Prevalence and Clinical Profile of Megaloblastic Anemia in Children

Abstract

Introduction: Megaloblastic anemia is an underestimated disease of nutritional origin in children. Contrary to earlier times, this entity has become much more frequent today. Veganism is one of the common reasons for an increase in the prevalence of nutritional megaloblastic anemia. Deficient mothers often have children with vitamin B12 deficiency with megaloblastic anemia and various neurologic manifestations. It presents with varied clinical features in childhood, sometimes mimicking a hematological malignancy like leukemia. Diagnosing this disease assumes great clinical importance since it responds exceedingly well to treatment. Objective of the Study: (1) To study the prevalence and clinical profile of megaloblastic anemia in children referred for anemia. (2) To determine the high risk factors for occurrence of megaloblastic anemia in children and (3) To find out the effectiveness of treatment in these children. Material(s) and Method(s): This study was a retrospective analysis of children referred for anemia to the Pediatric Hematology-Oncology Division of LTMG Hospital over the last 3.5 years from January 2009 to July 2013. Clinical data was charted in a proforma and all patients underwent a complete hemogram, corrected reticulocyte count and peripheral blood smear examination, biochemical investigations including serum bilirubin levels, lactate dehydrogenase levels, serum vitamin B12 levels (NR: 200-950 pg/ml) and red cell folate levels (NR: 175-700 ng/ml). Bone marrow was done to confirm the diagnosis in those children who could not afford B12 and folate levels. The diagnosis of megaloblastic anemia was established on the basis of serum Vitamin B12 levels below 200 pg/ml and/or RBC folate levels below 175 ng/ml or bone marrow suggestive of megaloblastic changes along with the clinical findings and smear picture suggestive of megaloblastic anemia. Result(s): A total of 1,365 patients were referred for anemia during the study period. Of these 56 (4.1 %) children were diagnosed as per the predefined criteria as megaloblastic anemia. Among these children, the age and sex distribution was as follows: 25 (44.64 %) were males 31 (55.35 %) were females with male to female ratio of 0.8:1. The youngest was 3 month old and the oldest was 12 years old. 22 (39.28 %) of them were in age group of 0-12 months, 8 (14.28 %) in 1-3 years, 9 (16.07 %) in 3-6 years, 5 (8.92 %) in 6 to 9 years and 12 (21.42 %) in 9-12 years age group. When evaluating diet in these children, history of milk based diet was obtained in 24 (42.85 %) children, 15 (26.78 %) were lactovegetarians and 17 (30.35 %) consumed a mixed (non-vegetarian) diet. Clinical presentations varied from recurrent infections to various hematological manifestations including mucosal or skin bleeds. 23 (41.07 %) patients were incidentally found to have megaloblastic anemia on routine blood counts when they were seen for acute infections. 6 (10.71 %) children had listlessness and 12 (21.42 %) had pallor as presenting complaint. 5 (8.92 %) children presented with skin and mucosal bleeds. 10 (10.71 %) of them presented with neurological complications; 4 (7.14 %) of these had infantile tremor syndrome and the remaining 6 had gross developmental delay. On examination, pallor was present in all, hyperpigmented knuckles were seen in 47(83.927 %) children, where as sallow complexion was found in 30 (53.57 %) children. 38 (67.85 %) children had mild hepatosplenomegaly. On investigations, hemoglobin ranged from 1.6 to 7.5 g % (mean Hb 5.7 +/- 1.02 g %). MCV ranged from 85 to 123 fL (Mean MCV was 102.43 +/- 6.94 fL). 14 (25.00 %) children had pancytopenia and 18 (32.14 %) had bicytopenia (anemia with leucopenia). 6 (10.71 %) patients who presented with mucosal and skin bleeds had thrombocytopenia (platelet counts ranged from 30,000 to 50,000 per c.mm). Peripheral blood smear showed macrocytes, macroovalocytes and pear shaped poikilocytes in all of them. Hypersegmentation and large sized neutrophils were seen in 31 (55.35 %) cases. Serum bilirubin levels ranged from 0.4 to 4.7 mg/dl (with high indirect bilirubin in those with elevated levels). Serum LDH levels>1,000 IU/L was seen in as many as 34 (60.71 %) children. Serum vitamin B12 and red cell folate levels could be done in 45 (80.35 %) patients. Of these, 8 (17.77 %) patients had low levels of both serum vitamin B12 and RBC folate, 24 (53.33 %) had only low serum vitamin B12 levels, 6 (13.33 %) had low folate levels and 7 (15.5 %) patients had normal levels. 11 (19.64 %) children were diagnosed on the basis of bone marrow aspirate findings of megaloblastic anemia. Treatment was effective in a short duration with a mean rise in hemoglobin of 1-2 g % in the 1st week and by 4-4.3 g % in 2nd week. Thrombocytopenia and other morphological parameters also showed improvement on treatment within 4 weeks. Conclusion(s): We conclude that appropriate diet would prevent occurrence of megaloblastic anemia in children, which is almost always nutritional in etiology. Additionally, timely diagnosis and treatment with specific hematinics can avoid unnecessary transfusion of blood components.