Influence of infection on iron profile in severely malnourished children.
ABSTRACT To study the iron profile and find out an accurate diagnostic tool which reflects iron status in different types of infection in severely malnourished children aged 12 months to 71 months.
Hundred and Eight (108) children of whom 72 children were infected and 36 non infected severely malnourished children according to WHO criteria in the age group of 12-71 months were interrogated. 36 healthy control in the same age group were also interrogated.
Mean serum iron, total iron binding capacity (TIBC), ferritin concentration in normal children were significantly higher (P<0.001) than non-infected severely malnourished children. On the other hand mean serum ferritin concentration was significantly higher (P<0.001) in infected group than non-infected group but still lower than normal. Mean serum TIBC concentration significantly reduced in severely malnourished children than normal children but no significant difference was observed between non-infected and infected group. Mean serum iron, and transferrin saturation were significantly reduced (P<0.05) in parasitic infestation.
Severely malnourished children had reduced mean serum iron profile. Parasitic infestation influenced the marked reduction of mean serum iron concentration and transferrin saturation level. Mean serum iron concentration was reduced in acute respiratory infection(ARI) and parasitic infestation than other infections. Serum ferritin concentration was elevated in all types of infection as acute phase protein but still lower than normal. So Iron, TIBC and Transferin saturation <16% constitute good evidence for iron deficiency in both infected and non-infected severely malnourished children.
- SourceAvailable from: Bassem Abou Merhi[Show abstract] [Hide abstract]
ABSTRACT: Pneumonia is the biggest single cause of childhood death under the age of 5 years, and anemia affects approximately 30% of infants and children all over the world. Determination of the relationship between anemia and lower respiratory tract infection as a risk factor in Lebanese children. A total number of two hundred infants and children aged nine months to twelve years were included; One hundred cases were hospitalized for lower respiratory tract infection in Department of Pediatrics, Makassed General Hospital, and one hundred healthy, age and sex matched controls, were selected from outpatient department. Complete blood count, iron level, ferritin level, and total iron binding capacity were taken if hemoglobin level less than eleven gram per deci-liter. In addition peripheral blood smear, chest radiograph and C-reactive protein were done to hospitalized cases. Definition of iron deficiency anemia and normal laboratory values were predetermined. Anemia was found in 32% of hospitalized cases and 16% of healthy controls. Mean hemoglobin level was 9.99 ± 0.62 gram per deci-liter and 11.99 ± 0.92 gram per deci-liter in anemic and non-anemic group respectively with a significant P-value of 0.001. C-reactive protein levels and number hospitalization days were similar among the anemic and non-anemic group. History of recurrent chest infections was significantly higher in both anemic group and hospitalized cases compared to non-anemic group and healthy controls. Low hemoglobin level was a risk factor for lower respiratory tract infection with a P-value of 0.008. Anemic children were two times more susceptible to lower respiratory tract infection compared to the control group, and iron deficiency anemia was predominating. Accurate diagnosis and prevention of anemia, whatever its etiology, is essential.North American journal of medical sciences. 10/2010; 2(10):461-6.
Correspondence and Reprint requests : Dr. M.Atiar Rahman
Assistant Professor, Pulmonary, Department of Pediatric, Room
No. 307, D-Block, BSMMU, Shahbagh, Dhaka-1000, Bangladesh.
[DOI- -10.1007/s12098- -009- -0098- -x]
[Received April 12, 2008; Accepted July 24, 2008]
Influence of Infection on Iron Profile in Severely
M. Atiar Rahman, M.A.Mannan and Md Hamidur Rahman
Department of Pediatrics, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh
Objective. To study the iron profile and find out an accurate diagnostic tool which reflects iron status in different types of
infection in severely malnourished children aged 12 months to 71 months.
Methods. Hundred and Eight (108) children of whom 72 children were infected and 36 non infected severely malnourished
children according to WHO criteria in the age group of 12-71 months were interrogated. 36 healthy control in the same age
group were also interrogated.
Results. Mean serum iron, total iron binding capacity (TIBC), ferritin concentration in normal children were significantly
higher (P<0.001) than non-infected severely malnourished children. On the other hand mean serum ferritin concentration
was significantly higher (P<0.001) in infected group than non-infected group but still lower than normal. Mean serum TIBC
concentration significantly reduced in severely malnourished children than normal children but no significant difference was
observed between non-infected and infected group. Mean serum iron, and transferrin saturation were significantly reduced
(P<0.05) in parasitic infestation.
