ORIGINAL

Niger J Paed 2014; 41 (2):129 –132

Ekwochi U

Prevalence of iron deficiency

anaemia in anaemic under-5

children in Enugu South East

Nigeria

Osuorah DIC

Odetunde OI

Egbonu I

Ezechukwu CC

DOI:http://dx.doi.org/10.4314/njp.v41i2,10

Accepted: 12th October 2013

Abstract: Background: Iron defi-

ciency anaemia has been described

as the commonest type of nutri-

tional anaemia in infancy and

childhood. The associated adverse

health sequelae include permanent

behavioural and cognitive impair-

ments. Early detection and prompt

treatment are necessary to prevent

these complications.

Aim: To determine the prevalence

and socio-demographic distribution

of iron deficiency anaemia among

anaemic under five children in

Enugu.

Subjects and methods: Under-five

children presenting at a tertiary

hospital were consecutively en-

rolled and screened for iron defi-

ciency anaemia using haematocrit

and serum ferritin levels. Iron defi-

ciency anaemia was defined as

haematocrit level <30% and fer-

ritin level <12ng/ml.

aged below 60 months had a PCV

check out of which 178 (57.1%)

were anaemic (PCV< 30%). Of the

anaemic group, 61(34.3%) had

iron deficiency anaemia. Preva-

lence of iron deficiency anaemia

was higher among the males

(38.0%) [p=0.235], age group 13-

23months (40.0%)[p=0.575] and

children from lower socioeco-

nomic class (43.5%)[p=0.158].

There is a positive but weak corre-

lation between serum ferritin and

haematocrit levels [r= 0.11

p=0.130].

Conclusion: The prevalence of

iron deficiency anaemia in the

study population was high and

varies with the child’s age group,

gender and parental socioeco-

nomic class.

(

)

Ekwochi U

Department of Paediatrics,

Enugu State University Teaching

Hospital,

Enugu, Nigeria.

Email: uekwochi@yahoo.co.uk

Tel: +2348034317785

Osuorah DIC

Child Survival Unit

Medical Research Council UK, The

Gambia Unit

Odetunde OI

Department of Pediatrics,

University of Nigeria Enugu Campus

Nigeria.

Egbonu I, Ezechukwu CC

Department of Pediatrics,

Nnamdi Azikiwe University Teaching

Hospital,

Nnewi, Anambra State

Keywords: iron deficiency anae-

mia, serum ferritin, haemtocrit,

Enugu.

Results: Three hundred and twelve

children (187 males, 125 females)

8

Introduction

followed by percentage saturation . According to WHO,

serum ferritin level below 12ng/ml is the generally

accepted cut-₁o₂ ff level at which iron stores are consid-

ered depleted

Anaemia is a common clinical problem encountered

among the under-fives in everyday paediatric practice.

Iron deficiency has been documented as t₁h_-₄e commonest

cause of nutritional anaemia worldwide . Prevalence

of iron deficiency anaemia varies between countries,

affecting 5.4% children in Spain, 30.8% and 22.3% un-

Iron deficiency anaemia is associated with adverse

health sequelae includi₁n₃g_,₁₄permanent behavioural and

cognitive impairments

. Therefore, early detection

and prompt treatment are necessary to prevent these

complications. However, not all childhood anaemia is

due to iron deficiency, and empirical iron therapy in all

anaemic patients in whom iron deficiency has not been

documented could lead to iron toxicity, it therefore be-

comes imperative to document the prevalence of iron

deficiency among the anaemic population, hence, justi-

fying the aim of the current study.

5,6,7

der-five children in Brazil and Nigeria respectively

.

Among the several parameters of iron homeostasis, se-

rum ferritin, being a major form in which iron is stored

in the body, and which easily shows changes in body

iron storage, has been favoured by many authors as th₈e_-

single best blood test for diagnosis of iron deficiency

1

1.

.

A study has documented that serum ferritin of less

than 60 ng /ml had a positive likelihood ratio of 24.35,

sensitivity of 69.5%, specificity of 97.1% and a positive

predictive value of 94.1% while an iron saturation of

less than 7% had a positive likelihood ratio of 21.62,

sensitivity of 44.1%, specificity of 98.0% and positive

predictive value of 93.8%. It was concluded that serum

ferrritin is the best marker for predicting iron deficiency,

Subjects and methods

This was a prospective and analytical study which was

carried out at the Enugu State University Teaching

1

30

Iron deficiency anaemia was defined as serum ferr₁i₉t₁i₇n

level of <12ng/ml plus haematocrit level of <30%

The results were analyzed by simple frequency count,

percentage and proportion and out-laid in tables and

scatter plots as deemed necessary. Chi-square tests were

employed for test of significance in each of the

Hospital, (ESUTH) from December 2009 to June 2010.

