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  • Research article
  • Open Access
  • Open Peer Review

Prevalence and risk factors of anemia among children aged 6–23 months in Huaihua, Hunan Province

BMC Public Health201818:1267

https://doi.org/10.1186/s12889-018-6207-x

  • Received: 15 March 2018
  • Accepted: 8 November 2018
  • Published:
Open Peer Review reports

Abstract

Background

Anemia is one of the most common diseases of childhood and is a health problem globally, particularly in developing counties and in children less than 2 years of age. Anemia during childhood has short- and long-term effects on health. However, few studies have investigated the prevalence of anemia among children in Huaihua. Therefore, this study analyzed the prevalence and risk factors of anemia among children 6 to 23 months of age in Huaihua.

Methods

This cross-sectional study was conducted at a maternal and child health care hospital in Huaihua, from September to November 2017. The study population recruited using a multistage sampling technique. A structured questionnaire was used to collect data on the characteristics of the children and members of their families. Hemoglobin (Hb) levels were measured by using a microchemical reaction method. Logistic regression analysis was used to identify associated factors and odds ratio with 95% CI was computed to assess the strength of association.

Results

In total, 4450 children were included in this study. The prevalence of anemia was 29.73%. In multivariate logistic regression analysis, the results show that mother and father of Miao ethnicity (OR = 1.23 and 1.31), diarrhea in the previous 2 weeks (OR = 1.35), breastfeeding in the prior 24 h (OR = 1.50), and caregivers able to identify the optimum timing of complementary feeding (OR = 1.15) had positive correlations with anemia. However, children aged 18 to 23 months (OR = 0.55), father of Dong ethnicity (OR = 0.82), addition of milk powder once or twice (OR = 0.71), addition of infant formula once or twice, three times, and four or more times in the previous 24 h (OR = 0.72, 0.70, and 0.75), and addition of a nutrient sachet four or more times in the prior week (OR = 0.70) were negatively associated with anemia.

Conclusions

The prevalence of anemia among children 6 to 23 months of age in Huaihua was higher than that in more developed regions of China. The feeding practice of caregivers was associated with anemia. nutrition improvement projects are needed to reduce the burden of anemia among children in Huaihua.

Keywords

  • Risk factors
  • Anemia
  • Children

Background

Anemia is one of the most common diseases of childhood and is a health problem globally, particularly in developing counties and in children less than 2 years of age [1, 2]. From 1993 to 2005, the global prevalence of anemia was 47.4% among children less than 5 years of age, and 46–66% in developing countries [3, 4]. In China in 2012, 28.2 and 20.5% of children 6–12 and 13–24 months of age, respectively, had anemia [5].

Anemia during childhood has short- and long-term effects on health. The former include an increased risk of morbidity due to infectious disease [4, 6, 7]. In addition, anemia during childhood is strongly associated with neurological development, and cognitive and immune function, and can lead to mental impairment and poor motor development [8, 9]. The long-term effects include reduced academic achievement and work capacity in adulthood [7, 10].

The majority of related studies show that anemia during childhood is strongly associated with food intake [11, 12]. Others reveal that economic status [13], residence in an urban or rural area [14], caregiver’s educational level [7], fever and diarrhea [15], low birth weight [7], and insufficient nutrition [15] are related to anemia during childhood.

The government of China provides nutrient sachets to children aged 6 to 23 months in poor areas of China, which has dramatically decreased the prevalence of anemia in children in western China [16, 17]. However, few studies have investigated the prevalence of anemia, or the effect of the nutrient sachet program thereon, among children in Huaihua.

Therefore, this cross-sectional study analyzed the prevalence and risk factors of anemia among children 6 to 23 months of age in Huaihua. Our findings will enable the development of countermeasures to reduce the burden of anemia and promote the health of children.

Materials and methods

Study design and area

This cross-sectional study was conducted at a maternal and child health care hospital in Huaihua, the largest city in midwestern China, from September to November 2017. The population of Huaihua in 2017 was 5,450,289, of which 322,876 were children under 5 years of age. A nutrient sachet program has been implemented in Huaihua since 2012.

