Anemia is one of the most common nutritional and hematological disorders in childhood and continues to be a major public health concern in low- and middle-income countries. It is broadly characterized by a reduction in hemoglobin concentration below the level required to meet physiological oxygen demands. In children, anemia has clinical and developmental relevance because rapid growth increases micronutrient requirements, while dietary inadequacy, recurrent infections, parasitic infestations, and poor socioeconomic conditions frequently coexist [1-4]. The global burden remains substantial, with children under five years carrying a disproportionate share of anemia-related morbidity [1,2]. The clinical importance of pediatric anemia extends beyond pallor and fatigue. Persistent anemia during infancy and childhood is associated with impaired neurodevelopment, reduced attention, poor physical activity, decreased resistance to infection, and delayed recovery from illness. Iron deficiency is the leading nutritional cause, but anemia in children is often multifactorial. Inflammation, infections, helminthic infestation, low dietary diversity, vitamin deficiencies, and hemoglobin disorders contribute variably across populations [3,4]. Therefore, the evaluation of anemia in children requires not only hemoglobin estimation but also attention to the social, dietary, and clinical background of the child. In India, anemia among children remains a persistent challenge despite public health programs focused on iron and folic acid supplementation, dietary improvement, deworming, and maternal-child nutrition services. Reviews from India have highlighted that the decline in childhood anemia has been slow and uneven, particularly among socioeconomically disadvantaged groups [5]. Studies from Indian community and hospital settings have reported high anemia prevalence among infants, preschool children, hospitalized children, toddlers, and adolescents, with moderate anemia commonly contributing to the highest proportion of cases [6-11]. These findings show that both population-level and facility-based assessments are useful for identifying children at risk. Hospital-based observational studies are valuable because many children attending tertiary care centres present with nutritional deficiencies, recurrent infections, gastrointestinal complaints, or chronic illness-related vulnerability. Such settings provide an opportunity for early diagnosis, parental counselling, and linkage with preventive measures. Inadequate dietary iron intake, low socioeconomic status, irregular deworming, pica, and recurrent infections are modifiable or partly modifiable factors that can be addressed through routine pediatric care and public health interventions [3,12-14]. The present study was conducted to estimate the prevalence and severity of anemia among children aged 6 months to 12 years attending a tertiary care hospital and to assess selected demographic, nutritional, and clinical risk factors associated with anemia.

Study design and setting: This was an observational cross-sectional study conducted among children attending Konaseema Institute of Medical Sciences & Research Foundation, Amalapuram, Andhra Pradesh, India. The institute functions as a tertiary care teaching hospital and provides pediatric outpatient, inpatient, emergency, laboratory, and specialist referral services to children from Amalapuram and surrounding rural and semi-urban areas of the Konaseema region. The hospital receives children from varied socioeconomic backgrounds, making it suitable for assessing anemia and related risk factors in a clinical care setting. Study period and sample size: The study was conducted over a six-month period from June 2020 to November 2020. A total of 100 eligible children aged 6 months to 12 years were included. Children were enrolled by consecutive sampling after applying the eligibility criteria. This sample size was considered adequate for describing anemia prevalence and exploring associations with commonly observed risk factors in a hospital-based observational design. Study population: Children aged 6 months to 12 years who attended the pediatric services during the study period and whose parents or guardians provided consent were included. Children who had received blood transfusion recently, those with known hematological malignancy, children already on active treatment for severe chronic hematological disease, and children whose clinical or laboratory details were incomplete were excluded. Age, sex, place of residence, socioeconomic status, dietary history, deworming history, history of pica, and recurrent infections were recorded using a structured data collection format. Assessment of anemia and risk factors: Hemoglobin estimation was used to determine anemia status. Anemia and its severity were classified using age-appropriate hemoglobin criteria consistent with standard pediatric and public health practice [4]. Children were categorized as non-anemic, mildly anemic, moderately anemic, or severely anemic. Dietary iron intake was assessed from caregiver history regarding regular consumption of iron-rich foods such as green leafy vegetables, pulses, jaggery, meat, egg, and fortified foods. Deworming history was categorized as regular or irregular based on caregiver reporting. Pica was recorded when there was a history of repeated ingestion of non-food substances. Recurrent infections were recorded when the child had repeated episodes of respiratory, gastrointestinal, febrile, or other clinically significant infections requiring medical attention. Ethical considerations: The study was conducted after institutional ethical approval. Written informed consent was obtained from the parent or legal guardian before enrolment. Confidentiality of patient information was maintained, and the data were used only for research analysis. Children identified as anemic were advised appropriate clinical evaluation, nutritional counselling, and treatment as per pediatric practice. Statistical analysis: Data were entered into a spreadsheet and analysed using descriptive and inferential statistics. Continuous variables were expressed as mean and standard deviation. Categorical variables were summarized as frequencies and percentages. The prevalence of anemia was calculated as the proportion of children with hemoglobin below the age-appropriate cutoff. Associations between anemia and selected risk factors were assessed using chi-square test or Fisher’s exact test where appropriate. Odds ratios were calculated to estimate the strength of association. A p-value less than 0.05 was considered statistically significant.

