Newer research areas in Pediatric anemia in India - PowerPoint Presentation

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Newer research areas in Pediatric anemia in India

Dr

Preeti

Singh

Associate Professor

Department of Pediatrics

Lady

Hardinge

Medical College

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Outline

Magnitude of anemia in India

Trend analysis of prevalence of anemia

Etiology and determinants of childhood anemiaTypes of anemia prevalent among children and adolescentsImplementational researchGaps in knowledge on POCT, dose of iron, role of hepcidin, secondary data analysis

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58%

Children

(6 – 59 months)

53%

Women in reproductive age54%Adolescent Girls

(15 – 19

yrs

)

29%

Adolescent Boys

(15-19

yrs

)

50%

Pregnant Women

58%

Lactating mothers

Consequences:

Anaemia

Impaired cognitive development

Impaired physical performance

Increased Maternal and Child mortality

Ministry of Health and Family Welfare, Government of India. India Factsheet. National Family Health Survey (NFHS-4) 2015–16. Mumbai: Indian Institute for Population Studies, 2016.

Prevalence of Anaemia in India

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Anaemia was most prevalent among children under two years of age41% of pre-schoolers, 24% of school-age children and 28% of adolescents were anaemic

Female adolescents had a higher prevalence of anaemia (40%) compared to their male counterparts (18%)Anaemia was a moderate or severe public health problem among preschoolers in 27 states, among school-age children in 15 states, and among adolescents in 20 states32% pre-schoolers, 17% of school-age children and 22% of adolescents had iron deficiency (low serum ferritin)Female adolescents had a higher prevalence of iron deficiency (31%) compared to male adolescents (12%)Children and adolescents in urban areas had a higher prevalence of iron deficiency compared to their rural counterparts

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Trend analysis of prevalence of anaemia in India

Gonmei Z, Toteja GS. Micronutrient status of Indian population. IJMR 2018

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Global Burden of Disease Study

1990–2017

Global burden of disease study (1990–2017) has highlighted anaemia is a health problem that caused most disability in India over a decade (2005-2016) 

Prevalence of anaemia in 2017 in children

59·7%

(56·2–63·8), & 15–49 years -

54·4%

(53·7–55·2)

If the trends for the indicators estimated up to 2017 continue in India, there would be

excess of 11·7%

for anaemia in children, and 13·8% for anaemia in women relative to the 2022 targets.

Interventions to optimise health of adolescents and young women would be more effective than any single intervention addressing macronutrient or micronutrient deficiency.

Swaminathan S,

Hemalatha

R, Pandey A, et al. The burden of child and maternal malnutrition and trends in its indicators in the states of India: the Global Burden of Disease Study 1990–2017. Lancet Child

Adolesc

Health 2019; 3: 855–70.

Ministry of Women and Child Development, Government of India. POSHAN

Abhiyaan

(National Nutrition Mission). Ministry of Women and Child Development, Government of India, 2019.

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Anemia – still a public health problem in childrenAnemia

is still one of the most salient nutritional disorder in Indian children; continues to be endemic and a public health priority (>40% prevalence)Unfortunately, economic development & national anemia-control programme have not translated to major reduction in anemia in India (NFHS-4; 11 % reduction 69.5% - 58.5%) Ministry of Health and Family Welfare, G.o.I., National Family Health Survey (NFHS-4), State Fact Sheet. Mumbai: International Institute for Population Sciences; 2015–16. India has the maximum number of anaemic children and women in the world

2017 Global Nutrition Report. Anaemia affects general health of the population taking toll for high mortality & morbidity and attenuate the optimal potential of physical and mental capacity of our population. Current rate of decline in the prevalence of anaemia is insufficient to meet the Global Nutrition Target 2025 ; this prompts us to re-examine the current approaches for control of nutritional anaemia in the country. 

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Causes of Childhood Anemia in India

Balarajan Y, et al. Anaemia in low-income and middle-income countries. Lancet. 2011

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Determinants of Childhood Anemia in India

Pasricha, S. R. et al. Determinants of anemia among young children in rural India. Pediatrics. 2010.Nair KM, et al. Characterisation of anaemia and associated factors among infants and pre-schoolers from rural India. Public Health Nutr. 2016.Onyeneho NG et al. Determinants of childhood anaemia in India.

Natureresearch. 2019

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Prevalence of anaemia among children & adolescents 1–19 years in India

Sarna et al. Characterisation of the types of anaemia prevalent among children and adolescents aged 1–19 years in India: a population-based study. Lancet Child Adolesc Health 2020; 4: 515–25

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Prevalence of types of anaemia among children and adolescents in India, 2016–18

IDA most common form of anaemia among younger children while anaemia of other causes among 5–9-year children and adolescents.

Folate or vitamin B12 deficiency anaemia accounts for more than a third of anaemia prevalence.

More research is needed to understand anaemia of other causes among school aged children and adolescents.

Screening for haemoglobinopathies should be a part of childhood anaemia evaluation, particularly in high prevalence regions.

Future research could consider the benefits, safety, and cost-effectiveness of vitamin B12 supplementation

.

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Implementation Research

Accelerate rate of decline in prevalence of anaemia in different states of India - Address unmet gaps for different context and setting

What is the

etiology

of anaemia? (other than Fe def)

How to address the non nutritional causes of anaemia (hemoglobinopathies, chronic infections, infestation)?

Tools for measurement of

hemoglobin

(POCT)?

Review the potential interventions for prevention & control of

anemia

Evaluate the best strategy to build the iron store (diet or supplements)

Assess the benefit of supplementation multiple micronutrients (Vit B12, vitamin A), in addition to iron and folic acid alone (plan RCT) on

hemoglobin

concentration and subsequent reduction in anaemia prevalence, compared to supplementation with IFA alone. 

