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Iron-deficiency anemia and use of ferrous sulfate: prevention facilitators and difficulties


Nayara Cristina Pereira HenriqueI, Paula Carolina Bejo WolkersII, Maria Cândida de Carvalho FurtadoIII, Aurea Tamami Minagawa ToriyamaIV, Débora Falleiros de MelloV

I Nurse. Master in Sciences by the Graduate Program Nursing in Public Health, Ribeirão Preto College of Nursing - USP, Ribeirão Preto, São Paulo, Brazil. E-mail:
II Nurse. PhD in Sciences. Nurse at the Pediatrics and Neonatology Outpatient Clinic of the Clinical Hospital, Federal University of Uberlância - MG. Brazil. E-mail:
III Nurse. Professor, Department of Maternal and Child Nursing and Public Health, School of Nursing, Ribeirão Preto-USP, Ribeirão Preto, São Paulo, Brazil. E-mail:
IV Nurse. PhD Professor, School of Nursing, University of São Paulo, São Paulo, SP, Brazil. E-mail:
V Nurse. Associate Professor, Department of Maternal and Child Nursing and Public Health, School of Nursing, Ribeirão Preto-USP, Ribeirão Preto, São Paulo, Brazil. E-mail:
VI Acknowledgments: to the Coordination of Improvement of Higher Education Personnel (CAPES), for the financial support granted (master level scholarship). Study linked to the research project CNPq Process 309085/2015-2.





Objective: to learn about mothers' and caregivers' knowledge in relation to iron-deficiency anemia and preventive use of ferrous sulfate, with emphasis on factors that facilitate and hinder prevention of the disease. Method: in this qualitative exploratory study, stimulated thematic data analysis was used after interviews of 12 mothers and caregivers of children from six to 11 months and 29 days of age attending a family health unit in a Brazilian municipality. Results: healthy eating was indicated as a facilitator of iron-deficiency anemia prevention. Weaknesses in knowledge about the disease and about use of ferrous sulfate as a preventive strategy, flaws in medication prescription and daily use, and a scarcity of guidelines were the factors hindering prevention of the disease. Conclusion: health education activities in iron-deficiency anemia prevention, that signal information about the disease and monitoring of prophylactic supplementation, are essential to strengthening children's health care.

Keywords: Child; iron deficiency anemia; prevention; ferrous sulphate.




Iron Deficiency Anemia (IDA) is the most common type of anemia and an important public health problem, as it presents high prevalence rates as well as adverse consequences1,2 such as compromised immune system, increased infant mortality rates, reduction of cognitive function, of child growth and child neuropsychomotor development3.

In a Brazilian demographic and health survey of children4, there was a higher prevalence of the disease in 21.4% of children under two years of age. In childhood, the main causes of IDA are the high iron demand coupled with insufficient consumption of the mineral3.

The association between iron supplementation, food fortification, and food education has been pointed out as the best strategy of disease prevention 5. The Ministry of Health, aiming at reducing cases of anemia, has undertaken actions with emphasis on the Iron Supplementation National Program (ISNP), whose main objective is the reduction of cases and prevention of IDA, essentially in the age group up to 18 months, as well as in pregnant women, through the use of ferrous sulphate3,6, which is considered to be economic, effective, traditional and rapid for the control of iron deficiency7.

In the implementation of child health care programs, the low adherence to preventive measures to combat IDA, especially the use of ferrous sulfate, is worrying. Investigations3,4 showed that about one-third of the interviewed mothers administered iron-based medications for children, which is below the recommendations of the program. When analyzing the mothers' knowledge about IDA and its prevention, results8,9 showed that 20.5% of them did not report any anemia prevention activity and some demonstrated little knowledge about the purpose of iron supplementation with ferrous sulphate. In addition, the side effects presented by children and forgetfulness in administering the drug8,10 are also factors that contribute to the low adherence to the use of ferrous sulfate.

In view of these data, it should be pointed out that the Family Health Strategy (FHS) has as one of its priority actions in the attention to children's health, the monitoring of child growth and development. Considering that, if untreated, IDA can lead to complications in child growth and development3,11, it is important that FHS teams monitor the adherence to the use of ferrous sulfate and instruct families about IDA and its prevention. Assuming that IDA is a public health problem in childhood, the objective of this study is to understand the knowledge of mothers/caregivers about IDA and its prevention, with emphasis on the preventive use of ferrous sulfate and elements that facilitate or hinder the prevention of the disease.



This is an exploratory study with qualitative data analysis developed in a city in the countryside of the state of São Paulo.

The study was conducted between October and December 2015 in a Family Health Unit (FHU)which was chosen because of the high number of children under one year of age being followed-up at the unit, as well as because a unit where the FHS has been in force since 2001.

