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Byline: Anwar Zeb Jan, Zahid Gul and Fahad Liaqat


Background: Megaloblastic anemia is common in clinical practice in children in Pakistan. Vitamin B12 and folate deficiency are the established causes. The aim of this study was to find the frequency of megaloblastic anemia, its clinical presentation and cause in children in our set-up.

Material and Methods: This was a retrospective study conducted at Rehman Medical Institute, Peshawar. Forty-eight children between 6 months to 14 years were studied for the causes of megaloblastic anemia.

Results: Among 48 patients there was male to female dominancy (1.64:1), mostly in the age group of 11-14 years. Megaloblastic erthyroid hyperplasia was the most common finding of bone marrow. Folate deficiency was seen in 33.34% of cases and vitamin B12 deficiency in 52.08% cases while 14.58% of cases had both folate and vitamin B12 deficiency.

Conclusion: Vitamin B12 deficiency is the major cause of megaloblastic anemia in children in our population. Proper dietary care should be taken in order to avoid it.

KEY WORDS: Megaloblastic; Anemia; Vitamin B12; Folate.


Anemia affects approximately two billion people worldwide mostly affecting women and children; Pakistan has lagged behind other low-income countries in terms of health and population outcomes1. Children under five-years are 18 % of population and 45-60 % is anemic due to poor diet1. Ten percent of the children die before the 1st birthday reflecting alarming level of infant mortality and another 14 percent before reaching 5 years of their age1. One child out of three children suffers from malnutrition and anemia. Seventy percent of all under 5 years deaths are attributed to food deficiencies2.Anemia is a blood condition in which there is too few red blood cells or is also defined as Hb less than 11.5 g/dl and severe anemia is defined as Hbless than 8.0 gm/dl1. Anemia appears in different symptoms as faint skin, cold hands and feet, lack of sensation or itching in hands, feet and legs, problem in appetite, sore tongue and mouth etc. There are primary and secondary factors of anemia.

Primary Factors basically have two types as exogenous and endogenous factors. Exogenous causes are social dimensions of illness and are potentially preventable3 and it is one of the problems with which children are hospitalized for proper work up and management. It is one of the important health problems in most of the developing countries like Pakistan and invariably a common accompanying feature of protein energy malnutrition.

Vitamin B12 is present as cobalamine in animal source of food and is not synthesized by humans. Megaloblastic anemia is an anemia that is characterized by the presence of precursor cells, megaloblast in the bone marrow and macrocytic red cells in the peripheral blood.4 These megaloblasts arise because of impaired DNA synthesis followed by ineffective erythropoiesis.4

Megaloblastic anemia is common in clinical practice in Pakistan5,6. Vitamin B12 deficiency in infants is mostly due to maternal dietary deficiency and is generally observed in infants exclusively breast fed by mothers who are strict vegetarians7,8. However regarding the prevalence, causative factors and associated symptoms in Indo-Pak subcontinent we have very limited data available.5,6,9,10,11

The aim of the present study was to find the incidence of megaloblastic anemia, its clinical presentation in children in our set-up.


The study was conducted at Pediatric Department of Rehman Medical Institute Peshawar, Pakistan on data of 6 years from January 1, 2006 to December 31, 2011.

A total of 48 cases were included in the study. The inclusion criteria was, children in the age group 6 months to 14 years admitted in the hospital with features suggestive of anemia, hemoglobin less than 11 gm/dl in children less than 6 years of age and hemoglobin less than 12 gm/dl in children 6-14 years age (WHO criteria). Children who received blood transfusion were excluded from the study. Detailed history was taken including dietary intake, ingestion of any drugs, worm infestation, and loss of blood and duration of onset of anemia. These patients were investigated for CBC, Peripheral smear, Serum ferritin, serum folate, serum vitamin B12 and bone marrow specimen being taken by a consultant pathologists under strict hygienic condition.


