Aetio-pathological profile of anaemic children belonging to upper socio-economic society in a tertiary care hospital of North India

Introduction: Anaemia is a major public health problem especially in the preschool age group. It is rampant even in children of upper and middle classes of society. Objectives : To study the aetio-pathology of anaemia in children belonging to upper and upper middle socio-economic scale and to correlate it with their nutritional status. Method: It was a cross-sectional descriptive study on 165 preschool children aged 6-59 months who presented with pallor on clinical examination. They were advised to undergo a complete haemogram and further specific tests as required. Results: The most common cause of anaemia was nutritional, including iron deficiency (92%), combined iron and B 12 deficiency (2%) and isolated B 12 deficiency (0.6%). Thalassaemia was the next common cause (3%) followed by B-acute lymphoblastic leukaemia (1%) and microangiopathic haemolytic anaemia (0.6%). Maternal education and nutritional awareness had positive correlation with anaemia. Majority of children were normally nourished despite being anaemic, However, undernourished children were more severely anaemic. Conclusions: Nutritional anaemia is the commonest cause of anaemia even in children belonging to higher socio-economic classes.

among women, and 42% of cases in children under 5 years of age worldwide 4 .It was noticed that prevalence of anaemia was high even in children belonging to upper and upper middle class socioeconomic scale according to Modified Kuppuswamy Classification 5 .Yet, there is no study on the prevalence or on the causes of anaemia in children belonging to this section of the society.

Objectives
To study the aetio-pathology of anaemia in children belonging to upper and upper middle socio-economic scale and to correlate it with their nutritional status.

Method
A descriptive hospital-based cross-sectional study was conducted in a tertiary care hospital in North India on all children aged 6-59 months presenting to the Department of Paediatrics with pallor and haemoglobin (Hb) levels lower than normal for age as per World Health Organisation (WHO) cut-off value (11g/dl) 6 .Critically ill children, diagnosed cases of haemoglobinopathies and red blood cell (RBC) defects and children with known chronic diseases were excluded from the study.
A detailed history was taken, physical examination was done and recorded in the study proforma.These children had a complete haemogram including Hb, RBC count, reticulocyte count, total and differential leucocyte count, platelet count, mean corpuscular volume (MCV), mean corpuscular haemoglobin, mean corpuscular haemoglobin concentration and red cell distribution width.Peripheral blood film, stool routine/ microscopic examination and stool for occult blood were done in all cases.Table 1 shows the cut-off values to label as deficient.
Iron studies [serum iron, serum ferritin and total iron binding capacity (TIBC)] were done in all cases.Transferrin saturation was derived from the serum iron and TIBC by using the formula:

Transferrin saturation = serum iron /TIBC
Mentzer index was derived from the values in the Coulter report by the formula:

Mentzer index = MCV/ RBC count
If the Mentzer index was less than 13 and anaemia was microcytic-hypochromic, high-performance liquid chromatography was done.If the anaemia was megaloblastic or dimorphic, plasma vitamin B12 and serum folic acid were estimated.If the anaemia was normocytic with thrombocytopenia and/or leucocytosis or leucopoenia or if the peripheral blood smear showed atypical cells or blast cells, a bone marrow examination was done.
Anthropometric measurements of weight, height, mid upper arm circumference (MUAC), were done in all children.All children were assessed according to WHO criteria 9,10 of weight for age (WFA), weight for height (WFH), height for age (HFA), MUAC and body mass index (BMI).Children whose BMI was >85 th centile for age were categorised as overweight, and those whose BMI was above 95 th centile, were categorised as obese.Undernourished children were categorised as wasted and stunted according to Table 2.

Results
Table 3 shows the demographic variables of the study population.Anaemia was found in 69.1% normally nourished children and in 29.7% undernourished children.
Table 4 shows the aetio-pathology of anaemia in the study population.Aetio-pathological profile showed iron deficiency anaemia to be the cause of anaemia in 92% of the study population.
Figure 1 shows the degree of anaemia in relation to the nutritional status of children.Children with severe anaemia were more in the undernourished group (57.1%) when compared to the normally nourished (28.9%) and overweight/obese group (50%).This difference in number was found to be statistically significant (p=0.007,Fisher Exact Test).Table 5 shows the comparison of variables with varying degree of anaemia.Of 119 children exclusively breast fed for 6-months, 5% had mild, 61.3% had moderate and 33.6% had severe anaemia.This difference was not significant (p=0.120,Fisher exact test).Of 109 children who were started on complementary feeds at 6 months, 65.1% had moderate and 34.9% had severe anaemia (p<0.001,Fisher exact test).Eighty-seven children were on a diet largely based on cow's milk and all of them had higher grades of anaemia (moderate and severe) (p<0.001,Fisher exact test); 116 children were on a vegetarian diet and all of them had higher grades of anaemia (moderate and severe) (p = 0.001, Fisher exact test).
Prevalence of anaemia was more in children whose mothers had studied till 10th class or below, whereas it was moderate in children whose mothers had studied in high school or were graduates (p<0.001,Fisher exact test).All 10 children (100%) whose fathers were deployed at or posted at other locations and living away from their families had moderate anaemia.Among the children whose fathers were living with them 3.9% had mild anaemia, 56.1% had moderate anaemia and 40% had severe anaemia.Only 35 (22.6%) children had received iron supplementation; 77.4% children who did not receive iron supplementation were found to be more severely anaemic than those who received it (22.7%)(p = 0.002, Fisher exact test).
Table 6 shows the IDA and non-IDA cases in nutritional status children of the study population.