Conclusion. Severely malnourished children had reduced mean serum iron profile. Parasitic infestation influenced the
marked reduction of mean serum iron concentration and transferrin saturation level. Mean serum iron concentration was
reduced in acute respiratory infection(ARI) and parasitic infestation than other infections. Serum ferritin concentration was
elevated in all types of infection as acute phase protein but still lower than normal. So Iron, TIBC and Transferin saturation
<16% constitute good evidence for iron deficiency in both infected and non-infected severely malnourished children. [Indian
J Pediatr 2009; 76 (9) : 907-911] E-mail: firstname.lastname@example.org
Key words: Iron; TIBC; Ferritin; Infection; Malnourished children
Malnutrition associated with infections are the leading
cause of death in children in developing countries1.
Poverty, illiteracy and infections are major risk factors
for both malnutrition and iron deficiency. 2-5 Infection
and malnutrition have a synergistic relationship.
Malnutrition leads to infection and vice versa. Infection
or inflammation is a common cause of mild iron
deficiency especially respiratory tract infection, diarrhea,
urinary tract infection and parasitic infestation. 6-7
The diets of a poor earning family contain mainly
whole grains, cereals and legumes which contain
relatively poor iron. This poor iron containing diet is
poorly absorbed which may be one of the reasons for
high prevalence of iron deficiency in malnourished
children.8 Currently available confirmatory tests for
iron deficiency include the serum iron serum ferritin,
total iron binding capacity (TIBC), transferrin saturation
and the free erythrocyte protoporphyrin. 9-11 But infection
or inflammation can influence iron status and thus
complicates the accurate detection of iron deficiency.
Serum ferritin is a new tool, appears to be the most
reliable test, it is depressed only in iron deficiency;
indeed, infection or inflammation raised serum ferritin
So the aim of this study was to estimate and observe
iron profile and find out an accurate diagnostic tool
which reflects iron status in different types of infection
in severely malnourished children.
MATERIALS AND METHODS
This descriptive study was carried out on 144 children
with age range of 12-71 months. The places of study
Indian Journal of Pediatrics, Volume 76—September, 2009907
M. Atiar Rahman et al
908 Indian Journal of Pediatrics, Volume 76—September, 2009
were the Department of Pediatrics, Dhaka Medical
College Hospital (DMCH), Bangabandhu Sheikh Mujib
Medical University (BSMMU) and AD-DIN Hospital.
The study period was July 2003 to June 2004.
Biochemical analysis was done at the Biochemistry
Department of BSMMU. Children were broadly divided
into two groups.
Group- I. Consisted of 36 apparently healthy children
whose weight for height Z- score (WHZ) and height for
age Z score (HAZ) >-2.
Group- II. Consisted of 108 severely malnourished
children of whom 72 children were infected and 36 non
infected whose weight for height Z- score (WHZ) and
height for age Z score (HAZ) were <-3.Detailed history
including birth history, feeding history, past and
present infection, treatment history and socio-economic
status of both the groups were taken. While taking
treatment history special emphasis was given on the
history of taking proteins, any vitamins, minerals and
iron before getting their admission in the respective
hospitals. For taking history and other laboratory
findings pre-tested questionnaire was used by the
investigator himself. The patients who clinically
appeared to have infection underwent relevant
investigation for the purpose of screening of infection.
Among the cases seventy two patients had acute
infection like acute respiratory tract infection (ARI),
acute diarrheal diseases, urinary tract infection (UTI),
and parasitic infestation. In this study infection was
diagnosed by taking history, physical examination and
confirmed by doing relevant investigations.Acute
respiratory tract infection was diagnosed on the basis
of WHO Integrated Management of Childhood Illness
(IMCI) criteria as presence of cough or difficulty in
breathing and respiratory rate more than 40/min or
chest indrawing or stridor in calm child and or
presence of any general danger sign like not able to
drink or breast feed, convulsion, lethargy or
vomiting.This was supported by auscultatory rhonchi,
crepitation, radiological evidence, complete blood count
(CBC) and C - reactive protein (CRP) level in blood.
Mantoux test where indicated.
Acute diarrheal diseases were diagnosed on the
basis of passage of 3 or more loose motions or a single
large watery motions in a day with or without bloody
stools, vomiting or dehydration. In each cases stool
routine microscopic examinations and culture
sensitivity, occult blood test were done.
Urinary tract infection was diagnosed by taking
history of fever, foul smelling urine and confirmed by
doing urine routine microscopic examinations (pus
cell> 5 HPF in centrifuged urine) and urine culture
Parasitic infestation was diagnosed on the basis of
loss of appetite, vomiting, abdominal pain and was
confirmed by stool routine and microscopic
examinations, CBC, peripheral blood film (PBF). In all
these cases CRP was >6 mg/dl.
