The Prevalance of Anemia and Nutriotional Anemia in Primary School Children in the City of Aydın - PDF

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Original Article / Özgün Araştırma Meandros Med Dent J The Prevalance of Anemia and Nutriotional Anemia in Primary School Children in the City of Aydın Aydın İl Merkezi İlköğretim Okulu Öğrencilerinde

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Original Article / Özgün Araştırma Meandros Med Dent J The Prevalance of Anemia and Nutriotional Anemia in Primary School Children in the City of Aydın Aydın İl Merkezi İlköğretim Okulu Öğrencilerinde Anemi ve Nütrisyonel Anemi Prevalansının Saptanması Emine Pektaş 1, Yusuf Ziya Aral 2, Çiğdem Yenisey 3 1Adnan Menderes University Faculty of Medicine, Department of Child Health and Diseases, Aydın, Turkey 2Adnan Menderes University Faculty of Medicine, Department of Pediatric Hematology, Aydın, Turkey 3Adnan Menderes University Faculty of Medicine, Department of Biochemistry, Aydın, Turkey Keywords Anemia, prevalance, school age children, iron, B12, folic acid Anahtar Kelimeler Anemi, prevalans, okul çağı çocukları, demir, B12, folik asit Received/Geliş Ta rihi : Accepted/Ka bul Ta ri hi : doi: /meandros.2479 Ad dress for Cor res pon den ce/ya zış ma Ad re si: Yusuf Ziya Aral MD, Adnan Menderes University Faculty of Medicine, Department of Pediatric Hematology, Aydın, Turkey Meandros Medical And Dental Journal, published by Galenos Publishing. Meandros Medical And Dental Journal, Galenos Yayınevi tarafından basılmıştır. Abstract Objective: To determine the prevalence of anemia and nutritional anemia in primary school children in the city of Aydın. Materials and Methods: In Aydın, the central town of Aydın province, a total of 496 students (56% were female) were enrolled into the study by using stratified random sampling method. The students were from the primary schools located in socio-economically low, medium, and high areas of primary health care centers. The avarage age of the students was 10.2±2 years. Statistical analysis was performed using the Kolmogorov-Smirnov test, Student s t-test, Mann-Whitney U-test and Chi-Square test. Results: The prevalence of anemia, iron-deficiency (ID), iron-deficiency anemia (IDA), vitamin B12 deficiency and vitamin B12 deficiency anemia was 15.7%, 38.7%, 8.3%, 9.1%, 0.8%, respectively. No folic acid deficiency was detected. Among the anemias, 42% of them were microcytic, 58% of them were normocytic and the 45.5% of the microcytic anemias were IDA. Among the females, the rate of ID was 45.1% and the rate of IDA was 11.6%, while in boys the same rates were 30.6% and 4.1%, respectively (p 0.05). Microcytosis was present in 36.5% of subjects with IDA. The Mentzer index was 13 in 13.3% of subjects with microcytic anemia and IDA, and in 77.7% of children with microcytic anemia and no IDA (p 0.001). Regarding socio-demographic characteristics of children; the only statistically significant difference was in the parameters of mother education and anemia. Conclusion: The prevalence of anemia represents a minor public health problem according to the World Health Organization criteria among the primary school students in the central town of Aydın province. Exploration of the reason of anemia among pre-school children, proper treatment of nutritional anemia cases with adequate duration and dose, dietary organizations and proper follow-up will lower the incidence of anemia and nutritional anemia among primary school children. Our study showed that thalassemia trait is defined as a major problem in the differential dignosis of IDA in our region. Diagnosing of these cases with thalassemia will prevent the unnecessary iron therapy and will provide a genetic counseling to the family. Öz Amaç: Aydın ili Merkez İlköğretim Okulu öğrencilerinde anemi ve nütrisyonel anemi sıklığını belirlemektir. Gereç ve Yöntemler: Aydın il merkezinde, öğretim yılında, sosyoekonomik düzeyi iyi, orta ve düşük sağlık ocağı bölgelerinde bulunan ve tabakalı 97 98 