Prevalence and Causes of Anemia in Six to Sixty Months Old Children : A Cross-Sectional Study at Kathmandu Medical College and Teaching Hospital

Introduction: Anemia is one of the most common problems in children, especially in the developing countries. Nutritional anemia is associated with impaired performance of a range of mental and physical functions in children. This study was conducted to evaluate the prevalence and possible causes of anemia in children attending tertiary care center in Nepal. Material and Methods: This was a prospective hospital based cross-sectional study done at Kathmandu Medical College and Teaching Hospital, Kathmandu, Nepal over a period of 10 months from March to December 2012. Children between the age group of 6 months to 60 months attending the Paediatric Out-Patient Department were randomly selected. The haemoglobin concentration was measured with an Automated Haematology Counter (Sysmex, Japan) following the manufacturer’s instructions. Anemia in children is defined as a hemoglobin level less than 11 gm/ dl. Results: There were 500 children enrolled in the study, out of which 191 (38.2%) were found to be anemic. Mild anemia was observed in 31.2%, moderate in 6.6% and severe in 0.4%. The commonest age group affected was between 24 months to 35 months old children. Anemia was more common in female children (41.9%) compared to males (35.8%). 118 anemic children were further investigated for the cause of anemia and 103 (87.3%) had iron deficiency anemia. Conclusion: This study reflects that prevalence of anemia still remains high and iron deficiency is the leading cause of nutritional anemia in children. Timely intervention can both prevent and treat childhood anemia.


Introduction
A nemia is a public health problem in both developing and industrialized countries.About 3.5 billion persons are affected by anemia in developing countries 1 .In most cases, anemia is caused by iron defi ciency, although a smaller proportion is due to defi ciencies of other micronutrients such as folate and Vitamin B 12 .Other diseases causing blood loss, chronic diarrhea and parasitic infections such as fi lariasis may also result in anemia.Anemia adversely affects health, cognitive development, school achievement and work performance.
The presence of anemia in children under fi ve years of age is of particular relevance because it negatively impacts mental development and future social performance.Children suffering from iron defi ciency anemia during their fi rst two years of life have slower cognitive development and poorer school performance and work capacity in later years 2 .Iron defi ciency anemia has also been associated with a diminished ability to fi ght infections by impairing cell-mediated immunity, resulting in greater rates of morbidity due to acute infections 3 .Growth and physical work capacity, especially endurance exercise, are also negatively affected by iron defi ciency anemia 4 .

Age in Months
Total Anemic the children.Children with chronic illnesses, previously diagnosed to have anemia, recent blood loss and those on iron therapy were excluded.Venous blood was collected by trained laboratory technicians.The haemoglobin concentration was measured with an Automated Haematology Counter (Sysmex, Japan) following the manufacturer's instructions.Anemia in children is defi ned as a hemoglobin level less than 11 gm/dl.Severity of anemia is classifi ed according to the standard set by World Health Organization (WHO) as: Severe anemia-less than 7.0 gm/dL, Moderate anemia-7.0 to 8.9 gm/dL, Mild anemia-9.0 to 10.9 gm/dL.Those found to be anemic were investigated with RBC indices and Peripheral blood smears (done by the Pathologist on duty).Some required further investigations such as Serum iron profi le, Reticulocyte level, Stool examination depending on the suspected cause of anemia.Bone marrow examination was not done in any of the subjects.

Results
In this study, 500 children between 6 months to 60 months of age were randomly selected, out of which 191 (38.2%) were found to be anemic.Out of these 191 children, mild anemia was seen in 31.2%,moderate anemia in 6.6% and severe anemia in 0.4% of children as shown in Figure 1.The commonest age group affected was 24 months to 35 months old (67.2%) as represented in Figure 2.
There were a total of 302 male children (60.4%), out of which anemia was detected in 108 of them.198 were females (39.6%) and 83 had anemia (Figure 3).Females were more likely to be anemic than males (41.9% v. 35.8% respectively).
Only 118 (61.8%) of the children who suffered from anemia were further investigated for the possible cause of anemia, as 24 of the parents declined investigations and 49 children were lost for follow-up.Amongst these 118 children, 103 (87.3%) were found to have iron defi ciency anemia.Hookworm infestation (Ancylostoma duodenale) was seen in 3 children.

Discussion
Anemia is a global public health problem and is more prevalent in young children.Anemia is caused by a number of conditions, often in combination, however the primary cause remains to be iron defi ciency.WHO Global Database on Anemia states 47.4% of pre-school age children to be anemic 5 .The prevalence of anemia in children of Nepal was fi rst studied in 1975 6 when the fi rst national representative study on nutritional status was done.
The overall prevalence of anemia in this study was 38.2%, out of which 31.2% were mildly anemic, 6.6% had moderate anemia and only 0.4% suffered from severe anemia.A similar study done at Kathmandu Medical College and Teaching Hospital in the past reported 46% children in the same age group to be anemic 7 .
In this study, we also found that anemia was more prevalent in females.41.9% of the females had anemia, whereas the prevalence in males was 35.8%.
In this study, the commonest age group affected was 24 months to 35 months old (67.2%) whereas the least affected were children between 48 months to 60 Total Population Anemic Population months (7.3%).In 1998, micronutrient status study was done which covered children, pregnant and nonpregnant women from all the ecological zones of Nepal.They have found that anemia reaches over 80% in the second half of infancy gradually declining to 59% by fi ve years 8 .
This study further investigated on 118 (61.8%) of the anemic children for the possible cause of anemia and 103 (87.3%) were found to have iron defi ciency anemia.Iron defi ciency is the most common cause of anemia in young children.Anemia tends to develop when iron defi ciency is severe and prolonged.In a given population, individuals with iron defi ciency or depleted iron stores may number two to fi ve times the number of individuals with anemia 9 .
A country like Nepal requires surveillance programs to identify at-risk populations and to monitor interventions to ensure utilization of resources 10 .Furthermore, WHO has proposed that if the prevalence of anemia in a region is between 5% and 20%, appropriate interventions based on food diversifi cation, food fortifi cation, iron supplementation and controlling infectious diseases should be considered 11 .

Conclusion
Childhood anemia is treatable and preventable.The resource-limited regions of the world bear the greatest burden of anemia.This study indicates that prevalence of anemia remains high in children in the age group of 6 to 60 months.Also, female children happen to suffer more from anemia.Result of this study is also consistent with the fi nding that iron defi ciency is the leading cause of nutritional anemia in childhood.Prevention of anemia can be brought through awareness programs and campaigns.
This was a prospective hospital based crosssectional study done in Kathmandu Medical College and Teaching Hospital, Sinamangal, Kathmandu, Nepal over a period of 10 months from March to December 2012.Children between the age group of 6 months to 60 months attending the Paediatric Out-Patient Department were randomly selected.Relevant history was taken and a physical examination was done in all Prevalence and Causes of Anemia in Six to Sixty Months Old Children: A Cross-Sectional Study at ...

Fig 1 :
Fig 1: Pie diagram showing Degree of Anemia in the Anemic Population

Fig 2 :Fig 3 :
Fig 2: Graph showing Age distribution of Anemic Children