literature review on nutritional anemia

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• Published: 19 February 2019

A systematic literature review of the relation between iron status/anemia in pregnancy and offspring neurodevelopment

• Janet Janbek 1 , 2 ,
• Mahesh Sarki 1 ,
• Ina O. Specht 1 &
• Berit L. Heitmann 1 , 2  

European Journal of Clinical Nutrition volume  73 ,  pages 1561–1578 ( 2019 ) Cite this article

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• Cognitive neuroscience
• Epidemiology

The fetal brain starts developing early and animal studies have suggested that iron plays several roles for the development, but results from epidemiological studies investigating associations between gestational iron and offspring neurodevelopment are inconsistent.

To systematically examine results from observational studies and RCTs on gestational iron and offspring neurodevelopment, with focus on the importance of four domains: iron status indicators, exposure timing, neurodevelopmental outcomes, and offspring age.

PRISMA guidelines were followed. Embase, PsychInfo, Scopus, and The Cochrane library were searched in September 2017 and February 2018. Overall, 3307 articles were identified and 108 retrieved for full-text assessment. Pre-specified eligibility criteria were used to select studies and 27 articles were included;19 observational and 8 RCTs.

Iron status in pregnancy was associated with offspring behavior, cognition, and academic achievement. The direction of associations with behavioral outcomes were unclear and the conclusions related to cognition and academic achievement were based on few studies, only. Little evidence was found for associations with motor development. Observed associations were shown to persist beyond infancy into adolescence, and results depended on iron status indicator type but not on the timing of exposure.

We conclude that there is some evidence that low pregnancy iron, possibly particularly in the 3rd trimester, may be associated with adverse offspring neurodevelopment. As most previous research used Hemoglobin, inferring results to iron deficiency should be done with caution. No conclusions could be reached regarding associations beyond early childhood, and supplementation with iron during pregnancy did not seem to influence offspring neurodevelopment.

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Acknowledgements

We acknowledge the contribution of the statistician Volkert Siersma from the University of Copenhagen to our work through providing statistical help and Gabriel Gulis from the University of Southern Denmark for supervising the writing process.

Twelve months of under-graduate research stipend was received from the Lundbeck Foundation.

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JJ, IOS, and BLH were responsible for project conception and developed the overall research plan. JJ and MS conducted the search. JJ analyzed data. JJ, IOS, and BLH wrote the paper. JJ had primary responsibility for final content. All authors read and approved the final manuscript.

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Janbek, J., Sarki, M., Specht, I.O. et al. A systematic literature review of the relation between iron status/anemia in pregnancy and offspring neurodevelopment. Eur J Clin Nutr 73 , 1561–1578 (2019). https://doi.org/10.1038/s41430-019-0400-6

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Received : 30 July 2018

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Accepted : 17 January 2019

Published : 19 February 2019

Issue Date : December 2019

DOI : https://doi.org/10.1038/s41430-019-0400-6

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SYSTEMATIC REVIEW article

Nutritional factors for anemia in pregnancy: a systematic review with meta-analysis.

• 1 Department of Obstetrics, Kunming City Maternal and Child Health Hospital, Kunming, China
• 2 Kunming Municipal Service Center for Maternal and Child Health, Kunming, China
• 3 Kunming Children's Hospital, Kunming, China
• 4 Department of Pharmacy, Children's Hospital of Kunming Medical University, Kunming, China

Background: Anemia in pregnancy is a serious threat to maternal and child health and is a major public health problem. However, the risk factors associated with its incidence are unclear and controversial.

Methods: PubMed, Ovid Embase, Web of Science, and Cochrane databases were systematically searched (inception to June 27, 2022). The screening of search results, extraction of relevant data, and evaluation of study quality were performed independently by two reviewers.

Results: A total of 51 studies of high quality (NOS score ≥ 7) were included, including 42 cross-sectional studies, six case-control studies, and three cohort studies. Meta-analysis showed that infected parasite, history of malarial attack, tea/coffee after meals, meal frequency ≤ 2 times per day, frequency of eating meat ≤ 1 time per week, frequency of eating vegetables ≤ 3 times per week, multiple pregnancies, multiparous, low household income, no antenatal care, rural residence, diet diversity score ≤ 3, have more than 3 children, history of menorrhagia, underweight, family size ≥ 5, middle upper arm circumference < 23, second trimester, third trimester, birth interval ≤ 2 year were all risk factors for anemia in pregnancy.

Conclusions: Prevention of anemia in pregnancy is essential to promote maternal and child health. Sufficient attention should be paid to the above risk factors from the social level and pregnant women's own aspects to reduce the occurrence of anemia in pregnancy.

Systematic review registration: https://www.crd.york.ac.uk/prospero/ , identifier: CRD42022344937.

As a global public health problem, anemia in pregnancy has been shown to be an independent risk factor for adverse maternal and infant outcomes such as blood transfusion, postpartum hemorrhage, cesarean section, hysterectomy, preterm birth, and infectious diseases ( 1 ). It directly threatens the health of about 32 million pregnant women around the world. Especially in developing countries, 56% of pregnant women are affected by it ( 2 , 3 ). Anemia in pregnancy is a global concern as it impairs physical health, cognitive development, productivity, and reflects lagging economic status ( 2 , 4 ). Improving anemia in pregnancy is essential to reduce maternal and infant mortality and serious complications. Unfortunately, even though extensive studies have been conducted over the past 20 years and various national nutrition programs have been implemented to reduce anemia in pregnancy, there has not been much success in eliminating anemia in pregnancy, and it remains a major public health problem ( 4 , 5 ).

It is critical to explore the risk factors that may cause anemia in pregnancy and take preventive strategies as soon as possible. However, the risk factors for anemia in pregnancy are controversial. For example, the findings of Kedir et al. suggest that parasite infection is not a risk factor for anemia in pregnancy ( 6 ). However, other studies in the same area identified parasitic infection as a risk factor for anemia in pregnancy ( 7 , 8 ). It has also been shown that tea/coffee after meals is not a risk factor for anemia in pregnancy (AOR = 1.03, 95% CI: 0.88–2.06) ( 9 ), but the results of Teshome et al. showed a very significant association between tea/coffee after meals and anemia in pregnancy (AOR = 18.49, 95% CI: 6.89–40) ( 10 ). In addition, iron deficiency is considered to be the most common cause of anemia in pregnancy, therefore, most studies recommend that pregnant women should take adequate iron supplements to prevent anemia in pregnancy ( 11 , 12 ). On the contrary, some studies have shown that iron supplementation did not reduce the incidence of anemia in pregnancy ( 13 , 14 ). Some studies have even concluded that even without iron supplementation during pregnancy, the incidence of anemia in pregnant women is not significantly higher ( 15 ). In conclusion, disparate findings on the same exposure factors pose an obstacle to the prevention of anemia in pregnancy and further public health decisions.

