Nutritional anemia -Dr JP Singh, Dept, of community medicine, SRMS IMS Bareilly
- 2. Dr JP Singh, Assistant Professor, Dept of Community Medicine, SRMS IMS Bareilly NUTRITIONAL ANEMIA
- 3. NUTRITIONALANEMIA DEFINITION It is a disease syndrome caused by Malnutrition. Acc to WHO – A condition in which haemoglobin content of blood is lower than normal, as a result of deficiency of one or more essential nutrient, specially iron.
- 4. NUTRITIONAL ANEMIA Deficiency of A. Iron B. Folate C. B12 D. Protein corrected by supplementation
- 5. NUTRITIONAL ANEMIA Examples: Iron deficiency anemia and pernicious anemia. A. Micro-: Iron deficiency anemia A. Plummer-Vinson syndrome B. Macro-: Megaloblastic anemia A. Pernicious anemia
- 6. ANEMIA ANEMIA - Insufficient Hb to carry out O2 requirement by tissues. WHO definition : Hb conc. 11 gm % CDC definition : Hb conc. < 11gm % in 1st and 3rd trimesters and < 10.5 gm% in 2nd trimester For developing countries : cut off level suggested is 10 gm % - WHO technical report Series no. 405, Geneva 1968 Centre for disease control, MMWR 1989;38:400-4
- 7. Adult man 13 gm/dl Adult woman (non pregnant) 12 gm/dl Adult woman (pregnant) 11 gm/dl Child above 6 yrs 12 gm/dl Child below 6 yrs 11 gm/dl WHO CUT OFF CRITERIA OF HB% (IN VENOUS BLOOD)
- 8. A) IRON DEFECIENCY ANEMIA INTRODUCTIÓN Iron deficiency (ID) is one of the most frequent nutrition deficiency all round the world.( In India - 50%) Its prevalence is higher in children and childbearing age women. Iron deficiency anemia (IDA) mainly affects child behavior and development, work performance and immunity.
- 9. WORLD It is a world wide problem with highest prevalence in developing countries. It affect nearly 2/3 of pregnant and ½ of non pregnant. INDIA- Overall , 72.7 % of children up to age of 3 year in urban and 81.2% in rural are anaemic . It was found that , except for Punjab , all other state had more than 50% prevalence of anaemia among pregnant women. PROBLEM STATEMENT
- 10. Vulnerable groups % of Population with Anemia Adult male 20 children 40 Adolescent girls 56 Adult female 60 Pregnant mothers 80 % OF IDA IN INDIA IN VULNERABLE GROUPS
- 11. PREVALANCE % PUBLIC HEALTH PROBLEMS Less than 5 % Not a problem 5-19.9 Low magnitude (Mild) 20-39.9 Moderate magnitude (Moderate) 40 and above High magnitude (Severe) MAGNITUDE OF IDA
- 12. SOURCES OF IRON Animal- meat, liver, kidney, egg yolk. Veg.- pulses, beans, peas, green vegetables and fruits Milk- Human milk -0.29- 0.45mg/dl (Cow’s milk –poor source with 0.01 – 0.38mg/dl)
- 13. CAUSES OF IDA 1. Diminished stores 2. Diminished intake: d/t cereals & pulse based diet 3. Diminished absorption 4. Increased demands: During pregnancy & infections 5. Defective metabolism 6. Infections: Ankylostomiasis, PU, Ulcerative colitis, hemorrhoids
- 14. 1. Pregnancy: Increases risk of maternal & fetal morbidity & mortality (INDIA: 19% maternal deaths). 2. Infection: Anemia can be caused by infections (malaria, intestinal parasites) and may increase susceptibility to infections. 3. Decreased work capacity. 4. Growth failure among children DETRIMENTAL EFFECTS OF IDA
- 18. SIGNS Pallor of skin And m/m Edema Platynychia Koilonychia Glossitis Stomatitis Tachycard ia Soft ejection systolic murmur Signs
- 19. ASSESSMENT OF IDA I. Clinical and II. Laboratory indices. Laboratory indices are the most common methods used to assess iron nutrition status.
