|Year : 2016 | Volume
| Issue : 2 | Page : 269-274
Evaluation of iron-deficiency anemia in infancy
Fahima M Hassan1, Fady M El-Gendy1, Hassan S Badra1, Samar M Kamal Eldin2, Dina M.M Elsayyad1
1 Department of Pediatric, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Clinical Pathology, Faculty of Medicine, Menoufia University, Menoufia, Egypt
|Date of Submission||14-May-2014|
|Date of Acceptance||02-Jul-2014|
|Date of Web Publication||18-Oct-2016|
Dina M.M Elsayyad
Ashmoon General Hospital, 32811
Source of Support: None, Conflict of Interest: None
The aim of this study was to evaluate iron-deficiency anemia (IDA) in infancy in relation to different patterns of feeding (exclusive breast milk, exclusive cow's milk, and milk fortified with iron).
Iron is a component of several metalloproteins and plays a crucial role in vital biochemical activities, such as oxygen sensing and transport, electron transfer, and catalysis. The biological functions of iron are based on its chemical properties. Decreased hemoglobin level and decreased serum ferritin level aid the identification of IDA in infants.
Patients and methods:
This study included 147 infants with different patterns of feeding (exclusive breast fed, exclusive cow's milk fed, and iron-fortified formula). The studied groups were subjected to a full detailed assessment of history, thorough clinical examination, anthropometric measurements, complete blood count, and determination of serum iron, serum ferritin, and total iron-binding capacity.
In our study, the results showed that 84 (57.1%) infants of the total group studied (147 infants) were found to have IDA. According to sex, IDA among girls was 51.2%, which is higher than that found among boys (48.8%). IDA was much higher in cow's milk-fed infants 24 (96%) than exclusively breast milk-fed infants 47 (66.2%), and less in infants receiving mixed feeding with a fortified formula, 13 (25.5%), respectively.
Our study found that infants aged 6–24 months represent one of the highest risk groups to develop IDA (57.1%) of the total study. The risk factors for IDA include consumption of cow's milk during the first year, delaying the introduction of solid foods, and lack of fortification of food with iron after 6 months of age.
Keywords: blood indices, iron-deficiency anemia, iron profile
|How to cite this article:|
Hassan FM, El-Gendy FM, Badra HS, Kamal Eldin SM, Elsayyad DM. Evaluation of iron-deficiency anemia in infancy. Menoufia Med J 2016;29:269-74
|How to cite this URL:|
Hassan FM, El-Gendy FM, Badra HS, Kamal Eldin SM, Elsayyad DM. Evaluation of iron-deficiency anemia in infancy. Menoufia Med J [serial online] 2016 [cited 2019 Nov 22];29:269-74. Available from: http://www.mmj.eg.net/text.asp?2016/29/2/269/192412
| Introduction|| |
Anemia is a condition in which there is a decrease in the number of red blood cells or less than the normal quantity of hemoglobin (Hb) in the blood for age. Also the term anemia can include decreased oxygen-binding ability of each Hb molecule because of deformity or lack of numerical development as in some types of Hb deficiency .
Iron-deficiency anemia (IDA) is the most common nutritional disorder worldwide, prevalent more in developing countries, particularly affecting infants, young children, adolescents, women of reproductive age group, pregnant, and lactating women .
Infants born at term and with an adequate birth weight have sufficient iron stores for the first 4–6 months of life. However, evidence suggests that infants with adequate birth weight born to anemic mothers have low iron stores and are more likely to develop anemia. By 6 months, complementary foods are required to provide the iron and other nutrients necessary for the growth and development of the infant .
Exclusive breastfeeding for more than 6 months places infants at risk for iron deficiency. Therefore, some form of dietary iron supplement that provides 1 mg elemental iron per kg per day is recommended for term infants starting at 4–6 months of age .
Infants from developing countries, preterm or low birth weight infants, or infants in whom the primary dietary intake is unfortified cow's milk are considered to be at high risk of iron deficiency .
Iron deficiency can cause a condition that can delay an infant's mental, motor, and behavioral development and result in problems that last long after the iron level has increased to a healthy level. Poor motor skill coordination, behavior problems at home and school, and poor performance in school can be the long-term consequences of not receiving enough iron as an infant .
The diagnosis of iron deficiency is not always easy. Low serum levels of ferritin or transferrin saturation imply a situation of absolute or functional iron deficiency. It is sometimes difficult to differentiate IDA from anemia of chronic diseases .
