From, Place : Bellary
Dr. Bharat kumar G.N Date : 24/11/2008
Post Graduate student in MD Pediatrics
Department of pediatrics
Vijayanagara Institute of Medical Sciences
Bellary
To,
The Principal
Vijayanagara Institute of Medical Sciences
Through proper channel
Respected Sir,
Subject : Submission and forwarding of synopsis for registration of dissertation topic
***
In accordance with subject cited above, I the undersigned studying in PG Course in MD-Pediatrics have been allotted the dissertation topic “The study of Severe anemia with respect to etiology, clinical features and hematological changes in infancy and childhood” in children admitted in VIMS/HQH Hospital, Bellary under the guidance of Dr. M. Lakshminarayana Reddy, Professor, department of Pediatrics, VIMS, Bellary.
I request you to kindly forward the dissertation topic in the prescribed form to the Registrar Rajiv Gandhi University of Health Sciences Bangalore, Karnataka for Approval.
Thanking You,
Signature of guide
DR. M. LAKSHMINARAYANA REDDY
Professor Dept. of Pediatrics, Yours faithfully
VIMS, Bellary
Signature of co-guide DR.BHARAT KUMAR.G.N
DR. C.BHARATH
Professor Dept. of Pathology,
VIMS, Bellary
From, Place : Bellary
The Professor and Head, Date : 24 /11/2008
Department of Pediatrics,
Vijayanagara Institute of Medical Sciences,
Bellary
To,
The Registrar,
Rajiv Gandhi University of Health Sciences,
Bangalore
Through Proper Channel
Respected Sir,
As per the regulations of the University for registration of Dissertation Topic, the following Post Graduate student in MD-Pediatrics has been allotted the dissertation topic as follows by the official registration committee of all qualified and eligible guides of the department of Pediatrics.
Name / Topic / GuideDr. Bharat kumar G.N
Post Graduate student in MD Pediatrics
Department of pediatrics
VIMS Bellary / “The study of Severe anemia with respect to etiology, clinical features and hematological changes in infancy and childhood” / DR. M. LAKSHMINARAYANA REDDY
Professor Dept. of Pediatrics,
VIMS, Bellary
Therefore, I kindly request you to communicate the acceptance of the dissertation topic allotted to the PG student at an early date.
Thanking you,
Signature of guideDR. M. LAKSHMINARAYANA REDDY
Professor, Dept. of Pediatrics,
VIMS, Bellary / Yours faithfully
Dr. VEERA SHANKAR.M
Professor and Head,
Dept. of Pediatrics,
VIMS, Bellary
6
6.1 / Brief Resume of the Intended Work
NEED FOR THE STUDY
Anaemia is one of the leading causes of morbidity and mortality in Pediatric age group.
In India about 70 million children i.e., 60%-70% of all children below 6 years suffer from varying degrees of anaemia1.
Iron Deficiency Anaemia is a major health problem in children. As much as 51% of children in 0-4 years and 46% of children of 5-12 years are anaemic in developing countries2.
Studies by G.C. Bothra et. al. 1969 and R.G. Goel et. al. 1981, showed Nutritional anaemia followed by hemolytic anaemias to be the main cause for severe anaemia3.
Malaria remains as a leading cause of mortality and morbidity. Severe malaria presents most frequently as severe anaemia in children less than 5 years4.
Certain Endocrine disorders like hypothyroidism present with microcytic hypochromic anaemia which is unresponsive to therapy with Iron, Vit B12 or Folic acid5.
Leukemias account for about 41% of all childhood malignancies, of which ALL accounts for 77% of childhood leukemias which present with anaemia and thrombocytopenia6a.
Anaemia in young children is associated with impairment of cognitive performance, behavioral and motor development, co-ordination, language development, Immune competence, learning ability and scholastic achievement7.
Since most of the childhood anaemias are preventable and treated easily, early identification and appropriate treatment helps in normal, physical and mental growth.
