Volume 17 Issue 3

Table of Content - Volume 17 Issue 3 - March 2021

Clinical study of anemia in all paediatric patients from birth till the age of 12 years with special reference to iron deficiency anemia

T L Sonawane¹, V J Pustake^2*, V K Gode³

^1,3Assistant Professor, ²Associate Professor, SMBT Institute of Medical Sciences and Research Centre. Nandi Hills, Dhamangaon, Taluka-Igatpuri, District-Nashik, Pin- 422403, INDIA.

Email: tusharsonawane123@gmail.com, vaibhavpustake@rediffmail.com

Abstract Background: Iron deficiency anemia is the most common nutritional deficiency disorder in the India. The present study was conducted to know the occurrence and severity of iron deficiency anemia among children from birth to 12 years. A large group of iron deficiency is preventable with appropriate and timely intervention. Methods: The study was done on 218 children clinically suggestive of anemia with hemoglobin level less than 11gm/dl admitted in pediatrics ward of tertiary care hospital. Blood sample was taken and complete hemogram, peripheral blood film and other necessary serum investigations were done as required. Cases were studied in reference to history, age, clinical examination and laboratory investigations. Results: The study screened all paediatric patients from birth till the age of 12 years. Out of the total 218 cases, 117(54.0%) patients were anaemic. Out of the 218 total patients studied, 62(53.0%) were male and 55(47.0%) were female. To analyse the severity of anaemia, hemoglobin concentration of each patient was categorised into mild, moderate and severe. It was found that most of the paediatric patients that were studied were moderately anaemic with 59(50.5%) patients, followed by 42(36.0%) mildly anaemic patients and 16(13.5%) severely anaemic patients. Anaemia was most common in toddlers with 56(48.0%) patients, followed by group of children with 40(34.0%) patients. Newborns and infants were less commonly found to be anaemic with only 10(8.5%) of newborns and 11(9.5%) of infants. Blood indices were also taken into consideration to classify the anaemias. The most commonly found morphological category was microcytic hypochromic with 78(66.67%) patients, followed by dimorphic with 19(16.25%) patients. There were 13(11.25%) patients with normocytic normochromic blood picture and 7(5.83%) macrocytic normochromic blood picture. Conclusions: Prevalence of iron deficiency anemia remains alarmingly high and major health problem in our country. Low socioeconomic status is a huge hurdle in child health and greatly influences prevalence of iron deficiency anemia.

Keywords: Prevalence, Socioeconomic status

INTRODUCTION

The WHO has estimated that, globally 1.62 billion people are anaemic, with the highest prevalence is of anaemia (47.4%) among preschool-aged (up to 23months) children, of these 293 million children, 89 million live in India. The third national family health survey (NFHS) revealed that at least 80% of Indian children aged 12-23 months were anaemic. Anaemia is especially prevalent among rural children. Prevalence rate of anaemia is an important indicator of the nutritional status within the pediatric population.¹ In premature infants, iron deficiency can occur only in X-linked causes of anaemia, like Glucose-6-phosphate dehydrogenase (G6PD) deficiency.¹ A newborn reclaims and stores iron as the hematocrit levels decrease during the first few months of life. Therefore, in full-term infants, iron deficiency is rarely the cause of anaemia until after six months of age.¹ Out of all the causes of anemia, like nutritional anemia, hemolytic anemias, chronic infections, lymphoreticular malignancies, etc. Nutritional anemias account for the major cause of anemias. The term nutritional anemia encompasses all pathological conditions in which the blood hemoglobin concentration drops to an abnormally low level, due to a deficiency in one or several nutrients. The main nutrients involved in the synthesis of hemoglobin are iron, folic acid and vitamin B12. Iron deficiency is the commonest cause of nutritional anaemias worldwide. Most children with anaemia are asymptomatic and have abnormal hemoglobin or hematocrit levels on routine screening. Thorough history and clinical findings on physical examination can reveal the underlying cause of anaemia.² A history of nutritional deficiency, pica, geophagia is suggestive of iron deficiency anaemia. A recent viral illness may suggest red cell aplasia. Recurrent diarrhea raises suspicion of malabsorption. Recent prescription drug use may suggest G6PD deficiency or aplastic anemia.³ The physical examination constitutes an important aspect, but is essentially normal in most children with anaemia. Findings that suggest chronic anaemia include irritability, pallor, glossitis, asystolic cardiac murmur, and delayed growth.¹ In screening situations, when anaemia is encountered, the patient should undergo a complete blood cell count (CBC) which includes Hemoglobin(Hb), Mean Corpuscular Volume(MCV), Mean Corpuscular Hemoglobin Concentration(MCHC), Red Cell Distribution Width(RDW) and Peripheral Blood Smear(PBS).³ If the diagnosis is still not clear after the analysis of the initial laboratory findings, other confirmatory studies may be required like, bone marrow examination, serum iron studies, vitamin studies, Hb Electrophoresis and High Performance Liquid Chromatography(HPLC).¹In India, Anaemia is an important health problem, especially among children. Anemia in children is one of the major social health problems, since anaemic children have reduced exercise capacity, slower rate of growth, impaired cognitive development, reduced behavioral and language development and scholastic achievement along with delayed wound healing.² These children are also at an increased risk of dying due to complications associated with malnutrition and infections. Because of these factors, the study of the etiopathogenesis of anaemia in infancy and childhood has attracted wide attention in the recent years in India.⁴ The present study is done to know the prevalence of iron deficiency anemia in the children from birth to 12 yr of age and confirmed by laboratory findings so as to diagnose anemia at an early age and to take the necessary steps to minimize the sufferings of children and others who are concerned about them.