Study population and sampling techniques

The study population consisted of caregivers and their children 6 to 23 months of age in seven rural regions of Huahuai recruited using a multistage sampling technique. Initially, the 13 regions of Huaihua line up according income, 7 rural regions were selected according income. Secondly, all towns of each region line up according income, ten towns were selected at random in each region. Then all villages of each town line up according income, three to five villages were selected at random in each town. According to the total number of live births, three villages were selected in Zhijiang and Huitong, four villages in Xinghuang, and five villages in Yuangling, Xupu, Mayang, and Chenxi. In total, 300 villages were selected. All children 6 to 23 months of age in each village line up according date of birth and 15 children 6 to 23 months of age in each village were selected by systematic random sampling, for a total of 4500 children (See Fig. 1). Income data were obtained from the 2016 Huaihua Statistical Yearbook and the number of live births from the 2016 Child Annual Report.
Fig. 1
Fig. 1

The flow chart of the sampling process

Data collection

A structured questionnaire was used to collect data on the demographic characteristics of the children and members of their families, as well as the children’s health status, feeding practice in the previous 24 h, and the caregivers’ level of knowledge of nutrition. Information on the children’s health status included gestational age, birth weight, and any episode of fever or diarrhea in the previous 2 weeks. The questionnaire was designed by the Chinese Center for Disease Control and Prevention to assess pilot projects for improving child nutrition in poverty-stricken areas of China. Hemoglobin (Hb) levels were measured in the fingertip peripheral blood of the children using a microchemical reaction method and Hemocue 301 instrument (Hemocue AB, Sweden), and were expressed as g/dL. Blood samples were collected in local public health centers. Anemia was assessed based on the criteria of Pediatrics, seventh edition published by the People’s Medical Publishing House. The cut-off point for anemia for children 6 to 23 months of age was < 11.0 g/dL Hb.

Statistical analysis

Data were cleaned, coded, and entered using Epidata 3.1 and analyzed by Statistical Product and Service Solutions 13. A descriptive analysis was performed to summarize the data, followed by bivariate logistic regression analyses of caregivers’ ethnicity, educational level, occupations, group, and level of knowledge of nutrition, as well as the age, sex, preterm birth, low birth weight, episode of diarrhea or fever in the previous 2 weeks, and food intake in the prior 24 h of the children. Factors with a value of P ≤ 0.10 in a bivariate analysis were included in the multivariable stepwise logistic regression model. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated to determine the strength of associations. A value of P < 0.05 was considered indicative of statistical significance.

Ethics approval and consent to participate

Informed consent was signed by the caregivers of the children prior to their being interviewed. The project complies with national guidelines and does not involve personal privacy. The project was approved by Huaihua Women's Federation and Municipal Commission of Health and Family Planning (No. 201563).

Results

Demographic characteristics and health status

In total, 4450 children were included in this study. Fifty children whose caregivers refused to be interviewed were excluded (collection rate, 98.88%). The characteristics of the 4450 children are listed in Table 1. The prevalence of anemia was 29.73%. The educational level of > 70% of the parents/caregivers was under senior. The parents of almost 50% of the children were of Han ethnicity. The majority of the mothers and caregivers were homemakers (48.74 and 99.64%, respectively). Of the caregivers of the children, 61.71% were their mothers. The incidences of premature birth and a low birth weight were less than 5%. Of the children, 18.58 and 12.20% reported that they had experienced fever and diarrhea in the previous 2 weeks (Table 2).
Table 1

The demographic characteristic of children 6 to 23 months of age (n = 4450)

Characteristic

Frequencies

Percent (%)

