European Journal of Cardiovascular Medicine

mortality in the world. It is widespread among the developing countries such as India. Undernutrition forms the bulk of the problem contributing to morbidity in about 178 million children residing in 20 countries. Majority of these countries geographically are located in the sub-saharan and south east asian region. About one third of these malnourished children reside in India. Malnourished children contribute to about half of the mortality in Indian children. Protein energy malnutrition is difficult to classify, it takes into consideration many age dependant and independent anthropometric parameters. Broadly, from a clinical management perspective undernutrition can be divided into chronic and acute malnutrition. Acute malnutrition can be classified into severe acute malnutrition and moderate acute malnutrition according to the severity of malnutrition.[1]

Severe acute malnutrition is a unique type of malnutrition that is has different pathophysiological effects on the human body from chronic malnutrition. SAM can occur in pathological phenotypes namely SAM with malnutrition and SAM without malnutrition. SAM is often precipitated 9 by an acute infection. The observed case fatality rate is about 23.5% in SAM and it may reach upto 50% in oedematous malnutrition. SAM is both a medical and social disorder.[2] With references from the NFHS-3, it has been estimated that about 6.4% of children below 6 years are suffering from SAM. SAM children are different from non SAM children in that the physiology of the body itself undergoes major changes and common infections like pneumonia and diarrhoea, which by itself are not very harmful may prove to be fatal in children with SAM. These physiological changes extend to major systems in the body and are different in pathological phenotypes of SAM.  The major causes of mortality observed in SAM children include reductive adaptive changes, impaired immunity, abnormal electrolyte profile, and management options like early intravenous fluids and high calorie diet in the early phase. The degree of wasting in SAM positively correlates with death.

According to the fourth Indian National Family Health Survey (NFHS-4) performed in 2015-16, 38.4% of children aged 6 to 59 months were stunted (height-for-age Z-score (HAZ) - 2) and 58.4% were anaemic (haemoglobin (Hb) 110 g/L) (IIPS 2017). Both of these disorders have a slew of negative health implications, including delays in physical and cognitive development.[1] Despite a 10% reduction in stunting and anaemia prevalence in the ten years from the third NFHS-3 (IIPS 2007, IIPS 2017), significant efforts are still required to reach the Sustainable Development Goal (SDG) objectives stated by the United Nations. By 2030, the United Nations (UN; 2015) aims to "eliminate all types of malnutrition". [2]

The International Food Policy Research Institute's newly issued Global Hunger Index 2017 study, in which India is rated 100th out of 119 countries, reveals a dire condition of hunger in the country. Globally, inadequate design of nutritional policies and programmes has resulted from a lack of consensus and prioritisation, and this is also true in India.[3]

The high frequency of anaemia in Indian children (over 40%) is a public health problem (WHO 2015). Despite this, only a few research have looked at the causes of anaemia in India in a range of contexts.[4]

This study was a hospital based prospective conducted in the Department of pediatrics, Niloufer Hospital for Women and Child Health, Hyderabad, Telanagana.

A total of 150 cases who met criteria for severe acute malnutrition after taking proper informed consent from18 months, January 2020 to June 2021

Inclusion Criteria: Children diagnosed with severe acute malnutrition according to the WHO guidelines between age groups of 6 months and 60 months.i.e, Weight for height less than 3 standard deviations and/ or, Visible severe wasting, Mid arm circumference less than 11.5cm and/or oedema of both feet.

Exclusion Criteria: Children less than 6months and more than 5years of age and with chronic systemic diseases.

Statistical analysis

Data was entered in Microsoft excel and analysed by statistical software SPSS v.23.0 and Jamovi 1.8.4. Normal distribution of data was checked by Shapiro wilk test. Normally distributed data was represented as Mean and SD. Non-parametric continuous data was represented as Median and IQR. Categorical data was represented as frequency and percentage.

For analysis of two independent parametric variable; independent t-test was used. For non-parametric variable; Mann-Whitney U test was used. To find association between categorial data Pearson’s chi-square test was used. P value <0.05 was considered as significant.

Data collection: 150 children between the ages of 6 months to 60 months admitted in Niloufer hospital who have satisfied the WHO criterion for SAM have been included in the study. Height, weight, weight for height and MUAC have been measured on the day of admission and plotted on WHO growth charts. Serum values of iron, vitamin b12, folate have been measured before starting the treatment

Table-1: Descriptive of Clinical, anthropometric and lab. characteristics of study population (n=150)

* Data were not in normal distribution (Shapiro wilk test; p<0.05).

With due consideration of eligibility criteria, A total of 150 children with severe acute malnutrition were recruited in our study.