Pektaş et al. The Prevalance of Anemia in Primary School Children in the City of Aydın rastgele örnek seçim yöntemine göre belirlenen ilköğretim okullarında eğitim gören 1-8. sınıf öğrencilerini kapsayan toplam 496 (%56 sı kız) öğrenci çalışmaya alındı. Çocukların yaş ortalamaları 10,2±2 idi. İstatistiksel analizler için Kolmogorov-Smirnov testi, Student t-testi, Mann Whitney U testi ve ki-kare testi uygulandı. Bulgular: Anemi, demir eksikliği (DE), demir eksikliği anemisi (DEA), B12 eksikliği ve B12 eksikliği anemisi prevalansı sırasıyla %15,7, %38,7, %8,3, %9,1, %0,8 saptandı. Folik asit eksikliğine rastlanmadı. Tüm anemilerin %42 si mikrositer, %58 i normositer; mikrositer anemilerin %45,5 i DEA idi. Kızlarda DE oranı %45,1, DEA oranı %11,6 iken, erkeklerde bu oranlar sırasıyla %30,6 ve %4,1 idi (p 0,05). DEA sı olanların %36,5 inde mikrositoz mevcuttu. Mikrositik anemisi ve DEA olan olguların %13,3 ünde, mikrositik anemisi olup DEA olmayan olguların ise %77,7 sinde Mentzer indeksi 13 idi (p 0,001). Daha önce anemi saptanması ve demir ilacı verilmesi oranları anemi saptanan çocuklarda %33,3 ve %29,5, anemi saptanmayan çocuklarda %18,2 ve %15,6 idi. DEA saptanan öğrencilerin %19,8 i, saptanmayan öğrencilerin ise %19,5 i daha önce demir ilacı almıştı. Sosyo-demografik özelliklerden sadece anne eğitim düzeyi ile anemi arasında anlamlı ilişki bulundu. Sonuç: Aydın il merkezi ilköğretim okulu öğrencilerindeki anemi prevalansı Dünya Sağlık Örgütü ne göre hafif düzeyde sosyal sağlık problemi oluşturmaktadır. Okul öncesi dönemde anemi saptanan çocuklarda nedenin aydınlatılması, tedavi verilen nütrisyonel anemili olguların uygun süre ve dozda tedavi almalarının sağlanması, beslenmelerinin düzenlenmesi ve izlemlerinin yapılması ilköğretim öğrencilerindeki anemi ve nütrisyonel anemi oranlarını düşürecektir. DEA saptanan çocukların yaklaşık 1/5 inin önceden tedavi alması, tedavi ve izlemlerin iyi yapılmadığını düşündürmektedir. Bu nedenle okul çocuklarında tarama programları yapılmalıdır. Introduction Anemia is a disease having high prevalence worldwide. Anemia can occur at all stages of life mostly in pre-school age of children and pregnancy period (1). Iron deficiency (ID) is the most common nutritional deficiency in childhood and affects 20-50% of world s population (2-4). ID is a condition which causes growth retardation and cognitive development retardation, therefore, reduces performance capacity of the country and causes damages on country s economic sources. Iron deficiency anemia (IDA) is observed 36% and 8% of people in developing countries and economically advanced countries, respectively. The World Health Organization (WHO) considers that it is an important health problem in Turkey with a rate of above 40% (5). In childhood, adequate level of vitamin B12 and folate are vital for the development of organ systems, such as central nervous system, hematopoetic system, and cardiovascular system. When deficiency takes place, particularly the tissues with fast regeneration capacity are affected (6). Childhood is the period when growth and development have the highest spead, therefore, problems of childhood are significantly important (7). If we take the clinical effects of all nutritional anemia into the consideration, it is important that we should provide necessary precautions for public health-care instead of just individual therapies. To produce this data, screening investigations are needed. This research was performed in order to evaluate the prevalence of anemia an nutrirional anemia among the students of Aydın primary schools. Materials and Methods This is a cross-sectional study which is performed between April and June 2009 on 496 children who were students of 1st to 8st grades of primary schools. Schools, which were selected by stratified random sampling method, are located in various areas of primary health care centers with high, medium and low socio-economic status. Sellection of schools was performed after categorizing them into three areas. Then, the schools