|Year : 2015 | Volume
| Issue : 1 | Page : 25-31
Iron deficiency anemia in an Egyptian pediatric population: A cross-sectional study
Mohamed M. E. Al Ghwass1, Eman Fawzy Halawa2, Samar Mohamed Sabry2, Dalia Ahmed3
1 Department of Pediatrics, Faculty of Medicine, Fayoum University, Faiyum, Egypt
2 Department of Pediatrics, Faculty of Medicine, Cairo University, Cairo, Egypt
3 Department of Public Health and Community Medicine, Faculty of Medicine, Cairo University, Cairo, Egypt
|Date of Web Publication||7-Jan-2015|
Eman Fawzy Halawa
23, Dr. Naguib Mahfouz Street, Abbas El Akad Street, 8th District, Nasr City, P. O. Box 11471, Cairo
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Objective: The aim of this study is to assess the frequency of iron deficiency anemia (IDA) and associated sociodemographic factors among children between 6 months and 12 years of age.
Materials and Methods: This cross-sectional study enrolled 300 children from June 2011 to June 2012 visiting the pediatric outpatient clinics of Al-Fayoum University Hospital. Data were collected using a structured interview questionnaire. Sociodemographic variables studied included sex, residence, family size, fathers' education, mothers' education, and crowding index. Included patients were evaluated clinically and laboratory for complete blood picture, serum iron, serum ferritin, and transferrin saturation.
Results: It was found that 64% of studied children had IDA (20% mild, 41.7% moderate, and 2.3% severe). The logistic regression analysis found that children from rural areas, those from low social class and those of low maternal educational level had a higher risk for IDA than other children. Infants with IDA were found to consume foods with low iron content 50% below recommended daily allowance.
Conclusion: The high frequency of IDA is a severe public health problem in developing countries like Egypt, especially in children from rural areas, those from low social class and those of low maternal educational level. Iron-rich foods should be advised by health care providers. Prophylactic iron supplements should be given to all infants from 6 to 23 months.
| Abstract in French|| |
Objectif: l'objectif de cette étude est d'évaluer la fréquence de l'anémie ferriprive et les facteurs sociodémographiques associés chez les enfants entre 6 mois et 12 ans.
Matériel et Méthodes: Cette étude transversale inscrits 300 enfants de Juin 2011 to Juin 2012 en visitant les cliniques externes de pédiatrie de l'hôpital universitaire Al- Fayoum. Les données ont été recueillies à l'aide d'un questionnaire d'entrevue structurée. Variables sociodémographiques étudiées comprenaient le sexe, la résidence, la taille de la famille, l'éducation des pères, mères '' éducation, et l'indice de surpeuplement. Les patients inclus ont été évalués cliniquement et en laboratoire pour obtenir des images de sang, le fer sérique, la ferritine sérique et la saturation de la transferrine.
Résultats: Il a été constaté que 64% des enfants étudiés avaient une anémie ferriprive (20% légère, 41.7% modérée et 2.3% sévère). L'analyse de régression logistique a constaté que les enfants des zones rurales, ceux de classe sociale inférieure et celles de faible niveau d'éducation maternelle avaient un risque plus élevé pour l'anémie ferriprive que les autres enfants. Les nourrissons atteints d' anémie ferriprive ont été trouvés à consommer des aliments à faible teneur en fer de 50% en dessous des apports journaliers recommandés.
Conclusion: La fréquence élevée de l'anémie ferriprive est un problème de santé publique grave dans les pays en développement comme l'Egypte, en particulier chez les enfants des zones rurales, ceux de classe sociale inférieure et celles de faible niveau d'éducation maternelle. Aliments riches en fer doivent être informés par les fournisseurs de soins de santé. Des suppléments de fer prophylactiques doivent être donnés à tous les nourrissons de 6 mois à 23 mois.
Mots clés: Enfants, égyptienne, l'anémie ferriprive
Keywords: Children, Egyptian, iron deficiency anemia
|How to cite this article:|
Al Ghwass MM, Halawa EF, Sabry SM, Ahmed D. Iron deficiency anemia in an Egyptian pediatric population: A cross-sectional study. Ann Afr Med 2015;14:25-31
|How to cite this URL:|
Al Ghwass MM, Halawa EF, Sabry SM, Ahmed D. Iron deficiency anemia in an Egyptian pediatric population: A cross-sectional study. Ann Afr Med [serial online] 2015 [cited 2020 Sep 30];14:25-31. Available from: http://www.annalsafrmed.org/text.asp?2015/14/1/25/148725
| Introduction|| |
Iron deficiency anemia (IDA) is the most common nutritional deficiency in both developing and developed countries.  It affects 20-50% of the world's population and is common in young children.  In Egypt, not many studies have been done on this problem in children, and little progress has been made in combating anemia and IDA, particularly in aboriginal and rural communities. A national survey, recently conducted on adolescents, detected overall prevalence of anemia of 46.6% among the age group 10-19 years.  Another clinic based Egyptian study showed that 43% of the study population from 6 to 24 months had IDA. 