A total of 100 children aged 6 months to 12 years were included in the study. The mean age of the study population was 5.8 ± 3.4 years. Among them, 54% were males and 46% were females. Children below 5 years constituted 38% of the study population, while 62% were aged 5-12 years. The overall prevalence of anemia was 58%. Among the total sample, mild anemia was observed in 24%, moderate anemia in 29%, and severe anemia in 5%. Moderate anemia was the most common severity category, as shown in Table 1. Table 1. Prevalence and severity of anemia among children Anemia status Number of children Percentage No anemia 42 42.0% Mild anemia 24 24.0% Moderate anemia 29 29.0% Severe anemia 5 5.0% Total 100 100.0% Anemia was more common among children aged 6 months to below 5 years when compared with children aged 5-12 years. Among children below 5 years, 27 of 38 had anemia, giving a prevalence of 71.1%. Among children aged 5-12 years, 31 of 62 had anemia, with a prevalence of 50.0%. The age-wise association showed borderline statistical significance. Anemia was almost equally distributed between males and females. Rural children had a higher prevalence of anemia than urban children, with a borderline association, as presented in Table 2. Table 2. Association of anemia with demographic characteristics Variable Total Anemia present n (%) Anemia absent n (%) p-value Age 6 months-<5 years 38 27 (71.1%) 11 (28.9%) 0.063 Age 5-12 years 62 31 (50.0%) 31 (50.0%) Male 54 31 (57.4%) 23 (42.6%) 1.000 Female 46 27 (58.7%) 19 (41.3%) Rural residence 60 40 (66.7%) 20 (33.3%) 0.052 Urban residence 40 18 (45.0%) 22 (55.0%) Anemia was higher among children from lower socioeconomic status, those with inadequate dietary iron intake, irregular deworming history, pica, and recurrent infections. The strongest association was observed with inadequate dietary iron intake, where 75.0% of children had anemia compared with 39.6% among those with adequate dietary iron intake. Irregular deworming, pica, recurrent infections, and lower socioeconomic status were also significantly associated with anemia, as shown in Table 3. Table 3. Association of anemia with selected risk factors Risk factor Total Anemia present n (%) Anemia absent n (%) Odds ratio p-value Lower socioeconomic status 56 39 (69.6%) 17 (30.4%) 3.02 0.014 Middle/upper socioeconomic status 44 19 (43.2%) 25 (56.8%) Reference Inadequate dietary iron intake 52 39 (75.0%) 13 (25.0%) 4.58 0.001 Adequate dietary iron intake 48 19 (39.6%) 29 (60.4%) Reference Irregular deworming history 36 28 (77.8%) 8 (22.2%) 3.97 0.005 Regular deworming history 64 30 (46.9%) 34 (53.1%) Reference Pica present 22 18 (81.8%) 4 (18.2%) 4.28 0.020 Pica absent 78 40 (51.3%) 38 (48.7%) Reference Recurrent infections 30 23 (76.7%) 7 (23.3%) 3.29 0.024 No recurrent infections 70 35 (50.0%) 35 (50.0%) Reference On risk-factor analysis, inadequate dietary iron intake, lower socioeconomic status, irregular deworming, pica, and recurrent infections showed statistically significant association with anemia. Sex was not significantly associated with anemia. Although anemia was more frequent among children below 5 years and among rural children, these associations remained borderline. Overall, anemia was a common health problem among children attending the tertiary care hospital, affecting more than half of the study population.

