Brief Reports

Indian Pediatrics 2002; 39:453-457

Folate and Cobalamin Deficiency in Megaloblastic Anemia in Children

From the Division of Pediatric Hematology and Biochemistry#, Kalawati Saran Children’s Hospital and Department of Pathology*, Lady Hardinge Medical College, New Delhi 110 001, India.

Correspondence to: Dr. Jagdish Chandra, 10, Lecturers Flats, Lady Hardinge Medical College, New Delhi 110 001, India.

E-mail: [email protected]

Manuscript received: September 4, 2000;

Initial review completed: October 25, 2000;

Revision accepted: November 6, 2001.

Nutritional megaloblastic anemia in children occurs commonly among under-nourished or malnourished societies of tropical and subtropical countries. The commonest age is 3-18 months with maximum number of cases being in 9-12 months(1). These children are generally exclusively breast-fed by mothers who are undernourished and have poor blood levels of folate and cobalamin (2-4).

Folate deficiency is considered to be more important cause of megaloblastic anemia and very little emphasis has been given to cobalamin deficiency. Over the last three decades the prevalence of folate deficiency seems to have fallen from 70-75% to 2-10% as reported in various studies in children and adults from different regions(5-7). Hence cobalamin deficiency appears to be emerging as a significant contributor to nutritional megaloblastic anemia.

In this study we have attempted to find out relative prevalence of cobalamin and folate deficiency in hospitalized children with megaloblastic anemia. We have also attempted to correlate serum cobalamin and folate levels of children with the serum levels of their mothers in a small group of children who were exclusively breast-fed.

This study was conducted in Divisions of Pediatric Hematology and Biochemistry, Kalawati Saran Children Hospital and Department of Pathology, Lady Hardinge Medical College, New Delhi. Inclusion criteria for the study were: (i) Age 6 months to 12 years, (ii) Hemoglobin less than 10 g/dl, and (iii) MCV more than 90 fl(8). From May 1998 to January 1999, all 68 cases fulfilling the inclusion criteria were initially enrolled. However, 9 children having received blood transfusion and/or hematinics and 8 seriously sick children were excluded. All patients at the time of admission were taken up for: (i) Complete blood count using automated Sysmex blood cell counter with recording of MCV, MCH, RBC count, TLC and Platelet count; and (ii) Peripheral smear examination. Those who qualified for inclusion criteria were taken up for bone marrow examination. Only those cases who were confirmed to have megaloblastic changes on bone marrow examination were included for final analysis. Cobalamin and folic acid assays were done by using SHIMADZU LC 10AT liquid chromato-graph with SPD 10A UV visual detector on CLS-ODS column and commercially available cobalamin (HIMEDIA labs) and folate (LOBA chemicals) standards(9). Cases with serum cobalamin and folate levels of less than 200 pg/ml and 5.0 ng/ml, respectively were considered as deficient(10,11). Neutropenia and thrombocytopenia were defined as ANC less than 1500 per cumm and platelet count less than 150,000 cumm. Mothers of some cases who were exclusively breastfed were taken up for serum cobalamin and folate estimation. For the description the exclusively breast fed group (children who had not/were not receiving any dietary article other than breast milk and water) is designated as group A and rest of the cases as group B. Statistical analysis was done using chi-square test (for comparing proportions) and non parametric median test (for comparing medians of the two independent groups). Spearman rank correlation was used to assess the significance of correlation.

Fifty-one patients, with male female ratio of 1.04 : 1 were included. The age range of the cases was 6-132 months (median 18 months) with 60.8% cases below 2 years of age. In one case, as the serum sample was misplaced, levels of folate and cobalamin could not be ascertained. Thus, the serum cobalamin and folate levels of 50 cases and 15 mothers were available.

Table I shows some important clinical and hematological features in both groups of children. As is evident the breast fed children (Group A) were significantly younger compared to other children (p <0.001). They belonged to vegetarian families significantly more often (p = 0.02). Other clinical features and hematological parameters were similar in both except median platelet count which was significantly lower in Group B (p <0.05).

The median of serum folate and cobalamin levels in Groups A and B were similar (p >0.05). Folate deficiency was observed in 25 cases (50%) and cobalamin deficiency was observed in 31 cases (62%). Fifteen cases (30%) had deficiency of both cobalamin and folate. Thus, 10 cases (20%) had pure folate deficiency and 16 cases (32%) had pure cobalamin deficiency. In 9 cases serum levels of both cobalamin and folate were within normal range (Table II).

