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Indian Journal of Community Medicine

A Cross-Sectional Study of the Association of Postnatal Growth and Psychosocial Development of the Infants in an Urban Slum of Delhi

Author(s): Meenakshi, SK Pradhan, JG Prasuna

Vol. 32, No. 1 (2007-01 - 2007-03)

Abstract

Background: Anemia is widely prevalent in India and affects both sexes and all age group. Although the National Anemia Prophylaxis Programme (NAPP) has been set up in all states of the country since 1970, the benefits have not yet been appreciated in the target population.
Objective: 1. To assess the prevalence of anemia and its severity in tribal children. 2. To find out age and sex wise distribution of Hb level in these children. 3. To explore different underlying factors of development of anemia.
Methods: The present study is a cross sectional study conducted in tribal villages of Mohana block in Gajapati district of Orissa. A total of 599 tribal children in the age group 6 month – 14 years were recruited from August 2004 to February 2005. The study variables included age, sex, Hb level, food consumption and clinicoepidemiological factors which were analysed by simple proportion and Z test.
Results: About 94% of under five children were found to be anemic and 8.8% of them were severely anemic. Almost all children of age group 5-14 years were anemic, amongst them 59.4% were moderately anemic and 5. 4% were severely anemic. There is no significant difference in mean Hb level between male and female in both the age groups. It was significantly more in the age group of 5-14 years. About 94% were taking food of low iron bioavailability. Pallor was found in 33.6% and H/O irregular fever in 28.7% of children. 26.9% children had splenomegaly. Only 2.3% children had taken IFA supplementation in last one year.
Conclusions: Anemia is a major health problem in tribal children. Reorientation of primary health care functionaries to cover the children under NNAPP with the help of ICDS workers and school authorities.

Keywords: Anemia in Children, Hb Level, Bioavailability of Iron

Anemia is widely prevalent in India and affects both sexes and all age group.1 It is a major public health problem in developing countries especially in preschool children and during pregnancy.2 The National Family Health Survey-II conducted in 1998-99, documented that about 74% children between the ages 6-35 months were anemic.3 Evidence indicates that iron deficiency anemia is associated with impaired performance on a range of mental and physical factors in children including physical coordination and capacity, mental development, cognitive abilities and social and emotional development.4

Although the National Anemia Prophylaxis Programme (NAPP) has been set up in all states of the country since 1970, the benefits have not yet been appreciated in the target population due to constraints like lack of operational feasibility to estimate the hemoglobin level, orientation of field workers and acceptance of the programme by the beneficiaries.

Therefore coverage of children under this programme is still poor and more marked in difficult tribal areas where the nutritional anemia remains as a major health problem due to nutritional deficiency, repeated infection and high prevalence of sickle cell anemia. Most physical examinations include clinical assessment of anemia in patients that form the tip of iceberg. But the “true state” can be assessed by verification of Hemoglobin concentration in blood5 and this should be done in a community setting.

An attempt was made to estimate the problem of anemia in tribal children with following objectives: (i) To assess the prevalence of anemia in tribal children. (ii) To assess the severity of anemia. (iii) To find out the age and sex wise distribution of anemia in children. (iv) To explore the different underlying factors for development of anemia.

Material and Methods

The cross sectional study was carried out in six randomly selected tribal villages of Mohana block in Gajapati district during Aug. 2004 to Feb. 2005. The study subjects included 599 children of age 6 month-14 years in these villages, who attended the health camp voluntarily. After thorough clinical examination, their hemoglobin level was estimated by Sahali’s acid haematin method as part of other laboratory examinations and degree of anemia was decided based on Hb level for the age group.6 Data on recent morbidities and type of food they consumed and iron and folic acid supplementation (Showing the IFA tablets) during last one year were collected from parents by oral questionnaire and analyzed in the Department of Community Medicine, M.K.C.G. Medical College, Brahmapur, Orissa.

Results

Out of 599 study subjects, 53.9% male children and 46.1% female children, 243 were on age group of 6 month-5 years (47.7% males and 52.3% females) and 356 were in age group of 5-14 years (58% males and 42% females).

Table 1: Hemoglobin level in under five children according to gender.

