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Evaluation report

2000 BHG: Intervention programme for Prevention of Nutritive Anaemia in Children Aged 0-6 in Federation Bosnia and Herzegovina

Executive summary


Nutritive anaemia poses a big health problem for the young, elderly, pregnant women and especially children younger than 5. One of the goals of the 1990 World Children Summit was the reduction of nutritive anaemia, particularly those caused due to iron deficiency among risk population groups, by the year 2000. The results toward achieving this goal and eliminate this condition show small progress. UNICEF and WHO in 1999 consulted representatives of 27 countries from the Central Eurpoean region, including the countries of the former Russian Federation, to start activities on prevention and control of nutritive anaemia, including changes in nutrition of infants and small children.

Purpose / Objective

An intervention to prevent nutritive anaemia was conducted in the region of Central Bosnia, Zenica-Doboj, Una-Sana, Sarajevo and Herzegovina-Neretva cantons. In health institutes in Travnik, Zenica, Bihac, Sarajevo, Konjic and Jablanica, teams of doctors have been set up to implement the programme. These teams were trained according to the diagnostic and therapeutic protocol for nutritive anaemia among children up to 6 years old.


The intervention programme included all children who went to see a doctor and who were diagnosed as anaemic, based on the criteria for Hb plasma concentration, one month since the start of the project.

A survey questionnaire was designed for the needs of the programme. It consisted of a questionnaire for the first examination and 5 control (check-up) questionnaires. At first examination, the questionnaire was filled out for all children. For children with anaemia, questionnaires were filled at every next check-up, 6 months after the first examination at the most.

Clinical signs were observed according to the determined protocol. If the child had just one clinical sign of anaemia, we believed that the clinical signs are there. Nutritive anaemia was diagnosed on the basis of haemoglobin concentrations in plasma according to the protocol criteria: Hg <11gr/dl for children up to 5 years of age and Hg<12gr/dl for children aged 6-12 (1, 6, 7). Other diseases found during examination were registered in the questionnaire, including respiratory, gastrointestinal and urinary infections.

In addition to therapy, dietary habits for children older than 6 were also observed. Mothers provided information about the type of food and number of meals that the child had. If the nutrition was made of iron-rich foods (defined by the protocol 7 on the type of foods) and if the child had at least two such foods per day, the nutrition was considered satisfactory; if the daily nutrition included one iron-rich food, it was considered partly satisfactory; and if the daily nutrition did not have iron-rich foods, the diet was considered unsatisfactory.

Key Findings and Conclusions

During a one-month period, as envisaged by the protocol, there were 826 anamnestic examinations of children up to 6 years of age with Hb<11 gr/dl.

Among the examined children, 8.8. percent belong to a high-risk (susceptible) group of children. The risk factors for the development of iron deficiency anaemia are prematurely-delivered babies, low-weight newborns, twins and children who had a haemorrhage in the perinatal period. The most at-risk were the prematurely delivered babies (1.4 percent) and twins (1.8 percent). The combinations of high-risk children are found in 4.7 percent of cases. The most frequent combination is prematurely delivered babies with low weight (2.1 percent). Within the high risk group, most frequent were prematurely-delivered babies -- 16.4 percent, and twins -- 20.5 percent, while there were 53.5 percent of the combined cases of lower birth weight. (Graph 3)

Of the children examined, 131 or 15.8 percent were never breastfed. The other 695, or 83.2 percent were breastfed for a different duration and period during the first year of their life. In the first year, 15.8 percent of children were not breastfed and received milk substitutes or cow milk, while 84.1 percent were breastfed for a different period. Of the total number of children, 61.7 percent were breastfeeding during the first four months of age, 19.4 during 6 months, 13.9 up to one year of age, and 4.7 percent continued to be breastfed after they turned 1 year.

Supplemental food to children with anaemia consisted of cow milk and milk substitutes. Within 4 months, 35.8 percent of children were given diluted cow milk, 12.7 percent pure cow milk and 36.3 percent milk substitutes. Only 15.2 percent of children were without supplemental food. In the sixth month, almost all children had supplemented diet, 42.4 percent were given pure and 42.0 percent diluted cow milk. Only a small number of children had industrial milk supplements. Only 3.2 percent were not given supplemental food.

