ANEMIA STATUS AMONG CHILDREN UNDER 5 YEARS OLD WITH ACUTE RESPIRATORY INFECTIONS AT HAI PHONG CHILDREN HOSPITAL IN 2015

MINISTRY OF HEALTH
HAI PHONG UNIVERSITY OF MEDICINE AND PHARMACY

VU THI NGOC
ANEMIA STATUS AMONG CHILDREN UNDER 5 YEARS OLD
WITH ACUTE RESPIRATORY INFECTIONS AT HAI PHONG
CHILDREN HOSPITAL IN 2015

GRADUATION ESSAY
BACHELOR OF NURSING
COURSE 2012-2016

MAJOR ADVISOR : dr. THAI LAN ANH PhD.
CO-ADVISOR

: HOANG THI OANH M.S.

HAI PHONG 2016


ACKNOWLEDGEMENTS

I am grateful for the school administrators, University training rooms, Nursing
faculty, Community Nursing Department in Hai Phong University of Medicine and
Pharmacy who have facilitated me to complete this thesis.
I am grateful for dr. Thai Lan Anh PhD. - Dean of Nursing faculty, Head of
Community nursing department in Hai phong University of Medicine and Pharmacy
and Hoang Thi Oanh M.S., who heartedly guide me during the study and
completing thesis.
My particular thank are for the staffs in Haiphong Children Hospital, who
facilitated me during data collection.

Last but not least, thank my parents, my teachers and my friends who have
been close, encouraging and helping me during learning process and completing my
study.
I gratefully acknowledge!

Student

Vu Thi Ngoc


SOCIALIST REPUBLIC OF VIETNAM
Independence - Freedom – Happiness
-------o0o-------

THE ASSURING

I hereby declare my results presented in the thesis are my own, not copied
from any other research. The process of collecting and processing data is
completely honest and objective.

Haiphong, June 5th, 2016
Student

Vu Thi Ngoc


ABBREVIATIONS

ACD

Anemia of chronic disease

ACI

Chronic inflammation

A.D.A.M

American Accreditation Health Care Commission

ALRTI

Acute lower respiratory tract infections

AURTI

Acute upper respiratory tract infections

ARI

Acute respiratory infections

CBC

Complete blood count

EPO

The hormone erythropoietin

MCH

Mean corpuscular hemoglobin

IDA

Iron deficiency anemia

MCHC

Mean corpuscular hemoglobin concentration

MCV

Mean corpuscular volume

MEDS

The monitoring, evaluation, and design support

NHLBI

National Heart Lung And Blood Institute

NIH

National Institutes of Health

NSAIDs

Anti-inflammatory drugs

PHNI

The population, health and nutrition information

TIBC

Total iron binding capacity

UNICEF

The United Nations Children’s Fund

WHO

World Health Organization.


CONTENTS
ACKNOWLEDGEMENT
THE ASSURING
ABBREVIATIONS
CONTENTS
TABLE LIST
1.10. The relation between ARI with anemia ..................................................................21
CHAPPTER 3: THE RESULT OF STUDY........................................................................26
4.1. General characteristics of the subjects......................................................................33
4.2.1 The average Hb concentration.............................................................................34
4.2.2 Anemia prevalence .............................................................................................35

4.2.3 Degree of anemia ................................................................................................37
4.2.4 The distribution of anemia..................................................................................38
REFERENCES

APPENDIX

TABLE LIST
Table 1.1 Prevalence of anemia in children under 5 years old by aged groups
2008………….............................................................................................................4
Table 1.2 Hemoglobin values defining anemia for population groups……………...7
Table 1.3 Recommendations of WHO: Hemoglobin levels to diagnose anemia at sea
level (g/L)…………………………………………………………………………..17
Table 1.4 Guidelines for iron supplementation to children 6- 24 months of age……...20

Table 1.5 Guidelines for iron supplementation to other population groups……….21
Table 3.1 General characteristics………………………………………..…………26
Table 3.2 Anemia prevalence of the population…………………………………...27
Table 3.3 Anemia prevalence in age group………………………………………..27
Table 3.4 Anemia prevalence by gender…………………………………………..28
Table 3.5 Anemia prevalence by residence………………………………………..28
Table 3.6 Degree of anemia by age group…………………………………………29


