The word Anemia originates from a Greek word “an-haîma” meaning "without blood" and is defined as a reduction in red cell mass or blood haemoglobin concentration below the normal values for that particular age and sex1. It may arise from- i. Reduced production of red blood cells, which may result from deficiency in nutrients or hormones or from disease or other conditions; ii. Excessive destruction of red blood cells, often a hereditary problem; iii. Excessive blood loss. Based on Hemoglobin, anemia is graded as- i. Mild-when Hemoglobin is above 10 g/dL and below the cut off value for age; ii. Moderate-when the Hemoglobin is between 7 &10 g/dL and iii. Severe-when the Haemoglobin is ≥7 g/dL2. Anemia is one of the important health problems in India and leading cause of morbidity and mortality in paediatric age group. Anemia in children is diagnosed by Hemoglobin <11 g/dL in age group 6 months to 6 years and Hemoglobin <12 g/dL above 6 years to 14 years2,3. Nearly half of the school going children in the developing countries are anaemic. Anemia in infants is associated with growth retardation, delayed motor development, poor cognitive abilities, reduced social performance and impaired immune system. Most of the children with anemia are asymptomatic and infrequently manifest with pallor, weakness, jaundice, tachypnoea, tachycardia and cardiac failure which results from severe anemia regardless of its cause. Paediatric anemia is classified as physiological, morphological and on basis of Mean Corpuscular Volume (MCV) and Red Cell Distribution Width (RDW)4. Nutritional anemia according to WHO is a state in which the Hemoglobin concentration in the blood is lower than levels normal for the age, gender, physiological state2,5. It encompasses all pathological conditions in which blood Hemoglobin concentration drops to an abnormally low level due to a deficiency in one or several nutrients. Nutritional anemia includes lack of nutrients such as Iron, Folic Acid, Vitamin B12, Copper, Vitamin C, Vitamin E and Vitamin A6. In public health terms, Iron Deficiency is by far the most common cause of nutritional anemia worldwide whereas folic acid deficiency is less wide spread and is often associated with iron deficiency and Vitamin B12 deficiency is rare. The present study was done to know the clinical manifestations, various haematological changes in children with nutritional anemia so that the problem can be tackled in a better way and steps can be taken to minimize the suffering of the children.

This study was conducted in the Department of Pathology at a Tertiary Care Centre. Subjects were recruited for the study for a period of two (02) years. Children between 5-15 years age group and Hb<10g/dL were included. Children in the age group of <5 years and >15 years with Hb >10 g/dL, having anemia due to acute blood loss secondary to trauma & all children with malignancies/ leukemia/ aplastic anemia and children with hemolytic anemias were excluded. Detailed clinical history was elicited and examination of all the cases of nutritional anemia was performed. Anticoagulated blood was collected in an EDTA vacutainer and the investigations that were carried out included-Complete Hemogram, Peripheral Blood Film using Leishman’s stain, Reticulocyte Count using Brilliant Cresyl Blue stain, Serum Ferritin, Serum Iron, TIBC, Vitamin B12 and Folic Acid assays (in relevant cases), Bone Marrow Examination (in relevant cases), Others-(Urine Examination and Stool Examination etc).

