European Journal of Cardiovascular Medicine

Anaemia is defined as decreased concentration of haemoglobin and RBC mass as compared to the values in age-matched controls. There are three primary causes: (1) reduced production of red blood cells, which may result from deficiency in nutrients or hormones, or from disease or other conditions; (2) excessive destruction of red blood cells, often a hereditary problem; and (3) excessive blood loss.1 Worldwide, anaemia among preschool children is one of the serious public health problems. Globally 1.62 billion people are anaemic, while among the preschool children the prevalence of anaemia is 47.4%.2 In India, about 89 million children are anemic.3 Thus, India is the highest contributor to child anaemia among the developing countries.4 According to the latest national representative survey of India, 70% children are anaemic in the age group of 6–59 months, including 3% severely anaemic, 40% moderately anaemic, and 26% mildly anemic.5 Anaemia is the most predominant factor for morbidity and child mortality6-8, and hence, it is a critical health issue for preschool children in India.9 Nearly half the children aged 6-59 months in Uttar Pradesh and Uttarakhand have moderate to severe anemia5.Moderate to severe anaemia (Hb <10.0 gm/dl) is a serious nutritional anomaly that requires an early recognition and management based on correct diagnosis of etiology and clinic-pathological profile of children which might further help to establish a correlation between different etiologies and clinic-pathological profile of anaemia in children. This might help in evolving simplified criteria based on clinical and pathological profile independently or in combination to differentiate between different etiologies of anaemia, and to suggest appropriate corrective measures in accordance with the specific etiology of the deficiency. The present study was carried out with an aim to study the etiology and clinic-pathological profile of moderate to severe anaemia in pre-school children.

AIMS AND OBJECTIVES

The present study was carried out with an aim to study the etiology and clinic-pathological profile of moderate to severe anaemia in pre-school children. This aim was achieved with the help of following objectives:

1.To find out the hospital-based prevalence of moderate to severe anaemia and its different types in children attending hospital.

2.To establish the etiology like iron deficiency anaemia, pernicious anaemia, folic acid deficiency anaemia, thalassemia and haemolytic anaemia in moderate to severe anaemic patients.

3.To study the clinic-pathological profile of moderate to severe anaemic children.

Present cross-sectional study was conducted in the Department of Paediatrics from April 2019 – March 2022.The sampling frame was children aged 6 months to 5 years having moderate to severe anaemia. Trauma victims or patients with injury resulting in severe blood loss, individuals having undergone blood transfusion within three months, child suffering from multiple congenital anomalies were excluded from the study. Informed consent was taken from the guardians of all the subjects before enrolling in the study. The demographic details were noted and a blood sample was obtained for the assessment of haemoglobin. On the basis of outcome of haemoglobin assessment, the subjects were categorized for their anaemic status based on the WHO criteria: Hb >11 mg/dl (Non-anaemic), Hb 10-10.9 (Mild anaemia), Hb 7-9.9(Moderate anaemia) and Hb < 7(Severe anaemia). Detailed clinical, pathological, dietary and medical history of children were obtained in order to ascertain the etiology.  In all the subjects diagnosed as anaemic, complete blood picture and general blood picture was done. Serum ferritin and iron levels were assessed in all microcytic hypochromic anaemia to ascertain the cause of anaemia as iron deficiency anaemia. In cases having macrocytic anaemia, vitamin B12 and folic acid levels were assessed. In subjects having normocytic normochromic anaemia, haemolysis, blood loss or bone marrow hypoplasia were ascertained by performing tests as indicated by general blood picture which included reticulocyte count, haemoglobin electrophoresis, test for sickle cells and Coomb’s test. Bone marrow examination was performed if required.

Statistical Analysis

Statistical analysis was done using Statistical Package for Social Sciences version 28 (IBM Corporation, SPSS Inc., Chicago, IL, USA). Chi-square test and independent samples t-test was used to compare the study parameters. The multivariate logistic regression analysis was carried to find the significant factors affect the prevalence of anaemia. The p-value<0.05 was considered significant.

The present study was conducted in the Department of Paediatrics in collaboration with Department of Pathology, SGRR Medical College, Dehradun with an aim to study the etiology and clinic-pathological profile of moderate to severe anaemia in pre-school (aged 6 to 60 months) children.  A total of 444 children were included in the study. More than one third of the children were between 24–35-month (38.3%) followed by 12-23 (28.8%), 48-60 (17.1%), 36-47 (9%) and <12 (6.8%) month. About half of the children were male (49.5%). More than half of the children belonged to rural area. More than half (54.1%) of the children were vegetarian (Table 1)

The prevalence of moderate to severe anaemia was observed to be higher among those who had exclusively breastfed upto 1–2-month (29.2%) than 5-6 (27.8%), 3-4 (20.5%) and >6 (14.3%) month.  However, this trend was statistically not significant (p>0.05) [Table 2].

