31

Original Article

Interaction Between Anemia and Blood Levels of Iron,

Zinc, Copper, Cadmium and Lead in Children
Sebahat Turgut1, Aziz Polat2, Murat Inan2, Gnfer Turgut1, Glten Emmungil1, Mevlt Bican2,
Tugrul Yasin Karakus2 and Osman Gen1
Departments of 1Physiology and 2Pediatrics, Pamukkale University Faculty of Medicine, Denizli, Turkey

ABSTRACT
Objective. Anemia is a widespread problem among infants and children in many parts of the world, and it is often associated
with some trace elements (iron, zinc, copper) and heavy metals (cadmium and lead). Aim of this study was to investigate the
relationship between anemia and these elements.
Methods. This research was performed on 256 children (mean age 6.8 0.2) living in Denizli city center. We observed iron
deficiency anemia (IDA) in 23 children, iron deficiency without anemia (ID) in 36 children and only anemia (ferritin level normal)
(OA) in 18 children, and 179 children were found healthy and they were regarded as controls (C). Blood samples were taken
from subjects and the concentrations of zinc, copper, iron, cadmium and lead in serum were measured with atomic absorption
spectrophotometer.
Results. The levels of copper, cadmium and lead in serum were significantly higher in children with IDA than those of controls
(p<0.05, p<0.05, p<0.01, respectively). The other elements in the serum of ID were not different from controls.
Conclusion. High copper, cadmium and lead decreased iron absorption and negatively affected hematological parameters.
[Indian J Pediatr 2007; 74 (9) : 827-830] E-mail: sturgut@pau.edu.tr
Key words : Children; Iron deficiency anemia; Cadmium; Copper; Iron; Zinc; Lead

The industrial wastes mixed with water and soil, air

pollution, using high levels of copper (Cu) and zinc (Zn)
salts in treatments and excessive levels of some substance
such as cigarette, alcohol, tea, and coffee can cause some
changes in trace element metabolism of animal and
human bodies and in the absorption and extraction of
trace elements.1-3

causes hypochromic microcytic anemia and increases

absorption of other elements such as Pb and Cd.
Therefore, the serum levels of these elements may
increase in patients with hypochromic microcytic anemia
and anemia may deteriorate. In the same way, heavy
exposure to these elements whatever the reasons are may
cause hypochromic microcytic anemia itself.

Deficiency or excess of a trace element may cause

disorders in the absorption, distribution, metabolism and
elimination of other trace elements. For example iron (Fe)
deficiency can increase absorption of lead (Pb) and
cadmium (Cd) from gastrointestinal tract.4,5 The levels of
Pb and Cd can be higher in the cities having heavy air
pollution, and for this reason trace element distrubition
may be affected.

The aim of this study was to evaluate serum Fe, Cu,

Zn, Cd and Pb levels of children living in Denizli, an
industrial city, and to explain association between anemia
and these elements. For this reason, we determined the
serum Fe, Cu, Zn, Cd, Pb levels of children living in
Denizli province, and investigated the relationships
among trace elements in the children.

The deficiency of trace elements generally cause

hypochromic microcytic anemia.5 Also iron deficiency

MATERIAL AND METHODS

Correspondence and Reprint requests : Dr. Sebahat Turgut,

Pamukkale niversity, Medical School, Department of Physiology
Denizli/Turkey, Telephone: +90-258-2134030, Fax: +90-258-2132874

This research was performed on 256 children (mean age

6.80.2 yr) living in Denizli city center. Parents of children
were acknowledged about the study and written
informed consent was obtained. Pamukkale University
Ethics Committee approved the study. Detailed

[Received March 14, 2006; Accepted June 22, 2007]