The participants were mothers/caregivers who met the following inclusion criteria: mothers/caregivers older than 18 years who cared for children in their daily routine, with children between the ages of 6 and 11 months and 29 days in the period of data collection, being followed-up in the FHS. The choice for this age group is justified by recommendations by the Brazilian Society of Pediatrics (BSP) and by the Ministry of Health to start the prophylactic iron supplementation at this age3,12. From the age of 12 months onwards, it is recommended that children be fed as in the usual routine by the family13,14. The exclusion criteria were: children who interrupted follow-up at the FHS, change of coverage area of the FHS unit, children with treatment for different types of diagnosed anemia or other conditions, and premature children.

To collect data, we used an interview guided by a semi-structured script with the main caregivers of the children, with questions about the child's health, IDA and its forms of prevention. After a survey conducted at the FHS, 16 eligible mothers/caregivers were identified; after applying the selection criteria, the study was composed of 12 mothers/caregivers. Participants were identified with the letter I (interviewee) followed by a number indicating the order of interviews: I1, I2 ... I12. The interviews were performed individually and recorded during home visits or after childcare consultation.

The interviews were conducted by the first author and had an average duration of 30 minutes each. The start of the interview was guided by the question "How is your child's health?" and then by the questions "What does iron deficiency anemia mean to you?", "How should children be cared in order to prevent anemia?", "Do you know what is ferrous sulfate?". From the thread of the interview, additional questions about child feeding, use or lack of use of ferrous sulfate, and experience in the use of the drug were also made. Of the 12 interviews, three were performed after the child care consultation at the health unit and during home visits.

Data were analyzed through content analysis of the inductive thematic type, in which the identified themes are extracted from the data itself15.

The master's dissertation from which the present study originated was approved by the Research Ethics Committee of the Nursing School of Ribeirão Preto-USP according to Official Letter 131/2016, CAAE nº 51885115.8.0000.5393. The Informed Consent Term was used, according to Resolution 466/12 of the National Health Council.



Of the twelve interviews conducted, eleven were with mothers and one with the maternal grandmother, who considered themselves primary caregivers of the child and who took them to the health care unit.

There was a predominance of the age group between 20 and 34 years at the time of delivery, of the occupation of housewife, and only three interviewees had seven or more years of schooling. Regarding the children, eight were males, born through normal birth; one of the children was born weighing less than 2500g, three had exclusive breastfeeding until six months, and in the case of one child there was a late introduction of food, at seven months of age.

In the data analysis, aspects that reflect the main elements of the research focus emerged and were grouped in the following thematic units: "Iron deficiency anemia: knowledge about the disease"; and "Prevention of anemia and use of ferrous sulfate".

Iron deficiency anemia: knowledge about the disease

In their reports, caregivers expressed knowledge about IDA and related the disease with blood problems; however, they did not specify the problem and there was little in-depth understanding of the issue.

I know it's lack of iron, but I do not know how to explain it to you. (I1)

It is the lack of iron in the body. (I5)

I guess it's [...] isn't it a problem in the blood? Is it the lack of blood or something? (I4)

All I know is we need more iron. It's a blood thing, right? (I11)

The relationship between anemia and food and some symptoms also came up.

For me, it means that the child does not eat some things that contain iron. So, therefore, anemia appears. (I2)

I think anemia is a poor diet. When the person eats badly, the person gets anemia.(I7)

It is when the child does not eat. The child will lose weight. I think that's it. (I9)

That's when you do not eat vegetables, these things, vegetables. (I10)

My friend, her daughter already had it. And her little eyes here turned white, you know? (I12)

Although they expressed the knowledge about the IDA disease, it is important to highlight speeches as the association between the disease and the appearance of neoplasms.

Anemia is when blood becomes weak, in my opinion, and it turns to blood cancer, right? (I6)

Anemia is a very serious thing, it causes cancer if not prevented, if care is not provided. So, it's dangerous if the child has anemia. (I3)

Concern with IDA due to previous experiences with the disease was demonstrated by one of the interviewees and it was related to a relative/acquaintance that had already been affected by the disease.

I am very scared of anemia because I had it before, in my pregnancy. (I2)

My mother already had anemia. So it's a very worrying thing for me. She was very sick, she passed out. Seriously, I was really worried. (I12)

Prevention of anemia and use of ferrous sulfate

Six participants reported no prescription of ferrous sulfate for the child; the others were using it at the time of the interview or had already used the drug. Of these, there was a prescription for a child at seven months of age, and for the others, the prescription followed the recommendations of the Brazilian Society of Pediatrics and the Ministry of Health 3,12.