The current field lacks definitive evidence on the risk factors for anemia in pregnancy. Therefore, as the first study to systematically summarize the risk factors of anemia in pregnancy, the results of this study can provide a reference for the prevention and treatment of anemia in pregnancy in the future.

This systematic review and meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines ( 16 ). The review protocol has been registered with PROSPERO, number CRD42022344937 ( https://www.crd.york.ac.uk/prospero/ ).

Inclusion and exclusion criteria

Patients and diseases (p).

Pregnant women.

Interventions (I)

Report at least one exposure factor associated with anemia in pregnancy.

Control (C)

Studies where adjusted odds ratio (AOR) for exposure factors were available or calculated.

Outcome (O)

Anemia in pregnancy occurs. The diagnostic criteria are hemoglobin ≤ 11 g/dL.

Type of study (S)

Cross-sectional studies, case-control studies, and cohort studies.

Exclusion criteria

Animal studies and cell experiments were excluded. Reviews, case reports, opinion articles, conference abstracts, and non-published data were also excluded.

Data sources and searches

Candidate studies were identified through searches of the PubMed, Web of Science, Cochrane, and Ovid Embase databases from inception until June 27, 2022. Also, the reference lists of the included studies were searched. The retrieval approach of the combination of free words and subject words was adopted. The following terms were combined to generate search keywords: [gestational anemia OR anemia in pregnancy OR (pregnancy OR pregnant OR gestation) AND anemia] AND (hazard OR risk factors OR risk factor OR related factors OR factors OR influence factors OR influencing factors). Further details of the search strategy are shown in Supplementary Table 1 .

Data extraction and risk of bias assessment

Literature screening and data extraction were performed by 2 trained researchers according to the inclusion and exclusion criteria as indicated previously. Extracted content includes: (1) Basic information of included studies: authors, year, country, type of study, sample size, age, method of obtaining information, diagnostic criteria for anemia, and data analysis methods. (2) Exposure factors: Risk factors related to dietary habits, self-condition, and disease history of pregnant women. (3) Key elements of risk of bias assessment.

Based on the Newcastle-Ottawa Scale (NOS), two qualified researchers independently evaluated the inherent risk of bias of included studies from three aspects, including the selection of participants, confounding variables, and measurement of exposure ( 17 ). The evaluation results were scored as low, medium, and high quality, respectively, with scores of 0–3, 4–6, and 7–9.

Statistical analysis

Statistical analysis was performed using STATA 16 software. Results were calculated using adjusted odds ratio (AOR) and 95% confidence interval (95% CI). The χ 2 test was used to evaluate the heterogeneity of the included studies (the test level was α = 0.05), and the size of the heterogeneity was judged according to the I 2 value. When P > 0.05 and I 2 ≤ 50%, it indicated that the heterogeneity of the results of each study was not statistically significant, and a fixed-effects model was used for meta-analysis; otherwise, after further analysis of the source of heterogeneity, a random-effects model was used.

Literature screening results

A total of 4,638 relevant records were obtained from the initial inspection, which were excluded from repeated studies, non-risk factor studies (prevalence, diagnosis, and treatment of anemia in pregnancy), pregnant women without anemia (postpartum anemia, women of childbearing age) and study types that are not consistent (review, conference summary, case report, etc.), 51 studies were finally included. The article screening process is shown in Figure 1 .

Figure 1 . Flow diagram for study inclusion.

Basic information and risk of bias assessment of included studies

A total of 51 studies were included ( 6 – 10 , 13 – 15 , 18 – 60 ), including 42 cross-sectional studies ( 6 – 9 , 13 – 15 , 18 – 29 , 31 – 37 , 39 – 43 , 45 , 47 – 49 , 51 , 53 , 54 , 56 – 58 , 60 ), six case-control studies ( 10 , 30 , 38 , 50 , 52 , 55 ), and three cohort studies ( 44 , 46 , 59 ). The entire population was from developing countries, and 36 study sites were in Ethiopia ( 6 – 10 , 13 – 15 , 18 – 20 , 23 , 26 – 31 , 34 – 43 , 50 , 52 , 55 – 60 ). The total number of patients was 73,919 and in individual study ranged from 163 ( 49 )−12,403 ( 53 ). The patients were aged between 15 and 49 years ( 40 ). Information was obtained through structured questionnaires ( 6 – 10 , 13 – 15 , 18 – 39 , 41 – 45 , 47 – 50 , 52 – 56 , 59 , 60 ), outpatient medical record data ( 40 , 46 , 51 , 58 ), and databases ( 57 ). The diagnostic criteria for anemia were hemoglobin < 11 g/dL, and the statistical analysis methods were multivariable logistic regression. See Table 1 for details.

Table 1 . Basic information of included studies.

The NOS scores of the 51 included studies were all ≥ 7 points, of which 38 studies had a NOS score of 8 points, and 13 studies had 7 points, indicating that the included studies had high research quality. See Supplementary Table 2 for details.

Meta-analysis results

Exposure factors associated with maternal medical history.

A total of four exposure factors associated with medical history may contribute to anemia in pregnancy. Since I 2 = 0, P > 0.05, indicating that there is little possibility of heterogeneity among the studies, a fixed-effect model was used for combined analysis. Meta-analysis showed that parasitic infection (AOR = 2.20, 95% CI: 1.63–2.76) and history of malarial attack (AOR = 2.86, 95% CI: 1.98–3.73) were risk factors for anemia in pregnancy, while HIV status (AOR = 1.36, 95% CI: 0.97–1.75) and abortion history (AOR = 1.05, 95% CI: 0.47–1.63) were not associated with anemia in pregnancy ( Figure 2 ).

Figure 2 . Exposure factors associated with maternal medical history.

