Iron Deficiency Anemia among Children

under Three years in Kassala, Eastern Sudan

original article

Iron Deficiency Anemia among Children under Three years in

Kassala, Eastern Sudan
Hiba H. Mahmoud1, Abdelrahim M. Muddathir2, Shams ElFalah M. Osman3, Mustafa A. AlKhawad3, Awadia K.
Mohamed3, ElHady E. ElMubarak3, Mamoun M. Mohamed3*
1) Ministry of Health, Kassala State, Sudan.
2) University of AlZaeim AlAzhari, Khartoum, Sudan.
3) Kassala University, Kassala, Sudan.

Correspondence:
Dr. Mamoun Magzoub Mohamed, Ph D
Assistant Professor, Department of Microbiology & Parasitology, Faculty of Medicine, University of Kassala,
P.O. Box 266Kassala, Sudan - Fax: +249411823501 - E-mail: mosmanmm@hotmail.com - Phone: +249912913999

Abstract

Background: Iron deficiency anemia is the most common form of anaemia. The aim of this study is
to determine the prevalence of iron deficiency anaemia among children aged from 12_36 months old.
Methods: A total of 100 children between 12 and 36 months old were attended at AlKwaity Pediatrics
Hospital and Kassala Teaching Hospital were enrolled in the study and prevalence of iron deficiency
anaemia was estimated by analyzing Haemoglobin (Hb) level, PCV, MCV, MCH, MCHC on a blood Counter
(Sysmex ). The concentration of serum ferritin was measured using radioimmunoassay. Results: Eightysix (86%) of all children were anaemic, 64 (64%) of them were severe anaemic. Conclusion: The study
showed high prevalence of anaemia among those children, so more studies were recommended to perform
in this area. Also health authorities may interfere by health education and other interventional methods.
Keywords: Anaemia, children, Kassala, eastern Sudan.

Background
Iron deficiency anemia is the most common form of
anemia. Iron is an essential part of hemoglobin, the
oxygen-carrying protein in blood(1).
Anemia refers to a state in which the level of
haemoglobin in the blood is below the normal
range appropriate for age(3). Anaemia in childhood
is defined as a haemoglobin concentration below
established cut off levels(4). Healthy newborn infants
have a total body iron of 250 mg, which is obtained
from maternal sources. Infants consuming cow
milk have a greater incidence of iron deficiency
because bovine milk has a higher concentration of
calcium, which competes with iron for absorption.
Subsequently, growing children must obtain
approximately 0.5 mg more iron daily than is lost
in order to maintain a normal body concentration
of 200 mg(5).
Inadequate dietary iron, iron absorption and
intense exercise, along with blood loss and parasitic
infestations, are some etiologies of Iron Deficiency
Anemia(6).
A study carried out in public day care centers in
the city of Cuiab, state of Mato Grosso, Brazil to
determine the prevalence of anemia in children aged
SUDANESE JOURNAL OF PUBLIC HEALTH - January 2014, VOL. 9 No. 1

33

less than 36 months indicates that high prevalence

(63%) of anemia among these children(7). The
prevalence of childhood iron deficiency anemia in
the United States as a whole has declined in the past
decade, also the prevalence of anemia remains high
among Alaskan Native children. The database was
taken from the Alaska Area Native Health Service
for children aged 5-72 months; the computerized
medical-record database for the Alaska Area Native
Health Service includes hemoglobin values from
1983 to 1985 for children aged 5-72 months who
were eligible for care. Testing is recommended as
part of routine well-baby care at ages 6, 10, and
18 months and before the child enters school. In
the years 1983-1985, more than 4,000 test results
were recorded annually, and the prevalence of
anemia (haemoglobin less than 11 g/dl,) was 22%
in children under 5 years of age(8). A cross-sectional
survey method was used for data collection to
detect the prevalence of iron deficiency anaemia,
among under five children in Imo State of Nigeria.
The sample was randomly selected to cover the
three geopolitical zones in Imo State. A total of four
hundred (400) under-five children were selected by
purposive sampling method. Two hundred were from
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Iron Deficiency Anemia among Children

