Anemia Exhibits Limited Association with Early Childhood Development

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A cross-sectional analysis of nine low- and middle-income countries revealed few statistically significant associations between anemia and early childhood development.

A cross-sectional analysis examined the association between anemia and early childhood development in population-based surveys from nine low- and middle-income countries, in which the condition was a serious public health concern.1

Results demonstrated little connection between severe or moderate anemia and early childhood development domains and overall early childhood development among children aged 36–59 months across the nine countries included for analysis.

“In adjusted regressions, we found a lack of association between anemia and early childhood development outcomes except for small associations with social-emotional and physical development in two countries,” wrote the investigative team led by Rukundo K. Benedict, PhD, The Demographic and Health Surveys Program, ICF.

Approximately 2 in 5 children under the age of 5 years in low- and middle-income countries were estimated at risk of missing their development potential. These children are often exposed to numerous risk factors for poor development, ranging from poor environmental conditions to psychological and individual-level risk factors.

Anemia is a significant public health issue in many of these countries, particularly among young children and reproductive-aged women. Iron deficiency is a major cause of anemia, estimated to be responsible for ≥1 billion cases globally. Notably, iron is important for early brain development and prior evidence has linked low iron status with poor child development outcomes.

Few studies, however, have assessed the link between anemia and early child development in large, population-based surveys. The current analysis utilized nine Demographic and Health Surveys (DHS), involving early childhood development variables and hemoglobin data, to examine the association in routinely collected data.

In these surveys, eligible women aged 15–49 responded to maternal and child health, nutrition, and early childhood development questions. Variables were calculated using the Early Childhood Development Index (ECDI), a 10-item binary (yes/no) survey covering four domains of child development: physical, social-emotion, learning, and literacy-numeracy.

For this analysis, the key independent variable of interest was the presence of anemia, defined using World Health Organization (WHO)-recommended categories for hemoglobin concentrations. Investigators assessed the link between anemia presence, the overall ECDI score, and individual ECDI domains for children aged 36–59 months. Multivariate models controlled for early learning/interaction variables, child, maternal, and paternal characteristics, and socioeconomic and household covariates

The nine low- and middle-income countries included in the study were Benin, Burundi, Cambodia, Haiti, Jordan, Maldives, Rwanda, Senegal, and Uganda. More than 40% of the children aged 36–59 months showed any anemia in 7 of 9 countries, ranging from 26% in Rwanda to 62% in Benin.

Upon analysis, moderate or severe anemia was significantly associated with a lower likelihood of being developmentally on track for multiple domains. However, the magnitude of the association ranged only from an odds ratio (OR) of 0.99 to 1.0. As a result, Benedict and colleagues noted these data may not be clinically meaningful.

In the adjusted model, investigators found many significant findings were attenuated after controlling for child, family, and household characteristics and early learning/interaction variables.

These results exhibited no significant association between anemia and early childhood development domains or the overall index, aside from social-emotional development in Benin (adjusted OR [aOR], 1.00; P <.05) and physical development in the Maldives (aORs, 0.97; P <.05).

Multiple covariates were significantly associated with early childhood development domains and the domain overall index, with variations by country. Attendance at an early childhood education program was consistently associated with on-track development for the overall index in 6 countries, literacy-numeracy in all 9 countries, learning in 6 countries, and socio-emotional and physical development in a single country.

Benedict and colleagues noted many factors contribute to a child’s development, with anemia being only a single potential adverse exposure a child might face. They indicated the importance of a multi-faceted, nurturing care framework to promote early childhood development in low- and middle-income countries.

“Studies unpacking the complex pathways between nutrition indicators and all domains of nurturing care, and early childhood development outcomes in different contexts could inform targeted ECD policies and programs,” investigators wrote.


  1. Benedict RK, Pullum TW, Riese S, Milner E. Is child anemia associated with early childhood development? A cross-sectional analysis of nine Demographic and Health Surveys. PLoS One. 2024;19(2):e0298967. Published 2024 Feb 28. doi:10.1371/journal.pone.0298967