MATERIALS AND METHODS

The present study was carried out in the Department of Pediatrics in a rural tertiary care hospital from November 2019 to September 2020. All the patients admitted to indoor patient department of our hospital with anemia were selected using systematic random sampling technique and included in the study. Details regarding age, sex, clinical presentation were collected, detailed clinical history was recorded and a thorough physical examination was done. This study was conducted on 218 children in the age group of newborn to 12 yr old who were hospitalized in pediatrics ward for some other illness, but incidentally were found to have anemia. These were subjected to complete blood count, red cell indices, reticulocyte count and serum ferritin levels as and when required. The WHO criterion (hemoglobin <11 g/dL) was used to diagnose anemia.⁵ To categorize the degree of anemia, the following cut-off points were used: 10.0-10.9 g/Dl- mild anemia; 7.0-9.9 g/dl - moderate anemia; <7 g/dl -severe anemia. Since acute infections were not ruled out, cut off for S. ferritin <30ng/dl was taken as hypoferritinemia according to the WHO guidelines, hence diagnosed as iron deficiency anemia (IDA). Cases were studied in reference to history, age, clinical examination, hemoglobin level, and confirmation of iron deficiency anemia was done on the basis of serum ferritin levels. Children suffering from proven hemoglobinopathies and hemorrhagic disease were excluded. Approval from ethical committee of institute taken. Written consent was obtained from parents. 5 ml of venous blood was drawn under aseptic precautions. Hemoglobin, red blood cells count, platelet count, RBC indices, MCV, MCHC, MCH, were estimated using automated cell counter method using Horiba ABX Pentra XL80 analyzer. Peripheral film was read by a pathologist and on the basis of characteristics of cells, peripheral blood picture was labeled as microcytic hypochromic, macrocytic normochromic or normocytic normochromic type. Serum ferritin measured by chemiluminescence immunoassay (Lilac Acculite CLIA) method.

Sample size:

Sample Size for Frequency in a Population
Population size(for finite population correction factor or fpc)(N):	500
Hypothesized % frequency of outcome factor in the population (p):	50%+/-5
Confidence limits as % of 100(absolute +/- %)(d):	5%
Design effect (for cluster surveys-DEFF):	1

Sample Size(n) for Various Confidence Levels
Confidence	Level(%)	Sample Size
95%		218
Equation
Sample size *n = [DEFFNp(1-p)]/ [(d²/Z²_1-α/2(N-1)+p(1-p)]**

Results from OpenEpi, Version 3, open source calculator—SSPropor

RESULTS

The present study was carried out at a rural tertiary care hospital from August of 2019 till the June of 2020. The study screened all paediatric patients from birth till the age of 12 years. Out of the total 218 cases, 117(54%) patients were anaemic.