under Three years in Kassala, Eastern Sudan

original article
the urban and another two hundred from the rural
locations. Food samples were analyzed for proximate
composition. Blood samples for determination
of serum ferritin, was obtained by vein puncture.
The results showed that 48.1% were iron deficient
although iron intakes were above recommended
allowances. Variables strongly associated with
iron deficiency were previous health status of the
child, diarrheal treatment, feeling sleepy, tired and
weak, complementary feeding timing(9). A total of
150 children were selected from four different area
of Allahabad district, India. Data on dietary intake
was collected by using 3 days dietary recall method.
Haemoglobin levels of children were estimated
by cyanmethaemoglobin method. Clinical status
assessing anemia was also recorded. Consumption
of all the nutrients by majority of the children was
comparatively less than the recommended dietary
allowances. Data on anthropometry revealed that
out of total children screened (N=150), Hemoglobin
test revealed that 65.33% had hemoglobin level
below the normal (12 g dl/1) values, indicating
anemia, out of which approximately half (53.33%)
were mild anemic and 12% were moderate anemic.
Feeling breathlessness and easily tired were
experienced by 30.5 and 23.73% of the subjects
respectively(10). In a Representative sample of 400
schoolchildren from Elminopheia district, Egypt,
iron status was assessed by haemoglobin, and serum
ferritin from a venous blood sample. The prevalence
of iron deficiency in this study was 65% and 55%
of anaemia was associated with iron deficiency. An
iron deficient child was defined as every Child with
either serum iron less than 50 g/dl, or Serum TIBC
more than 400 g/dL. In this study iron deficiency
was more common in children who did not usually
have breakfast as opposed to those who did(11). A
study was conducted in Islamic Republic of Iran as
the part of the National Health and Disease Survey
in 1999 that used a cluster sample of 1 in 1000 of
the Iranian population. Haemoglobin levels were
used to estimate the prevalence of anaemia in
children 212 year old of 4170 children aged 26
years, 7.3% were diagnosed with mild anaemia,
2.5% moderate anaemia and 1.0% severe anaemia
(WHO definitions). Of 8461 children aged 712
years, 10.9% were diagnosed with mild anaemia,
3.0% moderate anaemia and 1.1% severe anaemia.
The prevalence of anaemia was significantly higher
in rural than urban areas(12).
A study was carried out in Eskisehir, Turkey to
determine the prevalence of anaemia among infants
4-11 months age. Haemoglobin was estimated
SUDANESE JOURNAL OF PUBLIC HEALTH - January 2014, VOL. 9 No. 1

using Hemocue haemoglobinometer. Anaemia was

diagnosed if Haemoglobin concentration 12g/dl.
Prevalence of anaemia among 3039 healthy infants
was found in 40.6%(13). A study was performed to
determine the prevalence of iron deficiency anemia
among 1-year-oldinfants of disadvantaged families
in five poorest health districts in Montreal, Canada.
Participants: Infants 10 to 14 months of age were
identified from registration lists of births from May
1988 to August 1989. During a home visit capillary
blood samples were obtained from the child, and
the mother answered a questionnaire about infantfeeding practices. Infants with a serum ferritin level
of 10, ug/L or less and either a hemoglobin level of
1 15 g/L or less or a mean corpuscular volume of 72
fL or less were considered as having iron deficiency
anemia. Iron deficiency anemia was found in 25%
of the infants (95% confidence interval [CI] 19%
to 31%). The mean hemoglobin level was 115g/dl
(standard deviation 1 1) The serum ferritin level,
assessed routinely in the last 62 infants, was 10 ug/l
or less in 37% of the infants. The factors that were
found to be predictors of iron deficiency anemia
included the use of whole cows milk before 6
months of age (odds ratio [OR] 3.56 [95% CI 1.07 to
11.26]) and the use of iron-fortified infant cereal for
less than 6 months (OR 3.15 [95% CI 1.25 to 7.96]).
A low birth weight and the use of iron-fortified
formula for less than 6 months were associated
with iron deficiency anaemia(14).

34

Methods
A cross sectional study was conducted in at
AlKwaity Pediatrics Hospital and Kassala Teaching
Hospital. Kassala eastern Sudan during the period
of January - March 2011. The study group composed
of 100 children between 12 and 36 months old
were attended at AlKwaity Pediatrics Hospital,
Kassala and Kassala Teaching Hospital. The first
step of the work was to select patients from these
two hospitals containing those all children who
were attended at out patient clinics. All candidate
cases were evaluated by physical examination. The
informed of children parents is obtained to be a part
of the study. Data was collected by using pre-tested
questionnaire. Haemoglobin (Hb) levels, PCV, MCV,
MCH, and MCHC were analyzed on a blood Counter
(Sysmex). The concentration of serum ferritin was
measured using radioimmunoassay(15,16). (Normal
Range of Serum Ferritin Level for children aged 6
months to 14 years: 7-140 ng/ml)(17, 18).
The purpose of this work was explained to the
health authorities at the federal Ministry of Health
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Iron Deficiency Anemia among Children

under Three years in Kassala, Eastern Sudan

original article
in Kassala. The study also was discussed with the
directors of the AlKwiety Paediatrics Hospital
and Kassla Teaching Hospitals. The consent for
acceptance of participation of parents (Guardian) of
selected subjects in the study was obtained.

Table (2): Shows Anaemia and Serum Ferritin Level

for all children (n= 100)
Serum Ferritin

Results
The population included in the study comprised 100
children up to three years old, 50 (50%) males and
50 (50%) females. Packed cell volumes of most of
the patients were less than normal. Also mean cell
haemoglobin and mean haemoglobin concentration
for most of the patients were less than normal.

