chapter iii review of literature 3.1 prevalence of...
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CHAPTER III
REVIEW OF LITERATURE
3.1 PREVALENCE OF ANEMIA IN CHILDREN
The exact prevalence figures vary from study to study, there is no doubt that
anemia is an extremely serious public health problem in India.
3.1.1 Prevalence of anemia in pre school children
Giebel HN et al (1998) [28] conducted a study to examine prevalence
and correlates of anemia in 433Young Children (1 to 4 years old) of the
Muynak District of Karakalpakistan, Uzbekistan. The results showed that the
mean hemoglobin level was 9.78 (SD = 1.80) g/dL. 72.5% of the children had
anemia (26.3% mild, 38.8% moderate and 7.4% severe). The prevalence of
anemia rates were 89%, 79%, 66% and 48% for 1,2,3 and 4 years old children
respectively. Only age, history of pica, and primary household water source
were significantly associated with anemia status (P < .05).
Cornet M et al (1998) [29] conducted a longitudinal survey in
Ebolowa in southern Cameroon, to identify the prevalence and the main risk
factors for anemia in young children. Authors enrolled children in two cohorts
and follow up done for a three years period. The first cohort was composed of
122 children from 0 to 36 months of age and the second cohort was composed
of 84 children from 24 to 60 months of age. The children were grouped into
six-month age groups. Weekly for symptomatic malaria, monthly for both
symptomatic and asymptomatic malaria, and every six months for
hematologic data were determined for two cohort’s children. The result shows
that the prevalence of anemia was the highest in the six month old age group
(47%) and 42% of the children less than three years of age were anemic,
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while 21% of the children between three and five years of age were anemic.
The lowest hemoglobin mean (10.7 ± 2.1 g/dl) was observed in the six-
month-old children and a regular improvement in the hemoglobin level
occurred from six months to three years of age. Hookworm infection was
diagnosed in two children in the study population. Results of a multivariate
analysis of the study showed that placental malaria infection was the strongest
risk factor for anemia in the six-month-old children and was independent of
the frequency of parasitemia. In the one-year-old age group, microcytosis was
a significant factor related to anemia, pointing out the role of iron deficiency
at this age. Parasitemia at the time of Hb measurement was significantly
associated with anemia in all age groups (except in 54- and 60-month-old
groups).
A.A. Adish et al (1999) [30] the result revealed that 42% of preschool
children in northern Ethiopia had anemia. In a sub-sample of 230 anemic
children, 56% had a low red blood cell (RBC) count, and 43% had a serum
ferritin of less than 12 mg l-1 indicating that the anemia was largely due to
iron deficiency. Unlike other regions in developing countries, hookworm
(0.4%) and malaria (0.0%) were rare and contributed little to the anemia.
Even though their diet lacked variety, the amount of iron consumed through
cereal-based staple foods was adequate. However, the iron in these foods was
not readily available and their diets were probably high in iron absorption
inhibitors and low in enhancers. Dietary factors associated with anemia
included frequent consumption of inhibitors, such as fenugreek and coffee,
and poor health in the child such as diarrhea and stunting.
S.Jain et al (2000) [31] in their study found that the prevalence of
anemia was 59.9 % in 137 children of age 1-2 years in urban slums of Meerut.
Of these anemic children, 24.3% had severe anemia (Hb less than 7 g %),
49.8% children had moderate anemia ( Hb between 7-9.9 g %) and 26.8% had
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mild anemia (Hb between 10-11g%). The study also indicated that
socioeconomic status, mother's educational status, birth weight, sibling order,
sex and type of weaning food did not show any significant relationship with
the prevalence of anemia in these children (p > 0.05 by X 2 test). Prevalence
of anemia was also found to be significantly higher in children having low
nutritional status (84.3%) as compared to children of borderline (51.4%) or
normal nutritional status (52.9%). A highly significant impact, of early iron
supplementation was also found on prevalence of anemia (p < 0.001) being
23.8% among the children who were on regular iron supplementation from
age of 6 months and 68.4% among the children who were on either occasional
or irregular iron supplementation or no iron supplementation as elicited by
history.
K.A. George et al (2000) [32] conducted a study to analyze the
anemia and Nutritional status of pre-school children in Kerala. 3633 children
were participated in this study (1873 male children and 1760 female children).
Capillary blood was collected from each child and hemoglobin was estimated
by cyanomethemoglobin method. Weight and height of children were
measured for assessing their nutritional status. The results showed that
overall prevalence of anemia was found to be 11.4%. The percentage of
anemic children among male and female children was 10.25 and 12.55
respectively. Most of the children belong to the low-income group. Dietary
survey revealed that majority of children was non-vegetarians (74.5%).
Statistical analysis (Chi square) showed that there is an association between
anemia and dietary habits (p value 0.021). Among 927 vegetarians, 86
(9.27%) were anemic and among 2706 non-vegetarian, 328(12.1%) were
anemic. Even though larger percentage of anemic cases were reported in the
non-vegetarians group, the difference is not that statistically significant.
Nutritional status of children showed 46.8% children as nutritionally normal.
Among the undernourished, 43.7% were in Gomez grade I and 9.6% in
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Gomez grade II. There were no cases in Gomez grade III. This study observed
that there is a significant relationship between hemoglobin and nutritional
status (Chi square, p value 0.006).
Osorio M M et al (2001) [33] carried out a study to determine the
prevalence of anemia in 777 children in the age group of 6–59 months old in
Pernambuco, a state in northeastern Brazil. Blood was collected by
venipuncture, and hemoglobin was measured with a portable
hemoglobinometer. The result reveled that the prevalence of anemia among
children 6–59 months old was 40.9% for the state as a whole. Prevalence in
the metropolitan region of Recife was 39.6%, and it was 35.9% in the urban
interior. The rural interior had the highest prevalence, 51.4%. Prevalence was
twice as high in children aged 6–23 months as among those 24–59 months
old, 61.8% vs. 31.0% (_2 = 77.9, P < 0.001). The mean hemoglobin
concentrations in the younger and older age groups were 10.4 g/dl (standard
deviation (SD) = 1.5) and 11.4 g/dl (SD = 1.4), respectively. There was no
statistically significant difference between the sexes in terms of prevalence.
Brunken GS et al (2002) [34] studied the prevalence of anemia in
children aged less than 36 months in public day care centers in the city of
Cuiaba, state of Mato Grosso, Brazil. Among 271 children, 63% were anemic.
The finding of this study also revealed that the prevalence of malnutrition was
0.8% according to the weight/height ratio, 5.0% according to weight/age
deficit, and showed an inadequacy of 10.3% as to the height/age ratio. Thus,
the percentage of anemic children was six times higher than the height deficit
and twelve times higher than the weight deficit. Malnutrition was not in fact
associated with anemia, but at extreme anthropometric cut-off points of height
and weight for age (< -2 z score), there is an association between these
conditions.