The present study is done to know the causative factors, clinical manifestations, various hematological and morphological types in children with severe anaemia so that the problem can be tackled in a better way and steps can be taken to minimise the suffering of the children.
6.2 / REVIEW OF LITRATURE
Definition: Anaemia is defined as reduction of RBC volume or Hemoglobin concentration below the range of values occurring in healthy persons6b.
According to WHO, anaemia is diagnosed if Hb% is <11 gms/dl in children of 6 months to 6 years age group and Hb% is < 12 gms/dl in children of 6 years to 14 years age group8.
Anaemia is graded as mild if Hb% is above 10 gms/dl and below the normal range for age & sex, moderate if Hb% is 7-10 gms/dl, severe if Hb% is < 7 gms/dl8.
Iron Deficiency Anaemia is the most wide spread micronutrient deficiency in our country1b.
Recent evidences suggest that severe Iron deficiency anaemia during first 2 years of life, when the brain is still developing may cause permanent neurological damage7.
Iron is absorbed 2-3 times more efficiently from human milk than from cows milk. During the first year of life, small amounts of iron rich foods are eaten, hence there is a high incidence of iron deficiency. Infants breast fed exclusively should receive iron supplementation from 4 months of age6c.
The term megaloblastic anaemia is used to describe a group of clinical states characterised by a distinct morphological pattern in hematopoietic cells in the form of aregenerative macrocytic anaemia with nuclear dysmaturity. The most common causes of megaloblastosis are true cellular deficiencies of Vit B12 or folate, both being essential cofactors for DNA synthesis9a.
Thalassemia is due to reduction or absence of synthesis of one of the globin chains. Hemoglobinopathies are genetic defects resulting in abnormal structure or function of the hemoglobin molecule9b.
In children hemolytic anaemia is usually caused by intrinsic red cell defect leading to hemolysis and anaemia as seen typically in membranopathy or red cell enzymopathy and most of these are inherited in nature. At times hemolytic anaemia can result due to factors extrinsic to red cell and most of these causes are acquired in nature. Autoimmune hemolytic anaemia is one such cause resulting from interaction of red cell with the immune system. It is characterised by shortened red cell life, hemolysis and anaemia. It is caused by autoantibody to red cell antigens9c.
Bone marrow failure syndrome is a rare but potentially fatal hemotoligical disorder associated with pancytopenia and hypocullular bone marrow in the absence of abnormal infiltrate and no increase in reticulin9d.
Anaemia of chronic disease presents as normocytic, normochromic anaemia9e.
Studies by S.S.Manchand et.al 1961 shows that highest incidence of anaemia was present in children less than 3 years i.e., 51.42%10.
Studies by M.M.Kumbhat et.al 1959 showed that the male to female ratio of anaemia was 1.5:111.
Studies by Seema Jain et. al. 2000 showed that of the anaemia children studies 24.3% had severe anaemia. Prevalence was high in children with low nutrition status i.e. 84.3%12.
6.3 / OBJECTIVES OF THE STUDY
The present study undertaken,
1. To study the age and sex distribution of severe anaemia (Hb less than or equal to 7 gms/dl)
2. To study the etiology of severe anaemia.
3. To study hematological changes in severe anaemia.
4. To study the clinical presentation of anaemia in children.
7
7.1
7.2
7.3
7.4 / MATERIALS AND METHODS
Source of Data:
This study will be conducted in 100 children who are admitted with severe anaemia in pediatric wards of VIMS/HQH Hospital, Bellary prospectively during the period from December 2008 to December 2009.
Method of collection of data (including sampling procedure if any)
All children with Hb% less than 7 gms/dl at the time of admission will be included in the study. A detailed clinical evaluation (history and physical examination) and relevant laboratory investigations will be done for all subjects as per the proforma.
INCLUSION CRITERIA
All children with Hb% < 7 gms/dl and in the age group of 1 month to 12 years are included in the study.
EXCLUSION CRETERIA
1) Neonates < 1 month
2) Children > 12 years
3) Anaemia due to acute blood loss secondary to trauma
4) All patients who have received blood transfusion within the last four weeks.
