The Effect of Chronic Anemia on Physical Growth and Development among Children Under Five Years

Introduction

Anemia is one of the most common hematological conditions of infancy and childhood; it is not a disease but rather a symptom of other diseases. Anemia is a decrease in the number of RBCs, the reduction in circulating RBCs decreases the oxygen-carrying capacity of the blood (Ward, et al., 2016).

The first five years of children’s life is a golden period for their development, fostering their future learning skills and social and emotional abilities due to rapid gains in physical and cognitive growth and development (Butchon and Liabsuetrakul, 2017). Children are our future citizens and form an important segment of the human potential. They contribute to the vital strength of the national economy and development (Sandeep, et al., 2017).

Growth in childhood is one of the most fascinating, dynamic, complex and biological processes (Sayed, 2012). Measurement of physical growth in children is a key element in evaluating their health status. Physical growth parameters include weight, length/height, skinfold thickness, arm circumference and head circumference. Values for these growth parameters are plotted on percentile charts, and the child’s measurements in percentiles are compared with those of the general population. Growth charts use a series of percentile curves to demonstrate the distribution of body measurements in children (Hockenberry and Wilson, 2015).

The Denver Developmental Screening Test II (DDST-II) is a widely used assessment of developmental progress in children from birth to 6 years of age. The test takes approximately 20 minutes to be administered and be interpreted. The test detects slow development in four functional areas of development: social/personal, fine motor function, language, and gross motor functions (Pala, et al., 2010). DDST-II consists of 125 items, and the development of a child is measured based on these 125 items (Çelikkıran, et al., 2015).

The pediatric nurse must have an understanding of factors and influences, as well as normal or expected patterns related to growth and development of the infant, child, and adolescent, to help the nurse to ask age-related questions, as well as answer the caregiver’s questions regarding the child, being aware of a child’s language skills and development will enable the nurse to communicate at the child’s level of understanding. When working with a sick child, the nurse must be aware that the child’s age and stage of growth and development can affect the way the child copes with the situation or responds to treatment (Hatfield and Kincheloe, 2018).

The role of pediatric nurse in chronic anemia is very important. The nurse explains to child and parents the nature of the disease and treatment plans, does physical examination which yields valuable evidence regarding the severity of anemia and some indication of its possible cause and also be aware of the importance of taking a thorough history to obtain pertinent information that may aid in identifying the cause of the anemia. The nurse is responsible for preparing the child and parents for the laboratory tests and assesses the child’s level of tolerance for activities of daily living and play, and makes adjustments (Hockenberry and Wilson, 2015).

Significance of the study:

Worldwide, anemia affects up to one-half of children younger than five years (Wang, 2016). According to UNICEF, (2016) prevalence of any kind of anemia among children under five years in Egypt is 27.2 % and prevalence in Upper Egypt is 27.9%. Anemia is more prevalent in Rural Upper Egypt (30.2%) than in Urban Upper Egypt (22%). It is a global public health threat especially in the developing countries. Childhood anemia has serious consequences including growth retardation, poor immune system and increased susceptibility to diseases, and has severe socio-economic consequences for families and communities (Kuziga, et al., 2017).

According to the WHO, (2015) the percentage of children aged 6-59 months with blood Hb concentration < 11 g/dl in Egypt is 45%. WHO has issued criteria to define public health significance of a problem according to prevalence of it so 5–19.9 % is mild, 20–39.9 % is moderate and ≥ 40 % is regarded as a severe public health problem and as a result of this anemia ranks as a severe public health problem in Egypt (WHO, 2011).

Aim of the study:

The aim of this study was to assess the effect of chronic anemia on physical growth and development among children under five years.

Research questions:

• What is the relationship between chronic anemia with physical growth and development among children under five years?
• Is there a relationship between chronic anemia and malnutrition effect on physical growth and development among children less than five years?

Subjects and method:

Research design:

A cross sectional descriptive research design was used for this study.

Subjects:

A purposeful sample of 100 children diagnosed with any type of chronic anemia aged from (6 - 59 months) with their caregivers.