Sex No. of 6 month- 5 years age group children
Degrees of Anemia (Hb in gm./dl)
Mild Moderate Severe Subtotal Normal Total
(8.8-11.0) (6.6-8.8) (< 6.6) (< 11) (≥11)  
Male 41 55 13 109 (93.9%) 07 116
(37.6%) (50.5%) (11.9%) (100%)    
Female 55 57 07 119 (93.7%) 08 127
(46.2%) (47.9%) (5.9%) (100%)    
Total 96 112 20 228 (93.8%) 15 243
(42.1%) (49.1%) (8.8%) (100%)    

Table 1 shows about 94% of under five children were found to be anemic. 8.8% of them were severely anemic. Severity was found proportionately more in male children than females, but the difference was not significant (p>0.05)

Table 2: Hemoglobin level in 5 – 14 years children according to gender.

No. of 5-14 years age group children
Degrees of Anemia (Hb in gm./dl)
Sex Mild Moderate Severe Subtotal Normal Total
(9.6-12.0) (7.2-9.6) (< 7.2) (< 12) (≥12)  
Male 68 124 13 205 (99%) 02 207
(33.2%) (60.5%) (6.3%) (100%)  
Female 56 85 06 147 (98.6%) 02 149
(38.1%) (57.8%) (4.1%) (100%)  
Total 124 209 19 352 (98.9%) 04 356
(35.2%) (59.4%) (5.4%) (100%)  

Table 2 shows that almost all children (99%) were found to be anemic. More than 60% of them had moderate to severe anemia.

Table 3: Children according to their mean hemoglobin level

Age Mean Hb level ( in gm/dl)
Male Female Total***
6 months to 4 years* 8.53 + 1.16 8.70 + 1.29 8.62 + 1.29
(n = 116) (n= 127) (n=243)
5-14 years**
9.01 + 1.26 9.16 + 1.20 9.07 + 1.24
(n =207) (n =149) (n= 356)
* Z = 1.02, p > 0.05 ** Z = 1.12, p > 0.05 *** Z =4.29, p < 0.01

Mean Hb level in under five children was found to be 8.62 gm/dl (±1.29) which was 9.07 gm/dl (±1.24) in children of 5-14 year age group.

This difference in mean Hb level between two age groups was found significant (P < 0.01). The difference in mean Hb level between male and female children in each age group was not significant. (Table 3)

With a low bioavailability diet, children will not be able to meet their iron requirement. The bioavailability of iron in the diet was decided according to the predominant type of food consumed (WHO)6.

According to Table 4, 93.7% children were taking food of low iron bioavailability (5-10%) and 6.3% children taking food of intermediate bioavailability (11-18%) for iron and nobody was taking food of high iron bioavailability (>19%).

Table 4: Type of food consumed by Tribal children (Bioavailability of iron)

Bioavailability of
iron in food
Children 6 months
to 14 year age (%)
Male Female Total
Very low (3-4%) & Low (5-10%) 302 (93.5) 259 (93.8) 561 (93.7)
Intermediate (11- 18%) ** 21(6.5) 17 (6.2) 38 (6.3)
High (>19%) *** 0 0 0
Total 323 (100) 276(100) 599 (100)
* Mainly cereals, roots, and tubers, negligible amount of animal food.
** Mainly cereals, roots, and tubers with some food of animal origin and / or ascorbic acid.
*** Generous quantity of meat, fish, poultry and/or foods rich in ascorbic acid.6

Table 5 reveals that about 34% of children were having positive pallor sign (29.6% of 6m.-5 yrs. and 36.2% of 5-14 years). The 28.7% of children gave the H/O irregular fever during last 15 days (17.7% of children of 6m. – 5yrs. age and 36.2% of 5-14 yrs). Splenomegaly was found in 26.9% of children.

Table 5: Clinical correlation of Anemia in tribal children of 6m. – 14 years

Clinical finding/ Age Group No. of 6 months to 14 year age children
6-5 years
(n = 243)
5- 14 years
(n = 356)
Total
(n = 599)
Positive pallor sign 72 (29.6%) 129 (36.2%) 201 (33.6%)
H/O Irregular fever during last 15 days 43 (17.7%) 129 (36.2%) 172 (28.7%)
Splenomegaly 53 (21.8%) 108 (30.3%) 161 (26.9%)
Receipt of IFA during
last year
0 14 (3.9%) 14 (2.3%)

Only 3.9% of 5-14 yr. children had taken IFA supplementation during last year and none of under fives had taken IFA during last one year.