Investigation to be done
1. Hb% estimation, Hematocrit, RBC Indices – MCV, MCH, MCHC, RDW and WBC count, differential count and platelet count by Micros 60 auto analyser
2. Peripheral smear examination by leishman’s stain
3. Reticulocyte count by New methylene blue staining
4. Stool examination
5. Urine examination
6. Mantoux test
7. Radiological investigations like X-ray, USG abdomen, CT Scan in relevant cases.
8. Serum Ferritin in relevant cases
9. Hb electrophoresis in relevant cases
10. Bone marrow examination in relevant cases
11. Liver function tests, Renal function tests in relevant cases
Does the study require any investigations or interventions or interventions to be conducted on patients or other humans or animals? If so please describe briefly.
Yes the above investigations are done routinely in our hospital, no interventions are done.
Has Ethical clearance obtained from Your Institution in Case of 7.3?
Yes ethical clearance has been obtained from the VIMS Institutional ethics Committee, Bellary
8 / LIST OF REFERENCES
1. (a) Deeksha Kapur et.al. Nutritional anaemias and its control, Indian Journal of Pediatrics Vol. 69 July-2002 Page 607. (b) Umesh Kapil Ed, Status of micronutrient malnutrition in India and intervention strategies to combat them, Indian Journal of Pediatrics Vol. 69 July-2002 page 585
2. Sharada B. Iron Deficieny and Iron deficiency anaemia. Recent advances in Pediatrics 1st Edition 1995:5:205.
3. Bothra G.C. and J.B.Mehta, Severe anaemia in children below 2 years. Indian Pediatrics 1969.
4. Meherban singh medical emergencies in children 4th edition page 308.
5. Ernest Beutler, Marshal A. Lichtman, Barry S. Coller, Thomas J. Kipps, Uri Seligsohn, Williams hematology, 6th edition. Mcgrawhill 2001, page 407.
6. Kleigman, Behrman, Jenson, Stanton. Nelson Text Book Of Pediatrics 18th Edition volume 2 Saunders Elsevier (a) Page 2116-2118 (b) Page 2003 (c) Page 2015
7. Indian Journal of Pediatrics Volume 69 July-2002 Page-586.
8. Sachdev HPS, Panna chandhary, Nutrition in children: Developing country concerns Reprint 1st Edition 1995.
9. Dr. M.R. Lokeshwara, Dr. Nitin K. Shah, Dr. Bharat Agarwal, Dr Anupam Sachdeva. Ed. Indian Academy of Pediatrics. IAP Specialty Series on Pediatric Hematology and Oncology (Under IAP President Action Plan 2006) (a) Page No. 36, (b) Page No. 43, (c) Page No.117, (d) Page No. 124, (e) Page No. 267.
10. Manchanda .S.S. and H.L. Khanna, Severe anaemias in children, Indian Journal of Child Health 1962 : 11: 468.
11. Kumabhat M.M. Anaemias in Infancy and childhood. Indian journal of Child Health 1959: 8: 113.
12. Seema Jain. et. al. Indian Journal of Pediatrics 2000 Volume 67 Page 19.
9 / SIGNATURE OF THE CANDIDATE
10 / REMARKS OF THE GUIDE / Recommended And Forwarded
11 / NAME OF THE DISIGNATION OF
11.1 GUIDE / DR. M. LAKSHMINARAYANA REDDY
Professor Dept. of Pediatrics,
VIMS, Bellary
11.2 SIGNATURE
11.3 CO-GUIDE (IF ANY) / DR. C.BHARATH
Professor Dept. of Pathology,
VIMS, Bellary
11.4 SIGNATURE
11.5 HEAD OF THE DEPARTMENT / DR. VEERASHANKAR.M
Professor and Head,
Dept. of Pediatrics,
VIMS, Bellary
11.6 SIGNATURE
12 / 12.1 REMARKS OF THE CHAIRMAN AND PRINCIPAL
12.2 SIGNATURE