Factors Associated with Growth Retardation in Children Suffering from Sickle Cell Anemia: First Report from Central Africa

Prevalence of orofacial alterations in patients with sickle-cell disease: Systematic review and meta-analysis

OBJECTIVE

The aim of this study was to identify the prevalence of orofacial alterations in sickle-cell disease (SCD) and to compare it with the general population.

STUDY DESIGN

This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines. The search was conducted on PubMed, Embase, Scientific Electronic Library Online, Web of Science, Cochrane Library, gray literature, and references of the included articles.

RESULTS

A total of 770 records were found, and 28 studies were selected. In SCD, the prevalence of decreased bone density was 57% (95% CI: 35%-80%), with Q: P < .01 and I² = 95%; for stepladder pattern was 30% (IC: 13%-47%), Q: P < .01 and I²: 93%; for delayed eruption was 20% (95% CI: 6%-34%), with Q: P < .01 and I² = 86, Q: P < .01 and I² = 99%; and for malocclusion, 66% (95% CI: 39%-92%), Q: P < .01 and I² = 98%. A high risk of bias was observed in relation to the sample size of the studies. A limited number of articles compared the prevalence of orofacial alterations in patients with SCD and healthy individuals.

CONCLUSIONS

Decreased bone density, malocclusion, orofacial pain, tooth necrosis, eruption delay, periodontal disease, and neuropathies may be present in patients with SCD with variable prevalence.

Describing the growth and nutritional status of sickle cell disease children and adolescents with reference to WHO growth standards in Cameroon

BACKGROUND

Sickle cell disease (SCD) is a chronic disease with many complications among which is growth retardation. Here, we described the growth and nutritional status patterns of children with SCD and adolescents living in Douala, Cameroon.

METHODS

This cross-sectional study took place at the sickle cell treatment center of Douala Laquintinie Hospital from November 2015 to April 2016. The sociodemographic and anthropometric information of each SCD patient was determined, and then used for computing z-score indexes (weight for age, weight for height, body mass index for height, and height for age). The different indexes were used to determine the prevalence of malnutrition forms (stunting, wasting, underweight, and overweight/obesity) and compared to WHO standards by gender and age.

RESULTS

A total of 208 children and adolescents participated in the study. The mean age was 8 years (±5) and the median age was 7 years. Males accounted for 53.4% of cases, giving a sex ratio of 1:1.1. The proportions of wasting, stunting, underweight, and overweight/obesity in the overall population were 7.1% (n = 15), 9.1% (n = 19), 3.6% (n = 5) and 3.3% (n = 7) respectively. In children under 5, wasting, stunting, underweight, and overweight/obesity were noted in 1.4% (n = 1), 9.5% (n = 7), 1.4% (n = 1), and 5.4% (n = 4) respectively. In patients aged 5 years and above, a proportion of 10.5% (n = 14) was wasted, 9.0% (n = 12) were stunted, 5.9% (n = 4) were underweight and 2.2% (n = 7) were overweight/obese. The growth curve of children under five in our study was superimposable to the WHO standard growth curve. In children older than 5 years, the left shift for stunting was more pronounced for boys compared to girls.

CONCLUSION

Nine percent of children and adolescents with SCD are stunted. The growth deficit appeared to be higher in patients aged 5 years and above, more particularly in boys than girls. Overweight/obesity was uncommon in our series. More robust research designs and statistical analyses are needed to confirm or refute these findings.

Association of Iron-Deficiency Anemia and Non-Iron-Deficiency Anemia with Neurobehavioral Development in Children Aged 6-24 Months

