Iron-Deficiency Anaemia – From the Prospect of Community Health Nursing

 

Ms. Indu Rathore

Assistant Professor, Murari Lal Memorial School and College of Nursing, Village- Nagali, P.O. Oachghat

Solan (HP)- 173223

 

ABSTRACT:

Anaemia is the worldwide major public health problem. Globally, there are around two billion anemic people and approximately 50% of them are suffering from iron deficiency anaemia, which is one of the most common nutritional anaemia. Iron deficiency anaemia can be defined as the condition in which the total body iron content is decreased below a normal level that affects hemoglobin synthesis. A number of factors such as poor dietary intake, iron malabsorption, excessive blood loss, pregnancy, child birth, chronic inflammations and infections may contribute to iron deficiency anaemia. It is characterized by headache, difficulty in concentration, fatigue, weakness, palpitations, breathlessness, dyspnea, pallor skin and mucous membranes, smooth or sore tongue etc. If anaemia is not diagnosed and treated at an early stage, it may have severe health consequences that hamper the nation’s social and economic development. This review article throws the light on Anaemia, its risk factors, clinical manifestations, diagnosis, WHO cut-off points and their adjustment according to altitude and smoking habits, interventions in national health programmes and the role of the community health nurse in prevention and control of iron-deficiency Anaemia.

 

 

INTRODUCTION:

Anaemia is the worldwide major public health problem affecting the people in all the ages and both the sexes. As per WHO estimates there are around two billion anaemic people globally and approximately 50% of all them are suffering from iron deficiency. ¹Women and children are the most vulnerable groups. Over 50% of pre-school children and pregnant women in developing countries and at least 30-40% in industrialized countries are affected by Anaemia.²

 

If anaemia is not diagnosed and treated at an early stage, it may have severe health consequences such as increased risk of maternal and childhood mortality, poor cognitive and physical development of children, loss of work productivity in adults and increased risk of postoperative morbidity and mortality in surgical patients. Further, it affects the social and economic development. ¹ Hence it is important to understand multifactorial etiology behind the Anaemia for developing effective strategies to prevent and control this silent emergency.

 

Prevalence in India

In India, 50% of the young children and non-pregnant women are anaemic. According to NFHS-3, almost 7 in 10 children aged 6-59 months were anaemic. The prevalence of anaemia in children aged 6-35 months was 79%. Anaemia affected 55% of women and 24 % of men. The prevalence of anaemia for ever-married women was 56%. Pregnant women had  a  greater risk for anaemia as compared to non-pregnant women (NFHS-3). Anaemia is one of the non- obstetric causes contributing to 19% cases of maternal morbidity. ^3,4

 

Anaemia

According to WHO, “Anaemia is a condition in which the number of red blood cells or their oxygen-carrying capacity is insufficient to meet physiologic needs, which vary by age, sex, altitude, smoking, and pregnancy status.”⁵

 

Iron-Deficiency Anaemia

Iron deficiency anaemia is a condition in which the total iron content in the body is decreased below a normal level that affects hemoglobin synthesis. As a result RBCs become pale and small. ⁶ Iron deficiency is the most common, whereas folate, vitamin-B12 and vitamin-A deficiency is the less common causes of nutritional anaemias.

 

Risk Factors

There are various risk factors which may result in Iron-deficiency anaemia -

·         Diet with poor bioavailability of iron.

·         Poor iron absorption (due to presence of  inhibitors of iron absorption in the diet, such as phytates, oxalates, carbonates, phosphates, dietary fibers and diseases such as small bowel disease, gastroenterostomy)

·         Childhood and pregnancy (Increased demand due to rapid growth)

·         Excessive blood loss (during menses and delivery)

·          Acute and chronic inflammations (peptic ulcer, heamorrhroids, gastritis)

·         Parasitic infestations (Malaria, hookworm infestation)

·         Infections (Tuberculosis and HIV/AIDS)