Table 3.7 The Hb average concentration by age groups…………………………...29
Table 3.8 The Hb average concentration by types of ARI classification according to
anatomy…………………………………………….................................................30
Table 3.9 The Hb average concentration by types of ARI according to disease
classification………………………………………………………………………..30
Table 3.10 Hematological indices by age group……………………………….…..31
Table 3.11 Hematological indicator by residence and gender …………………….31

Table 3.12 Diagnosis of IDA by aged groups……………………………………...32
Table 3.13 Diagnosis of IDA in the community following residence and gender…32
Table 3.14 Diagnosis of IDA by aged groups……………………………………33


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INTRODUCTION
Anemia, a public health problem that affects low-, middle- and high-income
countries and has significant adverse health consequences, as well as adverse
impacts on social and economic development [45]. The numbers are staggering: 2
billion people – over 30% of the world’s population – are anemia, many due to iron
deficiency, and in resource-poor areas, this is frequently exacerbated by infectious
diseases. Malaria, HIV/AIDS, hookworm infestation, schistosomiasis, and other
infections such as tuberculosis are particularly important factors contributing to the
high prevalence of anemia in some areas [46].
Anemia may result from a number of causes, with the most significant
contributor being iron deficiency. Approximately 50% of cases of anemia are
considered to be due to iron deficiency, but the proportion probably varies among
population groups and in different areas, according to the local conditions. Anemia
resulting from iron deficiency adversely affects cognitive and motor development,
causes fatigue and low productivity and, when it occurs in pregnancy, may be
associated with low birth weight and increased risk of maternal and perinatal
mortality In developing regions, maternal and neonatal mortality were responsible
for 3.0 million deaths in 2013 and are important contributors to overall global
mortality. It has been further estimated that 90 000 deaths in both sexes and all age
groups are due to iron deficiency anemia (IDA) alone. Other causes of anemia
include other micronutrient deficiencies (folic, riboflavin, vitamins A and B12),
acute and chronic infections (malaria, cancer, tuberculosis and HIV), and inherited
or acquired disorders that affect hemoglobin synthesis, red blood cell production or

red blood cell survival [45].
In Vietnam, recent year the prevalence of anemia among children under 5,
pregnant women and non- pregnant women in Vietnam has decreased but remained
high. The prevalence of anemia 1995 and 2000: children under 5 years old,
pregnant women and non-pregnant women in nationwide has decreased respectively


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as follows: 45.3% down 34.1%; 52.7% down 32.2%; 40.2% down 24.3% [15]. In
2010 prevalence of anemia among children under 5 years old 29.2%, pregnant
women 36.5%, non-pregnant women 28.8%. According eco-region, anemia was
highest in the Central Highlands, the Southeast, the North in Central, the South
Central and Northern Mountains, the lowest was in the Red River Delta and
Mekong Delta [6]
Other hand, acute respiratory infections (ARI) is a major in three cause of death in
children under 5 years old. ARI with high morbidity and recur several times a year.
In developing countries, ARI including pneumonia, that is one of the major fatal
diseases in children under 5 years old. Statistics show that the average per child per
year caught from 4- 9 times. Estimated globally every year, about 2 billion children
caught ARI, of which approximately 40 million are pneumonia. Recently in
Vietnam ARI still cause high morbidity and mortality in children under 5 years old.
ARI in children now account for about 40.6% in the community and the highest
proportion (40 -50%) of children come to care and treatment in the health facilities
[1].
So far, studies of anemia in children ARI under 5 years old have not been
many authors performed. For more information about relation between anemia and
acute respiratory infections among children under 5 years old, I would like to
implement the study: "Anemia status among children with ARI under 5 years at
Haiphong Children Hospital in 2015"

Objective of the study is to determine the anemia status among children
under 5 years with ARI at Haiphong Children Hospital in 2015.

