ingd

SUDANESE JOURNAL OF PUBLIC HEALTH - January 2014, VOL. 9 No. 1 - - 33

original article

Iron Deficiency Anemia among Children under Three years in Kassala, Eastern SudanHiba H. Mahmoud1, Abdelrahim M. Muddathir2, Shams ElFalah M. Osman3, Mustafa A. AlKhawad3, Awadia K. Mohamed3, ElHady E. ElMubarak3, Mamoun M. Mohamed3*1) Ministry of Health, Kassala State, Sudan. 2) University of AlZaeim AlAzhari, Khartoum, Sudan.3) Kassala University, Kassala, Sudan.Correspondence: Dr. Mamoun Magzoub Mohamed, Ph D Assistant Professor, Department of Microbiology & Parasitology, Faculty of Medicine, University of Kassala, P.O. Box 266 Kassala, Sudan - Fax: +249411823501 - E-mail: [email protected] - Phone: +249912913999

AbSTrACT

background: Iron deficiency anemia is the most common form of anaemia. The aim of this study is to determine the prevalence of iron deficiency anaemia among children aged from 12_36 months old. Methods: A total of 100 children between 12 and 36 months old were attended at AlKwaity Pediatrics Hospital and Kassala Teaching Hospital were enrolled in the study and prevalence of iron deficiency anaemia was estimated by analyzing Haemoglobin (Hb) level, PCV, MCV, MCH, MCHC on a blood Counter (Sysmex ). The concentration of serum ferritin was measured using radioimmunoassay. results: Eighty-six (86%) of all children were anaemic, 64 (64%) of them were severe anaemic. Conclusion: The study showed high prevalence of anaemia among those children, so more studies were recommended to perform in this area. Also health authorities may interfere by health education and other interventional methods. Keywords: Anaemia, children, Kassala, eastern Sudan.

bACKgrounDIron deficiency anemia is the most common form of anemia. Iron is an essential part of hemoglobin, the oxygen-carrying protein in blood(1).Anemia refers to a state in which the level of haemoglobin in the blood is below the normal range appropriate for age(3). Anaemia in childhood is defined as a haemoglobin concentration below established cut off levels(4). Healthy newborn infants have a total body iron of 250 mg, which is obtained from maternal sources. Infants consuming cow milk have a greater incidence of iron deficiency because bovine milk has a higher concentration of calcium, which competes with iron for absorption. Subsequently, growing children must obtain approximately 0.5 mg more iron daily than is lost in order to maintain a normal body concentration of 200 mg(5).Inadequate dietary iron, iron absorption and intense exercise, along with blood loss and parasitic infestations, are some etiologies of Iron Deficiency Anemia(6).A study carried out in public day care centers in the city of Cuiab, state of Mato Grosso, Brazil to determine the prevalence of anemia in children aged

less than 36 months indicates that high prevalence (63%) of anemia among these children(7). The prevalence of childhood iron deficiency anemia in the United States as a whole has declined in the past decade, also the prevalence of anemia remains high among Alaskan Native children. The database was taken from the Alaska Area Native Health Service for children aged 5-72 months; the computerized medical-record database for the Alaska Area Native Health Service includes hemoglobin values from 1983 to 1985 for children aged 5-72 months who were eligible for care. Testing is recommended as part of routine well-baby care at ages 6, 10, and 18 months and before the child enters school. In the years 1983-1985, more than 4,000 test results were recorded annually, and the prevalence of anemia (haemoglobin less than 11 g/dl,) was 22% in children under 5 years of age(8). A cross-sectional survey method was used for data collection to detect the prevalence of iron deficiency anaemia, among under five children in Imo State of Nigeria. The sample was randomly selected to cover the three geopolitical zones in Imo State. A total of four hundred (400) under-five children were selected by purposive sampling method. Two hundred were from