75 patients with a nutritional anemia were studied during the period of two (02) years. The following data was recorded and analysed as shown in Table 1. Parameters No. of Cases Minimum Range Maximum Range Age (years) 75 5 15 Hemoglobin (g/dL) 75 3.3 9.4 Hematocrit (%) 75 13 30 RBC (x106/cu.mm) 75 2.5 5.2 TC (x103/cu.mm) 75 1.6 7.2 MCV (fL) 75 54 112 MCH (pg) 75 10.6 31 MCHC (g/dL) 75 20 33 RDW 75 15 29 Folic Acid 23 1.6 24.8 Vitamin B12 23 110 760 Serum Iron 61 15 38 Serum Ferritin 61 07 50 TIBC 61 240 786 Table 1: Range of Parameters In the present study 150 patients were examined, out of which 75 had nutritional anemia. Most of the patients were in the age group of 11-15 years (48%) and least occurrence was seen in the age group of 5-8 years (22.7%). Out of 75 cases studied, 42 (56%) were females and 33 (44%) were males with a female predominance. Severe anemia was seen in majority of cases 35 (46.7%), followed by moderate 29 (38.7%) and mild 11 (14.7%) as shown in Table 2. Degree of Anemia No. of cases Percentage Mild (Hb 8-10 g/dL) 11 14.7 Moderate (Hb 6-8 g/dL) 29 38.7 Severe (Hb<6g/dL) 35 46.7 Total 75 100 Table 2: Degree of anemia among nutritional anemia patients The common presenting symptoms were gastrointestinal in 35 cases (46.7%) which included vomiting, loose stools and pain abdomen followed by fever in 34 cases (45.3%), respiratory symptoms in 23 cases (30.7%) that included cough, cold and breathlessness with failure to thrive in 16 cases (21.3%). Pallor was found in all the cases. The common signs included features of dehydration that were seen in 27 cases (36%), fever seen in 13 (17.3%), nail changes in 7 cases(9.3%) that included platynychia and koilonychia. In the present study Iron Deficiency Anemia seen in 58 cases (77.3%) was most common cause of nutritional anemia followed by megaloblastic anemia that was seen in 17 cases (22.7%). The most common morphological type of anemia was Microcytic Hypochromic Anemia that was seen in 51 cases (68%) (as shown in Figure 1) It was followed by Dimorphic Anemia in 13 cases (17.3%). Macrocytic Anemia in 11 cases (14.7%) was the least common morphological type as shown in Table 3. Morphological type of anemia No. of cases Percentage Dimorphic 13 17.3 Macrocytic 11 14.7 Microcytic Hypochromic 51 68.0 Table 3: Percent distribution of morphological type of anemia among total patients Dimorphic anemia was seen in 13 patients (17.3%), out of which Iron Deficiency Anemia was seen in 7 cases (53.8%) and Megaloblastic Anemia in 6 cases (46.2%) patients. In this study among Megaloblastic Anemia (as shown in Figure 2) patients, Folic Acid deficiency was seen in majority of cases i.e.12 cases (70.6%), Vitamin B12 in 3 cases (17.6%) and Mixed in 2 cases (11.8%) cases. Figure 1: Microcytic Hypochromic Anemia on PBF with Reactive Thrombocytosis Figure 2: Megaloblastic Anemia with Sieve-Like Chromatin in Erythroblasts (seen in the inset) Stool examination was done in 11 patients, out of which stool for occult blood was positive in 4 patients (36.4%) and negative in 7 patients (63.6%). Bone marrow examination was done in four (04) patients of dimorphic anemia (57.1%) and three (03) patients of macrocytic anemia (42.9%). In this study, distribution of age by gender shows 6 males (35.3%) and 11 females (64.7%) in 5-8 years age group, 11 males (50%) and 11 females (50%) in 8-11 years age group, 16 males (44.4%) and 20 females (55.6%) in 11-15 years age group. In the 5-8 years age group shows 03 cases of mild anemia (17.6%), 5 cases of moderate anemia (29.4%) and 9 cases of severe anemia (52.9%). In the 8-11 years age group shows 4 cases of mild anemia (18.2%), 11 cases of moderate anemia (50%) and 7 cases of severe anemia (31.8%). In the of 11-15 years age group 4 cases of mild anemia (11.1%), 13 cases of moderate (36.1%) and 19 cases of severe anemia (52.8%) were seen. In this study 5-8 years age group shows 12 cases of Iron Deficiency Anemia (70.6%) and 05 cases of Megaloblastic Anemia (29.4%) cases, 8-11 years age group shows 15 cases of