ans classes were selected by using random number table. Children, who underwent acute infection during the study and whose parents did not give permission for blood tests, were excluded. Data Collection The aim of the study was explained to the Directorate of National Education of Aydın province and to the school administrations and necessary permissions were obtained. After that, the study was explained to parents and their written consent were taken. The research group whas composed of paediatricians and nurses. A questionnaire has been prepared and was distributed to the students in order for their parents to answer. The questionnaire included socio-demographic information about the students, alimentation conditions, anemia history and their medications. Development of participants were assessed by a paediatrician using a marked length scale and weighing machine with minimum intervals of one mm and 100 g, respectively. Two mililiters of blood was drawn by a paediatric nurse to an EDTA tube for hemogram, and 3 mililiters in order to measure serum iron, serum iron binding capacity, ferritin, B12 and folic acid to a regular test-tube by pediatric nurse. Pektaş et al. The Prevalance of Anemia in Primary School Children in the City of Aydın 99 Description For the diagnosis of anemia, the lowest limit of hemoglobin (Hb) level was defined as as 11.5 g/dl for children aged 5-7 years, 12 g/dl for those aged 8-11 years, 12 g/dl for females aged years, and 12.5 g/dl for males aged years. ID was diagnosed for students without anemia when low ferritin and transferrin saturation were observed (8). Vitamin B12 and folic acid levels below 200 pg/ml and 3 ng/ml, respectively were considered vitamin B12 and folic acid deficiency. Measurement and Assesment The blood samples were assessed in the hematology and biochemistry laboratories at Adnan Menderes University Medical Faculty using the kits which were provided by Adnan Menderes University Medical Faculty, Science Research and Project Board. 1. Routine hemogram analysis was performed by impedance method by Beckman Coulter appliance, 2. Serum iron level was evaluated with calorimetric spectrophotometric method by using commercial kit in routine biochemistry autoanalyzer ARCHITECT (Floor No: /R1), 3. Serum iron binding capacity was assessed with calorimetric spectrophotometric method by using commercial kit (REF 6K9520) in routine biochemistry autoanalyzer ARCHITECT, 4. Serum ferritin level was detected with electroluminescence method by using commercial kit (Floor No: L2KFE2) in IMMULATE 2000 routine hormone analyzer, 5. Serum folic acid level was detected with electroluminescence method by using commercial kit (Floor No: L2FO2) in IMMULATE 2000 routine hormone analyzer, 6. Serum vitamin B12 level was detected with electroluminescence method by using commercial kit (Floor No: L2KVB2) in IMMULATE 2000 routine hormone analyzer. Height and weight percentiles were assessed with respect to Turkish children development percentile tables. Statistical Analysis SSPS (Software Package) 14.0 statistics package program was used for statistical analysis of the study results. Concordance of constant variables to normal distribution was analyzed by the Kolmogorov-Smirnov test. Since mothers ages exhibited normal distribution, its descriptive statistics were shown as mean ± SD. Student s t-test was used for independent groups. The variables did not exhibit normal distribution, therefore, their descriptive statistics were shown as median (25-75%). The Mann-Whitney U-test was used for comparing the groups. Descriptive statistics of categorical variables were shown as frequency and percentages. Chi-square test was performed. P value of less than 0.05 was considered statistically significant. Results A total of 496 students [277 female (56%), 219 male (44%)] total 496 with the mean age of 10.2±2 years were included in this study between April and June Only 1.4% of students have failed one class and the success rates with respect to excellent, good, moderate was 35.7%, 39.7% and 14%, respectively. It was observed that approximately half of the students ate meat 1-2 times a week and drank milk less than one glass daily, and 71.4% of students drank tea more than two small glasses a day. Fifty-four percent of mothers and 46% of fathers had graduated from primary school and 1% of fathers were illiterate. 