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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 5  |  Issue : 1  |  Page : 23-27

Iron deficiency anemia among preschool children belonging to affluent families in Kerala, India


1 Department of Paediatrics, Believers Church Medical College Hospital, Tiruvalla, Kerala, India
2 Department of Pathology, Believers Church Medical College Hospital, Tiruvalla, Kerala, India
3 Department of Medical Research, Believers Church Medical College Hospital, Tiruvalla, Kerala, India

Date of Submission20-Nov-2018
Date of Acceptance31-Dec-2018
Date of Web Publication19-Jun-2019

Correspondence Address:
Jijo Joseph John
Department of Pediatrics, Believers Church Medical College Hospital, St. Thomas Nagar, Kuttapuzha, Tiruvalla - 689 103, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcrsm.jcrsm_41_18

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  Abstract 


Context: Anemia leads to impaired cognitive function, growth, and psychomotor development. Zeroing in on a specific socioeconomic or demographic group and a specific type of anemia, may help in better planning of resources in our battle against anemia.
Aims: The aim of this study is to determine the prevalence, severity, risk factors (age, gender, and nutrition status) of iron deficiency anemia (IDA) in apparently healthy preschool children (6–59 months) belonging to affluent families.
Settings and Design: A cross-sectional study conducted in a private teaching hospital.
Subjects and Methods: A total of 160 children aged 6–59 months, belonging to the upper middle class, who came to the pediatric outpatient department for routine visits over a period of 1 year were evaluated. Sociodemographic data with hemoglobin, red cell indices and iron studies of blood samples were estimated.
Statistical Analysis Used: Continuous data were described as mean and standard deviation. Odds ratio with 95% confidence interval was calculated using multiple logistics regression.
Results: Among the 160 children evaluated, 48 (30%) were anemic, of which 41 (85.4%) had IDA. Equal proportion (P = 0.84) of boys (25.0%) and girls (26.4%) and equal proportion (P = 0.75) of well-nourished (26.2%) and moderately nourished (23.3%) had IDA. A higher proportion (P < 0.0001) of children below the age of two (40.7%) had IDA. Children below the age of 2 years were more likely to have IDA (Odds ratio [OR]: 5.8 95% confidence interval [CI] 2.5–13.8) irrespective of gender and nutrition.
Conclusions: A high prevalence among apparently healthy children from affluent families is an indicator that the general population rates will be even higher. This study highlights the need to plan further intervention trials with either iron-rich or iron-fortified foods or iron supplementation, especially among children below the age of 2.

Keywords: Affluent family, anemia, India, iron deficiency anemia, Kerala, pre-school children


How to cite this article:
John JJ, Mohan G, Ajitha K, David A. Iron deficiency anemia among preschool children belonging to affluent families in Kerala, India. J Curr Res Sci Med 2019;5:23-7

How to cite this URL:
John JJ, Mohan G, Ajitha K, David A. Iron deficiency anemia among preschool children belonging to affluent families in Kerala, India. J Curr Res Sci Med [serial online] 2019 [cited 2019 Sep 18];5:23-7. Available from: http://www.jcrsmed.org/text.asp?2019/5/1/23/260638




  Introduction Top


Anemia leads to impaired cognitive function, growth, and psychomotor development. As per the National Family Health Survey-4 (2015–16) in the state of Kerala, children aged 6–59 months who are anemic (hemoglobin [Hb] <11 g/dl) is 35.5% in the urban area.[1] In India, iron-deficiency is the most common cause of anemia. Kerala, a state in southern India, has a reasonably strong primary healthcare system with a good infrastructure of primary health centers.[2] However, the prevalence of anemia varies widely.[3] It has been proven that anemia is higher among children belonging to the lower socioeconomic status.[4] Hence, we wanted to know the prevalence of iron deficiency anemia (IDA) in children belonging to the upper middle class where it is expected to be much lower than the rest of the population.


