Factores asociados a los niveles de hemoglobina en niños menores de 6 meses de edad hospitalizados en un centro pediátrico de Perú

Mamani-Urrutia, Víctor; Durán-Galdo, Rafael; Gonzales-Saravia, Carlos; Bustamante-López, Alicia; Espinoza-Rojas, Rubén; Escalante-Kanashiro, Raffo; Mamani-Urrutia, Víctor; Durán-Galdo, Rafael; Gonzales-Saravia, Carlos; Bustamante-López, Alicia; Espinoza-Rojas, Rubén; Escalante-Kanashiro, Raffo

doi:10.25176/rfmh.v23i1.5059

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Revista de la Facultad de Medicina Humana

versión impresa ISSN 1814-5469versión On-line ISSN 2308-0531

Rev. Fac. Med. Hum. vol.23 no.1 Lima ene./mar. 2023 Epub 25-Ene-2023

http://dx.doi.org/10.25176/rfmh.v23i1.5059

Original Article

Factors associated with hemoglobin levels in children under 6 months of age hospitalized in a pediatric center in Peru

Víctor Mamani-Urrutia1¹, nutritionist

Rafael Durán-Galdo¹, nutritionist

Carlos Gonzales-Saravia², pediatrician , pediatric dermatologist

Alicia Bustamante-López², statistical

Rubén Espinoza-Rojas³, statistical

Raffo Escalante-Kanashiro²⁴, pediatrician, pediatric intensivist

^¹Universidad Científica del Sur. Lima, Peru.

^²Instituto Nacional de Salud del Niño. Lima, Peru.

^³Escuela de Posgrado, Universidad Continental. Lima, Peru.

^⁴Universidad Peruana de ciencias aplicadas. Lima, Peru.

Abstract

Introduction:

Anemia is a condition in which there is a low concentration of hemoglobin (Hb) levels. Although many causes of anemia have been identified, there are few studies in which they are related to epidemiological factors in the first months of life.

Objective: to determine the factors associated with hemoglobin levels in children under 6 months of age hospitalized in a specialized pediatric center in Peru.

Methods:

Cross-sectional study of children under 6 months of age hospitalized in the medical services of a pediatric center in 2017; 267 medical records were reviewed, emphasizing clinical and epidemiological characteristics.

Results:

61.4% of the infants were women, and only 6.7% of the population studied were less than 1 month old. 6.7% had a low birth weight, and 53.2% had a normal delivery. The level of anemia in hospitalized children under 6 months of age is 66.7%.

Conclusions:

According to the bivariate analysis, a significant association is found between hemoglobin levels with the variables age, nutritional status, weight for length, and hospital causes. Regarding the multivariate analysis, only an association was found between age and the median Hb in boys and girls aged 0 to 5 months hospitalized in a pediatric center in Peru.

Keywords: child, hospitalized; anemia, iron-deficiency; epidemiologic study characteristics; hospitals, pediatric.(source: mesh nlm)

Introduction

Anemia is a condition in which there is a low concentration of hemoglobin (Hb) levels and red cell mass compared to the average¹. Although many causes of anemia have been identified, there are few studies in which they are related to epidemiological factors in the first months of life.

Worldwide, certain epidemiological factors related to anemia in infants are recognized. Studies carried out in latin american countries have found two epidemiological characteristics associated with the presence of childhood anemia: poverty and low educational levels on the part of the parents.²^,³. In addition, these same components have been repeatedly found in countries such as bangladesh and india.⁴^-⁸.

At the level of Peru, the educational and socioeconomic level of the parents is associated with predisposing factors to anemia.⁹^,¹⁰. It is worth mentioning that childhood anemia is a topic of main national interest because 40.1% of boys and girls under three years of age present it.¹¹.