35% of families had an income less than 500 TL and 55% of families had an income between 500 and 2000 TL monthly. Regarding height and weight: percentages of students for 3p, 3-97 p and 97 p ratio was 3%, 92%, 5% and 6%, 88.5%, 5.5%, respectively. The mean hemoglobin level of the students was 12.6±0.8 g/dl ( g/dl). The mean hemoglobin level of males was 12.9±0.9 g/dl and that of females was 12.5±1.05 g/dl. There was no statistically significant difference between the groups (p 0.05). The mean hemoglobin level in female and male children ages of 7-11 was 12.5±0.8 g/dl and 12.7±0.7 g/dl, respectively (p 0.05). The mean hemoglobin level in female and male students aged between 12 and 15 years was 12.6±1.2 g/dl and 13.3±0.9 g/ dl, respectively (p 0.05). Results of hematological parameters for genders are shown in Table 1. In our study, the prevalence of anemia, IDA and ID were found to be 15.7% (n=78), 8.3% (n=41) and 38.7% (n=192), respectively. The number of school children with high, medium and low socio-economic levels was 213 (42.9%), 151 (30.5%) and 132 (26.6%), respectively. The prevalence of anemia, ID and IDA was found to be 100 Pektaş et al. The Prevalance of Anemia in Primary School Children in the City of Aydın higher in schools with a high socio-economic level. However, this difference was not significant (Table 2). The prevalence of anemia among children aged 7-11 years was found to be 15.3% (n=46), that of ID 37.2% (n=112), IDA 6.3% (n=19), and B12 vitamin deficiency anemia (B12DA) 0.3% (n=1). The prevalence of anemia, ID, IDA, B12DA among children aged years was determined as 16.4% (n=32), 41% (n=80), 11.3% (n=22), 1.5% (n=3), respectively (p 0.05). The prevalence of B12 deficiency (B12D) among chidren aged 7-11 and years was 5.6% (n=17) and 14.4% (n=28), respectively (p 0.05). Although the frequency of ID and IDA in female students was found to be 45.1% and 11.6%, respectively, in male students, it was 30.6% and 4.1%, respectively (p 0.05). It was detected that 17.7% of female students and 13.2% of male students had anemia (p 0.05). Although anemia was found in 9.1% of all students, B12D was found in only 0.8%. In our study, we did not identify any folic acid deficiency case. Low ferritin level or low transferrin saturation definition was considered ID. The prevalence of ID and IDA was 8.7% and 4%, respectively for the cases where low ferritin level was used for diagnosis. The prevalence of ID and IDA was found to be 6.5% and 3.6%, respectively when low ferritin level and transferrin saturation were used for diagnosis (Table 3). Forty-two percent of all anemia cases were microcytic, the other 58% were normocytic. We did not detect macrocytosis. 45.5% of microcytic anemia cases were IDA. Microcytosis was detected in 36.5% of students who had IDA. Red blood cell (RBC) levels were normal in 14 (93.3%) of 15 children with microcytic anemia and IDA. RBC levels were low in one of them and were normal in 9 (50%) of 18 children with microcytic anemia but without IDA; RBC levels were high in the rest 50% of the cases (p 0.05). Mentzer index (mean corpuscular volume (MCV)/RBCx100) in 14 students with microcytic anemia (77.7%) without IDA was Table 1. Results of hematological parameters for genders; mean ± SD, minimum and maximum levels Hematological parameters Female Male Mean ± SD Min-Max Mean ± SD Min-Max Hb (g/dl)* 12.5± ± Htc * 36.6± ± RDW * 13.8± ± MCV (fl)* 80.7± ± Ferritin (ng/ml)* 24± ± B12 (pg/ml)* 344± ± Folate (ng/ml)* 8± ± p 0.05, SD: Standard deviation, min: Minimum, max: Maximum, Hb: Hemoglobin, Htc: Hematocrit, RDW: Red cell distribution width, MCV: Mean corpuscular volume Table 2. Distribution