Sex

 Boys

2345

52.70

 Girls

2105

47.30

Age

 6~ 11 months

1536

34.52

 12~ 17 months

1411

31.71

 18~ 23 months

1503

33.78

Mother’s ethnicity

 Han

2219

49.87

 Dong

991

22.27

 Miao

1012

22.74

 Others

228

5.12

Mother’s educational level

 Primary

409

9.19

 Junior

2953

66.36

 Senior

828

18.61

 University

260

5.84

Mother’s occupation

 Homemakers

2169

48.74

 Professionals

143

3.21

 Commerce

227

5.10

 Animal husbandry and fishery

1225

27.53

 Operators equipment

79

1.78

 Others

607

13.64

Father’s ethnicity

 Han

2133

47.93

 Dong

1120

25.17

 Miao

1007

22.63

 Others

190

4.27

Father’s occupation

 Homemakers

791

17.78

 Professionals

316

7.10

 Commerce

350

7.87

 Animal husbandry and fishery

1678

37.71

 Operators equipment

305

6.85

 Others

1010

22.70

Father’s educational level

 Primary

326

7.33

 Junior

2957

66.45

 Senior

858

19.28

 University

309

6.94

Caregiver’s groups

 Mothers

2746

61.71

 Fathers

42

0.94

 Grandparents

1651

37.10

 Others

11

0.25

Caregiver’s educational level

 Primary

3243

72.88

 Junior

938

21.08

 Senior

257

5.78

 University

12

0.27

Caregiver’s occupation

 Professionals

16

0.36

 Homemakers

4434

99.64

Anemia status

 Normal

3127

70.27

 Anemia

1323

29.73

Table 2

Health status of children 6 to 23 months of age(n = 4450)

Characteristic

Frequencies

Percent (%)

Gestational age

 Term

4270

95.96

 Premature

180

4.04

Birth weight

 Normal

4279

96.16

 Low birth weight

171

3.84

Fever in the previous 2 weeks

 No

3623

81.42

 Yes

827

18.58

Diarrhea in the previous 2 weeks

 No

3907

87.80

 Yes

543

12.20

Feeding practice and nutrition knowledge

In the previous 24 h, most of the children had consumed water, soup, rice soup (92.45%), and solid/semisolid food (92.61%), but only 6.94% had consumed yogurt. Of the children, 31.03% had consumed infant formula once or twice and 48.85% had consumed a nutrient sachet four times or more in the prior week (Table 3). Of the caregivers, 44.20% could identify the optimum timing of complementary feeding but only 5.06% could identify the first complementary food which should be consumed by infants (Table 4).
Table 3

Feeding practice of children 6 to 23 months of age in the previous 24 h (n = 4450)

Feeding Practice

Frequencies

Percent (%)

Breastfeeding

 No

3205

72.02

 Yes

1245

27.98

Consume water, soup, rice soup

 No

336

7.55

 Yes

4114

92.45

Consume sugary drink

 No

3160

71.01

 Yes

1290

28.99

Consume infant formula and frequencies

 0

1951

43.84

 1 to 2

1381

31.03

 3

613

13.78

 4 or more

505

11.35

Consume milk powder and frequencies

 0

3698

83.10

 1 to 2

474

10.65

 3

161

3.62

 4 or more

117

2.63

Consume yoghourt and frequencies

 0

4141

93.06

 1 to 2

279

6.27

 3

12

0.27

 4 or more

18

0.40

Consume solid/ semisolid food and frequencies

 0

329

7.39

 1 to 2

1289

28.97

 3

1715

38.54

 4 or more

1117

25.10

Consume nutrient sachet and frequencies*

 0

1773

39.84

 1 to 2

302

6.79

 3

201

4.52

 4 or more

2174

48.85

*Consume nutrient sachet in the prior week

Table 4

Caregivers nutrition knowledge of children 6 to 23 months of age (n = 4450)

Nutrition Knowledge

Frequencies

Percent (%)

Is able identify the optimum timing of complementary feeding

 No

2483

55.80

 Yes

1967

44.20

Is able identify to the first complementary food which should be consumed by infants

