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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 14  |  Issue : 1  |  Page : 60-65

A study of association between breastfeeding and iron-deficiency anemia status in infants and young children between 0 and 2 years


1 Department of Paediatrics, J.J.M Medical College, Davangere, Karnataka, India
2 Department of Paediatrics, Indra Gandhi Institute of Child Health, Bengaluru, Karnataka, India

Date of Submission31-May-2020
Date of Acceptance12-Sep-2020
Date of Web Publication09-Feb-2021

Correspondence Address:
Dr. Amit Magadum
Department of Paediatrics, J.J.M Medical College, Davangere - 577 004, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/kleuhsj.kleuhsj_169_20

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  Abstract 

Background: Iron deficiency is one of the biggest contributing factors to the global burden of anaemia. It is an indicator of both poor nutrition and poor health. Results of recent basic research support the concerns that IDA during infancy and childhood can have long lasting detrimental effects on neurodevelopment.
Objective: To study contributing factors for IDA in infants and young children between 6-24 months.
Study Design: A case control study.
Participants: Children aged between 6-24 months, admitted or attended OPD in paediatric wards of 3 hospitals attached to JJM medical college.
Intervention: No intervention was involved in this study.
Outcomes: This study findings revealed the status of iron deficiency anaemia among 6-24 months children and also its contributing factor which influence the indication.
Results: In our study 50% were anaemic, 50% were not anaemic, in that, 27.1% had moderate anaemia, 22.9% had severe anaemia. Compared to early initiation of breastfeeding at birth, delayed initiation of breastfeeding was associated with higher chances of IDA. Those children who were not exclusively breastfed for first 6 months had higher chances of IDA. Initiation of top milk before 12 months was associated with higher chances of IDA especially before 6 months.
Conclusion: Top feeding, faulty weaning and feeding practices are the main contributing factors of anaemia among children under 2 years.

Keywords: Breastfeeding, complementary feeding, iron-deficiency anemia, top milk feeding


How to cite this article:
Magadum A, Sowjanya GT, Koujalagi M B, Banapurmath C R. A study of association between breastfeeding and iron-deficiency anemia status in infants and young children between 0 and 2 years. Indian J Health Sci Biomed Res 2021;14:60-5

How to cite this URL:
Magadum A, Sowjanya GT, Koujalagi M B, Banapurmath C R. A study of association between breastfeeding and iron-deficiency anemia status in infants and young children between 0 and 2 years. Indian J Health Sci Biomed Res [serial online] 2021 [cited 2021 Feb 25];14:60-5. Available from: https://www.ijournalhs.org/text.asp?2021/14/1/60/308948




  Introduction Top


“Poor infant feeding practices and their consequences are one of the world's or problems and a serious obstacle to social and economic development. Being to great extent a man-made problem, it must be considered a reproach to our social and economic structures, and a blot on our so-called development achievements. It is not only a problem of the developing world: it occurs in many parts of the developed world as well” (statement from the joint WHO/UNICEF Meeting on infant and young child feeding WHO, 1979).

Infant and young child feeding practices are the most important determinants of nutritional status which determines the hemoglobin levels of children. The nutrient needs of full-time, normal birth weight infants typically can be met by human milk alone for the first 6 months if the mother is well nourished. However, in certain circumstances, some of the micronutrients may become limiting before 6 months. In the case of iron, the infant's reserves at birth play a major role in determining the risk for anemia during infancy because the iron concentration of human milk is low. Normal birth weight infants whose mothers had good prenatal iron status usually have adequate liver iron reserves, and thus, the risk of iron deficiency before 6 months is low.[1]

In general, infants born at term and with an adequate birth weight have sufficient iron stores for the first 4–6 months of life. However, evidence suggests that infants with adequate birth weight born to anemic mothers have low iron stores and more likely to develop anemia.[2],[3],[4],[5] Although the iron in human milk is highly bioavailable (50% absorption),[6],[7],[8],[9] the iron content is at its highest in early transitional milk and decreases steadily over the course of lactation.[10] By 6 months, complementary foods are required to provide the iron and other nutrients necessary for infant development.[11],[12]

