Ramesh Verma*, Meena**, Pardeep Khanna***, Varun****
*Assistant Professor, **Associate Professor, ***Senior Professor & Head
**** Senior Resident, Department of Community Medicine, Pt. B.D. Sharma PGIMS, Rohtak.
Correspondence:
Dr. Ramesh Verma 239, Subhash Nagar, Rohtak-124001 (Haryana) Ph.: 01262-210057 (R) Mobile: 0-94163-81012
e-mail: dr.rameshverma@yahoo.co.in INTRODUCTION
Nutritional anemia is a condition in which the haemoglobin content of the blood is lower than normal as a result of deficiency of one or more essential nutrients, regardless of the cause of such deficiency.
The usual causes of nutritional anemia include inadequate supply of iron, folic acid or vitamin B121. Anemia in children, especially iron deficiency, is the commonest health problem in many developing countries with an estimated prevalence of 43%2. There is convincing evidence that iron deficiency causes impaired growth, developmental delay, behavioural abnormalities and impairs cognitive function and school performance3. Other health consequences include reduced immunity, increased morbidity, increased susceptibility to heavy metal (including lead) poisoning4.It has also been associated with functional abnormalities of lymphocytes and neutrophils5-6.
Iron deficiency anemia (IDA) occurs mainly because of:
inadequate dietary intake, particulary of iron rich foods and increased body loss due to worm infestation (hookworm, roundworm). Average indian diet is generally inadequate in terms of iron, proteins, calcium and overall calories. Moreover, the non-haem content of cereal-based diets has much less bio-availability (5- 10%) as compared to haem iron (25-30%) present in the non-vegetarian diet ( meat, fish etc )7.
It is true that National Nutrition Anemia Control Program (NACP) was launched in the country in 1970 but the benefits of this programme have not been
reached to the target population like children, adolescent girls, pregnant women etc. This is due to the lack of operational feasibility to estimate the hemoglobin levels, orientation of field workers and acceptance of the programme by the beneficiaries8.
AIMS AND OBJECTIVES
To find out the prevalence and effect of weeky supplementation of iron- folic acid on anemia
MATERIAL AND METHODS
The present intervention study was carried out from March 2009 to September 2009. All children (n=490) in the age group of 6-11 years from government primary schools of urban slums ( field practice area of PGIMS, Rohtak) were covered. The blood samples for haemoglobin estimation were obtained by finger prick method using sterile needles. 20 microliters of blood sample was collected in 5 ml Drabkin solution. The baseline haemoglobin estimation was done by Cyanmethaemoglobin method. Haemoglobin cut-off level for labelling anaemia as per WHO guidelines was taken as 11.5g%9.
After obtaining baseline data of haemoglobin levels, the intervention was carried out. A tablet of Albendazole (400mg) was given one week prior to supplementation for deworming and supervised weekly IFA (20mg of elemental iron and 0.1mg folic acid) therapy were administered to all children for six months. The invesigator himself gave these IFA tablets by visiting the school once a week. The concerned class teacher was assigned the duty to ensure consumption of IFA tablets by children who were absent on those days. After six months, the repeat haemoglobin estimation was done to assess the impact of intervention in school children.
After collection, the whole data was complied, analysed and appropriate statistical tests were applied using SPSS software.
35 Ramesh Sharma 147-150.pmd 147 8/27/2012, 6:40 PM
Overall prevalence of anemia among children was found to be 76.3% with mild, moderate and severe anemia being 51.8%,23.7% and 1.3% respectively.
After intervention the prevalence of anemia decreased to 42.4% ( 33.9%). Also the degree of anemia
decreased significantly. The non anemic became 57.6%
from 23.2% while mild and moderate anemic decreased from 51.8% to 35.5% and 23.7% to 6.9%
respectively. No child was found in severe grade after intervention.
Table II. Mean Haemoglobin Before and After Intervention in 6-11 Years Children (N-490)
Degree of anemia Before intervention After intervention
N % Mean ± SD N % Mean ± SD
Non anemic 114 23.2 12.61 ± 0.64 282 57.6 12.21 ± 0.76
Mild 254 51.8 10.68 ± 0.42 174 35.5 10.61± 0.40
Moderate 116 23.7 8.91 ± 0.58 34 6.9 09.20 ± 0.42
Severe 06 1.3 6.50 ± .00 00 0.0 0.0 ± 0.0
Total 490 100 10.6 ± 1.44 490 100 11.4 ± 1.15
Z=16.85 P< 0.000
There was rise in mean haemoglobin concentration from 10.6 ±1.44 g/dl to 11.4 ±1.15 g/dl after intervention. The rise in mean haemoglobin before and after intervention (0.80g/dl) was found to significant.
DISCUSSION
A reduction in the frequency of iron supplementation to once ortwice weekly is being widely examined in developing countries on the assumption that the side effects of oral iron will decrease and that thereduction in administered iron will be offset by a lesser inhibition inabsorption from iron taken on the previous day.
