ANAEMIA

DEFINITION OF ANAEMIA

The word anaemia is a Latin word meaning "no blood." It describes a condition where there is
lack of heam in the blood. Heam is the oxygen carrying and iron-containing molecule. This is
attached to a protein called globin to form haemoglobin (Hb), which is contained in the red blood
cells. This haemoglobin is responsible for the red colour of the blood.

What is anaemia?

It is important that you understand what anaemia is. Anaemia is not a diagnosis. It is a condition
whereby there is a reduction in number of red blood cells (RBCs) in the body.
What causes Anaemia
Diminished formation of red blood cells in the bone marrow.
A deficiency of iron or folic acid in the diet, which are required to form haemoglobin.
Excessive loss of blood (haemorrhage)
Premature destruction of the red blood cells, haemolysis.

Certain hereditary diseases may result in improper formation of red blood cells.

Diminished production of red blood cells.

This is a condition where there is lack of raw materials to make sufficient haemoglobin or red
blood cells in which haemoglobin is carried. Examples of this type of anaemia are nutritional
anaemias, which are due to a lack of nutrients in the diet, particularly iron and some vitamins
like folic acid and B12 and protein.

Alternatively, there could be a failure to manufacture enough red blood cells in the bone marrow.
This is called red-cell aplasia or hypoplasia. Aplastic or hypoplastic anaemias sometimes have
no obvious cause. In some instances, toxins from within and outside the body cause these
anaemias. Examples of external poisons are chemicals such as lead and certain drugs
(sulphonamides and chloramphenical) or physical radiation. Those from within the body include
chronic infections and illnesses such as nephritis and malignant tumours spreading throughout
the bone marrow thus diminishing the bone marrow space.

Blood loss.

These include the haemorrhagic anaemias that may be acute or chronic. Newborn babies may
lose blood through bleeding from the cord or due to birth injury, either inside the skull (subdural
haematoma) or outside the skull (cephalohaematoma).

In older children, blood may be lost from accidental injuries, nose bleeding (epistaxis), gastric
bleeding or bleeding after uvulectomy or circumcision.

Loss of blood may be chronic particularly, especially if it occurs in the gastro-intestinal tract due
to peptic ulcers, hookworm disease, chronic dysentery and haemorrhoids. Hookworms are the
biggest cause of gastrointestinal bleeding. The more the hookworms the more severe the loss of
blood thus resulting in severe anaemia.

CLINICAL FEATURES OF ANAEMIA

The main symptom of anaemia is tiredness, and this symptom is common to all varieties of
anaemia. Loss of appetite and irritability may develop. There is an increased vulnerability to
infection and breathlessness. Rapid pulse and oedema are seen only in the most severe cases of
anaemia.

The symptoms are most obvious if a child develops anaemia due to sudden loss of blood (e.g. in
severe bleeding), because the body has had no time to adjust to the sudden change. However, in
chronic anaemia where the blood loss is gradual, low levels of Hb. is tolerated because of the
body is able to gradually adjust to the anaemia.

Physical signs are minimal, pallor often being the only sign. The assessment of this feature must
be made from an examination of the mucous membranes. You should look for pallor in the
conjunctiva, the lips, the gums, the tongue, and the palms and soles of the feet and nail beds.
This is often useful especially in babies and coloured children. Fast pulse and fast breathing are
also common signs of anaemia.

In severe anaemia, children will also show signs of heart failure such as:
● Breathless at rest;

● Swelling of the ankles (oedema);

● Fluid in the base of the lungs (crepitations);

● Enlarged liver, which is usually soft, smooth and tender;

● Raised veins in the neck;

● Rapid heart rate (rapid pulse rate)

 ● CONDITIONS WHICH CAUSE ANAEMIA

Iron Deficiency Anaemia

Iron deficiency anaemia is a common condition worldwide but most prevalent in the developing
countries. Iron is a most abundant micronutrient occurring in a variety of foods yet its deficiency
occurs with far reaching public health consequences. As health workers, we need to control and
prevent this condition in order to avert these bad consequences.

Role of iron in Formation of Haemoglobin

As we mentioned earlier, in this Unit, iron plays an important part in the formation of
haemoglobin. It plays a particular role in the formation of the haem part, while the globin part is
contributed by protein, thus forming haemoglobin. Haemoglobin plays the essential role of
carrying oxygen from the lungs to various body tissues. When iron is deficient it means that the
haemoglobin formed is not enough, hence there is insufficient transportation of oxygen from the
lungs to the tissues. In addition, haemoglobin gives the red colour of the blood. When enough
haemoglobin is not formed, there is pallor, which is seen and can be detected in the tissues as
described earlier.

Sources of Iron
The iron needed by the body comes from the diet, mainly from the following sources:

● Leafy green vegetables

● Meat – beef, fish and poultry

● Cereals – sorghum, and millet

● Breast milk

Causes of Iron Deficiency Anaemia

Iron exists in the body as:

Haemoglobin
Body tissue iron (haemoglobin)
Transit iron transferring

In iron deficiency anaemia, the body iron stores are depleted first, followed by reduction in
transport iron and finally reduction of haemoglobin. These occur when there is reduced dietary
intake of iron. This means that the child is not being offered the following:

● Adequate breast milk

 ● cereals

● meat

Unfortunately cereals, which may provide iron, also have a substance, which lowers absorption
of iron thus making dietary iron not to become available to the body. This substance is called
phytic acid and it binds iron making it unavailable for absorption.
Breast milk is a good source of iron during infancy. The iron in breast milk is easily absorbed
and utilized by the child. However, cow’s milk and fortified formula milk do not have adequate
iron.

