European Journal of Cardiovascular Medicine

Anemia remains a major global public health issue, impacting human health, social, and economic development across both developing and developed nations. In developing countries, prevalence rates range from 29.2% to 79.6%, with 13.6% reported in Southeast Asia[1,2]. Among children, anemia impairs cognitive performance, behavioral and motor development, coordination, language skills, scholastic achievement, and increases susceptibility to infectious diseases[3].

Megaloblastic anemia (MA), a subtype of macrocytic anemia caused primarily by deficiencies in vitamin B12 (cobalamin) or folate, is a leading cause of anemia and pancytopenia in pediatric populations, especially in India where vegetarian diets contribute to B12 deficiency[4]. Over the past two decades, the incidence of MA has risen in India due to dietary patterns. Vitamin B12, a water-soluble vitamin essential for DNA synthesis, fatty acid, and amino acid metabolism, is obtained mainly from animal products, making vegetarians particularly vulnerable. Folate deficiency, though less common, exacerbates the issue[5-7].

MA results from impaired DNA synthesis, leading to nuclear-cytoplasmic asynchrony in erythroid precursors, macro-ovalocytes, hypersegmented neutrophils, and often pancytopenia. In underdeveloped countries, malnutrition drives its prevalence, which varies from 2% to 40% in Indian studies[8-9].– This study investigates the prevalence, associated factors, and clinico-hematological profile of MA in children aged 1-14 years to guide early diagnosis and intervention.

Aims & Objectives

1. To estimate the prevalence of megaloblastic anemia among children aged 1–14 years presenting with anemia.
2. To identify factors associated with megaloblastic anemia (diet, socioeconomic).
3. To describe clinical presentations and hematologic features of MA in this population.

Study Design and Setting

This retrospective observational study was conducted at the Department of pathology, MNR Medical College, Telangana, India,  serving a predominantly rural and low-socioeconomic population. The study period was from January 2023 to December 2024. Ethical approval was obtained from the Institutional Ethics Committee , and the study adhered to the Declaration of Helsinki principles. As a retrospective review, informed consent was waived.

Study Population

Children aged 1-14 years diagnosed with anemia (hemoglobin <11 g/dL for 6 months-5 years, <11.5 g/dL for 6-11 years, <12 g/dL for 12-14 years, per WHO criteria) and confirmed MA were included. Diagnosis of MA required: (1) macrocytic anemia (MCV >95 fL); (2) hypersegmented neutrophils (>5% with ≥5 lobes) or megaloblastic changes on peripheral blood smear (PBS); (3) confirmation via bone marrow aspiration showing megaloblastic erythropoiesis; and (4) low serum vitamin B12 (<200 pg/mL) and/or folate (<3 ng/mL). Exclusion criteria included hemolytic anemias, thalassemia, leukemia, or drug-induced anemias.

A total of 524 anemic children were screened from hospital records; 150 met the inclusion criteria, yielding a prevalence of 28.6%.

Data Collection

Data were extracted from medical records using a structured proforma. Variables included: demographics (age, sex, socioeconomic status); clinical features (pallor, anorexia, weakness, irritability, glossitis, knuckle hyperpigmentation, icterus, neurological symptoms); hematological parameters (hemoglobin, MCV, MCH, WBC count, platelet count, reticulocyte count); biochemical tests (serum B12, folate, homocysteine); and etiological factors (dietary history, malabsorption). Bone marrow reports and treatment responses were noted.

Laboratory tests:

Complete blood count using automated Sysmex analyzer (MCV, RBC count, TLC, platelets). Peripheral blood film (PBF) examination. Serum vitamin B12 and folate by Chemiluminescence Immunoassay (CLIA). Deficiency thresholds: B12 <200 pg/mL, folate <5.0 ng/mL. Other tests as clinically indicated (reticulocyte count, LFTs, LDH, haptoglobin, bone marrow exam when performed).

Definitions & grading:

WHO hemoglobin thresholds for age-groups were used. Macrocytic anemia defined as MCV >95 fL. Leukopenia <4000/cumm; thrombocytopenia <1.5 lakh/cumm.

Statistical Analysis

Data were analyzed using Python 3.12 with pandas and scipy libraries. Categorical variables were summarized as frequencies and percentages. Continuous variables as means ± SD. Associations between variables  were assessed using chi-square tests or Fisher's exact test. Prevalence was calculated as (number with MA / total anemic children) × 100. P < 0.05 was considered significant.

Demographic Characteristics

Of 150 patients, 78 (52%) were males and 72 (48%) females. Age distribution: 1-5 years (n=92, 61.3%), 6-10 years (n=42, 28%), 11-14 years (n=16, 10.7%). Mean age was 5.2 ± 2.8 years. Most (92%) were from low socioeconomic status with vegetarian diets(table 1 &2).

