Anaemia and malnutrition continue to be major public health challenges, particularly in developing countries, where they disproportionately affect children under five. Anaemia, characterized by a reduced haemoglobin concentration, is commonly caused by iron deficiency but may also result from vitamin B12 and folate deficiencies, parasitic infections, and chronic illnesses [1]. Children with anaemia often suffer from impaired cognitive development, stunted physical growth, and increased vulnerability to infections, which can lead to severe developmental setbacks if left untreated [2]. Malnutrition, especially undernutrition, frequently coexists with anaemia, further heightening the risk of morbidity and mortality in this vulnerable group [3]. Globally, approximately 40% of children under five are affected by anaemia, with the highest prevalence observed in regions such as Southeast Asia and sub-Saharan Africa [4].

According to the World Health Organization (WHO), the prevalence of anaemia in children under five was estimated at 42% in 2019, with malnutrition playing a key role in its persistence [5]. India, which carries a significant share of the global anaemia burden, has implemented various public health initiatives to combat the issue. However, the condition remains widespread, particularly in rural and low-income communities [6]. Recent national surveys highlight micronutrient deficiencies, particularly in iron and zinc, as major contributors to the high anaemia rates among children [7]. Malnutrition in early childhood can lead to stunting, wasting, and a weakened immune system, all of which increase the likelihood of anaemia. Research indicates that inadequate dietary intake, recurrent infections, and poor socioeconomic conditions are primary factors driving both anaemia and malnutrition in children [8].

Addressing these issues requires a comprehensive approach that integrates nutritional supplementation with efforts to improve food security, hygiene, and healthcare access [9]. While interventions such as iron supplementation and food fortification have been introduced to reduce anaemia and malnutrition, recent studies suggest that their effectiveness is often hindered by socioeconomic challenges such as poverty, education, and healthcare accessibility [10]. Understanding the intricate link between anaemia and malnutrition is crucial for designing effective strategies to combat these conditions, particularly in resource-limited settings. This study aims to examine the relationship between anaemia severity and malnutrition profiles in hospitalized children aged 6 months to 5 years, offering insights into potential interventions to alleviate these burdens.

Study Design: This observational, cross-sectional study was conducted in the paediatric department of a tertiary care hospital to assess the association between anaemia severity and malnutrition in children aged 6 months to 5 years. Study Participants: All the children with anaemia and malnutrition in paediatric department were included, while those with congenital haematological disorders such as thalassemia were excluded. Sample size and period: A sample size of 218 children was calculated based on a prevalence of anaemia of 42%, a margin of error of 5%, and a 95% confidence level. A study was conducted between July 2024 to October 2024. Data Collection: Data were collected by clinical observation, medical records, and laboratory tests. Haemoglobin concentrations were measured using a portable hemoglobinometer (HemoCue Hb 301) and categorized as mild, moderate or severe based on WHO guidelines. Anthropometric measurements, such as weight and height, were used to evaluate malnutrition. Variables: The dependent variable was anaemia severity, while the independent variables included malnutrition indicators (wasting, stunting). Statistical Analysis: Descriptive statistics summarized the data, correlation analysis and Regression Analysis was conducted using Pearson’s correlation coefficient and chi-square test, with statistical significance set at p < 0.05. SPSS version 26. Ethical Considerations: Ethical approval was obtained from the Institutional Ethics Committee and consent from caregivers was taken. Participant data were anonymized to maintain confidentiality.

Ethics Approval: The study received ethical clearance from the institutional ethical committee (CUSMC/IEC(HR)/RP/39/2024/ Pro. Approval

The study explored the link between anaemia severity and the prevalence of wasting and stunting in children, uncovering key patterns through statistical analysis.

Results showed a clear trend: as anaemia worsened, the prevalence of wasting increased. Among children with mild anaemia (haemoglobin 10–10.9 g/dL), 34.48% (10 out of 29) were wasted. This proportion rose to 44.19% (19 out of 43) in those with moderate anaemia (haemoglobin 7–9.9 g/dL) and peaked at 50.00% (24 out of 48) in children with severe anaemia (haemoglobin <7 g/dL).

