Nutritional deficiencies as the cause of severe- and very-severe anaemia and its outcome in under-5 children
Jivansha Dua, Sumaira Khalil, Kanchan Taneja, Piyush Gupta, Dheeraj ShahBackground and objectives
While nutritional deficiencies are the most common cause of anaemia in children, there is scarcity of information regarding their contribution to severe- and very-severe anaemia. We conducted this study to evaluate nutritional deficiencies as the cause of severe- and very-severe anaemia in under-5 children in a hospital setting and assess their outcome after 3 mo of appropriate treatment.
Methods
In this longitudinal study, 100 children (6 mo to 5 y) with severe anaemia (Hb <7 g/dL), including those with very-severe anaemia (Hb <5 g/dL) were included. Venous blood was collected and analysed for complete blood count, serum ferritin, C-reactive protein (CRP), serum vitamin B12, serum folate and serum immunoglobulin A tissue trans glutaminase (IgA-TTG). Iron deficiency was defined as serum ferritin <12 µg/L in absence of inflammation (CRP ≤ 5 mg/L) and <30 µg/L with inflammation, whereas vitamin B12 and folate deficiencies were defined as serum levels <203 pg/mL, and <4 ng/mL, respectively. These investigations were repeated after 3 mo of appropriate treatment as per the documented aetiology. Children with iron deficiency were treated with oral formulation of iron (3 mg/kg/d elemental iron, once daily). Those having vitamin B12 deficiency were managed using repeated intramuscular injections of hydroxycobalamin, and folate deficiency was treated with 1-5 mg/day of folic acid.
Results
Out of 100 children (mean (SD) age 19.85 (10.76) mo; 64% males), with severe anaemia [mean (SD) Hb 5.26 (1.20) g/dL with minimum upto 2.0 g/dL], 40 (40%) had very severe anaemia. Iron deficiency was documented in 73 (73%) children (82.5% in children with very severe anaemia), followed by vitamin B12 (25%) and folate deficiency (15%). Combined nutrient deficiencies were observed in 23% children, and were significantly more common in those with very severe anaemia (14/40 vs. 9/60; P= 0.020). Following 3 mo of treatment (n=91), there was a marked increase in mean (SD) haemoglobin levels [(5.28 (1.19) g/dL to 9.95 (1.94) g/dL; mean difference (95% CI) 4.67 (4.20, 5.13); P <0.001], with 58 (63.7%) continuing to have low haemoglobin (Hb <10.5 g/dL for 6-23 mo, and <11 g/dL for 23-59 mo).
Interpretation and conclusions
Iron deficiency, in isolation or combination with B12 or folate deficiency appears to be the most common cause of severe- and very-severe anaemia in under-five children presenting to the hospital without obvious symptoms and/or signs of non-nutritional causes. This may result in severely low haemoglobin levels, requiring blood transfusion and supportive care.