European Journal of Cardiovascular Medicine

Pediatric anemia is one of the major health burden in India and in major parts of the world, as it results in reduced exercise tolerance, slower rate of growth, impaired development and delayed wound healing [1]. Anemic children are also at a higher risk of death due to complications associated with malnutrition and infection. Prevalence rate of anemia is an essential indicator of the nutritional status within the pediatric population. In the United States, around 18% of the children and in the developing countries about 82% of the children are anemic. [2] Because of these factors, the study of the etiopathogenesis of anemia in infancy and childhood has attracted wide attention in the recent years in India. [3,4]

In most children, anemia is asymptomatic but has abnormal hemoglobin levels on routine screening. A child with anemia would not always have pallor or all other related symptoms, so acquiring a complete history and elucidating proper physical examination can help in identifying the cause of anemia [5]. The iron stores are easily restored during the first few months of life even when the hemoglobin levels tend to fall. Thus iron deficiency is very rare to induce anemia until the reach of six months. Glucose-6- phosphate dehydrogenase (G6PD) deficiencies occur more commonly in males. [6] Habits Pica or geophagia usually results in iron deficiency. History of recent drug use may suggest G6PD deficiency or aplastic anemia and so does viral illness cause red cell aplasia. Recurrent diarrheal episodes show suspicion of malabsorptive occult blood loss that occurs in inflammatory bowel disease. The physical examination constitutes an important aspect, but is essentially normal in most children with anemia. Findings that suggest chronic anemia include irritability, pallor, glossitis, a systolic cardiac murmur, delayed growth and changes in the nailbed. [7]

Acute anemia presents clinically with jaundice, splenomegaly, tachypnoea, hematuria, tachycardia and even congestive heart failure. Anemia is defined as a reduced hemoglobin concentration as compared to the levels in agematched controls. 2 in screening situations, when anemia is encountered, the patient should undergo a complete blood count evaluation (CBC). Anemia can be classified into microcytic, normocytic and macrocytic types based on the Mean Corpuscular Volume (MCV) estimation. [8]

Next, anemia work-up includes peripheral smear examination and reticulocyte count measurement. Peripheral smear indicate the etiology of the anemia based on the red cell morphology. Basophilic stippling representing clumped ribosomes is in thalassemia syndromes, iron deficiency anemia and lead poisoning. Howell-Jolly bodies (nuclear fragments) are noted in asplenia, pernicious anemia and severe iron deficiency. The reticulocyte percentage is essential in segregating anemia due to decreased RBC production from a hemolytic anemia (increased RBC destruction). Bone marrow disorders or aplastic anemia show a low reticulocyte count, whereas a hemolytic process or active blood loss represents higher reticulocyte count. Corrected reticulocyte counts more than 1.5 indicates increased RBC production. [9]

If the diagnosis is still not clear after the analysis of the initial laboratory findings, other confirmatory studies may be required. In very low MCV, serum iron level and total iron binding capacity (TIBC) estimation is suggested. In case of suspicion of hemolysis, G6PD assay, hemoglobin electrophoresis, direct Coombs’ test, lactate dehydrogenase (LDH), and bilirubin (indirect) estimation may help in arriving at a diagnosis. Anemic children with an elevated MCV, requires vitamin B12 and folate to be estimated in doubtful cases. [10] Eenzymopathies by RBC enzyme panel, hereditary spherocytosis by osmotic fragility testing, membranopathies by membrane protein studies are other confirmatory tests that can be employed. In certain circumstances, such as a suspected hematologic malignancy, a bone marrow aspiration may be indicated [11-15]

A prospective study, for a period of 1 year at Department of Paediatrics, Chalmeda AnandRao Institute of Medical Sciences. The children who were admitted in the hospital with sign of Pallor were selected as per inclusion criteria into the study.

Routine Investigations for anaemia and its causes were done. Anaemia was classified morphologically based on peripheral smear findings. Packed-cell volume (PCV), mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH), mean corpuscular hemoglobin concentration (MCHC) and red cell distribution width (RDW) were determined by automated cell counter. Hemoglobin was estimated by Sahli’s method and expressed in gm%, peripheral smear was stained by Leishman’s stain. Reticulocyte count was done by brilliant crystal stain method, serum iron determination was done by Ramany’s dipyridyl method, Total iron binding capacity was determined by Ramsay’s method, serum vitamin B12 and folic acid was determined by architect method.

Inclusion criteria used in the study was children of age group 6 months to 12 years with pallor, admitted in Medical College and Hospital, while exclusion criteria was infants less than 6 months of age and teenagers more than 12 years old, out patients who were not admitted in the hospital, patients who collapsed due to congestive cardiac failure within 12 hours of admission and patients with communicable diseases like human immunodeficiency virus (HIV), tuberculosis and hepatitis were excluded.

 Statistical Analysis

Data were entered in Microsoft excel and all statistical analyses were performed. Statistical package for the social sciences (SPSS) for Windows version 25.0, Chicago, USA, was also used for data analysis. Descriptive characteristics (mean and standard deviation) and percentage were performed for each parameter separately. Chi-square and independent - test were used for proportions and mean comparisons between groups, respectively.

