during childhood , anemia is one of the most frequently seen intractable health concern that has both social and economic implications all around the world . who estimates that almost one - third of the world s population is anemic , most of which are due to iron deficiency ( 1 ) .
iron deficiency anemia ( ida ) compromises 90% of all anemia cases in the world ( 2 ) .
it usually occurs as a result of insufficient dietary intake of iron as well as gastrointestinal tract losses and infections ( 3 ) .
ida is the most encountered form of malnutrition in the world with a prevalence of 43% ( 4 ) .
american academy of pediatrics ( aap ) recommends pis from 4 mo old up to 1 year of age , especially in developing countries ( 5 ) .
although ida is usually a concern of developing countries , there is no national data or a study describing the prevalence of pis usage or ida among children in north cyprus .
meanwhile , thalassemia is another common reason of anemia , being the most frequent inherited genetic disease worldwide , and especially one of the major causes of anemia in the mediterranean area , the middle east , central asia , india and the far east ( 6 ) .
thalassemia is an autosomal recessively inherited hemoglobinopathy which affects the synthesis of globin chain of hemoglobin .
it has three forms based on which globin chain is affected ;  ,  and .  thalassemia is the major type seen in mediterranean region including cyprus and it is more prevalent in malaria - endemic areas . in this type ;  globin chain synthesis is either decreased or absent leading to three forms of the disease as major , minor or intermediate ( 7 ) .
carrier frequency varies from 3% to 17% in different populations ( 8) . over 9000 thalassemic children are born every year and treatment are very expensive ( 9 ) .
therefore , strategies for prevention and management of thalassemia had been initiated in 1976 ( 5 ) .
there were only two published studies on thalassemia in north cyprus up to date conducted in 1946 and 1973 demonstrating frequency of thalassemia trait as 18.2% and 15% respectively in north cyprus ( 10 , 11 ) .
the main approach for taking thalassemia under control is screening programs , especially in countries with a high number of carriers like cyprus . as a government policy
pre - marital screening is mandatory since 1980 in north cyprus ( 5 ) , and as a result no new baby with thalassemia major has been delivered since 2001 .
although thalassemia is a major public health problem in cyprus ; no studies have been carried out to investigate the recent prevalence of carrier status in north cyprus since 1970s .
the objective of this study was to investigate the prevalence of ida and thalassemia trait in north cyprus among healthy infants being followed up by near east university hospital , department of pediatrics .
in addition , it was aimed to determine the compliance to pis recommendation and its effect on the prevalence of ida .
the participants were chosen among the children whose complete blood count and ferritin levels were checked between apr 2011 and jul 2013 as part of healthy infant follow - up procedure in the department of pediatrics , near east university hospital , north cyprus .
the enrollment criteria were as follows ; 
 to be in regular follow - up in near east university university hospital , department of pediatrics.the presence of complete blood count and ferritin levels documented between 1018 mo of age .
information on birth data ( birth weight , height and percentiles ) , breastfeeding status , duration of breastfeeding , usage and duration of pis , weight and height at 1 year of age and percentiles , parental education status and parental thalassemia carrier status had been achieved from hospital database or by phone calls in demand . 
  to be in regular follow - up in near east university university hospital , department of pediatrics .
the presence of complete blood count and ferritin levels documented between 1018 mo of age .
information on birth data ( birth weight , height and percentiles ) , breastfeeding status , duration of breastfeeding , usage and duration of pis , weight and height at 1 year of age and percentiles , parental education status and parental thalassemia carrier status had been achieved from hospital database or by phone calls in demand .
complete blood count ( cbc ) , ferritin and if present hemoglobin electrophoresis results had been obtained from hospital database program .
diagnosis of ida and thalassemia trait are as follows : anemia was defined as hemoglobin level below 10.5 gr / dl whereas mean corpuscular volume ( mcv ) below 70fl has been used to indicate microcytic anemia ( 12 , 13 ) . within the microcytic anemia group ; if ferritin level was below 15mg / ml and mentzer index ( mcv / rbc ) was above 13 , this was considered as ida , while high rbc level , normal rdw value and mentzer index smaller than 13 was considered as thalassemia trait ( 12 ) .
