of Iron on Growth in Iron Deficient Anemic School Going Children
R. BANDHU*, N. SHANKAR AND O. P. TANDON
Department of Physiology,
University College of Medical Sciences
Guru Teg Bahadur Hospital,
Dilshad Garden, Delhi - 110 095
(Received on September
Abstract : Iron deficiency anemia (IDA) in children
has been associated with retardation in growth and the
cognitive development. In the ongoing study on the effects
of IDA in school going children, the effects on anthropometric
parameters such as height (Ht), Weight (Wt), head circumference
(HC), body mass index (BMI) and the mid arm circumference
(MAC) were studied along with the hematological parameters such
as hemoglobin (Hb), hematocrit (Hct), MCV, MCH, serum iron (SI),
total iron binding capacity (TIBC) and % saturation. The pre-supplementation
values of all these parameters were taken in anemic and control
groups of girls and boys. After deworming all the children
with albendazole (400 mg ), the anemic group was put on iron
supplementation (Ferrous iron 3-4 mg/ kg body weight/day) along
with vitamin C (100 mg OD) and the control children were given
vitamin C (100 mg OD), for 90 days. Pre-supplementation values
of IDA children were significantly lower for MAC and HC in girls
and for Ht and MAC in boys, when compared to the control group.
After the therapy both the groups of girls showed improvement
in the hematological parameters though it was greater in the
anemic girls. Ht and Wt of both groups also improved significantly
but the anemic girls showed increase in BMI also. Both the control
and anemic boys showed gain in weight. Post therapy, improvement
in hematological parameters for both the anemic girls and boys
were greater than their respective control groups. The MAC
value for anemic girls were in the control range but those of
anemic boys remained lesser than the control boys. So, it can
be concluded from the present study that the IDA children lagged
behind the control children in terms of anthropometric parameters
and they benefited relatively more in terms of anthropometric
improvement and hematological improvement after iron supplementation.
Key words : iron deficiency, anemia, anthropometry, school children, iron supplementation
Anemia has been described as a major health problem in the
developing countries (1). In Indian children, a high prevalence
of anemia varying from 27% to 90% has been reported in different
studies (2, 3), with iron deficiency anemia (IDA) being the
most common cause (4). Several studies in the past and more
recently have reported an impairment of physical growth in children
suffering from IDA (5, 6, 7). Kwik-Urbe et al (8) have also
shown reduction of body weight in iron deficient rats.
The detrimental effects of IDA on physical growth have been
attributed to poor appetite, altered endocrinological profile
and neurotransmitter metabolism consequent to iron deficiency.
The appetite is seen to decrease in IDA independently of plasma
leptin levels (9), but improves with iron supplementation (10).
IDA has been compared to stress, and in IDA plasma norepinephrine
as well as urinary excretion of epinephrine and norepinephrine
are increased (11). An elevated cortisol and parathormone level
along with altered metabolism of calcium, phosphorus and magnesium
has also been observed (12). The effects of IDA on physical
growth have been shown to be resistant even to the administration
of growth hormone (13).
The thyroid gland metabolism is also affected (14) with impaired
thermoregulation (15) and a hyperadrenergic state is seen in
hypothyroid individuals suffering from iron deficiency (16).
In our ongoing study on IDA and its effect on physical and mental
growth in school children belonging to a low socioeconomic strata
of the society, the anthropometric and the cognitive parameters
were studied. Here we are reporting the findings of anthropometric
parameters studied together with the effect of 90 days of iron
supplementation on them.
The study was conducted over a period
of one year. About 800 children from MCD
School, Nand Nagri, Delhi, were examined and only 400 out of these, found suitable
for the study were given letters of information and consent.
From those who responded favourably, a comprehensive data could
be obtained from 94 children. A formal consent letter from
the parents of each child included in the study was obtained
after explaining to them the whole procedure. The children
with any history of acute/chronic disease/infection, h/o of
hospitalization, h/o neurological/hematological/genetic diseases,
h/o blood transfusion and h/o hematinic therapy were not included
in the study. A thorough physical examination was done to rule
out any other ailment besides anemia.
Malnutrition was ruled out by excluding those children whose
height was less for age, BMI < 0.15 and mid arm circumference/
head circumference ratio < 0.30.