The present hospital-based observational study found that 58% of children aged 6 months to 12 years had anemia. This indicates a considerable burden among children attending pediatric services at a tertiary care hospital. Moderate anemia was the most frequent category, followed by mild anemia, while severe anemia was less common. This pattern is clinically meaningful because moderate anemia often remains under-recognized until routine blood testing or intercurrent illness brings the child to medical attention. Similar hospital-based Indian studies have reported anemia as a frequent finding among pediatric patients, although the exact prevalence varies according to age group, setting, inclusion criteria, nutritional background, and method of hemoglobin estimation [7-9]. The higher prevalence of anemia among children below 5 years in this study is consistent with the biological vulnerability of early childhood. Rapid growth, transition from breast milk to complementary foods, recurrent infections, poor dietary diversity, and inadequate iron intake increase anemia risk in younger children. Nair et al. documented high anemia prevalence among infants and preschool children from rural India and identified iron deficiency, maternal anemia, inflammation, and younger age as important associated factors [6]. Kalhan et al. also reported a high prevalence among toddlers, emphasizing the importance of early screening and iron supplementation practices [9]. Inadequate dietary iron intake showed the strongest association with anemia in the present analysis. This finding agrees with the established role of insufficient iron consumption, low bioavailability of plant-based iron, and poor dietary diversity in childhood anemia [3,10,11]. Children from lower socioeconomic status also showed significantly higher anemia prevalence. This reflects the combined influence of limited access to iron-rich foods, overcrowding, infections, poor sanitation, and delayed healthcare use. Large regional analyses from South and Southeast Asia have also identified household wealth, maternal factors, child age, and nutritional conditions as important determinants of childhood anemia [13,14]. Irregular deworming was another significant risk factor. Helminthic infections contribute to anemia through chronic intestinal blood loss, reduced appetite, inflammation, and impaired nutritional absorption. A systematic review on deworming among school children reported that deworming programs can reduce anemia prevalence and improve hemoglobin levels, supporting routine preventive deworming in endemic regions [12]. The association of pica with anemia in this study is also relevant. Pica can be both a manifestation and a marker of iron deficiency, and its presence should prompt hemoglobin testing and dietary assessment. Recurrent infections were significantly associated with anemia. Infection-related inflammation alters iron metabolism, reduces erythropoiesis, and worsens nutritional deficiencies. This supports the concept that childhood anemia is not merely a dietary disorder but a multifactorial condition requiring integrated management [3,4]. The absence of a significant sex difference in this study suggests that boys and girls in this age range share similar vulnerability before adolescence. The findings highlight the need for routine anemia screening, early dietary counselling, deworming, infection control, and follow-up of children with moderate or severe anemia in tertiary care pediatric practice [5]. Limitations This study was limited by its single-centre hospital-based design and modest sample size. Dietary iron intake, deworming history, pica, and recurrent infections were assessed from caregiver history, introducing recall bias. Serum ferritin, transferrin saturation, C-reactive protein, stool examination, and micronutrient assays were not included, so the precise etiological classification of anemia remained incomplete.

This observational study showed that anemia was present in 58% of children aged 6 months to 12 years attending a tertiary care hospital. Moderate anemia was the most common severity pattern. Inadequate dietary iron intake, lower socioeconomic status, irregular deworming, pica, and recurrent infections were significantly associated with anemia. Younger age and rural residence showed higher anemia prevalence with borderline statistical significance. These findings support routine hemoglobin screening in pediatric services, especially among nutritionally vulnerable children. Preventive strategies should include dietary counselling, iron-rich complementary feeding, regular deworming, infection control, parental education, and follow-up care for children detected with anemia.

