Editorial Current Research in Food Technology and Nutritional Sciences VOLUME: 01 Nutritional Anemias in Childhood ISSUE: 01 Agarwal KN1* and Dewan P2 RECEIVED DATE: President Health Care & Research Association for Adolescent, India July 15, 2020 Department of Pediatrics, University College Medical Sciences, India ACCEPTED DATE: Aug 03, 2020 *Corresponding author PUBLISHED DATE: Kailash Nath Agarwal, President Health Care & Research Association for Adolescent, D-115, Sector 36, Gautam Buddha Nagar, Aug 11, 2020 Noida-201301, India. E-mail: [email protected] JOURNAL SHORT NAME: Curr Res Food Technol Nutr Sci Keywords : Platysma free graft; Neurotized; Functional reanimation; Facial paralysis; Technique Under/Malnutrition (UN/Mn) and Anemia in Indian children- Summarized in natio- Citation: JAgarwal KN, Dewan P. nal surveys Nutritional Anemias in Childhood. Curr Res Food Technol Nutr Sci. suer from ‘hidden hunger’, i.e. the deciency of 2020;1(1):1-4 one or more micronutrients such as iron, folate, zinc, vitamin A, vitamin B12 and vitamin D. Under/malnu- trition, iron and vitamin deciencies of B12, folate, C, Copyright: © 2020 Kailash Nath A and riboavin have been known causes of anemia. Agarwal. This is an open access article distributed under the Creative Nutrition Foundation of India in 2002-2003 studied prevalence of anemia in pregnancy and lactation in 7 Commons Attribution License, which states (Assam, Himachal Pradesh, Haryana, Kerala, permits unrestricted use, distribution, Madhya Pradesh, Orissa, Tamil Nadu). The anemia and reproduction in any medium, prevalence was- Pregnancy 86.1% (Hb <7.0 g/dl- in provided the original work is properly 9.5%); Lactation 81.7 % (Hb <7.0 g/dl in 7.3%) Agarw- cited. al et al (2006); IJMR 124: 173-184. ICMR –1999-2000 11 states 19 districts in the District Nutrition Survey found pregnancy anemia prevalence of 84.6% (Hb <7.0 g/dl-in 9.9%). These workers also found 90% adolescent girls with anemia Undernutrition (UN) and Anemia in National Family Teoteja et al (2001). Health survey (NFHS)- Arnold et al (2005-2006) >87% < 3 yrs children were iron decient (Kapur, Anemia NFHS II (74.3%), III (78.9%). Agarwal et al 1999, Indian Pediatr). 48% are chronically UN- stunted. Wasted -20%. The above studies clearly showed that prevalence as well Underweight-43%. as severity of anemia during pregnancy and lactation is Anemia and Malnutrition are more prevalent and grave (child growth and brain growth & development). This severe in children 12-36 months of age. is the period when child receives iron for brain. In addition, ‘Rapid growth is a potential cause of ANEMIA, in the rst years of life and adolescence, as rapid growth has NFHS IV 2015-2016-Nutrition and priority for nutrients (Agarwal & Agarwal Acta Sci Paeditr Anemia (Paswan et al) 2019). Nutritional status of children: Thirty-eight percent of children under age ve years are stunted (short Denition of Anemia for their age); 21 percent are wasted (thin for their height); 36 percent are underweight (thin for their Anemia is a condition in which the number of red blood age); and 2 percent are overweight (heavy for their cells (and consequently their oxygen-carrying capacity) is height). insucient to meet the body’s physiologic needs. Specic physiologic needs vary with a person’s age, gender, x Anemia among children: Fifty-eight percent of residential elevation above sea level (altitude), smoking children age 6-59 months have anemia (hemoglo- behavior, and dierent stages of pregnancy. Iron decien- bin levels below 11.0 g/dl), an improvement from cy is thought to be the most common cause of anemia the NFHS-3 estimate of 79 percent. globally, but other nutritional deciencies (including folate, vitamin B12 and vitamin A), acute and chronic Micronutrient intake: Sixty percent of child. inammation, parasitic infections, and inherited or acquired disorders that aect hemoglobin synthesis, red UNICEF report released on Oct 31, 2019: Over blood cell production or red blood cell survival, can all 50% of adolescents (about 63 million girls and 81 cause anemia. Hemoglobin concentration alone cannot be million boys) in the age group of 10 to 19 years in used to diagnose iron deciency. However, the concentra- India are, short, thin, overweight or obese, the tion of hemoglobin should be measured, even though not report said that over 80% of adolescents also all anemia is caused by iron deciency. The prevalence of http://www.inquestpublications.com/pdf/crftns-v1-1001.pdf page 1 anemia is an important health indicator and when it is used with other measurements of iron status the hemoglobin (Hb) concentration can provide informa- tion about the severity of iron deciency. Decrease ( ) in Hb, HCT (hematocrit) or RBC count < 2SD below age specic norm. Anemia is best dened as a hemoglobin level that is too low to meet tissue oxygen demand or there are not enough red blood cells, lled with hemoglobin (special