·         Inherited or acquired disorders that affect haemoglobin synthesis, production or survival of red blood cells.^2,4,5,6

 

 Clinical manifestations-

·       Headache

·       Dizziness (difficulty with attention or concentration)

·       Fatigue, Weakness

·       Tinnitus (ringing or buzzing sound coming from the  

      body)

·       Palpitations

·       Breathlessness

·       Dyspnea on exertion

·       Pallor skin and mucous membranes

·       Smooth or sore tongue

·       Cheilosis (fissures at angles of mouth)

·       Koilonychia (spoon-shaped nails)

·       Pica (craving to consume non-food materials) 6

 

Diagnostic tests-

Laboratory tests to evaluate the iron status are based on - haemoglobin concentration, serum iron concentration, serum ferritin and serum transferrin saturation.⁴

 

WHO cut-off points for anaemia

Anaemia is established if hemoglobin level is below cut-off points for different age groups as recommended by WHO in 1968  (Table-1). ⁷ The cutoff points help in identification of populations at greatest risk of developing anaemia and priority areas for action.  They also facilitate the monitoring of progress towards international goals of preventing and controlling iron deficiency and further provide the basis for advocacy for the prevention of anaemia (Table-2).⁸

 

 

 

Table-1: WHO cut-off points for diagnosis of Anaemia⁷

 

 

Table-2: Haemoglobin levels to diagnose anaemia at sea level (g/l) ⁸

As the haemoglobin concentration is affected by habits such as smoking and living at high altitude. Thus, WHO (2011) recommended some adjustments to measure haemoglobin concentrations according to smoking habits and altitude (Table-3 and 4). Smoking adjustments are derived from National Health and Nutrition Examination Survey (NHANES-II). The altitude adjustments are based on the data gathered by WHO from the US Centers for Disease Control and Prevention’s (CDC) and Pediatric Nutrition Surveillance System in children living in the mountainous states. The adjustment values are additive. Smokers living at higher altitudes would have two adjustments made. There are variations in the distributions of hemoglobin values among different ethnic groups, but only a little data is available to make necessary adjustments.

 

Table -3: Altitude adjustments to measured haemoglobin concentrations⁸

Altitude (metres above sea level)	Measured haemoglobin adjustment (g/l)
< 1000	0
1000	-2
1500	-5
2000	-8
2500	-13
3000	-19
3500	-27
4000	-35
4500	-45

 

Table-4:  Adjustments to measured haemoglobin concentrations for smokers⁸

Smoking status	Measured haemoglobin adjustment (g/l)
Non-smoker	0
Smoker (all)	-0.3
1/2 -1 packet/day	-0.3
1-2 packets/day	-0.5
≥ 2 packets/day	-0.7

 

IRON DEFICIENCY ANAEMIA- PREVENTION AND MANAGEMENT

Contribution of National Health Programmes

National Nutritional Anaemia Prophylaxis Program (1970)

The government of India sponsored National Nutritional Anaemia Prophylaxis Programme during the Fourth Five Year Plan. It consists of the daily supplementation with Iron and folic acid (IFA) tables to “at risk” groups (pregnant mothers, lactating mothers and children below 12 years of age). Maternal and Child Health Centre (MCH) in urban areas and PHC in rural areas and ICDS projects engage in the implementation of this program. As per eligibility criteria, if the haemoglobin level is between10-12, daily supplement with IFA tablets is advised, if it is less than 10g, the patient is referred to the nearest Primary health centre.

 

 

In mothers- The expected and nursing mothers are given one tablet of IFA containing 100mg elemental iron (300mg of ferrous sulphate) and 0.5 mg of folic acid daily. The duration of supplementation depends upon the progress of beneficiary.