Serum cobalamin and folate levels of mothers of 15 cases were done. All of these 15 children were from exclusively breast-fed group.

Median cobalamin level of 15 mothers was found to be 43.23 pg/ml, with 11 (73.33%)) having levels below 200 pg/ml. Median folate level in mothers were 5.24 ng/ml with 6 (40%) mothers having folate levels below 5 ng/ml.

Maternal cobalamin level had a significant positive correlation with the cobalamin level in children ( r = 0.585, p = 0.022). Coefficient of correlation r for folate level was –0.264 (p = 0.34).

Relative prevalence of cobalamin and folate deficiency in cases with megaloblastic anemia has been a subject of some debate. The studies in early sixties showed that folate deficiency was more prevalent, a trend similar to one observed in developed countries. However, compared to developed countries cobalamin deficiency was more common in India(12). Over the last four decades, the pro-portion of cases having cobalamin deficiency appears to have increased. This increase in cobalamin deficiency appears to be a global phenomenon as the recent reports appearing from other developing countries indicate. In a Mexican study on preschool children no folate deficiency was seen, but 41% had cobalamin deficiency(13). A Zimbabwean study on megaloblastic anemia (including adults and children) reported cobalamin deficiency being three times more common than folate deficiency(14). Similar observations are reported from Pakistan(6). Sarode et al. from Northwest India reported cobalamin deficiency in 74% compared to folate deficiency in 8.6% cases of megaloblastic anemia. Rest of the cases had combined deficiency(7). Gomber et al. found even lower prevalence of folate deficiency in a study on preschool children from Delhi(5).

In our study folate and cobalamin levels were low in 50% and 62% cases respectively. Of total cases, 20% had pure folate deficiency and 30% showed combined deficiency. In our study, folate deficiency was not as low as reported by others. We feel that this changing trend might be related to National Nutritional Anemia Prophylaxis Program introduced in 1970 and revised to National Nutritional Anemia Control Program in 1991, in which 5 mg of folic acid is given with iron to all pregnant women. Folate stores at birth would generally be normal in children of these mothers. The population studied by Gomber et al.(5) is from ICDS blocks and in these blocks the implementation of control program is generally good and more of population might have received folic acid through normally available iron folic acid tablets. Some of the children also might have been the beneficiary of the program. On the contrary, cases in our study belonged to more under-privileged class from different jhuggi clusters of the city.

Cobalamin deficiency in the mothers is regarded as the commonest cause of cobalamin deficiency in children(15). These children are born with depleted stores and receive inadequate amount of cobalamin through breast milk(13). The axis of maternal mal-nutrition, vegetarian/lactovegetarian and pro-longed exclusive breastfeeding has been earlier referred to as a factor responsible for megaloblastic anemia in children(2,3). In our country this probably holds true even today as most of the Indian mothers even at present are classified by WHO as severely anemic and prolonged breastfeeding is quite common in such familites(16). Our finding of nearly three fourth of mothers having cobalamin deficiency and a significant positive correlation of serum cobalamin levels of mothers and their breast-fed children strongly support maternal cobalamin deficiency being reflected in their children. The fetus probably extracts adequate folate from mothers even in presence of folate deficiency, hence cord blood folate have been shown to be higher than maternal levels(17). The same may not be true about cobalamin. Secondly, cobalamin content of breast-milk is lower in vegetarian mothers and it is posi-tively correlated with their serum cobalamin levels(11,18). Therefore, cobalamin defi-ciency was more common in these suckling children.

Anemia is not the only problem in these children, as is evident from the finding of neutropenia and thrombocytopenia in 50% and 80% cases, respectively.

To conclude, our observations show that deficiency of folate and cobalamin both contribute significantly as an etiological factor for megaloblastic anemia in children. In young exclusively breast-fed children, cobalamin deficiency appears to be more common and in these children decreased serum cobalamin levels probably reflect maternal cobalamin status. Since cobalamin deficiency is on the rise globally there is a need to study the pre-valence and etiology of cobalamin deficiency in children and women of childbearing age.

Contributors: JC was the main supervisor, drafted the paper and will act as guarantor. VJ was responsible for data collection and helped in drafting the paper. SN and SS supervised the hematological data collection and interpretation. VS supervised and helped in drafting the paper. SB and AK contributed in carrying out vitamin assays.

Funding: None.

Competing interests: None stated.

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