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Table: 3.2 Prevalence of Anemia among Infants and Toddlers in India
Study region Study done by Age Anemia
prevalence %
North India
Delhi Dhar et al, 1969 6m -3y 60
Varanasi Singla et al, 1982 6m-5y
urban 56
Delhi Gomber et al, 1998 3m -3y 76
Ludhiana
Kapur et al, 2002 9-36m 64
South India Hyderabad
ICMR – 1977 1-3 y 54.3
West India Bombay
ICMR – 1977 1-3 y 70.6
East India Kolkatta
ICMR – 1977 1-3 y 38.9
Source adopted from Deeksha.K et al 2002 [35].
Review of literature clearly shows that in the last five decades,
prevalence of anemia was severe public health problem (more than 40%) [6]
in various state of India.
Karimi et al (2004) [36] reported that the prevalence of Iron
deficiency and iron deficiency anemia was higher in children 6 – 23 months
old and the prevalence rate is decreased as age increased. The prevalence of
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anemia, iron deficiency, and IDA in 997 rural children (6-60 month old) in the
Yazd province of Iran was 24.9%, 8.5%, and 4% respectively. The study also
found iron deficiency and IDA, without a relation, were higher among boys
than in girls. There was no relationship between iron deficiency or IDA and
some variables such as birth rate, number of family members, and mother’s
education. Prevalence of iron deficiency in our study was higher in children
with weight to height (W/H) under the fifth percentile. The majority of
anemia cases in this study were normocytic anemia
.
National family health survey – 2 (NFHS -2 (2000) [37] of India,
about 74% children between the ages of 6 to 35 months were anemic.
According to the NFHS -3 [38] the prevalence of Anemia in India between
2000 and 2005 is increased from 74% to 79% in children aged 6 to 36
months. As per NFHS-3 (2005) report,[39] of Tamil nadu children aged 6-35
months had 72.7 % of anemia.
A research by Anna Christofides et al (2005) [40] on the prevalence
of anemia and to identify its associated risk factors among 115 young children
(4 to 18 months) in Aboriginal communities in northern Ontario and Nunavut.
The mean hemoglobin concentration of the study population was 114.8 ± 12.2
g/L (n=115). The overall prevalence of anemia was 36% (41/115), with the
highest prevalence in the Inuit community (48%, 24/50) as compared to the
First Nations communities (26%, 17/65), however the difference was not
significant. The prevalence of ID was similar between Inuit and First Nations
communities, 25.5% and 27.7% respectively. Depleted iron stores were
present in 53.3% (56/105) of the study population. This study also revealed
that infection with H. pylori, prolonged consumption of breast milk and
cow’s/evaporated milks were significant risk factors associated with anemia.
The study concluded that both dietary factors and evidence of H. pylori
infection were identified as associated risk factors for anemia in young
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children in northern Ontario and Nunavut. The researcher stress the
importance of feeding iron-rich complementary foods in addition to breast
milk or use of iron-fortified formula to replace evaporated or cow’s milk in
young children should be revitalized.
Schneider JM et al (2005) [41] did a cross-sectional study to identify the
prevalence of anemia, low iron stores, iron deficiency, and iron deficiency
anemia in children 12 to 36 months old participating in the Special
Supplemental Nutrition Program for Women, Infants and Children (WIC)
population in California. Hemoglobin, serum ferritin (immunoradiometric
assay), serum transferrin receptor (human transferrin receptor immunoassay
kit), serum transferring (nephelometric assay), serum iron (atomic absorption
spectrophotometry), and serum CRP (radial immunodiffusion) Transferrin
saturation and Total iron binding capacity (TIBC) was analyzed for 425
children. The results revealed that the prevalence of anemia was 11.1%.
Research used two cut off values for each iron measures as follows: serum
ferritin <8.7 or, <10.0µg/L, serum transferrin receptor >8.4 or >10.0 µg/mL
and transferrin saturation <13.2% or <10.0%.
The prevalence of low iron stores (low ferritin) on the basis of study and
literature determined cutoffs were 24.8% and 29.0%, of ID were 16.2% and
8.8%, and of IDA (ID with low hemoglobin) were 3.4% and 3.2%.,
respectively.
Siegel EH et al (2006) [42] described the distribution of hemoglobin
and prevalence of anemia in 569 Nepali children 4 to 17 month’s old living in
the Terai region. The results found that 58% of the children were anemic and
having mean hemoglobin value of 105g/L. Bivariate analyses revealed age,
caste, socio-economic status (SES), dietary diversity, stunting, and
underweight were associated with hemoglobin concentration and/or anemia.
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In multivariate models with and without EP, age and caste were found to be
strong predictors of both hemoglobin concentration and anemia.
Lozoff B et al (2007) [43] find out the impact of iron deficiency
anemia on children’s social looking toward adults, affect, and wary or hesitant
behavior in response to novel situation. Play observations, social looking
toward adults and wariness or inhibition in reaction to novelty was observed
for 74 iron deficiency anemic and 164 non anemic preschool aged Indian
children. Results were compared between the non anemic group and the IDA
group. Mean hemoglobin concentration of anemic and non anemic children
was 94.0 (±1.4), 119.0 ± (0.6) g / L respectively. Pre school children with
IDA displayed less social looking toward their mothers, moved close to their
mothers more quickly, and were slower to display positive affect and touch
novel toys for the first time. These results indicate that IDA in the preschool
period has affective and behavioral effects.
Sharda Sidhu et al (2007) [44] done a study on the prevalence of
anemia among the Bazigar preschool children age between 1 and 5 years old
of Amritsar, Ludhiana, Moga and Patiala districts of Punjab. The results
showed that only 9.50% were normal and 90.50% were affected with various
grades of anemic conditions, 6.33% had mild anemia and 75.75% moderate
anemia while 8.42% suffered form severe anemia. A higher proportion of
children were severely anemic in age groups 1+ (15.00%) and 2+ (13.64%) as
compared to the older age groups. It became evident that the frequency of
severe anemia decreases as the age increases, but the frequency of mild
anemia increases as the age increases.
Hanumante and colleagues (2008) [45] conducted a pilot study to
assess the iron status and dietary intake of 1-3 year old apparently healthy
toddlers of the lower socio-economic class, and the effect of eight weeks
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intervention with liquid oral iron in an urban slum in Pune, India.
Anthropometry, Food Frequency Questionnaire, a hemogram and ferritin
were measured for 50 toddlers (Male 25 and female 25). Twenty mg of
elemental iron was given to all toddlers. After 8 weeks clinical examination,
anthropometry, hemoglobin (Hb) and Ferritin were measured. Prevalence of
anemia was 66% (Hb <11gm %) and ferritin (iron stores) were low (< 12
μgm/L) in 45 (90%). The prevalence of anemia significantly ((p<0.001).)
decreased from 66 to 30% after treatment with liquid iron. The authors
therefore concluded that there was a significant difference in the HGB and
ferritin levels of children after eight weeks of therapy.