 

In children-If anaemia is suspected, a screening for the anaemia should be done on infants at 6 months, 1 and 2 years age. One tablet of IFA containing 20 mg of elemental iron (60mg of ferrous sulphate) and 0.1mg of folic acid should be given daily for 100 days. Children aged 6-60 months are given Ferrous sulphate and Folic acid in liquid form. These bottles are designed in such a way that only 1ml can be dispensed each time. School children 6-10yrs of age are provided 30mg elemental iron and 250mcg of folic acid for 100 days daily in a year. Adolescents are given same dosage and duration as adults.⁴

 

Integrated Management of Neonatal and Childhood Illness (IMNCI)

As per IMNCI guidelines (2003) all the sick children should be assessed for anaemia. Nutritional anaemia is common in children due to parasitic or helminthic infections. Other severe conditions such as haemolytic anaemia, aplastic anaemia or leukaemia may also result in anaemia in children.  While checking for anaemia in children aged 2 months to 5 years, firstly, look for the palmer pallor. Then ensure that weather is it ‘Severe palmar pallor?’ Or ‘Some palmar pallor?’ Now classify the anaemia as (Table-5)

 

Table-5:  IMNCI classification of anaemia in children from age 2 months to up to 5 years

Signs	Classify As	Treatment
Severe palmar pallor	SEVERE ANAEMIA	·     Refer URGENTLY to hospital.
Some palmar pallor	ANAEMIA	·     Give Iron folic acid therapy for 14 days. ·     Assess the child’s feeding and counsel the mother on feeding. -If feeding problem, follow-up in 5 days. ·     Advice mother when to return immediately. ·     Follow-up in 14 days.
No palmar pallor	NO ANAEMIA	·     Give prophylactic  Iron folic acid therapy if the child is 6 months or older

 

Drug Dosage: Give syrup to the child below 12 months of age. If the child is 12 months or above, give iron tablets. Give the mother enough iron for 14 days. Advice her to give her child single dose daily for those 14 days. Ask her to return for more iron in 14 days to health centre. Also tell her that the iron may turn the child's stools black. Assess pallor after 1 month of treatment. Refer if the child is not improved after 1 month of treatment with Iron.⁹

 

National Rural Health Mission (NRHM) /Reproductive Child Health Program (RCH)

In 2005 the Government of India developed the guidelines to equip Staff Nurses (SNs) and Auxillary Mid-Wives (ANMs) for managing normal deliveries, identifying complications, their basic management and earliest refer to higher facilities. These guidelines were further modified in 2010. Anaemia is one of the major complications during pregnancy and childbirth. The guidelines for ante-natal care and skilled attendance at birth by ANMs and LHVs’ provides valuable, up to date and evidence based information to manage anaemia during pregnancy and childbirth at different referral levels. As per information given in guidelines iron deficiency anaemia can be managed before and during pregnancy as-

 

Before pregnancy-An interval of less than 2 years from the previous pregnancy or less than 3 months from the previous abortion increases the chances of the mother developing anaemia. Hence there should be a gap of  3-4 years between two pregnancies¹⁰

 

During pregnancy-

Pallor- Pallor during pregnancy is an indicative of anaemia (Table-6). Increasing pallor should be co-related with haemoglobin estimation and would require investigation or referral to the medical officer.

 

Table-6: How to look for pallor in a pregnant woman?¹¹

·          Examine conjunctiva, nails, tongue, oral mucosa and palms in a pregnant woman for the presence of pallor. ·          To look for conjunctival pallor, ask the woman to look up and pull down the lower lid with gentle but firm pressure of your index finger. Look at the colour of the inside of the lid. It should be bright pink or red. If it is a pale pink or white, the woman has pallor. ·          Examine the tongue. If it is white and smooth, the woman has pallor. Also examine the oral mucosa and palate. ·          Examine the nails. If they look white instead of the usual light pink, the woman has pallor. In case of severe and long-standing iron deficiency anaemia, the nails also become thin and brittle. They lose the normal convexity and become concave or spoon-shaped(koilonychias)

 

Respiratory Rate

Respiratory rate above 30 breaths per minute with pallor indicates that the woman may have severe anaemia. She must be immediately referred to the medical officer for further investigation and management.