Table 1: Sex-wise distribution of Anaemia

Sex	Number of anaemic patients
Male	62 (53%)
Female	55 (47%)
Total	117 (100%)

Table 2: Age-wise distribution of Anaemia

Age	Number of anaemic patients	Percentage (%)
Newborn (1 day-2 months)	10	8.5
Infant (>2 months-6 months)	11	9.5
Toddler (>6 months-6 years)	56	48
Children (>6 years-12 years)	40	34
Total	117	100

Table 3: Severity of Anaemia

Severity	Number of patients	Percentage (%)
Mild (9.0-11.0g/dl)	42	36
Moderate (6.0-8.9g/dl)	59	50.5
Severe (<6.0g/dl)	16	13.5
Total	117	100

Table 4: Morphologic distribution of anaemia

Morphology	Number of patients	Percentage (%)
Microcytic Hypochromic	78	66.67
Normocytic Normochromic	13	11.25
Dimorphic	19	16.25
Macrocytic Normochromic	7	5.83
Total	117	100

After analysing all the data that were collected, like the complete blood count, peripheral blood smear, reticulocyte counts, serum ferritin and other necessary investigations.. All the anaemic cases could be distributed into some of the etiological causes of anaemias. These include iron deficiency anaemia, megaloblastic anaemia and others [thalassemia major, thalassemia trait, sickle cell anaemia, sickle cell trait, infectious agent induced red cell injury (malaria)].

Table 5: Etiological Distribution of Anaemias

Etiology	Number of cases	Percentage (%)
Iron Deficiency Anaemia	76	65
Iron Deficiency and Megaloblastic Anaemia	17	14.5
Megaloblastic Anaemia	9	7.5
Others	15	13
Total	117	100

The most commonly seen etiological cause of anaemia was iron deficiency anaemia with 76 (65.0%) cases, followed by the combination of iron deficiency anaemia and megaloblastic anaemia was seen in 17 (14.5%) cases and then megaloblastic anaemia with 9 (7.5%) cases. 15(13%) of the cases were due to other causes that lead to anaemia. Most of these cases were of normocytic normochromic anaemias and the clinical diagnoses of the patients were malaria, gastric bleeding, severe diarrhea, anaemia of chronic diseases.

DISCUSSION

The WHO has estimated that, globally 1.62 billion people are anaemic, with the highest prevalence of anaemia (47.4%) among preschool-aged (up to 23 months) children. Of these 293 million children, 89 million live in India. The third National Family Health Survey (NFHS) revealed that at least 80% of Indian children aged 12-23 months were anaemic. Anaemia is especially prevalent among rural children.⁷ Prevalence rate of anaemia is an important indicator of the nutritional status within the pediatric population.⁸ The present study was attempted to assess the prevalence of paediatric anaemia in a rural tertiary care hospital. The total number of paediatric patients that were found to be anaemic was 117(54.0%) and this was done with the help of hemoglobin estimation, red cell indices, and morphology of RBCs on peripheral blood smear. According to the National Family Health Survey, in India (2015-2016) the prevalence of anaemia in paediatric population in Maharashtra was 53.8%¹⁶ which is comparable to our study. (Table 6)

Table 6: Comparable studies of Occurrence of Anaemia

Study	Total percentage of anaemia (%)
Nanjunda et al. (2014) [12]	62.0
Nasrin Qureshi et al. (2015) [10]	43.5
Gomber et al. (2015) [17]	41.8
Verma et al. (2016) [13]	51.5
Behera S et al. (2016) [14]	48.5
Sudhagandhi et al. (2017) [15]	52.8
M Muthuraman et al. (2017) [9]	52.0
Present Study	54.0

Table 7: Comparable studies of Sex-wise distribution of Anaemia

	Male	Female
Saba Firdos et al. (2014) [19]	58%	42%
Jigalur PS (2015) [20]	42.7%	57.3%
Nasrin Q et al. (2015) [10]	50.2%	49.8%
Sandeep B et al. (2017) [11]	45.4%	54.6%
Sudhagandhi B et al. (2017) [15]	38%	62%
Muthuraman M et al. (2017) [9]	61.2%	38.8%
Venugopal V et al. (2017) [18]	55.6%	44.4%
Present Study	53%	47%