Severely malnourished children according to WHO
with or without infection between 12-71 months of age
with symmetrical edema involving at least the feet were
selected as the case. The apparently healthy normal
siblings of admitted children for others causes during
study period both male and female children between
12 -71 months of age with weight-for-height Z score
(WHZ) >-2 and height-for-age Z score (HAZ) >-2 of the
median NCHS/WHO reference values without any
systemic disease or pallor were selected as control.
Children between 12-71 months of age with severely
wasted malnourished children and having anemia due
to other causes e.g., Hemolytic anemia; Leukemia,
Bleeding disorders and other malignant disease and
having history of intake of iron were excluded from the
Sample collection, Separation and Preservation
The attendants of study subject were given a detailed
briefing about the purpose of the study. With all aseptic
precautions 5 ml of venous blood was drawn randomly
on day of admission before the treatment was started.
Immediately after collection, blood was centrifuged at
3000 rpm for 5 minutes on the same day. Supernatant
clear serum was preserved at -35° c in different vials till
used for analysis.
Serum iron, ferritin and TIBC were determined by
commercially available kits (India. UK and Germany).
Both serum iron and TIBC were estimated by
spectrophotometric technique and serum ferritin was
estimated by enzyme immunoassay.
Transferrin saturation = Serum iron x 100
Statistical analysis was done by students “ t ” test to see
the significance of variations in the iron profile using
SPSS software. P value <0.05 was taken as significant
and <0.001 was taken as highly significant.
This Descriptive study included 144 children, among
them 108 were severely malnourished and 36 were well
nourished (normal children).
Influence of Infection on Iron Profile in Severely Malnourished Children
Indian Journal of Pediatrics, Volume 76—September, 2009909
TABLE 1. Characteristics of Children
> 59 (n=3)
<36 (n =27)
36-59 (n = 18
>59 (n = 3)
<36 (n = 39)
36-59 (n = 21) 19.44
>59 (n = 0)
< 36 (n=26)
36-59 (n=10) 27.78
< 36 (n=12)
> 59 (n=0)
< 3 6 (n=14)
> 59 (n=0)
The characteristics of severely malnourished children
are shown in table 1. Most of the cases 66 (61.11%)
were below 36 months of age group. Regarding sex
distribution, in both sexes below 36 months age group
were most vulnerable. In male 27 (25.00%) and in
female 39 (36.11%) cases were observed in this group.
In normal children vast majority were below 36
months age group in both sexes. In present study about
seventy two percent (72.22 %) were below 36 months
age group, (33.33%) were male (38.89%) were female.
TABLE 2. Iron Profile Amongthe Normal Children and Non-infected Several Malnourised Children
Types of subject Number Serum Iron (µg/dl)
Mean ± SE
63.50 ± 0.97
Mean ± SE
30.23 ± 0.58
Mean ± SE
330.86 ± 2.43
36 35.91 ± 0.70 a**7.02 ± 0.30 a**230.00 ± 1.16 a**15.65 a**
*P<0.05, ** P<0.001
a when compared with normal children.
TABLE 3. Iron Profile in Different Types of Infection of Severely Malnourished Children
Types of subjectNumber Serum Iron (µg/dl)
Mean ± SE
Mean ± SE
Mean ± SE
35.91 ± 0.70 a
32.18 ± 0.91* b
7.02 ± 0.30 a
20.22 ±1.24 **b
230.00 ± 1.16 a
224.64 ± 3.05 b
1831.9 ± 1.35* b
19.48 ± 1.71** b
225.29 ± 4.65 b
1833.80 ± 1.99 b
18.61 ± 1.32** b
231.12 ± 2.12 b
1836.15 ± 0.99 b
22.47 ± 4.03** b
227.33 ± 3.52 b
1826.96 ± 1.76* b
22.61 ± 4.84** b
210.40 ± 13.73 b
*P<0.05, ** P<0.001
b when compared with non-infected malnourished children.
Table 2 showed that the mean serum iron, TIBC,
ferritin and transferrin saturation in normal children
were (63.50 ± 0.97 µg / dl, 330.86 ± 2.43 µg / dl, 30.23 ±
0.58 ng /ml, 19.35%) respectively which were
significantly higher (P<0.001) than non infected
severely malnourished children (35.91 ± 0.70 µg / dl,
230.00 ± 1.16 µg / dl, 7.02 ± 0.30 ng /ml, 15.65 %).
On the other hand table 3 showed mean serum
ferritin concentration 20.22 ± 1.24 ng /ml was
significantly higher (P<0.001) in infected group than
non infected group (7.02 ± 0.30 ng /ml).