Psirropoulou TE et al (2008) [46] estimated the prevalence of iron
deficiency anemia in children 12-24 months old in a specific area of Thessalia
, located in the central part of Greece, and also identified the environmental
risk factors associated with anemia. Hemoglobin, hematocrit, mean
corpuscular volume, mean corpuscular hemoglobin, mean corpuscular
hemoglobin concentration, zinc protoporphyrin, serum iron, serum ferritin,
transferring saturation, total iron binding capacity and Hb electrophoresis
were analyzed for 938 children. Seventy-five children (7.99%) out of 938
children participated in the study had iron deficiency anemia and 20 children
(2.13%) were carriers of b-thalassaemia. Concerning the anthropometric
indices, the highest statistical difference between the two groups was
observed with respect to the weight of the children with p value <0.001. The
height also differentiates the two groups in a statistically significant way (p <
0.003). Significant differences were recorded (p<0.001) in all hematological
and anthropometric parameters except for head circumference. Regarding
environmental factors, significant differences were found in the following
parameters: ratio rooms/number of family members (p=0.01), number of
family members (p=0.01), number of children in the family (p<0.001), birth
rate (p<0.001), education and profession of the parents (p<0.001), source of
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drinking water and sewage system (p<0.001), duration of breast feeding
(p<0.001), milk consumption by the child during the period of the reported
research (p<0.001), child’s health status according to the mother (p<0.001),
and frequency of seeking pediatric care (p=0.02).
Kikafunda JK et al (2009) [47] carried out a study to determine the
prevalence of anemia and associated factors among under-five year old
children and their mothers in a rural area of Bushenyi district, Western
Uganda. The results revealed that the overall prevalence of iron deficiency
anemia among children and their mothers was 26.2% and 17.9%, respectively.
There was a significant correlation (r=50.5, P=0.008) between the
hemoglobin levels of the mothers and their children. Place of birth, age of the
child, factors related to complementary foods, and formal education and
nutrition knowledge of the mother were major factors that were significantly
associated (r=50.05, P=50.05) with low hemoglobin levels among the
children. This study concluded that iron deficiency anemia was found to be a
major problem of these children and their mothers. Dietary factors and socio
demographic factors were the major factors associated with high levels of
anemia among the children and their mothers. This study recommended that
rural mothers should be sensitized on best practices for prevention of anemia
among both women and children.
Uddin MK et al (2010) [48] determined the prevalence of anemia in
767 children of 6 to 59 months old in Narayanganj, Bangladesh. The results
reveled that the prevalence of anemia among the children of 5-59 months old
was 40.9% for the district as a whole. Prevalence in the municipal region of
Narayanganj was 40.9%. The rural areas had the highest prevalence of 66.9%.
Prevalence was almost two times higher in children of 6-23 months in
comparison to children of 24-59 months i.e. 61.8% and 31.0% respectively.
The mean haemoglobin concentrations in the younger and older age groups
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were 10.4 (±1.5) g/ dl and 11.4 (±1.4) g/dl respectively. There was no
difference find between the sexes.
Ainur Baizhumanova et al (2010) [49] conducted a study in children
and women to evaluate the prevalence of anemia, iron deficiency and IDA
before and after the campaign in Kyzyl-Orda region, Kazakhstan. The results
revealed that after communication campaign the prevalence of anemia had
significantly decreased among rural women (from 65.9% to 48.0%, p < 0.05)
and among urban children (from 63.1% to 11.5%, p < 0.001). The prevalence
of iron deficiency was significantly reduced among the children (from 51.1%
to 24.8%, p < 0.001). IDA prevalence was meaningfully decreased among
women in urban and combined areas (from 37.5% to 15.0% and 40.5 to
14.8%, respectively, p < 0.001) and among urban children (from 7.1% to
2.1%, p < 0.05). The study concluded that the communication campaign was
effectively carried out in Kazakhstan before implementation of the wheat
fortified flour program, giving a biological impact on hematological indices.
Carvalho AGC et al (2010) [50] did a study to diagnosis iron
deficiency anemia in 301 children aged six to thirty months attending public
daycare centers in the city of Recife, Northeast Brazil. 92.4% of the children
had anemia (Hb <110 g/L) and 28.9% had moderate/severe anemia (Hb <90
g/L). 58.1% had anemia with iron deficiency, 34.2% had anemia without iron
deficiency and 2.3% had iron deficiency without anemia. About 51% of
subjects had an inflammation. Only ferritin was significantly associated with
CRP. High ferritin levels were significantly associated with high CRP levels.
The mean ferritin concentration was significantly higher in subjects with
inflammation when compared with those with normal CRP (22.1 vs. 14.8
μg/L, p = 0.01).
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Heckman J et al (2010) [51] did a study to find out the prevalence of
anemia and to investigate possible etiologies’ including malnutrition,
intestinal helminthes infection and Helicobacter pylori infection in 52
children aged under 5 presenting for well-child examinations at a community
health centre in Thohoyandou, Limpopo Province. The result found that 75%
of the children had anemia and girls were significantly more anemic then
boys. The median hemoglobin concentration was 9.65±2.6 g/dl. Anemic
children were significantly less likely to be underweight compared with their
peers (32/38 v. 5/12 respectively; p=0.007). There was no significant
association between anemia and infection with Helicobacter pylori (p=0.729),
intestinal helminthes (p=1.000) or food insecurity (p=0.515).
Health and Science Bulletin (2010) [52] reported that the prevalence
of anemia in children (>2 years) in rural Bangladesh was 60% (755/1,237)
when a single parameter hemoglobin level <11.0 g/d was used. However
considering other parameters of low iron status such as ferritin (<12 μg/L) and
C-reactive protein (<5 mg) along with low hemoglobin level, only 25%
children had iron deficiency anemia. When low hemoglobin and high serum
transferrin receptor (>5 mg/L) was considered as an indicator of iron
deficiency, 30% of anemic children had iron deficiency anemia. The study
team compared the 225 iron deficient anemic children with 209 non-anemic
children matched for age, sex and village. Diagnosed iron deficient anemic
children received 30 mg ferrous sulphate syrup daily for 6 months. All the
enrolled children were reassessed for their iron status 6 months later. All the
iron deficient anemic children responded adequately to 6 months of iron
treatment. Mothers of anemic children scored low in an intelligence test and
provided less care to their children compared to mothers of non-anemic
children. They were also from poorer economic conditions, Children with iron
deficiency anemia were more likely to be stunted compared with non-anemic
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children; a higher percentage of anemic children were severely stunted
children.
Santos RF et al (2011) [53] conducted a study among 595 children (6
to 59 months old) in a children's hospital in Recife, Brazil with the objectives
of identifying the prevalence of anemia and their associated factors. Anemia
was reported among 56.6 % of children. Only 34.1% anemic students were
aware of being anemic. Anemia was significantly correlated with low weight
young age and a diagnosis of acute lower respiratory disease.
Muoneke VU et al (2011) [54] determined the prevalence, etiology
and outcome of severe anemia in children aged 6 months to 5 years in
Abakaliki South Eastern Nigeria. Out of 1450 children under the age of 5
years 140 had severe anemia. The finding of this study shows that the
prevalence rate of severe anemia was 9.7%. Malaria was the commonest
cause of severe anemia 64.3%. Other common causes included sickle cell
anemia 9.3%, Septicemia 13.6 %, and malnutrition 7.1%. One hundred and
seventeen (83.6%) patients recovered
The results shown by Onyemaobi and Onimawo etal (2011) [55] was
that 70.5% of under five children aged 6 to 60 months were anemic in Imo
state of Nigeria, and 48.1% were iron deficient. The results also showed that
the overall mean haemoglobin of the subjects investigated (n=400) aged 12-
60 months were 10.478g/dl. The most affected age group was 12-23 months
(84.8%). Anemia was much more prevalent in rural (78.7%) than urban
(61.3%) areas. The prevalence of anaemia decreased with age group i.e.
