Effect of Iron on Growth in Iron Deficient Anemic School Going Children

Department of Physiology,

University College of Medical Sciences &

Guru Teg Bahadur Hospital,

Dilshad Garden, Delhi - 110 095

 

(Received on September 25, 2001

 

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

 

INTRODUCTION
METHODS
RESULTS
DISCUSSION
REFERENCES

 

INTRODUCTION

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.
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METHODS

The study was conducted over a period of one year.  About 800 children from MCD Primary 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.

Investigations done:

Hematological parameters 

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. 

Anthropometric measurements 

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: 

                                                                   Wt

BMI = -------            (19)

  (Ht)² 

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RESULTS  

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 click to see full view

Table II: Comparison among the pretreatment (I) and post treatment (II) values for the control group of girls (CG) and boys (CB).

 

 

Table III click to see full view

Table III: Comparison among the pre (I) and post treatment (II) values for the anemic group of girls (AG) and boys (AB).

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).

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DISCUSSION  

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 et al (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 on physical growth parameters of iron deficient anemic children.
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REFERENCES  

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