 

Haemoglobin (Hb) Estimation

The initial haemoglobin level will function as a baseline with which the later outcomes, received on the next three antenatal visits, can be compared. Haemoglobin may be estimated at sub-centres or the outreach level by the Sahli method. A woman who has a haemoglobin level lower than 11 g/dl at any time during the pregnancy is considered to be suffering from anaemia (Table-7).

 

Table-7: Classification of anaemia during pregnancy-

Haemoglobin level	Degree of anaemia
> 11 g/dl	Absence of anaemia
7–11 g/dl	Moderate anaemia
Less than 7 g/dl	Severe anaemia

 

Iron-Folic Acid (IFA) supplementation-

·         Prophylactic dose (to prevent anaemia): All pregnant women should be given one IFA tablet (100 mg elemental iron and 0.5 mg folic acid) every day for at least 100 days after the first trimester, at 14–16 weeks of gestation. This dosage regimen is to be repeated for three months during post-partum period.

 

·         Therapeutic dose (to correct anaemia): If a pregnant woman is anaemic (haemoglobin below 11 g/dl) or has pallor, she should be given two IFA tablets per day for three months (200 tablets). This dosage regimen is to be repeated for three months during post-partum period in women with moderate to severe anaemia. The haemoglobin level should be estimated again after a month. If the level has increased, continue with two IFA tablets daily till it comes up to normal. If it does not rise in spite of the administration of two IFA tablets daily and dietary measures, refer the woman to the medical officer at the Primary Health Centre.

 

·         Women with severe anaemia (haemoglobin of less than 7 g/dl), or those who have breathlessness and tachycardia (pulse rate of more than 100 beats per minute) due to anaemia- They should be started therapeutic dose of IFA and referred immediately to the medical officer at First Referral Unit for further management. All the women must be counseled regarding anaemia, its prevention and management during pregnancy.

 

During Delivery-

Cutting the cord after an interval of 1–3 minutes during delivery, helps to avoid neonatal anaemia, as it results in transfusion of an increased amount of blood into the fetal circulation.¹⁰

 

Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCH+A)

National Iron + Initiative

National Iron + Initiative was launched in 2013 to prevent and control the iron deficiency anaemia in adolescents (10–19 years), both inside and out of school. Those in school has been reached through Weekly Iron and Folic Acid Supplementation (WIFS), while ‘out of school’ adolescents has been reached through Anganwadi Centers. Under this initiative, adolescents as well as pregnant and lactating mothers have been supplemented differently. The blue colour (‘Iron ki nili goli’) IFA tablet is for adolescents while the red color IFA tablet is for pregnant and lactating women.

 

Weekly IFA supplementation scheme (WIFS)

It is a community-based intervention that addresses nutritional (iron deficiency) anaemia amongst adolescents (girls and boys) in both rural and urban areas. It cover adolescents enrolled in VI–XII class of government, government aided and municipal schools as well as ‘out of school’ girls. The salient features of the scheme are as under-

(1) Supervised administration of weekly IFA supplements of 100 mg elemental iron and 500 mcg folic acid.

(2) Target groups screening for moderate and severe anaemia and referral to an appropriate health care facility.

(3) Biannual de-worming with Albendazole (400 mg)        

(4) Information and counselling to improve dietary intake and preventive actions for intestinal worm infestation.¹²

 

ROLE OF COMMUNITY HEALTH NURSE - PREVENTION AND MANAGEMENT OF IRON DEFICIENCY ANAEMIA

A community health nurse should have complete knowledge regarding iron deficiency anaemia, its causes, risk factors, sign and symptoms, prevention and management.  She should know the functions, sources and daily requirement of iron in the diet.

A community health nurse must keep herself up-to-date for various activities of the programme. The role of the community health nurse in prevention and control of iron-deficiency anaemia can be well described through the nursing process-

 

Assessment

·         A community health nurse carries out a complete community assessment to know the magnitude of Iron deficiency Anaemia through health surveys, routine screening and conducting research.