The national institute of child health (INSN) of Peru treats pediatric patients in the hospitalization area for various diseases, including infectious diseases; which, being linked to other epidemiological factors such as nutritional status and anemia, can impact immunity, increasing infant morbidity and mortality¹²^,¹³. In addition, there are chronic diseases associated with anemia, such as heart failure, cancer, and inflammatory bowel disease.¹³. For this reason, recognizing factors that predispose to presenting anemia in the first months of life is a strategy to consider to mitigate its prevalence at the national level and, above all, to avoid any in-hospital complication.

The objective of this study was to determine the factors associated with hemoglobin levels in children under 6 months of age admitted to a specialized pediatric center in Peru.

Methods

Cross-sectional analytical study carried out in a specialized hospital in the capital of Peru.

Population and sample

The population consisted of infants under 6 months of age hospitalized in the medical services of the INSN of Peru. A census of hospitalized patients was carried out taking as a reference the hospital discharges of the year 2017, finally 267 hospitalized infants were obtained who met the inclusion criteria of the study, being hospitalized in the INSN medicine services and with complete records of the study variables. In the medical records (figure 1). Those with congenital malformation, genetic disorder, hiv infectio

Figura 1. Flowchart for the selection of hospitalized children. Lima, Peru 2017.

Variables and instruments

The dependent variable was the hemoglobin (Hb) level, taken on admission to hospitalization, determined from the medical records. For the determination of anemia, the ministerial resolution of the ministry of health of Peru no. 250-2017 was used, which uses the cut-off points pre-established by the who. Anemia was considered in children under 2 months of age with <13.5 g/dl of Hb in blood, and from 2 to 6 months with <9.5 g/dl of Hb in blood⁽¹⁴⁾. The independent variables were birth weight, length at birth, head circumference at birth, delivery characteristics, sex, origin, poverty quintile, age, nutritional status, causes of hospitalization, and hospital stay. The technique was data collection from medical records.

Procedure

Data collection from medical records was performed, with emphasis on clinical and epidemiological characteristics. There was a format designed for the study, the data entered in the formats was entered in an excel spreadsheet for subsequent analysis. To establish the poverty quintiles, the infant's district of residence and the monetary poverty map of Peru were used. The quintiles are a subdivision of the population into 5 partially equal parts, with the first quintile being the one that groups the poorest population (154). On the other hand, the monetary poverty map can be estimated thanks to the national household survey (enaho) that allows obtaining an estimate of income and expenses of Peruvian households (156).

The sample for the determination of Hb upon admission to hospitalization was obtained by venipuncture. All Hb blood analyzes were processed in the sysmex model xn-1000 hematology analyzer, using the cyanide-free sodium lauryl sulfate (sls) methodology. Additionally, the analytical methodology had interlaboratory and external evaluation programs that ensured the quality of the results issued.

Statistical analysis

Statistical analyzes were performed using the statistical package for social science (spss, inc.) Software, version 26.0, which was also used for data management and cleaning. Descriptive statistics were reported as numbers and percentages for categorical variables. The evaluation of the normal distribution of the numerical variables was carried out with the kolmogorov-smirnov test, the student's t-test, and anova were used to compare hospital hemoglobin between participants with different clinical epidemiological characteristics, for the bivariate analysis of the qualitative variables. The chi-square test was used and regarding the multivariate analysis, a logistic regression was performed to obtain the adjusted or. The significance level was set at p<0.05 for all statistical analyses.

Ethical aspects

The manuscript was part of the results of the research project approved by the institutional research ethics committee of the INSN of Peru (code: pi-79/2018).

Results

It was observed that the population of infants was mostly male, with 61.4%. The analyzed population consisted predominantly of 2-month-old boys and girls, with 29.2%. 79.8% correspond to metropolitan lima and callao districts, and 96.3% belong to the quintiles with the highest economic income. When observing the nutritional status at the hospitalization time, acute malnutrition was found in 5.6% and severe malnutrition in 3% of the cases.