Setting of the study:

This study was conducted in the Pediatric Hematology Clinic at Minia University Hospital for Obstetric and Pediatric.

Tools of data collection:

Two tools were used to collect the required data for the study:

Tool I: A structured interview questionnaire designed by the researcher included three parts:

Part 1: Bio-demographic data of children and their parents include:

Data related to children such as age, gender, birth order and residence and data related to parents such as education and occupation of children's parents.

Part 2: Medical history for children with emphasis on child's diagnosis, the onset, duration, Hb level and grading, number of hospitalization during the previous 6 months, complications from disease if present, the presence of relevant family history and degree of consanguinity between parents.

Part 3: Anthropometric measurements was used according to the WHO growth charts to measure weight, length/height, head circumference, mid-arm circumference and body mass index and plotted on the chart appropriate for age and sex (WHO, 2006).

Tool II:  Denver Developmental Screening Test 2nd edition (DDST II) (Ricci, et al., 2013). The test consists of up to 125 items, divided into four parts:

Part 1: Personal/Social: aspects of socialization inside and outside the home.

Part 2: Fine motor adaptive: eye/hand coordination, and manipulation of small objects.

Part 3: Language: production of sounds, ability to recognize, understand, and use of language.

Part 4: Gross motor functions: motor control, sitting, walking, jumping, and other movements.

Scoring system for Tool II was done as follows:

P: Pass-child successfully performs item or caregiver reports the child can do the item.

F: Fail-child does not successfully perform the item and/or the caregiver reports the child cannot do the item.

N.O.: No Opportunity-the child has not had the opportunity to perform the task due to restrictions.

R: Refusal-the child refuses to attempt and the parent cannot report.

Tools Validity:

         Tool one was tested for content validity by a panel of five experts in the field of the study from Minia and Assuit University, Faculty of Nursing, Pediatric Nursing Department and necessary modifications were done and its result was 95%. These modifications were education and occupation of children's parents and interpretations of DDSTII.

Tools Reliability:

                Reliability of tool one was performed to confirm its consistency by using Cronbach's alpha test and the result was 0.72. Tool two is valid and reliable.

Pilot study:

A pilot study was conducted on 10 % of sample which equal 10 children who met the inclusion criteria for selection to test clarity, completeness, adequacy, objectivity, applicability, content validity and internal consistency of the study tools and to determine possible problems in the tool. According to the results of pilot study, the needed omissions, and/or additions were done. Children involved in the pilot study were excluded from the main study sample. Pilot testing helped the researcher plan for data collection.

Ethical considerations:

A written initial approval was obtained from the Research Ethical Committee of the Faculty of Nursing, Minia University. Oral consent was obtained from all the caregivers of children who met the criteria of selection and accepted to be included in the study. The purpose and nature of the study was explained by the researcher through direct personal communication prior to starting their participation in the study and the caregivers were assured that they could withdraw at any time from the study. Confidentiality was assured through coding the data. Each assessment sheet was coded anonymous

Procedure:

Administrative approval was obtained from the Dean of Faculty of Nursing, Minia University to the director of Minia University Hospital for Obstetric and Pediatric and the director of outpatient clinics before implementation of the study. The researcher interviewed each child and his caregiver individually after introducing herself and explaining the purpose and nature of the study. Caregiver’s consent to participate in the study was secured orally.

The interview was conducted in the hematology clinic at Minia University Hospital for Obstetric and Pediatric. Demographic and health history data was obtained from the caregiver. Hb level and grade was recorded in the sheet according to WHO grading of anemia depending upon Hb level, anemia is graded: mild when Hb level between 10-10.9 g/dl. Hb level between 7-9.9 g/dl indicates moderate anemia and severe anemia when Hb level below 7g/dl (WHO, 2011).

The anthropometric measurements were carried out once to children, recorded immediately in the sheet and plotted on WHO growth chart appropriate for gender and age. The time taken for filling each sheet ranged from 40- 50 minutes depending on the response of the child and the caregiver to questions. Data collection was conducted in the period from the beginning of April to the end of September 2017 by interviewing the caregivers & children on Wednesday every week.