Table-2: Descriptive of different socio-demographic characteristics of study population

54 % of children were 6-12 months of age followed by 13-24 months (24%) and 25-60 months (22%). 64% of children were male and 36% female. 32% children were 1^st in birth order and 25% children were 2^nd in birth order. 24% children were completely immunized and 34% were un-immunized and 42% were incomplete immunized. 96% children were in delayed development. 65% children from Rural area of residence and 35% were from urban area of residence. 59% children belonged to lower socio-economic status.

Table-3:  Feeding pattern in children

The feeding pattern of 56% children was exclusive breast feeding. 69% cases were on mixed diet.

Table-4: Descriptive of clinical findings among children with SAM

Table-5: Descriptive of physical findings among children

76% of children had Wt/Ht. <-3SD. 71% of children had MUAC <11.5 cm. 76% children presented with wasting.Edema was presented in 53% of children.

Table-6: Descriptive of different co-morbidities among children with SAM

48% children had severe anemia and 38% had moderate anemia. Pneumonia was presented in 26% of children. Diarrhea was presented in 22% of children. Malaria was presented in 6% of children. 6% of children had other co-morbidities like worm infestation and protein energy malnutrition.

Table-7: Descriptive of different lab. parameters for anemia in children with SAM

74% children had serum iron level was <60 mcg/dl. 6% of children had serum ferritin <12ng/ml. 65% of children had transferrin saturation <15%. 6% of children had Serum folate<10 nmol/L. 34% of children had vitamin B12 level<203 ng/ml. 70% of children had MCV less than 80 fl. 74% of children had MCH <28 pg.

Table-8: Difference in different characteristics by serum iron and ferritin among children

Table-9: Difference in different characteristics by serum folate and vit B12

Table -10: Difference in different characteristics by serum iron and ferritin among children with SAM

Table -11: Difference in different characteristics by serum folate and vitaminB12 among children with SAM

* Categorical data was represented as Frequency and N%. Chi-square test was applied to evaluate association the different characteristics of children with SAM and serum hematopoietic factors. P<0.05 was considered  as statistically significant.

There was significant association was found with male children with SAM and iron deficiency (p=0.042). it means male children with SAM were in higher risk than female in term of iron deficiency anemia. Severe fall in hemoglobin level was significantly associated with iron deficiency(p=0.03).

Feeding pattern of children was significantly associated with low ferritin level. It means children who were predominantly breast feeding had lower serum ferritin level (p=0.009). There was significant correlation was observed in Vit. B12 deficiency (0.026) and higher folate level >10 nmol/L.

Severe acute malnutrition (SAM) still has a high prevalence, especially in South-East Asia. Globally, there are estimated 20 million children suffering from SAM; less than 2 million received treatment in 2011, and one million die each year with SAM. In 2005–2006, among all the children under 5y of age 48 % were stunted, 43 % were underweight and 20 % were wasted.[5] The prevalence of anemia is reported to be high in children with SAM and iron deficiency anemia was found to be the commonest. [6] There are limited data on the status of hematopoietic factors in patients with severe acute malnutrition. Hence this hospital based single centered prospective cross-sectional study was designed to assess the prevalence of deficiencies of Iron, folate and vitamin B12 in severely acute malnourished children. The major objectives of this study were to assess iron, folate and vitamin b12 status in severely acute malnourished and correlation of these levels with severity of malnutrition. This was conducted over a total of 150 children with severe acute malnutrition over a time period of 18 months. Children with SAM between 6 months to 5 years of age admitted to pediatric department were enrolled based upon eligibility criteria.

A similar study was previously conducted by Taorem et.al[7] in Bal Chikitsalaya, RNT Medical College, Udaipur Rajasthan. This study enrolled 50 children of age 6 months to 5 years of age. with severe acute malnutrition. In our study, 54 % of children were 6-12 months of age followed by 13-24 months (24%) and 25-60 months (22%). 64% of children were male and 36% female. 32% children were 1^st in birth order and 25% children were 2^nd in birth order. 24% children were completely immunized and 34% were un-immunized and 42% were incomplete immunized. 96% children were in delayed development. 65% children from Rural area of residence and 35% were from urban area of residence. 59% children belonged to lower socio-economic status. The feeding pattern of 56% children was exclusive breast feeding. 31% children had glossitis and 69% had PICA.76% of children had Wt/Ht. <-3 SD. 71% of children had MUAC <11.5 cm.76% children presented with wasting. Edema was presented in 53% of children. Among 150 children; 96% of children had anemia-48% children had severe anaemia; 38% had moderate anaemia and 10% had mild anaemia. Pneumonia was presented in 26% of children. Diarrhea was presented in 22% of children. Malaria was presented in 6% of children.6% of children had other co-morbidities.