Regarding malnutrition due to excess, 7.9% presented overweight compared to 6.4% of the cases that presented obesity. The mean Hb was 10.4 g/dl with a standard deviation (sd) of 2. The mean Hb to the epidemiological characteristics was similar; however, it could only be associated with the age variable, reaching mean values of 14.4 g/dl (sd=2.2) in children under 1 month of age and up to a mean of 9.6 g/dl in infants of 2 months (sd=1.3),table 1.

Table 1. Hospital hemoglobin among participants with different clinical characteristics epidemiological, INSN 2017.

Variables				Total		Hemoglobin (g/dl)	P value
Variables				N	%	Media	Of
Total				267	100,0	10,4	2,0
Sex					0,023
Masculine	164	61,4	10,2	1,7
Femenine	103	38,6	10,7	2,3
Age					0,000
< 1us	18	6,7	14,4	2,2
1 us	67	25,1	10,8	1,5
2 months	78	29,2	9,6	1,3
3 months	40	15,0	9,7	1,7
4 months	36	13,5	10,2	1,8
5 months	28	10,5	10,2	1,9
Residence area								0,75
Metropolitan lima and callao				213	79,8	10,4	1,9
Rest of the country	54	20,2	10,3	2,1
Wealth quintile					0,680
Quintile 2 and 3 - lowest income				10	3,7	10,0	3,0
Quintile 4 and 5 - higher income				257	96,3	10,4	1,9
Birth weight					0,335
Low birth weight (<2500 g)				18	6,7	9,8	2,8
Normal birth weight (≥2500 g)				249	93,3	10,4	1,9
Length at birth					0,483
Short length at birth (<45.4 cm-female; ≥46.1 cm-male)				28	10,5	10,1	2,4
Adequate length at birth (≥45.4 cm-female; ≥46.1 cm-male)				239	89,5	10,4	1,9
Head circumference at birth								0,952
Microcephaly risk (<2ds)				12	4,5	9,3	1,7
Normal (+-2ds)	208	77,9	10,4	2,0
Macrocephaly risk (>2ds)				47	17,6	10,7	1,8
Delivery characteristics								0,428
Eutocic	142	53,2	10,5	2,3
Dystocia	125	46,8	10,3	1,6
Nutritional status (deficit and excess)								0,426
Obesity	17	6,4	9,5	2,1
Overweight	21	7,9	10,4	1,5
Normal	206	77,2	10,4	1,9
Acute malnutrition				15	5,6	10,5	2,7
Severe malnutrition				8	3,0	10,5	3,5

When making the association between the presence of anemia in infants with the clinical and epidemiological variables (table 2), no association could be found with the parameters weight, length, head circumference, delivery characteristics, sex, origin, poverty quintile, hospital stay, and weight-for-age and length-for-age nutritional status. However, statistically significant associations were found in 3 different parameters: age, nutritional status, weight for length, and causes of hospitalization.

Table 2. Association between Hb level and clinical-epidemiological characteristics of hospitalized children under 6 months of age, INSN 2017.