Exposure factors associated with dietary habits of pregnant women

A total of eight exposure factors related to dietary habits may contribute to anemia in pregnancy. The fixed effect model was used to analyze the exposure factors of I 2 < 50%. The results showed that tea/coffee after meals, meal frequency ≤ 2 times per day, frequency of eating meat ≤ 1 time per week, diet diversity score ≤ 3 were risk factors for anemia in pregnancy. Iron supplementation was a protective factor for anemia in pregnancy ( Table 2 ). Meta-analysis of the potential risk factors for I 2 > 50 % using a random effect model showed that frequency of eating vegetables ≤ 3 times per week was a risk factor for anemia in pregnancy, while no iron supplementation and drinking were not associated with anemia in pregnancy ( Table 2 ).

Table 2 . Exposure factors associated with dietary habits of pregnant women.

Exposure factors associated with maternal conditions

A total of 20 exposure factors associated with maternal conditions may contribute to anemia in pregnancy. Multiple pregnancies, multiparous, low household income, no antenatal care, rural residence, have more than 3 children, history of menorrhagia, underweight, family size ≥ 5, middle upper arm circumference < 23, second trimester, third trimester, and birth interval ≤ 2 year were all risk factors for anemia in pregnancy. Overweight was a protective factor, and the remaining exposure factors were not associated with anemia in pregnancy ( Table 3 ).

Table 3 . Exposure factors associated with maternal conditions.

Publication bias

Funnel plots were drawn for exposure factors with more than 10 studies to detect publication bias. The results showed that the funnel plots were basically symmetrical, suggesting a small possibility of publication bias ( Figure 3 ).

Figure 3 . Results of publication bias. (A–I) Funnel plots of exposure factors with more than 10 studies.

Summary of evidence related to maternal medical history

Due to poverty, lack of safe drinking water, poor hygiene, and malnutrition, combined with the immunomodulatory and physiological changes that occur during pregnancy, pregnant women are often more vulnerable than non-pregnant women to intestinal parasite invasion, especially in developing countries ( 61 ). More than 7 million pregnant women worldwide are infected with hookworm, and 10 million pregnant women in Africa are infected with schistosomiasis ( 62 , 63 ). Parasites entering the gut can attach to the mucosa and submucosa of the small intestine, destroy capillaries and arterioles and feed on the exuding blood ( 64 ). Our findings suggest that parasitic infection is one of the risk factors for anemia in pregnancy. This finding is consistent with the study conducted by Alem et al. ( 65 ). In developing countries, infection of young women, pregnant women, and their infants with intestinal parasites, especially hookworms, can lead to deficiencies in iron, total energy, protein, and folic acid and zinc, leading to low birth weight, intrauterine growth retardation, and higher morbidity and mortality of anemia in pregnancy ( 58 ). Moreover, as another common risk factor, infection with malaria is also susceptible to anemia in pregnancy. Notably, studies on malaria have come from both Ethiopia and Ghana. Their geographical location in the tropics has an important impact on the distribution of malaria. Sequestration of plasmodium in the placenta avoids spleen clearance, thereby predisposing pregnant women to malaria. Malaria causes anemia in a variety of ways, including excessive depletion of non-parasitic red blood cells, immune destruction of parasitic red blood cells, and impaired erythropoiesis due to bone marrow dysfunction ( 66 , 67 ). Other studies have shown that pregnant women infected with HIV are more likely to develop anemia than those who are not infected with HIV ( 41 ). This may be due to the properties of the virus that lead to increased metabolic and nutritional requirements and directly inhibit the production of red blood cells in the body ( 68 ). Although our meta-analysis showed no significant association between HIV infection and anemia in pregnancy. However, the lower limit of confidence interval of our results is close to 1, suggesting to some extent the correlation between HIV infection and anemia in pregnancy.

Summary of evidence related to maternal status

Previous study has shown that the risk of anemia in pregnancy increases with the number of births. The risk of developing anemia in pregnancy was nearly 3 times higher for women with 2–3 children and 4 times higher for women with 4 or more children compared to only one child ( 69 , 70 ). This is because pregnant women do not have enough time to recover from the nutritional burden of their previous pregnancy, especially folic acid, and iron deficiency. Maternal serum and erythrocyte folate concentrations also decline from the fifth month of pregnancy and remain low for a considerable time after delivery ( 6 ). The same is true for our combined analysis of 12 studies, finding that women with more than 3 children were more likely to develop anemia in pregnancy. In addition, multiple pregnancies, multiparous, and birth interval ≤ 2 years are also risk factors for anemia in pregnancy. Like the reasons for having more children, these factors lead to impaired iron stores in pregnant women, and to a certain extent, they impair the normal physiological functions and anatomical structures of pregnant women. Studies have shown that during pregnancy, the incidence of anemia increases more than 4 times from the first trimester to the third trimester, and the prevalence in the third trimester is as high as 30–45% ( 71 ). This is consistent with our findings that early pregnancy is less prone to anemia, whereas second and third trimesters are significantly associated with anemia. It may be related to the rapid growth of the fetus in the second and third trimesters and the significant increase in the demand for nutrients such as iron ( 72 ).

According to the World Health Organization, anemia in pregnancy is more prevalent in developing countries, such as Africa and Southeast Asia, where dietary diversity, living standards, and education levels are all poorer ( 73 ). In addition, lack of knowledge about anemia, infrequent antenatal check-ups, and unplanned pregnancies naturally lead to more threats of anemia in local pregnant women ( 74 ). As our study shows, 51 studies are from developing countries, especially Ethiopia, Ghana, and other countries. Also, low household income, no antenatal care, rural residence, underweight, middle upper arm circumference < 23, and illiteracy are all risk factors for anemia in pregnancy. Although unplanned pregnancy and lack of understanding of anemia were not statistically associated with anemia in pregnancy. However, according to the OR value of more than 1, and the lower limit of the 95% confidence interval close to 1, it is suggested that these two exposure factors are related to anemia in pregnancy to a certain extent.