A similar but even stronger trend was observed for stunting. Among children with mild anaemia, 51.72% (15 out of 29) were stunted. The prevalence increased to 65.12% (28 out of 43) in those with moderate anaemia and reached 72.92% (35 out of 48) in children with severe anaemia. These findings suggest a more pronounced association between anaemia and stunting than between anaemia and wasting.

Pearson’s correlation analysis confirmed these trends. The relationship between anaemia severity and wasting was weaker, with correlation coefficients of r = 0.144 (mild), r = 0.168 (moderate), and r = 0.198 (severe). In contrast, the association with stunting was stronger, with coefficients of r = 0.235 (mild), r = 0.271 (moderate), and r = 0.302 (severe), indicating a moderate positive correlation.

However, statistical significance differed between the two conditions. The Chi-square test revealed that the association between anaemia severity and wasting was not significant, with p-values of 0.256 (mild), 0.181 (moderate), and 0.128 (severe). In contrast, the association with stunting was statistically significant, with p-values of 0.036 (mild), 0.020 (moderate), and 0.015 (severe), confirming a strong link between increasing anaemia severity and stunting.

Regression analysis further supported these findings. For wasting, anaemia severity had the strongest effect in children with severe anaemia (β = 0.332, p = 0.015), whereas the effect was weaker and not statistically significant in mild and moderate anaemia (β = 0.155, p = 0.314 and β = 0.240, p = 0.089, respectively).

For stunting, the association was stronger across all levels of anaemia. Even mild anaemia significantly increased the risk (β = 0.289, p = 0.019), with the effect becoming more pronounced in moderate (β = 0.370, p = 0.002) and severe anaemia (β = 0.418, p = 0.001).

Overall, the findings highlight a significant association between anaemia and stunting, while the link with wasting appears weaker. These results emphasize the need for targeted interventions addressing both anaemia and malnutrition to mitigate their long-term impacts on child growth and development.

Table 1: Prevalence of Wasting and Stunting by anaemia Severity

Table. 1 presents the prevalence of wasting and stunting among children, highlighting a clear trend of increasing prevalence with greater anaemia severity.

Table 2: Correlation between anaemia Severity and Wasting

Table. 2 illustrates the correlation between anaemia severity and wasting, showing a weak positive relationship that slightly strengthens as anaemia severity increases.

Table 3: Correlation between anaemia Severity and Stunting

Table. 3 shows a moderate positive correlation between anaemia severity and stunting, with the association strengthening as anaemia severity increases.

Table 4: Chi-Square Test for anaemia Severity and Wasting

Table. 4 indicates no significant association between anaemia severity and wasting at any level of anaemia.

Table 5: Chi-Square Test for anaemia Severity and Stunting

Table. 5 demonstrates a significant association between anaemia severity and stunting across all levels of anaemia.

Table 6: Regression Coefficients (β) for anaemia Severity on Wasting

Table. 6 presents regression analysis findings, indicating that severe anaemia has a statistically significant effect on wasting.

Table 7: Regression Coefficients (β) for anaemia Severity on Stunting

Table. 7 presents regression coefficients demonstrating a significant relationship between anaemia severity and stunting, with the strongest effect observed in cases of severe anaemia.

Figure 1: Box Plot: Hemoglobin Levels by Age

The median hemoglobin level increases with age, indicating improved hemoglobin levels in older children, but with greater variability and presence of outliers. There is a significant improvement in hemoglobin levels between 24-30 months and 31-36 months, emphasizing the need for individualized assessment.

Figure 2: Area Chart: Malnutrition Prevalence by Age Group

Stunting is more prevalent than wasting across all age groups, with the highest number of cases observed in the 18-24 months age group. After 24 months, stunting decreases, indicating improved nutritional status, while wasting remains relatively consistent across age groups.