ESUTH is a tertiary health facility situated in the Enugu

Metropolis. ESUTH serves as a referral centre for the

primary and secondary health facilities in Enugu state

and environs. Enugu State is in the South-East geopoliti-

cal zone of Nigeria and has a population of 3.5 million

people₁,₅according to the National Population Census of

.

characteristics of the population at p ≤ 0.05.

2

5

006 . The study population was children aged 2-

9months presenting in Children’s Emergency Room

(

CHER) and Children Outpatient (CHOP) unit of the

Department of Paediatrics. Patients aged 3-59months

were consecutively selected. The haematocrit of identi-

fied subjects was done and those with values below 30%

were recruited into the study while those not anaemic

Results

Three hundred and twelve children (187 males, 125 fe-

males) aged below 60 months had a PCV check out of

which 178 (57.1%) were anaemic (PCV< 30%).

Of the anaemic group, 100 (56.2%) were males and 78

(43.8%) were females. Sixty-five (36.0%) were aged 3-

12months, 45 (25.3%) between 13 and 23 months and

68(38.8%) aged 24 months or more. Children from

lower, middle and upper socio-economic class ac-

counted for 62(34.8%), 56(31.5%) and 60(34.8%)

respectively (table 1).

(

haematocrit 30% and above) were dropped. Information

on personal data (age, sex, residential address and phone

number of parents) was obtained from caregivers. The

socioeconomic class of the parents was determined in

accordance with the me₁₆thod described by Olusanya,

Okpere and Ezimokhai . Serum from 2ml of venous

o

blood was stored at -20 c -0 c in a freezer in the Chemi-

cal Pathology laboratory until analysis for ferritin. Se-

rum ferritin analysis was carried out in batches every

three. The haematocrit was done using capillary blood

from a finger prick.

Table 1: Socio-demographic distribution of children with

anaemia

Variable

Proportion

N=178

PCV%

Mean ± SD

(Range)

Serum ferritin

ng/dl Mean ± SD

(Range)

Laboratory methods for serum ferritin estimation

Sex

The assay system (Human Ferritin Enzyme Immunoas-

say Test Kit) manufactured by Diagnostic Automation/

Cortez Diagnostics, Inc. California, USA, utilizes one

anti-ferritin antibody for solid phase (microtitre wells)

immobilization and another mouse monoclonal anti –

ferritin antibody in the antibody–enzyme (horseradish

peroxidase) conjugate solution. The test sample was

allowed to react simultaneously with the antibodies,

resulting in the ferritin molecule being sandwiched be-

tween the solid phase and enzyme linked antibodies.

After 60mins incubation at room temperature, the wells

were washed with water to remove unbound labeled

antibodies. A solution of TMB was added and incubated

for 20mins resulting in the development of blue colour.

The colour development was stopped with the addition

of 2N HCL and the colour was changed to yellow and

measured spectrophotometrically at 450nm. The concen-

tration of ferritin is directly proportional to the colour

intensity of the test sample.

Male

100 (56.2)

78 (43.5)

23.44± 5.69

76.80 ± 120.63

(0.50, 531.3)

77.97 ± 107.76

(0.80, 473.0)

(

8, 29)

23.13 ± 5.11

10, 29)

Female

(

Age category

3

- 12 months

12- 23 months

4-59 months

Socioeconomic class

65 (36.0)

45 (25.3)

68 (38.8)

25.09 ± 4.60

12, 29)

22.64 ± 4.84

12, 29)

22.08 ± 6.02

8, 29)

62.44 ± 84.39

(0.5, 467.0)

75.86 ± 113.62

(1.2, 468.0)

92.17 ± 137.67

(0.8, 531.3)

(

2

(

Upper

Middle

Lower

56 (31.5)

23.90 ± 5.38

(8, 29)

23.70± 5.10

62.62± 87.71

(0.8, 443.9)

83.23±126.48

(0.8, 531.3)

83.17±125.11

(0.5, 473.0)

60 (33.7)

62 (34.8)

(

10, 29)

23.23± 5.59

10, 29)

(

PCV- Pack cell volume, SD- Standard deviation, Range (min, max value)

The mean serum ferritin and PCV level for the anaemic

subjects stratified by their iron status is shown in table 2.

Ethical clearance

Table 2: Serum ferritin level and packed cell volume of the

study population.

Ethical clearance was obtained from the Ethics Commit-

tee of the hospital. Informed consent was obtained from

parents or caregivers of the patients.

Variable

Mean ±

SD

Max

.

Min. Rang

e

t (p)

Serum ferritin ng/

dl

45.2(0.001)

Iron deficient

5.7±3.8

11.8

0.8

11.3

Data management and analysis

Non iron defi-

cient

114.7±1

26.5

531.

0

12.4

518.9

Data were collected from the proforma and stored in a

Microsoft Excel file and later transferred to Statistical

Package for Social Sciences (SPSS, version 15, Chicago

IL, USA) for analysis. The study population was catego-

rized into three age groups; 3months -12months,

Pack cell volume

Iron deficient

Non iron defi-

cient

4.3(0.04)

22.2±5.7

23.9±5.2

29.0

10.0

8.0

19.0

21.0

1

3months -23months and 24months - 59months.

