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 Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 32  |  Issue : 2  |  Page : 96-100

Iron-deficiency anemia as a risk factor for pneumonia in children


1 Department of Pediatric, Faculty of Medicine, Benha University, Benha, Egypt
2 Department of Clinical Pathology, Faculty of Medicine, Benha University, Benha, Egypt
3 Department of Pediatric, Shebin El-Kom Teaching Hospital, Shebin El-Kom City, Egypt

Date of Submission21-Jun-2015
Date of Acceptance14-Aug-2015
Date of Web Publication14-Apr-2016

Correspondence Address:
Mohamed M Rashad
MD, 78 El-Manial St., 11451, Cairo
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-208X.180321

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  Abstract 

Background
Pneumonia is the most common single cause of death among children under 5 years of age in the developing countries. Anemia is the most common ailment affecting health, socioeconomic development, and overall betterment of mankind.
Objective
The aim of this study was to determine the relationship between iron-deficiency anemia (IDA) and pneumonia in Egyptian children.
Patients and methods
This case-control study included 100 children aged 9-72 months, selected from Benha University Hospital and Shebin El-Kom Educational Hospital from January to December 2014. A total of 50 children with pneumonia and 50 age-matched and sex-matched controls were included in the study. After taking an informed verbal consent from the parents, our children were subjected to medical history taking, clinical examination, and complete blood count. For children with hemoglobin less than 11 g/dl, serum iron, serum ferritin, and total iron binding capacity were detected. C-reactive protein and chest radiography were performed for the patients.
Results
Anemia, particularly IDA, was significantly more frequent among patients (54 and 22%, respectively) than among controls (24 and 22%, respectively) (P = 0.001 and 0.002, respectively). Hemoglobin level was significantly lower in the IDA patients than in the IDA controls (P = 0.03). Anemia was a risk factor for childhood pneumonia (P = 0.001, odds ratio 4.03, and confidence interval 1.71-9.49) and recurrent chest infection (P < 0.001, odds ratio 15.55, and confidence interval 4.88-49.53).
Conclusion
Anemia, particularly IDA, is a community problem in Egypt. Anemic children are about four times more susceptible to develop pneumonia compared with the nonanemic ones, and IDA is predominating. Prevention, accurate diagnosis, and prompt treatment of anemia are necessary.

Keywords: Iron deficiency anemia, pneumonia in children, a risk factor


How to cite this article:
Rashad MM, Fayed SM, El-Hag AK. Iron-deficiency anemia as a risk factor for pneumonia in children. Benha Med J 2015;32:96-100

How to cite this URL:
Rashad MM, Fayed SM, El-Hag AK. Iron-deficiency anemia as a risk factor for pneumonia in children. Benha Med J [serial online] 2015 [cited 2017 Oct 22];32:96-100. Available from: http://www.bmfj.eg.net/text.asp?2015/32/2/96/180321


  Introduction Top


Pneumonia killed about 935 000 children younger than 5 years in 2013, accounting for 15% of all deaths of children in that age. It affects children everywhere, but is most prevalent in South Asia and Sub-Saharan Africa. Children can be protected from pneumonia with simple interventions, and treated with low-cost, low-tech medical care [1].

Anemia is the most common ailment affecting human health, socioeconomic development, and the overall betterment of mankind. Nutritional deficiency, particularly iron deprivation, is the most common cause of anemia [2]. Globally, anemia affects 1.62 billion people [confidence interval (CI) 1.50-1.74], representing 24.8% of the population (CI 22.9-26.7%). It affects 305 million school-age children, with a prevalence of 25.4% (CI 19.9-30.9) [3].

The major health consequences of anemia include physical and cognitive impairment, as well as increased morbidity and mortality related to liability to infection. Adequate and balanced nutrition is important for the immune system development and maturity with the consequent development of resistance against infections. Thus, it has been stated that malnutrition including iron deficiency forms an indirect risk factor for contracting acute lower respiratory tract infection [4].

Various risk factors have been proposed to increase the chances of developing pneumonia, some of them are definite, some are likely, and a few are possible [5]. As infections of the lower respiratory tract are the major causes of morbidity and mortality among children, gaining control over their risk factors will have a promising effect on the growth and development of children [4].