The main cause of anemia is iron deficiency due to inadequate intake of bioavailable iron from the diet.  Furthermore, it may be due to factors such as reduced absorption during meals (e.g., due to tannin in tea and phytate in unleavened bread) or to infection with intestinal helminthes, which cause blood loss (e.g., Trichuris trichiura, Schistosoma mansoni, hookworms, Fasciola spp.) or interfere with iron absorption in the intestinal tract (e.g., Giardia intestinalis, Ascaris lumbricoides).  Risk factors for IDA include high birth order, big family size, limited maternal education, and low family income. 
Many vital aspects of human health are adversely affected by anemia, including energy, temperature regulation, behavior, and immune function.  Literature over the past three decades show links between iron deficiency (particularly during early childhood) and poor cognitive performance and motor and psychomotor development.  Consequently, negative correlations have been identified between childhood anemia and academic achievement, including grades, attendance, and attainment.  Recognizing and treating anemia are especially critical since developmental and behavioral damages have been shown to have long-lasting effects into adulthood in animal studies of biological mechanisms  and also in human studies. 
This study was aimed to assess the frequency of IDA and associated sociodemographic factors among children between 6 months and 12 years of age at Al-Fayoum Government.
| Materials and Methods|| |
This cross-sectional descriptive study was carried out from June 2011 to June 2012, in the outpatient pediatric clinics of Al-Fayoum University Hospital in Al-Fayoum Governorate, Egypt. These clinics serve most infants and children from middle and low socioeconomic standards. A total of 345 children aged 6 months to 12 years who were seeking medical advice for mild acute complaints as upper respiratory tract infections, mild gastroenteritis or other complaints, were enrolled in the study. Online statistical calculator was used for sample size determination guided by power test of 80%, confidence level of 95%, and α error of 5%. The sample size was calculated to be 294 infants. Exclusion criteria were ex-premature infants, iron treatment before or during the study period, any history of chronic illness, or recent blood transfusion.
Data collection was carried out using a field pretested interviewing questionnaire covering the following elements:
· Child age, sex, residence (urban or rural), family size and date of attending.
Sociodemographic status of children and their families, socioeconomic score, which contained social variables including fathers' education and work (score 2-10), mothers' education and work (scores 1-10) and crowding index (scores 1-5). The total score calculation was: Score from 19-25 means high social class, score from 12 to 18 means middle social class and score below 12 means low social class. 
· Anthropometric measures: Children were weighed without wearing clothes or shoes using a calibrated SECA scale, which has intervals of 0.1 kg. Height was measured to the nearest 0.1 cm using the same device that has a scale and a sliding head piece. To reduce individual errors, weight, and height were measured twice by different well trained senior residents and the mean value was used for the analysis. Height-for-age, weight-for-age, and weight-for-height were used to denote stunting, underweight and, wasting, respectively. They were expressed in Z-scores and calculated with Epi Info 2002 (CDC, Atlanta, GA, USA) with the use of the National Center for Health Statistics reference (NCHS) data. Children who had Z-scores below −2 standard deviation (SD) of the NCHS reference population were considered to be malnourished. 
Full nutritional history was obtained during visits and included type of milk consumed during the first 6 months (breast milk, artificial, or a combination), age at which solid foods were introduced in addition to milk, and the age of introduction of cow's milk products (yogurts, cheese, and cream). Exclusive definitions of exclusive breast-feeding and time of introduction of solid foods are in accordance to the World Health Organization (WHO) definitions.  Dietary recall and the record was used for mothers who were asked for all foods and fluids consumed by the infant, while she was at home. Daily iron intake of each infant was calculated using the "Diet Analysis Program, 1995" (Lifestyles Technologies, Inc., Northbridge Point, Valencia, California) and was then compared with the recommended daily allowance (RDA) according to the infant's age. 