 No

4225

94.94

 Yes

225

5.06

Has know the optimum food of supplementary iron

 No

3185

71.57

 Yes

1265

28.43

Is able identify nutrient relate to anemia

 No

2522

56.67

 Yes

1928

43.33

Is able identify the optimum timing of breastfeeding

 No

3852

86.56

 Yes

598

13.44

Bivariate logistic regression analyses

Table 5 shows the results of bivariate logistic regression analyses of anemia among children 6 to 23 months of age. Compared to children 6 to 11 months of age, the prevalence of anemia was lower among those 12 to 17 and 18 to 23 months of age (OR = 0.64, 0.39 and P < 0.001, < 0.001, respectively). Compared to children with Han mothers and fathers, the prevalence of anemia was higher in those with Miao mothers and fathers (OR = 1.46, 1.44 and P < 0.001, < 0.001, respectively) and lower in children with Dong mothers and fathers (OR = 0.80, 0.80 and P = 0.010, 0.007, respectively). Compared to the children of homemaker mothers, those of mothers employed in the professions, commerce, as equipment operators, and other occupations had a lower risk of anemia (OR = 0.70, 0.65, 0.61, 0.60 and P = 0.072, 0.008, 0.073, < 0.001, respectively). Compared to the children of homemaker fathers, those of fathers employed in animal husbandry and fishery, and others had a lower risk of anemia (OR = 0.85, 0.81 and P = 0.085, 0.038, respectively). Compared to children cared for by their mothers, those cared for by their father or grandparents had a lower prevalence of anemia (OR = 0.46, 0.59 and P = 0.050, < 0.001, respectively). In addition, female gender (OR = 0.89, P = 0.078), mothers and fathers’ education to university level (OR = 0.65, 0.70, and P = 0.016, 0.046, respectively) were associated with a lower risk of anemia. Diarrhea in the previous 2 weeks was also correlated with anemia (OR = 1.50, P < 0.001).
Table 5

Bivariate regression analysis of anemia among children 6 to 23 months of age

Parameters

N

n

(%)

OR(95%CI)

P value

Sex

 Boy

2345

724

30.87

1

 

 Girl

2105

599

28.46

0.89(0.78,1.10)

0.078

Age

 6~ 11 months

1536

604

39.32

1

 

 12~ 17 months

1411

414

29.34

0.64(0.55,0.75)

< 0.001

 18~ 23 months

1503

305

20.29

0.39(0.33,0.46)

< 0.001

Mother’s ethnicity

 Han

2219

637

28.71

1

 

 Dong

991

241

24.32

0.80(0.67,0.95)

0.010

 Miao

1012

374

36.96

1.46(1.24,1.70)

< 0.001

 Others

228

71

31.14

1.12(0.84,1.51)

0.440

Mother’s educational level

 Primary

409

133

32.52

1

 

 Junior

2953

879

29.77

0.88(0.70,1.10)

0.256

 Senior

828

249

30.07

0.89(0.69,1.15)

0.381

 University

260

62

23.85

0.65(0.46,0.92)

0.016

Mother’s occupation

 Homemakers

2169

704

32.46

1

 

 Professionals

143

36

25.17

0.70(0.48,1.03)

0.072

 Commerce

227

54

23.79

0.65(0.47,0.89)

0.008

 Animal husbandry and fishery

1225

376

30.69

0.92(0.79,1.07)

0.290

 Operators equipment

79

18

22.78

0.61(0.36,1.04)

0.073

 Others

607

135

22.24

0.60(0.48,0.76)

< 0.001

Father’s ethnicity

 Han

2133

617

28.93

1

 

 Dong

1120

274

24.46

0.80(0.68,0.94)

0.007

 Miao

1007

372

36.94

1.44(1.23,1.89)

< 0.001

 Others

190

60

31.58

1.13(0.82,1.56)

0.441

Father’s educational level

 Primary

326

108

33.13

1

 

 Junior

2957

874

29.56

0.85(0.66,1.08)

0.182

 Senior

858

261

30.42

0.88(0.67,1.16)

0.369

 University

309

80

25.89

0.70(0.50,0.99)

0.046

Father’s occupation

 Homemakers

791

259

32.74

1

 

 Professionals

316

102

32.28

0.98(0.74,1.29)

0.882

 Commerce

350

100

28.57

0.82(0.62,1.10)

0.162

 Animal husbandry and fishery

1678

492

29.32

0.85(0.71,1.10)

0.085

 Operators equipment

305

85

27.87

0.79(0.59,1.06)

0.120

 Others

1010

285

28.22

0.81(0.66,0.99)

0.038

Caregiver’s groups

 Mothers

2746

928

33.79

1

 

 Fathers

42

8

19.05

0.46(0.21,1.00)

0.050

 Grandparents

1651

385

23.32

0.59(0.52,0.68)

< 0.001

 Others

11

2

18.18

0.43(0.09,2.02)

0.288

Caregiver’s educational level

 Primary

3243

990

30.53

1

 