This study emphasizes the strong link between anaemia severity and malnutrition, particularly wasting and stunting, in children aged 6 to 59 months. The increasing prevalence of both conditions with worsening anaemia aligns with previous research indicating that malnourished children are more susceptible to severe anaemia [11]. The association between anaemia and stunting was more pronounced than that with wasting, as evidenced by a moderate positive correlation in the statistical analysis. This aligns with global findings showing that chronic malnutrition, reflected in stunting, is more closely linked to long-term micronutrient deficiencies, especially iron deficiency anaemia, than acute malnutrition (wasting) [12]. The significant association between anaemia severity and stunting at all levels of anaemia in this study is consistent with research from sub-Saharan Africa, which observed similar patterns [13]. This suggests that chronic malnutrition, as indicated by stunting, increases the risk of anaemia and vice versa. Conversely, the weaker and statistically non-significant association between anaemia and wasting in this study highlights the distinct impact of acute and chronic malnutrition on anaemia outcomes [14]. These findings underline the importance of interventions addressing both acute and chronic malnutrition to effectively mitigate anaemia risk. Regression analysis further corroborates this, demonstrating that severe anaemia significantly influences both wasting and stunting, with a more substantial effect on stunting. The stronger regression coefficients for stunting suggest that anaemia prevention strategies should take a comprehensive approach to child nutrition, with a particular focus on preventing stunting, given its long-term health implications [15]. Although this study aligns with research linking anaemia and stunting, some regional studies have reported differing results. For example, research from South Asia has identified a significant correlation between wasting and anaemia, potentially due to varying socioeconomic and environmental conditions that contribute to both acute malnutrition and anaemia [16]. This variation suggests that the anaemia-malnutrition relationship may be influenced by regional factors such as dietary patterns, healthcare access, and the prevalence of infections like malaria and intestinal worms, which can exacerbate both conditions [17]. A key strength of this study is its use of regression analysis to identify severe anaemia as a major predictor of both wasting and stunting, reinforcing the necessity of targeted interventions for at-risk populations. However, due to its cross-sectional design, causality cannot be established. Future longitudinal studies could provide deeper insight into the temporal dynamics between anaemia and malnutrition [18]. These findings highlight the critical need for integrated interventions that extend beyond iron supplementation. Tackling broader nutritional deficiencies, especially those contributing to stunting, could greatly enhance public health strategies in developing nations where both anaemia and malnutrition are widespread.

Limitations of the study:

This study's cross-sectional design limits the ability to establish causality between anaemia severity and malnutrition. The data provide only a snapshot, and longitudinal studies are needed to determine directionality. The sample size was limited to a single tertiary care hospital, potentially reducing generalizability. Additionally, confounding factors like parasitic infections, chronic illnesses, and genetic disorders were not accounted for, which could influence anaemia and malnutrition outcomes.

This study highlights the strong link between anaemia severity and malnutrition, particularly stunting, in children aged 6 to 59 months. The findings reveal a clear pattern: as anaemia worsens, the prevalence of both stunting and wasting rises, with stunting showing a stronger correlation. This suggests that chronic malnutrition plays a more significant role in anaemia than acute malnutrition, reinforcing the need for comprehensive public health strategies that address both anaemia and underlying nutritional deficiencies.

The study emphasizes that simply providing iron supplements is not enough—improving overall nutrition is crucial in preventing stunting and reducing the burden of anaemia. Since the relationship between anaemia and malnutrition can vary across regions, interventions should be tailored to local contexts for greater effectiveness. Future research should focus on understanding the long-term impact of anaemia and malnutrition through longitudinal studies while considering factors like infections and socioeconomic conditions.

Tackling these complex health challenges requires an integrated approach that goes beyond medical treatment. Strengthening nutrition programs, ensuring better access to healthcare, and improving socio-economic conditions are all essential to reducing the risk of anaemia and its associated complications.

Contribution:

Tirth Prajapati, Radhikaba N Vaghela, and Kamleshkumar G Rathod played a key role in conceptualizing and designing the study. Ketan Gadhvi and Kishan Patel were responsible for data collection, ensuring accuracy and completeness. Bharat Muliya and Radhikaba N Vaghela conducted the statistical analysis and interpreted the findings. Kamleshkumar G Rathod took the lead in drafting the manuscript, while Ketan Gadhvi and Bharat Muliya provided critical revisions to enhance its intellectual depth. All authors actively participated in refining the manuscript and gave their final approval for publication.

Funding Source: This study did not receive any external funding.

Conflict of Interest: All authors declare that they have no competing interests to disclose.

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