|Year : 2015 | Volume
| Issue : 3 | Page : 663-669
Epidemiology of iron-deficiency anemia among primary school children (6-11 years), Menoufia governorate, Egypt
Gaafar M Abdel-Rasoul, Rabie E El Bahnasy, Hewaida M El Shazly, Hala M Gabr, Nehad B Abdel-Aaty
Department of Public Health and Community Medicine, Faculty of Medicine, Menoufia University, Al-Menoufia, Egypt
|Date of Submission||10-Mar-2014|
|Date of Acceptance||10-Apr-2014|
|Date of Web Publication||22-Oct-2015|
Nehad B Abdel-Aaty
Departments of Public Health and Community Medicine, Faculty of Medicine, Menoufia University, Gamal Abdel Nasser Street, Shebin El-Kom, Al-Menoufia 32111
Source of Support: None, Conflict of Interest: None
Iron deficiency is the most prevalent nutritional disorder worldwide and nearly two billion individuals have anemia. Iron deficiency is the most frequent cause of anemia, especially in infants, preschool children, and school-aged children; it is related to a variety of developmental and behavioral changes.
This study aimed to estimate the prevalence and identify possible risk factors of iron-deficiency anemia (IDA) among a representative sample of primary school children (6-11 years), Menoufia governorate.
Participants and methods
A cross-sectional descriptive study was carried out in Menoufia governorate. This study was carried out in Shebin El-Kom city. The study sample included 497 students (242 boys, 255 girls). Blood samples and questionnaires were collected through school visits. A complete blood count was performed on all collected samples, and a serum ferritin test was carried out for anemic ones.
The prevalence of IDA was 25.6%. The result showed that anemia was higher in children from urban areas (63.8%) than rural areas (36.2%) and in children from low and middle socioeconomic (59.1%) backgrounds than those from high socioeconomic standard (40.9%). There was a significant relationship between children without IDA and anemic children in dietary habits, school achievements, and manifestations related to anemia (P < 0.05).
Conclusion and recommendations
The prevalence of iron deficiency is high among primary school children; to combat this problem, a program should be implemented by the government, especially the Ministry of Education and Ministry of Health, targeting both children and their parents through different public media approaches. Programs should focus on the nutritional and behavioral needs of this group of children, such as comprehensive iron supplementation programs.
Keywords: Anemia, epidemiology, iron deficiency, school children, serum ferritin
|How to cite this article:|
Abdel-Rasoul GM, El Bahnasy RE, El Shazly HM, Gabr HM, Abdel-Aaty NB. Epidemiology of iron-deficiency anemia among primary school children (6-11 years), Menoufia governorate, Egypt. Menoufia Med J 2015;28:663-9
|How to cite this URL:|
Abdel-Rasoul GM, El Bahnasy RE, El Shazly HM, Gabr HM, Abdel-Aaty NB. Epidemiology of iron-deficiency anemia among primary school children (6-11 years), Menoufia governorate, Egypt. Menoufia Med J [serial online] 2015 [cited 2020 Feb 24];28:663-9. Available from: http://www.mmj.eg.net/text.asp?2015/28/3/663/165127
| Introduction|| |
Iron-deficiency anemia (IDA) is a decrease in the total hemoglobin (Hb) levels caused by iron deficiency. It is the most common cause of anemia worldwide . The WHO defines anemia as an Hb concentration 2 SD below the mean Hb concentration for a normal population of the same sex and age range .
IDA is caused by inadequate intake of iron, chronic blood loss, or a combination of both . Vulnerable age groups such as infancy, early childhood, and adolescence are placed at a high risk level for the development of IDA because of rapid physical growth, especially in boys, and menstrual iron losses in girls . Poor diet quality and low dietary iron bioavailability are the principal factors that contribute toward the increased incidence of IDA .
According to a UNICEF report, more than two billion individuals have anemia worldwide and most of them have IDA, especially in underdeveloped and developing countries, where 40-50% of children are iron deficient compared with 6-20% in developed countries .