 Junior

938

262

27.93

0.88(0.75,1.04)

0.127

 Senior

257

69

26.85

0.83(0.63,1.11)

0.217

 University

12

2

16.67

0.45(0.10,2.08)

0.310

Caregiver’s occupation

 Professionals

16

2

12.50

1

 

 Homemakers

4434

1321

29.79

2.97(0.67,13.08)

0.150

Gestational age

 Term

4270

1265

29.63

1

 

 Premature

180

58

32.22

1.13(0.82,1.55)

0.455

Birth weight

 Normal

4279

1276

29.82

1

 

 Low birth weight

171

47

27.49

0.89(0.63,1.26)

0.513

Fever in the previous 2 weeks

 No

3623

1077

29.73

1

 

 Yes

827

246

29.75

1.10(0.85,1.18)

0.991

Diarrhea in the previous 2 weeks

 No

3907

1119

28.64

1

 

 Yes

543

204

37.57

1.50(1.24,1.81)

< 0.001

Breastfeeding

 No

3205

788

24.59

1

 

 Yes

1245

534

42.89

2.30(2.00,2.64)

< 0.001

Consume water, soup, rice soup

 No

336

107

31.85

1

 

 Yes

4112

1215

29.55

0.90(0.71,1.14)

0.377

Consume sugary drink

 No

3146

976

31.07

1

 

 Yes

1290

343

26.59

0.79(0.69,0.91)

0.001

Consume infant formula and frequencies

 0

1951

697

35.73

1

 

 1 to 2

1381

328

23.75

0.56(0.48,0.65)

< 0.001

 3

613

152

24.80

0.59(0.48,0.73)

< 0.001

 4 or more

505

146

28.91

0.73(0.59,0.91)

0.004

Consume milk powder and frequencies

 0

3698

1145

30.96

1

 

 1 to 2

474

101

21.31

0.60(0.48,0.76)

< 0.001

 3

161

45

27.95

0.86(0.61,1.23)

0.418

 4 or more

117

32

27.35

0.84(0.55,1.27)

0.405

Consume yoghourt and frequencies

 0

4141

1242

29.99

1

 

 1 to 2

279

74

26.52

0.84(0.64,1.11)

0.220

 3

12

3

25.00

0.78(0.21,2.88)

0.707

 4 or more

18

4

22.22

0.67(0.22,2.03)

0.476

Consume solid/semisolid food and frequencies

 0

329

99

30.09

1

 

 1 to 2

1289

410

31.81

1.08(0.83,1.41)

0.550

 3

1715

515

30.03

0.99(0.77,1.29)

0.982

 4 or more

1117

299

26.77

0.85(0.65,1.11)

0.236

Consume nutrient sachet and frequencies

 0

1773

581

32.77

1

 

 1 to 2

302

115

38.08

1.26(0.98,1.62)

0.071

 3

201

69

34.33

1.07(0.79,1.46)

0.656

 4 or more

2174

558

25.67

0.71(0.62,0.81)

< 0.001

Is able identify the optimum timing of complementary feeding

 No

2483

697

28.07

1

 

 Yes

1967

626

31.83

1.20(1.05,1.36)

0.007

Is able identify to the first complementary food which should be consumed by infants

 No

4225

1246

29.49

1

 

 Yes

225

77

34.22

1.24(0.94,1.65)

0.131

Has know the optimum food of supplementary iron

 No

3185

939

29.48

1

 

 Yes

1265

384

30.36

1.04(0.91,1.20)

0.565

Is able identify nutrient relate to anemia

 No

2522

772

30.61

1

 

 Yes

1928

551

28.58

0.91(0.80,1.03)

0.142

Is able identify the optimum timing of breastfeeding

 No

3852

1151

29.88

1

 

 Yes

598

172

28.76

0.95(0.78,1.145)