In our study the prevalence of anaemia was observed 96%. 48% children had severe anaemia; 38% had moderate anaemia and 10% had mild anaemia. Taorem et.al.[7] found the prevalence of anaemia was 94% among children with SAM. 46% had severe anaemia; 40% had moderate anaemia and 20% had mild anaemia. The high prevalence of anaemia is reported by Thakur et al.[8] (moderate to severe anaemia in 81.1 %), Kumar et al.[9] (88.5 %) and RCH-2 (96.78 % of under-nourished children).

In our study, iron deficiency was observed in 74% of children with SAM; 6% of children had low ferritin level, 65% had low transferrin saturation, 6% children had low serum folate level and 34% had vitamin B12 deficiency. 70% children had low MCV, and 74% children had low MCH level. Taorem et.al.[7] also observed 6% children with low serum ferritin level: 6% children with low serum folate level and 34% children with vitamin B12 deficiency.

In the earlier study conducted by Ejaz et.al[10] on hematopoietic micronutrient levels in anaemic children, iron deficiency was found to be the commonest whereas in the index study on SAM patients, Iron deficiency was more common (74%) than ferritin; folate (6 % each) and vitamin B12 deficiency (34%).

In our study, here was significant association was found with male children with SAM and iron deficiency (p=0.042). it means male children with SAM were in higher risk than female in term of iron deficiency anaemia. Severe fall in hemoglobin level was significantly associated with iron deficiency(p=0.03).Feeding pattern of children was significantly associated with low ferritin level. It means children who were predominantly breast feeding had lower serum ferritin level (p=0.009).There was significant correlation was observed in higher folate level >10 nmol/L and Vit. B12 deficiency (0.026). Taorem et.al.[7] observed that only one patient had combined folate and vitamin B12 deficiency. Only 8.8 % CRP negative patients had low serum ferritin whereas none of the CRP positive patients had serum ferritin below 30 ng/ml. This could be due to presence of infection in these patients and routine iron folic acid supplementation to the pregnant and lactating mothers, whereas higher vitamin B12 deficiency rate could be due to low maternal vitamin B12 levels in predominantly vegetarian community where no vitamin B12 supplementation is routinely given. Vitamin B12 deficiency is well recognized in exclusively breastfed infants of vitamin B12 deficient mothers.[11]

Concentrations of vitamin B12 in breast milk reflect maternal vitamin B12 stores, and maternal vitamin B12 stores are depleted in up to one-third of rural Indian women.[12] A study in rural Karnataka by Pasricha et al[2]. also found that concentrations of ferritin and vitamin B12 were decreased in toddlers who continued to receive breast milk. Folate concentrations in breast milk are generally high  and independent of maternal stores thus, prolonged breastfeeding in most of the index patients might be protective from folate deficiency. The adverse neurological outcome in the form of delayed and regression of milestones in these patients can be attributed to vitamin B12 deficiency. Kumar et al[9] also found that 14.4 % of the SAM patients were serum vitamin B12 deficient.  Taneja et.al[13] conducted a study of about 2482children aged 6–30 months in New Delhi reported vitamin B12deficiency in 28 % and folate deficiency in 15 % of children. Gomber S et al[14] conducted a study of 100 anaemic children who lived in Delhi slum showed that 14.4 % of children had vitamin B12 deficiency alone, 22.2 % of children had combined vitaminB12 and iron deficiency, and 2.2 % of children had folate deficiency.  Hanumante et al[15] conducted a study in 51 urban toddlers in Pune, the prevalence of vitamin B12 deficiency was 14 %.Chandra et al [16] also documented 20 % folate deficiency and 32 % serum vitaminB12 deficiency in children.

LIMITATION OF STUDY

• The measurement of holotranscobalamin and metabolites such as homocysteine and methylmalonic acid are more sensitive indicators than serum vitamin B12.
• Pre-analytic hemolysis of blood samples might also be a factor for higher folate values. The maternal diet and breast milk micronutrient contents might have also strengthened the results.
• Absence of a comparative group is also another setback of the study.
• In this study we recruited only a small sample size.
• In future a large prospective case control study is required to assess the serum iron, folate and vitamin B12 status in severely acute malnourished children.

In conclusion, iron deficiency was more common than deficiencies of vitamin B12 and folate in these SAM patients. The index findings provide a framework for the development of strategies to improve the micronutrient status and to prevent hematological as well as non-hematological manifestations, mainly that of iron, folate and vitamin B12 in this specific population. To disseminate knowledge regarding timely introduction of complementary feeding. In national nutritional anemia prophylaxis program, vitamin B12 supplementation can also be given along with iron and folic acid.

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