Nutritional Anemia Etiology, Pathogenesis, Clinical features, Diagnosis, Management

1. ANEMIA
DR SHAHNAWAZ F SHAH
MD, FPM, FIAPM,FCPM (MUHS)
Interventional Spine & Pain Physician
Surat

2. INTRODUCTION
 Anemia is a major killer in India.
 Statistics reveal that every second Indian
woman is anemic
 One in every five maternal deaths is directly
due to anemia.
 Anemia affects both adults and children of
both sexes, although pregnant women and
adolescent girls are most susceptible and
most affected by this disease.

3. OBJECTIVES
 Definition of anemia
 Classification of anemia
 Anemia Cause
 Anemia Symptoms
 Lab Investigation of Anemia
 Treatment
 Prevention

4. What Are Red Blood Cells?
 Red blood cells are one of the components of blood. (The others
are plasma, platelets and white blood cells.)
 They are continuously produced in our bone marrow.
 Just two or three drops of blood can contain about one billion red
blood cells – in fact, that’s what gives our blood that distinctive
red color.
 Also known as erythrocytes

5. What Is the Function of Red Blood
Cells?
Red blood cells carry oxygen from our lungs to the
rest of our bodies. Then they make the return trip,
taking carbon dioxide back to our lungs to be
exhaled.

6. Erythropoiesis
 Greek 'erythro' meaning "red" and 'poiesis' meaning "to make"
 the process which produces red blood cells (erythrocytes)
 development from erythropoietic stem cell to mature red blood
cell.

9. DEFINITION
 Anemia (An-without,emia-blood)
 decrease in the RBC count,
 hemoglobin and/or
 Hematocrit values
 resulting in a reduced ability of the blood to
carry oxygen to body tissues .

10. PATHOPHYSIOLOGY

11. PATHOPHYSIOLOGY

13. NORMAL VALUES
 Category Reference Values
 Men >13 g/dl
 Women >12 g/dl
 Pregnant women
 Infants from 2 to 6month
>11g/dl
s >9.5 g/dl
 Children from 6 months
to 24 months
 2yrs to 11yrs
>10.5 g/dl
>11.5 g/dl
 Children from 12 years >12 g/dl
Category Values Reference
Men >13 g/dl
Women >12 g/dl
Pregnant women >11g/dl
Infants from 2 to 6 months >9.5 g/dl
Children from 6 months to 24
months
>10.5 g/dl
2yrs to 11 yrs >11.5 g/dl
Children from 12 years >12 g/dl

14. Haemoglobin levels to diagnose anaemia
(g/dl)

15. CLASSIFICATION
ANAEMIA
CAUSE
Blood Loss
Inadequate
production of
normal blood
cells
Excessive
destruction of
blood cells
MORPHOLOGY
Normocytic Microcytic Macrocytic

16. TYPES OF ANEMIA
Based on clinical picture-
 Iron deficiency anemia.
 Megaloblastic anemia.
 Pernicious anemia.
 Hemorrhagic anemia.
 Hemolytic anemia.
-Thalassemia anemia
-Sickle cell anemia
 Aplastic anemia
 The commonest causes of anemia in developing countries, particularly
among the most vulnerable groups (pregnant women and preschool age
children), are nutritional disorders and infections.

17. TYPES OF ANEMIA
 IRON DEFICIENCY ANEMIA
Iron deficiency is the result of long-term negative iron
balance.
Iron deficiency anaemia (IDA) should be regarded as a
subset of iron deficiency, that is, it represents the
extreme lower end of the distribution of iron deficiency

18. Iron deficiency adversely affects
 The cognitive performance, behaviour and physical growth of
infants, preschool and school-age children;
 The immune status and morbidity from infections of all age
groups;
 The use of energy sources by muscles and thus the physical
capacity and work performance of adolescents and adults of all
age groups.

19. Iron deficiency is a consequence of:
 Decreased iron intake
 Increased iron loss from the body
 Increased iron requirement: increase during the period of
active growth in childhood, especially from 6 months to 3
years
Blood loss during menstruation and increased iron requirements
during pregnancy and lactation predispose women to poor iron
stores.
Traditionally, the Indian housewife eats last, after all male members and children have eaten
and in many families, the women eat only the leftovers.
Hence, even though the food prepared for the family is the same, women are more prone to
develop IDA than other members of the family.

20.  MEGALOBLASTIC ANEMIA
♣ Less intake of vitamin B 12 and folic acid
 Diets with little or no animal protein
 Malabsorption related to parasitic infections of the small
intestine
 Folic acid is also essential for the formation and
maturation of RBCs and is necessary for cell growth and
repair
♣ Red bone marrow produces abnormal RBC.
 PERNICIOUS ANEMIA
♣ Inability of stomach to absorb vitamin B 12 in small
intestine.

21. TYPES OF ANEMIA
 HEMORRHAGIC ANEMIA
♣ Excessive loss of RBC through bleeding
♣ Stomach ulcers, menstruation
 HEMOLYTIC ANEMIA
♣ RBC plasma membrane ruptures.
♣ may be due to parasites, toxins, antibodies
 THALASSEMMIA
♣ due to decreased or negligible amount of globin chain of
haemoglobin
♣ Less synthesis of hemoglobin .
♣ one of the major haemoglobinopathies among the
population all over the world

22. TYPES OF ANEMIA
 SICKLE CELL ANEMIA
♣ Hereditary disorder of hemoglobin
♣ Characterized by red blood cells that assume an abnormal,
rigid, sickle shape.
♣ Results in recurrent haemolytic anaemia.
 APLASTIC ANEMIA
♣ destruction of red bone marrow .
♣ caused by toxins, gamma radiation.