From our study, it was evident that most common age group affected by anaemia was toddlers (48%), followed by children (34.0%). We found that 8.5% newborns were anaemic and 9.5% of the Infants were anaemic. According to Muthuraman M et al. 20.9% of children below the age of 1 year were anaemic. 31.4% of children between the age of 1 to 3 years, 20.9% of the anaemic children were between the age of 3 years to 6 years and the highest prevalence of anaemia (26.6%) was seen in children between the age of 6 to 12 years.⁹ Another study by Madhusudhan Sr et al. in AIIMS found that 39% of the anaemic children were between the age of 6 months to 2 years and remaining 61% were found in age between 2 years to 5 years.²² The study by Chithambaram et al. found that 10.2% of the anaemic cases were below 1 year of age, 21.4% cases were between age of 1 to 2 years. 20.4% of the cases were between the ages of 2 to 5 years, 25.5% of the cases were between 5 to 10 years and 22.4% of the cases were more than the age of 10 years.²³A study by Dutta T S et al. showed that the most common age group that was affected was between 9 years to 12 years with 23.6% cases, followed by children between 5 to 7 years with 21% cases. Age group between 7 to 9 years consisted of 19.6% cases.²⁴The study by Venugopal V et al. suggested that 37% of the anaemic cases were seen in children older than 5 years, followed by 33% cases seen in children between the age of 2 years to 5 years and 29.8% of the cases were seen in children below the age of 29.8%.¹⁸ In our study, anaemia was commonest (48%) among toddlers which is similar to the findings by Muthuraman M et al. (52.3%).⁹

Table 8 Comparable studies of Severity of Anaemia:

Study	Mild	Moderate	Severe
Saba Firdos et al. (2014) [19]	12.7%	75.8%	11.4%
Jigular P et al. (2015) [20]	68.9%	28.0%	3.0%
Nasrin Qureshi et al. (2015) [10]	46.3%	43.4%	10.2%
Behera S et al. (2016) [14]	27.4%	23.6%	17.0%
Muthuraman M et al. (2017) [9]	4.1%	45.0%	50.9%
Madhusudan Sr (2018) [22]	38.0%	54.0%	8.0%
Present Study	36.0%	50.5%	13.5%

Our findings are comparable with the findings of other authors and it is found that microcytic hypochromic anaemia is the commonest type of morphological anaemia in the paediatric population.

Table 9: Comparable studies of Morphological types of Anaemia

Study	Normocytic Normochromic	Microcytic Hypochromic	Macrocytic Normochromic	Dimorphic
Senthamarai MV et al. (2014) [25]	16.0%	82.0%	-	2.0%
Nasrin Qureshi et al. (2015) [10]	42.2%	46.50%	9.88%	1.36%
Muthuraman M et al. (2017) [9]	28.2%	59.2%	2.8%	9.6%
Madhusudan Sr et al. (2018) [22]	45.0%	37.0%	-	18.0%
Present Study	11.25%	66.67%	5.83%	16.25%

Table 10: Comparable studies of Etiological causes of Anaemia

Etiology	*Dutta T et al.(2016)²⁴*	*Muthuraman M et al.* (2017)⁹**	Present Study
Iron deficiency anaemia	54.3%	71.3%	65.0%
Megaloblastic anaemia	7.0%	0.8%	7.5%
Iron deficiency and Megaloblastic anaemia	7.0%	-	14.5%
Others	31.7%	27.9%	13.0%

Most of the parameters that were analysed in our study were comparable with other studies carried out in recent years in rural hospitals in India.

CONCLUSION

From our study we can conclude that majority of the paediatric population in the rural area of Maharashtra are anaemic. The high frequency of anaemia was due to the poor bioavailability of dietary iron coupled with low intake of heam iron derived from animal products. Our study recommended that the highest occurence of anaemia was seen in the age group between 6 months to 6 years. The factor that plays a role in more frequent cause of anaemia in this age group is that, after 6 months of age, exclusive breast feeding is weaned off and the child does not get enough nutritional support that aids the increased demand due to fast growth. Severity of anaemia is an important parameter. In our study, we were frequently presented with mild and moderately anaemic patients. Mild and moderately anaemic children do not necessarily show symptoms and can often be missed out therefore screening for them is essential. Anaemia in children results in impaired cognitive performance, behavioral and language development and scholastic achievement. The study of occurrence of anaemia in children is essential to be constantly monitored as it helps identify causes, formation of intervention strategies as well as ensure that the already formed national programs are effective.

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