Discussion

It was observed that among the study population, 53.9 % were male children and 46.1% were female children. About 93.8% of under five children were found to be anemic; of them 42.1% had mild anemia, 49.1% had moderate anemia and 8.8% had severe anemia. Schellenberg D. et al found anemia in 87% Tanzanian under five children, 37% of them had moderate and 3% had severe anemia.7

Almost all children (99%) of age group 5- 14 years were anemic. 64.8% of 5-14 years children were having moderate to severe anemia and rest of them were also anemic according to their Hb level. Verma M. et al in their study on urban school children of age group 5-15 years in Punjab found prevalence of anemia was 51.5%.8 In contrast to higher mean Hb concentration in anemia, severe form of anemia were prevalent in this age group as compared to under fives. Verma A. et al, in their study on adolescent girls found mild, moderate, severe anemia to be 36.6%, 22.4%, 4.8% respectively.1 The causes may be associated with hookworm infestation, malaria and menstrual blood loss in girls.

On analysis of food consumed by tribal children, it was found that about 93.7% children were taking food in which bioavailability of iron was low i.e. 5-10% This may be due to poverty, ignorance etc.

It was observed that about 34% of children were having positive pallor sign of which 29.6% were 6m.-5 yrs. and 36.2% were of 5-14 years. Positive pallor sign could be less sensitive to detect anemia in children as the clinical methods like palmar pallor and pallor in lower palpebral conjunctiva are not standardized and subject to observer variation. In the study by Verma M. et al found clinical pallor in 44% of total children while 51.5% were anemic.8 High proportion (28.7%) of irregular fever and splenomegaly (26.9%) was suggestive of malaria in these children contributing towards anemia in tribal area. Only 3.9% of 5-14 yr. children had taken IFA tablets during last year. None of the under fives received IFA within one year which shows poor coverage of children in NNAPP through primary health care.

Anemia is a major health problem in tribal children. Proportion of children with moderate to severe anemia was quite high. Malaria and splenomegaly add to the problem and increase the severity. Poor coverage of IFA prophylaxis in children is a matter of concern. Reorientation of primary health care functionaries to cover the children under NNAPP with the help of ICDS workers and school authorities and early presumptive antimalarial prophylaxis in all fever cases can prevent anemia in tribal children.

References

  1. Verma A, Rawal VS, Kedia G, Kumar D, Chauhan J. Factors infl uencing anemia among girls of school going age ( 6-18 years) from the slums of Ahmedabad City. Indian Journal of Community Medicine Jan.- Mar. 2004; 29 (1): 25-26.
  2. Ghosh S, Mohan M. Screening of Anemia. Lancet 1978; 1: 823.
  3. Technical consultation on “Strategies for Prevention and control of Iron Deficiency Anemia amongst under three children in India.” Indian Pediatrics 2002; 39 (7): 640-647.
  4. Preventing Iron deficiency in women and children, technical consensus on key issues.7-9 October 1998, UNICEF, UNU, WHO, MI, Technical group International Nutrition Foundation, USA 1998;
  5. Gjorup T, Bugge PM, Hendriksen C, Jensen AM. A critical evaluation of the clinical diagnosis of anemia. American journal of epidemiology 1986; 124 (4): 657.
  6. DeMeyer EM. Preventing and controlling Iron deficiency anemia through Primary health care. World Health Organization, Geneva, 1989; 20-1.
  7. Schellenberg D, Armstrong Schellenberg JRM, Mushi A, de Savigny D, Mgalula L, Mbuya C. et al. The silent burden of anemia in Tanzanian children: a community based study. Bulletin of the World Health Organization 2003; 81 (8): 581- 590.
  8. Verma M, Chhatwal J, Kaur Gurumeet. Prevalence of anemia among urban school children of Punjab. Indian Pediatr 1998; 35 (12):1181-1186.

Deptt. of Community Medicine, M.K.C.G. Medical College,
Brahmapur, Orissa.
E-mail: [email protected],
[email protected]
Received: 7.12.05

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