Prevalence of microcytic
hypocromic anemia in children with LRTI in the age group of 3 months to
5year: Is iron deficiency anemia a risk factor for LRTI?
Chandrashekar B1
1Dr. Chandrashekar B, Assistant Professor, Department of Pediatrics,
Institute of Medical Sciences, Shivamogga, Karnataka, India
Address for
Correspondence: Dr Chandrashekar B,
Email:chandrashekarb2007@yahoo.com
Abstract
Introduction:
Lower respiratory tract infection (LRTI) include all infections of the
lungs and the large airways below the larynx and includes croup
syndromes, bronchitis, bronchiolitis and pneumonia. Anemia is a major
public health problem that can occur at any stage of the life cycle,
but is more prevalent in pregnant women and young children having iron
deficiency. Methods:
Objective: To evaluate prevalence of microcytic hypocromic
anemia in children with LRTI in the age group of 3 months to 5 year: Is
iron deficiency anemia a risk factor for LRTI. Design: Cross
sectional study. Setting:
A tertiary care center Karnataka, india (SIMS, shivamogga)
Participants: 50 children who admitted for LRTI were included in the
study group. Age and sex-matched 50 children, not having any
respiratory illness, were taken as control group. Main outcome
measures: They were subjected to complete blood count (CBC) mainly for
hemoglobin, hematocrite, RBC indices and RDW in those children. Result: 35 out of 50
children of study group (70%) and 5 out of 50 children of control group
(10%) had anemia. Out of 35 anemic children in study group 21(60%) and
out of 5 anemic children in control group 4 had peripheral blood
picture showing microcytic hypochromic anemia. And out of 35 anemic
children in study group 28 (80%) and out of 5 anemic children in
control group 2 had low ferritin. Conclusion:
these value shows anemia is more prevalent in children with LRTI and
most of those anemic have microcytic hypochromic anemia with high RDW
indicating iron deficiency is the cause for anemia and probably iron
deficiency is a risk factor for LRTI.
Key words:
LRTI, Anemia, Hemoglobin, Serum Ferritine, Hematocrit
Manuscript received: 6th
October 2014, Reviewed:
15th October 2014
Author Corrected: 23rd
October 2014, Accepted
for Publication: 30th October 2014
Introduction
Lower respiratory tract infection (LRTI) includes all infections of the
lungs and the large airways below the larynx and includes croup
syndromes, bronchitis, bronchiolitis and pneumonia [1]. On an average,
children below 5 years of age suffer about 5-6 episodes of LRTI per
year [2]. Anemia is a major public health problem that can occur at any
stage of the life cycle, but is more prevalent in pregnant women and
young children having iron deficiency [3]. Approximately over 75% of
children between the age of 1-3 years are anemic in India [4]. Iron
deficiency anemia in children occurs most frequently between the age of
6 months and 3 years, the same period of age when repeated infections
occur [5].
Lower respiratory tract infections associated with anemia occur more
commonly in children than in adults. But prevalence of anemia in LRTI
and iron deficiency per se as a risk factor for LRTI not evaluated. And
there were only studies on hemoglobin level in respiratory infection.
Hence this cross sectional study was conducted for assessing prevalence
of microcytic hypochromic anemia, and iron deficiency as a risk factor
for developing LRTI in children in the age group of 3months to 5 years.
Aim and objective of
study- To study the Prevalence of microcytic hypocromic
anemia in children with LRTI in the age group of 3 months to 5year: Is
iron deficiency anemia a risk factor for LRTI?
Material
and Methods
This cross sectional comparative study was conducted in Department of
Pediatrics in SIMS, shivamogga between March 2013 to August 2013. A
total of 100 children aging between 3 months and 5 years were selected;
study group included 50 cases hospitalized for lower respiratory tract
infection (LRTI) as per criteria of WHO, and 50 healthy children
without any respiratory problems, age and sex matched, attending Out
Patient Department were included in control group. A written consent
was taken from parents or guardians before they were subjected to
investigations. The following laboratory tests were done in all
children: complete blood count mainly considering hemoglobin,
hematocrit, RBC indices, serum ferritin. Other tests like blood
culture, CXR were done as per respiratory tract infection investigation
protocol.