CHAPTER 1: LITERATURE REVIEW


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1.1.Anemia status among children under 5 years old in the world and in
Vietnam
1.1.1 In the world
Anemia is a public health problem, affecting both developed countries and
developing countries, causing severe consequences for the health people as well as
for economic development and social. Anemia occurs at all stages of the life cycle,
but is most common in pregnancy women and children.
The WHO (2008) has estimated the worldwide prevalence of anemia by
regions and population groups. Women and young children are the most vulnerable
to anemia. The highest prevalence of anemia was 47.4% in preschool-aged children
(293 million preschool-aged children). The proportion of children is the highest in
the Africa region where 67.6% of pre-school children (83.5 millions) are anemic.
While the proportion of people with anemia is lower in South-East Asia, the number
of people with anemia is higher than in the Africa region. In Southeast Asia, 65.5%
of preschool children (115.3millions) suffer from anemia [29].
The WHO (2011) has estimated the worldwide prevalence of anemia by
regions and population groups. The highest prevalence of anemia was in children
42,6 % ( 273.2 million children. Of these, 9.6 million children had severe anemia,
with severe anemia was highest in Africa Region, with 3.6% of children affected.
Children in the Africa Region represented the highest proportion of individuals
affected with anemia, at 62.3% (95% CI: 59.6-64.8), while the greatest number of
children with anemia resided in the South-East Asia Region, including 96.7 million

(95% CI: 71.7-115.0) children in 2011. The Eastern Mediterranean Region had the
next highest anemia burden for children, accounting for 35.7 million (95% CI: 29.741.9) children with anemia [45].

1.1.2 In Vietnam


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Like many other developing countries, anemia in Vietnam is considered to be
public health problems. Although anemia has improved in the past few decades, but
the decease is slow. According to National Institute of Nutrition - UNICEF in report
"review of the nutrition situation in Vietnam 2009-2010" (2011), the prevalence of
anemia by ecological region in of children under 5 years old in 2000 was 34.1%
and 29.4% (7509 children) in 2008. The prevalence of anemia among children was
markedly different between regions: The highest was Northern Midlands and
Mountain areas with 35.5 % (1872 children), the second was North Central areas
and Central coastal area: 34.7 %(1288 children), the next ones were in Mekong
River Delta with 32%(1545 children), Southeast with 30.2% (597 children), Red
River Delta with 23.9 % (1505 children), Central Highlands with 23.1% (702
children). [6].
Table 1.1 The prevalence of anemia in children under 5 years old by aged
groups 2008.
Month
<12 months
12-23 months
24-35 months
36-47 months
48-59 months

Prevalence (%)

43.3
44.4
27.5
17.4
14.2

The prevalence in anemia among children was markedly different between
aged of groups: The highest was the children 0- 23 months with 44-45% then
gradually decreased with age, the lowest was 48-59 months of age group 14.2% [5].
The study belongs to Nguyen Cong Khan and Nguyen Xuan Ninh. That was
carried out during March 2006 in order to determine the prevalence of anemia, the
sub-clinical vitamin A deficiency in children under 5 years old in 6 provinces
(Hanoi, Hue, Backan, Bacninh, Angiang, Daklak) in Vietnam. Blood hemoglobin
and serum retinol were analyzed, Hb <110g/L were considered anemia deficiency
respectively. The prevalence of anemia is 36.7% in average (mild level in Public
Health Significant-PHS according to WHO). The highest rates were found in


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Backan 73.4% and the lowest in Angiang17.0%. The rates found in Bacninh &
DaKlak were 25,6%; urban areas 32.5% (Hanoi 30%, Hue 38.6%); Sub-urban
38.4% (Hue 42%, Hanoi 35%). The prevalence of anemia is the highest in infant
aged 6-12 months (56.9%), then reduced: 45% in 12-24 months, 38% in 24-36
months, 29%in 36-48 months, and 19.7% in 48-59 months [15].
According to the research result "Describe nutritional anemia in children under
5 years old at the Consultation Department in Pediatrics Hospital 2013" by Nguyen
Thi Kim Phung shows around 33% of children suffered from anemia, of which
about 27% of children suffer moderate and severe anemia [16].
According to the research conducted by Ta Thi Vinh and Nguyen Thi Viet

Hoa performed on 1,206 children younger than 13 years old in two communes: Tra
Mai Commune, Tra My district in Quangnam province and Phu Rieng commune,
Phuoc Long district in Binhphuoc province in 2 years 1999-2000. The results
showed that the general rate of anemia of children is 21.6% in Tra Mai commune
(group ≤ 5 years old: 16.5%, 6-13 years: 25.1%),the general rate of anemia of
children in Phu Rieng commune is 33.5% (group ≤5 years old: 25.6%, 6-13 years:
40.4%). As for degree of anemia: mostly mild anemia (16.5% and 24.3%
respectively for the group ≤5 years old and 6-13 years old in Tra Mai commune,
20.6% and 38.8% respectively for the group ≤ years old and 6-13 years old in Phu
Rieng) the average anemia is low, no cases of severe anemia [17].
The study on the nutritional anemia in children under 5 years old and some
factors in Thua Thien Hue province, 2009 of Phan Thi Lien Hoa colleagues studied
on 779 children under 5 years old in Thua Thien Hue province by random sample
method, some remarks as follow: the prevalence of anemia in under 5 years old is
35.4%, in mild anemia and severe anemia: 22.3% and 13.1%, respectively.
Especially, the prevalence of anemia in children under 12 months is very high: 62%
[10].


