Prevalence of anemia in pediatric patients of traumatic brain injury and problems associated with management in a developing country: Unfolding of an underrated comorbidity
- Medical Student, Wolfson School of Medicine, University of Glasgow, Glasgow, Scotland, United Kingdom,
- Department of Neurosurgery, Allama Iqbal Medical College, Jinnah Hospital Lahore, Lahore, Punjab, Pakistan.
Department of Neurosurgery, Allama Iqbal Medical College, Jinnah Hospital Lahore, Lahore, Punjab, Pakistan.
DOI:10.25259/SNI_944_2020Copyright: © 2020 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Mohammad Ashraf1,2, Usman Ahmad Kamboh2, Mohammad Zubair2, Kashif Ali Sultan2, Muhammad Asif Raza2, Syed Shahzad Hussain2, Naveed Ashraf2. Prevalence of anemia in pediatric patients of traumatic brain injury and problems associated with management in a developing country: Unfolding of an underrated comorbidity. 23-Feb-2021;12:75
How to cite this URL: Mohammad Ashraf1,2, Usman Ahmad Kamboh2, Mohammad Zubair2, Kashif Ali Sultan2, Muhammad Asif Raza2, Syed Shahzad Hussain2, Naveed Ashraf2. Prevalence of anemia in pediatric patients of traumatic brain injury and problems associated with management in a developing country: Unfolding of an underrated comorbidity. 23-Feb-2021;12:75. Available from: https://surgicalneurologyint.com/?post_type=surgicalint_articles&p=10610
Background: Pediatric anemia has a high prevalence in developing countries such as Pakistan. It is common knowledge among hospital specialties but little is done to manage this condition by hospitalists. The issue is compounded with a poor primary care infrastructure nationally. The aim of this study is to bring to light the high prevalence of anemic children in neurosurgery and to describe the difficulties in managing their anemia in a tertiary hospital setting. A literature review is presented highlighting the socioeconomic difficulties that contribute to this widespread comorbidity and the difficulty in managing it from a hospital specialty point of view.
Methods: A prospective descriptive case series was carried out between March 2020 and September 2020. All patients under the age of 13 who presented to our department for traumatic brain injury (TBI) meeting our inclusion and exclusion criteria were enrolled and assessed for the presence and severity of anemia. Demographic data were collected. Following discharge, patients were referred to our hospital’s pediatrics’ anemia clinic which was before their first neurosurgery follow-up 2 weeks following discharge and attendance to follow up was documented.
Results: The prevalence of anemia was 78.9%. Over 95% of patients attended their neurosurgery follow-up but only 28% of patients attended their referral to the anemia clinic.
Conclusion: Anemia is highly prevalent in children presenting to neurosurgery for TBI and its longitudinal management has difficulties with lost to follow up in a tertiary hospital setting. There is a need for national initiatives to reduce the prevalence of anemia but concurrently better strategies need to be devised to manage anemic children in a hospital setting.
Keywords: Anemia and traumatic brain injury, Anemia in children in a developing country, Anemia in children with traumatic brain injury, Anemia in pediatric neurosurgery patients, Pediatric anemia in a developing country
The primary health-care systems of developing countries are hard pressed and suffer from chronic disorganization, and a lack of consumer needs being adequately met by providers.[
Pakistan specifically has suffered numerous problems with its health infrastructure which amalgamated into a primary healthcare system that is virtually nonexistent with structural fragmentation, sparsity of resources, inaccessibility, and lack of gender sensitivity being contributing factors.[
One of the public health crises as a result of poor public and primary health-care systems along with general poverty in developing countries such as Pakistan is that of anemia, specifically in children, with a prevalence as high as 61% to nearly 80%.[
The aim of this study was to present the burden of anemia in pediatric patients who presented with TBI at our neurosurgery department and to discuss the peculiarities and hurdles faced from a health-care structural point of view in our efforts to treat their anemia.
In this prospective descriptive case series, following ethical review board approval, we followed all pediatric patients who presented to our Neurocritical Care department following head injury and met our inclusion and exclusion criteria. The study duration was between March 2020 and September 2020. During this period, eligible patients were enrolled within the study and assessed for the presence of anemia. Blood was drawn on admission following informed consent and anemic patients were graded for anemia severity according to the World Health Organization (WHO) anemia grading severity scale which is adjusted for difference age ranges.[
These appointments were before the patient’s neurosurgery outpatient follow-up which was 2 weeks following discharge. All information was entered and analyzed in Statistical Package for the Social Sciences version 27. The primary outcome was to describe the prevalence of anemia in pediatric patients presenting to neurosurgery for TBI. The secondary outcome was to provide an overview of the difficulties of treating anemia in children in a tertiary hospital setting.
All TBI patients aged 12 years or less, of both sexes, who presented within the study duration. Patients of whom TBI were managed conservatively. Parental consent to have blood drawn to assess for the presence of anemia in their child after informing them of the study rational, importance of managing anemia, and the possibility of having their child referred to an anemia clinic.
All TBI patients aged 12 years or less, of both sexes, who presented within the study duration.
Patients of whom TBI were managed conservatively.
Parental consent to have blood drawn to assess for the presence of anemia in their child after informing them of the study rational, importance of managing anemia, and the possibility of having their child referred to an anemia clinic.
The following criteria were excluded from the study:
All patients of polytrauma. Patients who underwent neurosurgical intervention. Patients with significant subgaleal hematoma requiring transfusion. Patients with any significant blood loss that could be a cause of anemia (no more than 300–400 ml) Patients of chronic anemia due to any underlying hemopathy whether known at the time of enrolment or at subsequent follow-up.