Given that growth is generally not improved by complementary feeding before 6 months even under optimal conditions (i.e., nutritious, microbiologically safe food) and that complementary foods introduced before 6 months tend to displace breast milk, the Expert Consultation concluded that the potential health benefits of waiting until 6 months to introduce other foods outweigh any potential risks.[13] After 6 months of age, however, it becomes increasingly difficult for breastfed infants to meet their nutrient needs from human milk alone. Furthermore, most infants are developmentally ready for other foods at about 6 months.[14] Feeding patterns differ in families but are established during the 1st year and affect later feeding and the overall health of the child. Hence, rational complementary feeding practices play a very important role in preventing iron-deficiency anemia (IDA). Despite several studies during the last 25 years regarding high prevalence of iron deficiency and its consequences, the condition still exists, and its prevention is important. The objective of the study is to evaluate the association between breastfeeding and anemia status of young children between 0 and 2 years.


  Methods Top


A case–control study was conducted on children aged between 6 and 24 months who were admitted or attended Outpatient Department (OPD) in pediatric wards of 3 hospitals (Bapuji Child Health Institute and Research Centre, Chigateri District Hospital Davangere, and Women and Children Hospital) attached to JJM Medical College included in the study for the period of 1 year.

A total of 150 children aged 6–24 months with hemoglobin <10.9 g/dl who were admitted/attended OPD for various reasons in any of the abovementioned hospitals were selected as cases of anemia group and drawn blood for serum ferritin values. A total of 109 out of 150 children who had serum ferritin values <10 ng/mL (WHO cutoff value for IDA) were included in the study. The remaining 41 children were excluded due to various reasons such as normal serum ferritin values, high C-reactive protein (CRP) values, refusal to get serum ferritin done by attendants, high serum ferritin values, and congenital anomaly. A total of 109 children aged 6–24 months with hemoglobin >11 g/dl who were admitted/attended OPD for various reasons in the same hospitals were selected as controls or no anemia group, and the data were collected using a predesigned pro forma.

Sample size

The sample size for the case–control study was calculated using the formula:



P1 = 64 P2 = 49 P = 56

Zβ=0.84 Z α/2 = 1.96

r = 1 (ratio of cases to controls)

P1 = Prevalence among controls

P2 = Prevalence among cases

P = (P1 + P2)/2.

Substituting, we get n = 172.48, which is rounded to 180, that is minimum 90 in each group.

Study: Pasricha SR, Black J determinates of anaemia among young children India Paediat 2010;126:E140-9.

Inclusion criteria

Anemia group:

  1. All infants and young children aged between 0 and 2 years
  2. Hemoglobin level <10.9 g/dl
  3. Serum ferritin <10 ng/dl.


No anemia group:

  1. All infants and young children aged between 0 and 2 years
  2. Hemoglobin level >11 g/dl.


Exclusion criteria

  1. All children aged more than 2 years
  2. Hemolytic anemic
  3. Low birth weight
  4. Preterm birth
  5. Twins
  6. Acute/chronic infectious disease with laboratory evidence of infection (raised CRP)
  7. Those parents who refused to get serum ferritin investigated.


Before initiating, the purpose of the study was explained to parents with specific questionnaires to the mothers, as mentioned in the pro forma regarding several maternal factors and infant and young child feeding practices. All children were investigated according to the need for the study. A sample of venous blood was collected for the estimation of hemoglobin percentage by sodium lauryl sulfate method, performed on fully automated six-part differential cell counter – SYSMEX XN1000 (Sysmex Corp., Japan). If the child is found to be anemic (Hb: 10.9 g/dL), then serum ferritin levels were estimated by a microplate chemiluminescence immunoassay which is based on the principle of immunoenzymometric sequential assay.