1.Stevens GA, Finucane MM, De-Regil LM, Paciorek CJ, Flaxman SR, Branca F, et al. Global, regional, and national trends in haemoglobin concentration and prevalence of total and severe anaemia in children and pregnant and non-pregnant women for 1995-2011: a systematic analysis of population-representative data. Lancet Glob Health. 2013;1(1):e16-e25. doi:10.1016/S2214-109X(13)70001-9. 2.Kassebaum NJ, Jasrasaria R, Naghavi M, Wulf SK, Johns N, Lozano R, et al. A systematic analysis of global anemia burden from 1990 to 2010. Blood. 2014;123(5):615-624. doi:10.1182/blood-2013-06-508325. 3.Chaparro CM, Suchdev PS. Anemia epidemiology, pathophysiology, and etiology in low- and middle-income countries. Ann N Y Acad Sci. 2019;1450(1):15-31. doi:10.1111/nyas.14092. 4.Garcia-Casal MN, Pasricha SR, Sharma AJ, Pena-Rosas JP. Use and interpretation of hemoglobin concentrations for assessing anemia status in individuals and populations: results from a WHO technical meeting. Ann N Y Acad Sci. 2019;1450(1):5-14. doi:10.1111/nyas.14090. 5.Kapil U, Kapil R, Gupta A. Prevention and control of anemia amongst children and adolescents: theory and practice in India. Indian J Pediatr. 2019;86(6):523-531. doi:10.1007/s12098-019-02932-5. 6.Nair KM, Fernandez-Rao S, Nagalla B, Kankipati RV, Punjal R, Augustine LF, et al. Characterisation of anaemia and associated factors among infants and pre-schoolers from rural India. Public Health Nutr. 2016;19(5):861-871. doi:10.1017/S1368980015002050. 7.Saba F, Poornima S, Balaji PAR, Varne SRR, Jayashree K. Anemia among hospitalized children at a multispecialty hospital, Bangalore (Karnataka), India. J Family Med Prim Care. 2014;3(1):48-53. doi:10.4103/2249-4863.130275. 8.Maiti D, Acharya S, Basu S. Recognizing missed opportunities to diagnose and treat iron deficiency anemia: a study based on prevalence of anemia among children in a teaching hospital. J Family Med Prim Care. 2019;8(3):899-903. doi:10.4103/jfmpc.jfmpc_81_19. 9.Dutta M, Bhise M, Prashad L, Chaurasia H, Debnath P. Prevalence and risk factors of anemia among children 6–59 months in India: a multilevel analysis. Clin Epidemiol Glob Health. 2020;8(3):868-878. doi:10.1016/j.cegh.2020.02.015. 10.Bhardwaj A, Sreedevi A, Vasudevan S, Vidyadharan G. Pattern of anaemia, determinants and weekly iron and folic acid supplementation programme among tribal adolescent girls attending a primary health centre in Wayanad, Kerala. Int J Community Med Public Health. 2020;7(7):2803-2807. doi:10.18203/2394-6040.ijcmph20203017. 11.Ahankari AS, Myles PR, Fogarty AW, Dixit JV, Tata LJ. Prevalence of iron-deficiency anaemia and risk factors in 1010 adolescent girls from rural Maharashtra, India: a cross-sectional survey. Public Health. 2017;142:159-166. doi:10.1016/j.puhe.2016.07.010. 12.Girum T, Wasie A. The effect of deworming school children on anemia prevalence: a systematic review and meta-analysis. Open Nurs J. 2018;12:155-161. doi:10.2174/1874434601812010155. 13.Pasricha SR, Black J, Muthayya S, Shet A, Bhat V, Nagaraj S, et al. Determinants of anemia among young children in rural India. Pediatrics. 2010;126(1):e140-e149. doi:10.1542/peds.2009-3108. 14.Habib A, Kureishy S, Soofi S, Hussain I, Rizvi A, Ahmed I, et al. Prevalence and risk factors for iron deficiency anemia among children under five and women of reproductive age in Pakistan: findings from the National Nutrition Survey 2018. Nutrients. 2023;15(15):3361. doi:10.3390/nu15153361.