PROFILE OF SEVERE NUTRITIONAL ANEMIA IN CHILDREN AT A TERTIARY CARE HOSPITAL SOUTH INDIA Madoori Srinivas, Kapil Challa, Mangat Bhukya, Srikanth Darisetty, Radhika Kodimela SRJI Vol

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72

PROFILE OF SEVERE NUTRITIONAL ANEMIA IN CHILDREN AT A

TERTIARY CARE HOSPITAL, SOUTH INDIA

Madoori Srinivas*, Kapil Challa, Mangat Bhukya, Sri kanth Darisetty, Radhika Kodimela

ABSTRACT

Anemia is the most prevalent problem in the world particularly in the developing countries1 NFH

survey (NFHS-3) data shows that 7 out of every 10 children age 6 to 59 months in India are anemia 2.

Here we report study done to find out the profile of hospitalized children with severe nutritional

anemia, to compare the clinical, and laboratory profile of iron deficiency anemia (IDA) and vitamin

B12 deficiency. Methods: This retrospective study was carried out in a tertiary care hospital at

Karimnagar in children aged 1 year to 14 years, admitted with severe nutritional anemia from January

2012 to August 2013. The Chalmeda Anand Rao Institute of Medical Sciences is located in north

Telangana which caters low and middle class people from Karimnagar, Adilabad and part of

Warangal district. Hemoglobin level less than 7 gm/dl was considered as severe anemia and

categorized into iron deficiency anemia and vitamin B12 deficiency in the light of historical

information, physical examination and relevant laboratory investigations and were compared. Results:

Out of 62 children with severe nutritional anemia, males were 35.5% (n=20), and females were 64.5

%( n=42). Mean age of presentation was 8.7 years. The common presenting symptom was pallor

(90.3%), followed by fever (83.87%). IDA was observed in 85.48% ( n=53) and vitamin B12 deficiency

was observed in 14.5% ( n=9). Mean age of presentation in IDA and VitaminB12 deficiency was 8.7

years and 12.7 years respectively. Children with hemoglobin less than 3 grams/dl, 44% (n=4), more in

Scientific Research Journal of India ● Volume: 3, Issue: 2, Year: 2014

73

vitamin B12 deficiency. Blood transfusion was given to children with Hb less than 3gm/dl, Iron,

vitamin B12 supplementation given to children with Iron deficiency and vitamin B12 deficiency

respectively. Nutritional advice was given to parents and during the course of the hospital stay no

advance effects noted. There was statistically significant difference in mean hemoglobin (p=0.05),

weight percentile (p=0.021), RBC count (p=0.01), MCV (p=0.000), MCH (p=0.000), MCHC

(p=0.000) in between two groups. Conclusion: Nutritional anemias are conditions in which Hb

concentration of a given individual is below the normal level due to deficiency of one or more nutrients

needed for haematopoiesis. The main nutrients are Iron, Folate, vitamin B12, Proteins and vitamin E.

In this Iron deficiency anemia is currently the most wide spread micronutrient deficiency and affects

nearly 1.5 billion people globally. Children with severe anemia younger the age mostly due to Iron

deficiency and preadolescence age group vitamin B12 deficiency. Early identification, prompt

nutritional supplementation at the community level will decrease the hospitalization of children with

severe nutritional anemia, also aids in their growth and intellectual development. Early

supplementation of iron in younger children especially with malnutrition, preterm, LBW babies.

Exclusive breast feeding and nutritional advice will improve the anemia status in children. In

preadolescence and pure vegetarians with severe anemia suspect B12 deficiency and supplement with

Vitamin B12.

Keywords: Iron deficiency anemia (IDA), Vitamin B 12 deficiency, cognitive impairment

INTRODUCTION

Anemia continues to be a public health problem

of global proportions. It is the most common

preventable nutritional deficiency in children.

The WHO has estimated that, globally 1.62

billion people are anemic with the highest

prevalence of anemia (47.4%) among preschool

aged children, of these 293 million children, 89

million live in India while prevalence of

anemia among school children is 25.4% 3. The

Term nutritional anemia encompasses all the

pathological conditions in which the blood

hemoglobin concentration drops to an

abnormally low level, due to one or more

several nutrients4. Iron deficiency is one of the

major causes of anemia among Indian

children5. Nutritional anemia develops

secondary to interplay of diverse factors like

poverty, malnutrition, large family size, faulty

dietary habits and repeated infections6 . In our

study children with severe nutritional anemia

were identified and categorized into iron

deficiency anemia and vitamin B12 deficiency

and their clinical and laboratory profile were

compared.