The earliest supplemental food started in the second month of life among 4.0 percent of children, with a fruit meal. In the fourth month, 51.8 percent of children had a fruit meal and 40.1 percent had vegetables. Meat is introduced as a meal among 66.9 percent of children at the age of six months. In the sixth month, 80.3 percent of children have a fruit meal, 61.8 percent meat meal and 77.1 percent have vegetables as a meal. Milk with biscuit or flour is a frequent meal among anaemic children. In the fourth month, as many as 68.0 percent of children have it and, in the sixth month, even 75 percent of children.

The primary clinical signs of anaemia were observed: pale skin, dry and desquamating skin, bright and brittle hair, brittle and breakable nails, slow growth and development. At the first examination, one or more clinical signs were detected among 54.4 percent of children. A total of 377 children did not have clinical symptoms of nutritive anaemia. These symptoms were equally distributed among regions, except in Zenica where clinical symptoms were detected only among 19.6 percent, while in Jablanica 90.3 percent of children manifested symptoms.

The concentration of haemoglobin in plasma is used as diagnostic criteria for nutritive anaemia. According to the adopted Protocol for diagnosing nutritive anaemia, the haemoglobin concentration of below 11 gr/dl is considered as anaemic condition for children under 5 (standard or borderline value). The average value of haemoglobin at first examination was 10.1 gr/dl. Regionally, the lowest values were detected among children from Bihac, Zenica and Konjic. Lower haemoglobin values were discovered among children older than 1 year, while the highest average haemoglobin values were among children up to 6 months.

The average values of haemoglobin in risk groups were lower compared to other anaemic children and varied between 8.7 to 8.8 gr/dl. The concentration of haemoglobin in children who eat artificial food, and who drink cow milk with biscuits or flour averaged 9.5 gr/dl.

Nutritive anaemia can appear in lighter cases of respiratory, gastrointestinal and urinary infections and these health conditions do not bear a significant effect on haemoglobin concentrations. Upon the first examination, 19.0 percent were diagnosed with respiratory infections, 1.5 percent with urinary and 1.2 percent with gastrointestinal infections.

After one month, all children came for a check-up. In total, there were four check-ups. The average haemoglobin values increased at every check-up, reaching normal values after three months of treatment. At first examination, the average Hb concentration was 10.1 gr/dl, which increased to 11.2 gr/dl at the third check-up and to 11.5 gr/dl at the fourth check-up. Regionally, the normal average values of haemoglobin were reached after the second check-up in Sarajevo and after fourth check-up in Konjic, Travnik and Zenica.

At first examination, nutrition was not satisfactory among 27.2 percent of children; it was partly satisfactory in 24.6 percent and adequate in 42.2 percent (for 6 percent, there is no data). The check-ups showed that the situation in nutrition was improving from 18.0 percent who did not have adequate nutrition at first, to 13.4 at the second, 8.7 at the third, to 0 percent at the fourth check-up, showing that there were no children who had inadequate foods.

At first examination, 57.6 percent of anaemic children received adequate therapy. At first check-up, 79.8 percent of anaemic children received adequate therapy and, at subsequent check-ups, the percentage of adequate therapy increased to 95 percent. With improved anaemic condition, subsequent examinations show a reduced number of other infections. At the first check-up, 2.1 percent had respiratory infections; the number dropped down to 1.3 percent at the second examination.


A relatively successful therapeutic and dietary effect of the treatment of anaemic children shows that the applied programme was a success that produced positive results. A precise diagnosis of anaemic condition, defining of risk factors for development of this disease, and proper therapeutic and dietary regimen indicate that the programme needs to be continued in other regions in FBiH. Although the goal of this programme was not to assess the prevalence of the anaemic condition among children, we found that this condition is significantly prevalent among children and that a more robust, corrective action is necessary.

Children with anaemic condition were mostly nourished with artificial foods or were exposed to breastfeeding for a shorter period of time, while the administering of additional food started almost immediately with cow milk mixed with biscuits or flour. Early introduction of cow milk and biscuits, as well as fruits and vegetables is a commonplace in these regions. Such diet is conducive to the development of disorders, especially because supplementation starts very early, before the fourth month of age. This is substantiated by the fact that the average haemoglobin values are the lowest among children who were given cow milk and biscuits (except the risk-groups of children).

The intervening programme was implemented only on one target group, according to the WHO and UNICEF recommendations. Namely, the Programme for Control and Prevention of Iron Deficiency Anaemia (1, 10) recommends the implementation of this programme not just for children, but also pregnant and lactating women, and women in adolescent age.

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