6

In research “Anemia situation in children and women in reproductive age in 6
representative provinces in Vietnam, year 2006” of Nguyen Xuan Ninh, Nguyen
Anh Tuan, Nguyen Chi Tam and et al. Transversal study was carried out in 1175
children under 5 years old, 934 pregnancy women and 1120 non-pregnant women,
during March 2006 (mild term of the National Strategy on Nutrition, 2001-2010) in
order to determine the prevalence of anemia in children under 5 years old, women
in reproductive age in 6 provinces (Hanoi, Hue, Backan, Bacninh, Angiang, Daclak)
in Vietnam. Blood hemoglobin concentrations were analyzied by using
cyanmethemoglobin method, Cut-off Hb <110g/L were considered as anemia for

children and pregnancy, and Hb <120 used for non-pregnant women. The
prevalence of anemia in children is 36.7% (belong to mild levels in Public Health
Significant- PHS), Backan 73.4%, Angiang 17,0%, Bacninh & Daclak 25.6%;
Hanoi 32.5%, Hue 38.6%. Anemia prevalence is the highest in infant age of 6-12
months (56.9%), then reduced: 45% in 12-24 months, 38% in 24-36months, 29% in
36-48months, and 19.7% in 48-59 months. The prevalence of anemia is 32,5% in
cities and 38,4% in sub-urban for children [31].
In Haiphong, the research “Nutritional anemia status and its determinant
factors among infants aged 0-9 months in Kien Thuy district, Haiphong city”
showed that the prevalence of nutritional anemia was 78.7% with the mean of
Hemoglobin concentration 103.5 ± 9.4 g/L. The differences between the prevalence
of anemia were not found among four communes, age group, and gender. No severe
case was reported, mild anemia was very common (74.1%), moderate anemia was
4.6%. Nutritional anemia due to iron deficiency accounted for approximately 90%,
the rest were other causes. [7]
The study about anemia at Haiphong children Hospital 2006-2007 showed that
the prevalence of anemia in rural children accounted for 62.4 % [3]. Another study
Anemia status among children aged under 5 years old who were admitted to
Haiphong children hospital in 2015 of Thai Lan Anh the results showed that:


7

Prevalence of anemia was 25.3%, mostly was mild anemia. The rate decreases with
ages. With 42.8% of children had iron deficiency anemia. [8]
1.2. Definition of anemia
Anemia is defined as a decrease in the concentration of circulating red blood
cells or in the hemoglobin concentration and a concomitant impaired capacity to
transport oxygen. It has multiple precipitating factors that can occur in isolation but
more frequently co-occur [29].

Hemoglobin is the substance in red blood cells that carries oxygen to the cells
of the body. The body’s cells need oxygen to function and enable a person to
perform all physical and mental activities. When hemoglobin levels are low, as in a
person who has anemia, less oxygen reaches the cells to support the body’s
activities. The heart and lungs also must work harder to compensate for the blood’s
low capacity to carry oxygen [43].
Internationally accepted hemoglobin values for defining anemia in different
population groups are shown in table 2.
Table1. 2 Hemoglobin values defining anemia for population groups [43].
Age or Sex Group
Children 6-59 months

Hemoglobin Value Defining Anemia (g/dL)
<11.0

Source: WHO/UNICEF/UNU (2001); values used in DHS.

