Nutritional deficiencies as the cause of severe- and very-severe anaemia and its outcome in under-5 children

Background and objectives While nutritional deficiencies are the most common cause of anaemia in children, there is scarcity of information regarding their contribution to severe- and very-severe anaemia. We conducted this study to evaluate nutritional deficiencies as the cause of severe- and very-severe anaemia in under-5 children in a hospital setting and assess their outcome after 3 mo of appropriate treatment. Methods In this longitudinal study, 100 children (6 mo to 5 y) with severe anaemia (Hb <7 g/dL), including those with very-severe anaemia (Hb <5 g/dL) were included. Venous blood was collected and analysed for complete blood count, serum ferritin, C-reactive protein (CRP), serum vitamin B12, serum folate and serum immunoglobulin A tissue trans glutaminase (IgA-TTG). Iron deficiency was defined as serum ferritin <12 µg/L in absence of inflammation (CRP ≤ 5 mg/L) and <30 µg/L with inflammation, whereas vitamin B12 and folate deficiencies were defined as serum levels <203 pg/mL, and <4 ng/mL, respectively. These investigations were repeated after 3 mo of appropriate treatment as per the documented aetiology. Children with iron deficiency were treated with oral formulation of iron (3 mg/kg/d elemental iron, once daily). Those having vitamin B12 deficiency were managed using repeated intramuscular injections of hydroxycobalamin, and folate deficiency was treated with 1-5 mg/day of folic acid. Results Out of 100 children (mean (SD) age 19.85 (10.76) mo; 64% males), with severe anaemia [mean (SD) Hb 5.26 (1.20) g/dL with minimum upto 2.0 g/dL], 40 (40%) had very severe anaemia. Iron deficiency was documented in 73 (73%) children (82.5% in children with very severe anaemia), followed by vitamin B12 (25%) and folate deficiency (15%). Combined nutrient deficiencies were observed in 23% children, and were significantly more common in those with very severe anaemia (14/40 vs. 9/60; P= 0.020). Following 3 mo of treatment (n=91), there was a marked increase in mean (SD) haemoglobin levels [(5.28 (1.19) g/dL to 9.95 (1.94) g/dL; mean difference (95% CI) 4.67 (4.20, 5.13); P <0.001], with 58 (63.7%) continuing to have low haemoglobin (Hb <10.5 g/dL for 6-23 mo, and <11 g/dL for 23-59 mo). Interpretation and conclusions Iron deficiency, in isolation or combination with B12 or folate deficiency appears to be the most common cause of severe- and very-severe anaemia in under-five children presenting to the hospital without obvious symptoms and/or signs of non-nutritional causes. This may result in severely low haemoglobin levels, requiring blood transfusion and supportive care.