(1) Background: Anemia has comprehensive adverse effects on the growth and development of children. In this study, we analyzed the potential effects of different types of anemia on early-life neurobehavioral development. (2) Methods: A total of 2601 children aged 6-24 months, whose parents agreed to participate in this study, underwent routine blood tests and neurobehavioral development assessment. The children's parents or other primary caregivers were interviewed with a face-to-face questionnaire at the time of enrollment in the study. Anemia was determined by hemoglobin < 110 g/L and classified into iron-deficiency and non-iron-deficiency anemia according to the levels of serum ferritin, C-reactive protein, and alpha-1-acid glycoprotein. Neurobehavioral development was assessed by the China Developmental Scale for Children and divided into five domains: gross motor, fine movement, adaptability, language, and social behavior. The development quotient (DQ) was used to measure the level of total neurobehavioral development and each domain of neurobehavioral development. (3) Results: The prevalence of anemia in children aged 6-24 months was 26.45%, of which iron-deficiency anemia only accounted for 27.33%. Compared with children without anemia, those with iron-deficiency anemia had a significantly lower developmental quotient (DQ) for total neurobehavioral development and gross motor and adaptability development. The partial regression coefficients were -1.33 (95% CI -2.36, -0.29; p = 0.012), -1.88 (95% CI -3.74, -0.03; p = 0.047), and 1.48 (95% CI -2.92, -0.05; p = 0.042), respectively. Children with non-iron-deficiency anemia had significantly lower DQ for total neurobehavioral development and gross motor and fine movement development than those without anemia. The partial regression coefficients were -0.94 (95% CI -1.64, -0.25; p = 0.008), -1.25 (95% CI -2.48, -0.03; p = 0.044), and -1.18 (95% CI -2.15, -0.21; p = 0.017), respectively. There were no statistically significant differences in total neurobehavioral development and the five domains of neurobehavioral development between children with non-iron-deficiency and iron-deficiency anemia. The partial β values were 0.40 (95% CI -1.53, 2.33; p = 0.684), 0.21 (95% CI -1.39, 1.81; p = 0.795), 0.63 (95% CI -1.03, 2.28; p = 0.457), 0.16 (95% CI -1.78, 2.10; p = 0.871), 0.35 (95% CI -1.32, 2.01; p = 0.684), and 0.34 (95% CI -0.77, 1.46; p = 0.545), respectively. (4) Conclusions: Both iron-deficiency anemia and non-iron-deficiency anemia were negatively correlated with the neurobehavioral development of children. Negative correlations were found between iron-deficiency anemia and gross motor and adaptability development and between non-iron-deficiency anemia and gross motor and fine movement development.

Nutritional and Hematological Status of Sudanese Women of Childbearing Age with Steady-state Sickle Cell Anemia

OBJECTIVES

We sought to investigate the nutritional and hematological status of Sudanese women of childbearing age with sickle cell anemia (SCA). Anthropometry and hematology were used to assess nutritional status and health and disease conditions, respectively.

METHODS

Women with steady-state (HbSS, n = 39; age = 19.0±2.7) and without (HbAA, n = 36; age, 19.8±2.7) SCA were recruited during a routine visit to the Hematology Clinic, Ibn-Auf Teaching Hospital, Khartoum, Sudan.

RESULTS

The two groups of women lived in similar environmental conditions and ate similar diets three times a day. However, despite taking regular meals, the women with sickle anemia were thinner and lighter (p < 0.001) and shorter (p = 0.002) compared with those who do not have the disease. Also, they had higher levels of mean corpuscular hemoglobin (Hb) concentration and white cell count (p < 0.001), mean corpuscular volume (p = 0.003), and platelet (p = 0.002) and lower packed cell volume and Hb (p < 0.001). There was no difference in levels of anthropometric and hematological variables between the hydroxyurea treated and untreated SCA patients (p > 0.050).

CONCLUSIONS

The low anthropometric (height, weight, and body mass index) and abnormal hematological values in the women with SCA in steady-state reflect sustained nutritional insults inflected by the disease and poverty. Tailored nutritional counseling/advice must be an integral part of managing patients with SCA. Such advice is particularly vital for women of childbearing age because of the adverse effects of prepregnancy nutritional deficiency on outcomes.

Nutritional perspectives on sickle cell disease in Africa: a systematic review

BACKGROUND

Sickle cell disease (SCD) is an inherited blood disorder that predominantly affects individuals in sub-Saharan Africa. However, research that elucidates links between SCD pathophysiology and nutritional status in African patients is lacking. This systematic review aimed to assess the landscape of studies in sub-Saharan Africa that focused on nutritional aspects of SCD, and highlights gaps in knowledge that could inform priority-setting for future research.

METHODS

The study was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Inclusion criteria comprised original, peer-reviewed research published between January 1995 and November 2020 involving individuals in Africa with any phenotypic variant of SCD and at least one nutritional status outcome. Nutritional status outcomes were defined as those that assessed dietary intakes, growth/anthropometry, or nutritional biomarkers. Databases used were Ovid Embase, Medline, Biosis and Web of Science.

RESULTS

The search returned 526 articles, of which 76 were included in the final analyses. Most investigations (67%) were conducted in Nigeria. Studies were categorized into one of three main categories: descriptive studies of anthropometric characteristics (49%), descriptive studies of macro- or micronutrient status (41%), and interventional studies (11%). Findings consistently included growth impairment, especially among children and adolescents from sub-Saharan Africa. Studies assessing macro- and micronutrients generally had small sample sizes and were exploratory in nature. Only four randomized trials were identified, which measured the impact of lime juice, long-chain fatty acids supplementation, ready-to-use supplementary food (RUSF), and oral arginine on health outcomes.