There was no significant (p>0.05) association between prevalence of moderate to severe anaemia with family history of anaemia. Chest drawing was present in 30.9% Manifestation of parasitic infections was present in 29.1% of the children who were having moderate to severe anaemia. The prevalence of stunting was observed among 36.9% and wasting was among 41% of the children. The prevalence of underweight was in 42.8% of the children. The prevalence of mild anaemia was 35.1% and moderate was 18.9% and severe anaemia was found to be 5.9%. The prevalence of moderate to severe anaemia was higher among the children of age <12 month than other age groups, however, this was statistically not significant (p>0.05). The prevalence was found to be significantly (p=0.0001) higher among females (30.4%) than males (19.1%). There was no significant (p>0.05) association of the prevalence of moderate to severe anaemia with place of residence and dietary habit. Serum ferritin deficiency was observed among 80 children and serum iron deficiency was found in 76 children. However, B₁₂ /Folic acid deficiency was seen in 20 children. Iron deficiency anaemia was most common followed by B12/Folic acid deficiency anaemia. Microcytic hypochromic anaemia was found in 70.9% of the children and macrocytic normochromic was found in 10.9% and macrocytic hypochromic anaemia was seen in 7.3% (Table 3).

Anaemia is one of the most common health problems in the world and one of the important clinical markers of the underlying disorder. Prevalence of anaemia in preschool children, particularly between 6 months and 5 years varies in different countries. Anaemia is graded as mild if Hb% is above 10 gms/dl and below the normal range for age & sex, moderate if Hb% is 7-10 gms/dl, severe if Hb% is < 7 gms/dl.¹¹ Iron Deficiency Anaemia is the widest spread micronutrient deficiency in India.¹² Globally, 50% of anaemia is attributable to iron deficiency and accounts for around 841,000 deaths annually worldwide. Africa and parts of Asia bear 71% of the global mortality burden. National family health survey (NHFS)-2 data shows that 74% children between the age of 6 – 35 months are anemic.¹³

In the present study, more than one third of the anaemic children were between 24–35-month (38.3%) followed by 12-23 (28.8%), 48-60 (17.1%), 36-47 (9%) and <12 (6.8%) month. About half of the children were male (49.5%). More than half of the children belonged to rural area.  The family history of anaemia was present among one third of the children. Manifestation of parasitic infections was the most common symptom among the children in this study. Prevalence of stunting, wasting and underweight was among more than one third of the children. In a population-based, cross-sectional survey of 858 children 6-35 months of age in western Kenya by Foote et al16, the stunting was significantly associated the prevalence of severe anaemia.  The prevalence of moderate to severe anaemia was significantly (p=0.0001) higher among females compared with males and was higher among under one year of age in the present study. Similar finding had been reported by Kadhim and Nawsherwan.¹⁸ There was no difference in the prevalence of moderate to severe anaemia between rural and urban children. This finding is inconsistent with the findings of Dey et al.¹⁰ in which rural children were at higher risk being anaemic. This might be due that the present study was a hospital based and their study was a community based. Anaemia was reported among both vegetarians and non-vegetarians; however, the difference was statistically not significant in the present study.  George et al.¹⁵ (2000) also reported similar findings in which among 927 vegetarians, 86 (9.27%) were anaemic and among 2,706 non-vegetarians, 328 (12.1%) were anaemic.

In the present study, the prevalence of moderate to severe anaemia was observed to be higher among those who had exclusively breastfed up to 1–2-month (29.2%) than 5-6 (27.8%), 3-4 (20.5%) and >6 (14.3%) month, however, this trend was statistically not significant (p>0.05).  Pasricha et al.³ found that Children's ferritin levels were directly associated with their iron intake and CRP levels and with maternal haemoglobin level and inversely associated with continued breastfeeding and the child's energy intake. Respiratory distress was present in 30.9% and manifestation of parasitic infections was present in 29.1% of the children who were moderate to severe anaemia.  This finding is similar to Goswami et al.¹⁷ The morphological classification of anaemia in this study revealed that microcytic hypochromic anaemia was the predominant class (70.9%) followed by macrocytic anaemia (18.2%) . This result is nearly identical to the study by Kadhim and Nawsherwan18 who found that types of anaemia were microcytic (60.7%) and macrocytic (12.6%). In present study Iron deficiency anaemia was the most common type of anaemia (69%) followed by vitamin B12 /Folic acid deficiency anaemia (18.2%). The result is consistent with Gomber et al¹⁴ in which pure or mixed iron deficiency anaemia was the commonest type of anaemia noted in 68.42 per cent (65 of 95) children followed by pure or mixed B12 deficiency noticed in 28.42 per cent (27 of 95) anaemic children.

Majority of children in present study had anaemia (59.9%). Prevalence of mild, moderate and severe anaemia was 35.1%, 18.9% and 5.9% respectively. A strong association between malnutrition (underweight, stunting or either of two) and prevalence of moderate to severe anaemia was established. Prevalence of moderate to severe anaemia was quite low (24.8%) in our settings which might be attributable to the better health programs in the region.

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