This study was carried out to determine the magnitude and type of anemia among under-five children of brick kiln workers, in rural area. These workers were from low socio-economic strata & were migrant laborourers. The anemia among under-five children has serious consequences & needs timely identification, treatment and prevention as they are more vulnerable and cognitive impairment resulting from Iron Deficiency Anemia, may be irreversible in them.10
In this study 90 children were enrolled (44 girls & 46 boys), majority (77.8%) were ≥ 24 months and 67.8% children were of birth order ≥ 2. 54.4% of the mothers of enrolled children were illiterate, as mentioned in Table 1. Out of the 90 children, 55children (61.1%) were found to have anemia, which is more than the anemia prevalence in Pune district (58.7%) reported in National Family Health Survey 5.11 As shown in Fig. 1, the majority of the anemic children had mild anemia 44/55(80.4%), whereas anemia of moderate & severe grade was seen in 8/55(14.3%) & 3/55 (5.4%) children respectively, this was similar to study by Janardhan R. Bandi et. al. 12 in which majority of children had mild anemia followed by moderate and severe anemia.
As shown in the flow diagram, Fig. 2a, out of 55 children with anemia, 26/55(47.3%) children had definitive iron deficiency anemia with low Hb, low MCV, low MCH, low ferritin, increased RDW levels and the peripheral blood smear revealed hypochromia, microcytosis, aniso poikilocytosis, occasional pencil cells and/or tear drop cells. Whereas 26/55(47.3%) children with anemia had low Hb, low MCV, low MCH, increased RDW levels, hypochromia, microcytosis but serum ferritin was normal i.e., > 12 ng/ml, though mean ferritin levels were below 30 ng/ml. So most likely these children would have iron deficiency anemia. We presumed that the serum ferritin values may have been normal due to previous, subclinical infection, inflammation etc. The Serum ferritin < 12 ng/mL is sensitive, with high false negative rates being common as it is an acute phase reactant13. Thus, in our study, majority of children 52/55(94.5%) were considered to have iron deficiency anemia. In the remaining 3/55(5.5%) children with anemia, Hb & MCH were low, but RDW& MCV was within normal range, Ferritin levels were normal and the peripheral blood smear was normochromic, normocytic, so less likely to be iron deficiency anemia & further studies would be needed to determine cause of anemia.
As seen in Fig. 3, there was significant association of anemia with low Mean Corpuscular Volume (p value < 0.001) in our study, similar to study by Vibha Awad et al. 14
Iron deficiency (ID) without anemia was observed in 7/90(7.8%) study children who had normal Hb, but low ferritin, low MCV & low MCH, which is similar to the study by Branly Kilola Mbunga et al 15 who have reported that among children aged < 5 years, anemia was highly prevalent (68.1%) while ID without anemia was remarkably low(12.9%).
Iron deficiency is the most common cause of anemia among children in low-income and middle-income countries like India.16 Specifically in India, over half of the anemia burden can be attributed to dietary iron deficiency. According to the Indian Council of Medical Research (ICMR), dietary iron deficiency contributed to 11% of all disability in India in 2016. 8 It’s reported that globally, fifty percent of anemia cases are caused by iron deficiency.8,17,18,19 Children are particularly vulnerable to iron-deficiency anemia because of their increased iron requirements during periods of rapid growth, especially in the first five years of life.
The association of demographic characteristics with Anemia & Vitamin B12 deficiency is delineated in Table 2. In our study the prevalence of anemia was significantly higher in children below 24 months i.e., 17/20 (85.7%). (p-value = 0.009). Various authors have also reported higher incidence of anemia in infants & toddlers, as compared to older children. 5,17,20,21 Solomon Gedfie et al22 have reported that children under the age of 2 years were 1.26 times more likely to acquire anemia, which may be attributed to lack of iron intake during the period of rapid growth and development. Literature has reported a similar trend that the risk of having anemia prevalence decreases with age.23We didn’t observe any significant difference between prevalence of anemia & gender of the child similar to few other studies.23,24 Birth order ≥ 2 was significantly associated with anemia similar to prior studies. 5,16,23It has been reported by many previous authors that the children of less educated mothers have higher prevalence of anemia, though we didn’t find such association, probably because majority of mothers were involved in brick making & children were looked after by other family members. Mili Dutta et al23 have reported that the prevalence of anemia is higher where community education is low and vice versa.
Socio-economic status of the family has a significant effect on degree and prevalence of anemia.12 A study by Ketan Bharadva et al13 have reported that being migrant worker parents is an additional risk factors for anemia along with low socioeconomic status. Association of low socioeconomic status with anemia has been reported by many previous authors.7,8,14,22,23,25,26 This study was carried out in rural area where brick kilns operate, the anemia prevalence is shown to be higher in rural as compared to urban, by many authors. 6,7,27,28
Prevalence of anemia in children who were exclusively breastfed for less than 6 months was significantly high i.e., 90.9% (p value = 0.00073) similar to report by Wubet Takele et al27. Exclusive breastfeeding not only gives adequate nutrition but also has immunological and anti-inflammatory properties which protects baby against lot of illnesses and diseases. Wubshet Fentaw et al25 have reported that children who were exclusively breastfed up to six months were 73% less likely to be anemic compared to children who were not exclusively breastfed.
As shown in Fig. 2b, the Vitamin B12 levels were low in 23 (25.6%) children out of which 13 children had anemia,. Macrocytosis i.e., high MCV, was not seen in any of these children. Swati Umasanker et al29 have stated that there is varying prevalence of B12 deficiency in developing countries & is reported as 21–45%. Jagdish Chandra et al.10 have stated that Iron deficiency was common in under-five children, while vitamin B12 deficiency was higher among school going and adolescent age groups.
Malnutrition is more prevalent among children from the marginalized population30. In our study all children with anemia (100%) were malnourished as depicted by bar diagram in Fig. 4. This is due to the fact that undernourishment leads to both macronutrient and micronutrient deficiencies, such as protein, iron, and vitamin A, which are responsible for iron deficiency.
Thus, multiple factors do contribute for anemia in young children e.g., increased demand, dietary insufficiency, cow’s milk consumption, acute or chronic blood loss, intestinal malabsorption of iron, worm infestation, high phytates in vegetarian diet, less intake of non vegetarian food, malnutrition, poor sanitation, low wages, poor housing, low education, living in rural areas, etc.
Limitations of the study were that the sample size was small & due to funding constraints, additional tests for anemia diagnosis could not be performed.