CONCLUSIONS

The findings reveal a moderate number of descriptive studies, most with small sample sizes, that focused on various aspects of nutrition and SCD in African patients. There was a stark dearth of interventional studies that could be used to inform evidence-based changes in clinical practice. Findings from the investigations were generally consistent with data from other regional settings, describing a significant risk of growth faltering and malnutrition among individuals with SCD. There is an unmet need for clinical research to better understand the potential benefits of nutrition-related interventions for patients with SCD in sub-Saharan Africa to promote optimal growth and improve health outcomes.

Interventions for Addressing Anemia Among Children and Adolescents: An Overview of Systematic Reviews

Context: Anemia is a public health problem that can lead to growth, cognitive, and motor impairments. Objective: To collate evidence on interventions for addressing childhood and adolescent anemia. Methods: In this overview of systematic reviews, we included Cochrane as well as non-Cochrane systematic reviews (SRs) irrespective of language and publication status. Two sets of review authors independently screened articles for eligibility and extracted data from relevant SRs. We present data in a tabular format and summarize results based on outcome reported, age of participants, and type of interventions. We also adopt a "measurement for change" approach to assess the utility of measurement for development of interventions in childhood and adolescent anemia. Results: Our search yielded 2,601 records of which 31 SRs were found eligible for inclusion. Results were favorable for fortification and supplementation with clear reduction in the risk of anemia and increase in hemoglobin levels across all age groups. Other interventions reported by the SRs were inconclusive and suggest further research. Conclusions: Current evidence suggests that fortification or supplementation with iron and micronutrients leads to better reduction in the risk of anemia and improvements in hemoglobin levels among children and adolescents. Results of this overview can help decision makers in informing selection of interventions to address childhood and adolescent anemia. Review Registration: PROSPERO CRD42016053687.

Association of sickle cell disease with anthropometric indices among under-five children: evidence from 2018 Nigeria Demographic and Health Survey

BACKGROUND

Malnutrition continues to affect under-five children in Africa to an overwhelming proportion. The situation is further compounded by the burden of sickle cell disease (SCD). However, association of SCD with stunting, wasting, and underweight in a nationally representative sample of under-five children remains unexplored. We aimed to describe prevalence of undernutrition by sickle cell status, to evaluate its association with growth faltering ascertained by anthropometric indices, and to explore mediating role of hemoglobin.

METHODS

We availed data from the 2018 Nigeria Demographic and Health Survey (DHS) and the sample comprised 11,233 children aged 6-59 months who were successfully genotyped for SCD. The DHS employed a two-stage, stratified sampling strategy. SickleSCAN rapid diagnostic test was used for SCD genotyping. Z-scores of length/height-for-age (HAZ), weight-for-height (WHZ), and weight-for-age (WAZ) were computed against the 2006 World Health Organization Child Growth Standards. We fitted logistic regression models to evaluate association of SCD with stunting, wasting, and underweight. Mediation analysis was performed to capture the indirect effect of and proportion of total effect mediated through hemoglobin level in SCD-anthropometric indices association.

RESULTS

Prevalences of stunting, wasting, and underweight among children with SCD were 55.4% (54.5-56.4), 9.1% (8.6-9.7), and 38.9% (38.0-39.8), respectively. The odds of stunting were 2.39 times higher (adjusted odds ratio (aOR) 2.39, 95% CI: 1.26-4.54) among sickle children than those with normal hemoglobin. SCD was also significantly associated with underweight (aOR 2.64, 95% CI: 1.25-5.98), but not with wasting (aOR: 1.60, 95% CI 0.85-3.02). Association of SCD with all three anthropometric indices was significantly mediated through hemoglobin level: for SCD-HAZ, the adjusted indirect effect (aIE) was - 0.328 (95% CI: - 0.387, - 0.270); for SCD-WHZ, the aIE was - 0.080 (95% CI: - 0.114, - 0.050); and for SCD-WAZ, the aIE was - 0.245 (95% CI: - 0.291, - 0.200).

CONCLUSION

We presented compelling evidence of the negative impact of SCD on anthropometric indices of nutritional status of under-five children. Integration of a nutrition-oriented approach into a definitive SCD care package and its nationwide implementation could bring promising results by mitigating the nutritional vulnerability of children with SCD.

Prevalence of sickle cell disorders and malaria infection in children aged 1-12 years in the Volta Region, Ghana: a community-based study

BACKGROUND

Alterations in the structure of haemoglobin (Hb) are usually brought about by point mutations affecting one or, in some cases, two codons encoding amino acids of the globin chains. One in three Ghanaians are said to have sickle cell disorders, whereas malaria continues to be one of the leading causes of mortality among children. This study determined the prevalence of sickle cell disorders and malaria infection among children aged 1-12 years in the Volta Region.

