Determinants of anemia among young children in rural India

Does Anaemia Have Major Public Health Importance in Children Aged 6-59 Months in the Duggina Fanigo District of Wolaita Zone, Southern Ethiopia?

BACKGROUND

Globally, a large number of children aged 6-59 months are affected by anaemia. In Ethiopia, like other developing countries, more than 40% of children under 5 years are affected by anaemia. Anaemia during infancy and childhood period is associated with poor health and impaired cognitive development, leading to reduced academic achievement and earning potential in their adult life. The aim of this research was to assess whether anaemia remained a major public health problem among children aged 6-59 months or not in Duggina Fanigo District of Wolaita Zone, South Ethiopia in 2016.

METHODOLOGY

A community-based cross-sectional study was conducted from February to March 2016, on 404 mothers with children aged 6-59 months who were selected through the systematic sampling method. Socio-demographic and other data on associated factors was collected using a pre-tested questionnaire. Capillary blood was taken from the fingertip of each child and hemoglobin was measured using Haemo-Cue digital photometer. All the necessary safety measures were taken during blood collection. Data analysis was made using SPSS version 21. Multivariable logistic regression analysis was used to assess the association of independent variables with outcome variables and to control the possible confounding factors.

RESULT

The overall prevalence of anaemia was 51.4%. Anaemia was common among young children as compared to older children. After controlling the effect of confounding and adjusting for age, gender and altitude, explanatory variables like low dietary diversity (AOR = 3.24; 95% CI [1.68-6.23]), food insecurity (AOR = 3.63; 95% CI [2.18-6.04]), stunting (AOR = 2.60; 95% CI [1.56-4.35]), underweight (AOR = 2.46; 95% CI [1.29-4.67]) and fever within 2 weeks (AOR = 2.49; 95% CI [1.29-4.81]) prior to the survey were significantly associated with anaemia. In conclusion, the overall prevalence of anaemia among children aged 6-59 months has remained a major public health importance in the study area. Integrated efforts need to be prioritized to improve the health as well as the nutritional status of children aged 6-59 months through appropriate feeding practices in infants and children.

Benefits and risks of Iron interventions in children (BRISC): protocol for a three-arm parallel-group randomised controlled field trial in Bangladesh

INTRODUCTION

Anaemia is a major global health problem affecting about 43% of preschool children globally and 60% of 6-24-month-old children in rural Bangladesh, half of which is attributed to iron deficiency (ID). Although WHO recommends universal supplementation with iron or home fortification with iron-containing multiple micronutrient powders (MMPs) to children under 2 years, evidence for benefits of these interventions on childhood development (a key rationale for these interventions) and harms (especially infection) remains limited. This study aims to evaluate the impact of iron or MMPs supplementation compared with placebo on (a) children's development, (b) growth, (c) morbidity from infections and (d) haematological and iron indices.

METHODS AND ANALYSIS

This study is a three-arm, blinded, double-dummy, parallel-group, placebo-controlled superiority trial using stratified individual block randomisation. The trial will randomise 3300 children aged 8-9 months equally to arm 1: iron syrup (12.5 mg elemental iron), placebo MMPs; arm 2: MMPs (including 12.5 mg elemental iron), placebo syrup; and arm 3: placebo syrup, placebo MNPs. Children will receive interventions for 3 months based on WHO recommendations and then be followed up for 9 months post intervention. The primary outcome is cognitive composite score measured by Bayley III. Secondary outcomes include motor and language composite score by Bayley III, behaviour rating using selected items from Wolke's rating scales and BSID-II behaviour ratings, temperament, growth, haemoglobin, anaemia and iron status, and infectious morbidity. Outcomes will be measured at baseline, at the end of 3-month intervention and after 9 months postintervention follow-up.

ETHICS AND DISSEMINATION

The trial has been approved by the Ethical Review Committee of icddr,b (Dhaka, Bangladesh) and the Melbourne Health Human Research Ethics Committee (Melbourne, Australia). Results of the study will be disseminated through scientific publications, presentations at international meetings and policy briefs to key stakeholders.

TRIAL REGISTRATION NUMBER

ACTRN12617000660381;Pre-results.

WHO UNIVERSAL TRIAL NUMBER

U1111-1196-1125.

Lay health workers perceptions of an anemia control intervention in Karnataka, India: a qualitative study

Background

Lay health workers (LHWs) are increasingly used to complement health services internationally. Their perceptions of the interventions they implement and their experiences in delivering community based interventions in India have been infrequently studied. We developed a novel LHW led intervention to improve anemia cure rates in rural community dwelling children attending village day care centers in South India. Since the intervention is delivered by the village day care center LHW, we sought to understand participating LHWs’ acceptance of and perspectives regarding the intervention, particularly in relation to factors affecting daily implementation.

Methods

We conducted a qualitative study alongside a cluster randomized controlled trial evaluating a complex community intervention for childhood anemia control in Karnataka, South India. Focus group discussions (FGDs) were conducted with trained LHWs assigned to deliver the educational intervention. These were complemented by non-participant observations of LHWs delivering the intervention. Transcripts of the FGDs were translated and analyzed using the framework analysis method.

Results

Several factors made the intervention acceptable to the LHWs and facilitated its implementation including pre-implementation training modules, intervention simplicity, and ability to incorporate the intervention into the routine work schedule. LHWs felt that the intervention impacted negatively on their preexisting workload. Fluctuating relationships with mothers weakened the LHWs position as providers of the intervention and hampered efficient implementation, despite the LHWs’ highly valued position in the community. Modifiable barriers to the successful implementation of this intervention were seen at two levels. At a broader contextual level, hindering factors included the LHW being overburdened, inadequately reimbursed, and receiving insufficient employer support. At the health system level, lack of streamlining of LHW duties, inability of LHWs to diagnose anemia and temporary shortfalls in the availability of iron supplements constituted potentially modifiable barriers.

Conclusion

This qualitative study identified some of the practical challenges as experienced by LHWs while delivering a community health intervention in India. Methodologically, it highlights the value of qualitative research in understanding implementation of complex community interventions. On the contextual level, the results indicate that efficient delivery of community interventions will require streamlining of LHW workloads and improved health system infrastructure support.

Trial registration

This trial was registered with ISRCTN.com (identifier: ISRCTN68413407) on 23 September 2013.

Re-Evaluation of Serum Ferritin Cut-Off Values for the Diagnosis of Iron Deficiency in Children Aged 12-36 Months

An ongoing challenge has been determining clinically relevant serum ferritin cut-offs in the diagnosis of iron deficiency in children aged 1-3 years. We identified 2 potential clinically relevant serum ferritin cut-off values through their association with clinically important cut-off of hemoglobin as the indicator of anemia.

Correlation between maternal and childhood VitB12, folic acid and ferritin levels

OBJECTIVE

To determine the correlation between serum folic acid, vitamin B12 and ferritin of mother and child and to study various neonatal risk factors as a cause of anemia in children.

METHODS

One hundred eighty children two months to two years of age admitted in the department of Pediatric Medicine of The Children's Hospital and The Institute of Child Health Lahore from January 2013 to January 2015 with common medical conditions having anemia were included. Complete blood count (CBC), serum ferritin level, folic acid and Vitamin (Vit) B12 level were sent of children and their mothers. Data was analyzed using SPSS version 20.

RESULTS

Out of 180 children with anemia, 66.7% were males. Mean age of children was 7.3months. Fifty-five percent children were malnourished according to z scoring. The mean Hemoglobin (Hb) of children was 8 g/dl. Only 4% children had low ferritin level while 60% had low folic acid and 45% had decreased VitB12. There was significant correlation between Hb of mother and child (p =0.02), Vit B12 deficiency (p=0.008) and iron deficiency (p<0.001). Premature children had lower folic acid levels (p =0.02), while prematurity, IUGR, previous admission and history of sepsis showed no association with anemia in our study. Both breast-feeding and top feeding showed significant association with anemia with p-value of 0.042 and 0.003 respectively while dilution showed no impact on anemia.

CONCLUSION

Maternal anemia has a significant impact on child's hemoglobin. As compared to previous concept of increased iron deficiency in children we found increased occurrence of folic acid and VitB12 deficiency in children and their mothers.

Quality of Life Among Women Living With HIV in Rural India

A cross-sectional examination was conducted on quality of life (QOL) among women living with HIV (WLWH) in rural Andhra Pradesh, India. Baseline data were collected from 400 WLWH and their children. QOL was measured with 10 items from the Quality of Life Enjoyment and Satisfaction Questionnaire. Findings revealed low QOL scores; on a scale from 0 to 3, the mean QOL score was 0.38 (SD = 0.30). Depression symptoms were reported by 25.5%, internalized stigma was high, and most reported little to no social support. Multivariable analysis revealed positive associations between QOL and CD4+ T cells (b = .0011, p = .021) and social support (b = .260, p < .0001), and a negative relationship between QOL and internalized stigma (b = -.232, p < .0001). Interventions focused on improving QOL for WLWH should incorporate strategies to improve social support and adherence to antiretroviral therapy, while mitigating internalized stigma.

Impact of malnutrition on pediatric risk of mortality score and outcome in Pediatric Intensive Care Unit

OBJECTIVES

This study was done to determine the effect of malnutrition on mortality in Pediatric Intensive Care Unit (PICU) and on the pediatric risk of mortality (PRISM) scoring.