of the prevalence of anemia, iron deficiency, iron deficiency anemia, B12 deficiency, B12 deficiency anemia according to schools+ High Total Medium Total Low Total MAE* GP** HCO*** FMU**** Ilicabası HUR***** p Anemia 20 (19.4) 15 (13.6) 35 (16) 12 (11.5) 12 (25.5) 24 (15.8) 5 (10.2) 14 (16.9) 19 (14.3) 0.05 ID 33 (32) 48 (43.6) 81 (38) 34 (32.7) 20 (42.6) 54 (35.7) 19 (38.8) 38 (45.8) 57 (43.1) 0.05 IDA 8 (7.8) 8 (7.3) 16 (7.5) 8 (7.7) 7 (14.9) 15 (10) 3 (6.1) 7 (8.4) 10 (7.5) 0.05 B12D 8 (7.8) 6 (5.5) 14 (6.5) 8 (7.7) 9 (19.1) 17 (11.2) 6 (12.2) 8 (9.6) 14 (10.6) 0.05 B12DA 2 (1.9) 0 (0) 2 (0.9) 0 (0) 2 (4.3) 2 (1.3) 0 (0) 0 (0) 0 (0) 0.05 ID: Iron deficiency, IDA: Iron deficiency anemia, B12D: B12 deficiency, B12DA: B12 deficiency anemia, +: Schools included in the study were divided into three categories as a high, medium and low sosyo-economic leves. *Mehmet Akif Ersoy Primary School; **Gazipaşa Primary School; ***Hacı Celal Oto Primary School; ****Fevzi Mürüvvet Uğurlu Primary School; *****Hürriyet Primary School Pektaş et al. The Prevalance of Anemia in Primary School Children in the City of Aydın 101 13, whereas in four of the subjects (22.3%) it was 13 (p 0.001). Red cell distribution width (RDW) was 14 in 13 (86.7%) of 15 children with microcytic anemia and IDA and in 17 (94.5%) of 18 children with microcytic anemia but without IDA (p 0.05) (Table 4). Children with or without anemia, ID, IDA, B12D and B12D anemia were assessed with regard to anorexia, weakness, abdominal pain and pica history. No significant difference was detected. Anemia was diagnosed previously in 26 (33.3%) of 78 children with anemia and in 76 (18.2%) of 418 children without anemia; 23 (29.5%) children with anemia and 65 (15.6%) children without anemia received iron treatment for ID previously (p 0.05). Anemia was diagnosed previously in 38 (19.8%) of 192 children with ID and 32 (16.7%) children received medical treatment for ID; anemia was diagnosed previously in 9 (22%) of 41 children with IDA and 8 (19.5%) children received iron treatment for ID. A significant difference was found between proportion of getting iron treatment for ID and anemia in children with and without ID and IDA (p 0.05). The relationship between children with anemia, ID, and IDA and history of iron therapy and anemia is shown in Table 5. Starting age for nourishment with cow milk was 7 months (range: 1-36 months), 8 months (range: 1-36 months), and 7 months (range: 1-18 months) in children with anemia, ID and IDA, respectively. The duration of nourishment with breast milk was 10.2 Table 3. The revalence of iron deficiency and iron deficiency anemia according to the criteria of identification Low ferritin Low ferritin or TS Low ferritin and TS ID 8.7% 38.7% 6.5% IDA 4% 8.3% 3.6% ID: Iron deficiency, IDA: Iron deficiency anemia, TS: Transferrin saturation months (range: 1-36 month), 10 months (range: 1-36 months), 9 months (range: 1-24 months) in children with anemia, ID and IDA, respectively. Starting age for drinking tea was 25 months (range: months), 26 months (range: 3-20 months), and 25 months (range: 5-84 months) in children with anemia, ID and IDA, respectively. The age when meat was first added to the diet was 18 months (range: 3-96 months), 17 months (range: 5-72 months), 17 months (range: 6-72 months) in children with anemia, ID and IDA, respectively. When children with anemia, ID, IDA, B12D, and B12DA were compared with regard to their socio-demografic features, it was observed that 16.7% of mothers of children with anemia had high school or lower level of education and it was the only one parameter which showed a significant difference (Table 6). Discussion Anemia is defined as a reduction in RBC and/or hemoglobin levels (9). According to WHO s research, the prevalence of anemia was found to be Table 4. Comparison of Mentzer index, red cell distribution width and red blood cell values in microcytic anemia with or without iron deficiency anemia Micr
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