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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


ABSTRACT
Anemia is the most prevalent problem in the world particularly in the developing countries
1
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 nutrients
4
. Iron deficiency is one of the
major causes of anemia among Indian
children
5
. Nutritional anemia develops
secondary to interplay of diverse factors like
poverty, malnutrition, large family size, faulty
dietary habits and repeated infections
6
. 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
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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
Scientific Research Journal of India Volume: 3, Issue: 2, Year: 2014



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)
CI10.42% 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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76
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
12.77781.09
(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
Scientific Research Journal of India Volume: 3, Issue: 2, Year: 2014


(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 world
6
.
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
gender
7
. 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 anemia
8
. 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 al
6
. A study done on
young Mexican
9
children and another study
conducted in Malawi
10
, iron deficiency is not a
predominant cause of severe nutritional anemia,
this is contradictory to the present study.
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78
Majority of children with iron deficiency
anemia presented with symptoms of pallor
(90.6%) which is a similar finding by Rachana
Bhoite et al
11
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 (3
rd
to 25
th

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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CORRESPONDING AUTHOR:
*Dr. Madoori Srinivas, Professor, Department of Pediatrics, Chalmeda Anand Rao Institute of Medical
Sciences, Karimnagar, Andhra Pradesh, Ph No: 9866535700, Email ID: madoorisrinivas@gmail.com
Contribution details:-
Concept and guarantor: Author Madoori Srinivas
Manuscript preparation: Mangat B, Radhika K, Srikanth D
Data compiled: Kapil C