European Journal of Cardiovascular Medicine

The most common cause of anaemia globally is iron deficiency anaemia  (IDA).¹ According to the Indian National Family Health Survey-5 (NFHS 2009-11), the prevalence of anaemia has risen from 59% to 67% in the last five years.² Despite the existence of National Anaemia Control Programs and treatment guidelines, anaemia is still very common.³  There are few comprehensive studies that look at the factors that facilitate and hinder oral iron therapy.⁴  The present study was designed to examine the various non-modifiable and modifiable factors that affect the outcome of oral iron therapy even when there is good compliance.

Aim:

The current study's goal was to identify iron deficiency anaemia in children and factors affecting response to oral iron therapy in an indian population.

Objectives:

To determine the prevalence of iron deficiency anaemia in children aged 1 to 5 who visited the Medicine department's outpatient department, casualty room, and inpatient unit at Saraswathi Institute of Medical Sciences, Hapur.

Study time and place This observational study was conducted in the Medicine department of Saraswathi Institute of Medical Sciences, Hapur. The study was carried out between December 2012 and March 2014. Study population Children in the 1–5 age range who are presenting to our hospital with signs of iron deficiency anemia. Sample size, sample size calculation and sampling technique The study included 416 participants in total. The study by Inderpreet Santokh et al., which found that 56% of children in a teaching hospital between the ages of 6 and 60 months had iron deficiency anemia, was used to determine the sample size.4. The formula was 𝑛 = 𝑧2𝑝𝑞÷𝑑2. Where; n is sample size, z=1.96 (at 95% confidence interval), p=prevalence=56%, q=100-p=44%, d=precision=5%. Therefore, n=sample size for this study =378. By adding a 10% loss to follow up total sample size becomes 378+38= 416. Consecutive sampling, a type of convenience sampling is followed in the selection of cases till the desired sample size is achieved Inclusion criteria Children whose parents or guardians consented to participate in the study were included. Children between the ages of 1 and 5 who visited the outpatient department, casualty department, and in-patient department at Saraswathi Institute of Medical Sciences, Hapur. Exclusion criteria Children under one year old and those over five years old, as well as those whose parents or guardians declined to allow them to take part in the study, Participants with iron deficiency Anaemia who were not eligible for Iron therapy: In a peripheral smear, lymphoreticular malignancy-blasts Increased reticulocyte count due to hemolysis Pancytopenia Hb <4 gm% requiring a blood transfusion, congenital heart disease, Gastritis continuous vomiting, Children with chronic illnesses and those already receiving iron therapy Data management and analysis The Statistical Software for Social Sciences version 20.0 was used to perform statistical analysis on the data gathered from the questionnaires, which were entered into Microsoft Excel Home & Student . The significance of the relationships between different factors and IDA as well as the factors influencing iron therapy were assessed using the chi-square test and Fisher's exact test. Haematological parameters were compared before and after treatment using the paired t-test. A significant p-value was defined as less than 0.05.

Table 1: factors determining iron deficiency anaemia in children (n=405)

Table 2: factors affecting iron therapy outcome among those who took daily iron therapy (n=154). Parameter N (%)

Haemoglobin, MCV, MCH, Reticulocyte count, and Serum Ferritin levels increased after iron therapy, whereas RDW decreased after treatment. 17.65% (33 out of 187) of children did not take iron syrup daily (poor compliance) due to various reasons. Even with good compliance, some children (25) did not respond to oral iron therapy, the reasons being H/O Low birth weight, Nutritional status of the child, and not following advice regarding medications and gastrointestinal side effects.  Iron taken along with food, tea, and milk has shown a significant negative effect in response to oral iron therapy. IDA is corrected in all 33 children (100%) who have taken iron syrup along with vitamin C-rich foods like lime, and orange. This shows a positive association between vitamin C and iron absorption (p<0.001). History of hospital admission and having gastrointestinal side effects like vomiting and loose stools during the course of therapy has shown a significant negative association in the correction of IDA, whereas constipation, stomach pain, and dark stools have no association.