  Patients and methods Top


This case-control study took place from January to December 2014 in the Pediatric Departments of Benha University Hospital and Shebin El-Kom Educational Hospital and the Clinical Pathology Department of Benha University Hospital. It included 100 infants and children aged from 9 months to 6 years. They were divided into two groups.

Group 1 included 50 patients hospitalized for pneumonia, with a median age of 24 months (range 6-72 months): 32 (64%) male and 18 (36%) female patients.

Group 2 included 50 clinically healthy controls with a median age of 30 months (range 9-72 months) attending the outpatient clinic of the same hospital: 31 (62%) male and 19 (38%) female patients.

Inclusion criteria

All hospitalized children between 9 months and 6 years with a diagnosis of pneumonia according to the WHO [1] criteria - namely, cough and/or difficult breathing, with or without fever, fast breathing, or lower chest wall indrawing where their chest moves in or retracts during inhalation (in a healthy person, the chest expands during inhalation). Diagnosis was confirmed by the presence of bronchial breathing, crackles, and bronchophony on auscultation, as well as consolidation in chest radiography. Informed consent was taken from the parents of children before being included in the study.

Exclusion criteria

  1. Congenital chest anomalies.
  2. Intake of iron supplements.
  3. Other diseases such as congenital heart disease, tuberculosis, diabetes, liver cell failure, etc.


The children were subjected to the following:

  1. Medical history taking, including age, sex, residence, cough, fever, difficult breathing, grunting, past history of recurrent chest infection, and vaccination.
  2. Clinical examination, including weight and height recording to assess the nutritional status, as well as chest, cardiac, and abdominal examination.
  3. Complete blood count: For children with hemoglobin level below 11 g/dl, serum iron, serum ferritin, and total iron binding capacity (TIBC) were detected. Chest radiography was performed and C-reactive protein was evaluated for the hospitalized patients.


Sampling

Blood samples (5 ml) were obtained by means of vein-puncture. Each sample was divided into two parts: one part was put in an EDTA tube for complete blood count and the other part was put in a plain vaccutainer for serum iron, TIBC, serum ferritin, and C-reactive protein evaluation.

Serum iron and total iron binding capacity

Stanbio iron and TIBC procedure no. 0370 (Stanbio Laboratory Anekf Diagnostics Company, Boerne City in Texas, USA) was used. Reference ranges for serum iron were 40-100 μg/dl for infants and 50-120 μg/dl for children. For TIBC, they were 100-140 μg/dl for infants and 250-400 μg/dl for children [6].

Serum ferritin was detected using Accu Bind ELISA Microwells (Monobind Inc., LaForest, California, USA). The cutoff value for diagnosing iron-deficiency anemia (IDA) is serum ferritin less than 10 ng/ml [7]. The Mentzer index was calculated using the following formula: Mentzer index = mean corpuscular volume/red blood cell count, and transferrin saturation was calculated using the following formula: transferrin saturation = iron level/TIBC×100 (normal value = 20-45%) [7].

C-reactive protein more than 0.3 mg/dl was considered positive. In the control group, IDA was diagnosed when serum ferritin was less than 10 ng/ml [7], or when serum iron was lower than 50 μg/dl and serum TIBC was higher than 400 μg/dl [6].

Considering the fact that infection can affect iron panel studies by increasing serum ferritin level (usually by more than 50 μg/l if no iron deficiency) and decreasing serum iron level and TIBC. The diagnosis of IDA in pneumonic patients was made when at least three of the below parameters were present:

  1. Hypochromia and microcytosis seen in blood smear [8].
  2. Low mean corpuscular volume (MCV) (specificity around 96%) (not affected by infections).
  3. Red cell distribution width greater than 14.5 (sensitivity of 92.1% and specificity of 90.9%).
  4. Mentzer index greater than 13.5 (with around 85% specificity and sensitivity).
  5. Transferrin saturation less than 10% (with a specificity of 85% if below 15% and sensitivity around 80%).


Statistical methodology

The collected data were tabulated and analyzed using the suitable statistical methods. The 'SPSS' computer program was used (IBM, Endicott, Broome_County, New York, United States). Two types of statistics were performed: descriptive statistics including percentage (%), mean, and SD, and analytic statistics, which includes the χ2 -test, Fischer exact test, Student's t-test, Mann-Whitney test, CI, and the odds ratio (OR).