Variables	Hb blood levels in infants				P value
	Anemia		Well, anemia
	N	%	N	%
Total	178	66,7	89	33,3
Birth weight
Low birth weight (<2500 g)	11	61,1	7	38,9	0,605
Normal weight at nacer (≥2500 g)	167	67,1	82	32,9	0,605
Length at birth
Short length at birth (<45.4 cm-female; <46.1 cm-male)	18	64,3	10	35,7	0,778
Adequate length at birth (≥45.4 cm-female; ≥46.1 cm-male)	160	66,9	79	33,1	0,778
Head circumference at birth
Microcephaly	9	75,0	3	25,0	0,531
Normal	138	66,3	70	33,7	0,835
Macrocephaly	31	66,0	16	34,0	0,910
Delivery characteristics
Dystocia	86	68,8	39	31,2	0,488
Eutocic	92	64,8	50	35,2	0,488
Sex
Masculine	116	70,7	48	29,3	0,075
Femenine	62	60,2	41	39,8	0,075
Origin
Callao	2	50,0	2	50,0	0,476
Metropolitan lima1/	143	68,4	66	31,6	0,248
Lima provincias2/	5	55,6	4	44,4	0,472
Rest of country	28	62,2	17	37,8	0,488
Poverty quintile
Quintile 2	2	100,0	0	0,0	0,315
Quintile 3	3	37,5	5	62,5	0,076
Quintile 4	64	64,6	35	35,4	0,052
Quintile 5	109	69,0	49	31,0	0,591
Age
<1 month	1	5,6	17	94,4	0,000
1 month	39	58,2	28	41,8	0,090
2 months	65	83,3	13	16,7	0,000
3 months	32	80,0	8	20,0	0,052
4 months	24	66,7	12	33,3	1,000
5 months	17	60,7	11	39,3	0,480
Nutritional status- weight for age
Normal	132	64,7	72	35,3	0,221
Overweight	31	79,5	8	20,5	0,066
Under weight	15	62,5	9	37,5	0,650
Nutritional status - weight for length
Over weight	29	76,3	9	23,7	0,173
Normal	138	67,0	68	33,0	0,837
Acute malnutrition	11	47,8	12	52,2	0,045
Nutritional status - length for age
Normal	161	66,0	83	34,0	0,441
Low stature	17	73,9	6	26,1	0,441
Causes of hospitalization (icd-10)
Acute bronchiolitis (j21)	52	73,2	19	26,8	0,170
Whooping cough (a37)	24	63,2	14	36,8	0,620
Intestinal infections (a09)	10	66,7	5	33,3	1,000
Septicemia (a41)	6	60,0	4	40,0	0,649
Pneumonia (j15-j18)	19	86,4	3	13,6	0,041
Urinary tract infection (n39)	8	80,0	2	20,0	0,362
Conditions of perinatal origin (p00)	0	0,0	8	100,0	0,000
Blood volume depletion (e86)	3	75,0	1	25,0	0,722
Epilepsy (g40)	9	56,3	7	43,8	0,362
Other causes of hospitalization	47	64,4	26	35,6	0,627
Hospital stay
0 a 4	68	66,7	34	33,3	1,000
5 a 9	77	68,1	36	31,9	0,661
10 a 14	25	69,4	11	30,6	0,704
15 and over	8	50,0	8	50,0	0,145

Regarding age, an association was only found with children under 1 month and 2 months; with nutritional status, only those who presented acute malnutrition; and with the causes of hospitalization, pneumonia, and conditions of perinatal origin.

It is important to highlight that anemia levels progressively increase to 83.3% in the second month of life, decreasing to 60.7% in the fifth month. Although there is no obvious association, it should be noted that 70.7% of men have anemia, 10% higher than women, and the 2 cases of the poorest quintile have anemia. Infants with excess weight present approximately a 10% increase in the level of anemia in relation to those classified with normal nutritional status, a progressive decrease in anemia levels is evident with longer hospitalization (table 2).

When performing a multivariate analysis between the median Hb (10.1 g/dl) and clinical-epidemiological factors (table 3), it was only possible to determine a statistically significant relationship (p<0.05) between Hb levels with the age of infants and that age progress increases by 3.8 if Hb levels drop. Although another multivariate association could not be determined, it can be established that a short length at birth increases the chances by 2.2 of presenting lower Hb levels.

Table 3. Multivariate analysis of Hb levels in hospitalized children under 6 months of age, INSN 2017.