In Egypt, previous studies have indicated that anemia is a major public health problem among children, especially school children. It affects ~30-40% of children . Iron deficiency anemia found to be the most common cause of anemia among Egyptian infants 6 to 24 months of low socioeconomic standard affecting 43% of them . In Qena governorate, the prevalence of IDA was 12% among children in the age group of 6-11 years . Recent studies have shown that iron deficiency may be associated with both hematologic and nonhematologic adverse effects, which may be irreversible .
The diagnosis of iron deficiency is made primarily on the basis of laboratory measurements. However, the tests used commonly have limitations because of their poor sensitivity or specificity, or because they are modified by conditions other than iron deficiency (such as inflammation). Therefore, combining several iron status indicators provides the best assessment of iron status .
A complete blood count may indicate low Hb levels. Serum ferritin reflects total body iron stores. The most useful single laboratory value for the diagnosis of iron deficiency may be plasma ferritin .
The treatment of IDA depends mainly on oral iron supplements, which are desirable as a first-line therapy. The most commonly used preparations are ferrous fumarate, ferrous sulfate, and ferrous gluconate and the main side effects are gastrointestinal disturbances. Treatment should be continued for at least 3 months at a dose of 3-6 mg/kg/day, best taken between meals on an empty stomach .
Strategies for the prevention of IDA in infants and children should be directed toward ensuring adequate iron status from the fetal stage by improving maternal iron status; interventions to ensure that the iron needs of the infant continue to be met postpartum are also important - for example, management of the delivery process, feeding practices of the newborn, including breast or formula feeding, complementary food practice, and finally provision of adequate iron through supplements or iron-rich foods .
The motivation behind this study is the importance of iron deficiency anemia and expected adverse effect on Scholastic achievement and growth development in children. Also, there is a lack of sufficient information on IDA among primary school children (6-11 years) in Menoufia governorate.
| Participants and methods|| |
This study was carried out during the period from 1 March to 31 December 2013 (practical part and data collection were carried out from the beginning of March to the end of April 2013) in Menoufia governorate primary schools. The Menoufia Faculty of Medicine Committee for Medical Research Ethics reviewed and formally approved the study before it was initiated. Approval from the Ministry of Education was obtained, and the guardians of all participants provided written consent.
In this study, the calculated sample size was 500 using the Epi Info program (Atlanta, Georgia, USA) depending on the total number of primary schools children during the scholastic year (2012-2013), which was 72 259; the lowest prevalence in previous studies was taken into consideration in this calculation. There were three dropouts; thus, the response rate was 99.4% and the total sample size was 497 children. The sample was a multistage random sample; one district (Shebin El-Kom) out of 10 districts was chosen randomly. One urban primary school (El-Salam) in Shebin El-Kom city and another rural primary school (El-Nagah) in El-Batanon village were chosen randomly and then one class from each grade was chosen randomly in the selected schools.
Written consents were obtained from the guardians of the participants after explaining the aims and benefits of the study through personal interviews; then, they were subjected to a predesigned questionnaire including personal data (age, sex, family size, income, etc.). Socioeconomic standard was determined according to the scoring system of Ibrahim and Abdel Ghaffar; it includes education of the mother, occupation and education of the father, family size, and income. The socioeconomic scores were as follows: high (9-12), middle (5 to <9), and low (<5). Information on food habits was obtained, and assessment of previous medical history, general, local examination, and blood investigations were performed.
Local examination was performed that included appearance (pallor, jaundice, and cyanosis), weight and height, and local (chest, heart, and abdominal examinations). Weight was measured on a calibrated digital electronic scale that was set to 0 before the student stood on it, and was checked weekly with known calibration weights . Height was measured by a tape measure permanently fixed to a wall or a door frame; the head was held firmly at the top of the board .
Blood samples were collected from venous blood that had been anti coagulated with ethylenediaminetetraaceticacid and thoroughly mixed, which is essential for accurate test results. The test was performed within 6 h of obtaining blood samples. The samples were then analyzed in an automated blood content instrument.