  Results Top


Out of our 100 infants and children, 38 (76%) patients and 22 (44%) controls (44%) were anemic, with a mean Hb level of 9.9 ± 1.4 mg/dl in patients and 11.4 ± 1.5 mg/dl in controls.

IDA was found in 27 (54%) patients and 12 (24%) controls. Thus, IDA was found in 71.1% of anemic patients and 54.5% of anemic controls.

Compared with anemic controls, anemic patients had significantly lower hemoglobin (P = 0.007), serum iron (P = 0.003), and transferrin saturation (P = 0.01), but higher serum ferritin (P = 0.001). However, there was no significant difference as regards the TIBC.

Anemia was found to be a risk factor for pneumonia, with an OR of 4.03, CI of 1.71-9.49, and P-value of 0.001. This means that anemic children were about four times more susceptible to develop pneumonia compared with nonanemic children.

History of recurrent chest infection was significantly more common in anemic than in nonanemic children, with a P-value less than 0.001, OR of 15.55, and CI of 4.88-49.53 [Table 1],[Table 2],[Table 3],[Table 4] and [Table 5] and [Figure 1],[Figure 2],[Figure 3],[Figure 4] and [Figure 5].
Figure 1: Frequency of anemia among patients and controls.

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Figure 2: Type of anemia in the patient and control groups.

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Figure 3: Hemoglobin level in anemic patients and anemic controls.

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Figure 4: Iron profile in iron-deficiency anemic patients and iron deficiency anemic controls.

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igure 5: Recurrent chest infection in anemic and nonanemic children.

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Table 1: Frequency of anemia among our patients and controls

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Table 2: Type of anemia in the patient and control groups

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Table 3: Hemoglobin level in anemic patients and anemic controls

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Table 4: Iron profile in iron deficiency anemic patients and iron defi ciency anemic controls

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Table 5: Recurrent chest infection in anemic and nonanemic children

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  Discussion Top


The current study shows that anemia, especially IDA, is still a community problem in Egyptian children. In addition, it provides a statistically significant positive association between anemia, predominantly IDA, and chest infection, particularly pneumonia.

We found that the prevalence of anemia was significantly higher among patients than among controls, with 38 (76%) patients and 22 (44%) controls being anemic. Moreover, anemia was found to be a risk factor for chest infections in general (OR 15.55; CI 4.88-49.53; and P < 0.001) and pneumonia in particular (OR 4.03; CI 1.71-9.49; and P = 0.001). Thus, anemic children were about four times more susceptible to develop pneumonia compared with nonanemic children.

WHO [9] reported that, in 2005, 60.3% of the Egyptian children from 6 months to 8.2 years of age had hemoglobin levels less than 11 g/dl. El-Sakka et al. [10] stated that low hemoglobin level is a risk factor for acute lower respiratory infections as it was detected in 62.5% of pneumonic patients, 56.25% of bronchiolitis cases, and 42.71% of the control group, with a P-value of 0.044. Moreover, among Indian children, Hussain et al. [4] reported that 64.5% of their hospitalized patients and 28.2% of the healthy controls were anemic and that the anemic children were 4.6 times more susceptible to lower respiratory tract infection.

The mean hemoglobin level of our patients was 9.9 ± 1.4 mg/dl, which is significantly lower than that of the controls (11.4 ± 0.15 mg/dl) (P = 0.001). Moreover, the mean hemoglobin level of the anemic patients was 9.5 ± 1.1 mg/dl, which is significantly lower than that of the anemic controls (10.1 ± 0.60 mg/dl) (P = 0.007). These results are in agreement with those of Zamzam et al. [11], who found a significant difference between patients and controls as regards the hemoglobin level, with means of 9.5 ± 0.76 and 11.3 ± 0.55 mg/dl, respectively (P < 0.001).

In our children, IDA was the predominant type of anemia. It was detected in 24 (63.2%) anemic patients and 12 (55%) anemic controls. Hussain et al. [4] reported that iron deficiency was found in 78.9% of anemic patients, with a P-value less than 0.01. Mourad et al. [12] also found that the percentage of IDA in anemic patients (48) was 75% and that in anemic controls (22) was 68.75%.