  Subjects and Methods Top


This is a cross-sectional study conducted in a private teaching hospital for a period of 1 year. To assess IDA in children aged 6–59 months, belonging to the upper middle class, we evaluated 160 patients who came to the pediatric outpatient department for routine visits over a period of 1 year from September 2017 to August 2018.

Inclusion criteria

Children belonging to parents of the upper middle class and above as per the Kuppuswamy's socioeconomic status scale revised for 2018 using real-time update tool.[5]

Exclusion criteria

  1. Children who were on hematinics
  2. Low birth weight or preterm
  3. Requiring frequent blood transfusion
  4. Malignancy, bleeding disorders or any other severe illness
  5. History of surgery within the past 2 months.


The parent/care taker of the child was well informed about the study and written, informed consent was obtained from them. Ethical approval for the study was taken from the Institutional Review Board. Information regarding age, sex, weight, history of blood transfusion or being treated for anemia, socioeconomic status was collected. Nutritional status was assessed through weight for height using an electronic weighing scale. The WHO growth charts were used to determine the nutritional status as normal nutrition, moderate acute malnutrition, or severe acute malnutrition. The data were compiled as per age group, gender, and nutritional status (weight for height).

For serum collection, blood (3 mL) was collected into trace mineral-free SST (Vacutainer; Becton Dickinson, Plymouth, United Kingdom) and allowed to coagulate (25 min) at room temperature. The coagulated blood was centrifuged at 1315 ×g for 15 min at 25°C. Serum was divided into aliquots for the measurement of Iron and transferrin saturation. Venous whole blood (3 mL) was collected into Ethylenediamine tetraacetic acid-containing tubes (vacutainer) for automated blood analysis. Samples were run on the DXH 600 (Beckman coulter) within 1 h of collection. Complete blood count which includes hemoglobin, red blood cell count, white blood cell count, platelet count and red cell indices, i.e., mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH), mean corpuscular hemoglobin concentration (MCHC), and red cell distribution width (RDW) was obtained. Serum iron and unsaturated iron binding capacity (UIBC) was assessed with spectrophotometry in Beckman Coulter AU 680. Total iron binding capacity (TIBC) is calculated by adding iron and UIBC. The percentage of transferrin saturation was subsequently calculated as (serum iron/TIBC) × 100.[6] Patients were considered to have iron deficient anemia if the following criteria were fulfilled–serum iron <50 mg/dl, transferrin saturation <16% and Hb <11 gm%.[7] Ferritin levels, as it is an acute-phase reactant and expensive, was not done. The severity of anemia was classified based on the WHO classification of anemia as mild 10–10.9 mg/dl, moderate 7-9.9 mg/dl and severe <7 mg/dl.

Statistical analysis

Data were analyzed using SAS University Edition and summarized in frequency tables and a pie chart. Continuous data were described as mean and standard deviation. Differences in mean were tested using Student's t-test and differences in proportions using Z-test for proportions. Odds ratio with 95% of confidence interval was calculated using multiple logistics regression.


  Results Top


Among the 160 children evaluated, 48 (30%) were anemic, of which 41 (85.4%) had IDA. When classified according to the severity of anemia, 51.2% were mild, 43.9% were moderate and only 4.9% were severe. The demographic profile and nutritional status of the studied cases is depicted in [Table 1] and the classification according to the severity of anemia is shown in [Figure 1], and its relationship to age, gender, and nutrition is described in [Table 2].
Table 1: Demographic profile and nutritional status of the study subjects

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Figure 1: Severity of anemia

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Table 2: Classification according to the severity of anemia

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There were slightly more boys (55.0%) than girls (45.0%) in the study population. However, equal proportion (P = 0.84) of boys (25.0%) and girls (26.4%) had IDA. In the case of nutritional status among the study children, 81.3% were normal category and only 18.8% had moderate acute malnutrition. There were no cases of severe acute malnutrition. However, equal proportion (P = 0.75) of well-nourished (26.2%) and moderately nourished (23.3%) children had IDA. The study population was equally distributed with 81 (50.6%) children below the age of 2 years and 79 (49.4%) above the age of 2. However, a significantly higher proportion (P < 0.0001) of children below the age of 2 (40.7%) had IDA than those above 2 years of age (10.1%), irrespective of their gender and nutritional status, as shown in [Table 3]. As shown in [Table 4], multiple parameters such as MCV, MCH, MCHC, and RDW showed a clear separation of iron deficient anemia from normal. However, this was not the case for TIBC (P = 0.0752).
Table 3: Factors associated with iron deficiency anemia