Summary of evidence related to dietary habits in pregnant women

In fact, the most common cause of anemia in pregnancy is iron deficiency, while other causes are rare ( 2 ). Although our study shows that lack of iron supplementation during pregnancy is not associated with anemia, the likely reason is that pregnant women obtain adequate iron intake through other means such as diet. However, our study also shows that iron supplementation is a protective factor in reducing the occurrence of anemia. This fully illustrates the importance of ingesting or supplementing adequate iron during pregnancy. Adequate intake of macro- and micronutrients, quantity and variety of diets is a challenge in many countries, especially developing ones ( 75 , 76 ). After combined analysis of exposure factors related to dietary habits of pregnant women, we found that meal frequency ≤ 2 times per day, frequency of eating meat ≤ 1 time per week, tea/coffee after meals, diet diversity score ≤ 3, frequency of eating vegetables ≤ 3 times per week were all risk factor for anemia in pregnancy. This is consistent with the findings of Roess et al. Tea and coffee contain compounds that affect iron absorption such as tannins and polyphenol, meat is a good source of heme iron and protein of high biological value, and fruits rich in ascorbic acid can enhance iron absorption ( 77 ). Therefore, eating less or not eating meat and fruits will also lead to insufficient iron intake, which will eventually lead to the occurrence of anemia ( 78 , 79 ). In addition, vegetables are a food source of folic acid, and folic acid deficiency is associated with anemia in pregnancy ( 80 ).

Although anemia in pregnancy is a global public health problem, we must acknowledge that anemia in pregnancy often differs between developed and developing countries and is one of the distinct health disparities between developed and developing countries ( 81 ). The prevalence of anemia in pregnancy in developing countries ranged between 53.8 and 90.2%, compared with 8.3% in developed countries ( 82 ). There are many factors that contribute to this difference. Compared with developed countries, medical resources are scarce in developing countries, pregnant women are less likely to receive adequate or quality health care, and they are at higher risk of exposure to diseases such as malaria and parasitic infections that cause anemia in pregnancy ( 83 ). Although we conducted a comprehensive search of current mainstream databases, the studies we included were all from developing countries, and evidence from developed countries was lacking. Therefore, our findings are only applicable to developing countries. More findings from developed countries are needed in the future to provide a global picture of risk factors for anemia in pregnancy.

Strengths and limitations

Strengths: (1) As the first study in the current field to systematically summarize the risk factors of anemia in pregnancy, this study may serve as the best evidence for the prevention of anemia in pregnancy in the future. (2) This study was based on AOR rather than OR analysis, avoiding the interaction between multiple exposure factors, and the results were more in line with the actual situation. (3) According to the NOS scoring results, we found that the quality of evidence of the 51 included studies was high, which ensured the reliability of the meta-analysis results.

Limitations: (1) The included studies were all from developing countries, especially Ethiopia, therefore, our findings are only applicable to some countries, not all countries. (2) Include only English literature, which may lead to language bias. (3) The gray literature and conference abstracts were not searched, which may lead to publication bias.

Conclusions

The high incidence and serious harm of anemia in pregnancy make it urgent to systematically summarize its risk factors. Evidence from 51 high-quality studies showing infected parasite, history of malarial attack, tea/coffee after meals, meal frequency ≤ 2 times per day, frequency of eating meat ≤ 1 time per week, frequency of eating vegetables ≤ 3 times per week, multiple pregnancies, multiparous, low household income, no antenatal care, rural residence, diet diversity score ≤ 3, have more than 3 children, history of menorrhagia, underweight, family size ≥ 5, middle upper arm circumference < 23, second trimester, third trimester, birth interval ≤ 2 year, these 20 exposure factors were all risk factors for Anemia in Pregnancy. Therefore, health institutions and pregnant women themselves should focus on the above risk factors for better prevention and early detection of anemia in pregnancy.

Data availability statement

The original contributions presented in the study are included in the article/ Supplementary material , further inquiries can be directed to the corresponding author/s.

Author contributions

YSu proposed ideas and designed protocol. JZ and QL were responsible for data analysis and writing of the paper. YSo, LF, and LH were responsible for literature screening, data extraction, and quality evaluation. All authors contributed to the article and approved the submitted version.

We acknowledge the financial support from Kunming Health Science and Technology Personnel Training Project (No. 2022-SW-93).

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Supplementary material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpubh.2022.1041136/full#supplementary-material

Abbreviations

PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses; AOR, adjusted odds ratio; NOS, Newcastle-Ottawa Scale.

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Keywords: anemia, pregnancy, systematic review, nutritional factors, evidence

Citation: Zhang J, Li Q, Song Y, Fang L, Huang L and Sun Y (2022) Nutritional factors for anemia in pregnancy: A systematic review with meta-analysis. Front. Public Health 10:1041136. doi: 10.3389/fpubh.2022.1041136

Received: 10 September 2022; Accepted: 26 September 2022; Published: 14 October 2022.

Reviewed by:

Copyright © 2022 Zhang, Li, Song, Fang, Huang and Sun. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Yu Sun, sunyu527826568@126.com

† These authors have contributed equally to this work and share first authorship

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

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Diagnosis, Treatment and Prevention of Nutritional Anemia in Children: Recommendations of the Joint Committee of Pediatric Hematology-Oncology Chapter and Pediatric and Adolescent Nutrition Society of the Indian Academy of Pediatrics

Recommendations.

• Published: 03 November 2022
• Volume 59 , pages 782–801, ( 2022 )

Cite this article

• Jagdish Chandra 1 ,
• Pooja Dewan 2 ,
• Praveen Kumar 3 ,
• Amita Mahajan 4 ,
• Preeti Singh 3 ,
• Bhavna Dhingra 5 ,
• Nita Radhakrishnan 6 ,
• Ratna Sharma 7 ,
• Mamta Manglani 7 ,
• Ashok Kumar Rawat 8 ,
• Piyush Gupta 2 ,
• Sunil Gomber 2 ,
• Sunil Bhat 9 ,
• Parag Gaikwad 10 ,
• K. E. Elizabeth 11 ,
• Deepak Bansal 12 ,
• Anand Prakash Dubey 1 ,
• Nitin Shah 13 ,
• Pranoti Kini 7 ,
• Amita Trehan 12 ,
• Kalpana Datta 14 ,
• G. V. Basavraja 15 ,
• Vineet Saxena 16 &
• Remesh R. Kumar 17  

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Justification

Anemia in children is a significant public health problem in our country. Comprehensive National Nutrition Survey 2016–18 provides evidence that more than 50% of childhood anemia is due to an underlying nutritional deficiency. The National Family Health Survey-5 has reported an increase in the prevalence of anemia in the under-five age group from 59% to 67.1% over the last 5 years. Clearly, the existing public health programs to decrease the prevalence of anemia have not shown the desired results. Hence, there is a need to develop nationally acceptable guidelines for the diagnosis, treatment and prevention of nutritional anemia.