1.3. Scientific bases
1.3.1 Blood
Blood has two major components:


8

- Plasma is a clear yellow liquid that contains proteins, nutrients, hormones,
electrolytes, and other substances. It constitutes about 55% of blood.
- Blood cells: White and red blood cells and platelets make up the balance of
blood. The white cells are the infection fighters for the body. Platelets are
necessary for blood clotting. The important factors in anemia, however, are red
blood cells. Red blood cells, also known as erythrocytes, carry oxygen

throughout the body to nourish tissues and sustain life. Red blood cells are the
most abundant cells in our bodies [44].
1.3.2 Hemoglobin and iron
Each red blood cell contains 280 million hemoglobin molecules. Hemoglobin
is a complex molecule, and it is the most important component of red blood cells. It
is composed of protein (globulin) and a molecule (heme), which binds to iron [44].
In the lungs, the heme component binds to oxygen in exchange for carbon
dioxide. The oxygenated red blood cells are then transported to the body's tissues,
where the hemoglobin releases the oxygen in exchange for carbon dioxide, and the
cycle repeats. The oxygen is used in the mitochondria, the power source within all
cells [44].
Red blood cells typically circulate for about 120 days before they are broken
down in the spleen. Most of the iron used in hemoglobin can be recycled from there
and reused [19].
1.3.3 Structure and shape of red blood cells
Red blood cells - the erythrocytes - are extremely small and look something
like tiny, flexible discs. This unique shape offers many advantages [19]:
- It provides a large surface area to absorb oxygen and carbon dioxide.
- It’s flexibility allows it to squeeze through capillaries, the tiny blood vessels
that join the arteries and veins.


9

- Abnormally shaped or sized erythrocytes are typically destroyed and
eliminated.
1.3.4 Blood cell production
The actual process of making red blood cells is called erythropoiesis. Most of
the work of erythropoiesis occurs in the bone marrow. In children younger than 5
years old, the marrow in all the bones of the body is enlisted for producing red

blood cells. As a person ages, red blood cells are eventually produced only in the
marrow of the spine, ribs, and pelvis. If the body needs more oxygen (at high
altitudes, for instance), the kidney triggers the release of the hormone
erythropoietin, a hormone that acts in the bone marrow to increase the production of
red blood cells. The lifespan of a red blood cell is 90-120 days. The liver and the
spleen remove old red blood cells are removed from the blood by the liver and
spleen. When old red blood cells are broken down for removal, iron is returned to
the bone marrow to make new cells [19].
1.4. Causes of anemia
1.4.1 Iron deficiency anemia
Iron deficiency affects more than 2 billion people worldwide [29], and irondeficiency anemia remains the top cause of anemia, as confirmed by the analysis of
a large number of reports on the burden of disease in 187 countries between 1990
and 2010 [17], and by a survey on the burden of anemia in persons at risk, such as
preschool children and young women [39]. Prevention programs have decreased
rates of iron-deficiency anemia globally; the prevalence is now highest in Central
and West Africa and South Asia [26] [39]. The estimated prevalence of iron
deficiency worldwide is twice as high as that of iron-deficiency anemia.
IDA occurs when the body lacks mineral iron to produce the hemoglobin it
needs to make red blood cells. In general, there are three stages leading from iron
deficiency to anemia [45]:


10

- Insufficient supply of iron, which causes iron stores in the bone marrow to be
depleted. This stage generally has no symptoms.
- Iron deficiencies develop and begin to affect hemoglobin production. (Tests
will show low hemoglobin and hematocrit levels.)
- Hemoglobin production declines to the point where anemia develops.
Most of the iron used in the body can be recycled from blood and reused.

Nevertheless, iron deficiency can occur from a number of conditions.
Inadequate iron intake
General, most people need just 1 mg of extra iron each day. This means that
lack of iron in the diet is not a common cause of iron deficiency anemia, except in
infants. Iron-poor diets are a cause of anemia only in people with existing risks for
iron deficiency. Children who have not yet eaten iron-fortified formulas or ironenriched cereal may also become anemic [44].
Blood loss
Blood loss due to some conditions:
- Peptic ulcers, which may be caused by H. pylori infections, or use of nonsteroid anti-inflammatory drugs (NSAIDs) such as aspirin, ibuprofen, and
naproxen,
- Chronic gastritis, caused by long-term use of NSAIDs, although it is rarely
significant enough to cause anemia.
- Duodenal ulcers
- Hemorrhoids, though rare...
If a lot of blood is lost, the body may lose enough red blood cells to cause
anemia [44].
Impaired absorption of iron


