Anemia severity among children aged 6–59 months in Gondar town, Ethiopia: a community-based cross-sectional study

Italian Journal of Pediatrics, Sep 2018

Anemia is a public health problem affecting both developed and developing countries. Childhood anemia is associated with serious consequences including growth retardation, impaired motor and cognitive development, and increased morbidity and mortality. Hence, this study aimed at assessing the prevalence and factors associated with severity of anemia among children aged 6–59 months in Gondar town, northwest Ethiopia. A community-based cross-sectional study was conducted. A multi-stage sampling technique was employed to select study participants. Socio demographic and socioeconomic data were collected using a pre-tested structured questionnaire. Anthropometric measurements were taken as per WHO recommendation. Hemoglobin (Hb) concentration was measured using a portable HemoCue301 instrument (A Quest Diagnostic Company, Sweden). Mild anemia corresponds to a level of adjusted Hb of 10.0–10.9 g/dl; moderate anemia corresponds to a level of 7.0–9.9 g/dl, while severe anemia corresponds to a level less than 7.0 g/dl. Descriptive statistics were used to describe the study participants. Both bivariable and multivariable ordinal logistic regression were done, and proportional odds ratio (POR) with a 95% confidence interval (CI) was reported to show the strength of association. A p-value < 0.05 was considered statistically significant. Out of the total of 707 children included in this study, more than half (53.5%) of them were male. The median age of children was 30 months. Two hundred two (28.6%) of children were anemic: 124(17.5%) were mildly anemic, 73(10.3%) were moderately anemic, and 5 (0.7%) were severely anemic. The young age of the child, low frequency of child complementary feeding per day, primary maternal educational status, unmarried maternal marital status, and home delivery were factors associated with severity of childhood anemia. Anemia among children aged 6–59 months in Gondar Town was a moderate public health problem. Improving access to education, providing regular health education about childcare and child feeding practices, strengthening the socioeconomic support for single-parent families and conducting regular community-based screening are recommended to reduce childhood anemia.

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Anemia severity among children aged 6–59 months in Gondar town, Ethiopia: a community-based cross-sectional study

Research Open Access Anemia severity among children aged 6–59 months in Gondar town, Ethiopia: a community-based cross-sectional study Mulugeta Melku1Email authorView ORCID ID profile, Kefyalew Addis Alene2, Betelihem Terefe1, Bamlaku Enawgaw1, Belete Biadgo3, Molla Abebe3, Kindie Fentahun Muchie2, Asemarie Kebede4, Tadele Melak3 and Tsedalu Melku5 Italian Journal of Pediatrics201844:107 https://doi.org/10.1186/s13052-018-0547-0 ©  The Author(s). 2018 Received: 2 May 2018Accepted: 26 August 2018Published: 3 September 2018 Abstract Background Anemia is a public health problem affecting both developed and developing countries. Childhood anemia is associated with serious consequences including growth retardation, impaired motor and cognitive development, and increased morbidity and mortality. Hence, this study aimed at assessing the prevalence and factors associated with severity of anemia among children aged 6–59 months in Gondar town, northwest Ethiopia. Method A community-based cross-sectional study was conducted. A multi-stage sampling technique was employed to select study participants. Socio demographic and socioeconomic data were collected using a pre-tested structured questionnaire. Anthropometric measurements were taken as per WHO recommendation. Hemoglobin (Hb) concentration was measured using a portable HemoCue301 instrument (A Quest Diagnostic Company, Sweden). Mild anemia corresponds to a level of adjusted Hb of 10.0–10.9 g/dl; moderate anemia corresponds to a level of 7.0–9.9 g/dl, while severe anemia corresponds to a level less than 7.0 g/dl. Descriptive statistics were used to describe the study participants. Both bivariable and multivariable ordinal logistic regression were done, and proportional odds ratio (POR) with a 95% confidence interval (CI) was reported to show the strength of association. A p-value < 0.05 was considered statistically significant. Result Out of the total of 707 children included in this study, more than half (53.5%) of them were male. The median age of children was 30 months. Two hundred two (28.6%) of children were anemic: 124(17.5%) were mildly anemic, 73(10.3%) were moderately anemic, and 5 (0.7%) were severely anemic. The young age of the child, low frequency of child complementary feeding per day, primary maternal educational status, unmarried maternal marital status, and home delivery were factors associated with severity of childhood anemia. Conclusion Anemia among children aged 6–59 months in Gondar Town was a moderate public health problem. Improving access to education, providing regular health education about childcare and child feeding practices, strengthening the socioeconomic support for single-parent families and conducting regular community-based screening are recommended to reduce childhood anemia. Keywords AnemiaAssociated factorsChildrenSeverity Background Anemia, defined as a low blood hemoglobin (Hb) concentration, is one of the most common and widespread disorders in the world, affecting one-quarter of the world’s population. It is a major public health problem in several countries, particularly common among preschool-aged children and women [1]. According to the 2011 World Health Organization (WHO) report, anemia resulting from iron deficiency was one of the most important factors contributing to the global burden of diseases, and it increases morbidity and mortality in preschool-aged children and pregnant women [2]. Globally, anemia affects 1.62 billion people, which correspond to 24.8% of the population. The highest prevalence is found in preschool-age children (47.4%). WHO regional estimate indicated that the highest proportion of anemic preschool-age children are residing in Africa [2, 3]. Anemia is also a major public health problem among preschool-aged children in Ethiopia [4]. Childhood anemia has a substantial association with social, economic, psychological, and health-related problems. The evidence demonstrated that early childhood anemia is a strong predictor of adulthood anemia [4]. A considerable number of studies reported that childhood iron deficiency anemia has been strongly