Anaemia is a common haematological condition in childhood and represents an important indicator of nutritional and general health status. It is defined by a haemoglobin concentration below the age- and physiological-status-specific reference threshold. The World Health Organization (WHO) has provided age-specific haemoglobin cut-offs for the diagnosis and assessment of anaemia severity. [1]

Childhood anaemia has multiple aetiologies. Nutritional iron deficiency is a primary cause, particularly during periods of rapid growth. Vitamin B12 and folate deficiencies, chronic infection and inflammation, haemoglobinopathies, blood loss, and inherited or acquired haematological disorders may also contribute.

Clinical manifestations depend on the severity, duration, and underlying cause. Children may present with pallor, fatigue, weakness, poor appetite, and other nonspecific symptoms, while some cases are detected incidentally during routine laboratory evaluation.

Complete blood count (CBC) parameters, such as mean corpuscular volume (MCV), mean corpuscular haemoglobin (MCH), mean corpuscular haemoglobin concentration (MCHC), and red-cell distribution width (RDW), assist in morphological classification. Microcytic hypochromic anaemia commonly suggests iron deficiency or haemoglobinopathy, whereas macrocytosis may indicate vitamin B12 or folate deficiency. Peripheral blood smear examination provides additional morphological information. Serum ferritin and other iron parameters further assist in evaluating iron status, although ferritin may be influenced by systemic inflammation. [2,3]

The present study evaluates the clinicopathological profile of anaemia among children aged 6 months to 12 years, with particular emphasis on morphological patterns, clinical and nutritional findings, and haematological and biochemical parameters.

Aim and Objectives

• To study the clinicopathological profile of anaemia in children and its association with nutritional and haematological parameters.
• To determine the frequency and severity of anaemia among children aged 6 months to 12 years.
• To classify anaemia according to red-cell indices and peripheral smear morphology.
• To assess the relationship between morphological patterns and nutritional/clinical findings.
• To evaluate the association of haemoglobin, MCV, MCH, and RDW with iron-study parameters.
• To assess the relationship between serum ferritin and morphological patterns.
• To identify the predominant clinicopathological patterns of anaemia in the study population.

Study design: This hospital-based observational study was conducted at Sudha Medical College and Hospital, Kota, Rajasthan, from January 2025 to December 2025..

Demographic Characteristics

A total of 300 children were included, comprising 148 males (49.3%) and 152 females (50.7%). The mean age was 6.22 ± 3.50 years (range: 0.5–12 years).

Table 1. Age distribution of the study population

Clinical Findings

Table 2. Clinical findings among the study participants

Nutritional Status

Table 3. Nutritional status of the study participants

Morphological pattern was not significantly associated with nutritional status (χ² = 6.77, df = 9, p = 0.661).

The distribution of morphological patterns is illustrated in Figure 1.

Severity and Morphological Pattern

Table 4. Severity of anaemia

Table 5. Morphological patterns of anaemia

Morphological pattern was not significantly associated with anaemia severity (χ² = 4.08, df = 6, p = 0.666).

The distribution of severity categories is illustrated in Figure 2.

Haematological Profile

Table 6. Overall haematological and iron-status profile

Note: RBC, red blood cell; MCV, mean corpuscular volume; MCH, mean corpuscular haemoglobin; MCHC, mean corpuscular haemoglobin concentration; RDW, red-cell distribution width; TIBC, total iron-binding capacity; TSAT, transferrin saturation.

Laboratory Parameters by Morphological Pattern

Table 7. Laboratory parameters according to morphological pattern

Note: Hb, haemoglobin; MCV, mean corpuscular volume; MCH, mean corpuscular haemoglobin; RDW, red-cell distribution width; TSAT, transferrin saturation.

ANOVA outcomes: haemoglobin, p = 0.431; MCV, p < 0.001; MCH, p < 0.001; RDW, p < 0.001; ferritin, p < 0.001; serum iron, p < 0.001; transferrin saturation, p < 0.001.

Peripheral Smear Findings

Table 8. Peripheral smear findings

Inflammatory and Micronutrient Parameters

C-reactive protein (CRP) was reported as normal in 251 (83.7%) and raised in 49 (16.3%) children. Mean serum vitamin B12 was 375.52 ± 102.96 pg/mL, and mean folate was 7.88 ± 2.16 ng/mL.

Iron Status

Iron deficiency was present in 130 (43.3%) children and absent in 170 (56.7%).

Table 9. Iron-status parameters according to iron-deficiency status

Note: MCV, mean corpuscular volume; MCH, mean corpuscular haemoglobin; RDW, red-cell distribution width; TIBC, total iron-binding capacity; TSAT, transferrin saturation.

Iron deficiency was strongly associated with morphological pattern (χ² = 114.01, df = 3, p < 0.001), occurring in 122 of 180 (67.8%) microcytic hypochromic cases and in none of the macrocytic or normocytic groups.