SUBJECTS AND METHODS

This was a prospective study done over 1 year. There were total 400 patients (1 month 14 years), who were divided into cases with weight for age <3(rd) centile and controls with ≥3(rd) centile of WHO charts. Cases were subdivided into mild/moderate (61-80% of expected weight for age) and severe malnutrition (<60%).

RESULTS

Out of total, 38.5% patients were underweight, and malnutrition was more in infancy, 61/104, i.e. 58.5% (P - 0.003). There was no significant difference in vitals at admission. Cases needed prolonged mechanical ventilation (P - 0.0063) and hospital stay (P - 0.0332) compared to controls. Mean and median PRISM scores were comparable in both the groups, but mortality was significantly higher in severely malnourished (P value 0.027).

CONCLUSION

Severe malnutrition is independently associated with higher mortality even with similar PRISM score. There is need to give an additional score to children with weight for age <60% of expected.

Maternal Micronutrient Supplementation and Long Term Health Impact in Children in Rural Bangladesh

Background

Limited data is available on the role of prenatal nutritional status on the health of school-age children. We aimed to determine the impact of maternal micronutrient supplementation on the health status of Bangladeshi children.

Methods

Children (8.6–9.6 years; n = 540) were enrolled from a longitudinal mother-child cohort, where mothers were supplemented daily with either 30mg iron and 400μg folic acid (Fe30F), or 60mg iron and 400μg folic acid (Fe60F), or Fe30F including 15 micronutrients (MM), in rural Matlab. Blood was collected from children to determine the concentration of hemoglobin (Hb) and several micronutrients. Anthropometric and Hb data from these children were also available at 4.5 years of age and mothers at gestational week (GW) 14 and 30.

Results

MM supplementation significantly improved (p≤0.05) body mass index-for-age z-score (BAZ), but not Hb levels, in 9 years old children compared to the Fe30F group. MM supplementation also reduced markers of inflammation (p≤0.05). About 28%, 35% and 23% of the women were found to be anemic at GW14, GW30 and both time points, respectively. The prevalence of anemia was 5% and 15% in 4.5 and 9 years old children, respectively. The adjusted odds of having anemia in 9 year old children was 3-fold higher if their mothers were anemic at both GW14 and GW30 [Odds Ratio (OR) = 3.05; 95% Confidence Interval (CI) 1.42, 6.14, P = 0.002] or even higher if they were also anemic at 4.5 years of age [OR = 5.92; 95% CI 2.64, 13.25; P<0.001].

Conclusion

Maternal micronutrient supplementation imparted beneficial effects on child health. Anemia during pregnancy and early childhood are important risk factors for the occurrence of anemia in school-age children.

Iron intakes and status of 2-year-old children in the Cork BASELINE Birth Cohort Study

Young children are at risk of iron deficiency and subsequent anaemia, resulting in long-term consequences for cognitive, motor and behavioural development. This study aimed to describe the iron intakes, status and determinants of status in 2-year-old children. Data were collected prospectively in the mother-child Cork BASELINE Birth Cohort Study from 15 weeks' gestation throughout early childhood. At the 24-month assessment, serum ferritin, haemoglobin and mean corpuscular volume were measured, and food/nutrient intake data were collected using a 2-day weighed food diary. Iron status was assessed in 729 children (median [IQR] age: 2.1 [2.1, 2.2] years) and 468 completed a food diary. From the food diary, mean (SD) iron intakes were 6.8 (2.6) mg/day and 30% had intakes < UK Estimated Average Requirement (5.3 mg/day). Using WHO definitions, iron deficiency was observed in 4.6% (n = 31) and iron deficiency anaemia in five children (1.0%). Following an iron series workup, five more children were diagnosed with iron deficiency anaemia. Twenty-one per cent had ferritin concentrations <15 µg/L. Inadequate iron intakes (OR [95% CI]: 1.94 [1.09, 3.48]) and unmodified cows' milk intakes ≥ 400 mL/day (1.95 [1.07, 3.56]) increased the risk of low iron status. Iron-fortified formula consumption was associated with decreased risk (0.21 [0.11, 0.41] P < 0.05). In this, the largest study in toddlers in Europe, a lower prevalence of low iron status was observed than in previous reports. Compliance with dietary recommendations to limit cows' milk intakes in young children and consumption of iron-fortified products appears to have contributed to improved iron status at two years.

Determinants of Anemia among School-Aged Children in Mexico, the United States and Colombia

Anemia affects approximately 25% of school-aged children (SAC-aged 5.00-14.99 years) globally. We determined in three countries the prevalence and determinants of anemia in SAC. Data on sociodemographics, inflammation and nutrition status were obtained from the 2006 Mexican National Nutrition Survey, the 2003-6 US National Health and Nutrition Examination Surveys, and the 2010 Encuesta Nacional de Nutrición Situación Colombia. In the US, vitamin A and iron deficiency (ID) were available only for girls aged 12.00-14.99 years to which our analysis was limited. Associations were evaluated by country using multivariable logistic regression adjusting for confounders and complex survey design. The prevalence of anemia and ID were: Mexico 12% (ID 18%), n = 3660; US 4% (ID 10%), n = 733; and Colombia 4% (ID 9%), n = 8573. The percentage of anemia associated with ID was 22.4% in Mexico, 38.9% in the US and 16.7% in Colombia. In Mexico, anemia was associated with ID (adjusted OR: 1.5, p = 0.02) and overweight (aOR 0.4, p = 0.007). In the US, anemia was associated with black race/ethnicity (aOR: 14.1, p < 0.0001) and ID (aOR: 8.0, p < 0.0001). In Colombia, anemia was associated with black race/ethnicity (aOR: 1.6, p = 0.005), lowest socio-economic status quintile (aOR: 1.8, p = 0.0005), ID (aOR: 2.7, p < 0.0001), and being stunted (aOR: 1.6, p = 0.02). While anemia was uniformly associated with iron deficiency in Mexico, Columbia, and the United States, other measured factors showed inconsistent associations with anemia. Additional data on anemia determinants in SAC are needed to guide interventions.

Prevalence and Predictors of Iron Deficiency Anemia in Children under Five Years of Age in Pakistan, A Secondary Analysis of National Nutrition Survey Data 2011-2012

BACKGROUND

Iron deficiency Anemia (IDA) in children is a recognized public health problem that impacts adversely on child morbidity, mortality and impairs cognitive development. In Pakistan information on the true prevalence and predictors of IDA is limited. This study sought to investigate IDA in children under five years of age using data from a nationally representative stratified cross-sectional survey.

METHODS

Secondary analysis was performed on the National Nutrition Survey in Pakistan 2011-2012. We used a pre-structured instrument to collect socio demographic and nutritional data on mothers and children. We also collected Anthropometric measurements and blood samples for micronutrient deficiencies. IDA was defined as having both haemoglobin levels of <110 g/L and ferritin levels of < 12 μg/L. Data analysis was performed by applying univariate and multivariate techniques using logistic regression through SPSS.

FINDINGS

A total of 7138 children aged between 6-59 months were included in the analysis. The prevalence of IDA was 33.2%. In multivariate regression analysis adjusted odds ratios (AOR) were calculated. Age < 24 months (AOR 1.40, 95% CI 1.18-1.55 p <0.05), stunting (AOR 1.42 CI 1.23-1.63 p<0.05), presence of clinical anemia (AOR 5.69 CI 4.93-6.56 p<0.05), having a mother with IDA (AOR 1.72 CI 1.47-2.01 p<0.05) and household food insecurity (AOR 1.20 CI 1.10-1.40 P<0.05) were associated with IDA. Living in a rural area (AOR 0.77 CI 0.65-0.90 p<0.05) and being a female child (AOR 0.87 CI 0.76-0.98 p<0.05) were associated with reduced odds of IDA.

CONCLUSION

The prevalence of IDA amongst Pakistani children represents a moderate burden that disproportionately affects the youngest, growth retarded children, affected children are more likely to have mothers with IDA and live in areas where food security is lacking. National efforts to alleviate the burden of IDA should involve both short term vertical programs such as iron supplementation and long term horizontal programs including wheat flour fortification.

Stunting, selenium deficiency and anemia are associated with poor cognitive performance in preschool children from rural Ethiopia

BACKGROUND

Anthropometric characteristics and iron status affect cognitive performance in children. In addition, selenium can influence cognitive outcomes; protection of the brain from oxidative stress and its role in thyroid hormone metabolism are putative mechanisms.

METHODS

To investigate their association with cognitive performance, anthropometric indicators, iron biomarkers, and serum selenium of children (n = 541) of 54-60mo of age from rural Ethiopia were assessed. Cognitive assessment was conducted with the administration of two reasoning subtests of the Wechsler Preschool and Primary Scale of Intelligence and the school readiness test.

RESULTS

Stunting was found in 41.4 % of children, 28.7 % were underweight, and 6.3 % were wasted. The mean score of stunted children was lower than that of non-stunted children on non-verbal reasoning (7.0 ± 3.2vs7.9 ± 3.1; p = 0.01) and the school readiness tests (4.3 ± 2.2 vs 3.3 ± 2.1; p < 0.001). Compared to non-anemic children, anemic children had lower score for the verbal reasoning test (9.5 ± 1.7 vs 8.9 ± 2.2; p = 0.02). However, except for hemoglobin, none of the iron biomarkers had significant associations with the cognitive score of the study children (p > 0.05). Selenium deficient children had lower scores on all cognitive tests than normal children (p < 0.05).