correlated with psychiatric disorders, mental retardation and developmental disorders [5–8]. Anemia dysfunctions recent and past memory concentration domain of the children. Children with anemia have a lower developmental index, poor motor development, no interest in their environment, a shorter attention span, diminished cognitive ability and behavioural problems [9]. As a result, anemia at early childhood continues to affect school achievement and behavioural development negatively [10, 11]. In addition, childhood anemia is a common condition causing significant morbidity and mortality. Severe anemia carries a high ‘hidden’ morbidity and mortality occurring months after initial diagnosis and treatment, and it is the common contributing factor for overall under-five mortality [12]. The etiology of anemia is often multi-factorial and interrelated in a complex way. In developing countries, micronutrient deficiency and infectious diseases take the greatest part [13–17]. Socio-economic status, demographic characteristics, child feeding practices, accessibility for preventive and curative health services have also been playing a major role [18–20]. Maternal anemia during pregnancy may also be associated with the development of childhood anemia [21, 22]. Besides, genetic factors like hemoglobinopathies are the cause of anemia [14, 23]. Anemia prevalence data remains to be an important indicator of public health since anemia is related to morbidity and mortality, particularly in a most vulnerable segment of the population such as preschool-aged children and pregnant women [22]. In order to make a full use of these prevalence data, information on factors associated with anemia should be collected so that interventions can be better adapted to the local situation and can, therefore, be more effective. However, much is not known about the prevalence and associated factors of childhood anemia severity in Ethiopia. Thus, the aim of this study was to assess the prevalence and factors associated with severity of anemia among children aged 6–59 months in Gondar town, northwest Ethiopia. Methods Study design, population, and sampling technique A community-based cross-sectional study was conducted in April 2015 among children aged 6–59 months in Gondar town, northwest Ethiopia. A sample size of 735 was calculated by single population proportion formula, considering estimated prevalence of anemia (35.1%) among children aged 6–59 month in Amhara region [4], 95%CI, 5% margin of error, design effect of 2, and 5% non- response rate. A multi-stage random sampling technique was employed to select study participants in two stages. At the first stage, four out of twelve kebeles (smallest administrative units) (i.e. 30% of the total area) were selected by simple random sampling technique. At the second stage, a total of 735 households were selected using a systematic random sampling method with proportional allocation to each selected kebeles. The total number of households with children aged between 6 and 59 months was obtained from the respective administrative areas and used to calculate the sampling fraction. In the case where more than one children were found eligible in the selected households, only one of them was chosen randomly using the lottery method. Data collection methods and instruments A pretested structured questionnaire was used to collect socio-demographic and economic data from mothers by face-to-face interview. Anthropometric measurements such as weight and height were measured for children according to the 2006 WHO recommendation [24]. Z-scores for weight-for-age (WAZ), height-for-age (HAZ), and weight-for-height (WHZ) were calculated using WHO Anthro software. Nutritional status was defined as underweight if WAZ was less than − 2 standards deviation (SD), stunting if HAZ was less than -2SD, and wasting if WHZ was less than -2SD [25]. Body mass index (BMI) was also calculated for the mothers according to the WHO STEP-wise surveillance manual [26]. Hb was measured by a portable HemoCue301 instrument (A Quest Diagnostic Company, Sweden) from capillary blood. HemoCue method of Hb determination is recommended by WHO to determine population prevalence of anemia, and several studies have established the validity of this instrument [24, 27]. After adjusting Hb concentration for altitude, anemia was defined as mild if Hb was between 10 and 10.9 mg/dl, moderate if between 9.9 and 7 g/dl, and severe if < 7 g/dl [24]. Data quality assurance The questionnaire was prepared in English, translated to Amharic and then translated back to English to check for consistency. Data were collected by trained data collectors (BSC nurses and senior medical laboratory technologists) after training was given about the objective of the study, confidentiality issues, study participants’ right, consenting, techniques of interview, and Hb and anthropometric measurements. The data collection process was closely supervised by investigators. All measurements were performed by following the manufacturers’ recommendation. Data management and analysis Data were entered using Epi Info version 3.5.3 statistical software, and then exported to SPSS version 20 for analysis. Descriptive statistics including frequencies, percentages, median, and interquartile range were performed to describe the study participants. The bi-variable and multi-variable proportional odds model (POM), the most widely used family of ordinal logistic regression in epidemiological studies, was fitted to identify factors associated with severity of childhood anemia. The proportionality assumptions for POM were checked using Chi-square parallel line tests, (p-value = 0.791) indicating that the assumption was not violated. The Pearson chi-square goodness-of-fit test showed that the model fitted the data well (p = 0.152). All variables with a p-value ≤ 0.2 in the bivariable analysis were fitted into the multivariable analysis to control confounding effects. Adjusted proportional odds ratio (aPOR) with a 95% CI was used to evaluate the strength of statistical association between explanatory and outcome variables. All variables with p-values < 0.05 in the multi-variable analysis were considered to be statistically significant. Result Characteristics of study participants A total of 735 children were selected; of whom 707 participated in the study, with a response rate of 96.2%. More than half, 378 (53.5%), of the children were male. The median age of children was 30 months (interquartile range (IQR) =24 months). From the total children, 323 (45.7%) were stunted, 562 (79.5%) were delivered at health institutions, and 577(81.6%) had been