Forty-eight children with a male predominance (1.64:1) were observed. The majority of patients were in the age group of 11-14 years (49% and only few cases (12%) were seen in infancy. (Figure 1)

On bone marrow examination frank megaloblastic erythroid hyperplasia was seen in 49% of cases. Mild megaloblastic changes in 35% cases while it was dimorphic in 11% cases and normoblastic in 5% cases. (Fig. 2)

Among these, folate deficiency was seen in 33.34% of cases and Vitamin B12 deficiency was seen in 52.08% of cases while 14.58% of cases had both folate and vitamin B12 deficiency. (Fig. 3)

Table 1: Prevalence of vitamin B12 and folate deficiency in children

Indian Series###Year, Country###Folate Def. (%)###B12 def. (%)###Combined defi-

###ciency (%)

Bhende et al###1965, India###54.9###7###5.3

Mittal et al###1969, India###57.1###22.4###10.2

Sarode et al11###1989, India###6.8###76.4###8.8

Mukibi et al###1992, Zimbabwe###17###51###32

Maddood-ul-Man-###1995, Pakistan###8###56###20

nan et al

Allen et al8###1995, Mexico###-###19-41###-

Casterline etal###1997, Guatemala###9###46.7###-

Gomber et al###1998, India###10###50###20

Chaudhry MW###2001, India###12###19###14

Chandra et al###2002, India###20###32###20

Khanduri et al10###2005, India###6.8###33###8.3

Garcia-Casal et al###2005, Venezuela###30 36.3###11.4 61.3###-

Saira PI et al###2009, Pakistan###43.4###78.5###-

Our study###2013, Pakistan###33.34###52.08###14.58


Folic acid and vitamin B12 are essential dietary components for human because they play a vital role in DNA synthesis.12 In our community we can see many cases of folate and vitamin B12 deficiency most probably due to imbalance of dietary products and inadequate calories intake. Anemia mostly due to poor dietary intake usually occurs in undernourished or malnourished children being in the age group of 3-18 months with maximum number of cases being between 9-12 months.13

The findings of our study are in consistence with other studies.14,15

In the past as shown in table, the studies have shown folate deficiency to be more common than vitamin B12 deficiency. This trend was observed both in the developed and developing countries but this trend has changed and now vitamin B12 deficiency is commoner as compared to folate deficiency. In our study 52.08% of cases had vitamin B12 deficiency, this finding of our study is consistent with the study done in Mexico8 who reported the deficiency of vitamin B12 to be 41%, a study done in India15 showed much higher incidence of vitamin B12 deficiency reported to be 88%, while another study done in India by Sarode reported it to be 74%. In our study folate deficiency was seem in 33% of cases which in contrast to other study is much higher, it was reported to be 8.4% in a study done by Sarode in India.26 In our study combined folate and vitamin B12 deficiency was seen in 16% of cases which is much low as compared to a study done in India15 who reported it to be 44%.


Vitamin B12 deficiency is a major cause of megaloblastic anemia in children in our set-up. Proper dietary care should be taken in order to avoid it.


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14. Goel RG, Bhan MK, Azany S. A study of severe anemia in hospitilized children in Afghanistan. Indian Pediatr 1981; 18:643-6

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18. Mukibi JM, Makumbi FA, Gwanzura C. Megaloblastic anemia in Zimbabwe: spectrum of clinical and hematological manifestations. East Afr Med J 1992; 9:83-7.

19. Madood-ul-Mannan, Anwar M, Saleem M, et al. Study of serum vitamin B12 and folate levels in patients of megaloblastic anemia in northern Pakistan. J Pak Med Assoc 1995, 45:187-8.

20. Casterline JE, Allen LH, Ruel MT. Vitamin B12 deficiency is very prevalent in lactating Guatemalan women and their infants at three months postpartum. J Nutr 1997; 127:1966-72.

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24. Garcia-Casal MN, Osorio C, Landaeta M, Leets I, matus P, Fazzino F, Marcos E. High prevalence of folic acid and vitamin B12 deficiencies in infants, children, adolescents and pregnant women in Venezuela. Eur J Clin Nutr 2005; 59:1064-70.

25. Saira PI, Ghulam NK, Saleem PI. Vitamin B12 deficiency - A major cause of megalblastic anemia in patients attending a tertiary care hospital. J Ayub Med Coll Abbottabad 2009; 21:92-4.

26. Sarode R, Garewal G, Marwaha N. Pancytopenia in nutritional megaloblasticanemia. A study from North-west India. Trop Geogr Med 1989; 41:331-6.
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Publication:Gomal Journal of Medical Sciences
Article Type:Report
Geographic Code:9PAKI
Date:Jun 30, 2016

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