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Malnutrition is a complex syndrome where several nutrient deficiencies exist simultaneously. Iron deficiency anaemia is the most common nutrient deficiency and is particularly common among preschool children. In many developing countries, the economic implications and public health consequences of anaemia have long being recognised. The well known consequences of anaemia are alteration of the immune status, adverse effects on morbidity, delayed behavioural and mental development, below average school achievements and growth retardation. The infections and reduced work capacity often associated with anaemia can result in educational and economic losses that eventually affect the well being of an entire population. Assessment of PEM has traditionally been clinical which is time consuming and skill dependent, with considerable inter-observer variability. So present study is undertaken to explore the significance of biochemical parameters serum iron and total iron binding capacity in the diagnosis and prognosis of malnutrition.

Aimée Mudekereza Musimwa et al.(2018) conducted a cross-sectional study from 01 July 2013 to 31 July 2014 to determine iron concentrations in malnourished children aged 6 -59 months and factors associated with variation in iron levels. They found that serum iron concentration was lower in acutely or chronically malnourished children on admission, with a mean iron concentration of approximately 159.5 μg/L; this would justify the vast iron fortification programs of different foods and/or the administration of iron in the first week while treating complications (malaria, bacterial infections and other parasitic infections). A.O.Saka etal.(2019) assessed the value of serum ferritin among PEM patients with iron deficiency. Patients with PEM were found to have high prevalence of iron-deficiency anemia and low serum ferritin levels. The sensitivity and specificity of serum ferritin levels were found to be high among PEM patients with iron-deficiency anemia. Prachiti Natekara et al.(2022) found a persistently high level of anemia among Indian women that is about 53% of all women have anemia, according to the National Family Health Survey (2015–2016) is a serious concern, and the 2017 National Health Policy recognizes such a high burden which is proposed by the Ministry of Health and Family Welfare, Government of India.

350 PEM cases and 70 healthy subjects (controls) belonging to 6 months to 12 years of age group were taken in the study. On the basis of wellcome trust classification 60 cases were diagnosed as undernutrition, 23 as kwashiorkor, 43 as Marasmic Kwashiorkor and 224 as Marasmus. Approximately 5-6 ml blood was taken by Venipuncture. The blood was allowed to clot at 37 degree celsius for half an hour and then centrifuged to get the serum. The separated serum was used for analysing serum iron and total iron binding capacity in control and pem cases. Serum iron and total iron binding capacity were estimated by using Dipyridyl method, Ramsay 1954, 1958. Patients were followed up to 45 days to determine the final outcome of the disease. Blood samples from Pem cases were collected on the day of admission (day 0), 7th day, 15th day, 30th day, and 45th day. Mean levels of serum iron and total iron binding capacity on the day of admission and follow-up were compared with respective levels of controls. The patients were graded into uncomplicated recovered, complicated recovered and expired cases according to the final outcome of the disease. Serum iron and total iron binding capacity were estimated in these cases to assess their role in pathogenesis and their diagnostic and prognostic importance. Student’s t-test was used to analyse the data for statistical significance.

Results

Table 1 Serum  Iron, Total Iron Biniding Capacity And Percent Saturation   In  Control  And  Pem  Cases

Groups (No. Of Cases)	Total Iron (µg/Dl)       Mean±S.D.          Range	Total Iron Binding Capacity  (µg/Dl)    Mean±S.D.       Range	Percent Saturation
Control Group (70)	83.70± 6.16 70.41-103.42	286.95± 19.41 214.52-311.45	29.17
Study Group Undernutrition (60)	71.63± 15.74 *** 50.62-93.11	331.95± 23.57 *** 258.11-363.76	21.58
Kwashiorkor (23)	56.77± 11.04 *** 39.83-78.45	363.84± 28.52*** 301.46-390.11	15.60
Marasmic Kwashiorkor (43)	63.12 ±13.94 *** 43.73-92.74	349.33± 21.86 *** 294.76-396.00	18.07
Marasmus (224)	68.86± 13.11*** 48.44-93.01	341.83± 20.98*** 259.78-367.76	20.14
Total (350)	67.84± 17.12*** 39.83-93.11	342.50± 25.88*** 258.11-396.00	19.81

*P < 0.05               **P < 0.01                           ***  P < 0.001

                Table 1 Shows Mean Values Of Serum Iron  And Total Iron Binding Capacity In Control And Pem Cases. The Table Reveals That Serum Iron Was Observed To Be Significantly Reduced And Total Iron Binding Capacity Was Significantly (P<0.001) Elevated In Pem Cases As Compared To Controls. Percent Saturation  Was Also Reduced In  Pem Cases As Compared To Controls. All The Study Groups Of Pem Showed Significant (P<0.001)  Reduction In Serum Iron Level And Significant (P<0.001) Elevation In Total Iron Binding Capacity( Tibc).