exclusively breastfed for 6 months (Table 1). Table 1 Characteristics of children aged 6–59 months who participated in the study, Gondar Town, April 2014 Characteristics Categories Frequency (n) Percentage (%) Sex of child Male 378 53.5 Female 329 46.5 Age of child (months) 6–11 74 10.5 12–23 181 25.6 24–35 174 24.6 36–47 155 21.9 48–59 123 17.4 Child’s place of delivery At home 145 20.5 At health institution 562 79.5 Child’s birth type Singleton 692 97.9 Twins 15 2.1 Mode of delivery CS or instrumental delivery 73 10.3 spontaneous vaginal delivery 634 89.7 Pre-lacteal feeding Yes 58 8.2 No 649 91.8 Exclusive breastfeeding statusa Exclusively breastfed 577 81.6 Not exclusively breastfed 130 18.4 Breastfeeding status Being breastfed 301 42.6 Not being breastfed 406 57.4 Preceding birth intervalb 12–24 months 83 19.9 25–48 months 149 35.6 > 48 months 186 44.5 WHZ Wasted 46 6.5 Normal 661 93.5 HAZ Stunted 323 45.7 Normal 384 54.3 WAZ Underweight 111 15.7 Normal 596 84.3 Complementary feeding frequency < 4 time per day 210 29.7 4–5 times per day 440 62.2 > 5 time per day 57 8.1 aAn exclusive breastfeeding time was until 6 months of age as to WHO standard; bPercentage was calculated for 418 children whose birth order is 2nd and above; CS: Caesarian section; HAZ: Height-for-Age Z-score; WAZ: Weight-for-Age Z-score; WHZ: Weight-for-Height Z-score Parental characteristics Concerning the maternal characteristics, 619(87.6%) were married, 500(70.7%) were housewives, 472(66.8%) had a normal weight, and 364(51.5%) were 25–30 years old. About 287(40.6%) of children’s fathers were governmental or private sector employees, and 237(33.5%) attended primary education. More than half, 376(53.2%), of children were living in a family with a monthly income of 60–124 US dollar ($). Moreover, 143(20.2%) of the children were living in a family with more than five members, and 142(20.1%) were living in a family with two or more under five-year-old children (Table 2). Table 2 Socio-demographic and economic characteristic of parents of children participated in the study, Gondar Town, April 2014 Characteristics Categories Frequency (n) Percentage (%) Maternal age(year) < 25 165 23.3 25–30 364 51.5 31–35 102 14.4 > 35 76 10.7 Maternal marital status Married 619 87.6 Unmarrieda 88 12.4 Maternal educational status No formal education 220 31.1 Primary education 210 29.7 Secondary education 218 30.8 Tertiary education 59 8.9 Maternal occupation Housewives 500 70.7 Government or private sector employees 38 5.3 Merchants 58 8.2 Daily laborer 111 15.8 Maternal BMI Underweight 95 13.4 Normal weight 472 66.8 Overweight 140 19.8 Paternal educational status No formal education 163 23 Primary education 237 33.5 Secondary education 220 31.1 Tertiary education 87 12.3 Paternal occupation Government or private sector employees 287 40.6 Merchants 236 33.4 Daily laborer 184 26 Family size <  4 250 35.4 4–5 314 44.4 > 5 143 20.2 Number of under-five children 1 565 79.9 ≥2 142 20.1 Family monthly income < $60 162 22.9 $60–124 376 53.2 > $124 169 23.9 aincludes single and widowed, 1USD is equivalent to 20.90 Ethiopian Birr based on the 2015 exchange rate; Unmarrieda: includes Single, divorced and widowed; BMI: Body Mass Index Prevalence of anemia The overall prevalence of anemia among children aged 6–59 months was 202 (28.6%) (95% CI: 25.2–31.9%). The prevalence of mild, moderate, and severe anemia were 124(17.5%), 73(10.3%), and 5(0.7%), respectively. The highest prevalence of anemia (46.8%) was found in children whose mothers did not receive antenatal care (ANC) during pregnancy period of sampled children. Regarding the severity, the highest prevalence of severe anemia (6.7%) was found in twin children. About 24.3%, 21.6% and 2.7% of children aged 6–11 months were mildly, moderately and severely anemic, respectively. Out of the total children being breastfed during the data collection, 1.3%, 15.9% and 23.6% of them were severely, moderately and mildly anemia, respectively (Table 3). Table 3 The prevalence and severity of anemia according to selected children and parental characteristics Variable Categories Anemic status and severity level (n (%)) Severely anemic Moderately anemic Mildly anemic Non-anemic Overall anemia prevalence Sex of child Male 3 (0.8) 38 (10.1) 69 (18.3) 268 (70.9) 110 (29.1) Female 2 (0.6) 35 (10.6) 55 (16.8) 237 (72.0) 92 (28.0) Age of child (months) 6–11 2 (2.7) 16 (21.6) 18 (24.3) 38 (51.4) 36 (48.6) 12–23 1 (0.6) 29 (16.0) 45 (24.9) 106 (58.8) 75 (41.4) 24–35 1 (0.6) 19 (10.9) 27 (15.5) 127 (73.0) 47 (27.0) 36–47 1 (0.6) 6 (3.9) 26 (16.8) 122 (78.7) 33 (21.3) 48–59 0 3 (2.4) 8 (6.5) 112 (91.1) 11 (8.9) WHZ Wasted 0 6 (13.0) 8 (17.4) 32 (69.6) 14 (30.4) Normal 5 (0.8) 67 (10.1) 116 (17.5) 473 (71.6) 188 (28.4) HAZ Stunted 3 (0.9) 30 (9.3) 60 (18.6) 230 (71.2) 93 (28.8) Normal 2 (0.5) 43 (11.2) 64 (16.7) 275 (71.6) 109 (28.4) WAZ Underweight 2 (1.8) 9 (8.1) 23 (20.7) 77 (69.4) 34 (30.6) Normal 3 (0.5) 64 (10.7) 101 (16.9) 428 (71.8) 168 (28.2) Maternal age < 25 years 1 (0.6) 18 (10.9) 41 (24.8) 105 (63.6) 60 (36.4) 25–35 years 0 7 (9.2) 13 (17.1) 56 (73.7) 20 (26.3) > 35 years 4 (0.9) 48 (10.3) 70 (15.0) 344 (73.8) 122 (26.2) Maternal education No formal education 2 (0.9) 25 (11.4) 42 (19.1) 151 (68.6) 69 (31.4) Primary education 0 27 (12.9) 44 (21.0) 139 (66.2) 71 (33.8) Secondary and above 3 (1.1) 21 (7.6) 38 (13.7) 215 (77.6) 62 (22.4) Frequency of ANC visits Never visited 1 (2.1) 9 (9.1) 12 (25.5) 25 (53.2) 22 (46.8) 1–4 times visited 4 (0.7) 55 (9.4) 101 (17.2) 428 (72.8) 160 (27.2) More than 4 times visited 0 9 (12.5) 11 (15.3) 52 (72.2) 20 (27.8) Child’s place of delivery At home 1 (0.7) 25 (17.1) 29 (20.0) 90 (62.1) 55 (37.9) At health institution 4 (0.7) 48 (8.5) 95 (16.9) 415 (73.8) 147 (26.2) Type of child birth Twin 1 (6.7) 4 (26.7) 3 (20.0) 7 (46.7) 15 (53.3) Singleton 4 (0.6) 69 (10.0) 121 (17.5) 498 (72.0) 194 (28.0) Frequency of Complementary feeding < 3 times per day 1 (3.7) 6 (22.2) 7 (17.1) 13 (64.8) 14 (519) 3–4 times per day 3 (0.6) 54 (10.0) 90 (16.6) 394 (72.8) 147 (27.2) >  4 times per day 1 (0.7) 13 (9.4) 27 (19.4) 98 (70.5) 41 (29.5) Loss of appetite Yes 2 (1.4) 15 (10.7) 34 (24.3) 89 (63.6) 51 (36.4) No 3 (0.5) 58 (10.2) 90 (15.9) 416 (73.4) 51 (9.0) Presence of morbidity symptoms Yes 2 (1.3) 16 (10.5) 38 (25.0) 96 (63.2) 56 (36.8) No 3 (0.5) 57 (10.3) 86 (15.5) 409 (73.7) 146 (26.3) Child being breastfed Yes 4 (1.3) 48 (15.9) 71 (23.6) 178 (59.1) 123 (40.9) No 1 (0.2) 25 (6.2) 53 (13.1) 327 (80.3) 79 (19.5) Presence of Diarrhea Yes 0 8 (9.6) 23 (27.1) 52 (62.7) 31 (37.3) No 5 (0.8) 65 (10.4) 101 (62.2) 453 (72.6) 624 (27.4) Preceding birth intervala 12–24 