Indian Journal of Pediatrics, Volume 74September, 2007

827

32

S. Turgut et al

The blood samples taken from all subjects were

separated two groups. Numbers of red blood cell (RBC),
Hb, mean corpuscular volume (MCV) and red cell
distribution width (RDW) of whole blood samples in first
group were measured with an automatic cell counter
(Coulter SKTS, Beckman Coulter, USA). Also serum
ferritin levels of the subjects were determined by
chemiluminescence method by an immunanalyser
(Immulite One, Bio DPC, CA, USA). Blood samples of
second group were collected from subjects into nonheparinised tubes free from Fe, Cu, Zn, Cd, Pb and sera
were obtained. The serum samples were preserved in 20
o
C until analysed. For the analyses of elements in serum,
standard solutions were prepared by using Fe, Cu, Zn,
Cd, Pb standards (Merck). Deionised distilled water was
used as blank. Blank and standard solutions were used
for calibration of atomic absorption spectrophotometer.6
The concentrations of Zn, Cu and Fe in serum were
measured
with
flame
atomic
absorption
spectrophotometer (Perkin Elmer AAS-700 Ueberlingen,
Germany). Serum concentrations of Cd and Pb were
determined by atomic absorption spectrophotometer
with a HGA graphite furnace (Perkin Elmer AAS-700
Ueberlingen, Germany).
Mean values of all data, standard error of the means
and importance checking of the differences between
groups were made in the SPSS 10.0 statistical package
program by using Mann Whitney U test and Student Ttest. Importance checking of the differences among
groups was made in the SPSS 10.0 statistical package
program by using ANOVA and Post Hoc Test-

Bonferroni. Results were expressed, as the mean S.E. P

values of less than 0.05 were considered significant.

RESULTS
We compared Hb, MCV, RDW, RBC and ferritin values
of children among all groups (ANOVA) and these values
differed significantly among groups, p=0.000 (Table 1).
We also found significant difference in the serum Cu and
Cd levels of children, when the element levels among
groups were compared (ANOVA) and the difference
among the groups was shown (Fig. 1 and 2). In this study,
when the parameters of IDA, ID and OA were compared
to controls, we observed a decline in the Hb, MCV, RBC
and ferritin levels of IDA group compared to controls
(p=0.000). Also RDW level was found significantly higher
in IDA group compared to controls (p=0.000).
3
*+

2.5
2
mg/L

anamneses were taken from the subjects. The information

about living area and nutrition habits of the subjects was
recorded. After physical examination, CBC and
peripheral separation were made and ferritin level in
serum was determined. We found that IDA was in 23
children (Ferritin<10 ng/ml, hemoglobin (Hb)<11 g/dl),
ID in 36 children (Ferritin<10 ng/ml, Hb>11 g/dl) and
only anemia in 18 children (ferritin normal, Hb<11 g/dl).
The number of healthy children was 179 in our study. In
this situation, we divided our subjects into four groups as
iron deficiency anemia (IDA), iron deficiency without
anemia (ID), only anemia (ferritin normal, low Hb) (OA)
and healthy children (Controls) (C).

1.5
1
0.5
0

00 00 00 0 0 0
00 00 00 00 00 00
000000
*

00 00 00
00 00 00 000 000 000
00 00 00 0 0 0
0 0 0 00 00 00

000
00 00 00 0 0 0
000000
00 00 00 00 00 00
000000
00 00 00 00

00 00 00 00 00 00
00 0 0 0 0 0
00 000 000 000 00 00
00

OA
FD
Control
ID Groups AA
Copper Zinc Iron
Fig. 1. The serum copper, zinc and iron levels in all groups
*: Shows significance between control and others groups
(significance between groups were evaluated by Mann
Whitney U and Student T-test), * p<0.05, **p<0.01. Significance among all groups was evaluated by ANOVA. Significance among all groups was evaluated by ANOVA. Post Hoc
Test-Bonferroni was used to find which group significant
arises from, +: Shows significance between control and others
groups +p<0.05.
IDA

When compared to the results of serum elements

levels between control and IDA group, serum Zn levels in
IDA group and control were found to be 1.370.16 mg/