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Impaired absorption of iron is caused by:
- Certain intestinal diseases (inflammatory bowel disease, celiac disease)
- Surgical procedures, particularly those involving removal of parts of the
stomach and small intestine, can impair the ability of the stomach or intestine
to absorb iron. (Such conditions also often impair vitamin B12 absorption.)
- Pica, the craving for non-food substances such as ice, starch, or clay, is a
possible cause of iron deficiency in young children.
- Certain intestinal infections, such as hookworm and other parasites [44].
Genetic causes

Some people are born with iron deficiency. Certain cases may be due to a
mutation of the Nramp2 gene, which regulates a protein responsible for delivering
iron to the cells [44].
1.4.2 Anemia of chronic disease (ACD)
Anemia of chronic disease, also called anemia of chronic inflammation (ACI),
is a common condition associated with a wide variety of persistent inflammatory
diseases. It can be very severe and require transfusions [44].
The inflammatory process and ACD
In ACD, iron is not efficiently recycled from blood cells and red blood cells do
not survive for as long as normal. In addition, there is impaired response to
erythropoietin, the hormone that acts in the bone marrow to increase the production
of red blood cells [44].

Diseases associated with ACD and inflammation
In ACD, iron is not efficiently recycled from blood cells and red blood cells do
not survive for as long as normal. In addition, there is impaired response to


12

erythropoietin, the hormone that acts in the bone marrow to increase the production
of red blood cells.
The chronic diseases that are associated with this process include:
- Certain cancers: lymphomas and Hodgkin's disease.
- Autoimmune diseases: rheumatoid arthritis, systemic lupus erythematosus,
inflammatory bowel disease, and polymyalgia rheumatica.
- Long-term infections: chronic or recurrent urinary tract infections,
osteomyelitis, HIV/AIDS, hepatitis C.
- Liver disease. Cirrhosis, Gastrointestinal
- Heart failure.

- Chronic kidney disease.
But not all chronic diseases involve the inflammatory process and anemia. For
example, high blood pressure is a chronic disease, but it does not affect red blood
cells [44].
1.4.3 Treatment-related anemia
Treatment-related anemia results from the therapies used to treat conditions.
For example, anemia is a common side effect of cancer treatments. Other
medications that increase the risk for anemia are certain antibiotics, some
antiseizure medications (phenytoin), immunosuppressive drugs (methotrexate,
azathioprine), antiarrhythmic drugs (procainamide, quinidine), and anti-clotting
drugs (aspirin, warfarin, clopidogrel, heparin) [44].

1.4.4 Megaloblastic anemia


13

Megaloblastic anemia results from deficiencies in the B vitamins folate or
vitamin B12 [44].
1.5. Types of anemia.
Common types of anemia include [24]:
- Iron deficiency anemia, caused by blood loss or a shortage of iron in the diet
- Vitamin deficiency anemia, caused by too little vitamin B12 or folic acid in
the diet or an inability to absorb these vitamins from food
- Anemia of chronic disease arises as a result of cancer, HIV/AIDS, Crohn’s
disease, and other chronic conditions that interfere with the production of red
blood cells
- Aplastic anemia, an uncommon but potentially deadly condition caused by
the inability of the bone marrow to make red blood cells
- Anemia due to bone marrow diseases such as leukemia or myelofibrosis

affect to the bone marrow’s ability to make blood cells.
- Hemolytic anemia occurs when the body destroys red blood cells faster than
it makes them
- Sickle cell anemia occurs in people who inherit genes for a type of
hemoglobin that forces red blood cells to assume a crescent, or sickle, shape.
1.6. Consequences of anemia in children
• Impaired cognitive performance at all stages of life.
• Significant reduction of physical work capacity and productivity.
• Increased morbidity from infectious diseases.
• Negative foetal outcome: intrauterine growth retardation, low birth weight,
prematurity. [42].


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Anemic children from Costa Rica showed worse verbalization rates during
interaction with their mothers, anemic Chilean children showed worse performance
with communicative language and vocalization, and Indian children with anemia
presented less social interaction than non-anemic children from the same place.
Although no studies were found in the literature specifically investigating speech
and hearing, other areas demonstrate the effects of anemia on the higher cognitive
processes that make language learning possible. Studies indicate that anemia acts
reducing oxygenation in the brain, altering the processes of neurotransmission and
myelination. Furthermore, there is increased vulnerability during development in
the presence of iron deficiency, which is demonstrated by abnormalities in the
structure of hippocampus pyramidal cell dendrites, important components of the
limbic system, which is also the seat of memory [36].
Impacts of anemia to health and development of infant
The risk to the infant may come from the fact that iron deficiency and anemia
in children, as well as in adults, produce alterations in brain function that may result