Acute phase reactants such as erythrocyte sedimentation rate and C-reactive protein levels were measured in all cases suggestive of infectious disease. Venous blood samples were drawn from all patients at the time of referral. Every sample was analyzed for hemoglobin (Hb) concentration, hematocrit value, erythrocyte indices (mean corpuscular volume [MCV], mean corpuscular Hb [MCH], MCH concentration, and red cell diameter width). The complete blood count was done using Coulter 1660 to determine the MCV, MCH, and red cell distribution width. Anemia was diagnosed when Hb concentrations below the values adjusted for age groups.  In infants from 6 months to 6 years mild, moderate and severe anemia was diagnosed if Hb level was 10-11, 7-9.9, or below 7 g/dl, respectively. In infants from 6 to 12 years mild, moderate, and severe anemia were diagnosed if Hb level was 10.5-11.4, 7.5-10.4, or below 7.5 g/dl, respectively.  Microcytosis was diagnosed when the MCV was below 80 fl and MCH below 27 pg. 
Serum iron (SI) levels, total iron binding capacity (TIBC) and serum ferritin (SF) were analyzed only among anemic children. SI and TIBC were measured using calorimetric kits (Stanibo Company, USA). SF was measured using Immulite/Immulite 1000 ferritin kits (Siemens, Los Angeles, California). Transferrin saturation (TS) was calculated as SI divided by TIBC. Iron studies diagnostic for IDA consist of a low Hb for age, together a low SF with below 12 μg/L) or low TS below 16%). , Hb electrophoresis was done to patients diagnosed with microcytic hypochromic anemia to exclude β thalassemia minor.
This study was conducted according to the guidelines laid down in the Declaration of Helsinki and all procedures involving patients were approved by the Ethical Committee of Al-Fayoum University. Verbal informed consent was obtained from all patients. Verbal consent was witnessed and formally recorded.
Data obtained from the study were coded and entered using the software Statistical Package for Social Science (SPSS) 16 version 15.0. Data were summarized using mean, SD and range for quantitative variables and number and percentage for qualitative variables. Comparison between groups was done using Chi-square and Fischer exact test for qualitative variables. Logistic regression analysis was done to test for significant predictors for the presence of IDA. P < 0.05 was considered as statistically significant.
| Results|| |
Among 345 patients enrolled, 45 (13%) children were not analyzed because of unavailability of consent for study or inadequate sample. The remaining enrolled 300 children aged 6 months to 12 years with a mean age of 5.2 ± 4.4 years with a median 4 years ranging from 0.5 to 12 years. They were 175 (58.3%) males and 125 (41.7%) females. The sociodemographic data are shown in [Table 1]. We found that 217 infants (72.3%) were anemic. Seven patients (2.3%) were diagnosed as macrocytic hyperchromic anemia and 14 (4.6%) patients had normocytic normochromic anemia. Four patients (1.3%) were diagnosed as β thalassemia minor.
Based on the biochemical iron status, 192 infants (88.4% of anemic infants and 64% of all infants) had IDA. About 42% of patients with IDA were below 2 years. Mild anemia was found in 60 infants (20% of total study population) while 125 infants (41.7%) had moderate anemia and only 7 infants (2.3%) had severe anemia. The mean Hb level of infants with IDA was 7.82 ± 0.67 g/dl. The hematological findings and iron profile among patients with IDA is shown in [Table 2]. The diagnosis of the 300 patients enrolled in the study was upper respiratory tract infection in 144 patients (48%), lower respiratory tract infection in 27 patients (9%), gastroenteritis in 112 patients (37.3%), 10 cases (3.3%) with ear infections, and 7 cases (2.3%) with skin infection.
A logistic regression model was used to assess the effects of the significant explanatory variables in order to distinguish predictors of IDA as shown in [Table 3]. It was found that children from rural areas (P = 0.026), those from low social class (P = 0.001) and those of illiterate mothers (P = 0.001) were the significant risk factors for IDA in these children.
|Table 3: Results of multivariate analysis of potential risk factors for IDA among studied children|
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On analysis of the dietary history and feeding habits, 27 (9%) infants were exclusively breast-fed until 6 months of age, 37 (12.3%) infants were fed only formula, 49 (16.3%) were fed only cow's milk and 187 (62.3%) consumed combinations of breast milk and formula or cow's milk. [Table 4] shows associations between feeding habits and IDA based on daily breakfast taking, consumption of tea after meals and adequacy of iron intake. Infants who were consuming iron containing foods below 50% of RDA of iron were significantly associated with IDA (P = 0.027).
[Table 5] shows that stunting, wasting and underweight were higher among children with IDA than other nonanemic children, but underweight only was statistically higher among anemic (28.1%) compared to nonanemic children (13.0%).
|Table 5: Relation between IDA and some anthropometric measures and mothers evaluation of child health|
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Mother's evaluation of child health status had no significant relation with IDA with 55.2% of mothers of anemic children compared to 51.9% of mother of nonanemic children reporting child health status as poor. Most of those who report their child health as poor among anemic group linked the health status to current illness and not due to anemia.