The serum ferritin is the sole useful measure of iron stores, setting the lower limit at 10 mg/dl for some populations to increase the sensitivity of the test .
Diagnosis is supported by low mean corpuscular volume and increased red cell distribution width .
Encouraging mothers to breastfeed their infants and to include iron-enriched foods in the diet of infants and young children are recommended as the main preventive measures .
| Patients and Methods|| |
A cross-sectional study was carried out from July 2012 to February 2013 in the Outpatient Clinic of Ashmoon Hospital and Shebeen Elkom district in Menoufia Governorate including a random sample of 147 infants (age 6–24 months) to cover many areas in Menoufia Governorate. During the study period, all infants attending the outpatient clinic on 2 successive days weekly (two different days each week to cover the 6 working days of the week) were enrolled in the study after informed consents were obtained from the parents. The inclusion criterion included age of range of infants of 6–24 months with different patterns of feeding (breast fed, cow's milk fed, and milk fortified with iron). Exclusion criteria included treatment of iron deficiency before or during the study period, any history of chronic illness, current severe illness requiring hospital admission, and recent blood transfusion.
All patients were subjected to the following: determination of infants' age, sex, birth order, family size, and date of attending, full assessment of dietary history (exclusive breast milk feeding, feeding of exclusive cow's milk, and feeding of milk fortified with iron), and anthropometric measurements including weight (kg) and length (cm). Analysis of anthropometrical data was carried out according to the Egyptian growth chart. Educational levels of the mothers were graded as under moderate (primary or preparatory education), moderate (secondary education), and high (university degree or postgraduate). To determine the socioeconomic status of the infants and their families, a household standard of living index was devised on the basis of household possessions. Three categories were created: low, medium, and high according to WHO (2001).
Venous blood samples were drawn from all the patients. Every sample was analyzed under aseptic conditions for complete blood counts with automated blood analyzers using Coulter 1660 to determine erythrocyte indices including Hb concentration for age (6–24 months < 10.5 g/dl), hematocrit (Hct) value 28%, Mean corpuscular volume (MCV), Mean corpuscular Hemoglobin (MCH), and red cell distribution width. MCH less than 27 pg and MCV below 75 fl were considered as indicators of hypochromic microcytic anemia, respectively. Iron profiles including serum iron level and total iron-binding capacity (TIBC) were measured using calorimetric kits (Stanibo Company, Boerne, USA), and serum ferritin was assessed for those diagnosed with microcytic anemia using Immulite/Immulite 1000 ferritin kits (Siemens, Los Angeles, California, USA). IDA was diagnosed in cases of decreased Hb level less than 10.5 g/dl, serum iron less than 50 mg/dl, TIBC more than 400 mg/dl, and serum ferritin less than 10 ng/dl .
Data were collected, and statistically analyzed using an IBM personal computer and statistical package SPSS (version 11; SPSS Inc., Chicago, Illinois, USA). Two types of statistics were calculated.
Descriptive — for example, percentage, range, mean, and SD.
Analytical: Student's t-test: it is a single test used to collectively indicate the presence of any significant difference between two groups for a normally distributed quantitative variable.
| Results|| |
The results of this study are presented in [Table 1],[Table 2],[Table 3],[Table 4] and [Figure 1] and [Figure 2].
|Table 1: Comparison between the studied participants when divided according to the type of feeding in terms of their demographic criteria|
Click here to view
|Table 2: Comparison between the studied groups in their demographic criteria, weight, and length|
Click here to view
|Table 3: Comparison between the studied participants when divided according to the type of feeding in terms of their anthropometric measurements|
Click here to view
|Table 4: Comparison between the studied participants when divided according to the type of feeding in terms of their laboratory investigations|
Click here to view
|Figure 1: Distribution of all the participants studied in terms of their type of feeding|
Click here to view
|Figure 2: Comparison between the anemic and non anemic groups studied in the type of feeding|
Click here to view
We found that IDA was present in 84 of 147 infants ranging in from 6 to 24 months. IDA was present in 84 (57.1%) infants with Hb level less than 10.5 g/dl and serum ferritin less than 10 ng/dl. Our results show that IDA was present more in females (51.2%) than in males (48.8%), with no significant difference in age and sex (P > 0.05) ([Table 2]). According to the demographic criteria, there was a highly significant difference between the studied groups in their socioeconomic status (P < 0.001) ([Table 2]). There was no significant difference between the studied groups in their demographic criteria for age, mean 11.0 ± 3.3, and sex according to the type of feeding (P > 0.05) ([Table 1]). Also, there was no significant difference between the studied groups in their weight and height, mean 8.8 ± 1.8 and 72.8 ± 5.8, respectively, according to the type of feeding (P > 0.05) ([Table 3]). Our results also indicated that the distribution of IDA among infants fed cow's milk was greater (96%) than that in breast-fed infants (66.2%) and mixed-fed infants (25.5%), respectively ([Figure 1]).