in poor mother-child interactions and impaired schooling later. There is mounting
evidence that in infants IDA may produce long-lasting defects in mental
development and performance that my further impair the child’s learning capacity.
[43]
Impacts of anemia to young child development and learning
Iron-deficiency anemia, particularly in children under 2 years of age, can result
in irreversible learning problems even if the iron deficiency and resulting anemia
are corrected. In malaria- endemic areas, many children are anemic because of a
combination of iron deficiency and untreated episodes of malaria. The hemoglobin
levels of these children can drop to life-threatening levels. Iron deficiency also
affects iodine uptake, increasing the risk of iodine deficiency disorders that can
have devastating effects on fetal brain development and a child’s IQ. Anemic
children of all ages are apathetic, which affects social development [43].


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1.7. Symptoms and signs of anemia
The signs and symptoms of anemia can be mild or severe. They depend on
how severe the anemia is and how quickly it develops. Generally, signs and
symptoms increase as anemia gets worse. Many of the signs and symptoms of
anemia also occur in other diseases and conditions. Mild anemia may have no signs
or symptoms. If you do develop signs and symptoms, you may have tiredness,
weakness, or pale or yellowish skin. These signs and symptoms also occur in more
severe anemia and are far more obvious. As anemia gets worse, you also may
experience faintness or dizziness, increased thirst, sweating, weak and rapid pulse,
or fast breathing. Severe anemia may cause lower leg cramps during exercise,
shortness of breath, or neurological (brain) damage. A lack of RBCs also may cause
heart-related symptoms because your heart has to work harder to carry oxygen-rich
blood through your body. These symptoms include arrhythmias (abnormal heart

rhythms), heart murmur (an extra or unusual sound heard during a heartbeat), an
enlarged heart, or even heart failure [32].
Symptoms of anemia vary depending on the severity of the condition. Anemia
may occur without symptoms and be detected only during a medical examination
that includes a blood test. When they occur, symptoms may include:
• Pale skin, lips, tongue and inner surface of eyelids (however, healthy-looking
skin color does not rule out anemia)
• Fatigue
• Irritability
• Weakness
• Shortness of breath
• Low blood pressure with position change from lying or sitting to standing
(orthostatic hypotension)
• Sore tongue


16

• Brittle nails, concave nails
• Unusual food cravings (called pica)
• Decreased appetite (especially in children)
• Headache - frontal
• Low hematocrit and hemoglobin in a RBC
• Low serum ferritin (serum iron) level
• Swollen hands and feet
Also, a newborn with hemolytic anemia may become jaundiced (turn yellow),
although many newborns are mildly jaundiced and do not become anemic. Children
who lack iron in their diets may also eat strange things such as ice, dirt, clay, and
cornstarch. This behavior is called “pica.” It is not harmful unless your child eats
something toxic, such as lead paint chips. Usually the pica stops after the anemia is

treated and as the child grows older [42].
1.8. Diagnosis of anemia
1.8.1 Clinical diagnosis
Most children with mild anemia have no signs or symptoms. Some may
present with irritability or pica (in iron deficiency), jaundice (in hemolysis),
shortness of breath, or palpitations. Physical examination may show jaundice,
tachypnea, tachycardia, and heart failure, especially in children with severe or acute
anemia.
Pallor has poor sensitivity for predicting mild anemia, but correlates well with
severe anemia. One study showed that physical examination findings of pallor of
the conjunctivae, tongue, palm, or nail beds is 93 % sensitive and 57 % specific for
the diagnosis of anemia in patients with an Hb level of less than 5 g/dL (50/L).The
sensitivity decreases to 66 % when the Hb level is 5 to 8 g/dL (50 to 80 g/L).
Chronic anemia may be associated with glossitis, a flow murmur, and growth delay
although these conditions are rare in developed countries [24]
1.8.2 Diagnosis test


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Laboratory tests used in the diagnosis of anemia include measurement of
ferritin, which reflects iron stores, and transferrin or total iron-binding capacity,
which indicates the body's ability to transport iron for use in RBC production.
Complete blood count (CBC)
A CBC checks your hemoglobin and hematocrit levels. Hemoglobin is an ironrich protein that helps red blood cells carried oxygen from the lungs to the rest of
the body [33]
Table 1.3. Recommendations of WHO: Hemoglobin levels to diagnose anemia at
sea level (g/L) ± [48].
Population
Children 6-59 months