The most prevalent anaemia in the world is iron deficiency anaemia (IDA).  According to estimates from the World Health Organization (WHO), nearly two billion people, or 25% of the global population, are anaemic, with about half of them having IDA. The prevalence of anaemia in children aged 6 to 59 months rose from 59% to 67%, and it remained higher in children living in rural areas.2 This demonstrates the growing impact of this illness on our nation and the necessity of efficient treatment and prevention plans. Iron deficiency anaemia was identified in 229 of the 416 children in our study. Iron deficiency anaemia affects 55.02% of children aged 1 to 5.  122 children, or 53.28% of the 229 children with iron deficiency anaemia, are between the ages of 1 and 2. In their cross-sectional study, LISBÔA et al. selected 725 male and female children under the age of 60 months at random. In their study, 37.4% of participants had anaemia. Ages 6 to 24 months had the highest prevalence (43.0%). It implies that IDA is more likely to develop in children younger than two. This result is in line with other Veira et al. studies. This might be explained by a combination of low iron intake and the age group's increased need for iron as a result of rapid growth and development. Of the 217 males and 199 females in our study, 115 (53%) and 114 (57.29%) had iron deficiency anaemia, respectively. There is no statistically significant correlation (p value of 0.379) between children's gender and iron deficiency anaemia.   Anaemia is classified as mild (10 g/dl to 10.9 g/dl), moderate (7 g/dl to 9.9 g/dl), and severe (<7 g/dl) based on haemoglobin levels. Most children have moderate anaemia (62.01%), followed by mild anaemia (25.76%) and severe anaemia (12.23%). Iron deficiency anaemia affected 56 out of 100 children in that study group, representing a 56% prevalence.  The age range of 6 to 24 months had the highest prevalence of IDA (65%). Additionally, there was no statistically significant difference (p value>0.05) in the gender of those with iron deficiency anaemia.  In line with our study, the majority of children (46%) had moderate anaemia, 37% mild anaemia, and only 17% severe anaemia.  The compulsive consumption of non-nutritious foods is known as pica. The literature contains numerous reports on the connection between iron deficiency and Pica, including both clinical cases and case series. As reported by other studies, there is a significant correlation between Pica and iron deficiency anaemia. Of the 91 children with Pica complaints, 71 were diagnosed with iron deficiency anaemia in our study with a p value of <0.001. Parents were asked if they had breastfed their children exclusively for the first six months of their lives. While 85 children were not exclusively breastfed for six months, 331 children received EBF in total. While 167 out of 331 children (50.45%) who received EBF developed iron deficiency anaemia, 62 out of 85 children (72.94%) who did not receive exclusive breastfeeding for the first six months of life did.  This implies that the risk of iron deficiency anaemia is high for people who have not breastfed. Lower levels of casein, phosphate, calcium, and substances believed to prevent iron absorption are found in human milk. Human milk contains higher levels of enhancing substances like lactoferrin, ascorbic acid, lactose, cysteine, taurine, and inosine.  However, because human milk is a poor source of iron, some studies have shown that exclusive breastfeeding after six months of age causes the development of IDA .With a p-value of 0.681, which is not statistically significant, 155 of the 278 children who consumed cow milk before the age of one year had iron deficiency anaemia(55.76%), and 134 of the children who did not consume cow milk before the age of one year had iron deficiency anaemia(53.62%). Consequently, in contrast to numerous studies that demonstrate a strong correlation between cow milk consumption and iron deficiency anemia, our study found no link between the development of iron deficiency anemia and cow milk consumption prior to one year of age. Given that the effect of cow's milk on iron absorption is not all or none, this could be the result of recall bias, a smaller sample size, and children consuming cow's milk in varying amounts. It depends on the dosage.14Using the Kuppuswamy scale, the children in our study group were categorized into various socioeconomic classes, and the prevalence of iron deficiency anemia was examined. IDA was present in 56 children (67.86%) in the lower class, 76 out of 105 children (72.38%) in the lower middle class, 91 out of 195 children (46.66%) in the upper middle class, and 24 out of 60 children (40%) in the upper class.  Iron deficiency anemia (IDA) is more common in the lower middle and lower classes, and there is a statistically significant correlation between IDA and various socioeconomic classes (P value <0.001). Our study's questionnaire revealed that 28 kids had either tea, coffee, or milk before or right after taking iron syrup. Of these, 12 kids (42.86%) had not seen an improvement in their IDA despite taking iron syrup every day as prescribed. A p-value of less than 0.001 indicates that these findings are statistically significant. This demonstrates how tea, coffee, and milk have a detrimental impact on iron absorption. All 33 children (100%) who have taken iron syrup along with foods high in vitamin C, such as oranges and lemons, have their IDA corrected, as do the 96 children (79.34%) who have not. This indicates that vitamin C and iron absorption are positively correlated (p value 0.001).  Numerous studies support this. Iron therapy frequently causes nausea and vomiting as side effects.  Significantly, it is present in 26.67% of children who did not respond to iron therapy (p value 0.024). Nine out of seventeen children (52.94%) who complained of loose stools during iron therapy did not have their IDA corrected; this relationship was statistically significant (p value=0.024). This implies that iron therapy is significantly impacted by gastrointestinal side effects.   However, our study found no significant correlation between constipation (p value=0.751) and stomach pain (p value=0.770). Intercurrent infections also affect how well iron is absorbed or used.  A significant determinant of the outcome was the history of hospitalization for any reason. Twelve out of twenty-five cases that did not improve had a history of hospitalization, whereas 125 out of 129 controls who improved had no history of hospitalization. This implies that despite regular iron intake, recurrent infections might be a contributing factor to the lack of improvement.

The substantial prevalence of IDA in children aged 1 to 5 is highlighted by this study. It identifies a number of risk factors that contribute to the development of IDA, such as young age, pica, lower socioeconomic status, and non-exclusive breastfeeding. Furthermore, dietary factors are important; drinking tea, coffee, and milk while taking iron supplements has a negative effect on iron absorption and treatment results. On the other hand, consumption of foods high in vitamin C shows a positive correlation with treatment response. Suggestions It is advised that children who need iron supplements refrain from consuming tea, coffee, and specific foods in order to achieve the best possible treatment results. In order to improve treatment outcomes for pediatric patients, parents must be informed about these dietary restrictions.

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