All patients of polytrauma.
Patients who underwent neurosurgical intervention.
Patients with significant subgaleal hematoma requiring transfusion.
Patients with any significant blood loss that could be a cause of anemia (no more than 300–400 ml)
Patients of chronic anemia due to any underlying hemopathy whether known at the time of enrolment or at subsequent follow-up.
A total of 120 children aged 12 or less presented to our Neurocritical Care department within the duration of the study. One hundred patients met our inclusion and exclusion criteria. Of these 100 patients, 10 did not participate in the study due to refusal of consent from their parents. Of the remaining 90, 71 patients had anemia. [
Patients who were admitted from the emergency department, to our Neurocritical Care Unit for head injury could have their injury classified into three groups. The majority had suffered a fall from a height (66.2%) followed by road traffic accidents (32.4%) with one patient suffering a cricket ball to the head injury. The majority of patients, 62%, had a mild TBI. The majority of the patients, 38 (53.5%), were mildly anemic but a substantial minority, 25 (35.2%), had moderate anemia. There were 8 patients (11.3%) with severe anemia. The prevalence of anemia was 78.9%.
Blood transfusions were only required by those who had severe anemia (8 patients). Of these, most patients required one transfusion except two patients, who required two transfusions each. About 96% of patients attended their follow-up appointment for neurosurgery but only 28% of patients attended their pediatrics outpatient follow-up appointment for the management of their anemia.
Anemia can be thought of as the reduction in mass of red blood cells leading them to be inefficient to meet the physiological needs of the body. It is a global problem which is a major public health concern, particularly in developing countries with Southeast Asia and Africa having the highest incidence worldwide.[
We know that in developing countries, major risk factors for anemia include poverty, poor personal hygiene, lack of sanitation, lack of awareness of anemia, poor nutritional intake, and unhealthy dietary choices, and poor maternal education.[
The problems with primary health care in Pakistan shed light on not only why anemia is so prevalent but also help in part to explain why the burden of this condition is lying with tertiary care hospital specialties such as neurosurgery and the difficulties associated with treating anemia from the point of view of a hospitalist who is not working in the community.
Primary health-care units exist as dispensaries and basic health units (BHU) in rural and peri-urban areas of Pakistan, but the services that they are able to provide are far from what would be considered a comprehensive primary health center.[
The problems with lost to follow up generally within longitudinal research are recognized in Pakistan.[
Most of the families in our cohort were from rural, villages, or tribal areas with poverty and low literacy rates, especially for females. At our own outpatient follow-up when probed about why parents did not choose to attend their child’s anemia appointment, the vast majority said that they did not feel a need to attend or did not believe it was of importance to treating their child’s anemia as per documented on the patient notes. This was despite being advised comprehensively of the long-term implications. Our assessment was that these parents did not feel that anemia was even affecting their child due to its’ asymptomatic nature. This is a cause of grave concern as chronic anemia has negative effects on linear growth during all stages of life from infancy to adolescence and infants are likely to develop delayed cognitive, motor, and affective development.[
The rational for studying TBI patients was 2-fold. First, the high incidence of TBI in Pakistan and at our center made it convenient a way to enroll children who would be eligible for the purpose of this study in a prospective manner. Our neurosurgery department is one of the referral centers for TBI that caters to the more than 12 million population of Lahore and surrounding rural villages and is referred a large volume due to the well equipped and advanced neuro-monitoring and critical care available. We are the only neurosurgery department in Pakistan, at the time of writing, to carry out Brain Micro-dialysis, and monitor ICP, ICPa and brain parenchymal oxygen and temperature. As a developing country, Pakistan with a population of 220 million has one of the highest incidences of TBI globally, 184/100,000, with a survey (n > 100,000) showing nearly one-third of patients suffered from TBI with about 10% having moderate-to-severe TBI.[
Second, TBI would serve as one example that would demonstrate in the literature how a national issue of widespread anemia prevalence in children should be recognized in neurosurgery as a cause of concern not only from a holistic point of view of child development but from the view of neurosurgical outcomes. There is evidence to say that anemia and correction with blood transfusions are associated with a poorer outcomes in adults with TBI.[
It is certain that national programs for iron supplementation and food fortification are required to bring the prevalence of iron deficiency anemia down nationally.[
We hope the data in our study bring to light the prevalence of anemia and highlight problems faced in addressing it from a neurosurgical/hospital-based specialty limelight which could serve as a foundation for future cohort studies to elucidate cause and effect between reasons for not attending anemia clinics. Then, we may be in a position to make guidelines on how to promote compliance, at tertiary hospital center level, of parents in treating their child’s anemia and giving the condition its due attention. However, these initiatives should not be a substitute for the long-term strategies to improve the nutrition status nationally.
Our study was a descriptive case series and a temporal and formal relationship between anemia, its risk factors, and reasons for not attending pediatric anemia clinic cannot be established. We lacked a detailed and systematic investigation into the reason’s patients did not attend their anemia clinic as assessment of poverty, rural living, and illiteracy was made subjectively by asking the parents regarding their education status, income, and their location of residence. Further studies should be done to see how neurosurgery, at a hospital-based specialty and cross-sectional level could play a role in reducing the burden of anemia in their patients as it is fundamental to a child’s development, can impact neurosurgical outcomes, and improve the socioeconomic outlook for these children.
Anemia has a high prevalence in children who present to neurosurgery for TBI. Parents are not giving due emphasis to the treatment of their child’s anemia and this needs to be improved. Food fortification programs and public health awareness measures need to be introduced nationally to reduce the prevalence of anemia.
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