months 1 (1.2) 9 (10.8) 16 (19.3) 57 (68.7) 26 (31.3) 25–48 months 1 (0.7) 19 (12.8) 24 (16.1) 105 (70.5) 44 (29.5) > 48 months 1 (0.5) 16 (8.6) 26 (14.0) 143 (76.9) 43 (23.1) Maternal marital status Married 4 (0.6) 61 (9.9) 106 (17.1) 448 (72.4) 171 (27.6) Unmarriedc 1 (1.1) 12 (13.6) 18 (20.5) 57 (64.8) 31 (35.2) Pre-lacteal feeding Yes 0 8 (13.8) 13 (22.4) 37 (63.8) 21 (36.2) No 5 (0.8) 65 (10.0) 111 (17.1) 468 (72.1) 181 (27.9) Number of under five children 1 2 (0.4) 58 (10.3) 100 (17.7) 405 (71.7) 160 (28.3) ≥2 3 (2.1) 15 (10.6) 24 (16.9) 100 (70.4) 42 (29.6) Family monthly incomeb < 108$ 4 (0.9) 50 (11.2) 88 (19.7) 304 (68.2) 142 (31.8) ≥ 108$ 1 (0.4) 23 (8.8) 36 (13.8) 201 (77.0) 60 (23.0) ANC antenatal care; aPercentage was calculated for 418 children whose birth order is 2nd and above. bclassified on the basis of the mean value; Unmarriedc: includes Single, divorced and widowed Factors associated with anemia In the bivariable POM, age of child, maternal age, maternal educational status, maternal marital status, ANC visit at that time of pregnancy, child’s place of birth(home delivery), frequency of complementary feeding per day, loss of appetite, presence of morbidity symptoms (fever, vomiting, fast breathing and cough), breastfeeding status at the time of survey, and family monthly income were associated with anemia severity. However, in multivariable POM, being a young aged child (5–11 months [aPOR =13.9, 95%CI: 3.50–35.02], 12–23 months [aPOR = 8.53, 95%CI: 3.8–19.18], 24–35 months [aPOR = 4.77, 95%CL: 1.67–10.04], 36–47 months [aPOR = 3.58, 95%: 1.67–7.65]), being child of a mother with a primary educational status [aPOR = 1.71, 95%CI: 1.10–2.65], being a child delivered at home [aPOR = 1.64, 95%CI: 1.03–2.61], being child of mother whose marital status was unmarried [aPOR = 1.8, 95%CI: 1.07–3.03], and low frequency of complementary feeding practice per day [aPOR = 2.46, 95%CI: 1.02–5.77] were the factors associated with childhood anemia severity (Table 4). Table 4 Factors associated with childhood anemia severity in multivariable POM considering anemic status as outcome variable with three ordered categories Variable Categories Anemic status and severity level(n(%)) Bivariable POM Analysis Multivariable POM analysis Severe or moderate anemia (n(%)) Mild anemia (n(%)) No anemia cPOR (95%CI) p-value aPOR (95%CI) p-value Age of child (months) 6–11 18 (24.3) 18 (24.3) 38 (51.4) 10.20 (4.81, 21.71) < 0.001 13.9 (5.5, 35.02) < 0.001 12–23 30 (16.6) 45 (24.9) 106 (58.6) 7.17 (3.56, 14.24) < 0.001 8.53 (3.8, 19.18) < 0.001 24–35 20 (11.5) 27 (15.5) 127 (73.0) 3.88 (1.92, 7.82) < 0.001 4.77 (1.67, 10.04) < 0.001 36–47 7 (4.5) 26 (16.8) 122 (78.7) 2.67 (1.29, 5.55) 0.008 3.58 (1.67, 7.65) 0.001 48–59 3 (2.4) 8 (6.5) 112 (91.1) 1.00   1.00   Maternal age < 25 years 19 (11.5) 41 (24.8) 105 (63.6) 1.51 (1.04, 2.19) 0.032 0.94 (0.60, 1.47) 0.7794 > 35 years 7 (9.2) 13 (17.1) 56 (73.7) 0.98 (0.57, 1.69) 0.943 0.92 (0.49, 1.74) 0.806 25–35 years 52 (11.2) 70 (15) 344 (73.8) 1.00   1.00   Maternal education No formal education 27 (12.3) 42 (19.1) 151 (68.6) 1.57 (1.06, 2.34) 0.025 1.19 (0.72, 1.96) 0.489 Primary education 27 (12.9) 44 (21) 139 (66.2) 1.74 (1.17, 2.59) 0.006 1.71 (1.10, 2.65) 0.017 Secondary and above 24 (8.7) 38 (13.7) 215 (77.6) 1.00   1.00   ANC visits Never visited 10 (21.3) 12 (25.5) 25 (53.2) 2.23 (1.06, 4.69) 0.035 1.42 (0.59, 3.39) 0.433 1–4 time visited 59 (10.0) 101 (17.2) 428 (72.8) 0.94 (0.55, 1.61) 0.831 0.72 (0.39, 1.31) 0.281 More than 4 times visited 9 (12.5) 11 (15.3) 52 (72.2) 1.00   1.00   Child’s birth place At home 26 (17.9) 29 (20.0) 90 (62.1) 1.8 (1.23, 11.99) 0.002 1.64 (1.3, 2.61) 0.038 At health institution 52 (9.3) 95 (16.9) 145 (73.8) 1.00   1.00   Frequency of Complementary feeding < 3 times per day 7 (25.9) 7 (25.9) 13 (48.1) 2.68 (1.22, 5.92) 0.015 2.46 (1.02, 5.77) 0.003 3–4 times per day 57 (10.5) 90 (16.9) 394 (72.8) 0.91 (0.61, 1.37) 0.853 1.51 (0.94, 2.43) 0.181 >  4 times per day 14 (10.1) 27 (19.4) 98 (70.5) 1.00   1.00   Loss of appetite Yes 17 (12.1) 34 (24.3) 89 (63.6) 1.51 (1.02, 2.20) 0.039 1.14 (0.74, 1.75) 0.554 No 61 (10.8) 90 (15.9) 416 (73.4) 1.00   1.00   Presence of morbidity symptom Yes 18 (11.8) 38 (25.0) 96 (63.2) 1.54 (1.06, 11.60) 0.025 1.46 (0.83, 2.58) 0.191 No 60 (10.8) 86 (15.5) 409 (73.7) 1.00   1.00   Child being breastfed Yes 52 (17.3) 71 (23.6) 178 (59.1) 2.88 (2.08, 4.01) < 0.001 1.24 (0.76, 2.03) 0.382 No 26 (6.4) 53 (13.1) 327 (80.5) 1.00   1.00   Presence of Diarrhea Yes 8 (9.6) 23 (27.7) 52 (62.7) 1.43 (0.89, 2.30) 0.135 0.64 (0.31, 1.31) 0.222 No 70 (11.2) 101 (16.2) 453 (72.6) 1.00   1.00   Preceding birth interval 12–24 months 10 (12) 16 (19.3) 57 (68.7) 1.04 (0.62, 1.75) 0.882 1.0 (0.52, 1.92) 0.9963 25–48 months 20 (13.4) 24 (16.1) 105 (70.5) 0.99 (0.65, 1.51) 0.949 0.76 (0.42, 1.35) 0.346 > 48 months 17 (9.1) 26 (14.0) 143 (76.9) 0.69 (0.46, 1.05) 0.087 0.71 (0.40, 1.24) 0.231 First child 31 (10.7) 58 (20.1) 200 (69.1) 1.00   1.00   Maternal marital status Unmarried* 13 (14.8) 18 (20.5) 57 (64.8) 1.43 (0.90, 2.28) 0.126 1.8 (1.07, 3.03) 0.026 Married 65 (10.5) 106 (17.1) 448 (72.4) 1.00   1.00   Pre-lactal feeding Yes 8 (13.8) 13 (22.4) 37 (63.8) 1.44 (0.83, 2.50) 0.194 1.33 (0.71, 2.46) 0.37 No 70 (10.8) 111 (17.1) 468 (72.1) 1.00   1.00   Family monthly income <$108 54 (12.1) 88 (19.7) 308 (68.2) 1.54 (1.09, 2.18) 0.015 1.35 (0.91, 2.01) 0.136 ≥$108 24 (9.2) 36 (13.8) 201 (77.0) 1.00   1.00   Family size > 5 17 (11.9)_ 26 (18.2) 100 (69.9) 0.95 (0.61, 1.47) 0.819 1.51 (0.83, 2.77) 0.179   4–5 33 (10.5) 47 (15.0) 234 (74.5) 0.84 (0.53, 1.10) 0.145 1.16 (0.71, 1.90) 0.562   < 4 28 (11.2) 51 (20.4) 171 (68.4) 1.00   1.00   The outcome variable, anemia, was classified in three ordered categories as 0 = no anemia, 1 = Mild anemia, and 2 = Moderate or Severe anemia; The reference category of each independent variables was set last during analysis; aPOR: adjusted Proportional Odds Ratio; cPOR: crude Proportional Odds Ratio; CI: confidence Interval; POM: Proportional Odds Model; Unmarried*: includes single, divorced and widowed Model fitness information: Test of parallel lines for the proportional odds assumption: Chi-square = 19.123, df = 25, p-value = 0.791; Goodness-of-fit test of overall model: Pearson Chi-square = 1275.797, df = 1225, p-value = 0.152, Pseudo R2 = 0.182 Discussion Anemia prevalence data remain to be an important indicator of public health since anemia is related to morbidity and mortality, particularly in more vulnerable -preschool aged children and pregnant women [22]. As per WHO and United Nations report on the progress of achieving Millennium development goals (MDG), even though substantial progress has been made towards achieving MDG4 to reduce the number of under-five mortality rate worldwide, the rate of decline remains insufficient to meet the stated goal, particularly in sub-Saharan Africa and southern Asia. By the year 2011, children born in sub-Saharan Africa faced a higher probability of dying before the age of five than children born elsewhere [28, 29]. This raises questions about the impact and effectiveness of interventions made to reduce the burden of anemia, since anemia prevalence is a useful indicator to assess the impact and effectiveness of interventions [22]. In this study, the overall prevalence of anemia among children aged 6–59 months was found to be 28.5%. It is a moderate public health problem and should be addressed using appropriate intervention strategies since anemia contributes to childhood morbidity and mortality [24]. This prevalence is consistent with studies done in South-central Ethiopia [30], Timor-Leste [18], and Northeastern Brazil [31]. However, it is lower than studies conducted in another part of Ethiopia [32–34]. Tanzania [35], Benin and Mali [36], Haiti [37], Bangladesh [38], Indonesia [17], and Pernambuco, Northeastern Brazil [39]. In contrary to this, it is higher than studies conducted in Acrelandia, Western Brazilian Amazonia [19], and Vitoria, Brazilian [40]. The plausible reasons for disparities in anemia prevalence between the present study and aforementioned studies might be related to the seasonal and geographic variability of risk factors, and differences in socioeconomic status of the populations in which the studies were conducted. In our study, the prevalence of mild anemia was higher than the other types of anemia. This result is consistent with previous studies conducted in Northern Ethiopia [33], Haiti [37], and Western China [41], in which mild anemia was reported as the most common type of anemia among children. This could be due to the fact that children with mild anemia are mostly asymptomatic, and they may not seek medical intervention and may not get treatment. The clinical symptoms may not be presented in children with mild anemia, as the body often compensates for the gradual changes in Hb concentration.. This indicates that anemia is a hidden public health problem that affects a significant number of children. The other possible reason could be due to the fact that almost half of the children in our study were stunted, where mild anemia is more common in stunted children. In this study, younger aged children were more likely to be anemic. The likelihood of being anemic among children aged 6–11 months was higher as compared to those who were within the age of 48–59 months. This is in agreement with other studies [34, 42]. Besides, the odds of being anemic were higher for children who were in the age group of 6–23 months, which is consistent with studies done elsewhere [19, 33, 37, 39, 43]. The reasons for a high likelihood of being anemic in younger aged children may be due to different factors. The first reason would be a nutritional imbalance, as young children require relatively large nutritional demands owing to the high rate of growth during the first two years of life in combination with rapid expansion of blood volume. Since the practices and timely initiation of complementary feeding is poor in Ethiopia as evidenced by Ethiopian Demographic and Health Survey [44], younger children may suffer from at least one micronutrient deficiencies (Vitamin B12, folate, or iron) which leads to the onset of anemia. The second reason may be due to the low concentration of iron and other micronutrients in breast milk that cannot be sufficient for daily requirement of child growth [45]. Thirdly, it would also be due to the high susceptibility of young children to infectious diseases, which affects the absorption and utilization of bioavailable of micronutrients. Although our study did not include infectious diseases such as malaria and intestinal parasitic infection, they are highly prevalent in Gondar town [46, 47], and may also be a cause for red blood cell hemolysis and loss of appetites, which exacerbate the problem [48]. Consistent with previous studies [18, 22, 49], our study showed that older children were less likely to be anemic as compared to younger aged children As described in previous research [39], the Hb concentration had a linear and a positive association with age. The possible explanation for this may be due to the fact that with an increase in age, the nutritional demand for growth relatively becomes lower than early age. In addition, the children tend to discontinue breastfeeding and get involved in complementary feeding so that they can eat more varied diet [50]. Thus, as the children getting older, they become less likely to be anemic. Children of mothers with primary education were two times more likely to be anemic as compared to children whose mothers attended secondary and/or above education. The finding is consistent with the literature [14, 49, 51]. This may be related to the knowledge and practices of mothers about child feeding and health care; mothers with low educational level may not have adequate knowledge regarding the appropriate child health care practices and feeding [31]. Moreover, low level of maternal education may have a negative impact on the socioeconomic status of the family, which would affect the child nutritional status and optimal childcare [3, 43]. In this study, children who had a low frequency of complementary feeding practices of less than three times per day were at a greater risk of being anemic as compared to those who had a practice of feeding five or more times per day. This is consistent with previous studies [52–54], revealing that low frequency of child complementary feeding practice increased the risk of anemia. After six months, the introduction of complementary feeding is a recommended practice to adequately support the daily nutritional requirement of children. However, the practices of timely introduction of complementary foods were reported to be poor in Ethiopia, which could contribute to the low body iron level in children and ultimately causes a higher prevalence of childhood anemia [44]. Moreover, since the iron concentration in breast milk is low, insufficient to meet the daily requirement for normal children’s physiological activities as well as due to the high prevalence of maternal micronutrient deficiencies in developing countries [43], consumption of balanced complementary foods which meets the minimum dietary diversity and frequency is mandatory for children [1]. With regard to