0.578

Breastfeeding in the past 24 h was correlated with anemia (OR = 2.30, P < 0.001). Compared to children who did not consume a sugary drink in the past 24 h, those who did consume a sugary drink had a decreased risk of anemia (OR = 0.79, P = 0.001). Compared to no addition of infant formula in the past 24 h, addition of infant formula once or twice, three times, and four times or more decreased the risk of anemia (OR = 0.56, 0.59, 0.73 and P < 0.001, < 0.001, 0.004, respectively). Compared to no addition of milk powder in the past 24 h, addition of milk powder once or twice decreased the risk of anemia (OR = 0.60, P < 0.001). Compared to no addition of a nutrient sachet in the previous week, addition of a nutrient sachet once or twice increased the risk of anemia (OR = 1.26, P = 0.071), while addition of a nutrient sachet four or more times decreased the risk of anemia (OR = 0.071, P < 0.001). The ability of caregivers to identify the optimum timing of complementary feeding was significantly associated with anemia (OR = 1.20, P = 0.007).

Multivariate logistic regression analysis

All variables with P < 0.10 in bivariate logistic regression analyses were entered into the multivariate logistic regression analysis (Table 6). Compared to children 6 to 11 months of age, the risk of anemia among those 18 to 23 months of age decreased by 45% (OR = 0.55, P < 0.001). Compared to children with Han mothers, those with Miao mothers had a 1.23-fold increased risk of anemia (OR = 1.23, P = 0.044). Compared to children with Han fathers, those with Miao fathers had a 1.31-fold increased risk of anemia (OR = 1.31, P = 0.013) and those with Dong fathers had an 18% decreased risk (OR = 0.82, P = 0.047). Having diarrhea in the previous 2 weeks increased the risk of anemia 1.35-fold (OR = 1.35, P = 0.003).
Table 6

Multivariate regression analysis of anemia among children 6 to 23 months of age

Parameters

OR(95.0% C.I)

P

Sex

 Boys

1

 

 Girls

0.93(0.81,1.07)

0.317

Age

 6~ 11 months

1

 

 12~ 17 months

0.84(0.70,1.00)

0.053

 18~ 23 months

0.55(0.45,0.67)

< 0.001

Mother’s ethnicity

 Han

1

 

 Dong

0.83(0.67,1.02)

0.069

 Miao

1.23(1.01,1.51)

0.044

 Others

0.98(0.71,1.35)

0.894

Mother’s educational Level

 Primary

1

 

 Junior

0.97(0.75,1.25)

0.804

 Senior

1.03(0.77,1.39)

0.838

 University

0.84(0.54,1.29)

0.423

Mother’s occupation

 Homemakers

1

 

 Professionals

0.96(0.61,1.51)

0.866

 Commerce

1.02(0.70,1.48)

0.936

 Animal husbandry and fishery

1.46(1.16,1.83)

0.081

 Operators equipment

0.99(0.54,1.80)

0.967

 Others

0.84(0.63,1.11)

0.221

Father’s ethnicity

 Han

1

 

 Dong

0.82(0.67,1.00)

0.047

 Miao

1.31(1.06,1.61)

0.013

 Others

1.14(0.80,1.62)

0.475

Father’s educational level

 Primary

1

 

 Junior

0.85(0.65,1.13)

0.266

 Senior

0.86(0.63,1.18)

0.339

 University

0.79(0.52,1.19)

0.257

Father’s occupation

 Homemakers

1

 

 Professionals

1.23(0.89,1.68)

0.206

 Commerce

1.00(0.72,1.40)

0.980

 Animal husbandry and fishery

0.85(0.65,1.09)

0.198

 Operators equipment

0.95(0.68,1.33)

0.768

 Others

1.09(0.84,1.41)

0.512

Caregiver’s groups

 Mothers

1

 

 Fathers

0.56(0.25,1.24)

0.153

 Grandparents

0.86(0.72,1.02)

0.085

 Others

0.50(0.10,2.40)

0.386

Diarrhea in the previous 2 weeks

 No

1

   

 Yes

1.35(1.11,1.65)

0.003

Breastfeeding

 No

1

 

 Yes

1.50(1.26,1.80)

< 0.001

Consume sugary drink

 No

1

 

 Yes

0.95(0.82,1.10)

0.495

Consume infant formula and frequencies

 0

1

 

 1 to 2

0.72(0.61,0.85)

< 0.001

 3

0.70(0.56,0.87)

0.001

 4 or more

0.75(0.60,0.96)

0.020

Consume milk powder and frequencies

 0

1

 

 1 to 2

0.71(0.56,0.90)