Hematological and anthropometric parameters were recorded before
starting the therapy. The children with hemoglobin concentration
[Hb] < 12 g/dL were assigned to the anemic group and those
with hemoglobin concentration ³ 12 g/dL were assigned to the control
group. Both the groups of children were given albendazole (400
mg) single dose therapy before starting the study and both groups
also received ascorbic acid 100 mg OD therapy for the 90 days
of the study period. The anemic group received iron therapy
in the form of Ferrous iron 3-4 mg/kg body weight for 90 days.
After 90 days the hematological investigations and anthropometric
profile of both the groups was measured again. For comparison
among anemic and control children, unpaired t test was
used whereas for comparing the pre and post treatment values
of same group paired t test was used. There were 52
boys and 42 girls in the study. The analysis of the boys and
girls was done separately. In boys there were 31 anemic and
18 control children and in the girls there were 19 children
in the anemic and 23 in the control group.
Hemoglobin, Red blood cell indices, serum iron values along
with peripheral blood smear to study RBC morphology were analysed.
Hemoglobin concentration values and RBC indices were measured
using automated hematology cell counter (Coulter T 890). Serum
iron was measured by method described by ICSH (17) and TIBC
was measured by Ressler and Zak (18) method.
Weight, head circumference and midarm circumference
were taken. The recording of weight was done with the child
in light clothing in early morning just before the breakfast.
Height recording was done with child standing bare feet on a
flat floor against a wall with feet parallel and with heels
buttocks, shoulders and occiput touching the wall. The head
was held erect with eyes aligned horizontally and ears vertically
without any tilt. With the help of wooden spatula the topmost
point of the vertex was identified on the wall on which a measuring
scale was inscribed. The occipito-frontal head circumference
was measured with a fibre glass type of tape encircling over
most prominent part of occiput and supraorbital frontal area.
For measuring the midarm circumference a fibre glass tape was
used at the midpoint between acromian and olecrenon. Body mass
index was calculated from height (in meters) and weight (in
kilograms) using the formula:
BMI = -------
In the pretreatment visit the hematological parameters of the
control girls (CGI) and anemic girls (AGI) (Table I), were significantly
different when statistically analyzed. The hemoglobin concentration
and hematocrit of anemic girls were significantly lesser than
control girls (P<0.001). The MCH of anemic girls was also
lesser than control girls (P<0.05). Anthropometric variables
showed significant differences between the anemic girls and
control girls for the head circumference and the midarm circumference
values with anemic girls showing significantly lesser values
(P<0.05). Similarly, when pretreatment analysis for the control
CBI and anemic boys ABI was done (Table I) the hematological
parameters showed significantly lesser values for the hemoglobin
concentration in anemic boys as compared to control boys (P<0.001).
The values for MCV, MCH, serum iron and total iron binding capacity
were also significantly lesser in anemic boys (P<0.05). Body
weight and the midarm circumference values for the anemic boys
were lesser than controls when various anthropometric variables
were compared (P<0.05).
| Table I
click to see full view
Table I: Pretreatment (I) comparison among control (C) and
anemic (A) groups of girls (G) and boys (B).
Post therapy observations for the control girls (CGII) (Table
II) showed highly significant increases in hemoglobin concentration
(P<0.001) and hematocrit (P<0.001) and significant increase
in serum iron values as well as total iron binding capacity
(P<0.05). Significant increases in both height (P<0.001)
and weight (P<.001) were observed. The control boys (CBII)
(Table II) showed significant increase in hematocrit (P<0.05)
and serum iron values (P<0.05) post therapy. Anthropometric
observation in control boys after the therapy showed significant
increase in height (P<0.05), weight (P<0.001) and body
mass index values (P<0.05). Post therapy observations in
the anemic girls (AGII) (Table III) showed increase in hemoglobin
concentration (P<0.001), hematocrit (P<0.001), MCV (P<0.05),
serum iron (P<0.05) and total iron binding capacity values
(P<0.001). Significant increases in their height (P<0.001),
weight (P<0.001) and body mass index were seen (P<0.001).