MATERIALS AND METHODS

This study is a hospital based retrospective


74

cross sectional observational study. It is

conducted at Chalmeda Anand Rao Institute of

medical sciences, Karimnagar,AP, South India

between Jan 2012 to Aug 2013. Children with

severe pallor aged 1 year to 14 years admitted

in the paediatric wards were enrolled. Complete

blood picture was carried out in all these

children. Using the WHO cut-off values anemia

was defined as Hb <11.0gm/dl and severe

anemia was defined as Hb < 7gm/dl . Children

with severe nutritional anemia were identified

and categorized in to Iron deficiency

group[IDA] and B12 deficiency group [B12

Def] in the light of history, physical

examination, relevant laboratory investigations

and were compared. We measured serum iron,

total iron binding capacity, folic acid and

vitamin b12 as indicated. Bone marrow

aspiration was performed in children with

pancytopenia to rule out bone marrow failure

syndromes or neoplastic disorders. Children

with severe anemia secondary to non-

nutritional causes like leukemia , MDS,

bleeding disorders were excluded from the

study.

Frequency and 95% confidence interval were

calculated for categorical variables, median and

interquartile ranges (IQR) for continuous

variables were calculated. Man-Whitney U test

was applied to calculate the significant

difference between the medians of two groups.

Epi info versions 7, SPSS 19 were the

statistical software used for the study. P value

of 0.05 was taken as significant.

RESULTS

Out of 62 children admitted with severe

nutritional anemia, median age of presentation

with severe anemia was 8.7 years ± 4.44, males

were 35.5 % (n=20) and females were 64.5%

(n=42) . Among the severe nutritional anemia

cases 17.7% (n=11) belonged to 1 to 3 years of

age group, 17.7% (n=11) were 4 to 6 years

age group,64.5% (n=40) belonged to 7 to 14

years age group, The older children have

increased prevalence of vitamin B12 deficiency

The iron deficiency anemia was observed in

85.48% (n = 53) [95%CI 6.8-25.7] and B12

deficiency was observed in 14.5% (n=9) [95%

CI 74.2-93.14]. Median age of presentation

was 8.1 years with iron deficiency anemia and

12.7 years in vitamin B12 deficiency anemia.

Among 53 Iron deficiency anemia children

found 19(35.8%) were males, 34(64.2%) were

females, out of 9 children with B12 deficiency

3(33.3%) were males, 6(66.7%) were females.

In both groups females are more affected than

males.

TABLE 1 :Hemoglobin categorization in two groups i.e. comparison between IDA

& B12 deficiency

Hemoglobin(gm /dl)

Level

No(%) of children Total

B12Deficiency IDA


3 4 (44.4%) 12 (22.6%) 16 (25.8%)

4 - 6 5 (55.6%) 36 (67.9%) 41 (66.1%)

7 0 (0.0%) 5 (9.4%) 5 (8.1%)

Total 9 (100.0%) 53 (100.0%) 62 (100.0%)

We categorized hemoglobin of severe

nutritional anemia into three groups (group I<3

gm/dl , group II 4 to 6 gm/dl , group III 7

gm/dl) among these 67.9% (n=36) of iron

deficiency anemia and 55.6 % (n=5) of B12

deficiency group had hemoglobin of 4 to 6

gm/dl (group II) as shown in table 3. Children

with hemoglobin less than 3gm/dl were more in

vitamin B12 deficiency anemia as compared to

iron deficiency anemia as shown in table 1

Among the children with severe nutritional

anemia, pallor was present in 90.3% {(n=52)

followed by fever (83.8%), Generalized

weakness 58.06% (n=36, 95% CI, 44.85% to

70.49%) , Icterus 24.19% (n=10, 95% CI,14.22

to 36.74%) cough 19.35% (n=12, 95% CI,

10.42% to 31.37%), and pain abdomen 16.13%

(n=10,95% CI,8.02 to 27.67%), breathlessness

8.2% (n=5,95%CI 2.72 to 18.10%) as in Table

2.