Blood Screening-
A trained phlebotomist drew blood from the antecubital vein of each
child. Sterile, disposable syringes and needles, and proper tubes were
used. The blood samples were analyzed at SIMS, Shivamogga clinical
laboratory for complete blood count. Hemoglobin level was estimated in
the blood samples using an automatic blood cell counter. The cutoff
point for low hemoglobin (Hb) level, low RBC indices, low hematocrit
and low ferritin were taken from table 1[6,7].
Table-1: Cut of values
for anemia
|
Age group
|
3m to 5 month
|
6 months to 5years
|
|
Hemoglobin (g/dl)
|
<9.5
|
<11
|
|
Hematocrit (%)
|
<35
|
<33
|
|
MCV
|
<95
|
<78
|
|
MCH
|
<25
|
<24
|
|
MCHC
|
<28
|
<33
|
|
Serum FERRITIN
|
<24mg/dl
|
Anemia is defined if patient had value of hemoglobin and hematocrit
below the cut of value for age according to WHO standard as defined in
above table and RBC indices and serum ferritin will be correlated.
Inclusion Criteria- We
included in the study all hospitalized children aged between 3 months
and 5 years with a diagnosis of LRTI; fever, cough, tachypnea, chest
retractions, and ronchi or crackles up on chest auscultation, as per
WHO criteria [2,8,9]. Weight and height were recorded to all children
in order to assess the nutritional status.
Exclusion Criteria-
Exclusion criteria included children with prematurity, congenital chest
wall malformations, severe systemic illness (congenital heart disease,
tuberculosis, etc), chronic diseases (diabetes, hepatitis, liver
failure, etc), intake of iron supplements, and previous history of
infection in the control group.
Statistical Analysis- Data
analysis was performed using statistical package of social science
(SPSS) version 16.0 for windows. Numerical variables were reported in
terms of mean and standard deviation. Categorical variables were
reported in terms of numbers and percentages. Association of each of
the categorical variable with response variable was assessed by
Chi-square test. In multivariate analysis, variables showing P-value
less than 0.05 were considered to be statistically significant. The
sample size, 50 in each group, was found to be capable to define the
expected result.
Results
Study population was taken between 3m to 5years of age. 50 children
with LRTI admitted in department were take in study group as per
definition of WHO and 50 healthy children attending pediatric OPD were
taken in control group.
Table 2: Age distribution
of children were as in below
|
|
Cases
|
Control
|
P
value
|
|
3m
– 5m
|
11
|
10
|
0.06
|
|
6m
–5year
|
39
|
40
|
|
As we can see from table 2 p value is >0.05. So in both groups,
age was not found as a significant factor affecting the result.
Table 3: Sex distribution
of children were as in below
|
|
Cases
|
Control
|
P
vale
|
|
male
|
18
|
20
|
0.17
|
|
female
|
32
|
30
|
As we can see p value >0.05, sex distribution in both groups is
not a significant factor affecting result.
Table-4: Shows the mean
hemoglobin, hematocrit (HCT), RBC indices and serum ferritin in cases
and control
|
|
3m
– 5m
|
6m
– 5year
|
|
Cases
|
Control
|
Cases
|
Control
|
|
HB
|
8.7±1.05
|
9.6±1.1
|
10.4±1.2
|
11.3±1.4
|
|
HCT
|
29.0±3.4
|
35.2±4.2
|
32.2±2.6
|
33.6±3.2
|
|
MCV
|
71.03±9.6
|
91.1±10.4
|
73.5±7.1
|
77.4±8.2
|
|
MCH
|
23.54±2.4
|
25.2±2.8
|
23.7±2.8
|
24.6±2.4
|
|
MCHC
|
31.26±1.7
|
32.4±1.4
|
31.9±1.5
|
33.5±1.8
|
|
S. Ferratin
|
16.79±1.9
|
23.8±1.3
|
17.04±2.6
|
23.2±1.8
|
Table-5: Shows number of
children who had anemia in study group and control group according to
WHO cutoff for age group
|
|
3m – 5m
|
6m -5year
|
Total
|
|
Case
|
Control
|
Case
|
Control
|
Case
|
Control
|
|
Anemic
|
7
|
1
|
28
|
4
|
35(70%)
|
5(10%)
|
|
Normal
|
4
|
9
|
11
|
36
|
15(30%)
|
45(90%)
|
|
P value
|
0.014
|
<0.01
|
<0.01
|
P value 0.014
<0.01 <0.01
From table 5 it seen that there are 70% (35 out of 50) of study group
children (with LRTI) had anemia and only
10% (5 out of 50) of controls (healthy children) had anemia with a
significant p value <0.01.