CONCLUSION

The present study finding linking chronic undernutrition and micronutrient deficiency to cognitive deficits suggests the need for designing effective intervention programmes to control for protein energy malnutrition and micronutrient deficiency and address cognitive development in children.

The Global Burden of Anemia

Anemia is an important cause of health loss. We estimated levels and trends of nonfatal anemia burden for 23 distinct etiologies in 188 countries, 20 age groups, and both sexes from 1990 to 2013. All available population-level anemia data were collected and standardized. We estimated mean hemoglobin, prevalence of anemia by severity, quantitative disability owing to anemia, and underlying etiology for each population using the approach of the Global Burden of Disease, Injuries and Risk Factors 2013 Study. Anemia burden is high. Developing countries account for 89% of all anemia-related disability. Iron-deficiency anemia remains the dominant cause of anemia.

Nutrient retention and fate of iron-binding phenolic compounds during the injera processing of tannin-free and high-tannin sorghum

BACKGROUND

Traits such as bird-, insect- and mould-resistance are the focus in selecting improved sorghum varieties, but this often increases the tannin content, which can negatively affect iron bioavailability. The grain characteristics, nutrient retention, and the fate of iron-binding polyphenols (IBPs) during injera processing, an Ethiopian traditional fermented pancake, were investigated using agriculturally improved tannin-free (TFC) and high-tannin (HTC) sorghum cultivars.

RESULTS

The HTC had significantly higher IBP contents than the TFC (P < 0.05). Decortication led to iron (24-27%), calcium (18-43%), IBP (catechol 35-41%, galloyl 35-42%), and tannin (12-35%) losses. Sourdough fermentation reduced the IBP and tannin concentrations in HTC, but had no effect on the IBP concentrations in TFC. The modified injera processing that included pre-soaking resulted in the highest IBP reductions (galloyl 73% and catechol 71%).

CONCLUSION

Nutrient retention in HTC and TFC processing was different. Including a pre-soaking step during injera processing of HTC could counter the negative effects of IBP on iron absorption, while benefiting from the agronomic features of HTC.

Overview of the Biomarkers Reflecting Inflammation and Nutritional Determinants of Anemia (BRINDA) Project

Anemia remains a widespread public health problem. Although iron deficiency is considered the leading cause of anemia globally, the cause of anemia varies considerably by country. To achieve global targets to reduce anemia, reliable estimates of the contribution of nutritional and non-nutritional causes of anemia are needed to guide interventions. Inflammation is known to affect many biomarkers used to assess micronutrient status and can thus lead to incorrect diagnosis of individuals and to overestimation or underestimation of the prevalence of deficiency in a population. Reliable assessment of iron status is particularly needed in settings with high infectious disease burden, given the call to screen for iron deficiency to mitigate potential adverse effects of iron supplementation. To address these information gaps, in 2012 the CDC, National Institute for Child Health and Human Development, and Global Alliance for Improved Nutrition formed a collaborative research group called Biomarkers Reflecting Inflammation and Nutrition Determinants of Anemia (BRINDA). Data from nationally and regionally representative nutrition surveys conducted in the past 10 y that included preschool children and/or women of childbearing age were pooled. Of 25 data sets considered for inclusion, 17 were included, representing ∼30,000 preschool children, 26,000 women of reproductive age, and 21,000 school-aged children from all 6 WHO geographic regions. This article provides an overview of the BRINDA project and describes key research questions and programmatic and research implications. Findings from this project will inform global guidelines on the assessment of anemia and micronutrient status and will guide the development of a research agenda for future longitudinal studies.

Determinants of iron status and Hb in the Bangladesh population: the role of groundwater iron

OBJECTIVE

Using data from the national micronutrients survey 2011-2012, the present study explored the determinants of Fe status and Hb levels in Bangladesh with a particular focus on groundwater Fe.

DESIGN

Cross-sectional study conducted at the nationwide scale. Settings The survey was conducted in 150 clusters, fifty in each of the three strata of rural, urban and slum.

SUBJECTS

Three population groups: pre-school age children (6-59 months; PSAC), school age children (6-14 years; SAC) and non-pregnant non-lactating women (15-49 years; NPNLW).

RESULTS

National prevalence of Fe deficiency was 10·7 %, 7·1 % and 3·9-9·5 % in PSAC, NPNLW and SAC, respectively. Prevalence of anaemia was 33·1 % (PSAC), 26·0 % (NPNLW) and 17·1-19·1 % (SAC). Multivariate regression analyses showed that the area with 'predominantly high groundwater Fe' was a determinant of higher serum ferritin levels in NPNLW (standardized β=0·19; P=0·03), SAC (standardized β=0·22; P=0·01) and PSAC (standardized β=0·20; P=0·03). This area also determined higher levels of Hb in PSAC (standardized β=0·14; P=0·01).

CONCLUSIONS

National prevalence of Fe deficiency in Bangladesh is low, contrary to the widely held assumption. High Fe level in groundwater is associated with higher Fe status (all populations) and higher Hb level (PSAC).

The Karnataka Anemia Project 2--design and evaluation of a community-based parental intervention to improve childhood anemia cure rates: study protocol for a cluster randomized controlled trial

BACKGROUND

Childhood anemia is highly prevalent worldwide. Improving the hemoglobin level of preschool age children could yield substantial benefits in cognitive and psychosocial development and overall health. While evidence-based recommendations for reducing childhood anemia in high anemia prevalence countries are available, there is no experimental evidence of community centered education and counseling programs, as a route to improved acceptance of iron supplements, demonstrating beneficial effects on anemia outcomes. We report on the evaluation protocol of a complex educational intervention led by the community lay health worker (LHW) and delivered to mothers of 12-59-month-old anemic children living in and visiting village day care centers in a large district of southern India.

METHODS AND DESIGN

The study is designed as a cluster randomized controlled trial. The intervention is based on the social cognitive theory and aims to promote among mothers, anemia awareness, dietary modifications to increase iron intake in the child, and recognition of the need for enhanced adherence to supplemental iron in the anemic child. From 270 eligible villages in the study area, a sample of 60 villages will be randomized to intervention [n = 30] or to treatment as usual [n = 30] of the study. LHWs in the intervention arm will be trained to administer the following intervention components to mothers of anemic children: 1] monthly distribution of Iron and folic acid (IFA) supplements to mothers of anemic children, and 2] five monthly counseling sessions of mothers of anemic children covering: a] anemia awareness education b] IFA adherence counseling and assessment, c] dietary modification to improve iron intake, and d] hygiene and sanitation. LHWs in the control arm will distribute IFA to mothers of anemic children as in the intervention arm but will not provide monthly education and counseling support. The primary outcome is the difference between the two experimental groups in anemia cure rates of children found to be anemic at baseline. Secondary outcomes, assessed as differences between all participants in both experimental groups, are: change in mothers' knowledge regarding anemia; 24 hour dietary iron intake; net improvement in individual hemoglobin values; serum ferritin; and the difference in overall cluster level childhood anemia prevalence. All outcomes will be measured 6 months after the start of the intervention. Multilevel linear and logistic regression models will be used to analyze differences between intervention and control groups in outcome variables.

DISCUSSION

This trial is designed to evaluate the effectiveness of an intervention intended to improve anemia cure rates in anemic children living in villages of Chamarajnagar, Karnataka a large district in south India. The extensive study of secondary endpoints will be used to identify possible weak points in the compliance to intervention delivery and uptake. This evaluation is one of the few large randomized trials evaluating the impact of an education and counseling intervention to reduce childhood anemia prevalence.

TRIAL REGISTRATION

This trial was registered with ISRCTN.com (identifier: ISRCTN68413407) on 17 September 2013.

Incidence and risk factors associated with iron deficiency anaemia among hospitalised Lebanese infants

OBJECTIVES

The primary objective of this study was to determine the prevalence of iron deficiency anaemia (IDA) in hospitalised 6- to 24-month-old infants in rural versus urban settings. The secondary objective was to determine associated risk factors in rural versus urban settings.

METHODS

A 6-month prospective multicentre cross-sectional study was conducted in paediatrics departments of three Lebanese hospitals. Preterm to term infants aged 6-24 months were included. Infants with blood disorders, chronic infections, congenital immunodeficiency and mental or congenital growth retardation were excluded. Incidence of IDA was assessed using haematologic laboratory values, while risk factors were assessed using questionnaires addressed to infants' caregivers. For data analysis, P values, chi-squared and logistic regression were used.

KEY FINDINGS

Among 520 screened infants, a total of 100 patients were selected. Thirty-seven per cent of patients were anaemic with haemoglobin levels <11 g/dl. Significant risk factors included: exclusive breastfeeding for more than 6 months (95% CI, 1.03 to 8.9; P = 0.043), low family income (95% CI, 0.19 to 0.98; P = 0.045), residing in rural areas (95% CI, 0.064 to 0.0509; P < 0.001), inadequate maternal iron supply (95% CI, 1.01 to 8.26; P = 0.05), low maternal education level (95% CI, 0.07 to 0.88; P = 0.03) and lack of infant iron supply (95% CI, 1.39 to 8.41; P = 0.007).