TABLE (2): CLINCAL PROFILE ANALYSIS

S. NO SYMPTOM PRESENT ABSENT

1 Pallor 90.3% (n=56)

CI� 80.12% to 96.37%

9.7% (n=6)

CI � 3.63 to 19.88%

2 Fever

83.87% (n=52)

CI � 8.02% to 27.67%

16.13% (n=10)

CI� 72.33 to91 .98

3 Weakness 58.06% (n=36)

CI� 44.85% to 70.49%

41.94% (n=26)

CI� 44.85%to 70.49%

4 Icterus 24.19% (n=10)

CI� 14.22 to 36.74%

75.81% (n=47)

CI� 63.26 to 85.78%

5 Cough 19.35% (n=12)

CI�10.42% to 31.37%

80.65% (n=50)

CI � 10.42 to 31.37%

6 Pain abdomen 16.13% (n=10)

CI� 8.02 to 27.67%

83.87% (n=52)

CI� 72.33 to 91.98%

7 Hepatomegaly 11.29% (n=7)

CI� 78.11 to95.34%

88.71% (n=55)

CI� 78.11 to 95.34%


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8 Breathlessness 8.20% (n=5)

CI� 2.72 to 18.10%

91.80% (n=56)

CI� 81.9 to 97.28%

9 Koilonychia 4.84% (n=3)

CI � 1.01 to 13.5%

95.16% (n=59)

CI� 86.5 to 98.99%

10 Previous blood transfusion 3.23% (n=2)

CI� 0.39 to 11.17%

96.77% (n=60)

CI� 88.83 to 99.61%

11 Lymphadenopathy 3.23% (n=2)

CI� 0.39 to 11.17%

96.77% (n=60)

CI� 88.83 to 99.61%

12 Hyperpigmentation 1.61% (n=1)

CI� 0.04 to 8.66%

98.39% (n=61)

CI� 91.34 to 99.96%

There is a significant statistical difference

between mean age at presentation (12.7 years

versus 8.11 years, p=0.008), mean hemoglobin

( 4.5 g/dl versus 3.5 gm/dl, p=0.05) mean

weight percentile ( 19.5 versus 43.33 p=0.021),

mean RBC count (2.70 versus 1.30, p=0.001),

mean WBC count (7433 versus 2711 ,p=

0.007), platelets (2.5 lakhs versus 0.79 lakhs,

p=0.00) and blood indices

(MCV,MCHC,MCH) between iron deficiency

anemia group and B12 deficiency anemia group

as shown in Table 3. Children treated

accordingly with iron, folic acid and Vitamin

B12 given, children with severe anemia were

give lasix, blood transfusion in the form of

packed cells, there is symptomatic

improvement. Vigorous counseling was given

regarding nutritional supplementation; there is

no mortality in our series.

TABLE (3): Comparison of variables in IDA& B12 deficiency anemia with P value

Variable B12 def IDA Pvalue

Mean ±std

(n)

Median[range]

(n)

Mean=±std

(n)

Median[range]

(n)

Age at

presentation

12.7778±1.09

(9)

13

(9)

8.1132+4.449

(n=53)

9

(n=53)

0.08

RBC 1.306+0.8032

(n=9)

1.10

(n=9)

2.7057+1.225

(n=53)

2.7

(n=53)

0.01

Wt percentile 43.33+32.88

(n=9)

50

(n=9)

19.528+26.95

(n=53)

3

(n=53)

0.021

Hb% 3.51+1.03 3.80 4.5132+1.447 4.2 0.05


(n=9) (n=9) (n=53) (n=53)

WBC 2711.1+822.26

(n=9)

2900

(n=8)

7433.9+5010

(n=53)

6100

(n=53)

0.07

PLT 0.7911+0.3452

(n=8)

0.8

(n=8)

2.566+1.9199

(n=53)

2.0

(n=53)

0.000

MCV 104.512+7.150

(n=8)

104.35

(n=8)

65.74+17.922

(n=43)

58

(n=43)

0.000

MCH 35.925+1.923

(n=8)

35.9

(n=8)

18.381+7.585

(n=42)

15

(n=42)

0.000

MCHC 0.7911+0.3452

(n=8)

33.75

(n=8)

26.98+4.132

(n=42)

25.75

(n=42)

0.000

DISCUSSION

Nutritional anemia has major consequences not

only on the morbidity and mortality but also

affects their growth and the intellectual

development in children. The prevalence of

severe anemia among children varies between

1.3 to 11% in different regions of the world6.

Iron deficiency is the most prevalent

micronutrient deficiency which affects nearly

70% of under 5 children a per NFHS 3 survey.