Impact of interventions to optimise health of adolescents & young women?

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Coverage of beneficiaries and compliance

Data on the coverage of IFA supplementation among children belonging to the age group of 6-59 months, 5-10, 11-19

yr

were neither collected nor documented in NFHS surveys 

The coverage of beneficiaries with IFA supplementation should be accounted

Training and orientation of the ASHA, AWW and school-teachers (procurement, distribution, monitoring)

Evaluation of compliance to iron supplementation (important reason for the lack of adequate success in reducing the high burden of anaemia). 

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Point‑of‑care testing (POCT) for

hemoglobin

POCT provides Hb results instantly and indeed aids in appropriate and timely management of

anemia. Other advantages such as requirement of less blood sample (one drop of capillary blood sample); usage at primary health‑care and community settings; and nonrequirement of sophisticated laboratory or trained laboratory technicians.Use of digital hemoglobinometers HemoCue301 and True Hb - potential POCTs for screening of anemia Both are comparable to screen anemia in adults and pregnant women in field settings & peripheral health facilities respectivelyNeogi SB, et al. Diagnostic accuracy of point-of-care devices for detection of

anemia in community settings in India. BMC Health Serv Res. 2020Yadav K et al. Digital Hemoglobinometers as Point‑of‑Care Testing Devices for Hemoglobin Estimation: A Validation Study from India. Indian journal of community Medicine 2020

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Point of Care Diagnostics

Comparison of invasive and non-invasive point of care devices against a gold standard

Validity of the digital hemoglobinometers needs to be established (in different age groups) at community settings.

Does

screen test and treat approach

lead to a greater decline in prevalence of anaemia as compared to the present rate of decline in the national program ?

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High Dose Iron supplementation –“double edged sword ”

Doses recommended under NIPI are slightly higher than the ones suggested by World Health Organisation (WHO)Excess iron is unlikely to be absorbed in the intestine and is likely to affect the GUT microbiome. Oral FeS may increase pathogenic bacteria in the faeces - risk of enteric and systemic infections Association between higher doses of Iron used for supplementation during childhood and future risk of early brain aging and neurodegenerative disease outcomes though more robust evidence is needed. Increased risk of insulin resistance and Obesity (altered GUT microbiota) 

 Mahajan PB, et al. Supplementation of higher doses of Iron in programmes to control anaemia is a double edged sword. Indian J Comm Health. 2018 

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Dose of Iron

Considering the current dosage in the program as high, is there a need to decrease the dose?

What is the optimum dose for treatment response?

Whether lowering of dose would have consequences on compliance and side effects?

Studies conducted to assess dose response and side effects

What is the bioavailability of iron from enteric coated tablets vs sugar coated tablets? - change in policy

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Role of Hepcidin

What is the role of hepcidin as a predictor of response to oral iron?

Does simultaneous administration of high dose iron supplements and fortification in different population groups beneficial or counterproductive?

Effectiveness of the strategy that integrates Nutrition and Water, sanitation and hygiene (WASH) interventions for the control of

anemia

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Childhood Anaemia 

Determinants of early onset of anaemia in children <2 years (delayed or faulty complementary feeding practices, LBW, Prematurity, maternal malnutrition, sociodemographic factors)

Nutrition specific interventions for

prevention & control of anemia

Dietary diversification

Nutrition education and provision of foods rich in minerals and vitamins such as fruits, vegetables, and iron‐rich foods; improving IYCF and BF practices (ASHA workers)

,

enhancing bioavailability by use of vitamin C with typical meals

Promote culturally appropriate & feasible methods of food processing to improve bioavailability and absorption (soaking , germination and fermentation)

Use of iron‐pot cooking and fish‐shaped iron ingots

Food Fortification (Double fortified salt or Micronutrient powders)

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Adolescent anemia

Impact evaluation of WIFS program

Nutrition specific interventions -

prevention & control of anemia

Dietary Diversification

Food Fortification

Efficacy of Point of use Multiple Micronutrient Powder (MMP) Vs. Double Fortified Salt.

Fortification of foods with vitamins and minerals (e.g. iron, folate, vitamin B

12

, zinc, vit A) alone or in combination. What is the best combination of micronutrients in MMP.

What is the cumulative benefit if multiple foods prepared for ICDS are all fortified?

Calculation of item wise cost and total iron delivered?

Feasibility and efficacy of oil fortification with micronutrients (nanotechnology)

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Anemia reduction targets - 2022

Target – 3 percent point reduction per year among each groups

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Research on secondary data 

Target based monitoring (

anemia

reduction targets 2022) , HMIS data reporting, Quarterly Progress Report (QPR), KPI reviews are the key features of

Anemia

Mukt

Bharat

Secondary data analysis (from different sources, annual health survey, NFHS, National sample survey) should be attempted to study relationship between reported coverage and decline in anaemia.

Secondary analyses to find the determinants of anaemia using spatial data analysis should also be initiated. 

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Way Forward

Need to bridge the gap between our desire to control and reduce anemia among children and the challenges toward implementing of an effective program

Set up a task force on childhood and adolescent anaemia, to brainstorm, evaluate the evidence and prioritise research questions for immediate implementation 

Implementation of quality research depends on a very strong managerial team, efficient team of researchers, resources and funds. NCEAR-A in association with Indian Academy of Pediatrics Nutrition Chapter and Pediatric and Adolescent Nutrition Society can work on key research areas to generate strong evidence on pediatric anemia and strengthen this component under the AMB programme to achieve the desired goals

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Thank you