A digital scale was used to measure weight. Infants and children were weighed without shoes and minimal clothing, the average weight of clothing material was then determined and subtracted from the reading. The child placed in the center of the scale. Weight was measured and recorded immediately (Bowden and Greenberg, 2016 and Gupta, et al., 2017).

Length was measured by placing the infant laid flat in supine position on a hard table, any hair ornament or hats were removed and straighten the infant's legs together. The head was positioned in Frankfort plane vertically with the help of the caregiver; the knees were extended by a firm pressure applied by the researcher to straighten the legs and prevent knees from flexing. Then, marking the end points of the vertex and the heels of the feet and measuring between these two points. Length was measured and recorded immediately and approximated to the nearest 0.1cm (Gupta, et al.,  2017). 

Height was measured through standing the child bare feet on the foot plate of the mechanical dial scale/wall with the calves, heels, buttocks, scapula and back of head touching the vertical board of the scale/wall, the head was positioned in Frankfort plane horizontally. The child was asked to maintain a fully erect position and slightly apart feet at a 60o angle and weight distributed on both feet. Then, moving the sliding headpiece tell it touched the top of the child's head compressing the hair. The vertical distance is measured by placing a firm, flat surface against the vertex or crown of the head, Height was measured and recorded immediately and approximated to the nearest 0.1cm (Gupta, 2011).

Head circumference was measured by using a non-stretchable measuring tape. The tape measure was placed around forehead just above the eyebrows anteriorly and around the occipital posterior. The tape was pulled snugly to compress hair and the measurements were approximated to the nearest 0.1 cm and recorded (Correia, 2017).

Mid-arm circumference was measured by using a non-stretchable measuring tape, placed on the acromion process and the olecranon and made a horizontal mark at the midpoint, then encircled the tape around the arm over the marked midpoint without compressing the skin or underlying tissue. The measurements were approximated to the nearest 0.1 cm and recorded (Gupta, 2011).

Body mass index is given by the following formula “weight in kilogram divided by height in square meter”. The value of BMI was plotted on age and sex specific BMI chart (Kavitha, 2015).

Developmental assessment was done according to DDST II by the researcher in the presence of the caregiver. The test was performed before any painful or frightening procedures, the researcher started by put one or two test materials in front of the child while taking history from the caregiver. The first few test items that was below the child's age level were administered first to assure him/her on initial successful experience. Items requiring less active participation were administered first.

A vertical line was drawn through the four sectors of the test form at the child's chronological age. The date of the test was written at the top of the age line. In each sector, the items to be administered were those below the age of the child, the items through which the child's chronological age line passes and the items to the right until the child has 3 items failures in the sector being tested.

Statistical analysis:

  Data entry was done using compatible personal computer. The collected data were coded, categorized, tabulated, analyzed and summarized by using Statistical Package for Social Science (SPSS version 20) and Excel 2010 has been used to generate figures. Data was presented using descriptive statistics in the form of frequencies and percentages for qualitative variables, and means and standard deviations for quantitative variables. Chi-square test was used. Statistical significance was considered at p-value < 0.05. WHO growth charts was used for this study. Health resources administration standard at < 3rd percentile; 3rd - 97th percentile and > 97th percentile was used to compare growth parameters of children.

Scoring of development was done by the researcher using Denver Developmental Screening Test score.

Limitations of the study:

The environment was not ideal for interviewing because of overcrowding and noise in clinic related to a big number of children, it was better to be present a separate room other than diagnosis room for applying DDST.

Results:

Table (1): Distribution of Studied Children with Chronic Anemia according to their Personal Characteristics

Table (1): Illustrates the personal characteristics of the studied children. It was found that children aged from 2 < 3 years were more frequent (26%) with a mean age of 2.71 ± 16.02 months. Males were higher (58%). The majority of our studied sample was living in rural areas (92%). The fourth or more birth order was more frequent represented (32%).