In the context of IDA prevention, some caregivers indicated healthy eating and regular health monitoring as prevention strategy.

Food is important to prevent it, in order to ingest proteins, vitamins, which are present in fruits and vegetables. I think that iron is also, it comes from fruits, vegetables and meats. (I1)

Food and medical follow-up. I think only good food is enough. (I8)

Foods that fight the disease are very important, and the care with food. (I11)

Also regarding the prevention of the disease, there was recognition of the importance of using a "medicine", and also doubts about this medicine. It was noted, in some statements, that the caregivers knew the medicine by name (ferrous sulfate). Moreover, it was believed that a healthy diet can replace the need to use ferrous sulfate.

You have to give ferrous sulfate, right? And also you have to give sugar beet, plenty of vegetables. (I6)

If you are preventing by giving the medicine [ferrous sulphate] before the problem appears, this is the best. This is the best thing to do. The reason I supported ferrous sulfate is because my child is not eating well. If someone eats well and rests well, you eat at the right time, you rest at the right time, yes it is ok; there is no need for ferrous sulfate. But if you are not eating, then you have the need to prevent it. (I4)

Some medicine, if I had some medicine to give, to avoid anemia, understand? It would be very important to prevent. (I7)

Some interviewees who reported the use of ferrous sulphate expressed difficulties related to administration of the drug and the adverse reactions caused by it; but also expressed their insistence on the use of the drug.

I think the problem is the taste, right? I realize it's kind of weird, at first he found it strange, then he took it. He would reject it always, but as I knew it was for his good, I insisted. (I6)

The first few times she did not take the juice at all, and the remedy was in the juice. After much insistence she took it. And her feces turned very dark. (I2)

He's even drinking now. So, he is and he is not, right? Because he is having a reaction and is throwing up. I have prepared it in every way possible, in the syringe, in the spoon, in the glass, in the juice, in the fruit. (I1)

It's difficult because most of the times he throws the medicine away. And I also noticed that after I gave the medicine, the color of the feces changed to dark green. (I4)

Among the children who did not have a prescription for ferrous sulfate, some interviewees reported knowing the medication and questioned the non-prescription of the medication for the child during health follow-ups.

I learned that when the babies start to grow they [doctors] prescribe it, don't they? And it is to give it in the juice. My mother always took care of the children here of the neighbor, and doctors always prescribed it and the children took it. So I said, 'Mother, did the physicians prescribe ferrous sulphate to him [child]?' and she said no. (I10)

When I took her [child], I asked if she needed to take it. Then the doctor said no, she was fine. When you have anemia, I think ferrous sulfate helps, right? Then the doctor said she did not need it, that the ferrous sulfate was not to prevent, it was to treat. (I7).



The results of the study suggest a superficial knowledge of mothers/caregivers about IDA, its definition and prevention, and the fragility of recognizing the need to use ferrous sulfate as a preventive measure.

Expressing a concept about IDA is a difficulty encountered by some mothers, demonstrated by the lack of definition or the occurrence of a relationship between IDA and its clinical signs. They frequently used the term "weak blood" to refer to anemia8. When expressing their concept about the disease, the participants brought their definitions permeated by doubts, characterizing an affirmation followed by a question. Still, some reports revealed the idea that anemia can progress to leukemia, a relationship already found in another study8. This fact suggests the need to provide more clarification and information for caregivers. Lack of knowledge about the disease was identified as a difficult factor for the prevention of IDA, because it is difficult to act in the prevention of a disease that mothers/caregivers do not know much about.

Relating IDA to poor feeding was a recurrent aspect in the interviews, with emphasis on the importance of food for disease prevention. In this way, this aspect is identified as a facilitator for the prevention of the disease. However, a study that investigated the feeding practices of children showed that both natural food sources of iron and those food which are fortified with the mineral were ingested in low quantities by children in their first year of life16. Offering assorted foods is a recommendation for children up to ten years of age17, however due to economic, social and cultural conditions, the diversification in this offer is not a reality present in several Brazilian families.

The individual experience or knowing someone affected by anemia brought a lot of apprehension among some interviewees, since the evolution of the disease and the vulnerability of children can bring consequences for their health. Therefore, it is necessary to know the consequences of the disease, so that this is reflected on the prevention of the disease and the promotion of children's health8.