·         She identifies “at risk” groups (Pregnant women, lactating women, adolescent girls and children below the 12 years of age).

·         She can assess the prevalence of anaemia during her routine visits among the vulnerable groups in families, children in anganwadis, crèches and schools, adolescent girls, antenatal and lactating mothers coming to anganwadis and in health centres.

·         During the home visits, she can examine conjunctiva, nails, tongue, oral mucosa and palms for the presence of pallor    (Table-6). Where feasible, the specificity of anaemia diagnosis may be greatly increased by using a simple laboratory test for Hb estimation (By using hemoglobinometer or by World Health Organization (WHO)-approved Haemoglobin Colour Scale)

·         She tries to find out the contributory factors responsible for iron deficiency anaemia (low dietary intake of iron, menstruation, childbearing in women, worm infestation in children, malaria, hemorrhoids and peptic ulcer).

·         She helps in the planning and administration of National Nutritional Anaemia Prophylaxis Program on the basis of data gathered.

 

Planning and Implementation

·         She helps in organizing and arranging the routine antenatal and immunization clinics where she can assess the pregnant woman and children respectively, for iron deficiency anaemia and distributes free iron folic acid tablets to them. 

·         She helps in screening of school children for worm infestation and iron deficiency anaemia in school health clinics.

·         During routine home visits in families, she demonstrates the preparation of low cost iron rich preparations e.g. Nutritious Laddo, Nutritious Khichdi etc.

·         She organizes In-service education programs of ANM, ANMs, ASHAs and Anganwadi workers and teaches them regarding iron deficiency anaemia its causes, risk factors, sign and symptoms, clinical diagnosis prevention and management.

·         She involves ANMs, ASHAs, Anganwadi workers and other health workers in the community for IEC activities, prevention and early detection of cases, appropriate referral and monitoring for iron deficiency anaemia.

·         She keeps up her records (antenatal cards, family cards/folders, antenatal records, stock registers) up to date.

·         She carries out periodic evaluation through family visits, re-visits, surveys and conducting research in her working area.

 

Health Education

A community health nurse has a great responsibility to teach people regarding nutritional anaemia. The opportunities are patients and relatives, mothers attending antenatal and postnatal clinics and pediatric departments and families during the home visits. A few words from the mouth of community health nurse will be more effective rather than volumes of printed material-

 

 

Health Education

While consuming IFA tablets-

·         IFA tablets should be taken early in the morning on an empty stomach with a full glass of water or fruit juice.

·         It is necessary to take the pill regularly in spite of some common side-effects such as epigastric discomfort, black stool, nausea, constipation or diarrhea.

·         Black stools are normal while taking IFA tablets.

·         IFA tablets may also be taken with meals or at night to avoid nausea and abdominal pain.

·         Drink plenty of water, consume fiber-rich and do exercise to prevent or treat constipation.

·         Avoid taking IFA tablets with tea or coffee as they reduce the absorption of iron.

·         IFA tablets may make feel less tired than before. However, despite feeling better, one should not stop taking the tablets.

·         Do not take iron and calcium pills together as an excess of calcium interfere with the absorption of iron. Similarly, avoid consuming Palak – paneer.

·         Liquid iron preparations may stain teeth so they should be mixed well with water or fruit juice or a straw should be used.

·         Keep iron medications out of the reach of children as overdose may be fatal.

·         Consume the pills until the hemoglobin reaches within the normal range.

·         Emphasize on the need for follow up visits and laboratory examinations.

 

Measures to restore iron in the body -

·         Eat foods rich in iron, e.g. green leafy veggies, legumes, eggs, meat, lentils, beans, jaggery, dry fruits and nuts.

·         Take all three meals with one extra bowl containing green leafy vegetables in each meal.

·          Add foods rich in Vitamin-C (amla, guava, lime, orange, fermented foods, germinating cereals and pulses) as they help to absorb iron.