Statistical analysis

The data were entered in Microsoft Excel and analyzed using EpiData and Stata 12.0 software (STATA Corporation, college station, TX, USA). The continuous data were represented with mean and standard deviation. The categorical data were expressed in frequency and percentages. Multivariate logistic regression was used to assess the adjusted significance between categorical variables.

Ethical clearance

Ethical committee clearence was obtained from JJM medical college, Davangere, Ref no-jjmmc/IEC-sy-30-2016.


  Results Top


Out of total 218 study population, 17% were <10 months old, 28% were 10–14 months old, 46.8% were 15–19 months old, and 8.2% were >19 months old. Both the anemic and nonanemic study population were age matched. In the present study, 41.3% were 1st born, 41.7% were 2nd born, 16.5% were 3rd born, and 0.5% were 4th born. Out of total 218 children, 62.4% were male and 37.6% were female. The study population was gender matched. Out of 218 study population, 39.4% of them were initiated breastfeeding at birth within 1 h of life, 26.1% between 1 and 4 h, and 34.4% after 4 h. In the present study, 80.7% of the study population were exclusively breastfeed for 6 months. At the time data collection, 17.9% of the study population had stopped breastfeeding, whereas 82.1% of the children were still breastfed [Table 1]. The results show that, compared to those babies who were initiated breastfeeding with 1 h of life, those who were initiated between 1 and 4 h have higher chances of IDA by odds 2.75, and it was statistically significant (P = 0.004), and those babies who were initiated breastfeeding after 4 h of life had higher chances of IDA by 5.22 odds, and it was statistically significant (P = 0.000). Findings revealed that, compared to those babies who were exclusively breastfed for the first 6 months, those who were not exclusively breastfed have higher chances of IDA by odds 19.68, and it was statistically significant (P = 0.000). In univariate analysis compared to those babies who were initiated with top milk after 12 months, those who were initiated before 6 months have higher chances of IDA by 49.79 odds, and it was statistically significant (P = 0.000). Those who were initiated between 6 and 12 months also have higher chances of IDA by odds of 1.31 (confidence interval [CI]: 0.73–2.36), but it was not statistically significant (P = 0.361). The results showed that we found that compared to those babies who were still breastfed at the time of data collection, those who were not breastfed have higher chances of IDA by odds of 9.43, and it was statistically significant (P = 0.000) [Table 2].
Table 1: Distribution of the study participants according to demographic details[15]

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Table 2: Association between initiation of breastfeeding, exclusive breastfeeding, age (in months) at initiation of cow milk, still breastfeeding, and anemia status of the babies[15],[16],[17],[18],[19]

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  Discussion Top


Time between birth and initiation of breastfeeding

In our study, 39.4% of the children were breastfed within 1 h of birth, 26.1% between 1 and 4 h, and 34.4% breastfed after 4 h of birth. According to the National Family Health Survey (NFHS)-4, in our state, the percentage of children initiated breastfeeding within 1 h of birth was 56.4% which has increased from 35.6% in NFHS-3. In our study, we found that those babies who were initiated delayed breastfeeding (after 1 h of life) had higher chances of IDA, and it was statistically significant (P = 0.004, 0.000) [Graph 1]. Breastfeeding problem in relation to initiation of breastfeeding revealed that the earlier the initiation, the lesser the incidence of breastfeeding problems. Early initiation is a good predictor of exclusive breastfeeding and prolonged breastfeeding. However, a study done by Mohamed and Abo-Donia showed no significant differences between early and delayed initiation groups (P = 0.828).[15]