Iron Deficiency Anemia among Children under Three years in Kassala, Eastern Sudan


original articlethe urban and another two hundred from the rural locations. Food samples were analyzed for proximate composition. Blood samples for determination of serum ferritin, was obtained by vein puncture. The results showed that 48.1% were iron deficient although iron intakes were above recommended allowances. Variables strongly associated with iron deficiency were previous health status of the child, diarrheal treatment, feeling sleepy, tired and weak, complementary feeding timing(9). A total of 150 children were selected from four different area of Allahabad district, India. Data on dietary intake was collected by using 3 days dietary recall method. Haemoglobin levels of children were estimated by cyanmethaemoglobin method. Clinical status assessing anemia was also recorded. Consumption of all the nutrients by majority of the children was comparatively less than the recommended dietary allowances. Data on anthropometry revealed that out of total children screened (N=150), Hemoglobin test revealed that 65.33% had hemoglobin level below the normal (12 g dl/1) values, indicating anemia, out of which approximately half (53.33%) were mild anemic and 12% were moderate anemic. Feeling breathlessness and easily tired were experienced by 30.5 and 23.73% of the subjects respectively(10). In a Representative sample of 400 schoolchildren from Elminopheia district, Egypt, iron status was assessed by haemoglobin, and serum ferritin from a venous blood sample. The prevalence of iron deficiency in this study was 65% and 55% of anaemia was associated with iron deficiency. An iron deficient child was defined as every Child with either serum iron less than 50 g/dl, or Serum TIBC more than 400 g/dL. In this study iron deficiency was more common in children who did not usually have breakfast as opposed to those who did(11). A study was conducted in Islamic Republic of Iran as the part of the National Health and Disease Survey in 1999 that used a cluster sample of 1 in 1000 of the Iranian population. Haemoglobin levels were used to estimate the prevalence of anaemia in children 212 year old of 4170 children aged 26 years, 7.3% were diagnosed with mild anaemia, 2.5% moderate anaemia and 1.0% severe anaemia (WHO definitions). Of 8461 children aged 712 years, 10.9% were diagnosed with mild anaemia, 3.0% moderate anaemia and 1.1% severe anaemia. The prevalence of anaemia was significantly higher in rural than urban areas(12).A study was carried out in Eskisehir, Turkey to determine the prevalence of anaemia among infants 4-11 months age. Haemoglobin was estimated

using Hemocue haemoglobinometer. Anaemia was diagnosed if Haemoglobin concentration 12g/dl. Prevalence of anaemia among 3039 healthy infants was found in 40.6%(13). A study was performed to determine the prevalence of iron deficiency anemia among 1-year-oldinfants of disadvantaged families in five poorest health districts in Montreal, Canada. Participants: Infants 10 to 14 months of age were identified from registration lists of births from May 1988 to August 1989. During a home visit capillary blood samples were obtained from the child, and the mother answered a questionnaire about infant-feeding practices. Infants with a serum ferritin level of 10, ug/L or less and either a hemoglobin level of 1 15 g/L or less or a mean corpuscular volume of 72 fL or less were considered as having iron deficiency anemia. Iron deficiency anemia was found in 25% of the infants (95% confidence interval [CI] 19% to 31%). The mean hemoglobin level was 115g/dl (standard deviation 1 1) The serum ferritin level, assessed routinely in the last 62 infants, was 10 ug/l or less in 37% of the infants. The factors that were found to be predictors of iron deficiency anemia included the use of whole cows milk before 6 months of age (odds ratio [OR] 3.56 [95% CI 1.07 to 11.26]) and the use of iron-fortified infant cereal for less than 6 months (OR 3.15 [95% CI 1.25 to 7.96]). A low birth weight and the use of iron-fortified formula for less than 6 months were associated with iron deficiency anaemia(14). METhoDSA cross sectional study was conducted in at AlKwaity Pediatrics Hospital and Kassala Teaching Hospital. Kassala eastern Sudan during the period of January - March 2011. The study group composed of 100 children between 12 and 36 months old were attended at AlKwaity Pediatrics Hospital, Kassala and Kassala Teaching Hospital. The first step of the work was to select patients from these two hospitals containing those all children who were attended at out patient clinics. All candidate cases were evaluated by physical examination. The informed of children parents is obtained to be a part of the study. Data was collected by using pre-tested questionnaire. Haemoglobin (Hb) levels, PCV, MCV, MCH, and MCHC were analyzed on a blood Counter (Sysmex). The concentration of serum ferritin was measured using radioimmunoassay(15,16). (Normal Range of Serum Ferritin Level for children aged 6 months to 14 years: 7-140 ng/ml)(17, 18).The purpose of this work was explained to the health authorities at the federal Ministry of Health