·         Avoid the food containing inhibitors of iron absorption in the diet, such as phytates, oxalates, carbonates, phosphates, dietary fibers.

·         Avoid tea or coffee immediately after the meal as tannin in the tea or coffee interferes with iron absorption.

·         Use the iron-fortified food such as wheat flour.

·         The vegetables should be washed and cooked properly to kill the parasites.

·         Cook the food in iron vessels or utensils.

·         Consult the physician and go for a stool test, especially in the case of children periodically. Take deworming treatment if ova or cyst is present in stool.

·         Immediately take the treatment for the underlying conditions (peptic ulcer, hemorrhoids, gastritis, malaria, hookworm infestation) that may cause anaemia.

·         Weaning at the right age, personal and environmental hygiene also helps to prevent Iron deficiency Anaemia. ^4,6,10

 

REFERENCES-

1.        WHO-UNICEF. Joint statement by the World Health Organization and the United Nations Children’s Fund. Focusing on anaemia towards an integrated approach for effective anaemia control. [Internet] 2004[cited 2016 Aug 25] Available from: http://www.who.int/medical_devices/publications/en/WHO_UNICEF-anaemiastatement.pdf?ua=1

2.        WHO. Medical devices -Anaemia prevention and control [Internet][cited 2016 Aug 25].Available from: http://www.who.int/medical_devices/initiatives/anaemia_control/en/

3.        International Institute for Population Sciences (IIPS) and Macro International. National Family Health Survey (NFHS-3), 2005–06- India-Volume I. [Internet] 2007. [cited 2016 Aug 18] Available from: http://rchiips.org/NFHS/NFHS-3%20Data/VOL-1/India_volume_I_corrected_17oct08.pdf

4.        Park.K. Parks text book of Preventive and Social Medicine. 23^rd edition: M/s Banarsidas Bhanot: 2015.p. 561, 604,622-624,642-643,661, 899

5.        WHO. Anaemia [Internet][cited 2016 Aug 25] Available from:  http://www.who.int/topics/anaemia/en/

6.        Nettina SM. Lippincott Manual of Nursing Practice, 10^th Edition: Wolters Kluwer:2014.p.978-979

7.        WHO. Nutritional anaemias. Report of a WHO scientific group. Geneva, World Health Organization, 1968. (WHO Technical Report Series, No. 405). [Internet] 1968[cited 2016 Aug 25] Available from:  http://whqlibdoc.who.int/trs/WHO_TRS_405.pdf

8.        WHO. Haemoglobin concentrations for the diagnosis of anaemia and assessment of severity .[Internet] 2011[cited 2016 Aug 25] Available from:  http://www.who.int/vmnis/indicators/haemoglobin.pdf

9.        Government of India. Ministry of Health and Family Welfare. Students’ Handbook for IMNCI Integrated Management of Neonatal and Childhood Illness. [Internet] 2003[cited 2016 Sep 15] Available from: https://www.scribd.com/doc/271437297/ IMNCI-Students-Handbook-pdf

10.     Government of India. Ministry of Health and Family Welfare. Guidelines for ante-natal care and skilled attendance at birth by ANMs and LHVs [Internet] 2010[cited 2016 Sep 15] Available from: www.nhp.gov.in/sites/default/files/anm_guidelines.pdf

11.     Government of India. Ministry of Health and Family Welfare. Guidelines for ante-natal care and skilled attendance at birth by ANMs and LHVs [Internet] 2005[cited 2016 Sep 15] Available from: www.indiannursingcouncil.org/pdf/SBA-MODULE-Guideline-for-Antenatal-Care.pdf

12.     Government of India. Ministry of Health and Family Welfare. A Strategic Approach to Reporoductive, Maternal, Newborn, Child and Adolescent Health (RMNCH+A) in India. [Internet] 2013 Jan [cited 2016 Sep 15] Available from:www.mohwf. nic.in  

 

 

 

Received on 11.09.2016          Modified on 25.09.2016

Accepted on 27.12.2016         © A&V Publications all right reserved