84.8%, 78.4%, 69.7% and 65.9% for 12-23, 24-35, 36-47, and 48-60 months
age groups, respectively. There was no difference in anemia among the boys
and girls in Imo State.
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N. Arlappa et al. (2012) [56] conducted a community based cross-
sectional study on Prevalence of anemia among rural pre-school children of
Maharashtra, India. It was found that the mean hemoglobin level among the
children of 1-5 years was 10.4 g/dL (CI: 10.2-10.6), with 9.6 g/dL (9.3-9.9) in
1-3 year and 10.6 g/dL (10.4-10.8) in 4-5 year-age group. The mean
hemoglobin values are significantly (p<0.01) different between different age
groups. The results showed that the overall prevalence of anemia among the
rural pre-school children of Maharashtra was 59.2%, and the prevalence was
significantly (p<0.001) higher (76.5% with CI: 68.1-84.9) among 1-3-year
children as compared to 53.6% in 4-5-year- children. a higher (63%)
proportion of girls were anemic compared to boys (57%). The prevalence of
anemia was decreased with increase in age where significantly (p<0.01) a
higher proportion (90.9%) of 1+ year- children were anemic compared to the
children of 4+ years (48.1%).
Souganidis ES et al (2012) [57] examined the relationship between a
mother’s knowledge of anemia with the prevalence of anemia in mothers and
their children from rural areas and urban slums in Indonesia. The mothers and
children from rural areas and mothers and children from urban slum areas of
Indonesia were participated in the study. The finding of this study revealed
that in urban slums, 28.7% of mothers and 62.3% of children were anemic
whereas in rural areas, 25.1% of mothers and 55.2% of children were anemic.
Maternal knowledge of anemia was associated with child anemia in urban and
rural areas, respectively (odds ratio [OR] 0.90, 95% confidence interval [CI]
0.79, 1.02, P = 0.10; OR 0.93, 95% CI 0.87, 0.98, P = 0.01) in multivariate
logistic regression models adjusting for potential confounders
Rocha DS et al (2012) [58] evaluated the prevalence and risk factors
of anemia in 312 children aged 7 to 59 months old attending daycare centers
in the city of Belo Horizonte. He diagnosed anemia in children by
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determining hemoglobin concentration, using the Hemocue portable photometer,
considering hemoglobin levels below 11.0 g/dL. Weight and height
measurement were done to evaluate the nutritional status of children. The
result shows that the prevalence of anemia in children aged 7 to 59 months
old attending daycare centers was 30.8%, with a higher prevalence in children
≤ 24 months of age (71.1%). Risk factors for anemia were nutritional status
and age and these two were the only variables associated with anemia of this
study population.
Table: 3.1 Prevalence of anemia between 1995 and 2011 in abroad
Children aged < 5 years
1995 2011
Mean
Hb g/L
Anemia
%
Severe
Anemia
Mean
Hb g/L
Anemia
%
Severe
Anemia
High income regions 123 11 0.3 123 11 0.1
Central & eastern Europe
116 29 1.4 117 26 .2
East and southeast Asia
118 29 0.9 118 25 0.2
Oceania 111 42 2.0 112 43 0.5
South Asia 100 70 5.9 106 58 2.1
Central Asia, Middle East, and north Africa
111 43 1.5 114 38 0.4
Central and west Africa
95 80 9.7 100 71 4.9
East Africa 96 74 10.2 107 55 2.5
Southern Africa 116 30 1.1 110 46 0.9
Andean and central Latin America and Caribbean
113 38 1.4 116 33 0.4
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Southern and tropical Latin America
117 28 1.3 119 23 0.2
Globe 109 47 3.7 111 43 1.5
Source adopted from Stevens GA et al. (2013)
Stevens GA et al. (2013) [59] indicated in their study that the Global,
regional, and national trends in hemoglobin concentration and prevalence of
total and severe anemia in children improved slightly for children aged 6–59
months, between 1995 and 2011.
Gao W et al (2013) [60] described the severity of anemia and explored
its determinants among children under 36 months old in rural western China.
From 9 province-level regions, 6711 children were selected and their
hemoglobin was measured. The prevalence of anemia among children
younger than 36 months in rural western China was 52.5% (95%CI 51.3%–
53.7%), of which mild anemia covered 27.4%, moderate anemia 21.9% and
severe anemia 3.2%. Among the 9 province-level regions, Qinghai had the
highest prevalence (72.75%) of anemia and Inner Mongolia the lowest
(41.73%). The analysis of the severity of childhood anemia shows that the
prevalence of moderate and severe anemia was the highest but that of mild
anemia the lowest in Qinghai, that of mild anemia the highest in Guizhou, and
that of moderate and severe anemia the lowest in Sichuan.
3.1.2 Prevalence of anemia in school children
Rajaratnam J et al (2000) [61] carried out a study to estimate the
prevalence of anemia among adolescent girls of rural tamil nadu. The age of
the girls ranged from 13-19 years Blood was drawn from 141 and 147 girls
from K.V. Kuppam block and Gudiyatham block of Vellore District,
45
respectively. The hemoglobin concentration was assessed by using the
cyanmethemoglobin method. The result shows that 44.8% of the adolescent
girls were anemic with severe anemia being 2.1%, moderate 6.3% and mild
anemia 36.5%. The prevalence of anemia was 40.7% in premenarcheal girls
as compared to 45.2% in post menarcheal girls. There was reduction in the
mean hemoglobin as the age increased. A similar decreasing trend was
observed with increasing age at menarche of the girls and also earlier the age
at menarche, the higher was mean hemoglobin. The mean hemoglobin of
premenarcheal girls was 11.63 g/dl (SD ±1.5) and that of post menarcheal
girls was 11.52 g/dl (SD ±1.54). Girl’s education, mother’s education and the
family type were identified as independent predictors for hemoglobin
concentration.
D. Shojaeizadeh (2001 ) [62] conducted a study to find out the factors
affecting Knowledge, Attitude and Practice among 218 secondary school girls
in Qazvin, Tehran, Iran, on iron deficiency anemia. The data revealed that
57.3% had poor knowledge, 54.1% Unfavorable attitude towards iron
deficiency anemia and 44.5% did not perform appropriate behavior (poor
practice) to prevent anemia. The knowledge was better among science
students than non-science students. The relation was significant. It was also
significantly better among those girls, whose mothers were employed. There
was significant relationship between knowledge and attitude and also
knowledge with practice.