To review the available literature and collate evidence-based observations to formulate guidelines for diagnosis, treatment and prevention of nutritional anemia in children.

These guidelines have been developed by the experts from the Pediatric Hematology-Oncology Chapter and the Pediatric and Adolescent Nutrition (PAN) Society of the Indian Academy of Pediatrics (IAP). Key areas were identified as: epidemiology, nomenclature and definitions, etiology and diagnosis of iron deficiency anemia (IDA), treatment of IDA, etiology and diagnosis of vitamin B12 and/or folic acid deficiency, treatment of vitamin B12 and/or folic acid deficiency anemia and prevention of nutritional anemia. Each of these key areas were reviewed by at least 2 to 3 experts. Four virtual meetings were held in November, 2021 and all the key issues were deliberated upon. Based on review and inputs received during meetings, draft recommendations were prepared. After this, a writing group was constituted which prepared the draft guidelines. The draft was circulated and approved by all the expert group members.

We recommend use of World Health Organization (WHO) cut-off hemoglobin levels to define anemia in children and adolescents. Most cases suspected to have IDA can be started on treatment based on a compatible history, physical examination and hemogram report. Serum ferritin assay is recommended for the confirmation of the diagnosis of IDA. Most cases of IDA can be managed with oral iron therapy using 2–3 mg/kg elemental iron daily. The presence of macro-ovalocytes and hypersegmented neutrophils, along with an elevated mean corpuscular volume (MCV), should raise the suspicion of underlying vitamin B12 (cobalamin) or folic acid deficiency. Estimation of serum vitamin B12 and folate level are advisable in children with macrocytic anemia prior to starting treatment. When serum vitamin B12 and folate levels are unavailable, patients should be treated using both drugs. Vitamin B12 should preferably be started 10–14 days ahead of oral folic acid to avoid precipitating neurological symptoms. Children with macrocytic anemia in whom a quick response to treatment is required, such as those with pancytopenia, severe anemia, developmental delay and infantile tremor syndrome, should be managed using parenteral vitamin B12. Children with vitamin B12 deficiency having mild or moderate anemia may be managed using oral vitamin B12 preparations. After completing therapy for nutritional anemia, all infants and children should be advised to continue prophylactic iron-folic acid (IFA) supplementation as prescribed under Anemia Mukt Bharat guidelines. For prevention of anemia, in addition to age-appropriate IFA prophylaxis, routine screening of infants for anemia at 9 months during immunization visit is recommended.

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Jagdish Chandra & Anand Prakash Dubey

Department of Pediatrics, UCMS and GTB Hospital, Delhi, India

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Department of Pediatric Hematology and Oncology, Indraprastha Apollo Hospital, Delhi, India

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AIMS, Bhopal, Madhya Pradesh, India

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Pediatric Hematology Oncology, Post Graduate Institute of Child Health, Noida, Uttar Pradesh, India

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MCGM- Comprehensive Thalassemia Care, Pediatric Hematology-Oncology & BMT Centre, Mumbai, Maharashtra, India

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Sree Mookambika Institute of Medical Sciences, Kulasekharam, Kanyakumari, Tamilnadu, India

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Chandra, J., Dewan, P., Kumar, P. et al. Diagnosis, Treatment and Prevention of Nutritional Anemia in Children: Recommendations of the Joint Committee of Pediatric Hematology-Oncology Chapter and Pediatric and Adolescent Nutrition Society of the Indian Academy of Pediatrics. Indian Pediatr 59 , 782–801 (2022). https://doi.org/10.1007/s13312-022-2622-2

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Nutritional factors for anemia in pregnancy: A systematic review with meta-analysis

1 Department of Obstetrics, Kunming City Maternal and Child Health Hospital, Kunming, China

2 Kunming Municipal Service Center for Maternal and Child Health, Kunming, China

Quanhong Li

3 Kunming Children's Hospital, Kunming, China

4 Department of Pharmacy, Children's Hospital of Kunming Medical University, Kunming, China

Liping Fang

Associated data.

The original contributions presented in the study are included in the article/ Supplementary material , further inquiries can be directed to the corresponding author/s.

Anemia in pregnancy is a serious threat to maternal and child health and is a major public health problem. However, the risk factors associated with its incidence are unclear and controversial.

PubMed, Ovid Embase, Web of Science, and Cochrane databases were systematically searched (inception to June 27, 2022). The screening of search results, extraction of relevant data, and evaluation of study quality were performed independently by two reviewers.

A total of 51 studies of high quality (NOS score ≥ 7) were included, including 42 cross-sectional studies, six case-control studies, and three cohort studies. Meta-analysis showed that infected parasite, history of malarial attack, tea/coffee after meals, meal frequency ≤ 2 times per day, frequency of eating meat ≤ 1 time per week, frequency of eating vegetables ≤ 3 times per week, multiple pregnancies, multiparous, low household income, no antenatal care, rural residence, diet diversity score ≤ 3, have more than 3 children, history of menorrhagia, underweight, family size ≥ 5, middle upper arm circumference < 23, second trimester, third trimester, birth interval ≤ 2 year were all risk factors for anemia in pregnancy.

Conclusions

Prevention of anemia in pregnancy is essential to promote maternal and child health. Sufficient attention should be paid to the above risk factors from the social level and pregnant women's own aspects to reduce the occurrence of anemia in pregnancy.

Systematic review registration

https://www.crd.york.ac.uk/prospero/ , identifier: CRD42022344937.

As a global public health problem, anemia in pregnancy has been shown to be an independent risk factor for adverse maternal and infant outcomes such as blood transfusion, postpartum hemorrhage, cesarean section, hysterectomy, preterm birth, and infectious diseases ( 1 ). It directly threatens the health of about 32 million pregnant women around the world. Especially in developing countries, 56% of pregnant women are affected by it ( 2 , 3 ). Anemia in pregnancy is a global concern as it impairs physical health, cognitive development, productivity, and reflects lagging economic status ( 2 , 4 ). Improving anemia in pregnancy is essential to reduce maternal and infant mortality and serious complications. Unfortunately, even though extensive studies have been conducted over the past 20 years and various national nutrition programs have been implemented to reduce anemia in pregnancy, there has not been much success in eliminating anemia in pregnancy, and it remains a major public health problem ( 4 , 5 ).

