Delayed iron improves iron status without altering malaria risk in severe malarial anemia

Sarah E. Cusick, Robert O. Opoka, Andrew S. Ssemata, Michael K. Georgieff, Chandy C. John, Chandy C. John

Research output: Contribution to journalArticlepeer-review

8 Scopus citations


Background: WHO guidelines recommend concurrent iron and antimalarial treatment in children with malaria and iron deficiency, but iron may not be well absorbed or utilized during a malaria episode. Objectives: We aimed to determine whether starting iron 28 d after antimalarial treatment in children with severe malaria and iron deficiency would improve iron status and lower malaria risk. Methods: We conducted a randomized clinical trial on the effect of immediate compared with delayed iron treatment in Ugandan children 18 mo-5 y of age with 2 forms of severe malaria: cerebral malaria (CM; n = 79) or severe malarial anemia (SMA; n = 77). Asymptomatic community children (CC; n = 83) were enrolled as a comparison group. Children with iron deficiency, defined as zinc protoporphyrin (ZPP) ≥ 80 μmol/mol heme, were randomly assigned to receive a 3-mo course of daily oral ferrous sulfate (2 mg · kg-1 · d-1) either concurrently with antimalarial treatment (immediate arm) or 28 d after receiving antimalarial treatment (delayed arm). Children were followed for 12 mo. Results: All children with CM or SMA, and 35 (42.2%) CC, were iron-deficient and were randomly assigned to immediate or delayed iron treatment. Immediate compared with delayed iron had no effect in any of the 3 study groups on the primary study outcomes (hemoglobin concentration and prevalence of ZPP ≥ 80 μmol/mol heme at 6 mo, malaria incidence over 12 mo). However, after 12 mo, children with SMA in the delayed compared with the immediate arm had a lower prevalence of iron deficiency defined by ZPP (29.4% compared with 65.6%, P = 0.006), a lower mean concentration of soluble transferrin receptor (6.1 compared with 7.8 mg/L, P = 0.03), and showed a trend toward fewer episodes of severe malaria (incidence rate ratio: 0.39; 95% CI: 0.14, 1.12). Conclusions: In children with SMA, delayed iron treatment did not increase hemoglobin concentration, but did improve long-Term iron status over 12 mo without affecting malaria incidence. This trial was registered at as NCT01093989.

Original languageEnglish (US)
Pages (from-to)1059-1067
Number of pages9
JournalAmerican Journal of Clinical Nutrition
Issue number5
StatePublished - May 1 2020

Bibliographical note

Funding Information:
Supported byEunice Kennedy Shriver National Institute of Child Health and Human Development grant 1U01HD064698-01 (to CCJ), National Institute of Neurological Disorders and Stroke grant R01 NS055349 (to CCJ), and Fogarty International Center grant D43 NS078280 (to CCJ).

Publisher Copyright:
Copyright © The Author(s) 2020.


  • cerebral malaria
  • inflammation
  • iron and malaria
  • iron deficiency
  • malaria
  • severe malarial anemia
  • zinc protoporphyrin


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