Table 1. Age distribution (n=150)

Table 2. Sex distribution

Clinical Profile

Pallor was the most common sign (147/150, 98%), followed by anorexia (128/150, 85.3%), generalized weakness (108/150, 72%), and irritability (98/150, 65.3%). Other features: knuckle hyperpigmentation (68/150, 45.3%), glossitis (48/150, 32%), icterus (22/150, 14.7%), and neurological symptoms (paresthesias, hypotonia; 15/150, 10%). Vomiting/diarrhea occurred in 28 (18.7%), and failure to thrive in 45 (30%). Comorbidities included hypocalcemia/vitamin D deficiency (n=32, 21.3%), scabies (n=8, 5.3%), UTI/AGN (n=6, 4%), and pneumonia (n=4, 2.7%)(Table 3).

Table 3. Clinical features (major items)

Females had higher rates of glossitis (p=0.02) and hyperpigmentation (p=0.04). Younger children (1-5 years) presented more with irritability (p<0.01).

Hematological Profile

Mean hemoglobin was 6.8 ± 1.5 g/dL (range 3.5-9.5). All had macrocytosis (MCV 102.4 ± 8.2 fL; range 96-125). Mean MCH was 32.1 ± 4.5 pg. Pancytopenia (Hb <10 g/dL, WBC <4,000/μL, platelets <1,50,000/μL) was seen in 102/150 (68%). Neutropenia in 95 (63.3%), thrombocytopenia in 88 (58.7%). Hypersegmented neutrophils on PBS: 138/150 (92%). Bone marrow showed megaloblastic changes in all, with giant metamyelocytes in 85%.

Reticulocyte count was low initially (0.5-1.5%) but rose post-treatment. Indirect bilirubin was elevated in 45 (30%), indicating ineffective erythropoiesis(Table 4).

Table 4. Cell lineage involvement

Etiological and Biochemical Profile

Vitamin B12 deficiency: 117/150 (78%); folate deficiency: 23/150 (15.3%); combined: 10/150 (6.7%). Causes: dietary inadequacy (138/150, 92%), malabsorption (8/150, 5.3%), and congenital (4/150, 2.7%). Elevated homocysteine (>15 μmol/L) in 72% of B12-deficient cases(Table 5).

Table 5. Peripheral smear morphology

Treatment and Outcome

All received intramuscular B12 (1 mg/day for 7 days, then weekly) and/or oral folate (5 mg/day). Iron/calcium/vitamin D supplemented as needed. Antibiotics for infections. Hematological recovery (Hb rise >2 g/dL, reticulocytosis >5%) occurred in 143/150 (95.3%) within 4 weeks. No relapses at 3-month follow-up in 120 cases(Table 6).

Table 6: Key Demographic, Clinical, and Outcome Summary

This study highlights MA as a common (28.6%) yet treatable cause of anemia in Indian children, aligning with prior reports of 2-40% prevalence[10].– The female predominance in certain symptoms (e.g., glossitis) mirrors Sudha Gandhi et al.'s findings (52.88% anemia prevalence, higher in girls)[11]. Nonspecific presentations like pallor and weakness underscore the need for high suspicion in anemic children.

Hematologically, universal macrocytosis and hypersegmentation corroborate classic descriptions[12]. B12 deficiency dominance (78%) reflects vegetarian diets, as humans rely on animal sources for cobalamin synthesized by microbes. Folate deficiency (15.3%) links to poor intake of leafy greens[13]. Pancytopenia (68%) indicates advanced disease, differing from milder cases in developed nations[14].

Rapid response to supplementation (95.3%) emphasizes treatability, as noted historically by Minot and Murphy[15-16]. Limitations include retrospective design and single-center data; prospective multicenter studies are needed. Public health interventions like food fortification (e.g., cereals with B12/folate) could reduce burden, as in the US post-1998 fortification.

The high rate of combined deficiency suggests dietary insufficiency (vegetarian diet) and socioeconomic determinants play a major role in this population. Severe anemia was frequent (40%); however, only 27.3% required PRBC transfusion, suggesting many severe cases were clinically compensated or managed conservatively until hematologic response to vitamin repletion.

MA in children aged 1-14 years presents with pallor, weakness, and macrocytic pancytopenia, predominantly due to B12 deficiency. Early PBS and vitamin assays enable prompt, effective treatment. Nutritional education and fortification are essential to curb this preventable disorder.

Clinical implications:

In any child with macrocytosis or cytopenia, prompt evaluation for B12/folate deficiency (and early supplementation) is warranted. Dietary counseling and, where appropriate, public health measures (fortification, supplementation programs) may reduce burden.

Limitations

• Single-center, hospital-based observational design — not population-based; may overrepresent severe cases.
• Some investigations (e.g., methylmalonic acid, holo-transcobalamin) were not used to refine subclinical B12 deficiency.
• Neurological follow-up and long-term outcomes were not systematically reported in the dataset provided.

Recommendations

• Routine vitamin B12 and folate assays for macrocytic anemias in children.
• Nutritional counseling targeting adolescents, especially vegetarian populations.
• Consideration of local public health measures (fortification/supplementation) and further population-based studies.

Acknowledgments

I thank all the faculty , teaching and non-teaching staff of Department of pathology, MNR Medical College, Telangana  and participants of my study for their valuable contribution The authors would like to thank all of the study participants and the administration of Department of pathology, MNR Medical College, Telangana, India  for granting permission to carry out the research work.

Conflicts of Interest

None declared.

Funding

None.

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