It is critical to explore the risk factors that may cause anemia in pregnancy and take preventive strategies as soon as possible. However, the risk factors for anemia in pregnancy are controversial. For example, the findings of Kedir et al. suggest that parasite infection is not a risk factor for anemia in pregnancy ( 6 ). However, other studies in the same area identified parasitic infection as a risk factor for anemia in pregnancy ( 7 , 8 ). It has also been shown that tea/coffee after meals is not a risk factor for anemia in pregnancy (AOR = 1.03, 95% CI: 0.88–2.06) ( 9 ), but the results of Teshome et al. showed a very significant association between tea/coffee after meals and anemia in pregnancy (AOR = 18.49, 95% CI: 6.89–40) ( 10 ). In addition, iron deficiency is considered to be the most common cause of anemia in pregnancy, therefore, most studies recommend that pregnant women should take adequate iron supplements to prevent anemia in pregnancy ( 11 , 12 ). On the contrary, some studies have shown that iron supplementation did not reduce the incidence of anemia in pregnancy ( 13 , 14 ). Some studies have even concluded that even without iron supplementation during pregnancy, the incidence of anemia in pregnant women is not significantly higher ( 15 ). In conclusion, disparate findings on the same exposure factors pose an obstacle to the prevention of anemia in pregnancy and further public health decisions.

The current field lacks definitive evidence on the risk factors for anemia in pregnancy. Therefore, as the first study to systematically summarize the risk factors of anemia in pregnancy, the results of this study can provide a reference for the prevention and treatment of anemia in pregnancy in the future.

This systematic review and meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines ( 16 ). The review protocol has been registered with PROSPERO, number CRD42022344937 ( https://www.crd.york.ac.uk/prospero/ ).

Inclusion and exclusion criteria

Patients and diseases (p).

Pregnant women.

Interventions (I)

Report at least one exposure factor associated with anemia in pregnancy.

Control (C)

Studies where adjusted odds ratio (AOR) for exposure factors were available or calculated.

Outcome (O)

Anemia in pregnancy occurs. The diagnostic criteria are hemoglobin ≤ 11 g/dL.

Type of study (S)

Cross-sectional studies, case-control studies, and cohort studies.

Exclusion criteria

Animal studies and cell experiments were excluded. Reviews, case reports, opinion articles, conference abstracts, and non-published data were also excluded.

Data sources and searches

Candidate studies were identified through searches of the PubMed, Web of Science, Cochrane, and Ovid Embase databases from inception until June 27, 2022. Also, the reference lists of the included studies were searched. The retrieval approach of the combination of free words and subject words was adopted. The following terms were combined to generate search keywords: [gestational anemia OR anemia in pregnancy OR (pregnancy OR pregnant OR gestation) AND anemia] AND (hazard OR risk factors OR risk factor OR related factors OR factors OR influence factors OR influencing factors). Further details of the search strategy are shown in Supplementary Table 1 .

Data extraction and risk of bias assessment

Literature screening and data extraction were performed by 2 trained researchers according to the inclusion and exclusion criteria as indicated previously. Extracted content includes: (1) Basic information of included studies: authors, year, country, type of study, sample size, age, method of obtaining information, diagnostic criteria for anemia, and data analysis methods. (2) Exposure factors: Risk factors related to dietary habits, self-condition, and disease history of pregnant women. (3) Key elements of risk of bias assessment.

Based on the Newcastle-Ottawa Scale (NOS), two qualified researchers independently evaluated the inherent risk of bias of included studies from three aspects, including the selection of participants, confounding variables, and measurement of exposure ( 17 ). The evaluation results were scored as low, medium, and high quality, respectively, with scores of 0–3, 4–6, and 7–9.

Statistical analysis

Statistical analysis was performed using STATA 16 software. Results were calculated using adjusted odds ratio (AOR) and 95% confidence interval (95% CI). The χ 2 test was used to evaluate the heterogeneity of the included studies (the test level was α = 0.05), and the size of the heterogeneity was judged according to the I 2 value. When P > 0.05 and I 2 ≤ 50%, it indicated that the heterogeneity of the results of each study was not statistically significant, and a fixed-effects model was used for meta-analysis; otherwise, after further analysis of the source of heterogeneity, a random-effects model was used.

Literature screening results

A total of 4,638 relevant records were obtained from the initial inspection, which were excluded from repeated studies, non-risk factor studies (prevalence, diagnosis, and treatment of anemia in pregnancy), pregnant women without anemia (postpartum anemia, women of childbearing age) and study types that are not consistent (review, conference summary, case report, etc.), 51 studies were finally included. The article screening process is shown in Figure 1 .

Flow diagram for study inclusion.

Basic information and risk of bias assessment of included studies

A total of 51 studies were included ( 6 – 10 , 13 – 15 , 18 – 60 ), including 42 cross-sectional studies ( 6 – 9 , 13 – 15 , 18 – 29 , 31 – 37 , 39 – 43 , 45 , 47 – 49 , 51 , 53 , 54 , 56 – 58 , 60 ), six case-control studies ( 10 , 30 , 38 , 50 , 52 , 55 ), and three cohort studies ( 44 , 46 , 59 ). The entire population was from developing countries, and 36 study sites were in Ethiopia ( 6 – 10 , 13 – 15 , 18 – 20 , 23 , 26 – 31 , 34 – 43 , 50 , 52 , 55 – 60 ). The total number of patients was 73,919 and in individual study ranged from 163 ( 49 )−12,403 ( 53 ). The patients were aged between 15 and 49 years ( 40 ). Information was obtained through structured questionnaires ( 6 – 10 , 13 – 15 , 18 – 39 , 41 – 45 , 47 – 50 , 52 – 56 , 59 , 60 ), outpatient medical record data ( 40 , 46 , 51 , 58 ), and databases ( 57 ). The diagnostic criteria for anemia were hemoglobin < 11 g/dL, and the statistical analysis methods were multivariable logistic regression. See Table 1 for details.

Basic information of included studies.

The NOS scores of the 51 included studies were all ≥ 7 points, of which 38 studies had a NOS score of 8 points, and 13 studies had 7 points, indicating that the included studies had high research quality. See Supplementary Table 2 for details.

Meta-analysis results

Exposure factors associated with maternal medical history.