CONCLUSION

Incidence of IDA among Lebanese infants is moderate and multifactorial. High maternal education level, urban residence, giving iron supplements to exclusively breastfed infants starting from 6 months of age, adequate family income and iron supplementation in both mother and infant are significant protective factors against anaemia in this population.

Effect of Home-Based Complementary Food Fortification on Prevalence of Anemia Among Infants and Young Children Aged 6 to 23 Months in Poor Rural Regions of China

Following the 2008 Wenchuan earthquake, the Chinese government instituted an infant and young and child nutrition program that included promotion of in-home fortification of complementary food with ying yang bao (YYB), a soy-based powder containing iron, 2.5 mg as iron-EDTA and 5 mg as ferrous fumarate, and other micronutrients. Ying yang bao was provided to participating families in 8 poor rural counties in Sichuan, Shaanxi, and Gansu provinces by the Ministry of Health. We assessed hemoglobin levels among infants and young children (IYC) aged 6 to 23 months at baseline in May 2010 (n = 1290) and during follow-up in November 2010 (n = 1142), May 2011 (n = 1118), and November 2011 (n = 1040), using the Hemocue method. Interviewers collected basic demographic information and child feeding practices from the children's caretakers. Altitude-adjusted hemoglobin level averaged 10.8 g/dL, and total anemia prevalence was 49.5% at baseline. Average hemoglobin was 11.3 g/dL at 6 months, 11.6 g/dL at 12 months, and 11.7 g/dL at 18 months after introduction of YYB. Moderate anemia (hemoglobin: 70-99 g/dL) decreased from 20.3% at baseline to 7.5%, 5.8%, and 7.3% after 6, 12, and 18 months of home fortification, respectively (P < .001), whereas mild anemia (hemoglobin: 100-110 g/dL) decreased from 29.0% to 16.7%, 18.1%, and 15.4%, respectively (P < .001). Among infants aged 6 to 23 months, 95% had regularly been fed YYB during the observation period. Regression analysis showed that the duration of YYB consumption and number of sachets consumed per week correlated positively with hemoglobin levels and negatively with anemia rates. Home food fortification with YYB is feasible and effective for nutrition promotion among IYC in high-risk regions of China.

Anemia, diet and therapeutic iron among children living with HIV: a prospective cohort study

BACKGROUND

Children living with HIV have higher-than-normal prevalence of anemia. The beneficial effect of therapeutic iron has been questioned in the setting of high prevalence of infections. This study examines anemia prevalence and effect of standard therapeutic iron on HIV disease progression among children.

METHODS

Perinatally-infected children aged 2-12 years were enrolled at three sites in southern India, and were followed for 1 year with clinical assessments, dietary recall and anthropometry. Laboratory parameters included iron markers (ferritin, soluble transferrin receptor) and other micronutrient levels (vitamin A, B12, folate). Iron was given to anemic children based on WHO guidelines. Statistical analyses including frequency distributions, chi square tests and multivariate logistic regression were performed using Stata v13.0.

RESULTS

Among 240 children enrolled (mean age 7.7 years, 54.6% males), median CD4 was 25%, 19.2% had advanced disease, 45.5% had malnutrition, and 43.3% were on antiretroviral treatment (ART) at baseline. Anemia was prevalent in 47.1% (113/240) children. Iron deficiency was present in 65.5%; vitamin A and vitamin B12 deficiency in 26.6% and 8.0% respectively; and anemia of inflammation in 58.4%. Independent risk factors for anemia were stunting, CD4 < 25%, detectable viral load ≥ 400 copies/ml and vitamin A deficiency. Inadequate dietary iron was prominent; 77.9% obtained less than two-thirds of recommended daily iron. Among clinically anemic children who took iron, overall adherence to iron therapy was good, and only minor self-limiting adverse events were reported. Median hemoglobin rose from 10.4 g/dl to 10.9 mg/dl among those who took iron for 3 months, and peaked at 11.3 mg/dl with iron taken for up to 6 months. Iron was also associated with a greater fall in clinical severity of HIV stage; however when adjusted for use of ART, was not associated with improvement in growth, inflammatory and CD4 parameters.

CONCLUSIONS

Children living with HIV in India have a high prevalence of anemia mediated by iron deficiency, vitamin A deficiency and chronic inflammation. The use of therapeutic iron for durations up to 6 months appears to be safe in this setting, and is associated with beneficial effects on anemia, iron deficiency and HIV disease progression.

Prevalence and factors associated with severe anaemia amongst under-five children hospitalized at Bugando Medical Centre, Mwanza, Tanzania

Background

Anaemia is a major public health problem in developing countries, contributing significantly to morbidity and mortality amongst children under-five years of age. About 43 % of under-fives are anaemic worldwide, and two-thirds reside in sub-Saharan Africa. Even where blood transfusion is available for treatment there is still a significant case fatality rate ranging between 6 and 18 %. This study aimed to determine the prevalence and morphological types of anaemia, as well as factors associated with severe anaemia in under-five children admitted at Bugando Medical Centre (BMC).

Methods

This was a hospital-based, cross-sectional study conducted between November 2012 and February 2013. Selected laboratory investigations were done on children admitted to BMC. Anaemia was defined using WHO criteria.

Results

A total of 448 under-five children were recruited into the study. The overall prevalence of anaemia was 77.2 % (346/448) with mild, moderate and severe anaemia being 16.5, 33 and 27.7 % respectively. Microcytic hypochromic anaemia was detected in 37.5 % of the children with anaemia. Of 239 children with moderate and severe anaemia, 22.6 % (54/239) had iron deficiency anaemia based on serum ferritin level less than12 μg/ml. The factors associated with severe anaemia included unemployment of the parent, malaria parasitaemia and presence of sickle haemoglobin.

Conclusion

The prevalence of anaemia among under-five children admitted at BMC was high. Iron deficiency anaemia was the most common type. Factors associated with severe anaemia were unemployment among caretakers, malaria parasitaemia and presence of sickle haemoglobin.

Household Food Insecurity, Mother's Feeding Practices, and the Early Childhood's Iron Status

BACKGROUND

Health consequences of food insecurity among infants and toddlers have not been fully examined. The purpose of this study was to assess the relationship between household food insecurity, mother's infant feeding practices and iron status of 6-24 months children.

METHODS

In this cross-sectional study, 423 mother-child pairs were randomly selected by multistage sampling method. Children blood samples were analyzed for hemoglobin and serum ferritin concentrations. Household food security was evaluated using a validated Household Food Insecurity Access Scale. The mother's feeding practices were evaluated using Infant and Young Child Feeding practice variables including: The duration of breastfeeding and the time of introducing of complementary feeding.

RESULTS

Based on the results, of the studied households only 47.7% were food secure. Mild and moderate-severe household food insecurity was 39.5% and 12.8%, respectively. Anemia, iron deficiency (ID), and iron deficiency anemia were seen in 29.1%, 12.2%, and 4.8% of children, respectively. There was no significant association between household food insecurity; mother's feeding practices and child ID with or without anemia.

CONCLUSIONS

We found no association between household food insecurity and the occurrence of anemia in the 6-24 months children. However, these findings do not rule out the possibility of other micronutrient deficiencies among the food-insecure household children.

Prevalence and determinants of anaemia among children aged 0–59 months in a rural region of Armenia: a case–control study

Objective

Despite the trend of increasing prevalence of childhood anaemia in Armenia, no studies exploring its risk factors have been conducted in the country. The present study aimed to investigate the prevalence and determinants of childhood anaemia in rural Armenia.

Design

Blood Hb level was measured among a representative sample of children using the HemoCue Hb201+ analyser. The revealed cases with anaemia were compared with randomly selected non-anaemic controls. Mothers of cases and controls were interviewed. Logistic and linear regression models were fitted to identify the risk factors of anaemia and low Hb level, respectively.

Setting

Talin communities, Aragatsotn Province, Armenia.

Subjects

Children under 5 years of age in Talin region.

Results

Of the 729 studied children, 32·4 % were anaemic with 14·7 % having moderate/severe anaemia. Infants were the most affected group with 51·1 % being anaemic before 6 months and 67·9 % at 6–12 months of age. Fitted regression models identified the following predictors of anaemia: younger age, male gender, shorter birth length, anaemia during pregnancy, lower meal frequency per day, lack of meat in the diet, using dung cakes for heating and living in a community that received an incomplete set of nutrition interventions.

Conclusions

The study identified several modifiable risk factors that could be targeted to reduce childhood anaemia in rural Armenia and, possibly, in rural areas in other low-/middle-income countries. The suggested interventions include prevention and treatment of anaemia during pregnancy, provision of adequate complementary feeding to children with inclusion of meat in their daily diet and reduction of their exposure to biomass fuel smoke.

Plasma Concentrations of Hepcidin in Anemic Zimbabwean Infants

OBJECTIVE

Anemia in infancy is a global public health problem. We evaluated the relative contributions of iron deficiency and inflammation to infant anemia.

