Improved adherence and anaemia cure rates with
flexible administration of micronutrient Sprinkles:
a new public health approach to anaemia control
H Ip1, SMZ Hyder2, F Haseen3, M Rahman3and SH Zlotkin4
1Formerly affiliated with the Department of Nutritional Sciences, University of Toronto and Program in Metabolism and Integrated
Biology, Research Institute, The Hospital for Sick Children, Toronto, Canada;2Program in Child Health Evaluative Sciences, Research
Institute, The Hospital for Sick Children, Toronto, Canada and Department of Public Health Sciences, University of Toronto, Toronto,
Canada;3Research and Evaluation Division, BRAC, Dhaka, Bangladesh and4Division of Gastroenterology, Hepatology and Nutrition
and Program in Child Health Evaluative Sciences, Department of Paediatrics and Research Institute, The Hospital for Sick Children,
Toronto, Canada and the Departments of Paediatrics, Nutritional Sciences and Public Health Sciences, University of Toronto, Toronto,
Background/Objectives: Despite repeated public commitments and availability of various forms of iron supplements, rates of
anaemia in developing countries remain high. A major reason for this lack of success has been poor adherence. The objective of
this study was to compare the effectiveness of daily and flexible administration of micronutrient Sprinkles on adherence,
acceptability and haematological status among young children in rural Bangladesh.
Subjects/Methods: A sample of 362 children (haemoglobin (Hb)X70gl?1) aged 6–24 months were cluster-randomized to
receive 60 sachets of Sprinkles either (i) daily over 2 months; (ii) flexibly over 3 months; or (iii) flexibly over 4 months. With a
flexible regimen, mothers/caregivers decided how frequently to use Sprinkles without exceeding one sachet per day. Adherence
was assessed monthly by counting the number of sachets used and acceptability was evaluated through focus group discussions.
Haemoglobin was measured at baseline, at the end of each intervention period and 6 months post-intervention.
Results: Mean percent adherence was significantly higher in the flexible-4-month group (98%) compared to the flexible-
3-month (93%) and daily-2-month (88%) groups (Po0.01). Most mothers found flexible administration to be more acceptable
than daily due to perceived benefits of use. Hb at the end of intervention was significantly higher in the flexible-4-month group
compared to the daily group (P¼0.03). Anaemia prevalence decreased by 65% in the flexible-4-month group compared to
54% in the flexible-3-month and 51% in the daily-2-month groups. Percent of cured children who maintained a non-anaemic
status 6 months post-intervention was significantly higher in the flexible-4-month (82%) and flexible-3-month (80%) groups
than the daily-2-month (53%) group (Po0.05).
Conclusions: The adherence, acceptability and haematological response to flexible administration over 4 months were found
preferable to daily.
European Journal of Clinical Nutrition advance online publication, 26 September 2007; doi:10.1038/sj.ejcn.1602917
Keywords: Sprinkles; anaemia; flexible administration; children; Bangladesh; iron deficiency
In South Asia, 60–75% of under-5 children suffer from
anaemia (ACC/SCN, 2004; BBS/UNCF, 2004). Among the
multiple causes of anaemia, iron deficiency due to insuffi-
cient dietary intake is the most common cause (Gibson et al.,
1998; UNICEF/UNU/WHO/MI, 1999). The consequences of
iron-deficiency anaemia (IDA) may include impaired cogni-
tive, motor and behavioural development (Lozoff et al.,
2000, 2003; Grantham-McGregor and Ani, 2001). Therefore,
effective public health strategies are needed to prevent and
treat the problem. Although iron supplementation with
ferrous sulphate drops and syrup has been the primary
therapeutic intervention for IDA in infants, iron drops have
not proven to be effective as a large-scale public health
Received 20 March 2007; revised 20 June 2007; accepted 6 August 2007
Correspondence: Dr SH Zlotkin, The Hospital for Sick Children, 555 University
Avenue, Toronto, ON, Canada M5G 1X8.
European Journal of Clinical Nutrition (2007), 1–8
& 2007 Nature Publishing Group All rights reserved 0954-3007/07 $30.00
Ahmed F (2000). Anaemia in Bangladesh: a review of prevalence and
aetiology. Public Health Nutr 3, 385–393.
Ahmed SM, Adams AM, Chowdhury M, Bhuiya A (2003). Changing
health-seeking behaviour in Matlab, Bangladesh: do development
interventions matter? Health Policy Plan 18, 306–315.
BBS/UNCF (2004). Anaemia Prevalence Survey of Urban Bangladesh and
Rural Chittagong Hill Tracts 2003. Bangladesh Bureau of Statistics/
United Nation’s Children’s Fund: Dhaka.
BRAC (2002). Annual Report. Bangladesh Rural Advancement Com-
Ciomarten T, Nanu R, Iorgulascu D, Moldovanue F, Popa S, Palicari G
(1995). Iron supplement trial in Romania. In: Nestel P (ed).
Proceedings, Iron Interventions for Child Survival. USAID and ICH:
London, pp 89–98.
Cohen AR, Seidl-Friedman J (1988). HemoCue system for hemo-
globin measurement. Evaluation in anemic and nonanemic children.
Am J Clin Pathol 90, 302–305.
Davidsson L, Jamil KA, Sarker SA, Zeder C, Fuchs G (2004). Human
milk as a source of ascorbic acid: no enhancing effect on iron
bioavailability from traditional complimentary food consumed by
Bangladeshi infants and young children.Am J Clin Nutr79, 1073–1077.
