Association Between Iron Deficiency Without Anemia and Cognitive Impairment in Children

Iron deficiency without anemia is a potentially serious, under-recognized nutritional problem that may adversely influence children's cognitive and behavioral development. Although the connection is supported globally, there is a lack of localized studies in Pakistan. This research investigates the relationship between iron deficiency without anemia and cognitive-behavioral problems in Pakistani children aged 5-18.

This cross-sectional study was conducted from February to June 2025, using convenience sampling of schools and communities in Islamabad. A total of 385 children participated. A three-part structured questionnaire, an Iron Deficiency Risk Questionnaire (IDRQ), and the Strengths and Difficulties Questionnaire (SDQ) were used to gather demographic data. Statistical analyses were performed using SPSS Version 26 (IBM Corp., Armonk, NY). They consisted of descriptive statistics, t-tests, analysis of variance (ANOVA), Pearson correlation, and linear regression to evaluate associations between the risk of iron deficiency and cognitive-behavioral functioning.

The sample consisted of 385 participants (N = 385), comprising females (n = 199, 52%) and males (n = 186, 48%), including both urban and rural children. The results of the correlation between the scores on the IDRQ and the SDQ showed a weak positive association (r = 0.272, P < 0.001). While the correlation was statistically significant, it indicates a modest relationship, suggesting that higher levels of iron deficiency risk are weakly associated with greater cognitive-behavioral difficulties. Children with celiac disease and recurring infections recorded the highest scores. Older children (17-18 years) displayed elevated scores on risk and difficulty compared to younger children (5-7 years). Linear regression analysis revealed that SDQ scores were significantly predicted by IDRQ scores (B = 0.669, P < 0.001), thereby validating the association.

The results indicate that iron deficiency without anemia is weakly associated with cognitive and behavioral issues among children. Although the correlation is statistically significant, it is modest, indicating the need for further research to fully understand the extent of this relationship. Community-based nutritional interventions are critical in reducing this hidden burden by recognizing that early detection enables better developmental outcomes among Pakistani children.