Severe acute malnutrition (SAM) is the most severe form of undernutrition affecting children aged 6–59 months. It is characterized by a very low weight-for-height (below −3 standard deviations), visible severe wasting, or bilateral pitting edema, and is associated with a markedly increased risk of infections, complications, and mortality if not recognized and treated promptly.(1) SAM remains a major public health challenge, particularly in low- and middle-income countries. Globally, an estimated 45 million children under five years of age are wasted, of whom approximately 13.6 million suffer from severe acute malnutrition.(2) Children with SAM have a five- to eight-fold higher risk of mortality than their well-nourished counterparts owing to impaired immunity, recurrent infections, and multiple metabolic derangements.(3) In addition to protein-energy deficiency, children with SAM frequently develop deficiencies of essential micronutrients, including vitamin A, vitamin D, iron, folate, and vitamin B12, because of inadequate dietary intake, impaired intestinal absorption, and increased physiological requirements. These micronutrient deficiencies adversely affect growth, immune function, neurodevelopment, and clinical recovery.(4) Vitamin B12 (cobalamin) is an essential water-soluble vitamin required for DNA synthesis, erythropoiesis, normal neurological function, and cellular metabolism. It is obtained predominantly from animal-derived foods; therefore, children consuming diets deficient in animal products or those born to vitamin B12-deficient mothers are at increased risk of deficiency. Vitamin B12 deficiency leads to ineffective erythropoiesis, megaloblastic or macrocytic anemia, and, if prolonged, irreversible neurological impairment.(5) In children with SAM, vitamin B12 deficiency is multifactorial and may result from poor dietary intake, low maternal vitamin B12 stores, inadequate breast milk concentrations, inappropriate complementary feeding practices, underlying malabsorption, and the generalized nutritional deprivation associated with severe malnutrition.(6) Recent Indian studies have reported that vitamin B12 deficiency affects approximately 41%–77% of children with severe acute malnutrition, highlighting its high prevalence in this vulnerable population.(7) Beyond hematological abnormalities, vitamin B12 deficiency has also been associated with delayed neurodevelopment, impaired cognitive function, and poor nutritional rehabilitation. Consequently, early identification and timely supplementation of vitamin B12 have become increasingly important components of comprehensive SAM management.(8) Despite the established biological importance of vitamin B12 and its potential impact on hematological and neurological outcomes, its status is not routinely evaluated in many children with severe acute malnutrition. Limited Indian data are available regarding the relationship between vitamin B12 deficiency and hemoglobin status among hospitalized children with SAM. Therefore, the present study was undertaken to determine the prevalence of vitamin B12 deficiency in children with severe acute malnutrition and to evaluate its association with hemoglobin levels and hematological abnormalities.

METHODS

Study Design and Setting - This hospital-based cross-sectional study was conducted in the Department of Pediatrics, Career Institute of Medical Sciences and Hospital, Lucknow, between 2022–2023.

Study Population - Children aged 6–59 months meeting WHO criteria for SAM were included. Exclusion criteria included chronic illnesses, recent transfusions or supplementation, and preterm birth . Sample Size and Sampling - A sample size of 110 was calculated based on a presumed prevalence of 43.5% (Verma et al., 2021) and a 5% margin of error.

Data Collection - A detailed history was obtained, including sociodemographic, dietary, and feeding practices. Anthropometric measurements were taken using standardized methods. Venous blood samples were analyzed for hemoglobin, mean corpuscular volume (MCV), and vitamin B12 using chemiluminescence immunoassay.

Definitions :

SAM: - weight-for-height <-3 SD, - MUAC <11.5 cm, - or bilateral edema

Anaemia: Hb <11 g/dL Mild (10–10.9) Moderate (7–9.9) Severe (<7)

Vitamin B12 deficiency: <200 pg/mL.

Statistical Analysis : Data were analysed using SPSS v29. Categorical variables were compared using Chi-square test; continuous variables were compared using t-test. P<0.05 was considered statistically significant.

RESULTS

Out of 110 children, 69 were male (62.7%) and 41 were female (37.3%). The mean age was 22.38 ± 13.93 months, and 77 children (70.0%) were younger than 24 months.

Table 1. Distribution of patients according to age and sex

χ² = 9.175; p = 0.057 for age-group distribution. Independent-samples t = 0.541; p = 0.590 for mean age.

The above table illustrates that, out of 110 study participants, 69 (62.7%) were male and 41 (37.3%) were female. The 6–12-month, 13–24-month, 25–36-month, 37–48-month and 49–59-month groups comprised 39 (35.5%), 38 (34.5%), 19 (17.3%), 10 (9.1%) and 4 (3.6%) children, respectively. The mean age was 21.83 ± 14.88 months among males, 23.32 ± 12.29 months among females and 22.38 ± 13.93 months overall. Neither age-group distribution nor mean age differed significantly by sex.

