Introducción
Anemia in children is one of the major health challenges with global impact, especially in developing countries.1 Globally, anemia affects 1.62 billion people, almost 24.8% of the world population. The highest prevalence is in pre-school age children i.e. 47.4%. However, 25.4% of school age children suffer from anemia.2 A person is said to be anemic if there is less hemoglobin level as per age and sex. Iron deficiency is observed as main cause of anemia globally3,4 The other common causes of anemia are inadequate feeding, frequent infections, micronutrients deficiency and hemoglobinopathies.(5 Few studies have indicated that anemia among school children of 7-14 years age group is also impacted by socioeconomic, nutritional, physical and life style factors.6) Intestinal parasitic infections and school non-enrollment were also identified as key factors responsible for anemia among young children.7) Anemia in children is a grave problem because it can lead to stunted growth, weakness, impaired cognitive development and other health complications if left untreated.8
According to WHO estimates, India is one of the countries with highest prevalence of anemia. Though the prevalence of anemia reduced by 10% during the time period between NFHS-3 (69.4%) and NFHS-4 (58.4%), but continued to be higher among rural children.9) Both malnutrition and anemia are frequently present together in pediatric populace of India.10,11 Anemia is considered to be late manifestation of nutritional deficiency. Severe malnutrition can be root cause of mortality among young kids aged 5-14 years old.12) Body Mass Index (BMI) has been used as indicator for measuring the malnutrition and to find the association of BMI with anemia.13,14
There is need for localized studies to understand the prevalence pattern and associated risk factors among children in rural region of India. On this line, the current study was aimed to investigate the prevalence of anemia among children of 5-12 years' age group in rural areas of Ghaziabad district, Uttar Pradesh and an attempt was also made to evaluate its relationship with body mass index (BMI).
Fusce at sodales eros. Fuscevulp
Methods
Study setting:
The cross-sectional study was conducted among children of rural region of Ghaziabad district of Uttar Pradesh from September 2018 to 2019. Children of desired age groups were randomly selected as subjects from the families residing in the study village.
Subject inclusion criteria:
About 600 children both boys as well as girls in the age group of 5-13 years were included in the study after obtaining consent from the parents. Children aged 14 years and above and those suffering from any illness were excluded from the study.
Sample size:
The sample size was determined by the standard formula n=z2p(1-p)/d2.15) Considering the prevalence of anemia as 50%, z- value at 95% confidence (1.96), desired precision (d) of 5% with an anticipated attrition of 20%, the sample size of 461 was calculated. More than required number was taken to minimize the permissible errors.
Anaemia screening:
Children were categorized in 3 age groups: Group-I children of 5-7 years age group, Group-II children of 8-10 years age group, Group-III children of 11-13 years age group. Portable Hemocue Hb 201+ analyzer was used for screening of Anemia. Safety lancets were used to collect blood by finger prick method. The first drop of blood was wiped off with a cotton wool, while the second drop was collected using a microcuvette. The blood sample was loaded in the calibrated Hemoglobin analyzer and Hb concentration read to the nearest 0.1g/dL. Children with Hb level <11 were considered anemic and graded as mild (10.0-10.9 g/dL), moderate (7.0-9.9g/dL) and severe (<7g/dL). WHO standards were used to detect anemia in children. Parents were informed about the results of anemia screening and the children who was found to have severe anemia (a hb level below 7.0 g/dl) were referred to a health center for further evaluation and treatment. A detailed questionnaire was used to collect the health details of the children, dietary habits of the children and socioeconomic status of the parents.
BMI measurement:
Weight and height of each child was measured using standardized procedures. Body mass index (BMI) for each child was calculated based on the ratio of weight (kg) to height in square meters. After BMI is calculated, the BMI number is plotted on the CDC BMI-for-age growth chart to obtain a percentile ranking. The percentile indicates the relative position of the child's BMI number among children of the same age and sex. Children whose weight were less than 5th percentile consider as underweight. Healthy children have a BMI percentile ranging between 5th percentile to 85th percentile. The children whose weight were more than 85th to less than 95th percentile was considered as overweight and obese who were equal to or greater than the 95th percentile.16
Ethics:
The study has got ethical approval from institutional review board. Consent of parents were taken before sampling.