There was a highly significant difference between the studied groups according to the type of feeding in terms of their laboratory data for Hb level, mean ± SD 8.9 ± 1.5, 8.2 ± 1.6, and 10.7 ± 1.6, for breast-fed infants, cow's milk-fed infants, and mixed group, respectively. However, for serum ferritin, the mean ± SD were 9.8 ± 2.3, 8.0 ± 1.4, and 12.1 ± 2.3 for the previous groups, respectively (P > 0.01) ([Table 4]). For Hct, the mean ± SD were 29.1 ± 2.7, 27.7 ± 1.7, and 32.2 ± 2.8. For MCV, the mean ± SD were 71.4 ± 4.8, 68.6 ± 4.7, and 75.6 ± 4.9. For MCH, the mean ± SD were 22.4 ± 3.5, 22.6 ± 9.8, and 25.0 ± 4.6. For serum iron, the mean ± SD were 63.6 ± 30.1, 48.8 ± 14.1, and 81.9 ± 29.5 and for TIBC, the mean ± SD were 46.7 ± 165.3, 526.3 ± 121.9, and 301.5 ± 146.5 for breast-fed infants, cow's milk-fed infants, and the mixed group, respectively (P > 0.01) ([Table 4]).
| Discussion|| |
The results of our study showed that 84 (57.1%) of the total infants studied (147 infants) were found to have IDA (the highest percent among infants 6 months–2 years of age). According to sex, the frequency of IDA among girls was 51.2%, which is higher than that found among boys (48.8%).
Although IDA was observed in girls (53.8%), it seen predominantly in boys (71 and 62%, respectively) in Turkey as shown in a study by Akarsu et al. 
Also, the study by El-Sayed et al.  reported that the prevalence of IDA was statistically significantly higher in boys than in girls (P > 0.01). We found in our study that there was no significant difference between the groups studied in demographic criteria for age (mean 11.0 ± 3.3) and height (mean 72.8 ± 5.8) (P > 0.05). This is in agreement with the findings of Ramakrishnan et al. , who reported that there was no statistically significant effect of iron supplementation on height for age in children.
Waterlow  reported that the etiology of linear growth retardation is multifactorial, but has been explained by three major factors: poor nutrition, high levels of infection, and problematic mother–infant interaction, which is closely related to the socioeconomic status of the family.
In our study, there was no significant difference between the groups studied in weight and length, mean 8.8 ± 1.8 and 73.4 ± 5.1, respectively (P > 0.05).
This is not in agreement with Alaa et al. , Mikki et al. , and Soliman et al. , who reported that IDA during the first 2 years of life significantly impairs growth.
Also, we found that there was a significant difference between the groups studied in the socioeconomic level (P > 0.001). IDA was more prevalent in infants from families with low incomes (44.2%) and less prevalent in infants from families with moderate incomes (40.1%) and high incomes (15.6%).
This is in agreement with Elalfy et al.  there is a higher frequency of IDA in infants of low-income families while it is low in infants receiving iron supplementation.
However, Odeh  showed that a higher prevalence of IDA was associated with increased family income: 24.9% low; 28.1% medium; and 30.2% high income.
Family behavior and social habits of eating and food types might have contribute toward these differences ,.
This is also in agreement with the study of Bobonis et al. , who reported that studies carried out in developing countries such as India have yielded values around 69% for the prevalence of iron deficiency in the 2–6 year age groups.
Hadeel et al.  evaluated socioeconomic status according to the incomes of the mother and father, and found that the prevalence of iron deficiency without anemia decreased with increasing income.
Our results suggest that the educational level of mother has an effect on iron status of the infants as IDA was less prevalent in infants of highly educated mothers.
In contrast, El-Sayed et al.  suggest that the educational level of the mother did not have an effect on the iron status of her infant.
Although many causes of anemia have been identified worldwide, IDA of dietary origin is the main cause of anemia and is attributed to poor nutritional iron intake .
Also, maternal iron deficiency during pregnancy and lactation leads to IDA in the baby .
