An Analysis of Anemia and Child Mortality

Over half of the children in developing countries suffer from anemia, with malaria and iron deficiency being the major etiological factors. In some parts of Africa where malaria infection is sustained throughout the year, severe anemia is responsible for more deaths than cerebral malaria (Snow et al. 1994). Increasingly, the contribution of Plasmodium falciparum–associated severe anemia to pediatric mortality is being recognized, even though the causal relationship between malaria parasitemia and Hb concentration is difficult to establish because most children in malaria holoendemic areas are harboring parasites continuously. Nevertheless, this analysis suggests that estimates of mortality due to malarial severe anemia are at least double those for iron-deficiency severe anemia. Standardized prospective hospital-based or community-based multicenter studies are needed in areas with different malaria endemicities to quantify the role of malaria in the causation of anemia, severe anemia and death from malaria.

Mortality is increased in anemic children with Hb values <50 g/L; the prevalence of such values can approach 3–12% in high risk populations. The strength of the causal evidence relating mild-to-moderate anemia to mortality is significantly weaker. It is critical that this question be resolved with the strongest possible research design. Even if the RR is low (<1.5), the high prevalence of this condition in developing countries (40–60%) in high risk populations could result in a significant attributable risk of child mortality. However, given the general weakness in the causal evidence relating most iron-deficiency anemia in young children to mortality, it is premature to generate projections regarding population-attributable risk. If mild-to-moderate disease is not an independent risk factor for child mortality, then intervention programs should consider either a test-and-treat approach or have other justifications for universal supplementation.

The burden of this disease assessed as years of life lost is large because mortality is highest in the youngest children. The burden for childhood malarial anemia is greatest in Africa, from where most of the reports originate. Despite the availability of regional estimates from the global burden of disease reports, few clinical data were found on mortality in severely anemic children who were from nonmalarious areas. For example, the inter-American investigation on mortality in childhood did not quantify anemia, although malnutrition was implicated in 56% of all deaths in children 1–4 y (Puffer and Serrano 1973). The paucity of information from nonmalarious locations is a deficiency, and obtaining data from these areas is a priority. The quantitative effect of anemia on child mortality will exhibit proportionate change across different populations with different disease ecology. At times, the etiology of anemia remains unexplained despite careful investigations (Hendrickse and King 1958), and for some key nutrient deficiencies associated with anemia (e.g., folate), no information was identified on mortality risk. 

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