Researchers who found a high prevalence of iron deficiency anaemia (IDA) among hospitalised children in Durban have called for an urgent review of the implementation of guidelines in investigating children with IDA, and for the provision of iron replacement in young patients who are admitted, if required.
They also said further studies are required in HIV-exposed, HIV-negative children regarding the prevalence of anaemia and possible cause.
The team, which found malnourished and/or HIV-exposed children have a higher prevalence of anaemia on admission, while HIV-positive children in the post-antiretroviral era seem to have no additional risk, wrote in the SA Medical Journal that fewer than 10% of anaemic children have basic screening for IDA, and very few are provided with iron replacement, even on discharge.
Childhood anaemia worldwide is a major public health challenge, with prevalence rates of 20% to 60% noted in sub-Saharan African countries, including South Africa.
IDA is the most common reason and has been documented to be associated with long-term negative neurocognition.
Multiple factors, including poor dietary diversity, especially in lower socioeconomic communities, a high parasitic burden and recurrent infections, have been postulated as possible factors contributing to this high prevalence in children under five, while children requiring hospitalisation have also been documented to have a high prevalence of IDA.
These children specifically have a high incidence of infections and IDA, and this has been documented in both malaria-endemic and non-endemic regions of sub-Saharan Africa.
This is further complicated in this region because children infected with HIV and those with malnutrition have also been shown to have higher rates of IDA.
Hospitalised children, the researchers wrote, generally have access to investigations for anaemia, which could potentially enable timely identification of the condition.
Durban hospital
A cross-sectional study was conducted at a referral tertiary hospital (Victoria Mxenge, formerly King Edward VIII Hospital) in Durban between 1 January 2019 and 31 December 2019.
The HIV antenatal seroprevalence of the population served by this hospital is high at 44.3% (confidence interval (95% CI) 41.6 – 46.7), reflecting a high burden of both HIV-exposed and infected children. Nearly 10% of all children at this hospital have severe acute malnutrition.
At admission, children typically have routine tests that include a full blood count (FBC), which result includes haemoglobin (Hb), mean cell volume (MCV), mean haemoglobin concentration (MCH), a total red cell count (RCC) red cell distribution (RDW), platelet and white cell count.
Children between 12 months and five years, admitted specifically to the paediatric medical wards (thus excluding children admitted for surgical and other non-medical reasons), and who had a FBC test result, were included.
For children with repeat admissions, only the first FBC was recorded. The primary investigator and a study assistant collected clinical and sociodemographic data from patients’ medical records.
Anaemia was defined as Hb below the fifth percentile for age. According to WHO criteria, in a child aged 12 months to five years, this is haemoglobin <11 g/dL.
The severity of anaemia was classified as mild, moderate and severe when Hb levels were between 10 and 10.9 g/dL, 7 and 9.9 g/dL, and <7 g/dL, respectively. Children with a Hb <11 g/dL were further categorised as having microcytic hypochromic anaemia if the MCV was <80 femtolitres and an MCH <27 picograms.
Children with anaemia were categorised into groups with microcytic hypochromic anaemia (MHA) compared with those without MHA. This was done as a low MCV is generally used as a surrogate marker for identifying the need to investigate iron deficiency.
Additionally, a Mentzer index (MCV/RCC) of >13 was used as a proxy indicator of presumed iron deficiency, and compared with the serum ferritin level measurement.
Findings
In this cohort, the prevalence of anaemia was 24%. This is lower than the 42.8%, 42.5% and 38.6% seen in Botswana, India and Vietnam, respectively, in similar-sized paediatric referral hospitals.
The proportion of anaemic children presenting with moderate to severe anaemia (46.2%) in the study was, however, similar to these cohorts in Botswana (43.9%) and Vietnam (50%).[
The Durban setting differs from most other countries in terms of much higher HIV exposure rates, and the widescale uptake of antiretrovirals in those children infected with HIV.
The prevalence identified in this study was similar to the point prevalence of anaemia (23.4%) seen in slightly older children in a peri-urban disadvantaged community in the same province, with the study showing that children with poor nutrition (severe and moderate malnutrition) had a higher prevalence of anaemia, similar to Brazil.
Despite the 2016 WHO recommendations for routine iron supplementation in countries with high burdens of iron deficiency, it is widely conducted practice not to start iron among hospitalised children due to the high infection burden.
This seems to be the case in this study’s cohort, where <5% of anaemic children were provided with iron on discharge, and <20% were provided with multivitamins.
More than half of this cohort were on intravenous antibiotics during the hospitalisation, suggesting a high infection disease burden. This common practice could be a factor in the poor provision of iron on discharge.
The study team said further research is required, including qualitative studies into the factors influencing decisions to recognise and investigate anaemic children for IDA in disease-burdened contexts.
The need for education of healthcare workers is also an intervention highlighted by this study.
Study details
K L Naidoo, L Munian, B Neethling, N Rapiti.
Identification and management of iron deficiency anaemia in hospitalised children in Durban
Published in the SA Medical Journal in April 2025
Background
Despite iron deficiency anaemia (IDA) being a global challenge, guidelines on identifying and managing children in infection-burdened areas are unclear. Little is known about the investigation and treatment of IDA for hospitalised children in HIV-endemic areas.
Objectives
To determine the prevalence of anaemia in hospitalised children and to describe the factors that impact the identification and management of IDA in an urban area of South Africa (SA).
Methods
A cross-sectional study was conducted at a referral hospital in Durban, SA, from 1 January 2019 to 31 December 2019. A chart review was performed for the clinical and laboratory data of 1 138 hospitalised children between 1 and 5 years old who had full blood count results. Standard statistical analyses were performed, including comparative analyses between those with and without anaemia.
Results
There was a 24% prevalence rate of anaemia (46.2% of whom were moderate-severe). There was a greater prevalence for anaemia in malnourished children (p<0.0001) and those HIV exposed (p<0.0001). Despite 65.9% of anaemic children having microcytic hypochromic anaemia, iron studies were only performed in 12/273 (4.4%), and stool samples were tested in 16/273 (5.9%). The majority (260/273, 95.2%) of all anaemic children had a Mentzer index >13, suggesting a high prevalence of IDA. Only 10/273 (3.7%) were provided with iron. Children with microcytic hypochromic anaemia were no different in clinical presentation or outcome to other anaemic children. High numbers (55.1%) were on antibiotics, and this high infection burden may have affected the identification and management of IDA.
Conclusion
Malnourished and HIV-exposed children have a higher prevalence of anaemia. Despite this, <10% of children had basic investigations to identify IDA. This study highlights the urgent need to implement guidelines in identifying IDA and providing iron replacement in hospitalised children in areas with high infection burdens, including SA.
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