In terms of the type of feeding in our study, there was a highly significant difference between the groups studied (P > 0.01). The incidence of IDA was much higher in infants exclusively fed cow's milk, 24 (96%), than exclusively breast milk-fed infants, 47 (66.2%), and less prevalent in infants receiving mixed feeding with fortified formula, 13 (25.5%).
Our findings are similar to the results of the survey conducted by Elalfy et al.  on 300 infants aged 6-24 months in Ain Shams University, which showed that IDA was more common in cow's milk-fed infants (77%) and exclusively breast-fed infants (62%) than formula-fed infants (16%). It was also concluded that it was the most common cause of anemia among Egyptian infants 6–24 months of age of low socioeconomic standard .
Also, our findings are similar to the results of the survey conducted by Wathorn and Lohajaroensub  on 140 Thailand infants, which showed that the incidence of IDA in breast-fed infants was significantly higher than that in formula-fed infants (25.7 and 2.9%, respectively, P < 0.001).
However, other studies found that exclusive breastfeeding until 4–6 months of age without iron supplementation was a risk factor for IDA; this can be attributed to the low iron content in breast milk .
Iron deficiency among cow's milk-fed infants is related to occult fecal blood loss because of protein allergy to cow's milk, low bioavailability of cow's milk iron (10%), and interference with iron absorption from food .
Some studies have reported a protective effect of BF against anemia and IDA because of the high bioavailability of its iron content (50%) .
According to laboratory investigations for Hb level, there was a highly significant difference between the groups studied (mean 8.9 ± 1.5, 8.2 ± 1.6, and 10.7 ± 1.6) for breast-fed infants, cow's milk-fed infants, and the mixed group, respectively. However, for serum ferritin, the mean values were 9.8 ± 2.3, 8.0 ± 1.4, and 12.1 ± 2.3 for the previous groups, respectively.
Also, our results showed that the mean values of Hb, Hct, MCV, and serum ferritin of infants who were breast fed were 8.9 g/dl, 29.1%, 71.4 fl, and 9.8 ng/ml, respectively, which were significantly lower than those of infants fed fortified formula (10.7 g/dl, 32.2%, 75.6 fl, and 12.1 ng/ml) (P < 0.001).
This is in agreement with Wathorn and Lohajaroensub , who found that the mean values of Hb, Hct, MCV, and serum ferritin of breastfeeding infants were 10.8 g/dl, 32.8%, 70.9 fl, and 16.7 ng/ml, respectively, which were significantly lower than those of infants fed on fortified formula (11.4 g/dl, 35.1%, 73.3 fl, and 36.9 ng/ml) (P < 0.05).
The diagnosis of IDA on the basis of serum ferritin levels was suggested by Fukunaga , who reported that ferritin is an iron–protein complex and is found in the liver, spleen, and bone marrow, and indicates the level of iron storage.
Also, studies by Jareen et al.  measured Hb in 183 infants at 9 months of age. Anemia at 9 months was defined as an Hb value less than 10.0 g/l. Hb (mean ± SD) was 11.4 ± 0.9 g/l.
Elalfy et al.  showed that the mean Hb level of infants with IDA was 9.35 ± 0.87 g/dl, with only three patients having severe anemia (Hb=7 g/dl), and lower mean MCV (67.63 ± 8.01 fl) (P > 0.001) and MCH (20.14 ± 3.12 pg) (P > 0.001) compared with non anemic infants (14.1 ± 0.97%, 80.62 ± 5.09 fl, and 26.69 ± 1.35 pg) .
| Conclusion|| |
We found that 57.1% infants aged 6–24 months have IDA. Consumption of cow's milk during the first year of life and delayed introduction of solid foods without fortification with iron after 6 months of age were the risk factors for IDA.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Pasricha SR, Drakesmith H. Iron Deficiency Anemia: Problems in Diagnosis and Prevention at the Population Level. Hematol Oncol Clin North Am 2016; 30:309–25.
Lokeshwar MR, Mehta N, Shelke, et al.
Prevention of iron deficiency anemia. Indian J Pediatr 2010; 53:156–159.
Meinzen-Derr JK, Guerrero ML, Altaye M, Ortega-Gallegos H, Ruiz-Palacios GM, Morrow AL. Risk of anemia on infant is associated with exclusive breast feeding and maternal anemia in Mexican cohort. ? 2006; 36:452–458.
Killip S, Bennett JM, Chambers MD, et al.
Iron deficiency anemia. Am Fam Physician 2007; 75:671–678.
Kazal LA. Prevention of iron deficiency in infants and toddlers. Am Fam Physician 2002; 66:1217–1225.