METHODS

We measured plasma hepcidin, ferritin, soluble transferrin receptor (sTfR), alpha-1-acid glycoprotein and C-reactive protein (CRP) by ELISA on archived plasma from 289 HIV-unexposed anemic or non-anemic Zimbabwean infants at ages 3 mo, 6 mo and 12 mo. Among anemic infants, we determined the proportion with iron-deficiency anemia (IDA) and anemia of inflammation (AI). We undertook regression analyses of plasma hepcidin and anemia status, adjusting for sex, age and birthweight.

RESULTS

Anemic infants at 3 mo were more stunted and had higher CRP (median 0.45 vs 0.21 mg/L; P = 0.037) and hepcidin (median 14.7 vs 9.7 ng/mL; P = 0.022) than non-anemic infants, but similar levels of ferritin and sTfR; 11% infants had IDA and 15% had AI. Anemic infants at 6 mo had higher hepcidin (median 7.9 vs 4.5 ng/mL; P = 0.016) and CRP (median 2.33 vs 0.32 mg/L; P<0.001), but lower ferritin (median 13.2 vs 25.1 μg/L; P<0.001) than non-anemic infants; 56% infants had IDA and 12% had AI. Anemic infants at 12 mo had lower ferritin (median 3.2 vs 22.2 μg/L; P<0.001) and hepcidin (median 0.9 vs 1.9 ng/mL; P = 0.019), but similar CRP levels; 48% infants had IDA and 8% had AI. Comparing anemic with non-anemic infants, plasma hepcidin was 568% higher, 405% higher and 64% lower at 3 mo, 6 mo and 12 mo, respectively, after adjusting for sex and birthweight (all p<0.01). Plasma hepcidin declined significantly with age among anemic but not non-anemic infants. Girls had 61% higher hepcidin than boys, after adjusting for age, anemia and birthweight (p<0.001).

CONCLUSION

Anemia is driven partly by inflammation early in infancy, and by iron deficiency later in infancy, with plasma hepcidin concentrations reflecting the relative contribution of each. However, there is need to better characterize the drivers of hepcidin during infancy in developing countries.

Food Insecurity and Its Relation to Psychological Well-Being Among South Indian People Living with HIV

Food insecurity (FI) and its link with depression and quality of life (QOL) among people living with HIV (PLHIV) in India are not well-documented. We analyzed cohort data from 243 male and 129 female PLHIV from Bengaluru, and found 19 % of men and 26 % of women reported moderate or severe FI over a 6-month period. Women reported higher mean depression than men, and lower mean QOL. In multivariate analyses adjusting for HIV stigma and demographic covariates, both male and female PLHIV with moderate to severe FI showed lower mean QOL than those reporting mild to no FI. Male but not female food insecure participants also had higher depression scores in adjusted regression analyses. As ART has improved the physical health of PLHIV, more effort is being invested in improving their psychological well-being. Our results suggest such interventions could benefit from including nutritional support to reduce FI among PLHIV.

Effect of early and current Helicobacter pylori infection on the risk of anaemia in 6.5-year-old Ethiopian children

BACKGROUND

Epidemiological and clinical studies in high income countries have suggested that Helicobacter pylori (H. pylori) may cause anaemia, but evidence is lacking from low income countries.We examined associations between H. pylori infection in early childhood and anaemia at the age of 6.5 years in an Ethiopian birth cohort.

METHODS

In 2011/12, 856 children (85.1 % of the 1006 original singletons in a population-based birth cohort) were followed up at age six and half. An interviewer-led questionnaire administered to mothers provided information on demographic and lifestyle variables. Haemoglobin level and red cell indices were examined using an automated haematological analyzer (Cell Dyn 1800, Abbott, USA), and stool samples analyzed for H. pylori antigen. The independent effects of H. pylori infection (measured at age 3.5 and 6.5 years) on anaemia, haemoglobin level, and red cell indices (measured at age 6.5 years) were determined using multiple logistic and linear regression.

RESULTS

The prevalence of anemia was 34.8 % (257/739), and the mean (SD) haemoglobin concentration was 11.8 (1.1) gm/dl. Current H. pylori infection at age 6.5 years was positively, though not significantly related to prevalence of anaemia (adjusted OR, 95 % CI, 1.15; 0.69, 1.93, p = 0.59). Any H. pylori infection up to age 6.5 years was significantly associated with an increased risk of anaemia at age 6.5 (adjusted OR, 95 % CI, 1.68; 1.22, 2.32, p = 0.01). A significant reduction in haemoglobin concentration and red cell indices was also observed among children who had any H. pylori infection up to age 6.5 (Hb adjusted β = -0.19, 95 % CI, -0.35 to -0.03, p = 0.01; MCV adjusted β = -2.22, 95 % CI, -3.43 to -1.01, p = 0.01; MCH adjusted β = -0.63, 95 % CI, -1.15 to - 0.12, p = 0.01; and MCHC adjusted β = -0.67, 95 % CI, -1.21 to -0.14, p = 0.01), respectively.

CONCLUSION

This study provides further evidence from a low income country that any H. pylori infection up to age 6.5 is associated with higher prevalence of anaemia, and reduction of haemoglobin level and red cell indices at age 6.5.

Characterisation of anaemia and associated factors among infants and pre-schoolers from rural India

Objective

In India, national databases indicate anaemia prevalence of 80 % among 6–35-month-old children and 58 % among 36–59-month-old children. The present study aimed to characterise anaemia and the associated factors among infants and pre-schoolers living in rural India.

Design

Multivariate logistic regression analysis of data collected prior to an intervention trial. Fe-deficiency with anaemia (IDA), Fe deficiency with no anaemia (IDNA) and anaemia without Fe deficiency were defined. Serum ferritin, soluble transferrin receptor (sTfR) and sTfR/log ferritin index were used to indicate Fe status.

Setting

Twenty-six villages of Nalgonda district, Telangana, India. Data were collected in community sites.

Participants

Four hundred and seventy-six infants (aged 6–12 months), 316 pre-schoolers (aged 29–56 months) and their mothers.

Results

Prevalence of anaemia among infants and pre-schoolers was 66·4 and 47·8 %, prevalence of IDA was 52·2 and 42·1 %, prevalence of IDNA was 22·2 and 29·8 %, prevalence of anaemia without Fe deficiency was 14·2 and 5·7 %. Among infants, anaemia was positively associated with maternal anaemia (OR=3·31; 95 % CI 2·10, 5·23;P<0·001), and sTfR/log ferritin index (OR=2·21; 95 % CI 1·39, 3·54;P=0·001). Among pre-schoolers, anaemia was positively associated with maternal anaemia (OR=3·77; 95 % CI 1·94, 7·30;P<0·001), sTfR/log ferritin index (OR=5·29; 95 % CI 2·67, 10·50;P<0·001), high C-reactive protein (OR=4·39; 95 % CI 1·91, 10·06,P<0·001) and young age (29–35 months: OR=1·92; 05 % CI 1·18, 3·13,P=0·009).

Conclusions

Anaemia prevalence continues to be high among infants and pre-schoolers in rural India. Based on sTfR/ferritin index, Fe deficiency is a major factor associated with anaemia. Anaemia is also associated with inflammation among pre-schoolers and with maternal anaemia among infants and pre-schoolers, illustrating the importance of understanding the aetiology of anaemia in designing effective control strategies.

Positive Effect of Large Birth Intervals on Early Childhood Hemoglobin Levels in Africa Is Limited to Girls: Cross-Sectional DHS Study

Background

Short birth intervals are independently associated with increased risk of adverse maternal, perinatal, infant and child outcomes. Anemia in children, which is highly prevalent in Africa, is associated with an increased risk of morbidity and mortality. Birth spacing is advocated as a tool to reduce anemia in preschool African children, but the role of gender differences and contextual factors has been neglected. The present study aims to determine to what extent the length of preceding birth interval influences the hemoglobin levels of African preschool children in general, as well as for boys and girls separately, and which contextual factors thereby play a crucial role.

Methods and Findings

This cross-sectional study uses data from Demographic and Health Surveys (DHS) conducted between 2003 and 2011 in 20 African countries. All preschool children aged 6–59 months with a valid hemoglobin measurement and a preceding birth interval of 7–72 months as well as their corresponding multigravida mothers aged 21–49 years were included in the study. Hemoglobin levels of children and mothers were measured in g/l, while birth intervals were calculated as months difference between consecutive births. Multivariate analyses were done to examine the relationship between length of preceding birth interval and child hemoglobin levels, adjusted for factors at the individual, household, community, district, and country level. A positive linear relationship was observed between birth interval and the 49,260 included children’s hemoglobin level, whereby age and sex of the child, hemoglobin level of the mother, household wealth, mother’s education and urbanization of place of residence also showed positive associations. In the interaction models, the effect of a month increase in birth interval is associated with an average increase of 0.025 g/l in hemoglobin level (P = 0.001) in girls, while for boys the effect was not significant. In addition, for girls, the effect of length of preceding birth interval was highest in young mothers and mothers with higher hemoglobin levels, while for boys, the highest effect was noticed for those living in more highly educated regions. Finally, significantly higher hemoglobin levels of girls compared to boys were observed at birth but with increasing age, the sex difference in hemoglobin level gradually becomes smaller.