A study among 800 school students in Jeddah, Saudi Arabia to identify
the prevalence of anemia, their awareness about anemia and the relation of
anemia with the literacy level of mothers. The results indicated that 20.5% of
students had anemia. Only 34.1% anemic students were aware of being
anemic. Anemia was significantly more prevalent among those born to low
educated mothers ( Bahaa Abalkhail et al (2002)) . [63]
46
Al-Sharbatti et al (2003) [64] determined the prevalence of anemia in
a healthy school adolescents aged 11 to 19 years old selected from 2 distinct
socio-economic areas (SEAs) in Baghdad; and to assessed the importance of
diet and some other factors which could be relevant in the epidemiology of
anemia in adolescents. The prevalence of anemia among 487 adolescents in
high socio-economic area (HSEA) was 12.9% and the prevalence of anemia
was 17.6% in 564 adolescents in low socio-economic area in Baghdad, Iraq.
Hemoglobin concentration in males was significantly correlated with age and
dietary iron intake. In females it was correlated significantly with years of
education of father and mother, number of pads and age at menarche.
The study was conducted by Sethi V et al (2003) [65] among the
prevalence of anemia amongst children in the age group of 6-11 years in
National Capital Territory (NCT) of Delhi. A total of 393 subjects (189 boys
and 204 girls) were included in this study. Hemoglobin estimation was carried
out by indirect Cyanmethemoglobin method. The finding of this study
revealed that the overall prevalence of anemia was found to be 66.4% (Hb <
11.5 g/dL). The prevalence of mild, moderate, and severe anemia was found
to be 33.3%, 32.6%, and 0.5% respectively. The mean hemoglobin
concentration of girls and boys was 10.7 ±1.3 and 10.9 ± 1.2 g/dL
Sharda Sidhu et al (2005) [66] reported that prevalence of Anemia
among 265 adolescent girls between the age group 11 and 15years old of
scheduled caste community of Punjab was 70.57%, of which 30.57% mildly
anemic, 27.17% moderately anemic and 12.83% severely anemic. The
prevalence of anemia increases with age and becomes maximum (78.57%) in
the age group 15 years. The frequency of mild anemia was displayed to the
maximum (38.46%) by age group 11 years and the minimum (21.43%) by age
group 15years. In this study, the largest number of girls fall in the category of
moderate anemia, with maximum (35.55%) present in age group 14years as
47
compared to age group 11years where the number of lowest moderate anemia
(21.54%). Maximum level of severity of anemia was present in age group
15years (30.95%). The age group 11years had the least (4.62%) number of
severely anemic girls. This may be accounted for as repeated menstrual blood
loss with each cycle which results in drainage of iron reserves ending in
anemia.
Gur E et al (2005) [67] determined the prevalence of anemia and the
risk factors associated with anemia among primary School children in
Istanbul. 1531 students between 6 and 16 years old (52.1 % (798 students)
were male and 47.9 % (733 students) were female) from 14 primary schools
located in seven different regions of Istanbul were participated in this study.
A complete blood cell count was done by an automated cell counter to
measure the prevalence of anemia. The overall prevalence of anemia among
primary School children in Istanbul was found to be 27.6 per cent. The rates
of mild, moderate, and severe anemia were 27.1 %, 0.2 % and 0.3 %
respectively. The anemia prevalence were 27.3 and 28.0 in males and
females, respectively (p>0.05). This prevalence was 28.9 per cent for children
aged 6–10 years and 26.2 per cent for 11 to 16 years (p>0.05). The results
also revealed that the prevalence of Microcytic anemia was 15.6 % (66 cases),
normocytic anemia prevalence was 84.2 per cent (356 cases), and macrocytic
anemia prevalence was 0.2 per cent (one case). The thalassemia minor rate
was found to be 0.8 % in this study population. There was no significant
relationship between the prevalence of anemia and the students’ age, gender,
parents’ educational level and employment, and monthly family income by
logistic regression analysis. Only the number of family members and
malnutrition were risk factors for anemia.
A study by Sabita et al (2005) [68] showed that the over all
prevalence of anemia among 1120 school going adolescents (12 to 18 years)
48
of Chandigarh were 16.25% and the Hemoglobin values ranged from 6.5 g/dl
to 18.2g/dl. Mean Hemoglobin was 13.35 1.54 g/dl. Prevalence of anemia
was significantly higher amongst girls (23.9 %, 141/590) as compared to the
boys (7.7%, 41/530). Anemia was observed significantly more in rural area
(25.4%) as compared to urban area (14.2%) adolescents (P < 0.01). 14.3%
(84/590) girls and 14.2%(76/530) boys were undernourished (BMI <5th
centile). Prevalence of anemia in girls whose weight was more than 5th
centile was 21.9% as compared to 35.7% in those whose BMI was less than
5th centile (P <0.001). Similarly, in boys 6.7% were anemic in well-nourished
group as compared to 14.4% in undernourished group (P <0.05).
Keskin Y et al (2005) [69] investigated the prevalence of iron
deficiency among schoolchildren (12 to 13 years) of different socio-economic
status (SES), living in the three largest cities of Turkey. Anthropometry,
hematological and biochemical indices of iron status and consumption of food
items related to dietary iron bioavailability were analyzed for 504 males and
510 female children. The finding of study revealed that the prevalence of Iron
deficiency was 17.5% among boys and 20.8% among girls. Low SES boys
exhibited significantly higher frequency of tea consumption and lower
frequency of citrus fruit, red meat and fish consumption, compared to their
higher SES counterparts.
Karur .S et al (2006) [70] studied the epidemiological correlation of
nutritional anemia among adolescent girls (13 to 19 years) in rural Wardha.
The prevalence of anemia was found to be 59.8%. In univariate analysis, low
socioeconomic status, low iron intake, vegetarian diet, history of worm
infestation and history of excessive menstrual bleeding showed significant
association with anemia. While Multivariate logistic regression analysis
suggested that strongest predictor of anemia was vegetarian diet followed by
history of excessive menstrual bleeding, iron intake <14mg followed by 14-
49
20mg and history of worm infestation. However age, education,
socioeconomic status, BMI and status of menarche did not contribute
significantly.
R.Gawarika, et al (2006) [71] conducted a study to find out the
prevalence of anemia in adolescent girls, aged 10.5 to 18 years in Ujjain city,
in western Madhya Pradesh, belonging to different economic groups. The
results revealed that the overall prevalence of anemia was 96.5%. The
prevalence of severe anemia was 11.0% in weaker income group and 2.63%
among middle income group. The prevalence of severe anemia was high in
girls above 14 years of age than girls below 14 years of age. The severe
anemia was high (13.49%) among girls above 14 years of age in weaker
economic group but it was 4.23% among below 14 years of age. The
association was significant between the age of the adolescent girls and the
prevalence of anemia.
Bulliyy et al (2007) [72] found in their study in three districts of
Orissa that out of 296 adolescent girls, 96.5% among non school going
adolescent girls were found to be anemic. Of which 45.2%, 46.9% and 4.4%
had mild, moderate and severe anemia respectively. They also found that
significant association between hemoglobin concentration and the educational
level of girls, their parent’s family income and body mass index.