in Kassala. The study also was discussed with the directors of the AlKwiety Paediatrics Hospital and Kassla Teaching Hospitals. The consent for acceptance of participation of parents (Guardian) of selected subjects in the study was obtained.rESulTSThe population included in the study comprised 100 children up to three years old, 50 (50%) males and 50 (50%) females. Packed cell volumes of most of the patients were less than normal. Also mean cell haemoglobin and mean haemoglobin concentration for most of the patients were less than normal.Table (1): Mean value and (SD) for all childrenAge (years) 2.1(0.8)Hb (g/dl) 6(2.2)PCV 24.2(7.5)MCV 75.3(12.1)MCH 18.4(4.1)MCHC 24.3(2.7)

35 (35%) of the study population patients were Baniamir, 21 (21%) were Hosa, 19 (19%) were Hadandawa, 8 (8%) were Rashaida and 17 (17%) were other tribes.Eighty-six (86%) of all children were anaemic, 22 (22%) of them were severe anaemic (Figure 2).Figure (1): Percentage of Anaemia for all children

original article

Table (2): Shows Anaemia and Serum Ferritin Level for all children (n= 100) Serum FerritinTotalNormal (7-140 ng/ml|)

High (more than 140 ng/ml)Low (less than 7 ng/ml)

Hb Normal (More than 9g/dl) 14 0 0 14Anaemic (7-9 g/dl) 13 3 6 22Severe anaemic (Less than 7 g/dl)

25 29 10 64Total 52 32 16 100p value: 0.00

Figure (3): Shows Anaemia and mother for education for all children (n= 100)

p value: 0.70Figure (4): Shows Anaemia and residence for all children (n= 100)

P value: 0.00



original articleIron Deficiency Anemia among Children

under Three years in Kassala, Eastern SudanIt was observed that anaemia found commonly among rural population where as severe anaemia prevalent among urban population. Figure (5): Shows Anaemia and Pica for all children (n= 100)

P value: 0.15DISCuSSIonIn this study the prevalence of iron deficiency anaemia among children was high (86%). also PCV, MCV, MCH and MCHC were low among most patients. There was significant difference between low haemoglobin level and low serum ferritin level (p value: 0.00), also there was significant difference between low haemoglobin level and rural patients (p value: 0.00). But there was no significant difference between anaemia and: pica, Refusal Feeding, Duration of Breast Feeding, Supplementary Feeding during Breast Feeding, cow milk intake and goat milk intake (p value: 0.15, 0.43, 0.14, 0.11, 53, 0.10 respectively).Prevalence of iron deficiency anaemia in this study was higher than the study carried out in children aged less than 36 months in public day care centers in the city of Cuiab, state of Mato Grosso, Brazil. The prevalence of anemia among these children was (63%)(7). And it was different from the study showed that the prevalence of iron deficiency anaemia in the U.S., in Infants 1-2 years was (6 to 17 per 1000)(19).This was different from the study was conducted in Natal, India, which indicates that the high incidence of iron deficiency anaemia was found in children under 10 years of age-28,6% for females and 41,6% for males(20). In contrast Haematological and iron parameters, measured in 907 children aged from 6 months to