METHODS

This was a community-based cross-sectional survey that involved 938 children aged 1-12 years selected from three districts, one each from the 3 geographical zones of the Volta Region using a multistage sampling method. Demographic information was collected using a standard questionnaire and anthropometric indices were measured. Isoelectric focusing (IEF) electrophoresis was used to determine the Hb genotypes and sub-microscopic parasites were determined by PCR.

RESULTS

The prevalence of sickling screening positive was 16.0% with an overall prevalence of sickle cell disorders being 2.0%. Among the individual genotypes making up the sickle cell disorders, genotype HbSF was the highest (0.9% as compared to 0.2%; HbSS, 0.6%; HbSC and 0.3%; HbSCF). Microscopic Plasmodium falciparum parasitaemia was detected among 5.5% of the children and 14.2% sub-microscopic prevalence by PCR. Children with sickle cell disorders were more likely to have sub-microscopic parasitaemia (AOR = 5.51 95%CI (2.15, 14.10), p < 0.001) as well as anaemia (AOR = 3.03 95% CI (1.04, 8.82), p = 0.042), compared to those with normal genotypes. There was no significant difference observed between sickle cell disorders and growth and development of the children screened.

CONCLUSIONS

Sickle cell disorders were significantly associated with sub-microscopic parasitaemia as well as anaemia in this study. Establishment of sickle cell clinics in the district and regional hospitals will help in the management of children with the disorder and also generate a national database on sickle cell disorders. National neonatal screening policies must also be put in place to help in early detection and management of these disorders.

Socioeconomic status dependent medical complexities in children with sickle cell disease in Saudi Arabia

A look into the associations of socioeconomic status (SES) with prevalence of various complications in sickle cell disease (SCD) is necessary, for an improvement of societal norms, governmental health policies and strategies. We therefore studied the influence of SES indices on certain hematological and clinical parameters in children with SCD in Saudi Arabia. We included 32 female and 33 male patients aged 5–16 years, who were classified based upon their family income. Family monthly income was divided into 4 categories from lowest to highest, with socioeconomic class1 having low earnings of <5000 SAR; the middle income class divided further into class 2 with earnings >5000–10,000 SAR, and class 3 with earnings >10,000–15,000 SAR; and the higher income class 4 with earnings of >15,000 SAR. The assessment indices used were, the frequency of vaso-occlusive crisis (VOC), adverse events, and hematological parameters. A higher percentage of children affected with the disease were from class1, which is the low socio-economic class. It was found that the percentage of frequency of VOC pain crisis, and adverse events was higher in social class 1 patients than in the classes 2, 3, and 4. Also, the age group 5–10 years appeared more susceptible to adverse events and VOC. Our findings suggest the need to conduct future larger studies, to deduce the modifying influence of disparity in SES on certain clinical and hematological indices in children with SCD.

Renal abnormalities among children with sickle cell conditions in highly resource-limited setting in Ghana

Sickle cell disease (SCD) is associated with progressive multi-organ failure especially, the brain and kidney and leads to high morbidity and mortality rate. The aim of this study was to determine the prevalence of renal abnormalities among children with SCD. This cross-sectional study recruited 212 sickling positive patients comprising of 96 Hb AS, 48 Hb SC, and 68 Hb SS phenotypes from the Pediatric Unit of Wassa Akropong Government Hospital, Wassa Akropong, Ghana. Early morning urine and venous blood samples were collected from each participant. Urinalysis was conducted and serum urea and creatinine levels were estimated. Estimate glomerular filtration rate (eGFR) was calculated using the Swartz equation. Classification of chronic kidney disease (CKD) was based on 'The Kidney Disease: Improving Global Outcomes (KIDIGO)' criteria. The mean age of the children were 7.90 years. Serum creatinine (p = 0.0310) and urea (p<0.0001) levels were significantly higher among Hb AS participants compared with Hb SS phenotype. The prevalent indicators of renal abnormalities were proteinuria (26.4%), urine granular cast (5.6%) and CKD (39.6%). Proteinuria, urine granular cast and CKD were most prevalent among Hb SS (47.1%, 11.8% and 73.5% respectively) compared with Hb SC (41.7%, 8.3%, and 45.8% respectively) and Hb AS (4.2%, 0.0%, and 14.5%) phenotypes, respectively. Sickle cell conditions were significantly associated with proteinuria (p<0.0001) and CKD (p = 0.0378). Children with Hb SS [aOR = 5.04, 95% CI (2.47-10.3); p<0.0001] and Hb SC [aOR = 3.14 95% CI (1.39-7.01); p = 0.0174] were at increased odds of developing CKD after adjusting for age, BMI and gender. Proteinuria and CKD are associated with sickle cell disease (Hb SC and Hb SS). Renal function should be routinely monitored for children with SCD.

