Observational studyPloS one2026
Hemoglobin outcomes associated with supervised therapeutic iron or preventive multiple micronutrient powder supplementation in high-altitude Peruvian infants: A real-world natural experiment.
Observational study in PloS one, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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6 authors.
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Abstract
backgroundIn Peru, legally mandated universal micronutrient supplementation policies preclude randomized trials.
objectiveTo evaluate hemoglobin (Hb) outcomes associated with enhanced follow-up of therapeutic iron or preventive multiple micronutrient powder (MNP) supplementation among high-altitude infants within a real-world natural experiment.
methodsThis observational study leveraged a policy-driven natural experiment to analyze two population-based cohorts of 317 infants aged 6-12 months from Puno, Peru (3,832 m), evaluated before and after implementation of strict follow-up. According to national guidelines, infants with anemia received therapeutic iron syrup (ferrous sulfate or iron polymaltose), while non-anemic infants received preventive MNP. Supplements were provided monthly for six months. Hemoglobin was measured at baseline and follow-up and adjusted for altitude using the WHO 2024 criteria. Adequate Hb response was defined as an increase ≥1 g/dL. Multivariable regression models assessed factors associated with hemoglobin response.
resultsOverall, 14.8% of infants achieved an Hb increase ≥1 g/dL (18.7% vs. 11.8% in the strict and non-strict follow-up groups, respectively). Among non-anemic infants at baseline, adequate Hb response was more frequent under strict follow-up (8.3% vs. 2.7%). In the prespecified primary adjusted model, strict follow-up was associated with higher odds of achieving an adequate Hb response (aOR 3.53; 95% CI 1.40-8.84), compared with the crude estimate (OR 2.45; 95% CI 1.30-4.63). In sensitivity analyses incorporating additional socioeconomic, nutritional, and program-related covariates, the association was attenuated (aOR 2.18; 95% CI 0.53-8.99). When evaluated as a continuous outcome, strict follow-up was associated with greater hemoglobin increases (adjusted mean difference 0.74 g/dL; 95% CI 0.23-1.25). At six months, altitude-adjusted anemia prevalence was lower in the strict follow-up group than in the non-strict group (25.2% vs. 38.2%, p = 0.019). Baseline anemia and older age were independently associated with larger hemoglobin gains.
conclusionsStrict follow-up was associated with greater increases in hemoglobin concentration and lower altitude-adjusted anemia prevalence at follow-up. Although anemia prevalence was lower among infants receiving strict follow-up, residual anemia remained common after six months of supplementation. These findings suggest that enhanced programmatic follow-up may improve hematologic outcomes under routine public health conditions, while additional factors contributing to anemia persistence warrant further investigation.
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