Table-6: Shows incidence
of microcytic hypochrmic anemia in cases and control
|
|
Total
|
|
Case
|
Control
|
|
Microcytic hypochromic
|
21
|
4
|
|
normal
|
29
|
46
|
|
P value
|
<0.01
|
P value 0.05
In study group 80% children (28 out of 35) and in control group 40%
children (2 out of 5) low serum ferritin indicting probably iron
deficiency is the cause for anemia.
Table-7: Shows low and normal ferritine value in anemic cases and controls
|
|
Cases
|
Control
|
|
Low ferritin
|
28
|
2
|
|
Normal ferritin
|
7
|
3
|
|
P value
|
0.05
|
Discussion
The prevalence of anemia varies between developed and developing
countries. Reaching up to 50% of preschool children in some developing
countries, and is principally caused by iron deficiency. As many as 20%
of children in the United States and 80% of children in developing
countries will be anemic at some point by the age of 18 years old [3].
As per studies published in AAP full-term healthy babies receive enough
iron from their mothers in the third trimester of pregnancy to last for
the first four months of life. However, human milk contains little
iron, so infants who are exclusively breastfed are at increased risk of
iron deficiency after 4 months of age and studies recommend iron
supplementation in full term from 4 months onwards. AAP also recommends
iron supplementation in preterm from 2weeks of age[8].
Most common affected age group was 3 months to 23 months, which is
quite comparable with the study conducted by Malla T et al [5]. The
common involvement of this age group could be because, supplementary
and complementary feeding practices that might be inadequate and
inappropriate, are practiced and advocated widely in this age, due to
which Hb could touch the nadir.
Several risk factors for developing LRTI had been reported in different
studies. Baskaran et al in a study of 43 children between 3-5 years had
found 83 % with pneumonia had hemoglobin less than 11 g/dL[10]. In
another study of iron deficiency anemia and respiratory infection by
De-Silva A et al, an overall prevalence of anemia was found in 52.6%
[11]. He concluded that iron treatment significantly reduced the
morbidity of even children with URTI.
In our study 70% study group and 10% control group had anemia which is
similar to result of Ramakrishnan et al in 2006 found, in a study of
200 infants and children between 9 months to 16 years, that 74% of
cases and 33 % of controls were anemic (with 80% and 82 % IDA,
respectively). In our study mean hemoglobin and hematocrit in study
group in the age group of 3m – 5m was
8.7±1.05mg/dl and 29.0±3.4% respectively and in
the age group of 6m – 5year was 10.4±1.2mg/dl and
32.2±2.6% respectively.
Attending a day care center was reported as the most important risk
factor for respiratory tract infections in children aged 2-5 years
[12]. In a community based study of 288 children, risk factors for LRTI
noted were being a boy, attending a child care center, exposing to
passive smoking and sharing a bed room with children aged 0-5 years
[13]. Few reports are available in literature regarding the role of low
hemoglobin level per se, as a risk factor for developing LRTI. We have
found that anemia more prevalent and most probably cause for anemia
being iron deficiency and iron deficiency is a significant risk factor
for developing LRTI.
It is feasible to recollect the normal functions of Hb. It facilitates
oxygen (O2) and carbon dioxide (CO2) transport. It carries and
inactivates nitric oxide (NO) and also play the role of a buffer [14].