0.005

 3

0.90(0.62,1.29)

0.556

 4 or more

0.74(0.48,1.14)

0.167

Consume nutrient sachet and frequencies

 0

1

 

 1 to 2

0.95(0.73,1.24)

0.697

 3

0.83(0.60,1.15)

0.270

 4 or more

0.70(0.61,0.82)

< 0.001

Is able identify the optimum timing of complementary feeding

 No

1

 

 Yes

1.15(1.01,1.32)

0.039

Children not breastfed in the past 24 h had a 1.50-fold greater risk of anemia than those breastfed (OR = 1.50, P < 0.001). Addition of milk powder once or twice in the previous 24 h decreased the risk of anemia by 29% (OR = 0.71, P = 0.005) compared to no addition of milk powder. Moreover, addition of infant formula once or twice, three times, and four or more times in the previous 24 h decreased the risk of anemia by 28, 30, and 25% compared to no addition of infant formula, respectively (OR = 0.72, 0.70, 0.75 and P < 0.001, 0.001, 0.020, respectively). Addition of a nutrient sachet four or more times in the previous week decreased the risk of anemia by 30% (OR = 0.70, P < 0.001) compared to no addition of a nutrient sachet. The risk of anemia for children whose caregivers were able to identify the optimum timing of complementary feeding was 1.15-fold higher than that of children whose caregivers were not (OR = 1.15, P = 0.039).

Discussion

Our findings revealed that almost 30% of children 6 to 23 months of age in Huaihua were anemic. The prevalence of anemia in our study is higher than the 4.54% of children under 2 years of age in Beijing [18], but lower than that in western rural areas of China (> 30%), such as 37.84% among children under 3 years of age in rural Tibet [19] and 64.7% among children 6 to 35 months of age in Yushu, Qinghai Province [20]. By contrast, the prevalence of anemia in children globally is 43%, and approximately 70% in Central and West Africa [21]. The burden of anemia in developed counties is much lower; 7–9% of children 1 to 3 years of age in the US [22] and 2–9% of children 6 to 39 months of age in Europe [23] are anemic.

In further analysis, the results show that mother and father of Miao ethnicity (OR = 1.23 and 1.31), diarrhea in the previous 2 weeks (OR = 1.35), breastfeeding in the prior 24 h (OR = 1.50), and caregivers able to identify the optimum timing of complementary feeding (OR = 1.15) had positive correlations with anemia. However, children aged 18 to 23 months (OR = 0.55), father of Dong ethnicity (OR = 0.82), addition of milk powder once or twice in the prior week (OR = 0.71), addition of infant formula once or twice, three times, and four or more times in the previous 24 h (OR = 0.72, 0.70, and 0.75), and addition of a nutrient sachet four or more times in the prior week (OR = 0.70) were negatively associated with anemia.

In our study, breastfeeding in the previous 24 h had a marked effect on the prevalence of anemia. A Chinese birth cohort study of the association between the duration of exclusive breastfeeding and infant anemia found that exclusive breastfeeding for 6 months was associated with an increased risk of anemia in infants 12 months of age [24]. The concentration of iron in human milk is relatively low, and so iron is supplied mainly from iron stores from birth until 6 months of age. However, iron stores are depleted after 6 months of age, the time at which iron demand increases because of rapid growth and development [25]. Therefore, the risk of anemia increases after 6 months of age in breastfed children; indeed, their risk is higher than that of children 18 to 23 months of age. Anemia in children 6 months of age is ameliorated by the intake of iron-rich foods, and their risk of anemia increases with age [19, 26].

Addition of milk powder or infant formula was associated with a decreased risk of anemia, likely because these have higher levels of minerals than breast milk. The production of powdered formulas was base on ordinary powdered, as iron has been added to powdered formulas to prevent anemia in recent decades [27].

