 months is 10mg iron and 150mcg folate given in the form of multiple micronutrient powders. If fortified rations are not being used then give 1 RNI per day for children 6 to 59 months. If fortified rations are being used then give 2 RNI per week. 

However if treating MAM the micronutrient profile of the food product needs to be considered. If RUSF is being used, this contains approximately 11mg iron and 300 mcg folate per packet (92g), which as Mark indicates is a therapeutic dose assuming the standard ration of 1 packet per day. If Supercereal is being used, this contains 6mg iron and 101mcg folate for an equivalent 92g amount.

For a 130g dose (500kcal) of super cereal per day this is approximately 8mg iron and 140mcg folate (e.g. Philippine guidelines quoted above). The Philippine guidelines recommend 2 sachets of MNP per week for a minimum of 2 months given with the 130g ration of supercereal (however MNP are not to be given with RUSF).

For a 200g dose (787kcal) per day (WFP food fact sheet recommended dose) this is approximately 13 mg iron and 220mcg folate which would also satisfy the UNICEF / WHO recommended daily RNI.

In short, guidelines vary and consultation of national guidelines and appreciation of local context are a necessity.

Paul