Exclusive breastfeeding for the first 6 months

In our study, 80.7% of the study participants were exclusively breastfed for 6 months [Graph 2]. In the recent NFHS-4, in our state, 54.2 were exclusively breastfed for 6 months which has dropped from 58.6% in NFHS-3 in Karnataka. Even though iron content in breast milk is low, it has high bioavailability. A study done by Gisela and Oita in children between 6 and 59 months in eastern Cuba concluded that the prevalence of exclusive breastfeeding for 6 months increased over their study period and lack of breastfeeding was found to be associated with anemia in 2005 (odds ratio: 1.57, CI: 1.05–2.34), which was consistent with our finding (P = 0.000).[16]



Age at initiation of top milk

In our study, 14.7% of the study participants were introduced cow's milk before 6 months, 45.9% between 6 and 12 months, and 39.4% after 12 months, wherein we found that introduction of top milk before 12 months was associated with a higher incidence of IDA, especially <6-month older children (P = 0.000) [Graph 3]. Both breast milk and cow's milk are iron poor foods. The iron content of the breast milk falls from about 0.5 mg/l during the 1st month after birth to about 0.3 mg/l between 4 and 6 months of age. The iron content of cow's milk ranges from 0.5 mg/l to 1.0 mg/l. Despite the small amount of iron in breast milk, bioavailability makes an important difference in the amount absorbed. On an average, 49% of the iron is absorbed from breast milk, a high figure compared with 10% of the iron absorbed from cow's milk. These data show that infants absorb iron from breast milk more efficiently than from any top milk. Breast milk also carries protection against the development of IDA, while early introduction of cow's milk to infants can cause iron deficiency.



A case–control study done by Michel in early childhood centers and long day-care centers in Sydney, Australia, in children aged 12–36 months concluded that the introduction of whole cow's milk before 12 months was confirmed as a major risk factor for IDA in infants and young children which is as per our study results.[17]

Still breastfeeding

In our study, 32.1% of the children were still breastfed at the time of data collection which was found to be a protective factor against the development of IDA as it was statistically significant (P = 0.000) [Graph 4]. However, few studies showed the opposite data. According to a study done by Jarren and Meinzenn et al.[18] on effect of EBF on infant anemia concluded that infants who were exclusively breastfed for >6 months in the developing countries where the incidence of maternal anemia is high may be at increased risk of anemia.[19] Maguire studied 1647 healthy children aged between 1 and 6 years to study the association between total duration of breastfeeding and iron deficiency, wherein they concluded that increased total breast duration is associated with decreased iron stores. Iron deficiency increased by 4.8% (95% CI: 2%–8%) for each additional month of breastfeeding.[20]




  Conclusion Top


In spite of so much emphasis on promotion of breastfeeding, the rate of exclusive breastfeeding is well below the desirable levels. This study emphasizes the critical importance of promoting exclusive breastfeeding during the first 6 months of life. The present study has shown that exclusive breastfeeding for 6 months and also early initiation of breastfeeding decrease the incidence of IDA among infants and young children. Introduction of cow's milk as the main milk drink should be delayed until after 12 months of age as introduction before 12 months was associated with IDA, especially before 6 months. The study concluded that faulty weaning and feeding practices are the main contributing factors of IDA in children < 2 years.

What is already known?

IDA is one of the major health-care problems in under 2-year children.

What this study adds?

Delayed initiation of breastfeeding, stopping of breastfeeding at early age, and top feeding are the main contributing factors of anemia among children under 2 years.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
World Health Organization. Guiding Principles for Complimentary Feeding of the Breastfed Child: World Health Organization; 2003. Available from: http://www.who.int/nutrition/publications/infantfeeding/a85622/en/ernan. [Last accessed on 2017 Nov 02].  Back to cited text no. 1
    
2.
Colomer J, Colomer C, Gutierrez D, Jubert A, Nolasco A, Donat J, et al. Anaemia during pregnancy as a risk factor for infant iron deficiency: Report from the Valencia Infant Anaemia Cohort (VIAC) study. Paediatr Perinat Epidemiol 1990;4:196-204.  Back to cited text no. 2
    