Overall iron-deficiency status is shown in Figure 3; mean ferritin by morphology is shown in Figure 4.

Correlation Analysis

Spearman correlation demonstrated positive associations of MCV with ferritin (rho = 0.568, p < 0.001), serum iron (rho = 0.458, p < 0.001), and transferrin saturation (rho = 0.506, p < 0.001). MCH was positively correlated with ferritin (rho = 0.595, p < 0.001), serum iron (rho = 0.461, p < 0.001), and transferrin saturation (rho = 0.520, p < 0.001). RDW showed inverse correlations with ferritin (rho = −0.327, p < 0.001), serum iron (rho = −0.223, p < 0.001), and transferrin saturation (rho = −0.236, p < 0.001). Haemoglobin did not show a statistically significant correlation with ferritin, serum iron, or transferrin saturation in this cohort.

Figures and Summary Table

The following figures provide visual summaries of the principal descriptive findings reported in the study. All values are derived directly from the study results.

Figure 1. Distribution of anaemia by morphological pattern.

Figure 2. Distribution of anaemia severity.

Figure 3. Iron-deficiency status among the study participants.

Figure 4. Mean serum ferritin concentration by morphological pattern.

This study of 300 children demonstrated that microcytic hypochromic anaemia was the predominant morphological pattern, accounting for 60.0% of cases. Normocytic normochromic anaemia accounted for 22.7%, dimorphic anaemia for 13.0%, and macrocytic anaemia for 4.3%. The predominance of microcytic hypochromic morphology is compatible with a substantial contribution from iron-restricted erythropoiesis, although morphology alone is insufficient to definitively establish iron deficiency. Half of the children had mild anaemia, 40.7% had moderate anaemia, and 9.3% had severe anaemia. Pallor was the most frequent clinical finding (86.7%), followed by fatigue/weakness (44.3%), poor appetite (32.7%), and pica (19.7%). These findings reiterate the value of thorough clinical assessment alongside laboratory testing. The study did not demonstrate a statistically significant association between morphological pattern and nutritional status (p = 0.661). The lack of a direct statistical association between specific nutritional phenotypes (such as stunting or underweight) and anaemia morphology highlights the multifactorial nature of paediatric anaemia. MCV, MCH, RDW, and iron-status parameters differed markedly across morphological groups. Microcytic hypochromic cases exhibited lower mean MCV, MCH, ferritin, serum iron, and transferrin saturation, alongside higher mean TIBC than the normocytic and macrocytic groups. RDW was highest in the dimorphic group. These patterns are biologically coherent with the observed red-cell morphologies. Iron deficiency showed a robust statistical association with microcytic hypochromic morphology. However, serum ferritin requires cautious interpretation because it is an acute-phase reactant and may rise during inflammation. In this cohort, CRP was elevated in 16.3% of children. Accordingly, ferritin should be interpreted in conjunction with inflammatory status and other iron parameters to reduce the risk of misclassification. [2,3] Correlation analyses further reinforced the relationships among red-cell indices and iron-status measures: MCV and MCH were positively associated with ferritin, serum iron, and transferrin saturation, whereas RDW was inversely associated with these parameters. The absence of a significant correlation between overall haemoglobin concentration and iron parameters illustrates that haemoglobin alone cannot adequately characterise iron status. xLimitations 1. This is a hospital-based study and may not be entirely generalisable to the wider community-dwelling paediatric population. 2. The observational design permits the identification of associations but does not establish causality. 3. Because the cohort consisted exclusively of anaemic children, the data cannot be used to estimate the baseline prevalence of anaemia in the source population. 4. Author to specify any study-specific limitations related to laboratory methods, including the assays used for CRP/ferritin and whether reticulocyte haemoglobin equivalent or other relevant tests were unavailable.

Microcytic hypochromic anaemia is the predominant morphological pattern among the 300 children studied. Red-cell indices and iron-related biochemical parameters demonstrated clear differences across morphological categories, whereas overall nutritional status (underweight/stunting) was not significantly associated with morphology. A comprehensive clinical, nutritional, morphological, and biochemical approach remains essential for accurately evaluating childhood anaemia.

Recommendations

• Children presenting with anaemia should undergo systematic clinical and nutritional assessments.
• A complete blood count with red-cell indices and peripheral smear evaluation should form the foundational laboratory investigation.
• Patients with suspected iron deficiency should undergo targeted iron-status profiling (including ferritin, serum iron, and TIBC) where feasible.
• Ferritin must be interpreted alongside inflammatory markers (such as CRP) when concomitant infection or inflammation is suspected.
• Children exhibiting atypical morphological findings or demonstrating an inadequate response to iron therapy should be thoroughly evaluated for haemoglobinopathies, vitamin deficiencies, and chronic diseases.