Compared with anemic controls, anemic patients had significantly lower serum iron (P = 0.003) and transferrin saturation (P = 0.01), but a higher serum ferritin (P = 0.01). We found no significant difference as regards the TIBC. This can be explained by the fact that infection can affect iron panel studies by increasing the ferritin level as an acute phase reactant and decreasing the iron level and TIBC [8]. Our results are in agreement with those of Hussain et al. [4], who found that serum iron of the anemic cases (35.3 ± 14.4 mg/dl) was significantly lower than that of the anemic controls (57.1 ± 13.8 mg/dl), with a P-value of 0.000.


  Conclusion Top


From the previous results, it can be concluded that anemia, predominantly IDA, is still a considerable community problem in Egyptian children. Moreover, anemia is a risk factor for chest infections, particularly pneumonia, with anemic children being about four times more susceptible to have pneumonia compared with the nonanemic children.

Prevention, early diagnosis, and prompt treatment of anemia, particularly IDA, in all Egyptian children, with special emphasis on those suffering from lower respiratory infections, including pneumonia, are necessary.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
WHO. 2014. Pneumonia; fact sheet no. 331. Available at: http://www.who.int/mediacentre/factsheets/fs331/en/# [Last accessed on 2015 Apr 10].  Back to cited text no. 1
    
2.
0 Kotecha PV. Nutritional anemia in young children with focus on Asia and India. Indian J Community Med 2011; 36 :8-16.  Back to cited text no. 2
    
3.
De Benoist B, McLean E, Egli I, Cogswell M. Worldwide prevalence of anaemia 1993-2005. WHO Global Database on Anaemia. Geneva: World Health Organization; 2008. Available at: http://whqlibdoc.who.int/publications/2008/9789241596657_eng.pdf.  Back to cited text no. 3
    
4.
Hussain SQ, Ashraf M, Wani JG, Ahmed J. Low hemoglobin level a risk factor for acute lower respiratory tract infections (ALRTI) in children. J Clin Diagn Res 2014; 8 :PC01-PC03.  Back to cited text no. 4
    
5.
Jackson S, Mathews KH, Pulanic D, Falconer R, Rudan I, Campbell H, et al. Risk factors for severe acute lower respiratory infections in children: a systematic review and meta-analysis. Croat Med J 2013; 54 :110-121.   Back to cited text no. 5
    
6.
Burtis CA, Edward RA. Principles of colorimetric determination of unsaturated iron binding capacity in serum. In: Burtis CA, Edward RA, David EB, editors. Tietz textbook of clinical chemistry. 4th ed. Philadelphia, Pennsylvania, USA: Elsevier Saunders 2006; 2195-2197.  Back to cited text no. 6
    
7.
McPherson RA, Pincus MR. Iron deficiency anemia: diagnosis and management. In: McPherson RA, Pincus MR, editors. Henry′s clinical diagnosis and management laboratory methods. 21st ed. Philadelphia, PA: WB Saunders 2007; 455-482.  Back to cited text no. 7
    
8.
Sipahi T, Köksal T, Tavil B, Akar N. The effects of acute infection on hematological parameters. Pediatr Hematol Oncol 2004; 21 :513-520.  Back to cited text no. 8
    
9.
WHO. Vitamin and Mineral Nutrition Information System (VMNIS). Egypt: WHO Global Database on Anaemia; 2006. Available at: http://who.int/vmnis/anaemia/data/database/countries/egy_ida.pdf.  Back to cited text no. 9
    
10.
El-Sakka AS, Imam SS, Amer HA, Moustafa SA. 2014 Vitamin D deficiency and low hemoglobin level as risk factors for severity of acute lower respiratory tract infections in Egyptian children: a case-control study, Egyptian Pediatric Association Gazette.  Back to cited text no. 10
    
11.
Zamzam WE, Ramadan IA, El-Sharkawy AR, et al. Molecular diagnostic value of Pneumococcal pneumonia among Egyptian children [MSc thesis]. Egypt: Benha University 2013.  Back to cited text no. 11
    
12.
Mourad S, Rajab M, Alameddine A, Fares M, Ziade F, Merhi BA. Hemoglobin level as a risk factor for lower respiratory tract infections in Lebanese children. N Am J Med Sci 2010; 2 :461-466.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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