3.
Kilbride J, Baker TG, Parapia LA, Khoury SA, Shuqaidef SW, Jerwood D. Anaemia during pregnancy as a risk factor for iron-deficiency anaemia in infancy: A case-control study in Jordan. Int J Epidemiol 1999;28:461-8.  Back to cited text no. 3
    
4.
Morton RE, Nysenbaum A, Price K. Iron status in the first year of life. J Pediatr Gastroenterol Nutr 1988;7:707-12.  Back to cited text no. 4
    
5.
De Pee S, Bloem MW, Sari M, Kiess L, Yip R, Kosen S. The high prevalence of low hemoglobin concentration among Indonesian infants aged 3-5 months is related to maternal anemia. J Nutr 2002;132:2215-21.  Back to cited text no. 5
    
6.
Dallman PR. Nutritional anaemia of infancy: Iron, folic acide, and Vitamin B12. In: T sang RC, Nichols BL, editors. Nutrition during infancy. Philadelphia, PA: Henley and Belfus; 1988. p. 216-35.  Back to cited text no. 6
    
7.
Oski FA. Iron deficiency in infancy and childhood. N Engl J Med 1993;329:190-3.  Back to cited text no. 7
    
8.
Saarinen UM, Siimes MA, Dallman PR. Iron absorption in infants: High bioavailability of breast milk iron as indicated by the extrinsic tag method of iron absorption and by the concentration of serum ferritin. J Pediatr 1977;91:36-9.  Back to cited text no. 8
    
9.
Krebs NF. Bioavailability of dietary supplements and impacts of physiologic state: Infants, children and adolescents. J Nutr 2001;131:1351S-4.  Back to cited text no. 9
    
10.
Siimes MA, Vuori E, Kuitunen P. Breast milk iron-a declining concentration duringte course of location. Acta Paediatr Scand 1979;68:29-31.  Back to cited text no. 10
    
11.
Picciano MF. Nutrient composition of human milk. Pediatr Clin North Am 2001;48:53-67.  Back to cited text no. 11
    
12.
Dewey KG. Nutrition, growth, and complementary feeding of the breastfed infant. Pediatr Clin North Am 2001;48:87-104.  Back to cited text no. 12
    
13.
Cohen RJ, Brown KH, Canahuati J, Rivera LL, Dewey KG. Effects of age of introduction of complementary foods on infant breast milk intake, total energy intake, and growth: A randomised intervention study in Honduras. Lancet 1994;344:288-93.  Back to cited text no. 13
    
14.
Naylor AJ, Morrow AL. Developmental Readiness of Normal Full Term Infants to Progress from Exclusive Breastfeeding to the Introduction of Complementary Food. Linkages/Well Start International; 2001.  Back to cited text no. 14
    
15.
Mohamed AA, Abo-Donia AS. Contributing factors of iron deficiency anaemia among children under two years attending family health centres in Alexandria. Life Sci J 2011;8:996-1007.  Back to cited text no. 15
    
16.
Gisela M, Oita, et al. Anaemia in children under five years old in Eastern Cuba, 2005-2011. MEDICC Rev 2014;16:16-23.  Back to cited text no. 16
    
17.
Michel M, et al. Haem Iron intake in 12-26 month of old children depleted in Iron: BMJ 1996;312:881-3.  Back to cited text no. 17
    
18.
Jareen K Meinzen-Derr et al. J Nutr 2006:136:452-8.  Back to cited text no. 18
    
19.
Meinzenn D, et al. Risk of infant anaemia is associated with exclusive breastfeeding and maternal anaemia in a Mexican Cohort. J Nutrit 2006;136:452-58.  Back to cited text no. 19
    
20.
Maguire JL, Maguire JL, Salehi L, Birken CS, Carsley S, Mamdani M, et al. Association between total duration of breast feeding and iron deficiency anaemia. Am Academy Paediatrics 2013;131:1530-37.  Back to cited text no. 20
    



 
 
    Tables

  [Table 1], [Table 2]



 

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