Scholastic achievements were compared among children with IDA and nonanemic child above 6 years and go to school (a total of 94 child with 53 anemic and 41 nonanemic). It was found that 23 (34.4%) out of 53 child had bad scholastic achievement compared to 11 (20.8%) out of 41 nonanemic child with no statically significant difference.
| Discussion|| |
Iron deficiency anemia continues to be an overwhelmingly the leading cause of anemia in early childhood and a global public health challenge.  Approximately 40% of children are anemic across various African and Asian settings. 
The frequency of anemia in Egypt (as developing countries) is much higher than developed countries, so this study was aimed to investigate the frequency of anemia in Al-Fayom Governorate. The frequency of IDA was 64% among the studied group. This is higher than other Egyptian studies where the prevalence of IDA was 43% and 55% among studied sample of school children in Cairo and El-Minofia, respectively. , When compared to other developing countries, the prevalence of IDA was 72% and 69% among children in Jordan and India, respectively. , On the other hand, in developed countries the prevalence of IDA is much lower as Norway (5%),  United States (3.6%),  and average of developed European countries (7%).  The disturbing high prevalence of iron deficiency among our study population might be explained by the consumption of unfortified cow's milk feeding during the 1 st year of life, low intake of iron-rich foods, unmet increased needs for iron due to rapid growth, intestinal parasitic infestation or frequent consumption of tea with meals. Unfortified cow's milk is not only a poor source of iron, but its use may also be associated with occult bleeding from the gut.  This high frequency is enough to consider IDA a severe public health problem according to WHO classification. 
A significant percentage of infants below 2 years in the developing countries are anemic, causing considerable health consequences for these age groups. In this study, infants below 2 years constituted 42% of the study population with IDA. This agrees with Villalpando et al. who found similar results.  This could be explained by the high prevalence of iron deficiency observed in pregnant women so that the babies are already born with poor iron stores and faulty weaning practices where the transition from full lactation to the family diet occurs within the first 2 years of life, and in this period weaning foods are mainly rice and starch and deficient in iron. Unfortunately, these faulty weaning practices couldn't be proved in this study due to the wide range of age of the included sample. However, this emphasizes the importance of prophylactic iron supplements recommended by CDC for children between 6 and 23 months, which is not applied in Egypt. 
Logistic regression analysis revealed that children from rural areas and lower social class children were significantly at higher risk for IDA. This agrees with other studies which stated that populations that belongs to a lower socioeconomic status are more prone to IDA. , This may be because lower-income households could have limited access to iron-rich foods and are more prone to parasitic infestations.
This study emphasized the importance of maternal education on the health of children. We found that children of illiterate mothers are more prone to develop IDA than children of mothers with higher educational levels with statistically significant difference. This is in accordance with similar studies from Malaysia and China who reported that the mean Hb and SF levels were lower among children of illiterate mothers. , However, other studies demonstrated that the association between low maternal education and anemia was not significant among preschool children. , This could be due to the different age groups involved in their study. Besides that, the introduction of iron-rich foods as weaning foods depends more on cultural-related beliefs than on the level of maternal education.
The current study highlighted the ingestion of low iron containing foods as a significant predictor of IDA, which agrees with previous similar studies. ,
This study showed that stunting, wasting and underweight were associated among iron deficient anemic children, but underweight only was statistically significant. This agrees with Soliman et al. who reported that IDA during the first 2 years of life significantly impairs growth, and there is a significantly correlation between growth velocity and SF concentration.  Also Luo et al. mentioned that children with anemia were shorter for their age, and a higher percentage of them of them had stunted growth. 
As regards scholastic achievements, it was better in the non-IDA group without a statistically significant difference. WHO reported that IDA evidently delays psychomotor development and impair cognitive performance of infants, preschool and school-aged children.  Furthermore, Luo et al., mentioned that anemia status negatively correlated with the performance on tests of physical and cognitive development. 
However, this study has some limitations: The first is that it is a hospital-based study. Second, this was a cross-sectional mainly laboratory-based study and thus, detailed information on patient clinical variables, treatments, and outcomes were unknown.
It can be concluded that there is a high frequency of IDA among Egyptian children, which appears to be a severe public health problem. Therefore, we recommend wider epidemiological studies to study this problem. Furthermore, arrangement of campaigns through the mass media to highlight the foods containing high iron contents is recommended. Prophylactic iron supplementations should be given to susceptible infants, especially from 6-23 months.
| Acknowledgments|| |
We thank the physicians, the patients and their families who participated in this work for their kind help.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
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