Brouwer TLH et al (2007) [73] studied an association between
anemia and intestinal parasite infection in 400 primary school children in
rural Vietnam. Hemoglobin (Hb), serum ferritin (SF), serum transferrin
receptor (TfR), serum C-reactive protein (CRP) total immunoglobulin E
(IgE) were analyzed for iron deficiency anemia. Stools samples were
examined for hookworm, Trichuris, and Ascaris infection (parasite infection).
The prevalence of anemia (Hb<115g/L) was 25%. Iron deficiency (TfR
50
>8.5mg/L) occurred in 2% of the children. The prevalence of intestinal
parasites was 92% with the highest prevalence for Trichuris (76%) and
Ascaris (71%). More than 30% and 80% of the children showed an elevated
CRP (≥ 8 mg/L) and IgE (> 90 IU/mL) concentration. Anemia status was
significantly associated with SF and not associated with TfR and CRP. The
study concluded that anemia was highly prevalent among primary school
children in Vietnam but not associated with iron deficiency. Trichuris
infection is associated with a doubled risk of anemia, not mediated through
iron deficiency. Chronic infection may play a role in anemia.
Chaudhary SM et al (2008) [74] found 35.1% anemia prevalence
among 296 adolescent females (10 to 19 years old) in the urban area of
Nagpur (India), of which 69.2 % had mild anemia, 30.8% moderate anemia
and non of the girls had severe anemia. They found significant association
between anemia and the socio – economic status of girls, their parents’
literacy.
SR Tatala et al (2008) [75] identified that the prevalence of anemia
among 845 school children age 7-14 years were 79.6%. Micronutrient
deficiencies were highly prevalent. Iron deficiency (SF <20 μg/dl) was 33%,
vitamin A deficiency (SR < 20 μg/dL) 31.9% and 25% of the children had
mild iodine deficiency (UIE < 20 μg/L). Intestinal helminths were also highly
prevalent; 68% of children had hookworm and 54% had urinary
schistosomiasis. Inadequate diet was a feature in >50% of children. About
10% of households had no latrines and multiple infection rank score was high
especially in older age children. The risk of having anemia was two times
higher in children with iron deficiency (RR=2.1) and 49% higher in those
with vitamin A deficiency. These deficiencies correlated significantly with the
anemia (P<0.05). Vitamin A deficiency and infections with hookworm and
schistosomiasis were the most significant factors predicting for anemia
51
(r=0.318 and r2=0.101). This study concluded that high prevalence of
infections and nutritional deficiencies were important risk factors for anemia
of this community. The high attributable fraction for hookworm,
schistosomiasis, iron deficiency and vitamin A confirms that these were
significant risk factors for anemia.
S.C. Jai prabhakar et al (2009) [76] study indicated that 77.7 % of
175 Jenukuruba Primitive Tribal Children (6 to 10 years) of Mysore District,
Karnataka were suffering from anemia. The study revealed that, 36.57% of
children were moderately anemic, 26.29 per cent were mildly anemic and
14.86 percent severely anemic. Their study indicates that prevalence of
anemia was significantly higher in girls when compared to boys, (Girls
83.33% and Boys 70.89%).
Gupta N et al (2009) [77] assessed the Pervasiveness of anemia in
adolescent girls of low socio-economic group of the district of
Kurukshetra (Haryana) India. 110 girl students (13-16 years) who were
studying in VIII, IX, X, XI class of Kurukshetra of Haryana were participated
in this study. It was found that out of one hundred ten girls, only 20 (18.19 %)
subjects were non anemic and remaining 90 (81.81 %) subjects were suffering
from various degree of anemia and their hemoglobin level ranges between 6.6
g/dl to 11.0 g/dl, among the anemic subjects, 20 % had mild, 73.33 % had
moderate and 6.67 % of subjects had severe degree of anemia. Prevalence of
anemia was found lower in nuclear families than joint families. Further, size
of family also affect, higher the number of members in the family, higher the
prevalence of anemia. As both quality and quantity of food consumption get
affected by number of members in family especially with limited income
sources.
52
In the study by Dharmistha Jadeja and Gayatree Jadeja a
supplementation of iron rich Date ball to the 70 anemic (Iron deficiency
anemia) girls for 21 days increases the hemoglobin concentration and
decreases the urinary calcium and creatinine of anemic girls. The findings of
this study also indicating that 76% girls were anemic due to iron deficiency.
(Jadeja D et al (2010). [78]
Gupta VK et al (2011) [79] observed in their study ‘a high prevalence
of anemia in both males and females in the rural population in Punjab’. The
prevalence of anemia was 95.2% among younger females of the age group of
5-9 years (n-807), 87% in the age group of 10-19 years. The prevalence of
anemia in males in both the age groups of 5 to 9 years (n-822) and 10-20
years (n- 399) was almost similar, that is 90.5% and 88.7% respectively.
N. Arlappa et al. (2011) [80] carried out a community-based cross-
sectional study on 3490 children of 6–12 years in West Bengal, India.
Prevalence of vitamin A deficiency (VAD), anemia and Iodine deficiency
disorders (IDD) were assessed. The results showed that the overall prevalence
of vitamin A deficiency in pre-school children was 0.6%. The overall
prevalence of anemia was 81.2% with a significantly ( p < 0.01) higher
(91.0%) proportion of 1–3 year children being anemic as against 74.6% in 3–
5 year age group. The prevalence of anemia was decreased with increased age
and ranged from a high (94.8%) in 1+ year to a low (71.9%) in 4+ year
children. However, no gender differentials were reported in the prevalence of
anemia in 1–5 year old children (p > 0.05). The overall prevalence of goiter in
6–12 year old children was 9%. The author therefore concluded that
micronutrient deficiencies were found to be of public health significance
among rural children of West Bengal. Therefore, there is a need to initiate
sustainable long term interventions for prevention and control of
micronutrient deficiencies in children.
53
T. Jain et al. (2011) [81] premeditated that Overall 43% of the boys
(10 to 19 years) were found to be anemic with 23% having moderate to severe
anemia in urban Meerut, India. Prevalence of anemia was significantly higher
among children who took 2 meals per day (49%) compared to those who took
3 meals per day (39%). This study also revealed that majority of upper lower
class students (55.6%) were anemic and the prevalence of anemia decreased
with increase in socio-economic status but the difference was not statistically
significant. Prevalence of anemia was higher among boys who had illiterate
mothers (47.4%) and just literate mothers (50.0%) and minimum in boys with
graduate mothers (36.9%) but the difference was not statistically significant.
Prevalence of severe anemia was, however, found to be significantly higher
among upper lower and lower middle class (p<0.05). Thirty-nine percent of
the students were underweight, and only 4.5% were overweight or obese.
Even among the overweight and obese students, the prevalence of anemia was
high at 50%.
Ahmed S. Selmi et al (2011) [82] determined the prevalence of
anemia (35.3%) among children aged 6-11 years old in Gaza Strip, Palestine.
The mean level of hemoglobin was 12 mg/dl; standard deviation was 0.915
while the hemoglobin values ranged between8.9 g/dl and 15.2 g/dl. This study
also indicates that anemia was slightly higher in girls (36.3%) than boys
(34%), but no significant difference was found.