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Table 4: Description of laboratory parameters

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  Discussion Top


Although a recent systematic review on prevalence of anemia in children of Kerala, included ten studies and two national reports, over 25 years,[3] there are not many published studies on IDA in young children of Kerala. It is assumed that most of the anemics are iron deficient. Moreover, the above study reported a very wide range in prevalence varying from 12% to 95% and a recent national survey reported that despite a substantial declining trend over the past few decades, the current prevalence of anemia in Kerala is still high, affecting one in every three children under 5 years of age.[1] Zeroing in on a specific socioeconomic or demographic group and a specific type of anemia, may help in better planning of resources in our battle against anemia. This study, which included only apparently healthy preschool children from a high socioeconomic background, describes IDA in children of affluent families of Kerala.

Our study showed that female children are no different than male children in their susceptibility to IDA (P = 0.84), unlike other studies of anemia such as the one by George et al.,[8] where females (12.6%) were more susceptible to anemia than males (10.25%), P = 0.012; and the one by Manoj and Meppadath where male (17.27%) children were more susceptible than female (32.5%) children, P = 0.037.

Most of the children in our study had a normal nutritional status (81.2%) based on weight for height. However, 26.1% of these had IDA whereas only 23.1% of the moderate acute malnutrition children were affected. Although a lower nutritional status has been associated with a higher incidence of anemia,[4],[9],[10] we did not find any such association in the study group.

Our results show that IDA among young children in Kerala remains a public health concern. Most (85.5%) of those with IDA were <2 years of age, with the age specific prevalence being much higher among infants (51.5%) than children less between 1 and 2 years (34.1%). The least affected were of the age group 36–60 months (6.7%) similar to the studies such as Arlappa et al. and Manoj and Meppadath.[9],[10] Further analysis confirmed that children below the age of 2 years were more likely to have IDA (OR 5.8 95% CI 2.5–13.8) for any given gender or nutritional status, when compared to those above the age of 2 years.

When classified according to severity of anemia, 51.2% were mild, 43.9% were moderate, and only 4.9% were severe. This finding is not surprising because the current study recruited subjects who belonged to affluent families who had very less malnutrition. However, the high proportion of IDA may be because of inadequate intake of iron as compared to the need and increased requirement during the rapid growth stage of infancy and early childhood, between 6 and 23 months. Other reasons for IDA in children include poor bioavailability of iron consumed, low consumption of absorption enhancers and a high consumption of absorption inhibitors. In Kerala, a cereal based diet is consumed regularly which unfortunately, decreases iron bioavailability because the phytates in grains sequester iron to a poorly absorbable complex.[11]

A high prevalence among apparently healthy children from affluent families is an indicator that the general population rates will be even higher. As per the WHO/UNICEF guidelines of 2016 recommendations, a universal supplementation is required and it is not cost-effective to screen children for anaemia, when the prevalence of anaemia is >40%. To prevent IDA, daily iron supplementation is recommended as a public health intervention for three consecutive months in a year for children living in settings where anaemia is highly prevalent, to increase Hb concentrations and improve iron status. The dose being 10–12.5 mg elemental iron given to infants and young children up to the age of 23 months and 30 mg elemental iron to preschool-age children aged 24–59 months. If the prevalence of anemia is 20%–40%, intermittent regimens of iron supplementation can be considered.[12] Under the National Iron Plus Initiative launched in 2013, bi-weekly 20 mg elemental iron and 100 microgram (mcg) folic acid per ml of liquid formulation and age appropriate de-worming for preschool children of 6–59 months is given.