Conclusions

A longer birth interval has a modest positive effect on early childhood hemoglobin levels of girls, and this effect is strongest when their mothers are in their early twenties and have a high hemoglobin level. Remarkably, although the physiological iron requirement is higher for boys than girls, birth spacing has little influence on hemoglobin levels of preschool boys. We speculate that the preference for male offspring in large parts of Africa significantly influences nutritional patterns of African preschool boys and girls, and as such also determines the different effect of birth spacing. Finally, gender aspects should be considered in intervention programs that aim to improve anemia in African children.

Factors Associated with Anemia among Children Aged 6-23 Months Attending Growth Monitoring at Tsitsika Health Center, Wag-Himra Zone, Northeast Ethiopia

Background. Globally, about 47.4% of children under five are suffering from anemia. In Ethiopia, 60.9% of children under two years are suffering from anemia. Anemia during infancy and young childhood period is associated with poor health and impaired cognitive development, leading to reduced academic achievement and earnings potential in their adulthood life. However, there is scarcity of information showing the magnitude of iron deficiency anemia among young children in Ethiopia. Therefore, this study aimed at assessing prevalence and associated factors of iron deficiency anemia among children under two (6-23 months). Methods. Institution based cross-sectional study was carried out from March to May, 2014, at Tsitsika Health Center in Wag-Himra Zone, Northeast Ethiopia. Systematic random sampling technique was employed. Automated hemoglobin machine was used to determine the hemoglobin level. Socioeconomic and demographic data were collected by using a pretested and structured questionnaire. Binary logistic regression analysis was used to identify associated factors and odds ratio with 95% CI was computed to assess the strength of association. Results. Total of 347 children participated in this study. The overall prevalence of anemia was 66.6%. In multivariate logistic regression analysis, male sex (AOR = 3.1 (95% CI: 1.60-5.81)), 9-11 months of age (AOR = 9.6 (95% CI: 3.61-25.47)), poor dietary diversity (AOR = 3.2 (95% CI: 1.35-7.38)), stunting (AOR = 2.7 (95% CI: 1.20-6.05)), diarrhea (AOR = 4.9 (1.63-14.59)), no formal education (AOR = 2.6 (95% CI: 1.26-5.27)), early initiation of complementary food (AOR = 11.1 (95% CI: 4.08-30.31)), and lowest wealth quintile (AOR = 3.0 (95% CI: 1.01-8.88)) were significantly associated with anemia. Conclusion. The overall prevalence of anemia among children who aged 6-23 months has sever public health importance in the study area. Integrated efforts need to be prioritized to improve health as well as appropriate infant and young child feeding practice among children under.

Bayesian random effects modelling with application to childhood anaemia in Malawi

BACKGROUND

Epidemiological studies in Malawi on child anaemia have neglected the community spatial effect to childhood anaemia. Neglecting the community spatial effect in the model ignores the influence of unobserved or unmeasured contextual variables, and at the same time the resultant model may under estimate model parameter standard errors which can result in erroneous significance of covariates. We aimed at investigating risk factors of childhood anaemia in Malawi with focus on geographical spatial effect.

METHODS

We adopted a Bayesian random effect model for child anaemia with district as spatial effect using the 2010 Malawi demographic healthy survey data. We fitted the binary logistic model for the two categories outcome (anaemia (Hb < 11), and no anaemia (Hb ≥ 11)). Continuous covariates were modelled by the penalized splines and spatial effects were smoothed by the two dimensional spline.

RESULTS

Residual spatial patterns reveal Nsanje, Chikhwawa, Salima, Nkhota-kota, Mangochi and Machinga increasing the risk of childhood anaemia. Karonga, Chitipa, Rumphi, Mzimba, Ntchisi, and Chiradzulu reduce the risk of childhood anaemia. Known determinants such as maternal anaemia, child stunting, and child fever, have a positive effect on child anaemia. Furthermore childhood anaemia decreases with child age. It also decreases with wealth index. There is a U relationship between child anaemia and mother age.

CONCLUSION

Strategies in childhood anaemia control should be tailored to local conditions, taking into account the specific etiology and prevalence of anaemia.

Prevalence and severity of anaemia stratified by age and gender in rural India

Anaemia is a major public health problem in India. Although nearly three quarters of the Indian population live in rural areas, the epidemiology of anaemia in rural settings is not well known. We performed a retrospective observational study using routine clinical data from patients attending the out-patient clinics of a rural hospital in India from June 2011 to August 2014. The study included 73,795 determinations of haemoglobin. 49.5% of patients were female. The median haemoglobin concentration was 11.3 g/dL (interquartile range (IQR), 9.8–12.4) in females and 12.5 g/dL (IQR, 10.6–14.2) in males. Anaemia was present in the majority of children <10 years, women after puberty, and older adults. Children <5 years had the highest prevalence of anaemia, especially children aged 1-2 years. The high proportion of microcytic anaemia and the fact that gender differences were only seen after the menarche period in women suggest that iron deficiency was the main cause of anaemia. However, the prevalence of normocytic anaemia increased with age. The results of this study can be used by public health programmes to design target interventions aimed at reducing the huge burden of anaemia in India. Further studies are needed to clarify the aetiology of anaemia among older adults.

Household food insecurity and dietary diversity as correlates of maternal and child undernutrition in rural Cambodia

OBJECTIVES

To assess household food insecurity and dietary diversity as correlates of maternal and child anthropometric status and anemia in rural Cambodia.

METHODS

Trained interviewers administered a survey to 900 households in four rural districts of Prey Veng, Cambodia. The Household Food Insecurity Access Scale (HFIAS) and Household Dietary Diversity Score (HDDS) were used to assess household food insecurity and dietary diversity. The height, weight and hemoglobin concentration of the mother and youngest child under 5 years in each household were measured. Multivariate logistic regression models were constructed to assess the association between household food insecurity and dietary diversity, and child stunting and wasting, maternal thinness, maternal and child anemia.

RESULTS

The mean (s.d.) HFIAS and HDDS scores were 5.3 (3.9) and 4.7 (1.6), respectively. The respective prevalences of mild, moderate and severe food insecurity were 33, 37 and 12%. Maternal thinness, child stunting and child wasting were present in 14.6, 25.4 and 8.1% of respondents, respectively. The risk of maternal thinness, but not child stunting or wasting, increased as the severity of household food insecurity increased. Household food insecurity was also positively associated with maternal, but not child, anemia. Household dietary diversity status was not significantly associated with any of the outcomes we assessed.

CONCLUSIONS

Efforts to improve household food security are important as a means of promoting maternal nutritional status; however, additional research is needed to better understand the role of other factors that are driving the burden of child undernutrition in Cambodia.

Extent of Anaemia among Preschool Children in EAG States, India: A Challenge to Policy Makers

Background. India is the highest contributor to child anemia. About 89 million children in India are anemic. The study determines the factors that contributed to child anemia and examines the role of the existing programs in reducing the prevalence of child anemia particularly in the EAG states. Methods. The data from the latest round of the National Family Health Survey (NFHS-3) is used. Simple bivariate and multinomial logistics regression analyses are used. Results. About 70% children are anemic in all the EAG states. The prevalence of severe anemia is the highest (6.7%) in Rajasthan followed by Uttar Pradesh (3.6%) and Madhya Pradesh (3.4%). Children aged 12 to 17 months are significantly seven times (RR = 7.99, P < 0.001) more likely to be severely anemic compared to children of 36 to 59 months. Children of severely anemic mothers are also found to be more severely anemic (RR = 15.97, P < 0.001) than the children of not anemic mothers. Conclusions. The study reveals that the existing government program fails to control anemia among preschool children in the backward states of India. Therefore, there is an urgent need for monitoring of program in regular interval, particularly for EAG states to reduce the prevalence of anemia among preschool children.

Food insecurity and nutritional biomarkers in relation to stature in Inuit children from Nunavik

OBJECTIVES

Inuit in Canada experience alarming levels of food insecurity, but nutritional and physiological consequences are poorly documented, especially in school-age children. The objective of this study was to assess the relation of food insecurity to iron deficiency and stature in school-aged Inuit children from Nunavik (Northern Quebec).

METHODS

Food insecurity, iron deficiency, and stature were assessed in a cohort of children. Food insecurity was determined by interviewing the children's mothers. Multiple logistic regression was used to evaluate the association of food insecurity to iron deficiency and short stature. We defined short stature as a height in the lowest tertile for age and sex, based on Canadian growth charts. The relation of food insecurity to height (cm) was analyzed with a general linear model. Statistical models controlled for age, sex, normal/overweight/obese status, prenatal lead exposure and postnatal polychlorinated biphenyls exposure.

RESULTS

Half of the children (49.7%, n=145) were food insecure, while one third were iron depleted, 12.6% had anaemia, and 8.7% had iron-deficiency anaemia. The multivariate odds ratio of anaemia was 1.82 (95% CI: 0.97, 3.42, p=0.06) for food-insecure children. Prevalence of short stature was 18.7%. Food-insecure children were an average of 2 cm shorter (95% CI: -0.48, -3.17) than food-secure children (p<0.01).

CONCLUSION

In this population, food-insecure children have greater burdens of nutritional deficiencies and slower linear growth. Considering the high prevalence of food insecurity among Inuit children in Nunavik, nutritional deficiencies and adverse effects on development should be carefully monitored.