Blood samples were sent to the laboratory, processed, and examined immediately for a complete blood count including Hb percent, RBC counts, hematocrite (HCT), mean corpuscular hemoglobin (MCH), mean corpuscular volume (MCV), and mean corpuscular hemoglobin concentration (MCHC) for the diagnosis of anemia. Children with a low Hb percent for their age were further tested to confirm the diagnosis of IDA through estimation of ferritin level; blood samples were collected from venous blood in plain sterile tubes, which were allowed to clot undisturbed for 1 h at room temperature. Tubes were centrifuged and the supernatant serum was then pipetted into another tube and centrifuged again. The supernatant serum was then transferred to tubes for testing. Collection of samples included information on the name, age, and sex of the student. The following precautions were taken during the collection of samples: all children involved were strictly advised to wash their arms and hands before the samples were obtained. The samples were barcoded to avoid error, carefully placed to avoid breakage, and transported to the laboratory in suitable tubes to avoid breakage and leakage of blood; infection control precautions were considered during the collection of blood samples.
Data were collected, tabulated, and analyzed statistically using an IBM personal computer with statistical package for the social sciences (SPSS, version 20; SPSS Inc., Chicago, Illinois, USA) and Epi Info 2000 programs, where the following statistics were applied: Student's t-test and Z-test for quantitative variables. Also, the χ2 -test was used for qualitative variables, the Mann-Whitney test for nonparametric data, odds ratio (OR), Spearman's correlation, and t-test for correlation, with a significance level of P value less than 0.05.
| Results|| |
Sociodemographic data of the group studied: there were 242 boys and 255 girls; 268 students were from rural areas and 229 students were from urban areas. The prevalence of IDA among primary school children was 25.6% [Table 1]. There was no significant difference in the prevalence of IDA between girls (57.3%) and boys (42.5%). IDA was high in students from urban (63.8%) areas [Figure 1] and students of low and middle socioeconomic classes (59.1%), children with lower mothers (55.9%) and father's education (53.5%) and big family size (66.1%) [Table 2].
|Figure 1: Prevalence of iron-deficiency anemia (IDA) among the children studied in terms of area of residence .|
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|Table 1: Sociodemographic data and prevalence of irondefi ciency anemia among the children studied (n = 497)|
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|Table 2: Distribution of studied children (n = 497) according to sociodemographic data|
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The mean hematological value of Hb, HCT, and MCV (10.78 ± 0.44, 33.9 ± 1.52, and 78.75 ± 3.69, respectively) was lower in anemic children [Table 3]. There was a significant positive correlation between increased number of meals containing liver (animal or chicken), eggs, milk, or its products and hematological values [Table 4] and a negative correlation between increased consumption of tea, chips, and soft drinks and hematological values [Table 5].
|Table 3: Distribution of the children studied (n = 497) according to complete blood picture|
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|Table 4: Correlation between dietary habits and laboratory investigations among the children studied (n = 497)|
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|Table 5: Correlation between dietary habits and laboratory investigations among the children studied (n = 497)|
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Scholastic achievement was significantly lower among children with IDA (60.6%) than those with high school marks [Figure 2]. The prevalence of IDA was significantly higher among children with a positive medical history for parasitic infestation (80.3%) than those with a negative medical history for parasitic infestation (19.7%) [Figure 3]. The prevalence of headaches was 57.5%, dizziness 58.3%, fatigue with any effort 62.2%, and lack of concentration 86.5%, which was significantly higher among children with IDA than those without IDA [Table 6].
|Figure 2: Prevalence of iron-deficiency anemia (IDA) among the children studied in terms of school marks .|
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|Figure 3: Prevalence of iron-deficiency anemia (IDA) among the children studied in terms of parasitic treatment .|
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|Table 6: Distribution of the children studied (n = 497) in terms of their medical history|
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| Discussion|| |
In this study, the prevalence of IDA was 25.6%; this result is similar to that of El-Zanaty and Way , who showed that the prevalence of anemia in children was ~29.9%.
Many factors were associated with or have been implicated in an increased risk of developing IDA. In this study, IDA occurred in both sexes, but more among females (57.5%), although no significant difference found; this in agreement with Mohamed et al. . No sex differences were found in the prevalence of anemia, although a slight difference was noted (12.8%) for girls and for boys (11.4%). This maybe due to unhealthy food consumption and blood loss during menstruation in older girls.