maternal marital status, children of unmarried mothers (i.e. single, widowed and divorced) were more likely to be anemic as compared to those whose mothers were married. Evidence speculated that parental marital status had an impact on family structure and socioeconomic status [55, 56]. The economic deprivation of unmarried mother may be partially responsible for the disadvantaged socioeconomic outcomes as well as the well-being of children. Moreover, children whose parents lack financial resources are less likely to receive high-quality of child care, health care and other social services [26]. Low socioeconomic status may, in turn, increase the risk of food insecurity, malnutrition and susceptibility to infectious diseases, which inevitably results in the development of childhood anemia [25]. Furthermore, evidence revealed that unmarried mothers experience a high rate of major depressive illness and distress [28], and they also spend less time with their children than married mothers do [57]. Therefore, low socioeconomic status and depression illness in unmarried mothers would likely influence the quality of child care that they provide for their children, and this may be the cause of childhood anemia. In this study, a place where a child was delivered has been significantly associated with severity of childhood anemia. In children who were delivered at home, the odds of being anemic was 1.64 times higher than those children who were delivered at a health institution. Institutional delivery improves maternal health as well as healthcare practices related to infant and child care. Contrary to this, home delivery has been implicated in maternal and child morbidity and mortality. Evidence revealed that delayed breastfeeding beyond two hours and pre-lacteal feeding were high in children who were delivered at home than health institution [58]. Delayed breastfeeding initiation and pre-lactal feeding increase the risk of child morbidity [59, 60], and thus contribute to anemia development. Limitations This study has some limitations. Firstly, the cross-sectional nature of the study design does not allow to establish a cause-and-effect relationship. Secondly, this study did not include all modifiable risk factors as well as common infectious diseases that potentially deregulate the hematopoiesis such as HIV intestinal parasite, and malaria. Thirdly, we used only Hb value to define anemia, and serum hematinic levels were not assessed. Despite these limitations, it is the first community-based cross-sectional study, which tried to show the prevalence and associated factors of childhood anemia severity in the study area. Conclusions In conclusion, anemia was found to be a moderate public health problem among children aged 6–59 months in Gondar Town. The study revealed that young child age, primary maternal educational level, low frequency of child complementary feeding practices, home delivery and unmarried maternal marital status (i.e. single, divorced and widowed) were factors associated with childhood anemia severity in the study setting. Therefore, appropriate and tailored interventional strategies are required to reduce the prevalence of childhood anemia. These include improving women’s access to education; providing health education on child feeding practices; and strengthening nutritional and social supports. Furthermore, further in-depth studies need to be conducted using a large sample size and including assessment of serum micronutrient level. Abbreviations ANC:  Antenatal care aPOR:  adjusted Proportional Odds Ratio BMI:  Body Mass Index CI:  Confidence Interval cPOR:  crude Proportional Odds Ratio CS:  Caesarian Section HAZ:  Z-score for Height-for-Age Hb:  Hemoglobin IQR:  Interquartile Range MDG:  Millennium Development Goals POM:  Proportional Odds Model SD:  Standard Deviation USD:  US Dollar WAZ:  Z-scores for Weight-for-Age WHO:  World Health Organization WHZ:  Z-score for Weight-for-Height Declarations Acknowledgements The authors would like to thank all children and their families who voluntarily participated in the study. We are also grateful to thank data collectors, Gondar Town Health Department and the University of Gondar for their logistics and material support. Funding The authors received no specific funding for this work. Availability of data and materials All data supporting the findings and conclusion are presented in the manuscript. The datasets during and/or analyzed during the current study is available from the corresponding author on reasonable request. Authors’ contributions Conceived and designed the experiments: MM. Helped in designing the study and participated in data collection: MM, KAA, TM, BE, BT, TM, AK, BB, MA. Supervised the data collection process: MM, TM, AK. Involved in data entry: MM, TM. Analyzed and interpreted the data: MM, KFM. Contributed reagents/materials/equipments: KAA, MA. Drafted the manuscript: MM. Critically edited and revised the manuscript. All authors read and approved the final manuscript. Ethics approval and consent to participate Ethical clearance was obtained from the Institutional Review Board of the University of Gondar (No: RPC/46/2014). Permission was sought from Gondar City Health Department. Written consent was obtained from each parent after the purpose and importance of the study were explained to them. The signed informed consent was kept confidentially, and the data were analyzed anonymously according to the Declaration of Helsinki for human studies. Nutritional and health advice were given to each parent at the end of the interview. Anemic children were referred to nearby health facilities to get standard treatment for anemia. Consent for publication Not applicable. Competing interests The authors declare that they have no competing interests. Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Authors’ Affiliations (1) Department of Hematology and Immunohematology, School of Biomedical and Laboratory Sciences, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia (2) Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia (3) Department of Clinical Chemistry, School of Biomedical and Laboratory Sciences, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia (4) School of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia (5) School of Medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia References McLean E, Cogswell M, Egli I, Wojdyla D, De Benoist B. Worldwide prevalence of anaemia, WHO vitamin and mineral nutrition information system, 1993–2005. Public Health Nutr. 2009;12(4):444–54.View ArticlePubMedGoogle ScholarSteel N. Global, regional, and national age-sex specific mortality for 264 causes of death, 1980–2016: a systematic analysis for the global burden of disease study 2016. Lancet. 