TABLE 1. The Comparison of Haematological Parameters Among Groups (MSE)

IDA
(n=23)
HB (g/dl)
MCV (3)
RBC (x106/mm3)
RDW
Ferritin (ng/ml)

9.91 0.31***
68.13 1.67***
4.49 0.10***
16.67 0.51***
5.93 0.71***

ID
(n=36)
12.64
77.89
4.90
14.11
8.27

OA
(n=18)

0.15**
0.91**
0.07
0.21**
2.67***

10.45 0.23***
68.90 0.21***
4.72 0.15
16.76 1.02***
32.10 3.46

Control
(n=179)
13.30 0.10
81.15 0.42
4.98 0.04
13.35 0.09
33.47 1.16

*:Shows significance between control and others groups (significance between groups were evaluated by Mann Whitney U and Student Ttest), ** p<0.01, *** p<0.001. Significance among all groups was evaluated by ANOVA. Post Hoc Test-Bonferroni was used to find significant
arising from which group, : Shows significance between control and others groups p<0.05, p<0.001.

828

Indian Journal of Pediatrics, Volume 74September, 2007

33

Interaction Between Anemia and Blood Levels of Iron, Zinc, Copper, Cadmium and Lead in Children

When compared the serum Pb level between in control

and IDA group, it was found to be 0.080.01g/L,
0.130.04 g/L respectively, accordingly the level Pb in
processes, and it is important to maintain iron IDA group
was found significantly increased compared to control,
p<0.05 (Fig. 3).
30

Cd g/L

25
20
15
10
5
0
IDA

ID

OA

Control

Groups
Fig. 2. The serum cadmium levels in all groups
Significance among all groups was evaluated by ANOVA.
Post Hoc Test-Bonferroni was used to find which group
significant arises from, : Shows significance between control
and others groups +p<0.05

There is only statistically significant in Hb, MCV and

RDW levels between control and OA group (Table 1). No
significant difference was seen in the levels of serum
elements between control and OA group (Figs. 1, 2 and 3).
The levels of Hb, MCV and ferritin in ID were found to be
low compared to control p<0.01, p<0.01, p<0.001,
respectively and RDW levels in ID group is higher than
control, p<0.01 (Table 1). There is significant difference in
the levels of serum copper between control and ID group
(Fig. 1). The Cu level in ID group is found 2.250.28 mg/
L and this value is significantly higher than control group
(p<0.05).
DISCUSSION

determined the serum levels of these trace elements in

children. Also, because of heavy air pollution in Denizli,
we approved to investigate Cd and Pb levels in serum of
our subjects. In our study, we investigated the
relationships among trace elements, heavy metals and
hematological parameters in IDA, ID, OA groups and
Controls.
In this research, the serum iron level in IDA group was
found significantly lower than the other groups as it is
expected (Fig. 1). Iron deficiency is a worldwide health
problem, especially for infants, rapidly growing
adolescents, pregnant women, and aged women. Iron
deficiency is associated with lower cognitive test scores in
infants, impaired scholastic performance, shortened
attention span, reduced muscle function and physical
activity, and impaired mental acuity in older children and
adults. 7 Iron plays an essential role in many biological
processes, and it is important to maintain iron
concentration within its narrow normal range.8
The serum Zn level of IDA group in our study is lower
than the other groups but this decline is not statistically
significant (Fig. 1). There is an antagonism between Zn
and iron absorption from the gastrointestinal tract. The
concentration of iron in the intestinal lumen may
antagonize the uptake of Zn.9 In our research, the serum
Cu level in IDA and ID groups is significantly higher than
control and OA group (Fig. 1). Cu has a role in the
absorption of iron. The oxidation of ferrous iron (Fe+2) to
the ferric state (Fe +3) is carried out by the ferroxidase
activity of the major plasma Cu protein, ceruloplasmin.
Thus, depletion of Cu could impair iron absorption.10
Cd is an abundant, nonessential element that has
raised concern recently due to its accumulation in the
environment as a result of industrial and agricultural
practices.11 The mean of serum Cd status in all children
who were added in this study was found higher than
world standards (Table 1). 12 Denizli where this
investigation is made is industrial city and there is heavy
0.2
*
0.16
Lead g/L