Non- Anemia
110 or higher

Anemia
Mild
100-109

Moderate
70-99

Severe
Lower than 70

of age
Hematocrit is a measure of how much space red blood cells take up in your
blood. A low level of hemoglobin or hematocrit is a sign of anemia. Anemic ranges
for hematocrit generally fall below: Children ages 6 months - 5 years: Below 33%
[44].
The CBC also checks the number of red blood cells, white blood cells, and
platelets. Finally, the CBC looks at mean corpuscular volume (MCV). MCV is a
measure of the average size of your red blood cells. MCV can be a clue as to what's
causing your anemia. In pernicious anemia, the red blood cells tend to be larger than
normal [33].
Other hemoglobin measurements such as mean corpuscular hemoglobin
(MCH) and mean corpuscular hemoglobin concentration (MCHC) may also be
calculated. Mean Corpuscular Volume. Mean corpuscular volume (MCV) is a
measurement of the average size of red blood cells. The MCV increases when red

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blood cells are larger than normal (macrocytic) and decreases when red blood
cellsare smaller than normal (microcytic) [19].
Other blood tests
- Tests to measure iron levels [19].
+ Serum iron: This test measures the amount of iron in your blood. A normal
serum iron is 60 - 170 mcg/dL
+ Serum ferritin: Ferritin is a protein that helps store iron in your body.
Normal values are generally 12 - 300ng mL for men and 12 - 150ng/mL for
women.
+ Transferrin level or total iron-binding capacity: Transferrin is a protein that
carries iron in your blood. Total iron-binding capacity measures how much of
the transferrin in your blood isn't carrying iron. If you have iron-deficiency
anemia, you'll have a high level of transferrin that has no iron [44].
Vitamin Deficiencies test: Tests for vitamin B12 and folic levels. Children also
may be tested for the level of lead in their blood. Lead can make it hard for the body
to produce hemoglobin [19].
1. 9. Anemia prevention
Nutritional anemia prevention: including some of the following measures:
1.9.1 Dietary improvement
Measures to improve diet, diversification diet, eat different types of foods
especially of animal food sources of iron such as meat, liver, eggs, blood, rich
vitamin C on foods such as fruits and vegetables [2].
Dietary improvement aims to improve and maintain micronutrient status
through changes in behavior that lead to an increase in the selection of
micronutrient-rich foods and a meal pattern favorable to increased bioavailability.


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Such changes can bring about important sustainable improvements, not only in
anemia and micronutrient status, but for nutrition in general.
Improving diet: increased iron foods and nutrients such as meat, organ meats,
eggs, fish and sea food... and rich vitamin C foods such as vegetables, ripens fruit.
To prevent IDA for children, first needed to prevent anemia for the mother,
because the child, since was a fetus has got iron from the mother to develop and
have a little reserve. In the first year of life, children continue to receive iron
through breast milk precious resources. Early breastfeeding, breastfeeding is
prolonged enough and very important measures. When starting complementary
feeding, babies need to eat nutrient-rich foods such as meat, eggs, shrimp, beans,
vegetables and fruits. Note the child's diet should be diversified, coordination many
different foods.

Currently in

our country hasn't applied popular iron

supplementation for children. Can use (note the correct dose) some drugs such as
syrup iron, multi-micronutrient syrup containing iron for children or iron fortified
foods such as nutrition powder, biscuits, milk ... were allowed to circulate on the
market today [4].
1.9.2 Micronutrient supplementation for those subjects of anemia
Iron supplementation for those subjects high risk of anemia. World Health
Organization recommendations apply as pregnant women, women of childbearing
age and young children.
In research “ Effectiveness of early 3 month-interval high dose vitamin A
combined with prophylaxis iron supplements on iron anemia among breastfeeding
children” of Thai Lan Anh the results showed that: Early supplement high-dose
vitamin A 3-months/times and

iron supplementation daily: Increased the

hemoglobin concentration to 13.6 g/L. Reduced the incidence of anemia 44.3%,
reduced the risk of anemia with RR 95% CI = 0.68 (0.55 to 0.84), increased serum
ferritin and iron storage, reduced the prevalence of iron reserves and depleted iron