Disparity of anemia prevalence and associated factors among rural to urban migrant and the local children under two years old: a population based cross-sectional study in Pinghu, China

BACKGROUND

Number of internal rural to urban migrant children in China increased rapidly. The disparity of anemia prevalence among them and children of local permanent residents has been reported, both in big and middle-size cities. There has been no population-based study to explore the associated factors on feeding behaviors in small size cities of China. This study aimed to identify whether there was a difference in the prevalence of anemia between children of rural to urban migrant families and local children under 2 years old in a small coastal city in China, and to identify the associated factors of any observed difference.

METHODS

A community-based, cross-sectional survey was conducted in Pinghu, a newly-developing city in Zhejiang Province, China, among the caregivers of 988 children (667 who were identified as children of migrants and 321 locals) aged 6-23 months. Disparity of anemia prevalence were reported. Association between anemia prevalence and socio-economic status and feeding behaviors were explored among two groups respectively.

RESULTS

Anemia prevalence among the migrant and local children was 36.6% and 18.7% respectively (aPR 1.86, 95% CI 1. 40 to 2.47). Results from adjusted Poisson models revealed: having elder sibling/s were found as an associated factor of anemia with the aPR 1.47 (95% CI 1.16 to 1.87) among migrant children and 2.58 (95% CI 1.37 to 4.58) among local ones; anemia status was associated with continued breastfeeding at 6 months (aPR = 1.57, 95% CI 1.15 to 2.14) and lack of iron-rich and/or iron-fortified foods (aPR = 0.68, 95% CI 0.50 to 0.89) among the migrant children but not among local ones.

CONCLUSION

Anemia was more prevalent among migrant children, especially those aged 6-11 months. Dislike their local counterparts, migrant children were more vulnerable at early life and seemed sensitive to feeding behaviors, such as, over reliance on breastfeeding for nutrition after aged 6 months, lack of iron-rich and/or iron-fortified foods. Future strategies to narrow the gap of anemia prevalence between the migrant and local children should target more susceptible groups and through improvement of feeding practices among younger children in those kinds of newly-developing areas of China.

Poor complementary feeding practices and high anaemia prevalence among infants and young children in rural central and western China

BACKGROUND/OBJECTIVES

Infant and young child feeding (IYCF) has not been documented in central and western China, where anaemia is prevalent. To support policy advocacy, we assessed IYCF and anaemia there using standardized methods.

SUBJECTS/METHODS

A community-based, cross-sectional survey of 2244 children aged 6-23 months in 26 counties of 12 provinces. Analysis of associations between haemoglobin concentration (HC), IYCF indicators and other variables using crude and multivariate techniques.

RESULTS

Only 41.6% of those surveyed consumed a minimum acceptable diet. Fewer still-breastfeeding than non-breastfeeding children consumed the recommended minimum dietary diversity (51.7 versus 71.9%; P<0.001), meal frequency (57.7% v. 81.5%; P<0.001) or iron-rich food (63.3% v. 78.9%; P<0.001). Anaemia (51.3% overall) fell with age but was significantly associated with male sex, extreme poverty, minority ethnicity, breastfeeding and higher altitude. Dietary diversity, iron intake, growth monitoring and being left behind by out-migrating parents were protective against anaemia. A structural equation model demonstrated associations between IYCF, HC and other variables. Meal frequency, iron intake and altitude were directly and positively associated with HC; dietary diversity was indirectly associated. Health service uptake was not associated. Continued breastfeeding was directly associated with poor IYCF and indirectly with reduced HC, as were having a sibling and poor maternal education.

CONCLUSION

Infant and young child anaemia is highly prevalent and IYCF is poor in rural central and western China. Continued breastfeeding and certain other variables indicate risk of poor IYCF and anaemia. Major policy commitment to reducing iron deficiency and improving IYCF is needed for China's rural poor.

Low Hemoglobin Level a Risk Factor for Acute Lower Respiratory Tract Infections (ALRTI) in Children

BACKGROUND

Acute lower respiratory tract infection is a major cause of death in under five years of age, and anemia is the commonest co-factor in pediatric patients seeking medical advice especially in developing countries.

AIM

To analyze whether a low hemoglobin level is a risk factor for acute lower respiratory tract infections (ALRTI) in children.

MATERIALS AND METHODS

Prospective case control study on 220 children (110 cases and controls each) was carried out in our children's hospital (G.B. Pant Hospital), an associated hospital of Government Medical College Srinagar, of Kashmir Northern India. All patients between the age of 1 month to 5 years of age who fulfilled the inclusion criteria were included. We used WHO criteria to diagnose ALRTI among the cases, and age and sex matched patients who did not have respiratory complaints were kept as controls. Patients who had congenital heart diseases, tuberculosis, malignancies, or dysmorphic features were excluded from the study. All patients were subjected to detailed history and through clinical examination followed by investigations like complete blood count (CBC), peripheral blood film (PBF) smear, blood culture and sensitivity test, X-ray chest, serum iron and iron binding capacity were done in all cases.

RESULTS

Our study had slightly male preponderance 57.3% in study group and 59.1% in control group. Maximum number of children were between 3 months and 23 months both in the study (80.9%) as well as in the control (81.8%) group. In this study hemoglobin level <11 gm/dl was considered low. Mean Hb level was 8.8 gm/dl in the study group and 11.6 gm/dl in the control group. Anemia was found in 71 (64.5%) cases in the study group and in 31 (28.2%) cases in the control group. Anemic patients were found to be 4.6 times more susceptible to ALRTI in our study (Odds Ratio was 4.63), p-value <0.01. Iron deficiency was found in 78.9% of total anemic cases in the study group, p-value <0.01. In the study group, the mean serum iron level was 35.3 mcg/dl in the anemic cases and 57.1 mcg/dl in the non-anemic cases. while in the control group, these values were 52.4 mcg/dl and 62.6% mcg/dl respectively, (p-value ,<0.01).

CONCLUSION

Anemia, predominantly iron deficiency anemia, was significantly found in ALTRI patients, and these patients were found to be 4.6 times more susceptible to ALRTI. Early and accurate diagnosis of anemia in children suffering from various ailments in particular to ALRTI will serve the mankind in a better way.

A systematic analysis of global anemia burden from 1990 to 2010

Previous studies of anemia epidemiology have been geographically limited with little detail about severity or etiology. Using publicly available data, we estimated mild, moderate, and severe anemia from 1990 to 2010 for 187 countries, both sexes, and 20 age groups. We then performed cause-specific attribution to 17 conditions using data from the Global Burden of Diseases, Injuries and Risk Factors (GBD) 2010 Study. Global anemia prevalence in 2010 was 32.9%, causing 68.36 (95% uncertainty interval [UI], 40.98 to 107.54) million years lived with disability (8.8% of total for all conditions [95% UI, 6.3% to 11.7%]). Prevalence dropped for both sexes from 1990 to 2010, although more for males. Prevalence in females was higher in most regions and age groups. South Asia and Central, West, and East sub-Saharan Africa had the highest burden, while East, Southeast, and South Asia saw the greatest reductions. Iron-deficiency anemia was the top cause globally, although 10 different conditions were among the top 3 in regional rankings. Malaria, schistosomiasis, and chronic kidney disease-related anemia were the only conditions to increase in prevalence. Hemoglobinopathies made significant contributions in most populations. Burden was highest in children under age 5, the only age groups with negative trends from 1990 to 2010.

Association between farming and chronic energy deficiency in rural South India

Objective

To examine factors associated with chronic energy deficiency (CED) and anaemia in disadvantaged Indian adults who are mostly involved in subsistence farming.

Design

A cross-sectional study in which we collected information on socio-demographic factors, physical activity, anthropometry, blood haemoglobin concentration, and daily household food intake. These data were used to calculate body mass index (BMI), basal metabolic rate (BMR), daily energy expenditure, and energy and nutrient intake. Multivariable backward stepwise logistic regression was used to assess socioeconomic and lifestyle factors associated with CED (defined as BMI<18 kg/m²) and anaemia.

Setting

The study was conducted in 12 villages, in the Rishi Valley, Andhra Pradesh, India.

Subjects

Individuals aged 18 years and above, residing in the 12 villages, were eligible to participate.

Results

Data were available for 1178 individuals (45% male, median age 36 years (inter quartile range (IQR 27–50)). The prevalence of CED (38%) and anaemia (25%) was high. Farming was associated with CED in women (2.20, 95% CI: 1.39–3.49) and men (1.71, 95% CI: (1.06–2.74). Low income was also significantly associated with CED, while not completing high school was positively associated with anaemia. Median iron intake was high: 35.7 mg/day (IQR 26–46) in women and 43.4 mg/day (IQR 34–55) in men.

Conclusions

Farming is an important risk factor associated with CED in this rural Indian population and low dietary iron is not the main cause of anaemia. Better farming practice may help to reduce CED in this population.

"How often? How much? Where from?" knowledge, attitudes, and practices of mothers and health workers to iron supplementation program for children under five in rural Tamil Nadu, south India

Iron deficiency anemia (IDA) affects 70% of under-5 children in India. The primary prevention strategy is regular iron supplementation. Little is known about what helps families adhere to daily iron supplementation. Our study explored the knowledge, attitudes, and practices of mothers and village health workers (VHWs) involved in a community health program in one hill district of Tamil Nadu. We conducted 30 semistructured interviews and 3 group discussions involving mothers, VHWs, and community stakeholders. Knowledge of IDA was widespread, yet no children were receiving the iron supplementation as recommended. The main determinants to adherence included the perception of its need, the ease of access, and the activity of VHWs. Preventive care requiring daily supplements is challenging. Our study suggests that increasing community awareness of mild anemia, simplifying dosage instructions, and further strengthening the supportive environment for VHWs would help in reducing the prevalence of IDA.