Variables		Probability Hb levels				P value	Adjusted or	Ic 95%
		Hb≤10,1 g/dl		Hb>10.1 g/dl
		N	%	N	%			That	Ls
Total		139	100,0	128	100,0
Birth weight	Low birth weight (<2500 g)	10	7,2	8	6,3	0,4	0,5	0,1	2,3
Birth weight	Normal birth weight (≥2500 g)	129	92,8	120	93,8	0,4	0,5	0,1	2,3
Length at birth	Short length at birth (<45.4 cm-female; <46.1 cm-male)	13	9,4	15	11,7	0,2	2,2	0,7	7,2
Length at birth	Adequate length at birth (≥45.4 cm-female; ≥46.1 cm-male)	126	90,6	113	88,3	0,2	2,2	0,7	7,2
Head circumference at birth	Risk	32	23,0	27	21,1	0,1	0,6	0,3	1,1
Head circumference at birth	Normal (+-2ds)	107	77,0	101	78,9	0,1	0,6	0,3	1,1
Delivery characteristics	Dystocia	64	46,0	61	47,7	0,6	1,1	0,7	1,9
Delivery characteristics	Eutocic	75	54,0	67	52,3	0,6	1,1	0,7	1,9
Sex	Masculine	91	65,5	73	57,0	0,2	0,7	0,4	1,2
Sex	Femenine	48	34,5	55	43,0	0,2	0,7	0,4	1,2
Age	0 to 1 my	28	20,1	57	44,5	0,000	3,8	2,1	6,9
Age	2 to 5 months	111	79,9	71	55,5	0,000	3,8	2,1	6,9
Hospital stay	0 to 6 days	86	61,9	72	56,3	0,3	0,8	0,4	1,3
Hospital stay	7 or more days	53	38,1	56	43,8	0,3	0,8	0,4	1,3
Origin	Metropolitan lima and callao	110	79,1	103	80,5	0,5	1,3	0,6	2,6
Origin	Rest of the country	29	20,9	25	19,5	0,5	1,3	0,6	2,6
Quintile	Quintile 2 and 3 - less income	5	3,6	5	3,9	0,6	1,5	0,3	6,3
Quintile 4 and 5 - higher income	134	96,4	123	96,1

Infigure 2, it can be verified that the Hb levels concerning the percentage of the infant population. It is observed that 65.1% present an average Hb between the values of 9 to 11 g/dl.

Figure 2. Distribution of hemoglobin (Hb) values in evaluated infants, INSN 2017.

Discussion

The results of this investigation are important because they allow associating clinical-epidemiological factors with anemia, especially at an early age; considering that the level of anemia in hospitalized children is usually 55%¹⁷or reaches values of 66.7% as in this investigation. In this first stage of life, one of the most common anemias occurs in neonates, known as physiological anemia. This occurs due to the progressive decrease in erythropoiesis that occurs from birth and reaches a peak between weeks 6 and 9.¹⁸

Internationally; it has been seen that the prevalence of anemia in this age group is slightly below that found in the present study. In nepal, a prevalence of 49% was found in children under 2 to 6 months of age.¹⁹; in a study from argentina carried out on children from 4 to 5 months, 28.9%²⁰; and in another in brazil carried out on children from 3 to 5 months, 20.2%²¹.

Regarding age, an association was found between anemia and children in their first month and 2 months of life in the bivariate analysis and a lower median Hb in infants from 2 to 5 months in the multivariate analysis. Some studies associate changes in hemoglobin with the increasing age of the infant, up to 18 and 12 months, respectively, with the presence of anemia.²^,²². Although this research worked with children under 6 months of age, the decrease in Hb levels due to the previously mentioned physiological anemia could still be extrapolated.¹⁸. On the other hand, infants, despite being hospitalized, present a decrease within what was expected in Hb levels given from month 1 to month 5. These results are similar to other studies in hospitalized infants in lebanon and turkey, where they observed that younger age of newborn hemoglobin levels²³and ferritin²⁴are older.

