Anaemia prevalence and causes among Syrian refugee children in Lebanon

Iron deficiency remains the most common nutrient deficiency in the world - causing an estimated 30-50% of anaemia cases in children. An estimated 40% of children aged 6-59 months and 36% of pregnant women aged 15-49 years are anaemic worldwide.

Syrian refugees in Lebanon - a country with underlying food insecurity brought about by a protracted economic crisis - are a particularly vulnerable group. However, there is a paucity of data for this group. This cross-sectional study aims to first quantify the prevalence of anaemia among 215 Syrian refugee children aged 6-23 months and their mothers (haemoglobin (Hb) finger prick and anthropometry). The study then identifies dietary and socio-economic determinants of anaemia, before investigating the relevant attitudes and perceptions of Syrian mothers and Lebanese healthcare staff (multi-component questionnaire). The qualitative assessment focused on 43 Syrian mothers and four Lebanese healthcare staff.

Child anaemia prevalence was 42% (29% mild, 13% moderate), which is in line with other studies and reflects a severe public health problem according to the World Health Organization. Comparison with other studies and data sources implies a worsening trend of anaemia in Beirut. Twenty percent of mothers were anaemic (15% mild, 5% moderate). Children were 3.5 times more likely to be anaemic if the mother was also anaemic.

Socioeconomic variables were found to not be determinants of anaemia among children aged 6-23 months, but the authors point to a homogenous study population as an explanation for this surprising finding. Mothers were generally able to describe some symptoms of anaemia, but knowledge on quality dietary sources of iron was poor. Compliance with iron supplementation protocols was found to be hampered by poor availability of supplements, financial constraints, and side effects such as vomiting. We encourage readers to review the detailed qualitative findings in the original paper, which are beyond the scope of this summary.

The sample size for the main study was appropriate based on the authors’ sample size calculation. The use of biomarkers is a strength of this study and the Hb cutoffs for study participants are in line with World Health Organization guidance for mild, moderate, and severe anaemia. A major caveat is that we are unable to distinguish non-iron deficiency anaemia from iron-deficiency anaemia, as no specific iron measures were taken - this reduces study specificity.

The sample size for the qualitative study is small, so its results should be interpreted with caution. The qualitative aspect may be affected by selection bias from both the researchers, who used convenience sampling to find participants, and those who accepted invitation to interview, who are unlikely to be representative. The study was also conducted in a small, urban area in a country that hosts an estimated 1.5 million Syrian refugees who are dispersed across the nation - so this is unlikely to capture the experiences of the broader group. Like all dietary recall studies, reporting bias may have been introduced, although steps were taken to ameliorate this during the study. Reverse causality cannot be ruled out with this study design. Nonetheless, this study highlights the high burden of anaemia among children aged 6-23 months and its key determinants in this population.