Table 2. Distribution of patients according to vitamin B12 status

The above table illustrates that, out of 110 study participants, 48 (43.6%) had vitamin B12 deficiency and 62 (56.4%) had normal vitamin B12 status. Deficiency was present in 27/69 males (39.1%) and 21/41 females (51.2%), with no significant sex-wise association (χ² = 1.528; p = 0.216). The mean vitamin B12 level was 219.16 ± 40.67 pg/mL among males, 216.77 ± 41.37 pg/mL among females and 218.27 ± 40.76 pg/mL overall, with no significant mean difference (t = 0.296; p = 0.768).

Table 3. Association of vitamin B12 deficiency with haematological status

The above table illustrates that, out of 110 study participants, anemia was present in 98 (89.1%): 24 (21.8%) had mild, 53

(48.2%) moderate and 21 (19.1%) severe anemia, while 12 (10.9%) were non-anemic. Severe anemia occurred in 15/48 vitamin B12-deficient children (31.3%) and 6/62 non-deficient children (9.7%), and the overall anemia distribution differed significantly (χ² = 13.77; p = 0.003). Platelet counts below 1 lakh/mm³ occurred in 10/48 deficient children (20.8%) and 7/62 non-deficient children (11.3%), without a significant association (χ² = 2.996; p = 0.392). Macrocytosis was present in 41/48 deficient children (85.4%) and 1/62 non-deficient child (1.6%), with a significant association between vitamin B12 status and MCV category (χ² = 80.94; p < 0.001).

DISCUSSION

The present study demonstrated that 43.6% of children with severe acute malnutrition (SAM) had vitamin B12 deficiency. This prevalence is comparable with previous Indian studies. Vaid et al. reported a high prevalence of vitamin B12 deficiency among hospitalized children with SAM, while Atiq et al. also observed that vitamin B12 deficiency is common in children with severe acute malnutrition and adversely influences nutritional recovery and development. Similar findings were reported by Nikièma et al., who demonstrated that vitamin B12 deficiency remains highly prevalent among malnourished children undergoing nutritional rehabilitation in low-resource settings. These findings indicate that vitamin B12 deficiency is a frequent micronutrient deficiency in children with SAM and warrants routine evaluation during management (7,8,10). The demographic profile of the present study showed that most children were below 24 months of age, with males constituting 62.7% of the study population. Although vitamin B12 deficiency was more frequent among females (51.2%) than males (39.1%), the difference was not statistically significant. Similar observations have been reported by Vaid et al. and Atiq et al., suggesting that vitamin B12 deficiency in SAM is more closely related to nutritional inadequacy than to gender (7,8). The present study further demonstrated a significant association between vitamin B12 deficiency and hematological abnormalities. Overall, 89.1% of the study population was anemic, and children with vitamin B12 deficiency had a significantly higher frequency of severe anemia compared with children having normal vitamin B12 levels. These findings are comparable with those reported by Arya et al., who described a high prevalence of anemia among children with SAM, and by Venigalla et al., who also reported severe anemia as a common hematological manifestation in severely malnourished children (9,13). A particularly important observation in the present study was the strong association between vitamin B12 deficiency and macrocytosis. Macrocytic blood picture was observed in 85.4% of vitamin B12-deficient children compared with only 1.6% of those without deficiency (p < 0.001). This finding is biologically plausible because vitamin B12 plays an essential role in DNA synthesis and erythrocyte maturation. Similar hematological changes have been reported by Mangshetty et al., who observed macrocytic anemia as the predominant presentation of pediatric vitamin B12 deficiency, while Halicioglu et al. demonstrated comparable hematological abnormalities among vitamin B12-deficient infants (6,14). Although thrombocytopenia was more common among vitamin B12-deficient children than those without deficiency, the difference was not statistically significant. This suggests that platelet abnormalities may accompany vitamin B12 deficiency but occur less consistently than anemia and macrocytosis. Similar observations have been reported in previous pediatric studies evaluating the hematological manifestations of vitamin B12 deficiency (6,14). Overall, the findings of the present study reinforce that vitamin B12 deficiency is highly prevalent among children with severe acute malnutrition and is closely associated with anemia and macrocytosis. Routine assessment of vitamin B12 status in children admitted with SAM may facilitate early diagnosis, timely supplementation, and improved hematological recovery, thereby strengthening existing nutritional rehabilitation protocols.

CONCLUSION

Vitamin B12 deficiency is highly prevalent among children with severe acute malnutrition and is significantly associated with severe anemia and macrocytosis. Routine screening and timely vitamin B12 supplementation should be considered as part of comprehensive management protocols for children with severe acute malnutrition.

DISCLOSURE

Conflict of interest- None

Funding- No

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