2017;390(10100):1151–210.View ArticleGoogle ScholarCentral Statistical Agency. Ethiopia Demographic and Health Survey 2011. Addis Ababa, Ethiopia; 2012. Available at: https://dhsprogram.com/pubs/pdf/FR255/FR255.pdf. Accessed date: 18/10/2017.Gessner BD. Early childhood hemoglobin level is a strong predictor of hemoglobin levels during later childhood among low-income Alaska children. Int J Circumpolar Health. 2009;68(5):459–70.View ArticlePubMedGoogle ScholarChen MH, Su TP, Chen YS, Hsu JW, Huang KL, Chang WH, et al. Association between psychiatric disorders and iron deficiency anemia among children and adolescents: a nationwide population-based study. BMC Psychiatry. 2013;13:161.View ArticlePubMedPubMed CentralGoogle ScholarChang S, Wang L, Wang Y, Brouwer ID, Kok FJ, Lozoff B, et al. Iron-deficiency Anemia in infancy and social emotional development in preschool-aged Chinese children. Pediatrics. 2011;127(4):e927–e33.View ArticlePubMedGoogle ScholarCarter RC, Jacobson JL, Burden MJ, Armony-Sivan R, Dodge NC, Angelilli ML, et al. Iron deficiency Anemia and cognitive function in infancy. Pediatrics. 2010;126(2):e427–e34.View ArticlePubMedPubMed CentralGoogle ScholarLozoff B, Beard J, Connor J, Felt B, Georgieff M, Schallert T. Long-lasting neural and behavioral effects of Iron deficiency in infancy. Nutr Rev. 2006;64(Suppl 2):S34–43.View ArticlePubMedPubMed CentralGoogle ScholarGrantham-McGregor S, Ani C. A review of studies on the effects of iron deficiency on cognitive development. J Nutr. 2001;131(2):649S–68S.View ArticlePubMedGoogle ScholarTrivedi M, Chansoria A, Dixit RK, Kholi A. Evaluation of brief cognitive rating scale of anemic patients and comparison with control. Int J of Res in Pharm Sci. 2012;2(4):89–95.Google ScholarHalterman JS, Kaczorowski JM, Aligne CA, Auinger P, PG S. Iron deficiency and cognitive achievement among school-aged children and adolescents in the United States. Pediatrics. 2001;107(6):1381–6.View ArticlePubMedGoogle ScholarPhiri KS, Calis JC, Faragher B, Nkhoma E, Ng'oma K, Mangochi B, et al. Long term outcome of severe Anaemia in Malawian children. PLoS One. 2008;3(8):e2903.View ArticlePubMedPubMed CentralGoogle ScholarEhrhardt S, Burchard GD, Mantel C, Cramer JP, Kaiser S, Kubo M, et al. Malaria, anemia, and malnutrition in african children--defining intervention priorities. J Infect Dis. 2006;194(1):108–14.View ArticlePubMedGoogle ScholarSingh RK, Patra S. Anemia. Extent of Anaemia among preschool children in EAG states. India: A Challenge to Policy Makers. Volume; 2014.Google ScholarSoares Magalha˜es RJ, ACA C. Mapping the Risk of Anaemia in Preschool-Age Children: The Contribution of Malnutrition, Malaria, and Helminth Infections in West Africa. PLoS Med. 2011;8(6):e1000438.View ArticleGoogle ScholarWirth JP, Rohner F, Woodruff BA, Chiwile F, Yankson H, Koroma AS, et al. Anemia, micronutrient deficiencies, and malaria in children and women in Sierra Leone prior to the Ebola outbreak - findings of a cross-sectional study. PLoS One. 2016;11(5):e0155031.View ArticlePubMedPubMed CentralGoogle ScholarSemba RD, de Pee S, Ricks MO, Sari M, Bloem MW. Diarrhea and fever as risk factors for anemia among children under age five living in urban slum areas of Indonesia. Int J Infect Dis. 2008;12(1):62–70.View ArticlePubMedGoogle ScholarAgho KE, Dibley MJ, D'Este C, Gibberd R. Factors associated with Haemoglobin concentration among Timor-Leste children aged 6-59 months. J Health Popul Nutr. 2008;26(2):200–9.PubMedPubMed CentralGoogle ScholarCardoso MA, Scopel KKG, Muniz PT, Villamor E, Ferreira MU. Underlying factors associated with Anemia in mazonian children: a population-based, Cross-Sectional Study. PLoS ONE. 2012;7(5):e36341.View ArticlePubMedPubMed CentralGoogle ScholarSinha N, Deshmukh PR, Garg BS. Epidemiological correlates of nutritional anemia among children (6 -35 months) in rural Wardha, Central India. Indian J Med Sci. 2008;62(2):45.View ArticlePubMedGoogle ScholarJaime-Perez JC, Herrera-Garza JL, Gomez-Almaguer D. Relationship between gestational iron deficiency and iron deficiency in the newborn; erythrocytes. Hematology. 1999;5(3):257–62.View ArticleGoogle ScholarPasricha SR, Black J, Muthayya S, Shet A, Bhat V, Nagaraj S, et al. Determinants of Anemia among young children in rural India. Pediatrics. 2010;126(1):140–e9.View ArticleGoogle ScholarSuchdev PS, Ruth LJ, Earley M, Macharia A, Williams TN. The burden and consequences of inherited blood disorders among young children in western Kenya. Matern Child Nutr. 2014;10:135–44.View ArticlePubMedGoogle ScholarWHO multicentre growth reference study group. WHO child growth standards based on length/height, weight and age. Acta Pædiatrica. 2006;450:76–85.Google ScholarSkalicky A, Meyers AF, Adams WG, Yang Z, Cook JT, Frank DA. Child food insecurity and iron deficiency anemia in low-income infants and toddlers in the United States. Matern Child Health J. 2006;10(2):177–85.View ArticlePubMedGoogle ScholarMcLanahan S, Percheski C. Family structure and the reproduction of inequalities. Annu Rev Sociol. 2008;34:257–76.View ArticleGoogle ScholarPatel AJ, Wesley R, Leitman SFBB. Capillary versus venous haemoglobin determination in the assessment of healthy blood donors. Vox Sang. 2013;104:317–23.View ArticlePubMedPubMed CentralGoogle ScholarAvison WR, Davies L. Family structure, gender, and health in the context of the life course. J Gerontol B Psychol Sci Soc Sci. 2005;60(Special Issue):S113–S6.View ArticleGoogle ScholarWHO. WHO STEPS surveillance manual : the WHO STEPwise approach to chronic disease risk factor surveillance / Noncommunicable Diseases and Mental Health. Geneva: WHO; 2005. Available at: http://apps.who.int/iris/bitstream/10665/43376/1/9241593830_eng.pdf. Accessed date: 10/1/2014Google ScholarGari T, Loha E, Deressa W, Solomon T, Atsbeha H, Assegid M, et al. Anaemia among children in a drought affected community in south-Central Ethiopia. PLoS One. 2017;12(3):e0170898.View ArticlePubMedPubMed CentralGoogle ScholarLeal LP, Batista Filho M, Lira PI, Figueiroa JN, Osório MM. Prevalence of anemia and associated factors in children aged 6-59 months in Pernambuco, Northeastern Brazil. Rev Saude Publica. 2011;45(3):457–66.View ArticlePubMedGoogle ScholarHabte D, Asrat K, Magafu MG, Ali IM, Benti T, Abtew W, et al. Maternal risk factors for childhood Anaemia in Ethiopia. Afr J Reprod Health. 