With regard to the use of ferrous sulfate, it was learned from the reports that some mothers recognize the importance of the medicine in the prevention of anemia and that the main difficulties are: rejection by the child to ingest the medication, suspicion that the taste is unpleasant, and the browning of the feces. However, it was noted that despite the difficulties faced, the interviewees understood the benefits of the medicine for the children's health and insisted on its use. Side effects resulting from the use of ferrous sulphate, besides forgetfulness, are indicated as the main factors for the continuation or even interruption of its use8-10. Thus, families and caregivers need guidance on the importance to continue the use of ferrous sulfate, as well as previous explanations, on possible side effects, aiming at the prevention of the disease and the correct use of the drug. Although some reports revealed the importance of ferrous sulfate, the difficulties encountered in its use, combined with side effects, are identified as hindering the prevention of the disease, similar to other studies8-10, in which the side effects were determinants for discontinuation of administration.

The lack of monitoring and follow-up of supplementation by FHS health professionals is also a factor that directly influences supplementation with ferrous sulfate18. In the present study, besides the prescription, there were no reports on the follow-up of health professionals regarding their use.

Although some interviewees pointed out the use of ferrous sulfate as a preventive measure, investigations have demonstrated that there is an understanding that the drug is related only with the treatment of IDA9; a low percentage of caregivers recognized ferrous sulfate as a preventive measure of the disease8. Such factors may contribute to both the low adherence to use of ferrous sulfate and low effectiveness of the supplementation program.

Problems of planning and management, motivation of mothers and health professionals, lack of professional training, and lack of prescription of the medication are some of the reasons cited as obstacles to the effectiveness of the Iron Supplementation National Program7,19. The reports showed that some children did not receive the prescription of the drug, a fact that suggests a professional attitude that is dissonant with public policy recommendations in favor of IDA prevention. The low number of children in the study who had received prescription of ferrous sulfate as well as the lack of guidance on its use were identified as factors that hindered the prevention of anemia, despite the recommendations of the public policies and the guidelines to promote the prevention of the disease. Furthermore, training for health professionals should take into account their beliefs and experiences so that the recommendations may be incorporated into care20.

Considering the gaps and weaknesses in the programmatic/care implementation of the Iron Supplementation National Program found in this study and considering that IDA can have irreversible consequences on the health and development of the children, we can affirm that we are before a situation of vulnerability in children development21. Insufficiencies in programmatic implementations also make the access difficult and deprive users of their rights, strengthening the chances of harm to health and negatively impacting the children's quality of life21.

A survey conducted in the city where this study was carried out identified a prevalence of 48% of anemia in the age group of six to twelve months of life in 201022. This fact reinforces the importance of implementing surveillance actions for the health of the children, and nurses are responsible for conducting actions for health promotion and prevention of diseases, educational actions, and care interventions as well as early detection of vulnerable situations. In this sense, the attention to children in the primary health care network aims to ensure the monitoring and surveillance of essential needs, growth and development of children, considering maternal and family values23. Therefore, comprehensive and longitudinal care for child's health is a fundamental part of the actions developed in the FHS.



The present study identified aspects related to the knowledge of mothers/caregivers about IDA and its prevention, demonstrating the deficiency and superficiality in this knowledge as well as gaps in the access to prescription of ferrous sulfate and information about its use. The results point to fragilities in the health care of children in the studied context, indicating a deprivation of rights in health and the predisposition to a situation of vulnerability which may favor the emergence of IDA and its complications in the short and long term.

Healthy eating was pointed out as a facilitator in the prevention of IDA. The fragility of the knowledge about the disease and the use of ferrous sulfate as a preventive strategy, failures in the prescription of ferrous sulfate, difficulties in the use of the drug, and a low repertoire of guidelines are elements that hinder the prevention of the disease.

The results may direct future health education practices focused on the prevention of IDA since they indicate that information about the disease and the daily use of ferrous sulfate in children are topics that deserve attention and should be highlighted when it comes to child care both among families as well as health professionals. In addition, it is important monitoring the routine of prophylactic supplementation, including prescription, adherence and interruption.

Nursing plays a fundamental role in the promotion of educational practices in health, guiding and clarifying doubts, and assisting in decision making and problems. In the routine of the FHS, childcare consultations and home visits should be considered practices that provide significant opportunities, with interaction and sharing of knowledge, in which nursing can act to prevent injuries, promote, treat and recover children health.

The present study has limitations due to the small number of participants and its realization in a contextualized reality. The approach used brings important aspects to the qualitative understanding of the phenomenon of the prevention of IDA in children and encourages reflection on the guarantee of rights and access to public health policies instituted for children. Finally, this study generates aspects to be investigated in further researches in different scenarios and contexts.



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Direitos autorais 2018 Nayara Cristina Pereira Henrique, Paula Carolina Bejo Wolkers, Maria Cândida de Carvalho Furtado, Aurea Tamami Minagawa Toriyama, Débora Falleiros de Mello

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