pigmented protein) that makes it possible to carry and deliver oxygen to other cells in the body. The cells in your child's muscles and all organs need oxygen to survive. Mechanism: i) Nutritional-deciency of iron, B12, folic acid or in PEM, ii) hemorrhage, iii) hemolytic or iv) infective hematopoietic. Garby et al. (1969), demonstrated irrespective of Hb level, if an individual shows rise in hemoglobin after hematinic administration, he/she is anemic. WHO criteria 2001 Age/sex cut o for HB to diagnose Anemia Age/Sex HB What are the “Nutrient Needs for Hemoglobin Synthesis” Protein – deciency causes Children 6-59 months (both sexes) 11.0 gm/dl 1. Decrease in RBC production/Reticulocyte count and ‘Fe’ utilization by RBC. Children 5-11 years (both sexes) 11.5 gm/dl 2. Erythroid hypoplasia in Bone Marrow. 3. Hypoxic response to erythropoietin production disappears. Children 12-14 years (both sexes) 12.0 gm/dl All 10 essential amino acids are needed for hematopoiesis. Deciency Non pregnant woman>15 12.0 of methionine -causes megaloblastic anemia. Pregnant woman>15 11.0 In breast milk infant Receives all vitamins, except K, D and B12 (deciency responsible for megaloblastic anemia). Men >15 13.0 Stages of Inadequate Iron Nutriture First Stage: Third Stage: Iron stores are absent but the Hb concentration remains above the anemia Third and most severe form of deciency is iron deciency anemia (IDA). cut o. low serum ferritin (SF) concentration (<12 μg/L) in CRP ¬-ve. Ferritin Iron supply inadequate for Hb synthesis, Hb concentration below the being an acute phase reactant rises in inammatory/infectious diseases. established cut o levels. MCV, MCH and MCHC decreases. About 25 percent of the iron in the body is stored as ferritin, found in cells Second stage: and circulates in the blood. The average adult male has about 1,000 mg of Iron decient erythropoiesis, Hb concentration above the anemia cut o stored iron (enough for about three years), whereas women on average levels. There is an increase in the transferrin receptor (sTfR) concentration have only about 300 mg (enough for about six months). and increased free protoporphyrin (FEP) in RBC (μmol/mol of heme) <5 yrs>70; >5 >80. Lab Tests to Diagnose Iron Deciency Measurement of serum ferritin (SF) is currently the test for diagnosing iron Reticulocyte Hemoglobin Equivalent-(RET-HE)/CHr-Measured by coulter deciency in absence of an associated disease CRP -ve, a low SF value is an Detects functional iron deciency because reticulocytes are the earliest early and highly specic indicator of iron deciency. WHO criteria for erythrocytes released into blood and circulate for only 1 to 2 days. depleted storage iron (SF) are 12 μg/L for children under 5 years and 15 μ g/L for those over 5 years. A higher threshold of 30 μg/L is used in the Delta HE- dierence between RET-HE and RBC-HE; -improved erythro- presence of infection. poiesis and - suppressed erythropoiesis. TfR index-ratio of sTfR to the log of ferritin, value >1.5 “Iron def”; <1.5 anemia chronic diseases. Hepcidin in Body Iron Regulation Hepcidin is a regulator’ of dietary uptake and iron metabolism low levels EPP- Erythrocyte Porphyrin increases in iron deciency, lead poisoning in serum <10 ng/ml- useful indicator of IDA. It increases in infections thus and chronic. Inammatory anemia. WHO age <5 years, levels 61 μmol/mol guides safe iron supplementation in high infection burden. This seems to haem; for all other subjects, levels should be > 70 μmol/mol haem have evolved as a defense mechanism to protect the host from infections/infestations. Absence of Bone marrow iron content. Low hepatic iron content (MRI – hepatic iron content- lancet 2004). Hepcidin blocks iron ows into plasma: duodenal absorption, release from macrophages recycling old red blood cells, and mobilization of Reticulocyte Indices stored iron from hepatocytes, blocking of iron ow is achieved by hepcidin causing degradation of its receptor, the iron transporter ferroprotein. Immature reticulocyte fraction (IRF) based on reticulocytes RNA content- Marker of Erythropoiesis, increase in IRF precedes the increase in total reticulocyte count by several days, monitors response to iron therapy. Mean Reticulocyte volume- Iron‐decient erythropoiesis ; On iron therapy . http://www.inquestpublications.com/pdf/crftns-v1-1001.pdf page 2 Reticulocyte Indices Inherited congenital folate malabsorption. A genetic problem - infants cannot absorb folic acid. A- mobilises Fe from stores & improves utilization (need 100 IU/d) Medicines. Antiepileptics, interfere with folic acid absorbtion. C- Fe+++ to Fe++ & Releases Fe from stores (25 mg/d). Diet. Certain restrictive diets Vegans/ Jains can develop low levels of Vitamins-B12 and folic acid-megaloblastic anemia. folate and/ or B12. B2- Bone marrow hypoplasia- N-N, decrease in Reticulocyte, vacuolization of normoblasts. Lab Investigations in Megaloblastic Anemia B6- macro/micro anemia.