Table 2 Serial Levels Of Serum Iron, Total Iron Binding Capacity And Percent Saturation In Cases Of Undernutrition During Follow Up

**P < 0.01                                                     ***  P < 0.001

Table 3 Serial Levels Of Serum Iron, Total Iron Binding Capacity And Percent Saturation In Cases Of Kwashiorkor During Follow Up

*P < 0.05                                                       ***  P < 0.001

Table 4 Serial Levels Of Serum Iron, Total Iron Binding Capacity And Percent Saturation In Cases Of Marasmic Kwashiorkor During Follow Up

*P < 0.05            **P < 0.01                              ***  P < 0.001

Table 5 Serial Levels of Serum Iron, Total Iron Binding Capacity And Percent Saturation In Cases Of Marasmus During Follow Up

**P < 0.01                                                     ***  P < 0.001

Table 2, 3, 4 And 5 Show Serial Levels Of Serum Iron, Total Iron Binding Capacity And Percent Saturation  In Undernutrition, Kwashiorkor, Marasmic Kwashiorkor And Marasmus Groups During Follow Up. Serum Iron Reached The Normal Level By 30^th Day In Undernutrition Group And By 45^th Day In Kwashiorkor And Marasmus Group. Marasmic Kwashiorkor Group Could Not Reach The Normal Iron Level Even By 45^th Day. Levels Of Tibc Became Normal By 45^th Day In Undernutrition Group And Kwashiorkor Groups. Marasmic Kwashiorkor And Marasmus Groups Could Not Reach The Normal Tibc Level Even By The Last Day Of Follow-Up.

Table 6 Serum Iron, Total Iron Biniding Capacity and Percent Saturation  In  Cases Of Pem With Iron Deficiency Anaemia

Groups (No. Of Cases)	Iron Deficiency Anaemia (No. Of Cases)	Total Iron        (µg/Dl) Mean± S.D. Range	Total Iron Binding Capacity   (µg/Dl) Mean±S.D. Range	Percent Saturation
Control Group (70)	_	83.70± 6.21 70.41-103.42	286.95± 19.41 214.52-311.45	29.17
Study Group Undernutrition (60)	17	63.78±18.17 *** 50.62-93.11	354.93± 28.48 *** 307.41-390.51	21.58
Kwashiorkor (23)	9	50.02±14.78 *** 39.83-61.76	382.73± 29.43*** 314.11-390.11	15.60
Marasmic Kwashiorkor (43)	23	52.91±12.48 *** 38.41-67.39	349.33± 21.86 *** 294.76-396.00	18.07
Marasmus (224)	132	53.68± 10.07*** 48.44-93.01	341.83± 20.98*** 259.78-367.76	20.14
Total (350)	181	54.35± 16.33*** 38.41-93.11	342.50± 25.88*** 258.11-396.00	19.81

      ***  P < 0.001

Table 6 Reveals That Out Of 350 Pem Cases 181 Cases Were Observed To Have Iron Deficiency Anaemia. In These Cases Serum Iron Was Observed To Be Significantly Reduced Whereas Tibc Was Observed To Be Significantly Elevated As Compared To Controls. Percent Saturation Was Observed To Be 14.87 In These Cases. Each Study Group Also Had Significantly Reduced (P < 0.001 ) Serum Iron Level And Significantly Elevated(P < 0.001 )  Tibc.

Table 7  Prognostic  Importance  of  Serum  Iron(µg/Dl)

 On The Day Of Admission  in  Pem  Cases

Study Groups (No. of Cases)	Uncomplicated Recovered Cases  Mean±S.D. Range  (No.of Cases)	Complicated Recovered Cases   Mean±S.D. Range   (No. of Cases)	Expired Cases     Mean±S.D.      Range     (No.of Cases)
Undernutrition (60)	72.80± 15.67 63.76-93.11 (50)	67.65± 14.77 59.00-87.61 (9)	50.63 (1)
Kwashiorkor (23)	68.23± 9.37 3.69-5.99 (9)	57.60± 7.69* 3.40-4.98 (6)	42.81 ±6.68*** 3.1-4.00 (8)
Marasmic Kwashiorkor (43)	72.11± 12.51 62.45-92.74 (20)	59.54± 9.47** 46.00-69.61 (13)	48.83± 8.67*** 43.73-59.45 (10)
Marasmus (224)	73.33± 11.93 61.40-93.01 (167)	56.13± 8.86*** 49.32-67.73 (39)	50.92± 7.16*** 48.44-57.45 (18)
Total (350)	72.94± 12.18 59.53-93.11 (246)	58.47± 10.38*** 46.00-87.61 (67)	48.59± 6.18*** 39.98-59.45 (37)

*P < 0.05               **P < 0.01                           ***  P < 0.001

Table 7 Reveals The Prognostic Importance Of Serum Iron  In Uncomplicated Recovered, Complicated Recovered And Expired  Cases. Serum  Iron Was  Significantly Reduced In Total Complicated Recovered (P < 0.001 ) And Expired Cases (P < 0.001 ) As Compared To Total Uncomplicated Recovered Cases. Complicated Recovered and Expired Cases of Kwashiorkor, Marasmic Kwashiorkor And Marasmus Groups Also Had Significantly Reduced Serum Iron Level As Compared To Uncomplicated Recovered Cases.