A cross sectional study of growth of children with sickle cell disease, aged 2 to 5 years in Yaoundé, Cameroon

Introduction

Growth of children affected by Sickle Cell Disease (SCD) is not well described in sub-Saharan Africa despite the high prevalence of the disease. Few data are available in this context and on the issue using the World Health Organization growth norms. We therefore conduct the present study with the aim of describing the growth of affected children aged less than 5 years. We also assessed correlation of anthropometric parameters with disease severity criteria.

Methods

A cross-sectional study was conducted during a period of 8 months, at the Mother and Child Center of Yaoundé. The sample included 77 children with SCD aged 2 to 5 years old in steady state. Anthropometric measurements and socio-demographic data were collected and analyzed. All statistical tests were two-tailed with p<0.05 considered significant.

Results

Median age of study population was 3.67 years. Low weight, height and weight for height Z-scores (<-2SD) were observed in 4%, 4%, and 5% of children, respectively. Projection of these parameters were stackable on WHO curves. Regression analysis indicated an association of low height-for-age and of low Body Mass Index (BMI)-for-age with age.

Conclusion

This study demonstrates unexpectedly lower mean Z-score for weight, height and weight for height than reported while using WHO norms.

Impact of omega-3 fatty acids on calorie intake and certain anthropometric measurements in children with sickle cell disease in Saudi Arabia

The nutritional status and growth in children with sickle cell disease is compromised due to intake of diet that is low in calories as well as deficient in nutrients. Growth stunting and a low body mass index have been observed in these children. Some children exhibit pica, which is an abnormal eating pattern by ingesting things other than food, like paper, wood etc. This also was found to correlate to lower hemoglobin values. Interventions with certain essential nutrients such as omega-3 fatty acids are known to benefit these children in terms of lowering their complications due to the disease. We therefore wished to see if omega-3 fatty acids exhibit positive effects on their nutritional intake and growth parameters too. Hence, we supplemented these children with omega-3 fatty acids for a period of six months. Both the male and female children with the disease significantly improved their calorific intake as well as body mass index. Also a lowering of pica status was distinctly observed.

Prevalence and correlates of growth failure in young African patients with sickle cell disease

Growth failure (GF) in children with sickle cell disease (SCD) tends to decline in high-income countries, but data are lacking in sub-Saharan Africa. We performed a cross-sectional study nested in the CADRE (Cœur, Artères et DREpanocytose) cohort in Mali, Senegal, Cameroon, Gabon and the Ivory Coast. SCD patients and healthy controls aged 5-21 years old were recruited (n = 2583). Frequency of GF, defined as a height, weight or body mass index below the 5th percentile on World health Organization growth charts, was calculated. We assessed associations between GF and SCD phenotypic group, clinical and biological characteristics and history of SCD-related complications. GF was diagnosed in 51% of HbSS, 58% of HbSβ⁰ , 44% of HbSC, 38% of HbSβ⁺ patients and 32% of controls. GF in patients was positively associated with parents' lower education level, male sex, age 12-14 years, lower blood pressure, HbSS or HbSβ⁰ phenotypes, icterus, lower haemoglobin level, higher leucocyte count and microalbuminuria. No association was found between GF and clinical SCD-related complications. In sub-Saharan Africa, GF is still frequent in children with SCD, especially in males and during adolescence. GF is associated with haemolysis and microalbuminuria, but not with the history of SCD-related clinical complications.

The role of nutrition in the pathophysiology and management of sickle cell disease among children: A review of literature

Sickle cell disease (SCD) is one of the common inherited blood disorders in humans and has been associated with decreased dietary intake which results in poor nutritional status and impaired growth. Nutrition is one of the most important but often forgotten aspect of care of patients with chronic disorders and there have been emerging concern in literature on increased nutritional needs of SCD patients. This paper sought to review the available literature on the roles of individual nutrients in the pathophysiology and management of SCD among children. Children with SCD have been shown to exhibit suboptimal status with respect to both macronutrients and micronutrients. Thus, nutrition could play an important role in the management of SCD. However, there is paucity of evidence coming from trials with large sample sizes to support the suggestion that supplementation with various nutrients that have been considered in this review will be helpful.