Discussion
The study population comprised 165 anaemic children aged 6-59 months, presenting to a tertiary care hospital of North India.All children belonged either to upper class or upper middle class according to modified Kuppuswamy classification.Significantly greater number of children had higher grades of anaemia (moderate and severe) in the upper middle class compared to upper class.Since Kuppuswamy classification takes into account the education, occupation and income of only the head of family, although all children belonged to the upper and upper middle classes, mothers of many of these children were less educated.Significant association was found between poor maternal education and the severity of anaemia.Due to job exigencies, there is separation of the family from the father in many homes.Hence, the association of this factor with the degree of anaemia was also studied.It was found that a greater number of children, whose fathers were staying with them, had higher grades of anaemia (moderate and severe) when compared to those children whose fathers were staying away from them but this difference was not statistically significant.Though these families belonged to higher socioeconomic status, still the most common cause of anaemia in these children was nutritional like in the general population.Thus, there definitely is a basic lack of awareness regarding the right feeding practices both among fathers and mothers of these children, reiterating the role of educational activities regarding proper feeding and nutrition.
The present study was conducted in India and the subjects belonged to the upper and upper middle class; hence, there were no cases of infections leading to anaemia; yet, nutritional anaemia was the commonest cause probably due to lack of nutritional awareness among parents.Mouneke VU, et al 11 in their study in Nigeria found malaria to be the commonest cause, followed by sickle cell anaemia, septicaemia and malnutrition.Ringhetti AA, et al 12 in their study in West Africa found that malaria was the main cause in infants and inflammation and/or irondeficiency anaemia were common causes in older children.Unnikrishnan SR, et al 13 in Chennai also found that hypochromic anaemia was the most common type followed by dimorphic anaemia and there was a good correlation between IDA and protein energy malnutrition.
In our study, the cause of anaemia in 92% was iron deficiency despite the study population belonging to the upper middle-class socio-economic status.A few cases of combined iron-vitamin B12 deficiency (2%) and isolated vitamin B12 deficiency (0.6%) were also found.Thus, the most common cause of anaemia in our study was nutritional.This indicates the need for health education to impart nutritional knowledge about the right infant and young child feeding practices.
Exclusive breast feeding was found to have no significant relationship to the degree of severity of anaemia.A significantly large number of infants who were started on complementary feeds at 6 months of age were found to have higher degrees of anaemia when compared to children who were started on complementary feeds later, again indicating the lack of knowledge regarding proper weaning practices and foods.A diet largely based on cow's milk was found to be significantly associated with higher grades of anaemia and so was vegetarian diet.
In the present study, children belonged to only upper and upper-middle socio-economic status and lived in hygienic living conditions; 61.8% mothers were educated more than Class X.In contrast, Leite MS, et al 14 in Brazil found that children had less chances of being anaemic if mothers had >10 years schooling and better hygienic environmental conditions.There were similar findings by Rani P J, et al 15 in India where anaemia was more prevalent in children with low socio-economic status, female sex and in vegetarians.Kikafunda JK, et al 16 [ in their study in Uganda and Sougandis ES, et al 17 in their study in Indonesia also found positive correlation with low maternal education and knowledge of anaemia.
In the present study, the majority of children were found to be normally nourished or overweight and only 49 out of 165 children studied were undernourished.Although undernourished children were more likely to be severely anaemic, within each category of mild, moderate and severely anaemic children, significantly greater number of children were found to be normally nourished (as per WFA, WFH, HFA and MUAC criteria) rather than being undernourished and 2 children were found to be overweight -one of them was moderately anaemic and the other severely anaemic.These findings indicate that it is not the lack of food and resources that is contributing to anaemia in this study population but the lack of nutritional knowledge in the parents regarding balanced and iron rich diet and also the fact that these children are growing up in compromised extrinsic social situations due to separation from the father and living alone with the mother.This is contrary to findings in many previous studies, where undernutrition was significantly associated with anaemia.George KA, et al 18 in their study in Kerala also concluded that nutritional status of the study population was associated with haemoglobin levels.Jain S, et al 19 studied children of slums of Meerut and found positive correlation between nutritional status and anaemia and concluded that maintaining adequate nutritional status had a definite role in preventing anaemia.Siegel EH et al 20 in their study in Nepal found that bivariate analyses showed stunting and underweight to be associated with low haemoglobin concentration and/or anaemia.Santos RF, et al 21 in Brazil found that anaemia had significant correlation with low weight for age.Rocha DS, et al 22 in Brazil also concluded that risk factors for anaemia were nutritional status and age.Unnikrishnan SR et al 13 in Chennai also found a positive correlation between anaemia and protein energy malnutrition.
The study had some limitations.It was conducted in a tertiary care hospital and hence had a greater probability of less common causes of anaemia like leukaemia and microangiopathic haemolytic anaemia to be overrepresented.The subject population belonged to the higher socioeconomic status and hence had a greater possibility of infections like malaria and helminthiasis to be underrepresented.Yet, the purpose of the study was to know the aetio-pathology in this particular stratum of the society.However, further randomized control trials in different centres are required to overcome the limitations.

Conclusions
In a study carried out in a tertiary care hospital in Northern India, nutritional anaemia was the commonest cause of anaemia in children belonging to the higher socioeconomic classes.

Table 5 :
Comparison of variables with varying degree of anaemia Variable

Table 2 :
9,10ropometric parameters9,10 variables.The significance threshold of p-value was set at <0.001.All analyses were carried out using Statistical Package for Social Sciences software version 23 (IBM SPSS Statistics for Windows, Version 23.0.Armonk, NY: IBM Corp).