Children from urban areas had IDA twice as much as those from rural areas (OR 2.29). This is similar to the result of a study carried out in Alexandria by Mohamed and Abo-donia ; the prevalence of anemia among infants living in urban areas was greater than that among infants living in rural areas (61%). This may be attributed to the fact that urban residents consume more junk food, which is less nutritional, than rural residents as most mothers in urban communities are busy in their jobs, hence, the children have to depend on junk foods.
In terms of socioeconomic standard, children from low and middle socioeconomic standard had a two-fold increased risk of developing IDA [OR 1.59, 95% confidence interval (CI) 1.1-2.4]. This is in agreement with the study carried out by Neuman et al.  in Brazil, in which IDA was more prevalent in children from low socioeconomic backgrounds. This can be as attributed to the fact that poverty is a contributing factor to IDA because families living at or below the poverty line may not be consuming enough iron-rich foods. Large family size and birth order more than three were found to increase the risk for IDA (66.1%, OR 1.83, 95% CI 1.2-2.8; 70.1%, OR 3.25, 95% CI 2.1-5.0, respectively). This is in agreement with Selmi and Al-Hindi ; in which 54% of the children were from big families and 31.6% had birth order above 3. This may be explained as big family makes the father or guardian generally unable to bring all requirements to each member of the family, increasing susceptibility for diseases.
Low educational level of the father and mother was found to significantly increase the risk for IDA (53.5%, OR 17.4, 95% CI 10-30.0; 55.9%, OR 11.8, 95% CI 7.2-19.2, respectively). This result is in agreement with the study carried out by Al-Othaimeen et al. ; the rate of illiteracy was found to be high among the parents of anemic children (49.4 and 24%, respectively, for mothers and fathers). This may be attributed to the lack of knowledge of basic food requirements and awareness of food rich in iron.
There was a significant positive correlation between increased number of meals containing animal meat, chicken meat, liver, and IDA. This is in agreement with Mamdooh ; there was a significant association between the consumption of food rich in iron and IDA. This can be as attributed to the fact that liver and meat are very rich in heme iron.
There was a significant negative correlation between increased consumption of tea, chips, and soft drinks and hematological values. This finding is in agreement with that of Selmi and Al-Hindi . This could be because soft drinks and tea contain polyphenols, which inhibit nonheme iron absorption.
IDA was found to have a direct effect on scholastic achievement; school achievement was significantly lower among anemic children (60.6%, OR 59.3, 95% CI 29.1-120.8). This result is similar to Fadila et al. , in which lower school performance is associated with anemia (OR 2.0, 95% CI 1.3-5.0).
The prevalence of IDA among children with a positive medical history for diarrhea and parasitic infestation was higher than that among children with a negative medical history for diarrhea and parasitic infestation (59.9 and 80.3%, respectively). This result is in agreement with Shubair et al. ; diarrheal and parasitic infestations were reported in different studies in the Gaza Strip and have been shown to be associated with anemia among school-age children in Gaza. This may be because diarrhea and parasitic infestation affect absorption and may lead to loss of blood from gastro intestinal tract (GIT).
In terms of manifestations related to anemia, there was a significantly higher prevalence of headaches (57.5%), dizziness (58.3%), fatigue with any effort (62.2%), and lack of concentration (86.5%), among children with IDA than those without IDA. This is in agreement with Fadila et al.  (OR 4.3, 95% CI 1.4-13.4); anemic children unusually feel dizzy and have fainting sensations.
Summary and recommendations
On the basis of the findings of the present study, we can conclude that the prevalence of anemia was 25.6% among children 6-11 years of age. Socioeconomic factors (such as level of father and mother education, residence, family size, and income) and poor dietary habits are the main contributing factors of IDA among the children studied. It is alarming that the prevalence of IDA is high among children 6-11 years of age. Screening for IDA should be directed at high-risk groups and school programs should be implemented to improve awareness of healthy food habits.
| Acknowledgements|| |
Conflicts of interest
There are no conflicts of interest.
| References|| |
Soliman G, Azmi M, El Said S. Prevalence of anemia in Egypt (Al-Gharbia Governorate). Egypt J Hosp Med 2007; 28
World Health Organization. Iron deficiency anemia assessment, prevention and control′: a guide for programme managers
. Geneva: WHO; 2008. Available at: . [Accessed November 2013].