Bermejo F, García-López S, World J. A guide to diagnosis of iron deficiency and iron deficiency anemia in digestive diseases. Gastroenterology 2009; 15:4638–4643.
Zhu A, Kaneshiro M, Kaunitz JD. Evaluation and treatment of iron deficiency anemia: a gastroenterological perspective. Dig Dis Sci 2010; 55:548–559.
Pusic MV, Dawyduk BJ, Mitchell D. Opportunistic screening for iron-deficiency in 6–36 month old children presenting to the paediatric emergency department. BMC Pediatr 2005; 5:42–51.
Brotanek JM, Gosz J, Weitzman M, et al.
Iron deficiency in early childhood in the United States: risk factors and racial/ethnic disparities. Pediatrics 2007; 120:568–575.
Alaa A, Gihan A, Hanan A, et al.
Epidemiology of iron deficiency anaemia: effect on physical growth in primary school children, the importance of hookworms. Int J Acad Res 2011; 3:167–177.
Akarsu S, Kilic M, Yilmaz E, et al.
Frequency of hypoferritinemia, iron deficiency and iron deficiency anemia in outpatients. Acta Haematol 2006; 116:46–50.
El-Sayed N, Gad A, Nofal L, et al.
Assessment of the prevalence and potential determinants of nutritional anemia in upper Egypt. Food Nutr Bull 2009; 21:417–421.
Ramakrishnan U, Aburto N, McCabe G, et al.
Multimicronutrient interventions but not vitamin A or iron interventions alone improve child growth: results of meta-analyses. J Nutr 2004; 134:2592–2602.
Waterlow, JC. Introduction, causes and mechanisms of linear growth retardation (stunting). Eur J Clin Nutr 1994; 48:S1–S4.
Mikki HF, Abdul-Rahim H, Stigum G, et al.
Anemia prevalence and associated sociodemographic and dietary factors among Palestinian adolescents in the West Bank. East Mediterr Health J 2011; 17:564–572.
Soliman AT, Al-Dabbagh MM, Habboub AH, et al.
Linear growth in children with iron deficiency anemia before and after treatment. J Trop Pediatr 2009; 10:1093–1098.
Elalfy MS, Hamdy AM, Maksoud SS, et al.
Pattern of milk feeding and family size as risk factors for iron deficiency anemia among poor Egyptian infants 6 to 24 months old. J Nutr 2012; 32:93–109.
Odeh MM. The prevalence of iron deficiency anemia among school children in Salfeet district, An-Najah National University, Nablus. Palestine 2006:30-40.
Oski, F. Iron deficiency in infancy and childhood. N
Engl J Med 1993; 329:190−193.
Sargent JD, Stukel TA, Dalton MA, et al.
Iron deficiency in Massachusetts's communities: socioeconomic and demographic risk factors among children. Am J Public Health 1996; 95:544–550.
Bobonis GJ, Miguel E, Sharma CP. Anemia and school participation. J Human Resources 2006; 41:692–721. 7, 2.3.
Hadeel M, Ayman H, Riad A, et al.
The prevalence of iron deficiency anemia among primary school children in Qalqilia City, An-Najah National University Faculty of Graduate Studies; 2008. p. 40–50.
Zlotkin S. Clinical nutrition: the role of nutrition in the prevention of iron deficiency anemia in infants, children and adolescents. CMAJ 2003; 168:59–63.
Hou XQ, Li HQ. Effect of maternal iron status on infant's iron level: a prospective study. Zhonghua Er Ke Za Zhi 2009; 47:4294–4299.
Wathorn ST, Lohajaroensub S. Incidence and risk factors of iron deficiency anemia in term infants. J Med Assoc Thai 2005; 88:45–51.
Heird WC. The feeding of infants and children. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF, eds. Nelson Textbook of Pediatrics. 18th ed. Ch. 42. Philadelphia, PA: Saunders Elsevier; 2007.
Fernandes SM, Morais MB, Amancio OM, et al.
Intestinal blood loss as an aggravating factor of iron deficiency in infants aged 9 to 12 months fed whole cow's milk. J Clin Gastroenterol 2008; 42:152–156.
Oliveira AS, Silva RC, Fiaccone RL, et al.
Effect of length of exclusive breastfeeding and mixed feeding on hemoglobin levels in the first six months of life: a follow-up study. Cad Saude Publica 2010; 26:409–417.
Fukunaga F. Iron deficiency and serum ferritin. Hawaii Med J 1990; 42:681–691.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]