5 years in rural Gambia at the start of the rainy season, differed from those in American reference populations as follows: mean haemoglobin levels were much lower at ages 1 and 2 years and mean levels of mean corpuscular volume (MCV) were lower at all ages (at age 1 year mean haemoglobin was 11.2g/dl and mean MCV 68.2 fl) and mean serum ferritin 8.8ng/ml. A total of 213 children (23%) whose haemoglobin and mean corpuscular volume were both less than the 3rd percentile of the reference population received oral iron or placebo from their mothers during the rainy season when malaria transmission is maximal(21). Also our results are higher than the prevalence of iron deficiency, which was done among the Indian population of metropolitan Durban. Iron deficiency was observed in 53 % of these subjects 2500 subjects were studied(22). And higher than The prevalence of iron deficiency in Delhi, India among children, 9-36 months of age, was 64 %, of these 7.8% had severe anemia (Hb >7.0 g/dl)(23). Our results also higher than the study conducted in Tunisia, the survey covered 955 children under the age of five years, native of two regions with the highest prevalent of anemia, the Southwest and the District of Tunis. The results showed that 29% of children suffered from anemia. About 70% of them were iron deficient(24).The study showed high prevalence of anaemia among those children in Kassala, this may be due the low economic status among population, particularly in rural areas around the study area and this may lead to not obtaining suitable nutrition for those children. Also many mothers are not educated, this may affect on high prevalence of anaemia in the study area. Conduction of more researches to assess nutritional status in children under 3 year old are recommended. Also there is the need for nutrition interventions in children under 3 years and also for mothers, for example by giving them oral iron. Using prospective studies in help in providing insight into how to approach prevention and treatment of iron deficiency anaemia in this age group of children. Ministry of Health, Kassala State can concentrate on heath education of mothers; we think it is important role in prevention of iron deficiency anaemia in children.Ethical Clearance:The study received ethical clearance from the Research Board at the Faculty of Medical Laboratory Sciences, University of AlZaiem AlAzhari.


original articleIron Deficiency Anemia among Children

under Three years in Kassala, Eastern Sudan

Data management and Statistical AnalysisVersion 18 was used for entry and analysis of data.Acknowledgement:The authors are grateful to the patients who participated in the study and their parents or guardians; also they thank the local heath authority in Kassala State, Sudan. Conflict of Interest:None declared.Authors contributions:HHM, AMM and MMM designed the study. SEM, AAK and AKM conducted the clinical work. HHM performed the laboratory work. MMM and EEE analyzed the data. All the authors shared in the drafting of the paper and all of them approved the paper. References:1. Iron deficiency anemia children, Medline Plus (Page last updated: 18 December 2009) available from: http://www.nlm.nih.gov/medlineplus/ency/article/007134.htm2. Conrad ME, Umbreit JN. Iron absorption and transport-an update. Am J Hematol. 2000; 64(4):287-98.3. Christopher Haslett, et al. Davidsons Principle and Practice of Medicine. Nineteenth edition, Churchill

Livingstone, India, 2004:902. 4. World Health Organization: Iron Deficiency Anaemia. Assessment, Prevention and Control; WHO 2001.5. Iron Deficiency Anemia, emedicine (Updated: Aug 4, 2009). Available from: http://emedicine.medscape.com/article/202333-overview6. Karimi M; Mirzaei M; Dehghani A. Prevalence of Anemia, Iron Deficiency and Iron Deficiency Anemia in 6-60 Month Old Children in Yazds Rural Area. International Pediatrics 2004; 19 (3): 180-4.7. Brunken G S, Guimares L V, Fisberg M. Anemia in children under 3 years of age in public day care centers. Jornal de Pediatria 2002; (78)1: 50-56.8. CDC. Topics in Minority Health High Prevalence of Iron Deficiency Anemia among Alaskan Native Children. MMWR 1998; 37(13): 200-2.9. Onyemaobi G A, Onimawo IA, Uwaegbute C A. Prevalence of Iron Deficiency Anaemia among Under-five Children in Imo State, Nigeria. Australian Journal of Basic and Applied Sciences 2011; 5 (2): 127-130.10. Handa R, Ahamad F, Kesari K K and Prasad R. Assessment of Nutritional Status of 7-10 Years School Going Children of Allahabad District: A Review. Middle-East Journal of Scientific Research 2008; 3 (3): 109-115. 11. Ali1 A, Fathy G A, Fathy H A, Abd El-Ghaffar N. Epidemiology of Iron Diffiency Anaemia: Effect on Physical Growth in Primary School Chidren, The Importance of Hookwors. International Journal of