Baker RD, Greer FR the committee on nutrition. Clinical report: diagnosis and prevention of iron deficiency and iron deficiency anemia in infants and young children (0-3 years of age). Pediatrics 2010; 126
Fomon S, Drulis J, Nelson S, Serfass R, Woodhead J, Ziegler E. Inevitable iron loss by human adolescents, with calculations of the requirement for absorbed iron. J Nutr 2003; 133
Tatala SR, Kihamia CM, Kyungu LH, Svanberg U. Risk factors for anaemia in schoolchildren in Tanga Region, Tanzania. Tanzan J Health Res 2008; 10
El Sayed NA, Gad A, Nofal A. Assessment of the prevalence and potential determinants of nutritional anemia in Upper Egypt. Food Nutr Bull 1999; 20
Elalfy MS, Hamdy M, Abdel Maksoud S. Pattern of milk feeding and family size as risk factors for iron deficiency anemia among poor Egyptian infants 6 to 24 months old. Nutr Res 2012; 32
Mansour P, Barduagni AS, Ahmed F. Anemia among schoolchildren in Qena Governorate, Upper Egypt East Mediterr Health J 2004; 10
Chang S, Wang L, Wang Y, Brouwer ID, Kok FJ, Chen C. Iron-deficiency anemia in infancy and social emotional development in preschool-aged Chinese children. Pediatrics 2011; 127
Skikne BS, Punnonen K, Caldron PH, Bennett MT. Improved differential diagnosis of anemia of chronic disease and iron deficiency anemia: a prospective multicenter evaluation of soluble transferrin receptor and the sTfR/log ferritin index. Am J Hematol 2011; 86
Cook JD. Diagnosis and management of iron-deficiency anemia. Best Pract Res Clin Haematol 2005; 18
National Institute of Health. Dietary supplement factsheet iron. Bethesda, MD: Office of Dietary Supplements. Ther Adv Gastroenterol 2010; 4
Lutter CK. Iron deficiency in young children in low-income countries and new approaches for its prevention. J Nutr 2008; 138
Borghi E, De Onis M, Garza C, Broeck J, Frongillo EA. Construction of the World Health Organization child growth standards: selection of methods for attained growth curves. Stat Med 2008; 25
De Onis M, Onyango AW, Broeck J, Chumlea WC. Measurement and standardization protocols for anthropometry used in the construction of a new international growth reference. Food Nutr Bull 2004; 25
El-Zanaty F, Way AA. Egypt Demographic and Health Survey. Ministry of Health and Population. Egypt J Hosp Med 2001; 28
Mohamed E, Ahmed O, Youssef A. Iron deficiency and anemia in rural school children in a coastal area of Morocco. Pak J Nutr 2008; 7
Mohamed A, Abo-donia A. Contributing factors of iron deficiency anemia among children under two years attending family health centers in Alexandria. N Y Sci J 2011 4:35. Available at: http://www.sciencepub.net/newyork
. [Accessed January 2014].
Neuman N, Tanak O, Szarfar S, Victora G. Prevalence and risk factors for anemia in Southern Brazil. Rev Saudi Publica 2000; 34
Selmi AS, Al-Hindi A. Anemia among school children aged 6-11 years old in Gaza Strip, Palestine. Ann Alquds Med 2011; 7
Al-Othaimeen A, Osman AK, Al Orf S. Prevalence of nutritional anemia among primary school girls in Riyadh City, Saudi Arabia. Int J Food Sci Nutr 1999; 50
Mamdooh A. Prevalence of iron deficiency anemia among female elementary school children in Northern Jeddah, Saudi Arabia. Med Sci 2008; 15
Fadila A, Mona A, Fatema S, Fasila A. Prevalence and associated factors of iron deficiency anemia among Kuwait children. Bull Alex Fac Med 2006; 42
Shubair M, Yassin M, Al-Hindi A, Shaaban NA. Intestinal parasites in relation to haemoglobin level and nutritional status of school children in Gaza. J Egypt Soc Parasitol 2000; 3:365-375.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]