Another significant association found in this study, according to the bivariate analysis, was the causes of hospitalization. Only 2 complications that presented statistically representative associations with anemia could be determined: pneumonia and perinatal conditions. Previously published research has found an association between respiratory infections and anemia²⁵^,²⁶; in this case, similar results were found, specifically with pneumonia. It should be noted that respiratory conditions are the most common cause of hospitalization in children¹⁷^,²⁷. Therefore, evaluating the repercussions of this association could be vital to grant better treatment.

In the same way, perinatal conditions have already been associated in previous studies with childhood anemia.²⁸^,³⁰, which in turn has been seen to be the cause of abnormal neurological development if children have severe anemia due to the constant hypoxia to which they are subjected³¹.

Acute malnutrition, due to low weight for height, was another statistically associated variable in the bivariate analysis. Some studies on children under 1 year of age in asia have reached this same association.²³^,³²; in addition, in the first of these, carried out specifically on the island of sri lanka, it was concluded that anemia has a greater association with acute malnutrition when hospitalized infants are younger and decreases concerning the age of the children.³².

The prevalence of anemia with hospital stay is another clinical-epidemiological factor that could not be associated in this investigation. This differs from the lebanese study carried out on children older than 6 months, where a statistically significant association was found with the presence of anemia, but from the fifth day of hospitalization²³. Also, a second study conducted in adults associated an increase in hospital stay with the presence of any degree of preoperative anemia.³³. It should be considered that a possible cause of this non-association in the present study may be due to the age difference of the patients in the two mentioned cases.

It should be considered that finding patients with anemia is recurrent in the hospitalization area¹⁷^,³⁴, and some investigations associate it with an increase in hospital mortality³⁵^,³⁶. In addition, it has already been determined by other studies that this condition could aggravate the outcome of other diseases.³⁵^,³⁶. For this reason, further research to relate this variable to anemia should be considered.

One limitation of the study was not having evaluated the parents' educational level, since in various investigations, it has been possible to determine a quite significant inverse association with the presence of anemia.²^,³^,⁵^-⁸^,¹⁷. Despite this, apart from the study carried out at the INSN in 2015¹⁷, the associations were made in infants from 6 months of age and under 5 years.

Although in this investigation, no association was found between the level of wealth and the presence of anemia, the 2 infants who were within the second quintile of poverty were anemic; which can be compared to a study from tanzania that associated parental unemployment with the presence of anemia in hospitalized children under 5 years of age.³⁷. Likewise, it has been seen in various studies carried out nationally and internationally, that the socioeconomic level does greatly influence the presence of this disease.⁹^,¹⁰.

It is recommended to continue investigating the characteristics of anemia in the first months of life, in order to ensure a decrease in intrahospital mortality and have more tools against the fight against childhood anemia in Peru.

Conclusion

In conclusion, according to the bivariate analysis, a statistically significant association was found between age, acute malnutrition and causes of hospitalization and the presence of anemia; and regarding the multivariate analysis, it was possible to associate the median of the Hb levels with the age of boys and girls from 0 to 5 months of age hospitalized in the INSN.

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Funding sources: self financed

⁸Article published by the journal of the faculty of human medicine of the ricardo palma university. It is an open access article, distributed under the terms of the creatvie commons license: creative commons attribution 4.0 international, cc by 4.0(https://creativecommons.org/licenses/by/1.0/), that allows non-commercial use, distribution and reproduction in any medium, provided that the original work is duly cited. For commercial use, please contact revista.medicina@urp.edu.pe.

Received: July 23, 2022; Accepted: December 19, 2022

Correspondence: víctor alfonso mamani urrutia. Address: scientific university of the south. Faculty of health sciences. Nutrition and dietetics careers. Panamericana sur km 19, villa, lima. Peru. Telephone number: 993078393 e-mail:vmamaniu@cientifica.edu.pe

Authorship contributions: the authors appreciate the valuable collaboration of mr. John moscoso in editing and diagramming the figures.

Conflicts of interest: the authors deny conflicts of interest.

Este es un artículo publicado en acceso abierto bajo una licencia Creative Commons