The present study comprised of 400 subjects, out of which 58% were males and 42% were females (table 1).

Table 1: Gender distribution of the study population (N=250)

Dimorphic, Macrocytic, Microcytic Hypochromic, Normocytic Hypochromic and Normocytic Normochromic Anaemia were reported in 12%, 4%, 50%, 4% and 30% of the subjects respectively. Maximum cases were of Microcytic Hypochromic type as shown in table 2.

   Table 2: Distribution according to the types of Anaemia based upon the morphology

Table 3 shows the distribution of anemia according to Vit. B12 and Folic acid. Total 50 patients were studied. 12 cases of macrocytic anemia, 12 had Vitamin deficiency (8 with reduced Vit B12, 3 with reduced Folic acid and in 1 case both were reduced) i.e. 22.2%. In 28 cases of Dimorphic anemia, 38 had Vitamin deficiency (19 with reduced Vit. B12, 10  with reduced folic acid and in 2 cases both were reduced) i.e. 72.2% as shown in Table 3. Therefore 34 cases were diagnosed with

Table 3: Distribution of anemia according to Vit. B12 and Folic acid (N=50)

Table 4: Distribution of Anemia according to Iron profile (N=400)

Table 5: Comparison of bone marrow findings with peripheral blood smear(N=15)

The present study comprised of 400 subjects, out of which 59% were males and 41% were females. These results were in accordance with study done by Taskesen et al¹⁶, Jain et Al¹⁷ and Gupta Set al¹⁸. Taskesen et al¹⁶ in his study found 57% boys and43%were girls. Jain et al¹⁷ have also reported increased incidence in males (71%) compared to girls (29%). Chauhan et al¹⁹ reported dissimilar results who reported44.2% boys and 55.8% girls in their study. Sastry CPV et al¹ also found female preponderance in their study (males 40/110 (36.3%).

In the present study, Dimorphic, Macrocytic, Microcytic Hypochromic, Normocytic Hypochromic and Normocytic Normochromic Anaemia were reported in 11.2%, 3.2%, 50%, 4% and 30% of the subjects. Sastry C.P.V¹⁹ in his study found that peripheral smear examination showed Microcytichypochromic anemia in 81.8% (90/110). Dimorphic anemia was seen in 9.09 %. Normocytic Normochromic anemia was seen in 9.09 % of patients. Venkatesh G²⁰ observed Microcytic hypochromic anemia in 54.4%, macrocytic hypochromic anemia is seen in 11.8% and dimorphic anemia is seen in36.6% of patients⁵.

In the present study, Vitamin B12 and Folic acid deficiency was found in 6.4% and 6% of the nutrition deficient subjects Sastry C.P.V¹ reported Vitamin B12deficiency anemia in 5% of the subjects. Madoori²¹ et al also found that 5% (16) cases had megaloblastic anemia. Venkatesh G²⁰, et al reported iron deficiency anemia the most common followed by dimorphic anemia and megaloblastic anemia. Early diagnosis and treatment is important in cases of vitamin B12 deficiency to prevent neurological       and         haematological complications. Diet rich in vitamin B12and vitamin B supplements are important in the prevention and treatment of nutritional vitamin B12deficiency. Strategies to improve vitamin B12 status in children should be developed such as creating awareness regarding intake of proper diet and vitamin B supplements by pregnant and lactating mothers, proper method of weaning and timely introduction of adequate complementary feeding in infants and introducing a modified meal plan in Anganwadis and schools to incorporate vitamin B rich food to children. In the National Nutritional Anemia Prophylaxis Programme, vitamin B supplementation should be given along with iron and folic acid to prevent vitamin B12 deficiency in children¹⁹

In the present study, iron deficiency anemia was found in 184 patients i.e. 46%. Ferritin is the intracellular storage form of iron found chiefly in the cytoplasm of the cells of the reticuloendothelial system. It can be quantitated in serum using immunoenzymatic assays. Serum ferritin concentrations have been documented to give an accurate indication of the amount of storage iron in healthy individuals and in patients with iron deficiency or iron overload²². It is the most specific biochemical test for iron deficiency anemia (IDA) because it correlates with total body iron stores. Low serum ferritin concentration reflects depleted iron stores. When compared with other iron status parameter, serum ferritin is one of the lowest biologically varying iron status markers, thus making it one of the most useful parameters. Ali et al²² in his study of 398 patients found lack of ironstores in 119 patients. Of these, the serum ferritin was elevated in 40 patients (29.89%) despite lack of demonstrable iron in the marrow specimen. They concluded that a low serum ferritin value probably indicates iron depletion, while an elevated value does not exclude that possibility²²

In the present study, 7 cases were diagnosed as nutritional deficiency anemia on bone marrow and 7 (77.7%) were diagnosed as Iron deficiency anemia with iron stores (Perl stain) ranging from 0 to 2. Approximately similar results were reported by Tabassum et al^23, Pujara et al² and Bableshwar et al^24.

In the current study, the preschool children are found to be the most affected. Hence, it is recommended that, this age group is compulsorily screened for anemia. A uniform definition of screening criteria and an effective system to respond to abnormalities is the need of the hour. The current study was taken up, keeping this need in view

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