A TRIAL OF IRON-BIOFORTIFIED PEARL MILLET ON NEUROCOGNITIVE DEVELOPMENT IN ANAEMIC PRESCHOOL CHILDREN IN A RURAL COMMUNITY

Saira Zubair; Fatima Ayub

Authors

Saira Zubair The Sahara College, Narowal, Pakistan. Author
Fatima Ayub University of Agriculture Faisalabad, Pakistan. Author https://orcid.org/0009-0000-8371-4794

Keywords:

Anaemia, Biofortification, Cognitive Development, Iron Deficiency, Nutritional Intervention, Pearl Millet, Preschool Children

Abstract

Background:
Iron deficiency anaemia remains a major public health issue affecting millions of children in low- and middle-income countries, with profound effects on neurocognitive development. Biofortification of staple foods, such as pearl millet, provides a sustainable dietary approach to improving iron intake and reducing the burden of anaemia among vulnerable populations.

Objective:
To assess the impact of consuming iron-biofortified pearl millet on cognitive performance and haemoglobin concentration in anaemic preschool children living in a rural community of Lahore, Pakistan.

Methods:
A 12-month randomized controlled trial was conducted among 120 anaemic preschool children (aged 3–5 years). Participants were randomly assigned to receive daily meals prepared from either iron-biofortified pearl millet (Fe-PM, 80 ppm Fe) or conventional pearl millet (control, 25 ppm Fe). Haemoglobin and serum ferritin concentrations were measured at baseline, 6 months, and 12 months using standardized laboratory methods. Cognitive development was assessed using the Ages and Stages Questionnaire (ASQ-3) and selected subtests from the Wechsler Preschool and Primary Scale of Intelligence (WPPSI-IV). Data were analyzed using t-tests, ANOVA, and Pearson’s correlation, with significance set at p < 0.05.

Results:
The intervention group showed significant increases in haemoglobin (from 9.3 ± 0.8 to 11.5 ± 0.9 g/dL; p = 0.001) and ferritin (from 18.2 ± 5.4 to 34.4 ± 6.8 µg/L; p = 0.002). Cognitive scores improved markedly in communication (+11.2), problem solving (+12.5), and working memory (+12.4) domains (p = 0.001). Positive correlations were observed between haemoglobin gains and cognitive improvements (r = 0.62–0.71). No adverse effects were reported, and compliance exceeded 90%.

Conclusion:
Iron-biofortified pearl millet significantly enhanced both haematological and neurocognitive outcomes, supporting its potential as a sustainable, community-based strategy to combat childhood anaemia and promote cognitive development in resource-limited settings.

Author Biographies

Saira Zubair, The Sahara College, Narowal, Pakistan.

Lecturer, The Sahara College, Narowal, Pakistan.
Fatima Ayub, University of Agriculture Faisalabad, Pakistan.

MPhil Microbiology University of Agriculture Faisalabad, Pakistan.

References

1. East P, Doom J, Blanco E, Burrows R, Lozoff B, Gahagan S. Young adult outcomes associated with lower cognitive functioning in childhood related to iron-fortified formula in infancy. Nutr Neurosci. 2022;25(4):709-18.

2. Jullien S. Screening of iron deficiency anaemia in early childhood. BMC Pediatr. 2021;21(Suppl 1):337.

3. Nampijja M, Mutua AM, Elliott AM, Muriuki JM, Abubakar A, Webb EL, et al. Low Hemoglobin Levels Are Associated with Reduced Psychomotor and Language Abilities in Young Ugandan Children. Nutrients. 2022;14(7).

4. Karatepe BA, Yıldız S, Yıldırım TT. Iron, Emotion, and Awareness: Exploring Alexithymia and Anxiety in Anemic Women. Medicina (Kaunas). 2025;61(8).

5. East PL, Reid B, Blanco E, Burrows R, Lozoff B, Gahagan S. Iron supplementation given to nonanemic infants: neurocognitive functioning at 16 years. Nutr Neurosci. 2023;26(1):40-9.

6. Samson KLI, Fischer JAJ, Roche ML. Iron Status, Anemia, and Iron Interventions and Their Associations with Cognitive and Academic Performance in Adolescents: A Systematic Review. Nutrients. 2022;14(1).

7. Mantey AA, Annan RA, Lutterodt HE, Twumasi P. Iron status predicts cognitive test performance of primary school children from Kumasi, Ghana. PLoS One. 2021;16(5):e0251335.