Mikki N et al (2011) [83] investigated the prevalence of anemia and
associated factors among Palestinian school adolescents (aged 13–15 years) in
Ramallah and Hebron governorates. Students from Ramallah area were
grouped as one group and the students from Hebron area were grouped as
other group. The prevalence of anemia in boys was significantly higher in
Hebron than Ramallah (22.5% versus 6.0% respectively) (P < 0.0001), while
54
the rates for girls were similar in the 2 areas (9.3% and 9.2% respectively).
No cases of severe anemia were detected and most of the cases of anemia
(90.8%) were mild. Mean hemoglobin level was 14.4 g/dl in Ramallah and
13.3 g/dl in Hebron. For girls, similar mean hemoglobin levels in both areas
(13.9 g/dl in Ramallah and 13.7 g/dl in Hebron).
Jain N et al (2012) [84] conducted a research to assess the prevalence
of anemia in school children within the ages of 5 to 16 years from
Government School of Rishikesh, Uttrakhand, India. Relevant history,
complete physical examination, hemoglobin estimation and Peripheral smear
were done for two hundred school children. The results revealed that 56.5%
of the children had anemia. A significantly higher number of girls were
anemic at all age (66.6%) and more menarcheal girls were anemic (36.5%).
At almost all ages significantly more (65.2%) vegetarian children were
anemic. Hemoglobin showed a rising trend with improved socio-economic
status. Most (90.90%) of the children belonging to lower socio-economic
groups were anemic. The prevalence of anemia was high (66.89%) in the
undernourished children, 29.09% were anemic in the well nourished group.
Clinical pallor was detected in 42% of total children while 56.5% were
anemic as per hemoglobin estimation. The commonest blood picture was
microcytic hypochromic seen in 54.86% followed by normocytic
normochromic in 42.47% and dimorphic picture was seen in 2.54% only. The
most common cause could be nutritional 48.67%, followed by different worm
infestation in 17.69% only.
Balci YI et al (2012) [85] carried out a study to determine the
prevalence and risk factors of anemia among 1120 adolescents (672 girls and
448 boys), aged 12 to 16 years in Denizli ,Turkey. The results indicated that
5.6 % had anemia. 8.3% of the girls and 1.6% of the boys were anemic.
55
Thirty-seven (59%) patients were diagnosed as IDA, and 26 (41%) were
diagnosed as combined iron deficiency and vitamin B12 deficiency anemia.
None of the patients were diagnosed as having folic acid deficiency. No
parasitic infestation was detected.
Biradar SS et al (2012) [86] conducted a cross-sectional study to
assess the prevalence and the severity of anemia among adolescent girls in
rural areas (Vantamuri PHC which is situated 22 kilometers away from
Belgaum city), and to study the association of anemia with respect to the age
of the participants and their socio-economic status. Eight hundred and forty
adolescent girls (10-19 years of age) were participated in this study.
Hemoglobin estimation (by using an automated cell counter) and clinical
examination were done for the girls. The adolescent girls were divided in to
two groups, early adolescence (10-14 years) and late adolescence (15-19
years). The overall prevalence of anemia was 41.1% (345 / 840), adolescent
girls had varying severity of anemia, 34.6% were mildly anemic, 6.3% were
moderately anemic and only 0.2% (2) were severely anemic. The prevalence
of anemia among the girls who belonged to class III was 4.1%, whereas it was
43.1% in girls of class IV and 100% in girls of class V. This was found to be
statistically significant. The prevalence of anemia among the late adolescents
was 60%, whereas; it was 38.9% among the early adolescents. This was found
to be statistically significant.
Kokore BA et al (2013) [87] determined the prevalence of anemia in
a school population of 310 children (172 girls and 138 boys) aged 5 to 11
years from three municipilities of Abidjan. Hematological parameters and the
electrophoretic profile of hemoglobin were done for all the children. The
results of study revealed that 82.9 % of children have indicated that at least a
parameter of the blood count was abnormal. The prevalence of anemia
(hemoglobin < 11.5 g/dl) was 30.3 % with 33.3 % of males and 29.1 % for
56
girls. In addition, haemoglobinopathies was found in 16.1 %, including sickle
cell trait and hemoglobin C trait.
In a study of Bhise RM, et al stated that overall prevalence of anemia
among school children aged 8-16 years of the Tribal community from Tribal
Ashram Schools in Ahmadnagar district of Maharashtra was 77.10 %
(239/310). The prevalence of anemia in girls (87.8%) was higher than the
boys (65.1%) (Bhise RM, et al, 2013) [88]
A Sumbele et al (2013) [89] did a study on 351 P. falciparum infected
children (46.2% females and 53.8% males) with a mean age of 6.45 ± 7.9
years (6 months to 14 years) residing in the Mount Cameroon region were
evaluated for the prevalence and risk factors of anemia. Anemia was assessed
by Hb concentration (Hb < 11 g/dl). The results revealed that 80.3% (282) of
the children had anemia and the prevalence of mild, moderate and severe
anemia in the study population was, 22.7% (64), 65.2% (184) and 12.1% (34)
respectively. Children ≤ 5 years had a significantly (P < 0.01) higher
prevalence of anemia when compared with those greater > 5 years. Similarly
the prevalence of anemia in children with enlarged spleens was significantly
(P < 0.01) higher than those with normal spleen Children who were malaria
parasite positive showed a higher prevalence of anemia on D14 (69.2%) and
D42 (78.6%) than those negative (D14 = 37.9%, D42 = 30.2%) post
treatment.This difference in prevalence was statistically significant (D14; χ2 =
4.7, P = 0.03 and D42; χ2 = 20.2, P < 0.001). The level of education of the
guardian/caregiver was identified as a risk factor (P = 0. 04) for anemia.
Children whose caregivers were illiterate had a higher prevalence of anemia
(90%) when compared with those whose caregivers had basic education (77.
8%).
57
3.2 PREVALENCE OF VITAMIN DEFICIENCY ANEMIA
Mao X eta al (1992) [90] conducted a study on 65 children with mild
iron deficiency anemia in china, to assess the effect of vitamin C
supplementation along with iron. Children were divided into 5 groups, and
received 7.5 mg of iron and 0, 25, 50, 100 and 150 mg/day of vitamin C
respectively every day for 8 weeks. Hemoglobin, serum ferritin, free
erythrocyte and hematocrit were determined every week. The results of the
study indicate that vitamin C supplement alone could effectively control
children's IDA. The finding also revealed that 50 mg/day of vitamin C is the
most efficient dosage and 6 weeks is the shortest time for an effective therapy.
They recommended that appropriate dose of vitamin C should be
supplemented for the children having a diet predominantly comprised of plant
foods.
In Malawi, infectious diseases and vitamin B12 and folate deficiencies,
but not iron deficiency, were important factors associated with severe
childhood anemia. Malaria was associated with severe anemia in the urban
site (with seasonal transmission) but not in the rural site (where malaria was
holoendemic). Seventy-six percent of hookworm infections were found in
children under 2 years of age. (Calis JC , 2008) [91].