Statistical analysis:
The data was collected and computed for all statistical analysis by Microsoft Excel 2016. Mean, standard deviation and percentage were performed for each parameter separately. The independent t-test with Bonferroni adjustment was performed to test the significance of difference in mean values between groups, with level of significance set at p< 0.05. The correlation between hemoglobin and BMI was assessed by calculating the Pearson's correlation coefficient (r) and the significance of correlation (p).
Results
We determined BMI and Hb value of 600 children of age group 5-13 years in rural area of Ghaziabad. Children were categorized in 3 age groups: Group -I children of 5-7 years age group, Group -II children of 8-10 years age group, Group -III children of 11-13 years age group. This study revealed that overall prevalence of anemia among children in the age between 5 to 13 years was 57.67% (346/600).
SEX | NO. | NORMAL | TOTAL ANEMIA | ||
---|---|---|---|---|---|
NO. | %AGE | NO. | %AGE | ||
MALE | 300 | 158 | 52.67 | 142 | 47.33 |
FEMALE | 300 | 96 | 32 | 204 | 68.00 |
OVER ALL | 600 | 254 | 42.33 | 346 | 57.67 |
Anemia is found to be more prevalent in girls (68%) when compared to boys (47.3%) in the age group of 5 to 13 years.
AGE IN YEARS | SEX | TOTAL NO. | HEMOGLOBIN | P VALUE |
---|---|---|---|---|
(g/dl) mean + SD | ||||
5 TO 7 (GROUP I) | BOYS | 100 | 10.41 ± 1.48 | 0.02926 |
GIRLS | 100 | 9.942 ± 1.50 | ||
8 TO 10 (GROUPII) | BOYS | 100 | 11.50 ± 1.63 | 0.00018 |
GIRLS | 100 | 10.64 ± 1.55 | ||
11 TO 13 (GROUP III) | BOYS | 100 | 11.19 ± 1.99 | 0.00021 |
GIRLS | 100 | 10.18 ± 1.78 |
Our study showed that Mean Hb concentration was 10.65± 1.75 and is significantly higher in boys in all age groups than those of girls. (p < 0.05)
On multiple comparison between groups by Bonferroni arrangement, we found that mean Hb value of boys in group I (10.41 ± 1.48) was significantly lower than mean Hb value of group II (11.50 ± 1.63) and group III (10.64 ± 1.55, p=0.001). The difference in mean Hb values of girls between group I (9.942 ± 1.5) and group II (10.64 ± 1.55) was highly significant (p=0.003).Our results indicated that the highest prevalence of anemia was present in the age group of 5 to 7 years for both the sexes and minimum frequency was seen in the age group of 8-10 years. Children participated in our study did not show any symptoms like easy fatigue, loss of appetite, pallor or dizziness.
AGE IN YEARS | SEX | % prevalence of different grades of anemia. | ||||
---|---|---|---|---|---|---|
NORMAL (%) | MILD ANEMIA | MODERATE | SEVERE ANEMIA | % ANEMIC | ||
5 TO 7 (GROUP I) | Boys | 35 | 30 | 33 | 2 | 65 |
Girls | 22 | 31 | 43 | 4 | 78 | |
8 TO 10 (GROUPII) | Boys | 63 | 22 | 15 | _ | 37 |
Girls | 42 | 31 | 27 | _ | 58 | |
11 TO 13 (GROUP III) | Boys | 59 | 15 | 25 | 1 | 41 |
Girls | 32 | 23 | 42 | 3 | 68 |
The occurrence of moderate anemia cases (53%) was higher than that of mild anemia (43.8%) and severe anemia cases (2.9%). Severity of anemia was present mostly in girls.
AGE IN YEARS | BMI (kg/m2) | ||
---|---|---|---|
5 TO 7 (GROUP I) | 8 TO 10 (GROUP II) | 11 TO 13 (GROUP III) | |
MALE | 16.97 ± 4.29 | 15.12 ± 2.48 | 15.81 ± 3.23 |
FEMALE | 15.37 ± 2.33 | 15.14 ± 2.01 | 15.13 ± 1.64 |
From the results it was revealed that mean valueof BMI (15.69±2.81) of study population was within the normal range. Based on the CDC BMI percentile scale, it has been determined that 60.33% children (187boys, 175 girls) were of normal weight having a BMI percentile ranging between 5th percentile to 85th percentile. 30.7% (99 boys, 85 girls) were underweight having BMI less than 5th percentile, 7.33% children (19boys, 25girls) whose wieght were more than 85th percentile and less than 95th percentile, were considered as overweight and 1.67% (3boys, 7 girls) were obese. 52.2% children with normal BMI were found to be anemic. However, a negative correlation was found with BMI and hemoglobin concentration in this study.