Although the present study is not a population-based study, the chosen study population can be considered as representative of a high socioeconomic group. Moreover, although it was not designed specifically to study all the risk factors for anemia, it highlights the need to plan further intervention trials with either iron rich or iron fortified foods or iron supplementation, especially among children below the age of two. Given the severity of the consequences of IDA, including delayed psychomotor development and impaired cognitive performance, impaired growth, and increased morbidity, it is evident that additional efforts are needed to reduce iron deficiency in at-risk children. The challenges of reducing anemia and iron deficiency in high-risk populations, such as children under 2 years of age, must be addressed through new national and state programs such as the National Iron Plus Initiative. Other possible measures include iron fortification of infant formulas and cereals and regular surveillance monitoring. Since many children with IDA do not have physical symptoms, a strong index of suspicion of IDA in vulnerable groups is required for early detection and appropriate action. We also recommend that healthcare providers educate all parents about timely introduction of appropriate complimentary food, meal frequency, iron-rich foods and enhancers of iron absorption, such as haem and Vitamin C.


  Conclusions Top


A high prevalence among apparently healthy children from affluent families is an indicator that the general population rates will be even higher. This study highlights the need to plan further intervention trials with either iron-rich or iron-fortified foods or iron supplementation, especially among children below the age of two.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
International Institute for Population Sciences (IIPS) and ICF. National Family Health Survey (NFHS-4), India, 2015-16. Kerala. Mumbai: IIPS; 2016.  Back to cited text no. 1
    
2.
Nayar P, Panikar PG, Soman CR. Health Status of Kerala: Paradox of Economic Backwardness and Health Development. Trivandrum: Centre for Development Studies; 1984. p. 159. J Asian Stud 1989;48:910-1.  Back to cited text no. 2
    
3.
Rakesh PS. Prevalence of anaemia in Kerala state, Southern India – A systematic review. J Clin Diagn Res 2017;11:LE01-4.  Back to cited text no. 3
    
4.
Saluja N, Garg S, Chopra H, Bajpai S. Socio-demographic factors affecting anaemia in school children in urban area of Meerut, India. Internet J Prev Med2010;2:1-5.  Back to cited text no. 4
    
5.
Sharma R. Online Interactive Calculator for Real-Time Update of the Kuppuswamy's Socioeconomic Status Scale. Available from: www.scaleupdate.weebly.com. [ Last accessed on 2017 Aug 05].  Back to cited text no. 5
    
6.
Burtis CA, Ashwood ER, Bruns DE. Hemoglobin, iron, and bilirubin. In: Tietz Textbook of Clinical Chemistry and Molecular Diagnostics. 5th ed., Ch. 32. St. Louis, Missouri: Elsevier; 2012. p. 1007-16.  Back to cited text no. 6
    
7.
Braunstein EM. Iron deficiency anaemia. In: MSD Manual Professional Version. Kenilworth, NJ, USA: Merck & Co., Inc.; 2018.  Back to cited text no. 7
    
8.
George KA, Kumar NS, Lal JJ, Sreedevi R. Anemia and nutritional status of pre-school children in Kerala. Indian J Pediatr 2000;67:575-8.  Back to cited text no. 8
    
9.
Manoj S, Meppadath IM. Anaemia in 6-59 months children in rural Kerala and its association with age, gender, nutritional status and dietary habits. J Evol Med Dent Sci 2017;6:2358-61.  Back to cited text no. 9
    
10.
Arlappa N, Balakrishna N, Laxmaiah A, Brahmam GN. Prevalence of anaemia among rural pre-school children of West Bengal, India. Ann Hum Biol 2010;37:231-42.  Back to cited text no. 10
    
11.
Camaschella C. Iron-deficiency anemia. N Engl J Med 2015;373:485-6.  Back to cited text no. 11
    
12.
World Health Organization. Nutrition for Health and Development. Guideline. Daily Iron Supplementation in Infants and Children. Geneva: World Health Organization; 2016. Available from: http://www.ncbi.nlm.nih.gov/books/NBK362032/. [Last accessed on 2018 Nov 18].  Back to cited text no. 12
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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