Common infections which are prevalent in the children precipitate iron deficiency. Although the
main mechanisms are unknown, the following infections are suspected to precipitate iron
deficiency:

Infections which reduce appetite therefore food intake;

Infections which may reduce iron absorption;
Infections which cause iron to be lost from the diet through vomiting and diarrhoea;
Infections that depress the bone marrow functions of formation of haemoglobin;
Infection that divert iron from the bone marrow and cause it to be deposited in other body tissue.

The other causes of iron deficiency anaemia include blood loss due to any bleeding disorder.
However, hookworm infestations are the major causes of iron deficiency anaemia. You will
learn more about hookworm infestations in Unit 15 on Helminthiasis.

There are also factors surrounding pregnancy and delivery that can predispose an infant to iron
deficiency anaemia. Ordinarily a foetus is a very successful parasite of the mother’s iron during
pregnancy, particularly during the third trimester. However, if the mother has iron deficient
mother the newborn baby may not have acquired enough iron from the mother during the third
trimester. Such a baby will develop iron deficiency anaemia during infancy. Also a child born
before term (preterm) may not have acquired enough iron from the mother during the third
trimester. Such a preterm infant may develop iron deficiency anaemia as he grows rapidly
during infancy.

Finally, in addition to the causes we have discussed above, the deficiency of other micronutrients
can cause iron deficiency anaemia. For instance, the deficiency of other micronutrients such as
of vitamin A, vitamin c, vitamin b12 and folic acid, may decrease the initialization of iron in the
formation of haemoglobin and thus lead to iron deficiency anaemia.

Effects of Iron Deficiency Anaemia

Iron deficiency anaemia has far reaching consequences. In its severe form, it impairs physical
growth leading into wasting whereby the individual child becomes thin. It also lowers immunity
thus leading or contributing to infections and the vicious cycle we described above. On brain
development iron deficiency anaemia in its severe form impairs learning due to reduced attention
span thus leading into lack of concentration and poor academic performance and achievement.

Achievement of Iron Deficiency Anaemia Diagnosis

The diagnosis of iron deficiency anaemia follows three levels:

detailed history,
clinical assessment and
laboratory investigations.

These three levels not only help to determine the underlying causes of iron deficiency anaemia as
we discussed earlier but also how to diagnose anaemia.

History Talking

In history talking you should make sure you go through in details all the possible causes we
discussed earlier. Enquire about the child’s diet to check if it is rich enough in iron and how long
the child was breastfed. Look for evidence of blood loss through bleeding and find out the
sanitary conditions where the child lives to evaluate whether hookworm infestation could be the
cause. In addition, you should determine the nutritional status of the mother during pregnancy.
Establish if the child was born premature; whether the child has developed normally physically
and in activities, and whether the child has suffered from any infections. Remember to enquire
about the presence of those clinical features related to anaemia which we discussed earlier.

Management

The treatment of iron deficiency anaemia consists of

Correcting the anaemia ;

Treating the causes of iron deficiency;
Treating any adverse effects of anaemia;

Iron deficiency is corrected by

Administering iron in the form of ferrous sulphate

Giving ferrous sulphate orally and checking Hb every two weeks to monitor the response.
Giving iron and folic acid according to the guidelines in Table 8.3 from the Ministry of Health.

Management of Iron Deficiency. Source MOH IMCI guidelines

Give Iron and Folate

Give one dose at 6mg/Kg of iron daily for 14 days
NB Avoid iron in a child known to suffer from Sickle Cell Anaemia
Avoid folate until 2 weeks after child has completed the dose of sulfa drugs
 AGE OR WEIGHT IRON/FOLATE IRON FOLIC ACID
TABLET TABLET TABLET
Ferrous Sulphate 200mg (200mg) (5mg)
+
250 mcg Folate
2 up to 4 months (4-6 - ¼ ½
kg)
4 up to 12 months (6- - ¼ 1
10kg)
12 mo up to 3 yrs (10-14 ½ ½ 1
kg)
3 yrs up to 5 years (14- ½ ½ 1
19kg)

Continuing with ferrous sulphate and folic acid for a duration of 2-6 weeks after Hb has come to
normal. This helps in replenishing iron stores in the tissues;
Administering Vitamin C to help in increasing iron absorption;
Correcting the diet and treating infections such as hookworms infestation.

In severe anaemia with cardiac failure a blood transfusion can be done. However, remember that
a blood transfusion should only be carried out in a health facility where proper clinical
assessment can be made and where procedures for collecting, grouping, cross-matching,
screening and storing blood can be carried out.

Prevention

Treat all pregnant mothers who have iron deficiency;

Give iron supplement to children born prematurely;
Encourage use of breastfeeding exclusively for six months;
At six months of age, children should be given leafy vegetables and cereals;
The community should use latrines to prevent hookworms infestations;
Where possible meat should be given to children as it has high iron content;
Follow up anaemia cases every 1-2 weeks until the haemoglobin level is normal.

Continue to give iron and folate supplements for a further 3-6 months. The haemoglobin level
should rise roughly 1g/dl every 7-10 days, although children recover faster

If the child fails to respond to treatment, the child should be referred for better management,
which may involve blood transfusion if the symptoms are very severe.
In case of other serious causes of anaemia such as leukaemia, sickle cell disease or bleeding
tendencies, specific diagnosis for each should be followed and action taken appropriately.