8. East P, Doom JR, Blanco E, Burrows R, Lozoff B, Gahagan S. Iron deficiency in infancy and neurocognitive and educational outcomes in young adulthood. Dev Psychol. 2021;57(6):962-75.

9. Yeboah FA, Bioh J, Amoani B, Effah A, Senu E, Mensah OSO, et al. Iron deficiency anemia and its association with cognitive function among adolescents in the Ashanti Region - Ghana. BMC Public Health. 2024;24(1):3209.

10. Dimas-Benedicto C, Albasanz JL, Bermejo LM, Castro-Vázquez L, Sánchez-Melgar A, Martín M, et al. Impact of Iron Intake and Reserves on Cognitive Function in Young University Students. Nutrients. 2024;16(16).

11. Ploug M, Qvist N, Jacobsen BG, Kroijer R, Nielsen J, Knudsen T. The impact of iron deficiency on patients under evaluation for colorectal cancer, a prospective cross-sectional study. Scand J Gastroenterol. 2024;59(9):1055-61.

12. Roy Choudhury D, Nair Krishnapillai M, Nagalla B, Vijaya Kankipati R, Ghosh S, Buwade J, et al. Guava with an institutional supplementary meal improves iron status of preschoolers: a cluster-randomized controlled trial. Ann N Y Acad Sci. 2021;1492(1):82-95.

13. Jia Q, Lei P, Sun L, Jia WL, Pan Y, Yuan B, et al. Efficacy and safety of Ferrous iron on the prevention of Vascular cOgnitive impaiRment among patients with cerebral Infarction/TIA (FAVORITE): rationale and design of a multicentre randomised trial. Stroke Vasc Neurol. 2025;10(1):136-41.

14. Moumin NA, Shepherd E, Liu K, Makrides M, Gould JF, Green TJ, et al. The Effects of Prenatal Iron Supplementation on Offspring Neurodevelopment in Upper Middle- or High-Income Countries: A Systematic Review. Nutrients. 2024;16(15).

15. Barnett AL, Wenger MJ, Yunus FM, Jalal C, DellaValle DM. The Effect of Iron-Fortified Lentils on Blood and Cognitive Status among Adolescent Girls in Bangladesh. Nutrients. 2023;15(23).

16. Greer FR, Baker RD. Early Childhood Chronic Iron Deficiency and Later Cognitive Function: The Conundrum Continues. Pediatrics. 2022;150(6).

17. Hua M, Shi D, Xu W, Zhu L, Hao X, Zhu B, et al. Differentiation between fetal and postnatal iron deficiency in altering brain substrates of cognitive control in pre-adolescence. BMC Med. 2023;21(1):167.

18. Bassouni R, Soliman M, Hussein LA, Monir Z, Abd El-Meged AA. Development and evaluating the biopotency of ready to eat liver meat balls in fighting anaemia and vitamin A deficiency, improving selected nutritional biochemical indicators and promoting the cognitive function among mildly anaemic Egyptian children aged 3-9 years. Public Health Nutr. 2022;25(11):3182-94.

19. Choi MS, Seiger ER, Murray-Kolb LE. Cognitive Function in Peri- and Postmenopausal Women: Implications for Considering Iron Supplementation. Nutrients. 2025;17(11).

20. Bürker BS, Brautaset Englund KV, Myrdal Østby C, Andersson S, Gullestad L, Broch K. Cognitive Function Among Heart Transplant Recipients Before and After Intravenous Iron Supplement for Iron Deficiency: Results From a Randomized, Placebo-Controlled, Double-Blind Treatment Trial. Clin Transplant. 2025;39(11):e70370.

21. Gingoyon A, Borkhoff CM, Koroshegyi C, Mamak E, Birken CS, Maguire JL, et al. Chronic Iron Deficiency and Cognitive Function in Early Childhood. Pediatrics. 2022;150(6).

22. Larson LM, Cyriac S, Djimeu EW, Mbuya MNN, Neufeld LM. Can Double Fortification of Salt with Iron and Iodine Reduce Anemia, Iron Deficiency Anemia, Iron Deficiency, Iodine Deficiency, and Functional Outcomes? Evidence of Efficacy, Effectiveness, and Safety. J Nutr. 2021;151(Suppl 1):15s-28s.

23. Pasricha SR, Hasan MI, Braat S, Larson LM, Tipu SMM, Hossain SJ, et al. Benefits and Risks of Iron Interventions in Infants in Rural Bangladesh. N Engl J Med. 2021;385(11):982-95.