Iron Deficiency Anemia (68.2%) and 07 cases of Megaloblastic Anemia (31.8%), 11-15 years age group shows 31 cases of Iron Deficiency Anemia (86.1%) and 05 cases of Megaloblastic Anemia (13.9%). Distribution of age by morphological type of anemia shows 03 cases of dimorphic anemia (17.6%), 03 cases of macrocytic anemia (17.6%), 11 cases of microcytic hypochromic anemia (64.7%). In 5-8 years age group 06 cases were dimorphic anemia (27.3%), 04 cases were macrocytic anemia (18.2%) cases and 12 cases were microcytic hypochromic anemia (54.5%). In 8-11 years age group 04 cases were dimorphic anemia (11.1%) , 04 cases were macrocytic anemia (11.1%) and 28 cases were microcytic hypochromic anemia (77.8%). Iron Deficiency Anemia was present in 24 males (41.4%) and 34 females (58.6%), Megaloblastic anemia was seen in 09 males (52.9%) and 08 females (47.1%). Out of 75 cases of nutritional anemia 58 was Iron Deficiency Anemia in which 07 cases (12.1%) were dimorphic, 51 cases were microcytic hypochromic (87.9%), and 17 cases were megaloblastic anemia (22.6%) in which 06 cases were dimorphic (35.3%) and 11 cases were macrocytic (64.7%). The distribution of anemia by gender shows 07 male (63.6%) and 04 female (36.4%) patients in mild anemia, 10 male (34.5%) and 19 female (65.5%) patients in moderate anemia, 16 male (45.7%) and 19 female (54.3%) patients in severe anemia as shown in Table 4. Anemia Male Female Total p value No. Percent No. Percent Mild 7 63.6 4 36.4 11 0.243 Moderate 10 34.5 19 65.5 29 Severe 16 45.7 19 54.3 35 Table 4: Percent distribution of anemia by gender In this study mild anemia was seen in 11 cases out of which dimorphic was present in 01 case (9.1%) and microcytic hypochromic in 10 cases (90.9%); moderate anemia was seen in 29 cases out of which dimorphic was present in 04 cases (13.8%), macrocytic in 06 cases (20.7%) and microcytic hypochromic in 19 cases (65.5%); severe in 35 cases out of which 08 cases were dimorphic (22.9%), 05 cases were macrocytic (14.3%) and 22 cases were microcytic hypochromic anemia (62.9%). Comparison of means of parameters by gender is shown in Table 5 and comparison of means of parameters by diagnosis is shown in Table 6. Parameter Male Female p value Mean SD Mean SD Hemoglobin (g/dL) 6.5 1.3 6.1 1.2 0.051 Hematocrit (%) 21.8 4.4 19.6 4.1 0.029* RBC (x106/cu.mm) 4.2 0.5 4.0 0.5 0.187 TLC (x103/cu.mm) 10.12 11.07 8.74 2.51 0.434 MCV (fL) 75.5 19.5 74.4 18.2 0.799 MCH (pg) 20.5 6.1 21.4 6.6 0.552 MCHC (g/dL) 27.0 3.8 26.9 4.2 0.955 RDW 21.6 2.3 21.2 2.7 0.509 Sr. Iron 20.7 4.2 19.8 2.3 0.312 Sr. Ferritin 12.4 8.6 10.4 1.7 0.177 *Significant with p value <0.05 Table 5: Comparison of means of parameters by gender Parameters Iron Deficiency Anemia Megaloblastic Anemia p value Mean SD Mean SD Hemoglobin (g/dL) 6.4 1.3 6.1 0.9 0.322 Hematocrit (%) 20.1 4.7 22.4 2.4 0.055 RBC (x106/cu.mm) 4.0 0.5 4.3 0.4 0.028* TLC (x103/cu.mm) 9.36 8.54 9.30 1.91 0.976 MCV (fL) 65.6 7.3 106.9 3.6 0.000* MCH (pg) 19.9 5.8 24.9 6.7 0.003* MCHC (g/dL) 26.2 3.7 29.4 4.2 0.003* RDW 21.2 2.8 21.7 1.5 0.508 Sr. Iron 19.6 1.9 30.7 6.4 0.000* Sr. Ferritin 10.3 1.7 30.0 19.1 0.000* *Significant with p value <0.05 Table 6: Comparison of means of parameters by diagnosis

Nutritional Anemia according to the WHO is a state in which the haemoglobin concentration in the blood is lower than levels normal for the age, gender, physiological state.2,5 The clinico-haematological profiles of nutritional anemia in children as analyzed in the present study of 75 children were compared with the other similar studies. Majority of the patients in our study were females 42 (56%) compared to males 33 (44%) and F:M ratio is (1:0.78) and age of presentation was between 5-15 years. Almost similar to our study Gombar S et al7 reported almost same age group with males being 53.7% and females being 46.3%. Ullah I et al8, Chitra B et al9 also reported almost the same age group. In our study majority of patients presented with gastrointestinal symptoms including vomiting, loose stools, pain abdomen (46.7%) followed by fever (45.3%) and respiratory symptoms (30.7%). As far as clinical features are concerned pallor was present in 100% of patients, followed by signs of dehydration (36%), fever (17%) and nail changes (9.3%). Similar findings were observed in other studies. Ullah I et al8 reported pallor as most common presenting symptoms in 67 patients (46.9%) followed by generalized weakness in 47 patients (32.9%) and fatigue in 23 patients (16.1%). Other symptoms were pale conjunctiva in 06 patients (4.2%) and nail changes. We found out that severe anemia was seen in majority of cases (46.7%) followed by moderate (38.7%) and mild (14.7%). Bibi S et al10 reported similar study with severe anemia in 74 patients (67.3%) followed by moderate anemia in 19 patients (17.3%) and mild anemia in 17 patients (15.5%). Chitra B et al9 reported similar results in their study with severe anemia in 54 patients (36%), followed by moderate anemia in 28 cases (22%). The most common cause of nutritional anemia was Iron Deficiency Anemia in 58 patients (77.3%) followed by megaloblastic anemia in 17 patients (22.7%). Similar results were reported by Gombar S et al7 in their study in which 39 patients (41.05%) had Iron Deficiency Anemia and 07 patients (7.37%) had megaloblastic anemia. Similar studies were conducted by Molla A et al11, Olivaries M et al 12, Lone AA et al13. In our study most common morphological type of anemia was microcytic hypochromic anemia seen in 51 patients (68%) followed by dimorphic anemia seen in 13 patients (17.3%), in which IDA was seen in 07 patients (53%) and megaloblastic anemia in 06 patients (46.2%). Macrocytic anemia was the least common morphological type, in which Folic Acid deficiency was seen in majority of cases i.e. in 12 patients (70.6%) and Vitamin B12 Deficiency was seen in 3 patients (17.6%) and mixed deficiency of Folic Acid & Vitamin B12 was seen in 02 patients (11.8%). Similar studies were reported by MollaM et al11 and Verma M et al14. The probable factors contributing to the prevalence of severe anemia in the present study may be attributed to the low socioeconomic status, illiteracy and ignorance of the parents because of which most of the children would have developed severe degree of anemia at the time of presentation.

Nutritional anemia is a common haematological problem encountered in clinical practice. One of the most important areas for scope in the improvement of primary health care is prevention of nutritional deficiency because it has been associated with delay in psychomotor development and increased morbidity and mortality in children. National guidelines can be followed for the prevention and management of anemia. Various strategies to prevent anemia are by improving dietary intake, by providing iron, folate rich foods and food items that promote iron absorption, providing awareness to the public by conducting health and nutrition education programmes and screening for early detection of anemia among children. Hence, the current study suggests that various measures should be taken to reduce the incidence of anemia to improve the quality of life of children, by providing patient counselling and health screening services. Children being the most vulnerable group for nutritional deficiencies, steps need to be undertaken to educate the masses and improve their living standards, so that, the initial symptoms of illness are not ignored and the children are brought to the hospital at the earliest for timely diagnosis and effective management. In the present study, the 11-15 years children were found to be the most affected. Hence, it is recommended that, this age group is compulsorily screened for anemia. Iron Deficiency Anemia was the commonest cause of nutritional anemia in children. A uniform definition of screening criteria and an effective system to respond to abnormalities is the need of the hour. The present study was undertaken, keeping this need in view. Conflicts of interest: Nil

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