SD- Standard deviation, t- independent sample t test

1

31

Sixty-one (34.3%) out of the 178 anaemic children sur-

veyed were iron deficient. Table 3 shows the sociode-

mographic distribution of the children with iron

deficiency anaemia.

attributed to increased iron requirements related to rapid

growth in this age group. There was no significant gen-

der difference in the prevalence of iron deficiency anae-

mia in the current study (p = 0.235). A₁ similar finding

1

has been documented by other authors . Menstrual loss

Table 3: Socio-demographic distribution of children with iron

and pregnancy which are the major factors accountable

for gender disparity in the prevalence of iron deficiency

are not implicated in this study age groups.

deficiency anaemia

2

Variables

Iron deficiency anae- χ (p)

mia

Yes

No

Although the observed progressive increase in the preva-

lence of iron deficiency anaemia from upper to lower

socioeconomic class in the current study was not signifi-

cant, other studies have documented a higher prevalence

of IDA₂₄_,₂a₅mong the children of lower socioeconomic

Sex

Male (n = 100)

Female (n = 78)

38(38.0)

23(29.5)

62(62.0)

55(70.5)

1.41(0.235)

1.11(0.575)

Age category

3

1

2

-12 months (n =65)

3-23 months (n =45)

4-59 months (n =68)

22(34.4)

18(40.0)

42(65.6)

27(60.0)

group

. Some earlier researchers in particular, have

reported that iron deficiency anaemia is three times

more prevalent in the low inc₂o₆_,m₂₇e-families than those

21(30.4)

17(30.4)

48(69.6)

39(69.6)

Upper (n =56)

Middle (n= 60)

Lower (n= 62)

3.69(0.158)

living above the poverty level

. The reason for such

17(28.3)

27(43.5)

43(71.7)

35(56.5)

trend is obvious as the lower socioeconomic groups due

to financial constraints and ignorance may not be able to

provide the recommended daily allowance for iron in

their children’s diets resulting in deficiency.

Discussion

Conclusion

In this study the prevalence of iron deficiency among the

anemic under-five children was 34.3%. The prevalence

was higher in males, age group 13-23months and chil-

dren of low socioeconomic parents though the variation

in these demographic groups was not statistically sig-

nificant. There was no available local study specifically

documenting the prevalence of iron deficiency in anae-

mic under-five population with which to compare the

prevalence value in this study. However, such a high

prevalence rate was expected as iron deficiency has long

been docum₁₈e_, n₁₉ted as the commonest cause of anaemia in

There is a high prevalence of iron deficiency anaemia

among anaemic under-five children in Enugu. This

prevalence however, did not significantly vary with, sex,

age-group or their parental socio-economic class.

Limitations

Due to limited access to facilities the authors could not

carry-out concomitant blood cultures to rule out pres-

ence of in infection in the subject. Also for similar rea-

son, we could not carry out other iron parameters in ad-

dition to ferritin level on the studied subjects. However,

we recommend that future researches involving ferritin

in infection prone environment should rule out presence

of infection in the subjects.

childhood

. A study in Imo state Nigeria, has docu-

ment ₂even a higher prevalence (48.1%) among under

0

fives , this study like the current study employed fer-

ritin as the only indices for iron status , however, their

studied subjects were not limited to anaemic patients

like in the current study.

The mean serum ferritin level of the iron deficient anae-

mic subjects (5.69 ± 3.8ng/dl) in this study was lower

than 50.6 ± 52.6ng/dl documented by earlier authors in

apparently healthy under-five children in Port Harcourt

Author’s Contributions

EU : Designed the study, data collection

OOI : Introductory text.

ODIC: Statistical analysis, wrote results section and the

abstract of the study.

1

. This was not surprising as the latter study was on

apparently healthy children who supposedly will have

adequate micronutrient level including iron and hence a

higher ferritin level compared to anaemic population in

this study. For similar reason, earlier researchers docu-

mented a lower₂p₁revalence of IDA among apparently

healthy infants compared to the prevalence docu-

mented on anaemic infants in the current study. Iron

deficiency anaemia was observed to be more prevalent

among the age group 13-23months compared to the

other age groups. This is in₂c₂o_,₂n₃sonance with the find-

EU, OOI and ODIC : Discussion

IE and CE Manuscript review.

Conflict of interest: None

Funding: None

Acknowledgement

The authors are thankful to the medical and nursing staff

of the Paediatrics department of ESUTH, Park Lane,

Enugu for their assistance during the sample collection

in this study.

ings of previous researchers

, who reported that se-

vere iron deficiency anaemia usually affects children

during their second year of life. Higher prevalence of

iron deficiency anaemia in this age group could be

1

32

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