 In total PEM cases there was a significant (P<0.001) lowering of serum iron and a significant elevation of TIBC as compared to controls. All the four study groups of PEM (Undernutrition, Kwashiorkor Marasmic kwashiorkor and Marasmus) showed significant (p<0.001) lowering of serum iron and significant elevation of TIBC . Similar to our results Hassanein et al. (1998) also reported significantly (p<0.001) reduced levels of serum iron and significantly elevated (p<0.001) TIBC in malnourished children as compared to controls. Nicklas(1998) reported that about one third of the 5 year old Haitian children were either anaemic or iron deficient.

Kwashiorkar is a syndrome of acute onset and shortage of dietary proteins means inadequate supply of amino acids available for  the synthetic process. Fechner et al.(2001) also reported marked decrease in albumin level in kwashiorkor patients. So in this study it has been observed that total protein and albumin are significantly lower in malnourished children as compared to normal healthy children.

During follow up  the levels of serum iron and percent saturation  were elevated by treatment and the TIBC was reduced to come to the normal level. In Undernutrition group the mean serum iron reached the normal level by the 30^th day and TIBC by the 45^th day of treatment. In Marasmic kwashiorkor group the mean serum iron level was significantly reduced and TIBC was significantly elevated even by the 45^th day of treatment. In Marasmus group, though serum iron level reached the normal value, the TIBC was significantly elevated even by the 45^th day of treatment(Table 2,3,4,5). Other workers have also reported similar results. Dossa et al (1981) reported that iron supplementation resulted in a 5g/l higher blood Hb level at month 3 and at month 10. This 5g/l increase in blood Hb level resulted in decrease  in prevalence of anaemia from 76% after 3 months .

Serum iron levels were significantly reduced in total complicated recovered (5.39±  1.21 gm/dl, p<0.01) and total expired cases (4.93 ±1.68gm/dl,p<0.001) as compared to total uncomplicated recovered cases (5.95±1.28gm/dl ) of PEM. Reduction in total protein level of complicated recovered and expired cases was significant in kwashiorkor (p<0.05) ,marasmic kwashiorkor(p<0.001) and marasmus(p<0.001) groups. Expired cases of each study group of PEM had significantly reduced(p<0.001)  serum iron level as compared to the uncomplicated recovered cases.

Anaemia is still a large public health problem throughout the world, especially in children in developing countries. Dossa etal.(2001) reported anaemia in 76% of Beninese preschool children. Though the disorder anaemia is not regarded as  life threatening, yet iron deficiency can have a multitude of effects and can even result in death.Kwashiorkar is a syndrome of acute onset and shortage of dietary proteins means inadequate supply of amino acids available for  the synthetic process. Fechner et al.(2001) also reported marked decrease in albumin level in kwashiorkor patients. So in this study it has been observed that total protein and albumin are significantly lower in malnourished children as compared to normal healthy children.

During follow up  the levels of serum iron and percent saturation  were elevated by treatment and the TIBC was reduced to come to the normal level. In Undernutrition group the mean serum iron reached the normal level by the 30^th day and TIBC by the 45^th day of treatment. In Marasmic kwashiorkor group the mean serum iron level was significantly reduced and TIBC was significantly elevated even by the 45^th day of treatment. In Marasmus group, though serum iron level reached the normal value, the TIBC was significantly elevated even by the 45^th day of treatment(Table 2,3,4,5). Other workers have also reported similar results. Dossa et al (1981) reported that iron supplementation resulted in a 5g/l higher blood Hb level at month 3 and at month 10. This 5g/l increase in blood Hb level resulted in decrease  in prevalence of anaemia from 76% after 3 months .

Serum iron levels were significantly reduced in total complicated recovered (5.39±  1.21 gm/dl, p<0.01) and total expired cases (4.93 ±1.68gm/dl,p<0.001) as compared to total uncomplicated recovered cases (5.95±1.28gm/dl ) of PEM. Reduction in total protein level of complicated recovered and expired cases was significant in kwashiorkor (p<0.05) ,marasmic kwashiorkor(p<0.001) and marasmus(p<0.001) groups. Expired cases of each study group of PEM had significantly reduced(p<0.001)  serum iron level as compared to the uncomplicated recovered cases.

Anaemia is still a large public health problem throughout the world, especially in children in developing countries. Dossa etal.(2001) reported anaemia in 76% of Beninese preschool children. Though the disorder anaemia is not regarded as  life threatening, yet iron deficiency can have a multitude of effects and can even result in death. 

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