DeMaeyer EM, Dallman P, Gurney JM, Hallberg L, Sood SK, Srikantia
SG (1989). Preventing and Controlling Iron Deficiency Anaemia
Through Primary Health Care: a Guide for Health Administrators and
Programme Managers. World Health Organization: Geneva.
Galloway R, McGuire J (1994). Determinants of compliance with iron
supplementation: supplies, side effects, or psychology? Soc Sci Med
Gibson RS, Ferguson EL, Lehrfeld J (1998). Complementary foods for
infant feeding in developing countries: their nutrient adequacy
and improvement. Eur J Clin Nutr 52, 764–770.
Giovannini M, Sala D, Usuelli M, Livio L, Francescato G, Braga M
et al. (2006). Double-blind, placebo-controlled trial comparing
effects of supplementation with two different combinations of
micronutrients delivered as Sprinkles on growth, anemia, and iron
deficiency in Cambodian infants. J Pediatr Gastroenterol Nutr 42,
Grantham-McGregor S, Ani C (2001). A review of studies on the
effect of iron deficiency on cognitive development in children.
J Nutr 131, 649S–666S; discussion 666S–668S.
Hirve S, Bhave S, Bavdekar A, Naik S, Pandit A, Schauer C et al.
(2007). Low dose ‘Sprinkles’—an innovative approach to treat iron
deficiency anaemia in infants and young children. Indian Pediatr
HKI/IPHN (2000). High Anemia Prevalence Among Bangladeshi Children
in Urban Slums: An Ethical and Economic Rationale for Multi-
Urban Anemia Prevalence Bulletin. Hellen Keller International and
Institute of Public Health Nutrition: Dhaka.
Hyder SMZ, Haseen F, Rahman M, Tondeur MC, Zlotkin SH (2007).
Effect of daily vs once weekly home fortification with micro-
nutrient Sprinkles on hemoglobin and iron status among young
children in rural Bangladesh. Food Nutr Bull 28, 156–164.
Khan ME (1990). Breast-feeding and weaning practices in India. Asia
Pac Popul J 5, 71–88.
Levin L (1981). Self-care in health: potentials and pitfalls. World
Health Forum 2, 177–184.
Lozoff B, De Andraca I, Castillo M, Smith JB, Walter T, Pino P (2003).
deficiency anemia in healthy full-term infants. Pediatrics 112,
Lozoff B, Jimenez E, Hagen J, Mollen E, Wolf AW (2000). Poorer
behavioral and developmental outcome more than 10 years after
treatment for iron deficiency in infancy. Pediatrics 105, E51.
Mora JO (2002). Iron supplementation: overcoming technical and
practical barriers. J Nutr 132, 853S–855S.
Nestel P, Alnwick D (1997) Iron/multi-micronutrient supplements for
young children. Summary and conclusions of consultation. UNICEF,
Copenhagen, August 19–20, 1996. Washington, DC: International
Life Sciences Institute.
Nestel P, Briend A, de Benoist B, Decker E, Ferguson E (2003).
Complementary food supplements to achieve micronutrient
adequacy for infants and young children. Pediatr Gastroenterol
Nutr 36, 316–328.
NIPORT (2004). Bangladesh Demographic and Health Survey. National
Institute of Population Research and Training, Mitra and Associ-
ates and ORC Macro: Dhaka.
Scrimshaw SCM, Hurtado E (1987). Rapid Assessment Procedures for
Nutrition and Primary Care: Anthropological Approaches to Improving
Programme Effectiveness. UCLA Latin American Center Publication:
Sharieff W, Wu M, Yin S, Yang Q, Schauer C, Asante KP et al. (2006).
Weekly Administration of Micronutrient Sprinkles in School has High
Compliance and Does not Cause Iron Overload in Chinese Children: A
Cluster-Randomized Trial. Public Health Nutrition 9, 336–344.
Stoltzfus RJ, Dreyfuss ML: Guidelines for use of iron supplements to
prevent and treat iron deficiency anaemia. INACG/WHO/UNICEF,
Tondeur MC, Schauer CS, Christofides AL, Asante KP, Newton S,
Serfass RE et al. (2004). Determination of iron absorption from
intrinsically labeled microencapsulated
(Sprinkles) in infants with different iron and hematologic
status by using a dual-stable-isotope method. Am J Clin Nutr 80,
UNICEF/MI (2004). Vitamin and Mineral Deficiency A Global Progress
Report. The Micronutrient Initiative: Ottawa.
UNICEF/UNU/WHO/MI. Preventing Iron Deficiency in Women and
Children: Technical Consensus on Key Issues, (1999): International
Nutrition Foundation: Boston, MA.
Viteri FE (1996). Weekly compared with daily iron supplementation.
Am J Clin Nutr 63, 610–612.
WHO (1993). Measuring Changes in Nutritional Status. World Health
Zlotkin S, Arthur P, Antwi KY, Yeung G (2001). Treatment of anemia
with microencapsulated ferrous fumarate plus ascorbic acid
supplied as Sprinkles to complementary (weaning) foods. Am J
Clin Nutr 74, 791–795.
Zlotkin S, Arthur P, Schauer C, Antwi KY, Yeung G, Piekarz A (2003).
Home-fortification with iron and zinc Sprinkles or iron Sprinkles
alone successfully treats anemia in infants and young children.
J Nutr 133, 1075–1080.
Zlotkin SH, Schauer C, Christofides A, Sharieff W, Tondeur MC
(2005). Micronutrient Sprinkles to control childhood anaemia.
PLoS Med 2, 24–28.
Daily versus flexible administration of multiple micronutrient Sprinkles
H Ip et al
European Journal of Clinical Nutrition