The values of serum iron, ferritin, TIBC and
transferrin saturation in non infected and infected
malnourished children are also shown in table 2 and
table 3. The serum iron, and transferrin saturation was
significantly reduced (P<0.05) in parasitic infestation.
The serum ferritin was significantly elevated (P<0.001)
in all types of infection as compared to non infected
In the present study serum iron concentration was
significantly lower in non-infected malnourished
children than that of the normal children as shown in
Table 2 (P<0.001). This observation was also observed
by other authors.6,8,14 But when compared between non-
M. Atiar Rahman et al
910Indian Journal of Pediatrics, Volume 76—September, 2009
infected and infected malnourished children mean iron
concentration was also significantly lower in infected
ones (P<0.05) table 3. Less intake, poor absorption and
the systemic effect of infection and utilization of iron by
microorganism for its growth and multiplication may
be responsible for their lower iron status.3, 7,9, 10, 15
In infection or inflammation there is a rapid drop in
serum iron concentration and a corresponding rise in
serum ferritin concentration, this may be due to
reticuloendothelial block which reduces the release of
iron from the phagocytic cells.The IL-1 a primary
mediator of acute phase response enhances apoferritin
When the concentration of serum ferritin was
compared between non-infected malnourished and
normal children, significantly lower level was observed
in non-infected ones as shown in table 2 (P<0.001).
This was also the observation of studies done by other
investigators.6,7,9 Severely malnourished children are
usually associated with iron deficiency which is
indicated by serum ferritin concentration.7,9,17 But when
compared between non-infected and infected ones,
ferritin concentration was significantly higher in
Infected groups than non-infected ones but still lower
than normal children (P<0.001) table 2 and 3. Serum
ferritin is one of the acute phase proteins, which
increased in presence of infection, inflammation or
tissue damage.13, 16 In the present study this may be the
reason of false elevation or raised serum ferritin
concentration in infected malnourished children. Other
authors also observed in their studies similar type of
findings in infected and non-infected children.6,7,9,10,12,13
Although TIBC bears an inverse relationship with
serum iron and ferritin concentration in general,9,10,18
this relationship was not observed in the present study.
Severely malnourished children without infection had
significantly lower TIBC level than normal children
(P<0.001) table 2, which is also consistent with those
reported by others.6,14 It is probably because of reduced
iron binding protein transferrin19. Total iron binding
capacity level was compared between infected and non-
infected groups, the difference between the groups was
not statistically significant. (P=0.107). This may be due
to that transferrin receptors are not affected by infection
or inflammatory diseases.13 This observation was
consistent with that of other authors. 17
In the present study the transferrin saturation was
significantly lower in malnourished children (Table 2
P<0.001). But when the value was considered between
non-infected and infected group, infected group had
also significantly lower value than non-infected peers
(P<0.05) table 3. Other authors also observed similar
findings in their studies. 6,7,8,9,20
When mean serum iron and transferrin saturation
were compared between non-infected malnourished
children with infected groups those who had different
types of infection, patient with parasitic infestation had
significant reduction level (P<0.05). But individually
each type of infection showed significantly elevated
ferritin concentration than non-infected malnourished
children (P<0.001). This finding was also observed by
other authors.6,9,12,13 because this low level in parasitic
infestation is possibly due to consumption of blood by
parasite as well as loss of blood through
gastrointestinal tract (GIT), anorexia, malabsorption
and systemic effect of chronic infection.7,9,14,20
In conclusion, malnourished children had reduced
mean serum iron concentration. Infection influenced the
reduction of mean serum iron concentration and
transferrin saturation but marked reduction was
observed in parasitic infestation. Elevated mean serum
ferritin concentration was observed in all types of
infection probably as acute phase protein. Mean serum
TIBC concentration was reduced in malnourished
children but no significant difference was observed
between infected and non-infected groups. Iron and
TIBC are the main tools in infected malnourished
children rather than ferritin.Transferin saturation
<16% constitutes good evidence for iron deficiency in
both infected and non infected malnourished children.
Contributions: Atiar Rahman; preparation of the protocol,
selection of the study subject, sample collection, separation,
preservation, self estimation of serum iron, TIBC, Ferritin and
transferrin saturation in the Biochemistry Department of
Bengabandhu Sheikh Mujib Medical University (BSMMU),
Dhaka, Bangladesh. Data preparation and processing
preparation of original article, submission, necessary corretions
and correspondence. To collect the reference papers M.A.
Mannan; to assist the preparation of the protocol , data
processing, analysis and also to guide original article preparation
Hamidur Rahman; to guide the preparation of original article.
Conflict of Interest : Not applicable.
Role of Funding Source : Principal author.
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