A total of four exposure factors associated with medical history may contribute to anemia in pregnancy. Since I 2 = 0, P > 0.05, indicating that there is little possibility of heterogeneity among the studies, a fixed-effect model was used for combined analysis. Meta-analysis showed that parasitic infection (AOR = 2.20, 95% CI: 1.63–2.76) and history of malarial attack (AOR = 2.86, 95% CI: 1.98–3.73) were risk factors for anemia in pregnancy, while HIV status (AOR = 1.36, 95% CI: 0.97–1.75) and abortion history (AOR = 1.05, 95% CI: 0.47–1.63) were not associated with anemia in pregnancy ( Figure 2 ).

Exposure factors associated with maternal medical history.

Exposure factors associated with dietary habits of pregnant women

A total of eight exposure factors related to dietary habits may contribute to anemia in pregnancy. The fixed effect model was used to analyze the exposure factors of I 2 < 50%. The results showed that tea/coffee after meals, meal frequency ≤ 2 times per day, frequency of eating meat ≤ 1 time per week, diet diversity score ≤ 3 were risk factors for anemia in pregnancy. Iron supplementation was a protective factor for anemia in pregnancy ( Table 2 ). Meta-analysis of the potential risk factors for I 2 > 50 % using a random effect model showed that frequency of eating vegetables ≤ 3 times per week was a risk factor for anemia in pregnancy, while no iron supplementation and drinking were not associated with anemia in pregnancy ( Table 2 ).

Exposure factors associated with dietary habits of pregnant women.

Exposure factors associated with maternal conditions

A total of 20 exposure factors associated with maternal conditions may contribute to anemia in pregnancy. Multiple pregnancies, multiparous, low household income, no antenatal care, rural residence, have more than 3 children, history of menorrhagia, underweight, family size ≥ 5, middle upper arm circumference < 23, second trimester, third trimester, and birth interval ≤ 2 year were all risk factors for anemia in pregnancy. Overweight was a protective factor, and the remaining exposure factors were not associated with anemia in pregnancy ( Table 3 ).

Exposure factors associated with maternal conditions.

Publication bias

Funnel plots were drawn for exposure factors with more than 10 studies to detect publication bias. The results showed that the funnel plots were basically symmetrical, suggesting a small possibility of publication bias ( Figure 3 ).

Results of publication bias. (A–I) Funnel plots of exposure factors with more than 10 studies.

Summary of evidence related to maternal medical history

Due to poverty, lack of safe drinking water, poor hygiene, and malnutrition, combined with the immunomodulatory and physiological changes that occur during pregnancy, pregnant women are often more vulnerable than non-pregnant women to intestinal parasite invasion, especially in developing countries ( 61 ). More than 7 million pregnant women worldwide are infected with hookworm, and 10 million pregnant women in Africa are infected with schistosomiasis ( 62 , 63 ). Parasites entering the gut can attach to the mucosa and submucosa of the small intestine, destroy capillaries and arterioles and feed on the exuding blood ( 64 ). Our findings suggest that parasitic infection is one of the risk factors for anemia in pregnancy. This finding is consistent with the study conducted by Alem et al. ( 65 ). In developing countries, infection of young women, pregnant women, and their infants with intestinal parasites, especially hookworms, can lead to deficiencies in iron, total energy, protein, and folic acid and zinc, leading to low birth weight, intrauterine growth retardation, and higher morbidity and mortality of anemia in pregnancy ( 58 ). Moreover, as another common risk factor, infection with malaria is also susceptible to anemia in pregnancy. Notably, studies on malaria have come from both Ethiopia and Ghana. Their geographical location in the tropics has an important impact on the distribution of malaria. Sequestration of plasmodium in the placenta avoids spleen clearance, thereby predisposing pregnant women to malaria. Malaria causes anemia in a variety of ways, including excessive depletion of non-parasitic red blood cells, immune destruction of parasitic red blood cells, and impaired erythropoiesis due to bone marrow dysfunction ( 66 , 67 ). Other studies have shown that pregnant women infected with HIV are more likely to develop anemia than those who are not infected with HIV ( 41 ). This may be due to the properties of the virus that lead to increased metabolic and nutritional requirements and directly inhibit the production of red blood cells in the body ( 68 ). Although our meta-analysis showed no significant association between HIV infection and anemia in pregnancy. However, the lower limit of confidence interval of our results is close to 1, suggesting to some extent the correlation between HIV infection and anemia in pregnancy.

Summary of evidence related to maternal status

Previous study has shown that the risk of anemia in pregnancy increases with the number of births. The risk of developing anemia in pregnancy was nearly 3 times higher for women with 2–3 children and 4 times higher for women with 4 or more children compared to only one child ( 69 , 70 ). This is because pregnant women do not have enough time to recover from the nutritional burden of their previous pregnancy, especially folic acid, and iron deficiency. Maternal serum and erythrocyte folate concentrations also decline from the fifth month of pregnancy and remain low for a considerable time after delivery ( 6 ). The same is true for our combined analysis of 12 studies, finding that women with more than 3 children were more likely to develop anemia in pregnancy. In addition, multiple pregnancies, multiparous, and birth interval ≤ 2 years are also risk factors for anemia in pregnancy. Like the reasons for having more children, these factors lead to impaired iron stores in pregnant women, and to a certain extent, they impair the normal physiological functions and anatomical structures of pregnant women. Studies have shown that during pregnancy, the incidence of anemia increases more than 4 times from the first trimester to the third trimester, and the prevalence in the third trimester is as high as 30–45% ( 71 ). This is consistent with our findings that early pregnancy is less prone to anemia, whereas second and third trimesters are significantly associated with anemia. It may be related to the rapid growth of the fetus in the second and third trimesters and the significant increase in the demand for nutrients such as iron ( 72 ).

According to the World Health Organization, anemia in pregnancy is more prevalent in developing countries, such as Africa and Southeast Asia, where dietary diversity, living standards, and education levels are all poorer ( 73 ). In addition, lack of knowledge about anemia, infrequent antenatal check-ups, and unplanned pregnancies naturally lead to more threats of anemia in local pregnant women ( 74 ). As our study shows, 51 studies are from developing countries, especially Ethiopia, Ghana, and other countries. Also, low household income, no antenatal care, rural residence, underweight, middle upper arm circumference < 23, and illiteracy are all risk factors for anemia in pregnancy. Although unplanned pregnancy and lack of understanding of anemia were not statistically associated with anemia in pregnancy. However, according to the OR value of more than 1, and the lower limit of the 95% confidence interval close to 1, it is suggested that these two exposure factors are related to anemia in pregnancy to a certain extent.