Tissue ‘oxygen buffer’ function is very important
one of buffering system. Hemoglobin in the blood is mainly responsible
for stabilizing the oxygen pressure in the tissues [15]. Quantitative
and/or qualitative reduction in Hb, may adversely affect the normal
functions. Probably it may be the reason for low hemoglobin level found
to be as a serious risk factor for developing LRTI.
Age distribution of our study is comparable to Sheikh Quyoom Hussain et
al in which he studied 220 children from age group of 2m to 5year. And
he mentions in his study that nutritional inadequacy including the iron
deficiency forms an indirect risk factor for the contracting acute
lower respiratory tract Infection (ALRTI) [16].
Table-8: Comparison of
present study with other studies showing association of LRTI with
gender and anemia
|
|
Present study
|
Sheikh et al[16]
|
Malla T et al[17].
|
Mourad S et al[18].
|
Ramakrishanan et al[19].
|
|
Cases (%)
|
Control (%)
|
Cases (%)
|
Control
(%)
|
Cases
(%)
|
Control
(%)
|
Cases
(%)
|
Control
(%)
|
Cases (%)
|
Control (%)
|
|
Sex
|
|
|
Male
|
36
|
40
|
57
|
60
|
71
|
67
|
51
|
52
|
63
|
58
|
|
Female
|
64
|
60
|
43
|
40
|
29
|
33
|
49
|
48
|
37
|
42
|
|
P value
|
NS
|
NS
|
NS
|
NS
|
NS
|
NS
|
|
|
|
|
|
anemia
|
|
|
Present
|
70
|
10
|
64.5
|
28.2
|
68.6
|
38.6
|
68
|
84
|
74
|
33
|
|
Absent
|
30
|
90
|
35.5
|
71.8
|
31.4
|
61.4
|
32
|
16
|
26
|
67
|
|
P value
|
<0.01
|
<0.01
|
0.001
|
<0.001
|
0.008
|
<0.001
|
|
|
|
|
P value <0.01
<0.01
0.001
<0.001
0.008
<0.001
NS: Non-significant
In our study we found in study group 80% of anemic children had low
ferratin. And we all know iron deficiency is the one of the main cause
for anemia and even Iron metabolism is of crucial importance in the
biology and pathophysiology of the lower respiratory tract. As with
many other factors involved in inflammation, it is very important that
an appropriate iron balance is maintained. Local deficiency could
impair growth and proliferation of cells responsible for the
inflammatory response and tissue repair (lymphocytes and fibroblasts)
and the synthesis of mediators (for example, arachidonic acid
derivatives)[16].
Conclusion
In conclusion prevalence of anemia is more in children with LRTI and
most of those anemic cases will have blood picture of microcytic
hypochromic anemia with low serum ferritin indicating probably iron
deficiency is the cause for anemia and probably iron deficiency is the
risk factor for LRTI. Further studies with iron profile needed to
confirm this hypothesis.
Recommendations
So we recommend:
• Screen for anemia in pediatric age group
on a regular bases.
• From the age of 4 months supplement iron
according RDA as recommended by AAP.
• In Indian children most common cause of
iron deficiency anemia is worm infestation. So antihelimenthic
prophylaxis should be offered to all children above the age of 1 year,
every 6 months and if possible to implement this in immunization
schedule like vitaminA as recommended by NRHM Assam in a article named
“Guidelines for Deworming of Young Children -
GiveWell”[20].
• Antenatal supplementation of iron should
be uniformed through national programs as anemia in mother leads to
anemia in infants.
Funding:
Nil, Conflict of
interest: None initiated.
Permission from IRB:
Yes
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How to cite this article?
Chandrashekar B. Prevalence of microcytic hypocromic anemia in children
with LRTI in the age group of 3 months to 5year: Is iron deficiency
anemia a risk factor for LRTI?. Pediatr Rev: Int J Pediatr Res
2014;1(3):82-87. doi: 10.17511/ijpr.2014.3.05.