The prevalence of anaemia in urban slum school children aged 6 to 11 yr was found to be 76.3 percent in the present study. DeMaeyer et al1 reported the prevalence of anaemia in 6-12 yr old children to be 36 per cent10, while Verma M et al found 77 % prevalence among 5-15 yr old urban school children of Punjab6. The National Family Health Survey –II conducted in 1998-99, documented that about 74% children between the ages 6-35 months were anemic11. The prevalence was as high as 93 per cent in children from Varanasi by Aggarwal etal.12 Murthy NK et al found the prevalence of anemia to be 81 % among school going girls in Tamilnadu13. The variations in the prevalence of anaemia in other studies could be explained on the
basis of heterogeneity of the studied population, dietary habits, different nutritional status and incidence of worm infestation in a defined geographical area.
After weekly iron supplementation, the anemia decreased from 76.3% to 42.4% among school children in the present study. Kotecha PV et al observed that anemia decreased from 74.7% to 53.2% after weekly iron supplementation in children14. Meenakshi et al conducted a study among adolescent girls and found a significant decrease (6.8%) in prevalence of anaemia after biweekly iron supplementation15.
The mean haemoglobin increased from 10.6 ±1.44 g/dl to 11.4 ±1.15 g/dl after weekly iron supplementation in the present study. Similar findings were observed by Aggarwal KN et al and Shobha S &
Sharada D16-17. Kapur D et al and Hall A et al also found that weekly iron supplementation significantly decreased the anemia in school children. They found that weekly iron supplementation took longer time to raise haemoglobin, but was found to be effective as well as practical 18-19.
Sunil Gomer et al also observed among pregnant women that equal rise of hemoglobin and hematocrit values in the weekly supplemented group as compared to daily supplemented therapy20.
RESULT
Table I. Degree of Anemia Before and After Intervention in 6-11years Children (N-490)
Degree of anemia Non-anemic Mild Moderate Severe Total
N % N % N % N % N %
Before intervention 114 23.2 254 51.8 116 23.7 06 1.3 490 100
After intervention 282 57.6 174 35.5 34 6.9 00 0.0 490 100
X2= 183.8 df=6 p<.000
Liu et al reported that the compliance was nine times higher with the weekly iron supplementation than that with daily dose in children21.
Tee ES et al conducted a study on Malaysian school girls and concluded that long term weekly iron-folate improved their iron stores and Hb concentration22.
Shah BK et al also observed that weekly supplementation of iron folic acid on adolescent Nepalese girl increased significantly the mean haemocrait levels23.
CONCLUSION AND RECOMMENDATIONS In India, the National Programme for Prevention and Control of Anemia focuses on pregnant women and young children less than 5 years. However, the status of anemia in children is not well documented.
Anemia in children therefore continues to be accorded a very low priority. School health services should be regularized and promoted for early intervention and prevention of long term sequelae of anemia. Amongst the intervention measures, it is important to take up sustained health education, provision of safe drinking water and improvement in environmental sanitation.
It would be also useful to teach them about personal hygiene and conduct health education like healthy eating habits especially consumption of iron rich foods (green leafy vegetables) and vitamin C rich foods and discouraging intake of tea afte meals through ‘School Health Projects’. Topics on health and nutrition should be made an essential part of the school curriculum.
Aanganwari workers, members of Mahila Swasthya Sanghs and Mahila Mandals and Community Volunteers should be involved in these programmes to promote the nutritional status of children.
It is concluded that once-weekly iron supplementation is as effective as daily supplementation for the treatment of iron deficiency anemia. Moreover, weekly iron supplementation is cost effective and has no or fewer side-effects.
However, supervised weekly iron and folic acid supplementation is more effective andhelps to lower the prevalence of anemia in children.
REFERENCES
1. WHO (1968) Techn. Rep. Ser. No. 405
2. DeMaeyer EM, Dallman P, Gurney JM, Hallberg L, Sood SK, Srikantia SG. Preventing and controlling iron deficiency anaemia through primary health care. Geneva : World Health Organization: 1989 p. 8-9.
3. Preventing iron deficiancy in women and children, technical consensus on key issuses. 7-9
october 1998, UNICEF, UNU, WHO, MI, Technical group International Nutrition Foundation, USA 1998
4. Scrimashaw N. 1990. Functional Significance of Iron Deficiency. In: Functional Significance of Iron Deficiency. Third Annual Nutrition Workshop.
Eds. Enwonwu, C, Meharry Medical College, Nashville, TN, USA, 1990, pp 1-14.
5. Demaeyer EM. Preventing and Controlling Iron deficiency anemia through primary health care.
A guide for health administrators and programme managers. Geneva: World Health Oraganisation: 1989. p.14
6. Verma M, Chhatwal J, Kaur G. Prevalence of anaemia among urban school children of Punjab.
Indian Pediatr 1998; 35 : 1181-1186.
7. Park K. Nutrition and Health. In: Park’s Textbook of Preventive and Social medicine. 19th ed.
Jabalpur. Banarsidas Bhanot Publishers; 2007. p.
8. Indian Council of Medical Research. Evaluation of the National Nutritional Anemia Prophylaxis Program. New Delhi. Indian Council of Medical Research, 1989.