The socioeconomic status and dietary habits of the subjects were studied and indicated that 90% of the study population belonged to lower socio- economic status.
Variable | Subjects (n) | % with Anemia | p-value |
---|---|---|---|
Meat | |||
Consumed | 105 | 62 | 0.6 |
not consumed | 495 | 57.1 | |
Vegetables | |||
Consumed | 174 | 23 | 0.001 |
not consumed | 426 | 72 | |
Fruits | |||
Consumed | 53 | 18 | 0.001 |
not consumed | 547 | 61.4 | |
Milk | |||
Consumed | 490 | 63.1 | 0.001 |
not consumed | 110 | 30 | |
Rice | |||
Consumed | 532 | 63.9 | 0.001 |
not consumed | 68 | 8.9 | |
Fat&oil | |||
Consumed | 422 | 64.9 | 0.003 |
not consumed | 178 | 40.9 |
The feeding habits of these children shown in table 5 indicates that daily intake of fruits and vegetables was very less while rice and milk were main component of their diet, both of which are deficient in iron. This may be a posible reason for prevalence of anemia in the study population. Feeding habits were found to be significantly associated with anemia amomg these children (p<0.05)
Discussion
In this cross-sectional study, 600 children of rural area of Ghaziabad between the ages of 5 to 13 years were screened for anemia, 57.6% of children found to have anemia. The prevalence of anemia in girls (68%)was significantly higher than in boys (47.3%).The result of this study corroborated the findings of Bulliyya G et al., that the prevalence of anemia in school- age children (6-12 years) of rural area of Odisha was 68.9%, of which 27.4% were mildly, 23.6% were moderately, and 17.9% were severely anemic.17 A similar study done at pediatric hospital, in a suburb of Chennai covering children between the age group of 4 months to 12 years showed a prevalence of 70% of anemia.18 Sundaresan S et al. has reported anemia in 52.88% children of 8-16 years age group.19 In his study the prevalence of anemia in girls (67.77%) was higher than in the boys (35.55%) which was also observed in our findings. Study conducted by Jhansi RP et al also showed higher incidence of anemia in female children.20 The occurrence of moderate (53%) and mild anemia (43.8%) cases in was still higher in our study.
Based on BMI, the results of present studies showed that higher percentage of children are of healthy weight while a low percentage of them were underweight. On comparing the anemia among BMI groups, it was observed that anemia in this population is not related to BMI. This in contrast with the studies elsewhere.21
The predominance of parasitic infestations and other risk factors for anemia were not studied in this population so we stipulate that the higher frequency of anemia in the age group of 5-7 years could be because of inadequate diet and poor access to health services. Consuming cereal-based diet by majority of the children can be the cause of iron deficiency among them. All these factors might have contributed to development of anemia in these children. Kalaivani K et al analyzed data from six different national surveys and results of hb mean of 5-9 age group was comparable to our study.22
Between 2006 and 2016, India made considerable progress in reducing anemia.23 Comparative outcomes were stated in the study conducted by Menon et al which showed that improvement in nutrition and health interventions are the strongest driver of anemia reduction in children.24 To tackle anemia in India, the Anemia Mukt Bharat (AMB) program was launched by the Government of India in March 2018. Target is to reduce anemia by 3% per year to attain a goal of malnutrition free India by 2022.25,26
Conclusion
Despite improvement over a decade, India still continues to be the country with highest prevalence of anemia in the world. The prevalence of anemia in young children is still a matter of concern. This study, however, is subject to certain limitations. The potential impacts of associated risk factors are not presented at large in this study. It can be concluded that less intake of iron rich food and nutritional diet are the leading cause of anemia in the rural children. Anemia is common not only among under-nourished persons but also in normal and over-nourished individuals Various strategies of increasing iron intake through dietary diversification, use of iron-fortified iodized salt, promoting healthy diets through nutrition education programs and early detection of anemia among children will accelerate the pace of reduction in anemia and enable the country to achieve the target for reduction in anemia.