statistical analyses were performed by means of spss 17 ( chicago , il , usa ) software .
groups were compared by means of students t test . a p value of < 0.05 was considered as statistically significant .
statistical analyses were performed by means of spss 17 ( chicago , il , usa ) software .
groups were compared by means of students t test . a p value of < 0.05 was considered as statistically significant .
the study group consisted of 89 infants , 44.9% being female and 55.1% being male ( table 1 ) .
demographic findings of the study group at least one parent s educational status was graduation from university or above both parents were graduated from high school or below compliance with pis recommendation of the study group was 85.3% and , the mean duration of iron usage was 6.443.18 mo . according to the pre - marital screening results
11.2% of mothers and 4.5% of fathers had been diagnosed as thalassemia trait . among infants
anemia has not been detected in 74% of the cases while 6.7% of cases had anemia other than ida and thalassemia .
seven infants were diagnosed as thalassemia trait based on the described criteria and three of them confirmed by hemoglobin electrophoresis .
frequency of anemia and compliance to prophylactic ron supplementation infants with and without ida were compared based on demographic characteristics , usage and duration of pis demonstrating no significant differences ( p>0.05 ) .
comparison of breastfeeding , pis and growth between iron deficiency anemia and non - anemic group are summarized in table 3 .
comparison of breastfeeding , prophylactic iron supplementation , duration and growth between iron deficiency anemia and others
cyprus had been the region with the highest prevalence of beta thalassemia since the 19th century ( 14,15 ) .
a frequency of 7.9% which shows a 50% decline in the prevalence of thalassemia trait compared to the study results of 1973 .
in addition , the frequency of ida was found to be 14.6% which is lower than other developing countries .
the importance of aap recommendation of pis for the prevention of ida in early childhood .
moreover , there were no significant differences between infants with and without anemia based on weight and height at birth and 1 year of age , duration of breastfeeding and compliance to pis .
the first epidemiologic study on thalassemia in cyprus demonstrating a thalassemia carrier status of 18.2% ( 10 ) .
thereafter , the second study , among turkish and greek cypriots showing a frequency of thalassemia trait of 15% ( 11 ) . a study performed 25 yr later in 1998 revealed cyprus as the region with the highest frequency of thalassemia trait worldwide ( 14 , 15 ) .
this decrease since 1946 is most probably due to the strict adherence to the pre - marital thalassemia trait screening policy .
malaria is the leading cause of the increase in thalassemia frequency in malaria endemic regions and eradication of malaria in cyprus in 1948 might have a role on the deceasing frequency in each generation ( 14 , 15 ) .
moreover , current prenatal diagnostic techniques such as chorionic villus sampling and dna analysis might have contributed to this decrease ( 5 ) .
after national screening law came into force in north cyprus in 1980 , the rate of thalassemia major births decreased dramatically and eventually no new thalassemia major case has been delivered since 2001 ( 5 ) .
national screening programs have also been established in italy , greece and the uk . when compared to these countries , cyprus has the lowest prevalence of thalassemia major births ( 16 ) . for prevention of ida
the recommendation of aap is to initiate pis at the age of 4 mo continuing at least for 8 mo till the age of 1yr ( 17 ) .
our institution s routine healthy infant follow - up protocol includes the recommendation of pis from 4 mo to 12 mo of age .
complete blood count and serum ferritin level are checked in - between the age of 1218 mo to evaluate the presence of ida and thalassemia trait , as well ( 18 ) .
the frequency of ida among infants in our study group was found to be 14.6% .
the frequency of ida between ages 05 in turkey is around 50% according to a national study ( 13 ) .
compliance to pis was found to be 43% and mean duration of usage was 12 mo , while the frequency of ida between 1223 mo was reported as 16.3% ( 19 ) .
accordingly , compliance to pis in north cyprus was 85.3% and mean duration of the prophylactic supplementation was 8 mo .
rate and duration of compliance to pis was also higher than turkey , supporting the finding of lower frequency of ida .
although uk has low ida prevalence , frequency of ida in inner cities approached to those in developing countries ( 20 ) .
frequency of ida in infants aged 624 mo of low socioeconomic families , especially of the ethnic minorities , changed between 2540% ( 21 ) .
frequency of ida in infants from high socioeconomic level families was 5% whereas 20% in those of low socioeconomic level ( 21 ) .
social status was determined by educational level of parents demonstrating no significant difference between ida and non - anemic groups .
a study carried out in cuba among infants of 623 mo of age concluded that prevalence of ida was 23.8% and 28.5% in urban and rural regions , respectively ( 22 ) .
another study which collected data from several european cities ( athens , bilbao , budapest , dublin , madrid , naples , porto , rostol , santiago , umea and vienna ) used levels of hb , ferritin , mcv , transferrin saturation and transferrin receptor and found out that infants aged 12 mo have frequency of iron deficiency and ida as 7.2% and 2.3% , respectively ( 23 ) . in iceland and norway ,
the frequency of ida at 12 mo of age was reported as 2.7% and 10% , respectively ( 23 ) . when compared to developed countries , ida frequency in north cyprus was higher .
the prevalence of ida in low socioeconomic countries is much higher ( 24 ) . in sub - saharan africa ,
ida in 1023 mo aged infants changed between 59 and 99.4% throughout 20012006 . in armenia and egypt , it was above 50% in 2005 and in india it was around 76% in 1999 . in latin america and caribbean countries ,
therefore , based on the results of our preliminary study , frequency of ida in north cyprus seems to be between developed and developing countries .
although thalassemia has been a major public health problem in cyprus since the mid-1900 s , no studies investigating the rate of in frequency of thalassemia trait status have been carried out in north cyprus during the last five decades . likewise
; there are no reports on the frequency of ida among infants in north cyprus .
although preliminary with a small sample size , this is the first study evaluating ida frequency and adherence to pis during infancy .
thalassemia trait frequency was 7.9% among infants demonstrating a decline of more than 50% since 1946 in north cyprus .
this result confirms the success of strict adherence to pre - marital screening policy conducted since 1980 .
in addition , prevalence of ida was relatively low in this region compared to other developing countries , supporting the beneficial effect of pis on prevention of ida .
ethical issues ( including plagiarism , informed consent , misconduct , data fabrication and/or falsification , double publication and/or submission , redundancy , etc . ) have been completely observed by the authors .
 background : iron deficiency anemia ( ida ) is an important health problem all around the world especially in developing countries . in the mediterranean countries another prevelant reason of anemia is thalassemia . 
 certain strategies had been established as a government policy to reduce prevalence in north cyprus , such as pre - marital screening of thalassemia . the prevalence of thalassemia trait has not been evaluated since then . 
 the aim of this study was to detect the prevalence of ida , thalassemia trait in infants under regular follow - up and to evaluate the compliance to prophylactic iron supplementation ( pis ) and its effect on ida.methods:healthy children admitted to department of pediatrics , near east university hospital , in 20112013 were included . 
 data of anthropometric measurements , parental thalassemia trait status , duration of pis usage , complete blood count , ferritin levels and hemoglobin electrophoresis were collected from hospital database program . 
 anemic children were grouped as ida , thalassemia trait , both ida and thalassemia trait and others.results:eghty-nine infants with a mean age 13.522.09 mo were included . 
 compliance with pis recommendation was 85.3% and , the mean duration of iron usage was 6.443.18 mo . 
 ida and thalassemia trait were found to be 11.2% and 4.5% respectively , while 3.4% of the infants had both ida and thalassemia trait.conclusion:prevalence of thalassemia trait was 7.9% demonstrating approximately a 50% decline within 5 decades . 
 this result confirms the success of premarital screening policy in north cyprus . 
 in addition , prevalence of ida was relatively low being 14.6% supporting the beneficial effect of pis on prevention of ida . 
Introduction
Methods
Statistical Analysis
Results
Discussion
Conclusion
Ethical considerations