9. WHO. Iron deficiency anemia, assessment, prevention and control- A guide for progrmme manager. UNICEF, United Nation, WHO;2001.
10. DeMaeyer E, Adiels-Tegman M. The prevalence of anaemia in the world. World Health Stat Q 1985; 38 : 302-316.
11. Nutrition and the prevalence of anaemia : anaemia among children. In : National Family Health Survey (NFHS-2), 1998-99, International Institute for Population Sciences, Mumbai, India;
2000 p. 271-273.
12. Agarwal DK, Upadhyay SK, Agarwal KN, Singh RD, Tripathi AM. Anaemia and mental functions in rural primary school children. Ann Trop Paediatr 1989; 9 : 194-198.
13. Murthy NK, Srinivasan S, Rani P. Anemia and endurance capacity among children and women of 6-26 years. The Ind J Nutr Dietet. 1989, 26:319- 325.
14. Kotecha PV, Karkar P, Nirupam S. Summary Report: Adolescent girl anemia control programme. Government of Gujrat ( Deptt. Of Health & Education ). UNICEFF;2004: 1-32.
15. Meenakshi et al. Study of prevalence of anemia
& impact of intervention on school going adolescent girls in a rural block of Haryana;
2005p 34
16. Agarwal KN, Gomber S, Bisha H, Som M. Anemia prophylaxis in adolescent school girls by weekly or daily iron-folate supplementation. Indian Pediatr. 2003; 40(4) :296-300
17. Shobha S, Sharada D. Efficacy of twice weekly iron supplementation in nemic adolescent girls.
Indian Paediatr. 2003 40 ( 12) : 1186-90.
35 Ramesh Sharma 147-150.pmd 149 8/27/2012, 6:40 PM
18. Kapur D, Sharma S, Agarwal KN. Effectiveness of nutrition education, iron supplementation or both on iron status in children. India Pediatr. 2003;
40 (12): 1131-1144.
19. Hall A, Roschnik N, Ouatta F, Toure I, Maiga F, Sack M et al. A randomised trial in Mali of the effectiveness of weekly iron supplements given by teacher on haemoglobin concentration of school children. Public Health Nutr 2002; 5(3):
413-418
20. Sunil Gomber, K.N. Agarwal, Charu Mahajan and N. Agarwal. Impact of daily vs weekly hematinic supplementaion on anemia in pregnant women.
India Pediatr 2002; 39:339-346
21. Liu XN, Kang J, Zhao L, Viteri FE. Intermittent iron supplementation in chinese pre-school children is efficient and safe. Food and Nutrition Bulletin. 1995;16: 139-1s46
22. Tee ES, Kandiah M, Awin N, Chong SM, Satgunasigam N, Kamarudin L et al. School administered weekly iron- folate supplement improve haemoglobin and ferritin concentration in Malaysian adolescent girls.American J Clin Nutr. 1999; 69:1249-1256.
23. Shah BK, Gupta P. Weekly vs daily iron and folic acid supplemenation in adolescent Napalese girl.
Arch Peditr Adolesc Med. 2002; 156(2): 131-135
INTRODUCTION
Biceps brachii is a muscle of anterior compartment of arm. By its value itself its clear that it has 2 heads. It is characteristically, described as a two headed muscle that originates proximally by a long head and a short head. Short head arises as a thick flattened tendon from the coracoid apex, together with coracobrachialis muscle. Long head arises as a long narrow tendon from the supraglenoid tubercle of scapula1.
The two heads fuse in the upper half of the arm to form the bulk of biceps muscle. The muscle ends as a flattened tendon, which passes ventrally, turns backwards and laterally to get inserted into the rough posterior area of the radial tuberosity. The biceps brachii muscle is innervated by musculocutaneous nerve (C5 and C6 spinal cord segments) and supplied by brachial and anterior circumflex humeral arteries.
The mode of insertion of biceps muscle makes it a powerful supinator of forearm2.
It has been reported in 10% cases the third head of biceps may arise from the superomedial part of brachialis and is attached to bicipital aponeurosis or medial side of bicipital tendon. Three different type of origin of third head of biceps have been described, they are superior, inferomedial and inferolateral varieties3. The supernumery heads of biceps brachii have clinical importance as they may confuse a surgeon who performs surgical procedures on the arm and may lead to iatrogenic injuries or they may cause compression of important neurovascular structures of upper limb4.
MATERIALS AND METHODS
The present study was undertaken in Department of Anatomy, JJM Medical College, Davangere where 32 (n = 64), formalin dried cadavers were dissected.
The upper extremities of 32 cadavers (n=64) were dissected irrespective of age and sex for undergraduate teaching purpose. The arm was dissected carefully and the biceps muscle was displayed along its whole extent.
The other related structures of the arm were also demonstrated.The details of the additional heads of biceps in 4 upper limbs were examined and photographs were taken accordingly.
Corresponding Author:
Dr. Ravikumar V., Assistant Professor
Department of Anatomy, J.J.M. Medical College, Davangere.
E-mail: drravi_v@rediffmail.com