Summary of evidence related to dietary habits in pregnant women

In fact, the most common cause of anemia in pregnancy is iron deficiency, while other causes are rare ( 2 ). Although our study shows that lack of iron supplementation during pregnancy is not associated with anemia, the likely reason is that pregnant women obtain adequate iron intake through other means such as diet. However, our study also shows that iron supplementation is a protective factor in reducing the occurrence of anemia. This fully illustrates the importance of ingesting or supplementing adequate iron during pregnancy. Adequate intake of macro- and micronutrients, quantity and variety of diets is a challenge in many countries, especially developing ones ( 75 , 76 ). After combined analysis of exposure factors related to dietary habits of pregnant women, we found that meal frequency ≤ 2 times per day, frequency of eating meat ≤ 1 time per week, tea/coffee after meals, diet diversity score ≤ 3, frequency of eating vegetables ≤ 3 times per week were all risk factor for anemia in pregnancy. This is consistent with the findings of Roess et al. Tea and coffee contain compounds that affect iron absorption such as tannins and polyphenol, meat is a good source of heme iron and protein of high biological value, and fruits rich in ascorbic acid can enhance iron absorption ( 77 ). Therefore, eating less or not eating meat and fruits will also lead to insufficient iron intake, which will eventually lead to the occurrence of anemia ( 78 , 79 ). In addition, vegetables are a food source of folic acid, and folic acid deficiency is associated with anemia in pregnancy ( 80 ).

Although anemia in pregnancy is a global public health problem, we must acknowledge that anemia in pregnancy often differs between developed and developing countries and is one of the distinct health disparities between developed and developing countries ( 81 ). The prevalence of anemia in pregnancy in developing countries ranged between 53.8 and 90.2%, compared with 8.3% in developed countries ( 82 ). There are many factors that contribute to this difference. Compared with developed countries, medical resources are scarce in developing countries, pregnant women are less likely to receive adequate or quality health care, and they are at higher risk of exposure to diseases such as malaria and parasitic infections that cause anemia in pregnancy ( 83 ). Although we conducted a comprehensive search of current mainstream databases, the studies we included were all from developing countries, and evidence from developed countries was lacking. Therefore, our findings are only applicable to developing countries. More findings from developed countries are needed in the future to provide a global picture of risk factors for anemia in pregnancy.

Strengths and limitations

Strengths: (1) As the first study in the current field to systematically summarize the risk factors of anemia in pregnancy, this study may serve as the best evidence for the prevention of anemia in pregnancy in the future. (2) This study was based on AOR rather than OR analysis, avoiding the interaction between multiple exposure factors, and the results were more in line with the actual situation. (3) According to the NOS scoring results, we found that the quality of evidence of the 51 included studies was high, which ensured the reliability of the meta-analysis results.

Limitations: (1) The included studies were all from developing countries, especially Ethiopia, therefore, our findings are only applicable to some countries, not all countries. (2) Include only English literature, which may lead to language bias. (3) The gray literature and conference abstracts were not searched, which may lead to publication bias.

The high incidence and serious harm of anemia in pregnancy make it urgent to systematically summarize its risk factors. Evidence from 51 high-quality studies showing infected parasite, history of malarial attack, tea/coffee after meals, meal frequency ≤ 2 times per day, frequency of eating meat ≤ 1 time per week, frequency of eating vegetables ≤ 3 times per week, multiple pregnancies, multiparous, low household income, no antenatal care, rural residence, diet diversity score ≤ 3, have more than 3 children, history of menorrhagia, underweight, family size ≥ 5, middle upper arm circumference < 23, second trimester, third trimester, birth interval ≤ 2 year, these 20 exposure factors were all risk factors for Anemia in Pregnancy. Therefore, health institutions and pregnant women themselves should focus on the above risk factors for better prevention and early detection of anemia in pregnancy.

Data availability statement

Author contributions.

YSu proposed ideas and designed protocol. JZ and QL were responsible for data analysis and writing of the paper. YSo, LF, and LH were responsible for literature screening, data extraction, and quality evaluation. All authors contributed to the article and approved the submitted version.

We acknowledge the financial support from Kunming Health Science and Technology Personnel Training Project (No. 2022-SW-93).

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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Abbreviations

Supplementary material.

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpubh.2022.1041136/full#supplementary-material

Anemia in Sri Lanka: A Literature Review

Affiliations.

• 1 Department of Medical Laboratory Science, Faculty of Allied Health Sciences, University of Ruhuna, Galle, Sri Lanka.
• 2 Department of Biochemistry and Clinical Chemistry, Faculty of Medicine, University of Kelaniya, Kelaniya, Sri Lanka.
• 3 Department of Medicine, Faculty of Medicine, University of Kelaniya, Kelaniya, Sri Lanka.
• PMID: 36000556
• DOI: 10.1080/03630269.2022.2096460

Anemia is a global health problem. This paper reviews literature on the prevalence of anemia in Sri Lanka. We searched EBSCO (Elton Bryson Stephens Company), Cochrane Library, and Medline for articles on prevalence and molecular basis of anemia in Sri Lanka from January 2000 to May 2021. Forty articles were selected. Most of the studies were on prevalence of anemia among children and pregnant women. All the studies had restricted themselves to assess the contributing factors for anemia in limited age categories. Most articles had attempted to determine the overall prevalence of anemia and the contribution of iron deficiency to it. There were only a few studies on prevalence and molecular basis of hemoglobinopathies and even fewer on the prevalence of anemia of chronic disease. None of the studies had attempted to assess the national prevalence of red cell membranopathies and enzymopathies. The published data on prevalence of anemia in Sri Lanka are incomplete. This review emphasizes the value of a much broader survey on anemia covering all age categories including the elderly and conducting a national survey including anemia of chronic disease and on red cell membranopathies and enzymopathies in Sri Lanka.

Keywords: Anemia; Sri Lanka; prevalence.

Publication types

• Anemia* / epidemiology
• Anemia* / etiology
• Sri Lanka / epidemiology
• Surveys and Questionnaires