2013;17(3):110–8.PubMedGoogle ScholarGebreegziabiher G, Etana B, Niggusie D. Determinants of Anemia among children aged 6–59 months living in Kilte Awulaelo Woreda. Volume: Northern Ethiopia. Anemia; 2014.Google ScholarMuchie KF. Determinants of severity levels of anemia among children aged 6–59 months in Ethiopia: further analysis of the 2011 Ethiopian demographic and health survey. BMC Nutr. 2016;2:51.View ArticleGoogle ScholarSchellenberg D, Schellenberg JR, Mushi A, Savigny DD, Mgalula L, Mbuya C, et al. The silent burden of anaemia in Tanzanian children: a community-based study. Bull World Health Organ. 2003;81(8):581–90.PubMedPubMed CentralGoogle ScholarNgnie-Teta I, Receveur O, Kuate-Defo B. Risk factors for moderate to severe anemia among children in Benin and Mali: insights from a multilevel analysis. Food Nutr Bull. 2007;28(1):76–89.View ArticlePubMedGoogle ScholarAg Ayoya M, Ngnie-Teta I, Séraphin MN, Mamadoultaibou A, Boldon E, Saint-Fleur JE, et al. Prevalence and risk factors of Anemia among children 6–59 months old in Haiti. Volume: Anemia; 2013.Google ScholarUddin MK, Sardar MH, Hossain MZ, Alam MM, Bhuya MF, Uddin MM, et al. Prevalence of anaemia in children of 6 months to 59 months in Narayanganj, Bangladesh. J Dhaka Med Coll. 2010;19(2):126–30.Google ScholarOso’rio MM, Lira PI, Ashworth A. Factors associated with Hb concentration in children aged 6–59 months in the state of Pernambuco. Brazil Br J Nutr. 2004;91(2):307–14.View ArticleGoogle ScholarSaraiva BC, Soares MC, Santos LC, Pereira SC, Horta PM. Iron deficiency and anemia are associated with low retinol levels in children aged 1 to 5 years. J Pediatr. 2014;90(6):593–9.View ArticleGoogle ScholarGao W, Yan H, DuolaoWang DS, Pei L. Severity of Anemia among Children under 36 Months Old in Rural Western China. PLoS ONE. 2013;8(4):e62883.View ArticlePubMedPubMed CentralGoogle ScholarKhanal V, Karkee R, Adhikari M, Gavidia T. Moderate-to-severe anaemia among children aged 6–59 months in Nepal: an analysis from Nepal demographic and health survey, 2011. Clin Epidemiol Glob Health. 2016;4:57–62.View ArticleGoogle ScholarKhan JR, Awan N, Misu F. Determinants of anemia among 6–59 months aged children in Bangladesh: evidence from nationally representative data. BMC Pediatr. 2016;16:3.View ArticlePubMedPubMed CentralGoogle ScholarDisha A, Tharaney M, Abebe Y, Alayon S, Winnard K. Factors associated with infant and young child feeding practices in Amhara region and nationally in Ethiopia: analysis of the 2005 and 2011 demographic and health surveys. Washington, DC: Alive and Thrive; 2015.Google ScholarEwusie JE, Ahiadeke C, Beyene J, Hamid JS. Prevalence of anemia among under-5 children in the Ghanaian population: estimates from the Ghana demographic and health survey. BMC Public Health. 2014;14:626.View ArticlePubMedPubMed CentralGoogle ScholarTilaye T, Deressa W. Prevalence of urban malaria and assocated factors in Gondar town, Northwest Ethiopia. Ethiop Med j. 2007;45(2):151–8.PubMedGoogle ScholarGelaw A, Anagaw B, Nigussie B, Silesh B, Yirga A, Alem M, et al. Prevalence of intestinal parasitic infections and risk factors among school children at the University of Gondar Community School, Northwest Ethiopia: a cross-sectional study. BMC public health. 2013;13:304.View ArticlePubMedPubMed CentralGoogle ScholarZanin FHC, da Silva CAM, Bonomo É, Teixeira RA, CAdJ P, dos Santos KB, et al. Determinants of Iron Deficiency Anemia in a Cohort of Children Aged 6–71 Months Living in the Northeast of Minas Gerais, Brazil. PLoS ONE. 2015;10(10):e0139555.View ArticlePubMedPubMed CentralGoogle ScholarLeite MS, Cardoso AM, Coimbra CEA Jr, Welch JR, Gugelmin SA, Lira PCI, et al. Prevalence of anemia and associated factors among indigenous children in Brazil: results from the first National Survey of indigenous People’s health and nutrition. Nutr J. 2013;12:69.View ArticlePubMedPubMed CentralGoogle ScholarEl Kishawi RR, Soo KL, Abed YA, Wan Muda WAM. Anemia among children aged 2–5 years in the Gaza strip- Palestinian: a cross sectional study. BMC Public Health. 2015;15:319.View ArticlePubMedPubMed CentralGoogle ScholarYang W, Li X, Li Y, Zhang S, Liu L, Wang X, et al. Anemia, malnutrition and their correlations with socio-demographic characteristics and feeding practices among infants aged 0–18 months in rural areas of Shaanxi province in northwestern China: a cross-sectional study. BMC Public Health. 2012;12:127.View ArticleGoogle ScholarHipgrave DB, Fu X, Zhou H, Jin Y, Wang X, Chang S, et al. Poor complementary feeding practices and high anaemia prevalence among infants and young children in rural central and western China. Eur J Clin Nutr. 2014;68(8):916–24.View ArticlePubMedGoogle ScholarHu S, Tan H, Peng A, Jiang H, Wu J, Guo S, et al. Disparity of anemia prevalence and associated factors among rural to urban migrant and the local children under two years old: a population based cross-sectional study in Pinghu, China. BMC Public Health. 2014;14:601.View ArticlePubMedPubMed CentralGoogle ScholarRoba KT, O’Connor TP, Belachew T, O’Brien NM. Anemia and undernutrition among children aged 6–23 months in two agroecological zones of rural Ethiopia. Pediatr Health Med Ther. 2016;7:131–40.View ArticleGoogle ScholarHannan C, Halpin B. The Influence of Family Structure on Child Outcomes: Evidence for Ireland. Econ Soc Rev. 2014;45(1, Spring):1–24.Google ScholarManning WD, Brown S. Children's economic well-being in marriage and cohabiting parent families. J Marriage Fam. 2006;68(2):345–62.View ArticleGoogle ScholarKendig SM, Bianchi SM. Single, cohabiting, and married mothers’ time with children. J Marriage Fam. 2008;70(5):1228–40.View ArticleGoogle ScholarJain A, Baliga BS, Rao S, Shankar MV, Srikanth BK. Does institutional delivery help in improving infant and child health care practices and health promotion related parameters? A study from Bellary, Karnataka. BMC Proceedings. 2012;6(Suppl 5):O22.View ArticlePubMed CentralGoogle ScholarEdmond KM, Zandoh C, Quigley MA, Amenga-Etego S, Owusu-Agyei S, Kirkwood BR. Delayed breastfeeding initiation increases risk of neonatal mortality. Pediatrics. 2006;117(3):e380–6.View ArticlePubMedGoogle ScholarHajeebhoy N, Nguyen PH, Mannava P, Nguyen TT, Mai LT. Suboptimal breastfeeding practices are associated with infant illness in Vietnam. Int Breastfeed J. 2014;9:12.View ArticlePubMedPubMed CentralGoogle Scholar Copyright © The Author(s). 2018


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Mulugeta Melku, Kefyalew Addis Alene, Betelihem Terefe, Bamlaku Enawgaw, Belete Biadgo, Molla Abebe, Kindie Fentahun Muchie, Asemarie Kebede, Tadele Melak, Tsedalu Melku. Anemia severity among children aged 6–59 months in Gondar town, Ethiopia: a community-based cross-sectional study, Italian Journal of Pediatrics, 2018, 107, DOI: 10.1186/s13052-018-0547-0