L, 1.680.08 mg/L respectively, serum Cd levels in IDA

and control groups were found to be 19.768.25 g/L,
5.811.34 g/L respectively. No significant difference
was seen in the serum Zn and Cd levels between IDA and
control groups (Fig. 1), but Cd level was found
significantly differ between these groups (Fig. 2). The
serum Cu level was found to be 2.400.20 mg/L in IDA
group and 1.610.08 mg/L in control. According to these
results, serum Cu level in IDA group is significantly
higher than control, p=0.000 (Fig. 1). Serum Fe levels of
IDA and control groups were observed to be 0.870.15
mg/L, 1.600.13 mg/L respectively and the serum Fe
levels in IDA group is significantly lower than control,
p<0.05 (Fig. 1).

0.12
0.08
0.04
0
IDA

ID

OA

Control

Groups

Fe, Cu, and Zn are essential elements for the maintenance

of life and health. Cd and Pb are heavy metals and they
can be harmful for human health. For this reason, we
Indian Journal of Pediatrics, Volume 74September, 2007

Fig. 3. The serum lead levels in all groups

*: Shows significance between control and others groups
(significance between groups were evaluated by Mann
Whitney U and Student T-test), * p<0.01.

829

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S. Turgut et al
air pollution in this area. We think that the air pollution
in the city may be responsible for the high level of Cd.
Also the serum Cd level of IDA group was found
significantly higher than controls (Fig. 2). The intestinal
absorption of Cd was found increased whenever total
body Fe was depleted.13,14 The mechanism of absorption of
Cd in the gastrointestinal tract is unknown, and it is also
not clear why and how Fe deficiency increases Cd
absorption in the intestine.15
Fe deficiency increases Pb absorption in the intestine.4,5
For this reason, although the Pb amount in serum of the
children living in Denizli was found to be same level
according to world standards, the level of serum Pb in the
IDA group is found to be significantly increased
compared to control (Table 1, Fig. 3). In a study made in
Canada, the blood Pb level was shown to be high in
babies with Fe deficiency. 16 Pb is a major hazard to
children in industrialized countries.17 It is notable that the
studies with the largest number of subjects for analysis all
found significant associations between Fe deficiency and
elevated blood Pb levels.18,19
Also, in our results show that hemoglobin, MCV, RBC
and Ferritin values of children with IDA were decreased
and RDW level was increased in IDA group versus
control subjects (Table 1). There is a negative correlation
between copper concentrations and MCV levels in all
subjects (r=-0.340 p<0.001). Also, Nagano et al. shows that
copper supplementation decreased MCV levels in
humans. 20 At the same time the results show that the
negative correlation is between serums copper
concentration and ferritin, hemoglobin values of serum in
this study (r= -0.203 p<0.01, r= -0.392 p<0.001
respectively). We observed that high copper negatively
affected hematological parameters in this research. The
serum copper concentrations were increased in IDA and
more copper absorption from gastro intestinal tract might
cause iron deficiency. There is negative correlation
between serum copper concentrations and iron levels, but
this correlation is not statistically significant.
We showed that the Cd levels of serum were of high
quantity in children living in industrialized city, Denizli.
The serum cadmium, copper and lead amount was
determined to be of high levels in children with IDA. It
may be that high copper, cadmium and lead decreased
iron absorption and negatively affected hematological
parameters.
Acknowledgments

2.

3.

4.

5.

6.

7.

8.
9.

10.

11.
12.
13.

14.

15.

16.

17.
18.

19.

This study was supported by Pamukkale University Research Fund

(Project No. 2002TPF008)
20.

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Indian Journal of Pediatrics, Volume 74September, 2007