- 20. I. CLINICAL INDICES Pallor of the: Conjunctiva, Tongue, Nail bed and palm
- 21. II. LABORATORY INDICES 1. Low Hemoglobin 2. Low Hematocrit 3. Low Mean Corpuscular Volume 4. Serum Ferritin <10ng/ml 5. Transferrin Saturation<15% 6. TIBC>350µg/dl 7. Increased free erythrocyte protoporphiryn
- 22. 1. Adequate nutrition 2. Nutrition education to improve dietary habit 3. Breast feeding and appropriate weaning diet 4. Iron rich food 5. Increase ascorbic acid 6. Health education 7. Periodical deworming specially among children and at least once during IInd trimester of pregnancy 8. Nutritional supplementation 9. Foot wear use 10. Safe drinking water 1. Food fortification 2. National nutritional anemia prophylaxis program (NNAPP) 3. National nutritional anemia control program (NNACP): The elemental iron was increased from 60 mg to 100 mg per tablet in 1992 I. HEALTH PROMOTION II. SPECIFIC PROTECTION PREVENTION OF NUTRITIONAL ANEMIA
- 23. 1. Infants b/w 5-12 months should also be included as beneficiaries for iron supplementation, under ICDS Scheme. 2. Liquid formulations to be prepared, each ml containing 20 mg of iron & 100 mcg of folic acid 3. For children b/w 6-10 yrs, 30 mg of iron and 250 mcg of folic acid. 4. For children b/w 10-18 yrs (adult dose) also to be included as beneficiaries for iron supplementation. NEW RECOMENDATIONS
- 24. BENEFICIERIES: A. Pregnant mothers B. Lactating mothers & C. Children b/w 1-12 yrs BENEFITS: Iron & folic acid (IFA) tabs are distributed free of cost. BENEFICIERIES & BENEFITS
- 25. • Iron & Folic Acid (IFA) supplementation: National Nutritional Anemia Prophylaxis Programme (NNAPP): • Eligibility criteria: Hb level 10-12 receives IFA tablets; <10 referred to PHC (MO). • Dosage: 1. Mothers: One IFA tablet (100 mg elemental iron + 500 μgm folic acid) X 2- 3 months after Hb level returned to normal. 2. Children: Screening for anemia at 6 mths, 1 yr & 2 yrs of age. 3. Children upto 6 yrs: One IFA tablet (20 mg elemental iron + 100 μgm folic acid) X 100 days. 4. Children 6-10 yrs: One IFA tablet (30 mg elemental iron + 250 μgm folic acid) X 100 days. DOSES
- 26. GRADE (WHO) DEGREE OF ANMIA TREATMENT 11-14 gm/dl Normal Nothing required 9-11 gm Mild Oral iron therapy required 7-9 gm Moderate Parenteral iron therapy Less than 7 gm Severe Blood transfusion GRADING & T/T OF ANEMIA
- 27. TREATMENT OF IDA 1. Treat underlying cause (hook worm etc) 2. Oral iron therapy: 3-6mg/kg in 3 divided doses ( Hb rises by 0.4g/day) 3. Vit C, empty stomach or in between meals: For 6-8 wks after Hb is normal 4. Parental iron therapy ( Iron in mg=wt in kg× Hb deficit in gm/dl×4) 5. Blood transfusion –rarely when Hb<4gm/dl, CCF, severe infection with poor iron utilisation
- 28. B) FOLIC ACID DEF 1. Necessary for DNA synthesis. 2. SOURCES: Liver, soya bean, dark green leafy vegetables 3. CAUSES: Strict vegetarian, Tape worm anemia, Repeated Pregnancy, Chronic diarrhea, malabsorption and recurrent infections 4. Cooking destroys folic acid 5. Deficiency disease: Megaloblastic anemia in children & pregnant mothers 6. Treatment with phenytoin / antimetabolites 7. T/T: Folic acid 2-5 mg/day 8. RDA: 500 mcg/day for pregnant mother
- 29. C) B12 DEFICIENCY Necessary for DNA synthesis. SOURCES: Foods of animal origin only (fish, egg, meat) DISEASES: Megaloblastic anemia, parasthesia of fingers & toes. It is observed in breast fed infants of vit. B 12 deficient mother & delayed weaning child RDA: Vit. B12 1µg/day
- 30. CLINICAL FEATURES 1. Pale 2. Very sick 3. Irritable 4. Severe anorexia 5. Failure to thrive 6. Knuckle pigmentation (hands and nose) 7. Tremor and developmental regression
- 32. Thank You
Editor's Notes
- #9: Introduction Despite the fact that iron is the fouth most common element on earth, Iron deficiency (ID) is one of the most frequent nutrition deficiency all round the world, in developing as well as in developed countries, its prevalence, which is arround 50% in developing and 10% in developed countries, the higher prevalence in children and childbearing age women, and the consequences of Iron deficiency anemia (IDA) on child behaviour and development, work performance and immunity, make IDA a very important problem from a public health perspective.
- #21: Assessment of IDA Several indices have been applied in assessing nutrition Iron status. They can be classified as Clinical and Laboratory indices. Laboratory indices are the most common methods used to assess iron nutrition status. Hemoglobin: Hemoglobin concentration varies considerably with age. Even when hemoglobin is related to iron deficiency and the definition of IDA is based on hemoglobin concentration, some authors have stated that it is not an adequate indicator when it is applied as the only measurement, specially in populations with low prevalence (it will be discussed later).
- #22: Transferrin Saturation: corresponds to plasma iron divided by plasma total iron-binding capacity X 100. Percentages below 16% in adults and children and below 12% in infants suggest insufficient iron delivery to the hematopoietic tissues Serum Transferrin receptors: Serum transferrin receptors reflect the number of receptors in immature red blood cells and thus the level of erythropoiesis. It is unaffected by infection or inflammation what makes Serum Transferrin receptors concentration be an accurate index of Iron nutrition status. Erythrocyte protoporphyrin: protoporphyrin combines with iron to form heme. Under ID conditions, the lack of iron determines an increase in erythrocyte protoporphyrin, which can not combined with Iron. Increased values of erythrocyte protoporphyrin indicate impaired erythropoyesis due to iron deficiency. Values greater than 100 ug/dl and 120 ug/dl have been used as cutoff points Pallor of the conjunctiva, tongue, nail bed and palm can be used as clinical indices of ID what is due to the low hemoglobin concentration in areas with high vascularization. Even when they are easily and inexpensively obtained, subjectivity is the main problem of clinical indicators.
- #23: Mean corpuscular volume: It depends on hemoglobin content in the red blood cell, so in absence of other conditions a decrease in hemoglobin is associated with a decrease in MCV. Ferritin: Even when ferritin is present within cells, a small amount circulates in plasma and permits estimation of total ferritin, been the earliest indicator of ID. As it has been mentioned before, Serum Ferritin expresses Iron Stores. During infancy Serum Ferritin concentration below 10 ng/ml are considered as the expression of depleted iron stores (Siimes et al, 1974; Thomas et al, 1977; Dallman et al, 1981). During infection or inflammation Serum Ferritin increases like other acute phase proteins, and then SF is not an accurate indicator in such situations.