Academic Research 2011 (Part II); 3 (1): 495 - 500.12. Sayyari AA, Eslam RS and Abdollahi Z . Eastern. Prevalence of anaemia in 212-year-old Iranian children. Mediterranean Health Journal. 2006; 12 (6): 804-808.13. Unsal A, Bor O, Tozun M, Dinleyici E C and Erenturk G. Prevalence of Anaemia and Related Risk Factors Among 4-11 Months Age Infants in Eskisehir, Turkey. J. Med. Sci. 2007; 7(8): 1335-1339.14. Lehmann F, Gray-Donald K, Mongeon M, Stephen Di Tommaso S. Iron deficiency anemia in 1-year-old children of disadvantaged families in Montreal. CAN MED ASSOC J 1992; 146 (9): 1571-7.15. Monica Cheesbrough. District Laboratory Practice in Tropical Countries Part Two. 2nd ed. Cambridge, 2006. pp 301. 16. DK Mendiratta, K Bhutada, R Narang, P Narang. Evaluation of different methods for diagnosis of P. falciparum malaria. Indian Journal of Medical Microbiology 2006: 24; 1: 49-51.17. Nusair Z, Al-Wraikat A , Nazih Abu Al-Shiekh NA, Kofahi S, Zoubi M. The Frequency of Iron Deficiency Anemia and Thalassemia Trait among Children: Experience at Prince Rashed Bin Al-Hassan Military Hospital. JRMS 2011; 18(1): 39-44.18. Iranikhah A, Farahmand F, Fallahi GH, Monajjemzadeh M. Case Report: Protein Losing Enteropathy as a Sole Manifestation of Intestinal Non-Hodgkins Lymphoma; A Case Report and Review of the Literature. Govaresh 2005; 10, (4): 238-240.19. Agency for Healthcare Research and Quality and Oregon Evidence-based Practice Center. Screening for Iron Deficiency Anemia in Childhood and Pregnancy: Update of the 1996 U.S. Preventive Services Task Force Review. AHRQ Publication AHRQ Publication No. 06-0590-EF-1; 2006.20. Mayet FG. The prevalence of anaemia and iron deficiency in the Indian community in Natal. S Afr Med J. 1976; 50(47): 1889-92.21. Smith AW, Hendrickse RG, Harrison C, Hayes RJ, Greenwood BM. Iron-deficiency anaemia and its response to oral iron: report of a study in rural Gambian children treated at home by their mothers. Ann Trop Paediatr. 1989; 9(1):6-16.22. Report of the 2004 International nutritional Anemia consultative group Symposium. Creed-Kanashiro H, Giyose B. Iron deficiency in early life: challenges and progress lima, peru 2004.23. Kapoor D, Agarwal KN, Sharma S, Kela K, Kaur I Iron status of children aged 9-36 months in an urban slum Integrated Child Development Services project in Delhi. Indian Pediatr. 2002; 39(2): 136-44.24. El Ati J, Gaigi S, Beji C, Haddad S, Cherif S, Farhat A, Fattoum S, Ben Abdeladhim A. Prevalence and causal factors of anemia in children in Tunisia. Tunis Med. 2005; 83(9): 511-8.

Documents

ingd