The most common cause of anemia was found to be IDA followed by
pure and mixed vitamin B12 deficiency (28.4%), and pure and mixed folate
(14.74 %) deficiency (92).
A community-based Study was conducted by Gamble MV et al
(2004) [93] among 919 preschool children in the Republic of the Marshall
Islands. The relationship of vitamin A and iron status and markers of
inflammation, tumor necrosis factor-α, α1-acid glycoprotein, and interleukin-
58
10 to anemia were studied in a subsample of 367 children. The prevalence of
anemia was found 42.5%. The prevalence of severe vitamin A deficiency
(serum vitamin A <0.35 mmol/l) and iron deficiency (serum ferritin <12
mg/dl) were 10.9 and 51.7%, respectively. In multivariate linear regression
models that adjusted for age, sex, and inflammation, both iron deficiency and
severe vitamin A deficiency were significantly associated with anemia. The
author concluded that both iron and vitamin A deficiencies were independent
risk factors for anemia, but inflammation was not a significant risk factor for
anemia among these preschool children.
Riboflavin enhances the hematological response to iron, and its deficiency
may account for a significant proportion of anemia in many populations [94].
Children in the Republic of the Marshall Islands, ages 1 to 5 years are at high
risk of anemia, Vitamin A deficiency and ID, and one third of these children
had the co occurrence of Vitamin A and ID [95].
3.3 SOCIO ECONOMIC VARIABLES
Poor socio- economic status is defined as a situation that is comprised
of a number of factors such as low educational attainment, limited access to
gainful resource, reduced access to sufficient amount and quality food leading
to malnutrition and under nutrition.
Bhargava et al. (2006) [96] indicated in their study that the social and
economic determinants affecting the iron intake from fish, meat, and poultry
which resulting iron deficiency in women. Iron deficiency anemia influences
a number of women in South Asian countries, particularly during
reproductive period.
59
A study conducted by Siddharam et al (2011) [97] among adolescent
girls in rural area of Hassan district, Karnataka, South India. According to this
study out of 314 adolescent girls, 142 (45.2%) were found to be anemic, of
which 57 (40.14%) had mild anemia (Hb 10.9-11gm %), 78 (54.92%) had
moderate anemia (Hb 10.9-8gm% %), and 7 (4.92%) had severe anemia (Hb
< 8gm %). Higher percentages (33%) of anemic girls were found in class four
and class five (32.4%). None of the subject belongs to upper class (class I)
was present in the study. A statistically significant association of anemia was
found with iron deficiency, weight loss and presence of pallor. Other factors
like socioeconomic status, attainment of menarche, age group were not
significantly associated with anemia. Among anemic subjects correlating with
Body Mass Index (BMI) it was found that 80 (60%) were underweight, 54
(38%) were normal weight and 2 (2%) were overweight. The prevalence of
anemia was 233(71%) in postmenerchal girls as compared to 91(29%) in
premenarchal girls. In present study among anemic subjects 121(85%) were
anemic had iron deficiency, 82(57.7%) presented with pallor and 75 (52.8%)
had normal weight.
Chandra Sekhar K et al (2011) [98] carried out a cross sectional
community based study to know the prevalence of anemia among 248
adolescent girls and to find the demographic profile among the adolescent
anemic girls in urban areas of Kadapa, south India. The results shows that the
prevalence of anemia in adolescent girls was 68.95%, of which 76.4% were
from the age group of 13-15 yrs and 65.8% were from the 10-12 yrs of age.
The results also revealed that out of 171 anemic adolescents, 75.4% (95) were
from the below poverty line and 62.3% (76) individuals from the above
poverty line group. There was significant association was found between the
below poverty line individuals and anemia (P<0.01). High prevalence of
anemia was observed in parents of truck, auto and laborers families and which
60
was significant (P<0.001). Father occupation was significantly associated
with anemic condition.
Rao et al. (2007) [99] explored that poverty is a major cause for
limited access to sample quantity and quality of nutrient rich food in South
Asia.
There is another study correlates family income of the respondents, utilization
of health facilities and level of hemoglobin. According to him, women in the
lowest income group were less likely to have used health services as
compared to high income women.
Saluja N et al (2011) [100] conducted a study to find out the
prevalence of anemia and the socio-demographic factors affecting anemia in
primary school children (5-11 years) in urban Meerut. Out of 515 children
(265 boys and 250 girls), 194 children (37.7 %) were found to be anemic.
Anemia was found to be more in girls (45.2%) as compared to boys (30.6%).
The results also shows that the prevalence of anemia was maximum in
children belonging to lower social class (100.0%) followed by upper-lower
(44.8%), lower-middle (25.9%) and upper-middle (22.2%) and this difference
in prevalence of anemia in relation to social class was found to be statistically
significant (p<0.001). Anemia cases were significantly higher (41.7%) in
vegetarians as compared to non-vegetarians (32.9%). It was also observed that
anemia was significantly (p<0.001) higher (52.7%) in children belonging to
joint families as compared to those belonging to nuclear families (31.5%).
Percentage of anaemia was significantly (p<0.001) higher in children of
illiterate mothers and working mothers (p< 0.001).
Leite et al (2013) [101] assessed the prevalence of anemia and
associated factors among indigenous children (less than 5 years old) in Brazil.
A hemoglobin level was evaluated for 5,397 children in 113 villages. The
61
results revealed that the overall prevalence of anemia (Hb < 11 g/dL) was
51.2%. Boys (52.79%) in all age groups had a slightly higher prevalence of
anemia than girls (49.6%). The risk of anemia decreased with increasing age
of the child, progressively lowering with each age group. Maternal schooling
showed a similar pattern, with lower risk among children whose mothers had
ten or more years of schooling. With regard to household and environmental
variables the risk of anemia was higher in households with floors made of
wood, walls of palm thatch, and roofing of nondurable materials such as
canvas, and plastic. Higher risk of anemia was also observed among children
in households with discontinuous electricity and drinking water originating
from rivers, lakes, or open reservoirs. It was also higher in households with
the predominant defecation location being outdoors in the open and in those
with trash disposal by means of discarding in a river, lake, or ocean.
Considering the variables related to household composition, children were
more prone to have anemia.
A cross-sectional descriptive study was carried out among 847 school
going adolescent girls in urban as well as rural schools of the Lucknow
district, Uttar Pradesh, India by Sachan B et al (2012) [102] to find out the
prevalence of anemia and the various socio-demographic characteristics in
relation to anemia. Among the 847 school going adolescent girls, 477 were
found to be anemic with a prevalence of 56.3%. Overall prevalence of anemia
was found higher (64.0%) in adolescent girls who belonged to socio-
economic status
(SES)-IV and it was statistically significant (p<0.05) and significant
association of anemia was observed with religion and caste (p value<0.05).
62
Keeton et al (2007) [103] revealed that nuclear families often do
better. Members in nuclear families have easy access to two parents earning
income. Normally, they are well off economically and this directs to have a
healthy and safe environment, good schooling, good health care and nutrition.
According to above literature, there was considerably rising trend in anemia
prevalence with decreasing socioeconomic situation.