In this study severe nutritional anemia of which

females (64.5%) were more compared to males

(35.5% respectively), our data is contradictory

to previous study which shows association

between low hemoglobin levels and male

gender7. Deeksha Kapoor et al have reported

that prevalence of severe anemia among Indian

children aged between 9 to 36 months was

7.8% but in our study 17.7% of children of

same age group had severe anemia8 . Young

children aged 6 to 24 months are particularly at

high risk for severe anemia and a study done by

Nasera Bhatti et al reported that children aged

1 to 3 years constitute the highest risk group

(72.6%) which in comparison to our study,

children aged 7 to 14 years constituted the

highest risk group (64.5%)6. May be due to

nutritional supplementation anganwadi centers

for below 5years children

Severe nutritional anemia was identified as iron

deficiency in 85.4% and vitamin B12

deficiency in 14.5%, younger the age group (<6

years) iron deficiency anemia is the cause for

severe nutritional anemia as opposed to older

age group (7-12yrs), where B12 is the most

common cause. This is consistent with the

study done by Nasera et al6. A study done on

young Mexican9 children and another study

conducted in Malawi10, iron deficiency is not a

predominant cause of severe nutritional anemia,

this is contradictory to the present study.


78

Majority of children with iron deficiency

anemia presented with symptoms of pallor

(90.6%) which is a similar finding by Rachana

Bhoite et al11 who reported pallor in 78.3% of

the children aged 5 to 12 years. Anemia

significantly causes growth impairment and in

the present study, children with iron deficiency

anemia compare to vitamin B12 deficiency

anemia were more underweight (3rd to 25th

percentile, Agarwal charts).

Pancytopenia is a consistent feature of

megaloblastic anemia as proved in earlier

studies and found in our studies, further

supported by Khunger et al who observed that

megaloblastic anemia accounted for over 72%

of cases presenting with pancytopenia 12.

Limitations of the present study are findings

cannot be extrapolated to the community as it is

a hospital based cross sectional study.

Incidence and prevalence of anemia have not

been characterized because of nature of the

study. Though this study was done in small

sample we need to remember that children with

severe anemia younger age IDA is common

older children with B12 deficiency. To validate

this a population based study with the large

number of sample is required.

CONCLUSION

Severe anemia due to nutritional deficiency

more common in younger age . we need to

strength the anganwadi centre for Early

identification, prompt nutritional

supplementation at the community level which

will decrease the hospitalization of children

with severe nutritional anemia, and also aids in

their growth and intellectual development

Acknowledgement: We would like to thank

Chalmeda Anand Rao Institute of Medical

Sciences for granting permission to conduct our

study.

Conflict of Interest: None

Role of Funding Source: None

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3. Worldwide Prevalence of Anemia 1993–2005. Geneva, Switzerland: world Health Organization; 2008.

4. Nutritional Anemia in Young Children with Focus on Asia and India, Prakash V Kotecha, Indian J Community

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in an urban slumIntegrated Child Development Services Project in Delhi. Indian Pediatr. 2002; 39: 136-144.

9. Duque X, Flores-Hernandez S, Flores-Huerta S, et al. Prevalence of anemia and deficiency of iron, folic acid, and

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10. Calis JC, Phiri KS, Faragher EB, et al. Severe anemia in Malawian children. N Engl J Med. 2008;358(9):888–899

11. Magnitude of Malnutrition and Iron Deficiency Anemia among Rural School Children: An Appraisal Rachana

Bhoite, Uma Iyer ASIAN J. EXP. BIOL. SCI. VOL 2(2) 2011

12. Khunger JM, Arulselvi S, Sharma U, Ranga S, Talib VH. Pancytopenia- a clinicohematological study of 200 cases.

Indian J Pathol Microbiol 2002; 45: 375-379.

CORRESPONDING AUTHOR:

*Dr. Madoori Srinivas, Professor, Department of Pediatrics, Chalmeda Anand Rao Institute of Medical

Sciences, Karimnagar, Andhra Pradesh, Ph No: 9866535700, Email ID: [email protected]

Contribution details:-

Concept and guarantor: Author – Madoori Srinivas

Manuscript preparation: Mangat B, Radhika K, Srikanth D

Data compiled: Kapil C

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PROFILE OF SEVERE NUTRITIONAL ANEMIA IN CHILDREN AT A TERTIARY CARE HOSPITAL SOUTH INDIA Madoori Srinivas, Kapil Challa, Mangat Bhukya, Srikanth Darisetty, Radhika Kodimela SRJI Vol