Table (2): Distribution of Families of Children with Chronic Anemia according to their Personal Characteristics

Table (2): Illustrates the personal characteristics of parents of children with chronic anemia. It was found that secondary school educated fathers were more frequent (39%), while regarding mother's education it was found that illiteracy was higher (56%). As regards father's occupation it was found that farmer fathers were more frequent (54%). Regarding mother's occupation it was found that the majority of mothers were housewives (97%).

Table (3): Presence and Degree of Consanguinity between Parents (N=100)

Table (3): Presents degree of consanguinity between parents. It was found that close consanguinity between parents represented (47%), remote consanguinity between parents was (28%) and no consanguinity was found in one fourth of parents (25%).

Figure (1): The Percent of Different Types of Anemia among Patients (N=100)

G-6-PD: Glucose-6- phosphate dehydrogenase

Figure (1): Shows the frequency distribution of different types of anemia among patients. Studied sample included 100 of children with chronic anemia. They were 39 patients with thalassemia (39%), 21 patients with G-6-PD deficiency (21%), 16 patients with sickle cell anemia (16%), 13 patients with aplastic anemia (13%) and  11  patients with iron deficiency anemia (11%).

Figure (2): The Percent of Severity of Anemia among Children with Chronic Anemia (N=100) 

Figure (2): Illustrates the frequency distribution of severity of anemia among studied children. It was found that severe anemia represented 65% and moderate anemia represented 28% while mild anemia represented 7%.

Table (4): The Growth Parameters of Children with Chronic Anemia

Table (4): Describes the growth parameters of children with chronic anemia. As regards weight for age percentile, it was found that high percentage of children (78%) were below 3rd percentile category. As regards length/height for age percentile, it was found that 69% of patients were below 3rd percentile category, while 53% of patients regarding weight for length / height percentile were between 3rd and 97th percentile category.

Concerning head circumference for age percentile, it was found that two thirds of patients were < 3rd percentile category (67%). As regards mid-arm circumference for age percentile, it was found that three fourths of patients were < 3rd percentile category (75%). Regarding body mass index for age percentile, 42% of patients were falling below 3rd percentile category.

Table (5): The Distribution Percent of Children with Chronic Anemia according to Pattern of Development using DDST II (N=100)

Table (5): Explains the pattern of development of children with chronic anemia. It was found that three fourths of studied children had abnormal DDST II, 18% had questionable DDST II and there is one untestable DDST II. 

Table (6): The Relationship between Anthropometric Indices and DDST II among Children with Chronic Anemia (N=100)

* Statistically significant difference (P < 0.05)                         

DDST II:  Denver Developmental Screening Test 2nd edition

Table (6): Presents the relationship between anthropometric indices and DDST II. No statistically significant difference was found between anthropometric indices and DDST II except weight for age percentile and DDST II (p=0.03).

Table (7): The Relationship between Grading of Hemoglobin and Anthropometric Indices among Children with Chronic Anemia (N=100).

*statistically significant difference (P < 0.05) 

Table (7): Presents the relationship between grading of hemoglobin and anthropometric indices. It was found that a very highly statistical significant difference was found between weight for age, mid-arm circumference for age percentiles and grading of hemoglobin (p=0.000). It was found a highly statistical significance difference between length/height for age and grading of hemoglobin (p=0.001) and a statistical significance difference was found between weight for length/height percentile and grading of hemoglobin (p=0.03). However no statistically significant difference was found regarding head circumference for age, BMI for age percentiles and grading of hemoglobin.

Table (8): The Relationship between Grading of Hemoglobin and Pattern of Development using DDST II among Children with Chronic Anemia (N=100).

* Statistical significant difference (p<0.05)   

Table (8): Shows the relationship between grading of hemoglobin and DDST II. It illustrates that a very highly statistical significance difference was found between DDST II and grading of hemoglobin (p=0.000). It was found that high percentage (90.8%) of studied patients with severe grade of hemoglobin were abnormal DDST II.

Discussion: