Iron deficiency anemia

Definition

Anemia is defined as a reduction of the red blood cell volume or hemoglobin

concentration below the level considered normal for the person's age/sex.

2.6. Epidemiology

According to WHO estimate of 1997, anemia is a major health problem world wide

affecting two billion people mainly in developing countries. The two major groups at

risk are children and pregnant women.

Young children and pregnant women are the most vulnerable and affected with an

estimated global prevalence of 48% and 51% respectively. Anemia prevalence in

school-age children is 37%, non-pregnant women 35% and adult males 18%.

Prevalence rates as high as 40.5% in the general population and 47.2% in children

were reported from North Western Ethiopia. Higher rates of about 57% have also

been reported in pregnant women in Jimma, Ethiopia.

Iron deficiency anemia is a problem of serious public health significance, given its

impact on psychological and physical development, behavior and work

performance.

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It is the most prevalent nutritional problem in the world today, affecting more than

700 million persons.

Iron deficiency anemia is considerably more prevalent in the developing than in the
developed world (36% or about 1.4 billion persons out of an estimated population of

3.8 billion in developing countries, versus 8% or just under 100 million persons out
of

an estimated population of 1.2 billion in developed countries).

Iron deficiency is by far the commonest nutritional cause of anemia; it may be

associated with folate deficiency, especially during pregnancy. Other nutrient

deficiencies such as vitamin B12, pyridoxine and copper are of little public health

significance due to their infrequent occurrence.

Malaria, nutritional deficiencies and intestinal helminthes all predispose to anemia.

It

is estimated to affect more than 103 million children aged 9 years and below in

Africa. In malaria endemic regions of Africa community surveys show prevalence of

anemia in children to be between 49.5 and 89%. It is estimated severe malaria

associated anemia causes 190,000 - 974,000 deaths per year in children under the

age of five years, with the highest mortality observed among infants.

In tropical regions where helminthiasis is nearly universal and nutrition is poor and

among impoverished people, multi-parous women and premature babies or those

breast-fed too long, and some traditional practices to let blood flow out from the

body, with such related factors iron deficiency is a prevalent disorder with adverse

consequences.

In areas in which intestinal helmenthiasis exists in a large proportion of the

population, iron deficiency anemia is nearly universal.

Intestinal parasitic infections are highly prevalent in developing countries like

Ethiopia, mainly due to poor sanitary facilities, unsafe human waste disposal

systems, inadequate and lack of safe water supply and low socio-economic status in

general indicating poor environmental conditions. Intestinal parasitic helminthic

infections are among the most common infections worldwide. The world health

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organization (WHO) estimates that there are over 800 million cases of ascaris, over

700 million cases of hook worm, 500 million cases of trichuris infection, 200 million

cases of entameoba hystolytica.

Recurrent droughts and famines continue to characterize the Ethiopian history. This

may be associated to a number of conditions like socio-cultural, political, ecological,

demographic and economic factors that predispose the population to continue to

suffer from the synergistic effects of drought, famine and malnutrition. Nutritional

surveys in 1980 showed that nearly 80% of urban and 75% of rural children aged

bellow five years were malnourished.

2.7. Etiology and Pathogenesis

Anemia can be caused by one or more of the following independent mechanisms.

Decreased Red Blood Cell (RBC) production: Anemia will ultimately result if the

circulating RBC mass that is normally destroyed each day is not replaced from

the bone marrow. The causes for reduced RBC production include:

Lack of nutrients such as Iron, copper, vitamin B6, vitamin B12 or folate.

Deficiency of protein in the serum.

Failure of bone marrow to produce RBC due to tumor infiltration, drugs,

chemical poisoning, etc.

Increase in RBC destruction (Hemolysis): The essential feature of hemolysis is a

shortened RBC life span. This is due to destruction by:

Infections like malaria.

Drugs like dapsone.

Chemical poisoning such as lead.

Genetic diseases such as sickle cell anemia.

RBC loss: Blood loss is the commonest cause of anemia. The bleeding may be

due to:

Trauma, including surgical procedures

Parasites, like hook worm and schistosomiasis.

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Intestinal bleeding, e.g. peptic ulcer disease (PUD), and gastrointestinal

Cancer.

Menstrual loss.

Iron deficiency anemia can be caused by:

Deficient iron content of the food: This is common in infants who are kept too long

exclusively on milk diet and in native populations living on marginal and poor

diets. Iron deficiency may occur in older people due to their limited food intake

like meat due to dental problem and poverty.

Deficient absorption of iron: Deficient absorption usually follow,

Poor dietary practice like, less consumption of diets rich in vitamin C which

enhance iron absorption,

 Drinking coffee and tea immediately after meal inhibits iron absorption,

Gastrointestinal tract operation. It may occur also in chronic malabsorption

states or diseases and consumption of antacids, fibrous diet and heavy

metals like calcium, zinc, magnesium.

Deficient transport: A decrease in transferring (iron-binding protein) is associated

with a number of inflammatory conditions particularly rheumatoid arthritis. This

may result in a decrease body iron content and finally production of less

pigmented (hypochromic) red blood cells.

Abnormal loss of iron: It is commonly caused by loss of circulating red cells

through hemorrhage, excessively heavy menstruation or due to parasites like

hookworm and schistosomiasis.

Increased physiologic requirements: This occurs primarily in children during

active growth and in pregnant women. When the infant is put on prolonged

exclusive milk diet, the need for iron is not met. Pre-term infants require more

iron. Pregnancy and lactation also places heavy demands on the iron stores of

the mother.

Anemia decreases the capacity of blood to carry oxygen. This may result in

decreased oxygen concentration in the tissue (hypoxia) and damage to different

organs because the RBC and its hemoglobin are important for the delivery of
oxygen

to tissues.

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2.8. Clinical Features

Anemic patients may present with the following manifestations.

2.8.1. Symptoms

Tiredness, weakness or fainting

Fatigue

Breathlessness (shortness of breath)

Exercise intolerance

Head ache

Tinnitus (ringing in the ear)

Blurred vision

Nausea

Poor appetite

Palpitation (uncomfortable awareness of ones heart beat).

Excessive desire to eat unusual substances (pica) such as clay or ice.

2.8.2. Signs

Paleness (skin and mucus membranes)

Edema in chronic and sever cases

Irritability

Poor growth and development in children

2.9. Diagnosis

The following steps are followed in the diagnosis of anemia.

2.9.1. Diagnosis of anemia

Anemia can be identified using the following methods:

History: Detect clinical symptoms of anemia, dietary history.

 Physical Examination: Examine mucous membrane (mouth, conjunctiva), palm

and finger nails (see figure 1).

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Figure: 1. Areas where to check for paleness during physical examination.

Laboratory Examination: Measure hemoglobin or hematocrit. The hemoglobin

levels indicating anemia are shown in table 1.

Table 1: Levels of hemoglobin which indicates anemia in different population groups

Population groups Hemoglobin gm/100 ml

Children 6 months to 4 years < 11

Children 5 - 11 years < 11.5

Children 12 - 14 years < 12

Women/adolescent girls - Not pregnant < 12

- Pregnant < 11

Men/ adolescent boys < 13

2.9.2. Diagnosis of causes

The possible causes of anemia are traced with the following steps.

History: age, sex, pregnancy, diet, clinical symptoms etc.

Physical examination: e.g. Signs of infection such as malaria.

Laboratory examination:

Blood film for hemoparasites like malaria

Peripheral blood morphology

Stool examination for hookworm and schistosomiasis

Urinalysis

Pregnancy test

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2.10. Management of Anemia

The general aims of management of anemia are:

To raise the level of hemoglobin to normal value. The hemoglobin level can be

raised by:

- Provision of foods rich in iron like meat, liver, fish, leafy vegetables and

vitamins.

- Administration of medicinal iron is the most important choice of therapy if iron

deficiency anemia is diagnosed.

- Administration of folic acid and vitamins.

- Blood transfusion.
 To treat underling causes (consider multiple causes)

To make proper follow-up.

During follow-up the important factors to consider are:

- Subsequent hemoglobin tests and clinical progress.

- Decision on added treatment if necessary.

- Decision on when to stop treatment.

- Decision on when to stop hemoglobin tests.

- Further care in health post.

- Health and nutrition education.

2.11. Prevention and Control

Early detection and treatment of underlying causes (as discussed in section 2.7).

Assessment and appropriate management of high risk groups:

E.g. - Pregnant women

- Pre-term infants

- Lactating mothers

- People with malnutrition

Preventing the underlying causes of anemia

Prevention of malaria

Prevention of parasites like hook worm infestation

Prevention of chemical poisoning, like lead poisoning.

Safety measures for the prevention of trauma causing blood loss.

Other public health measures such as:

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- Birth spacing.

- Immunization.
- Improved water supply and sanitation.

- Dietary improvement.

- Food fortification.

- Supplementation with iron tablets.

Health education pertaining to the causes, management and prevention of

anemia.

Nutrition Education emphasizing the avoidance of inhibitors of iron absorption

with food and increased intake of enhancers of iron absorption with food.

Inhibitors of Iron absorption

- Phytates (in cereals and legumes)

- Fiber (cereals and legumes)

- Tanins (in tea, coffee)

- Heavy metals (Ca, Zn, Mg)

- Achylohydria

- Low altitude

- Antacids

- Depleted stores

Enhancers of iron absorption

- Ascorbic acid (in Jucies, fruits)

- Amino acids (in meat, fish, chicken)

- Alcohol

- High altitudes

- HCL

- Deficient stores
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UNIT THREE

SATELLITE MODULE