Addition of a nutrient sachet four or more times in the previous week was significantly negatively associated with anemia. In rural areas of China, soybean powder-based micronutrient supplements (nutrient sachets) significantly reduced the burden of anemia among children 6 to 23 months of age. Consumption of four nutrient sachets weekly by infants is recommended in China. In this study, the risk of anemia in the 48.85% of the children who consumed a nutrient sachet four or more times weekly was 30% lower than that of those who did not consume any nutrient sachets. Zhouxun reported that the child’s age and ethnicity, the parents’ education and occupation, and adverse reactions to Yingyangbao were associated with taking Yingyangbao among children 6 to 23 months of age in poor rural areas of Hunan Province, China [28]. Therefore, provision of nutrient sachets reduced the burden of anemia among children in Huaihua; however, its implementation is unsatisfactory.

In this study, having parents of Miao ethnicity was associated with an increased risk of anemia, and a father of Dong ethnicity with a reduced risk of anemia. This is in agreement with several prior reports. For example, Luoyan reported that the prevalence of anemia in children of Kazakh ethnicity is higher than in those of Han ethnicity, which is likely due to the unique habitats and customs of minority ethnicities [29]. Therefore, health education in areas inhabited by minority ethnicities needs to be strengthened. In Yunnan Province, the risk of anemia among children of Li ethnicity is 1.9-fold greater than that of those of Han ethnicity due to Mediterranean anemia [30].

Of the children, 12.20 and 18.58% had experienced diarrhea and fever in the previous 2 weeks. Wuxiao-jian reported that the 2-week prevalence of diarrhea and fever among children less than 3 years of age is associated with socioeconomic status, healthcare during pregnancy and the puerperal period, and mothers’ knowledge of disease prevention [31]. Children with a history of diarrhea during the past 2 weeks were more likely to be anemic than children without diarrhea because of loss of appetite and malabsorption of nutrients in the intestine. Similar findings have been reported by studies conducted in Indonesia [32, 33].

The ability of the caregiver to identify the optimum timing of complementary feeding increased the risk of anemia in this study. Caregivers’ level of knowledge of nutrition and feeding may influence the feeding behavior of children [34, 35]. Although 44.20% of the caregivers were able identify the optimum timing of complementary feeding, only 5.06% were able identify to first complementary food which should be consumed by infants. A lack of knowledge of feeding practices among caregivers may explain the link between their ability to identify the optimum timing of complementary feeding and the risk of anemia.

This study had several limitations that should be taken into consideration. The cross-sectional design of this study prevents determination of the causality of the associations of factors with anemia. Further, the lack of information on family income, prenatal maternal anemia status, birth interval, and the timing of complementary feeding hampered analysis of the factors associated with anemia in children 6–23 months of age. However, this study involved 4500 children in a large geographic area (six regions of Huaihua), and considered caregivers’ knowledge of feeding practices and nutrition. Our findings clarify the prevalence and risk factors of anemia among children 6–23 months of age in Huaihua, and will facilitate the development of countermeasures to reduce the burden of anemia.

Conclusions

In conclusion, the prevalence of anemia among children 6 to 23 months of age in Huaihua was higher than that in more developed regions of China, and represents a considerable healthcare burden. The feeding practice of caregivers was associated with anemia. In addition, diarrhea, parents’ ethnicity, and caregivers’ level of knowledge of nutrition were associated with anemia. Therefore, nutrition improvement projects are needed to reduce the burden of anemia among children in Huaihua.

Abbreviations

AOR: 

Adjusted odds ratio

CI: 

Confidence interval

COR: 

Crude odds ratio

Declarations

Acknowledgements

We would like to thank maternal and child health care hospital of Yuangling, Mangyang, Xupu, Chenxi, Zhijiang, Huitong, Xinghuang to collected the data.

Funding

Self-funded.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Authors’ contributions

ZH, FJ and JL conceived the research idea. ZH collected the data, performed the statistical analyses and drafted the manuscript. TX, DJ and JZ participated in data acquisition, analysis, and reviewed the draft manuscript. FJ and JL provided the critical review of the manuscript. All authors approved the final version.

Ethics approval and consent to participate

Informed consent was signed by caregiver of children before the interview. The project was approved by Huaihua Women’s Federation and Municipal Commission of Health and Family Planning (No. 201563).

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

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Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Authors’ Affiliations

(1)
Hunan University of Medicine, No. 492 Jinxi South Road, Huaihua, 418000, Hunan, China
(2)
Huaihua Maternal and Child Health Care Hospital, Huaihua, China

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© The Author(s). 2018

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