Normal (More
than 9g/dl)
Hb

Table (1): Mean value and (SD) for all children

Age (years)

2.1(0.8)

PCV

24.2(7.5)

Hb (g/dl)
MCV

MCH

MCHC

Anaemic (7-9 g/
dl)

Severe anaemic
(Less than 7 g/dl)
Total

6(2.2)

p value: 0.00

High
Low
Normal
Total
(more
(less
(7-140 ng/
than 140 than 7
ml|)
ng/ml) ng/ml)
14

14

13

22

25

29

10

64

52

32

16

100

Figure (3): Shows Anaemia and mother for

education for all children (n= 100)

75.3(12.1)
18.4(4.1)
24.3(2.7)

35 (35%) of the study population patients were

Baniamir, 21 (21%) were Hosa, 19 (19%) were
Hadandawa, 8 (8%) were Rashaida and 17 (17%)
were other tribes.
Eighty-six (86%) of all children were anaemic, 22
(22%) of them were severe anaemic (Figure 2).

p value: 0.70

Figure (1): Percentage of Anaemia for all children

SUDANESE JOURNAL OF PUBLIC HEALTH - January 2014, VOL. 9 No. 1

Figure (4): Shows Anaemia and residence for all

children (n= 100)

35

P value: 0.00

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Iron Deficiency Anemia among Children

under Three years in Kassala, Eastern Sudan

original article
It was observed that anaemia found commonly
among rural population where as severe anaemia
prevalent among urban population.

5 years in rural Gambia at the start of the rainy

season, differed from those in American reference
populations as follows: mean haemoglobin levels
were much lower at ages 1 and 2 years and mean
levels of mean corpuscular volume (MCV) were
lower at all ages (at age 1 year mean haemoglobin
was 11.2g/dl and mean MCV 68.2 fl) and mean
serum ferritin 8.8ng/ml. A total of 213 children
(23%) whose haemoglobin and mean corpuscular
volume were both less than the 3rd percentile of the
reference population received oral iron or placebo
from their mothers during the rainy season when
malaria transmission is maximal(21). Also our results
are higher than the prevalence of iron deficiency,
which was done among the Indian population of
metropolitan Durban. Iron deficiency was observed
in 53 % of these subjects 2500 subjects were
studied(22). And higher than The prevalence of iron
deficiency in Delhi, India among children, 9-36
months of age, was 64 %, of these 7.8% had severe
anemia (Hb >7.0 g/dl)(23).
Our results also higher than the study conducted
in Tunisia, the survey covered 955 children under
the age of five years, native of two regions with the
highest prevalent of anemia, the Southwest and the
District of Tunis. The results showed that 29% of
children suffered from anemia. About 70% of them
were iron deficient(24).
The study showed high prevalence of anaemia
among those children in Kassala, this may be due the
low economic status among population, particularly
in rural areas around the study area and this may
lead to not obtaining suitable nutrition for those
children.
Also many mothers are not educated, this may
affect on high prevalence of anaemia in the study
area. Conduction of more researches to assess
nutritional status in children under 3 year old are
recommended. Also there is the need for nutrition
interventions in children under 3 years and also for
mothers, for example by giving them oral iron. Using
prospective studies in help in providing insight into
how to approach prevention and treatment of iron
deficiency anaemia in this age group of children.
Ministry of Health, Kassala State can concentrate on
heath education of mothers; we think it is important
role in prevention of iron deficiency anaemia in
children.

Figure (5): Shows Anaemia and Pica for all children

(n= 100)

P value: 0.15

Discussion
In this study the prevalence of iron deficiency
anaemia among children was high (86%). also
PCV, MCV, MCH and MCHC were low among most
patients.
There was significant difference between low
haemoglobin level and low serum ferritin level (p
value: 0.00), also there was significant difference
between low haemoglobin level and rural patients
(p value: 0.00).
But there was no significant difference between
anaemia and: pica, Refusal Feeding, Duration of
Breast Feeding, Supplementary Feeding during
Breast Feeding, cow milk intake and goat milk intake
(p value: 0.15, 0.43, 0.14, 0.11, 53, 0.10 respectively).
Prevalence of iron deficiency anaemia in this study
was higher than the study carried out in children
aged less than 36 months in public day care centers
in the city of Cuiab, state of Mato Grosso, Brazil.
The prevalence of anemia among these children was
(63%)(7).
And it was different from the study showed that the
prevalence of iron deficiency anaemia in the U.S., in
Infants 1-2 years was (6 to 17 per 1000)(19).
This was different from the study was conducted in
Natal, India, which indicates that the high incidence
of iron deficiency anaemia was found in children
under 10 years of age-28,6% for females and 41,6%
for males(20).
In contrast Haematological and iron parameters,
measured in 907 children aged from 6 months to
SUDANESE JOURNAL OF PUBLIC HEALTH - January 2014, VOL. 9 No. 1

36

Ethical Clearance:
The study received ethical clearance from the
Research Board at the Faculty of Medical Laboratory
Sciences, University of AlZaiem AlAzhari.

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Iron Deficiency Anemia among Children

under Three years in Kassala, Eastern Sudan

original article
Data management and Statistical Analysis
Version 18 was used for entry and analysis of data.

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Acknowledgement:
The authors are grateful to the patients who
participated in the study and their parents or
guardians; also they thank the local heath authority
in Kassala State, Sudan.
Conflict of Interest:
None declared.

Authors contributions:
HHM, AMM and MMM designed the study. SEM, AAK
and AKM conducted the clinical work. HHM performed
the laboratory work. MMM and EEE analyzed the data.
All the authors shared in the drafting of the paper and
all of them approved the paper.
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