Prevalence of anemia in pregnant women and its effect on neonatal outcomes in Northeast India

OBJECTIVES

To determine the prevalence of anemia in pregnant women and characterize its effect on neonatal outcome in Northeast India.

PATIENTS AND METHODS

Four hundred and seventy mothers and their newborn infants during a one month period were included. The association between maternal hemoglobin (Hb) at delivery and neonatal outcomes were determined.

RESULTS

Anemia (Hb < 110 g/L) was present in 421 (89.6%) mothers with 35 (8.3%) having severe anemia(Hb < 70 g/L). After adjusting for maternal and neonatal variables, each 10 g/L decrease in maternal Hb was associated with 0.18 week decrease in gestational length (p = 0.003) and 21 g decrease in birth weight (p = 0.093). Severe maternal anemia was associated with 0.63 week (95% CI, 0.03-1.23week) shorter gestation, 481 g (95% CI, 305-658 g) lower birth weight and 89% increased risk of small-for-gestation (OR 1.89, 95% CI, 1.25-2.86)in the offspring, compared with those born to mothers without anemia (p < 0.001).

CONCLUSION

Maternal anemia was highly prevalentin this population. Lower gestational age and birth weight, and increased risk of small-for-gestation were associated with maternal anemia, especially when maternal Hb was <80 g/L. Maternal anemia needs urgent attention to improve neonatal outcome in this population.

Effect of daily iron supplementation on health in children aged 4-23 months: a systematic review and meta-analysis of randomised controlled trials

BACKGROUND

About 47% of preschool children worldwide are anaemic. Daily oral iron supplementation is a commonly recommended intervention for treatment and prevention of anaemia, but the efficacy and safety of iron supplementation programmes is debated. Thus, we systematically reviewed the evidence for benefit and safety of daily iron supplementation in children aged 4-23 months.

METHODS

We searched Scopus and Medline, from inception to Feb 5, 2013, WHO databases, theses repositories, grey literature, and references. Randomised controlled trials that assigned children 4-23 months of age to daily oral iron supplementation versus control were eligible. We calculated mean difference (MD) or standard MD (SMD) for continuous variables, risk ratios for dichotomous data, and rate ratios for rates. We quantified heterogeneity with the I(2) test and synthesised all data with a random-effects model. This review is registered with the International Prospective Register of Systematic Reviews, number CRD42011001208.

FINDINGS

Of 9533 citations identified by the search strategy, 49 articles from 35 studies were eligible; these trials included 42,306 children. Only nine studies were judged to be at low risk of bias. In children receiving iron supplements, the risk ratio for anaemia was 0·61 (95% CI 0·50-0·74; 17 studies, n=4825), for iron deficiency was 0·30 (0·15-0·60; nine studies, n=2464), and for iron deficiency anaemia was 0·14 (0·10-0·22; six studies, n=2145). We identified no evidence of difference in mental (MD 1·65, 95% CI -0·63 to 3·94; six studies, n=1093) or psychomotor development (1·05, -1·36 to 3·46; six studies, n=1086). We noted no significant differences in final length or length-for-age, or final weight or weight-for-age. Children randomised to iron had slightly lesser length (SMD -0·83, -1·53 to -0·12; eight studies, n=868) and weight gain (-1·12, -1·19 to -0·33) over the course of the studies. Vomiting (risk ratio 1·38, 95% CI 1·10-1·73) and fever (1·16, 1·02-1·31) were more prevalent in children receiving iron.

INTERPRETATION

In children aged 4-23 months, daily iron supplementation effectively reduces anaemia. However, the adverse effect profile of iron supplements and effects on development and growth are uncertain. Adequately powered trials are needed to establish the non-haematological benefits and risks from iron supplementation in this group.

FUNDING

Victoria Fellowship (Government of Victoria, Australia); CRB Blackburn Scholarship (Royal Australasian College of Physicans); Overseas Research Experience Scholarship, University of Melbourne.

Socioeconomic determinants of iron-deficiency anemia among children aged 6 to 59 months in India

The extent of anemia and its socioeconomic determinants among the preschool children (6-59 months old) in India have been studied in this article. Relevant data are taken from the third round of the National Family Health Survey. The initial analysis reveals some interesting features. The most affected children are in the age-group of 6 to 23 months. Beyond this age a decreasing trend is observed up to the age of 48 to 59 months. The highest and the lowest prevalence of anemia have been found to be in the central and the northeast zones, respectively. The vulnerable groups are the children of illiterate parents and those belonging to the poor families in the rural areas. Categorical logistic regression also confirms that status of literacy and wealth of parents have strong negative association with the status of anemia of the children.

Biofortification of mungbean (Vigna radiata) as a whole food to enhance human health

Mungbean (Vigna radiata (L.) R. Wilczek var. radiata) is one of the most important pulse crops grown in South, East and Southeast Asia. It provides significant amounts of protein (240 g kg(-1)) and carbohydrate (630 g kg(-1)) and a range of micronutrients in diets. Mungbean protein and carbohydrate are easily digestible and create less flatulence than proteins derived from other legumes. In addition, mungbean is lower in phytic acid (72% of total phosphorus content) than pigeonpea (Cajanus cajan L. Millsp.), soybean (Glycine max L.) and cereals; phytic acid is commonly found in cereal and legume crops and has a negative impact on iron and zinc bioavailability in plant-based diets. Owing to its palatable taste and nutritional quality, mungbean has been used as an iron-rich whole food source for baby food. The wide genetic variability of mineral concentrations (e.g. 0.03-0.06 g Fe kg(-1), 0.02-0.04 g Zn kg(-1)) in mungbean indicates possibilities to improve its micronutrient content through biofortification. Therefore biofortification of existing mungbean varieties has great potential for enhancing the nutritional quality of diets in South and Southeast Asia, where protein and micronutrient malnutrition are among the highest in the world. This review paper discusses the importance of mungbean in agricultural production and traditional diets and the potential of enhancing the nutritional quality of mungbean through breeding and other means, including agronomic practices.

Prevalence of anemia and associated factors among indigenous children in Brazil: results from the First National Survey of Indigenous People's Health and Nutrition

BACKGROUND

Anemia is the most prevalent nutritional deficiency globally, affecting about a quarter of the world population. In Brazil, about one-fifth of children under five years of age are anemic. Previous case studies indicate prevalence rates much higher among indigenous peoples in the country. The First National Survey of Indigenous People's Health and Nutrition in Brazil, conducted in 2008-2009, was the first survey based on a nationwide representative sample to study the prevalence of anemia and associated factors among indigenous children in Brazil.

METHODS

The survey assessed the health and nutritional status of indigenous children < 5 years of age based on a representative sample of major Brazilian geopolitical regions. A stratified probabilistic sampling was carried out for indigenous villages. Within villages, children < 5 years of age in sampled households were included in the study. Prevalence rates of anemia were calculated for independent variables and hierarchical multivariate analysis were conducted to assess associations.

RESULTS

Evaluation of hemoglobin levels was conducted for 5,397 children (88.1% of the total sample). The overall prevalence of anemia was 51.2%. Higher risk of presenting anemia was documented for boys, lower maternal schooling, lower household socioeconomic status, poorer sanitary conditions, presence of maternal anemia, and anthropometric deficits. Regional differences were observed, with the highest rate being observed in the North.

CONCLUSIONS

The prevalence rates of anemia in indigenous children were approximately double than those reported for non-indigenous Brazilian children in the same age group. Similarly notable differences in the occurrence of anemia in indigenous and non-indigenous children have been reported for other countries. Deeper knowledge about the etiology of anemia in indigenous children in Brazil is essential to its proper treatment and prevention.

Plasma ferritin and indices of oxidative stress in Helicobacter pylori infection among schoolchildren

OBJECTIVE

Iron deficiency is one of the most common causes for anemia in Indian children. The present study was performed to evaluate the prooxidant status and ferritin levels in Helicobacter pylori-infected schoolchildren.

METHODS

The present study included healthy controls (control group), H pylori-infected children (group I), and H pylori-uninfected children with iron deficiency (group II). Group I was further subdivided into group Ia and Ib, depending on the presence or absence of iron deficiency, respectively. Serum levels of protein carbonyls, malondialdehyde (MDA), ferritin, total protein, and albumin were evaluated and compared among study groups.

RESULTS

In H pylori-infected schoolchildren, serum MDA and protein carbonyls were significantly increased and ferritin levels were significantly decreased compared with the controls and group II. In group I, irrespective of presence and absence of iron deficiency, MDA and protein carbonyls were significantly increased compared with group II. In anemic H pylori-infected schoolchildren, levels of serum total protein were significantly decreased compared with healthy controls. In H pylori-infected patients, MDA was found to have a significant negative correlation with ferritin levels and total protein by partial correlation analysis.

CONCLUSIONS

An increased level of oxidative stress was found in H pylori-infected schoolchildren. Furthermore, the findings from the present study indicate that prolonged oxidative stress may enhance protein degradation in children.