The anemic boys (ABII) (Table III) showed significant increase
in hemoglobin concentration (P<0.05), hematocrit (P<0.05)
and MCV (P<.05) values. Moreover, significant weight gain
was observed in this group (P<0.001).
| Table II
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Table II: Comparison among the pretreatment (I) and post
treatment (II) values for the control group of girls (CG)
and boys (CB).
| Table III
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Table III: Comparison among the pre (I) and post treatment
(II) values for the anemic group of girls (AG) and boys
Post therapy comparison between the anemic and control group
of girls (Table IV), showed persistence of difference between
hemoglobin concentration (P<0.05) and hematocrit values (P<0.05).
Head circumference values for the anemic girls remained significantly
lesser than control girls (P<0.05). The anemic boys when
compared to control boys post therapy (Table IV) showed persistently
lower values for hemoglobin concentration (P<0.05), MCH (P<0.05)
and total iron binding capacity (P<0.05). Their weight and
midarm circumference values were also significantly lower than
the control boys (P<0.05).
| Table IV
click to see full view
Table IV: Post treatment (II) comparison among the control
(C) and anemic (A) groups of girls (G) and boys (B).
The results of the present study show that the hematological
and anthropometric parameters are low in the anemic children
as compared to their controls, with a significant improvement
in both parameters in them following iron and vitamin
C supplementation, consequent to deworming, for 90 days. The
control children also benefited from the deworming and vitamin
C therapy. Several studies have suggested that lower growth
rates and impaired physical performance are the adverse effects
of ID/IDA in children (7,20) and that iron supplementation improves
both motor development and physical activity (21). Iron supplementation
has been shown to significantly benefit weight for age and height
for age parameters of IDA children (22). Chwang et al (23)
have also shown that hematological status, growth velocity and
morbidity levels improved significantly in IDA children receiving
10 mg FeSO4 /kg/day for 12 weeks.
A study on Swiss Webster mice to see the effects of marginal
ID showed a reduction in grip strength, a significant lowering
of body weight and a reduction in the iron levels in the liver
and brain of these animals. It was suggested that chronic marginal
ID during periods of growth could result in functional changes
in the motor development even in absence of IDA. Alteration
in the mineral status and oxidative stress are the mechanisms
contributing to the observed changes (8). Lindt F et al (24)
observed that veal calves fed very low iron content diet showed
marked anemia and reduced growth performance. Even when the
effects of administration of growth hormone were studied in
male veal calves, the feed intake, average daily weight gain
and growth: feed ratio were reduced in ID calves. Inspite of
high growth hormone levels after GH administration the effects
of GH on IGF-1, plasma IGF-1, insulin and T3 concentration
were reduced in ID calves (13).
Topaloglu et al (9) studied the correlation between plasma
leptin levels and appetite in ID children. Following iron treatment
both the appetite scores and food intake increased significantly
as did the serum ferritin levels but there was a lack of association
between plasma leptin levels and the degree of appetite suggesting
a leptin independent mechanism for the observed increase
in the appetite. Increased hemoglobin resulting from enhanced
food availability of iron in conjunction with increased appetite
was observed in anemic rats provided with ad libitum diet
supplemented with lyophilized chicken essence rich in iron (10).
Rozenweig et al (25) have suggested that IDA and iron depletion
both cause physiological changes in the body during exercise
and the resting conditions. The norepinephrine levels in the
blood and urine of' the iron deficient anemic subjects are elevated
and the metabolic rate also increased leading to slower growth
rates and lower body weights of IDA subjects. An adverse hormonal
profile affects the growth in ID/IDA. Campos MS
(12), observed that ID produces stress as evidenced by enhanced
cortisol levels in the serum of rats. High parathormone levels
and bone demineralization was also seen. IDA has been shown
to alter thyroid metabolism with goitrous ID children showing
improved responsiveness to iodine after iron supplementation
(14). The hyperadrenergic state consequent to IDA in hypothyroid
individuals causes intolerance in them to thyroxine administration
as evidence by nervousness, palpitation and restlessness. This
was corrected after iron supplementation (16). The impairment
in brain biochemistry, neurotransmitter production and function,
cognitive functions, motor activity, thermoregulation, endocrine
system dysfunctions and immune system dysfunctions are major
consequences of' ID (26). Thus, the exact mechanism causing
impairment in physical and mental growth in IDA children are
not known. There is enough evidence to show that decreased
appetite, increased metabolic rate and increased catabolism
resulting in enhanced morbidity may contribute towards the adverse
effects of iron deficiency. However, the findings of
present study demonstrate the beneficial effects of iron supplementation
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