23. TYPES OF ANEMIA

24.  Normochromic, Normocytic anemia
(normal MCHC, normal MCV).
These include:
anemias of chronic disease
hemolytic anemias (those characterized by
accelerated destruction of RBCs)
anemia of acute hemorrhage
aplastic anemias (those characterized by
disappearance of rbc precursors from the marrow)
TYPES OF ANEMIA

25.  Hypochromic, microcytic anemia
(low MCHC, low MCV)
These include:
iron deficiency anemia
thalassemias
anemia of chronic diseases
 Normochromic, macrocytic anemia
(normal MCHC, high MCV)
These include:
vitamin B12 deficiency
folate deficiency

26. RISK FACTORS
 Poor socio economic class
 Multiparity
 Teenage pregnancy
 Menstural problem

27. CAUSES

31. MALARIA especially by the protozoa Plasmodium falciparum and
vivax, causes anaemia by rupturing RBCs and suppressing
production of RBCs
HELMINTHS such as hookworm and flukes cause chronic blood
loss and consequently iron loss from the body, resulting in the
development of anaemia

32. CHRONIC DISEASES can interfere with the production of RBCs,
resulting in chronic anaemia
Cancer
HIV/AIDS
Rheumatoid arthritis
Crohn’s disease
other chronic inflammatory diseases
Kidney failure can also cause anaemia.

33. SIGNS&SYMPTOMS

34. SYMPTOMS
Common symptoms of anemia
 Easy fatigue and loss of energy
 Unusually rapid heart beat, particularly with
exercise
 Shortness of breath and headache, particularly with
exercise
 Difficulty concentrating
 Dizziness
 Pale skin
 Leg cramps
 Insomnia

35. Anemia Caused by Iron Deficiency
People with an iron deficiency may experience these
symptoms:
 A hunger for strange substances such as paper,
ice, or dirt (a condition called pica)
 Upward curvature of the nails, referred to as
koilonychias
 Soreness of the mouth with cracks at the corners

36. Anemia Caused by Vitamin B12 Deficiency
People whose anemia is caused by a deficiency of Vitamin
B12 may have these symptoms:
 A tingling, "pins and needles" sensation in the hands or
feet
 Lost sense of touch
 A wobbly gait and difficulty walking
 Clumsiness and stiffness of the arms and legs
 Dementia
 Hallucinations, paranoia, and schizophrenia

37. SIGNS OF ANAEMIA
 Brittle nails
 Koilonychia (spoon shaped nails)
 Atrophy of the papillae of the tongue
 Angular stomatitis
 Brittle hair
 Dysphagia and Glossitis
 Syndromes of Plummer-Vinson or Paterson-Kelly
(dysphagia with esophageal membrane and atrophic
glossitis)

38. SYMPTOMS&SIGNS

41. INVESTIGATIONS

42. The red cell population is defined by-
Quantitative parameters:
 Volume of packed cells i.e. the hematocrit
 Hemoglobin concentration
 Red cell concentration per unit volume.
Qualitative parameters:
 Mean corpuscular volume
 Mean corpuscular hemoglobin
 Mean corpuscular hemoglobin concentration.
INVESTIGATIONS

43.  Hematocrit ( Packed cell volume):
It is the proportion of the volume of blood sample
that is occupied by RBCs.
 Men -42-52%
 Women -36-48%
 Red Cell Count:
Total number of Red Cells per unit volume of blood
sample. [ No.of RBC/ cu.mm ]
 Men - 4.2-5.4*106//mm3
 Women- 3.6-5.0* 106/mm3
INVESTIGATIONS

44. INVESTIGATIONS
 Cell Volume Hemoglobin Concentration:
It is the amount of hemoglobin per unit volume of blood.
(Gms/dl)
 Women - 12-16gms/dl
 Men - 14-17 gms/dl

45.  Mean Corpuscular Volume:
It is the average volume a RBC. [ fL ]
 Normal 82-98fL
 Mean Corpuscular Hemoglobin:
It is the average hemoglobin content per RBC.
 Normal value is 27 to 31 pL
INVESTIGATIONS

46. INVESTIGATIONS
 Mean Corpuscular Hemoglobin Concentration:
It is the average concentration of hemoglobin in a given
Red Cell Volume. [gms/dL ]
 Normal 32-36 g/dL

47. INVESTIGATIONS
Direct measurement of iron stores
Assessment of serum iron, total iron binding capacity (TIBC), %
saturation, serum ferritin, bone marrow biopsy
Assessment of heme iron
Estimation of free erythrocyte protoporphyrin (EPP)
Assessment of iron uptake
Measuring the soluble serum transferrin receptor (sTfR), and
soluble transferrin receptor-log [ferritin] (sTfR-F) index, zinc
protoporphyrin(ZPP).

48. MANAGEMENT
Care Objectives
 Determine the Cause of Iron Deficiency
The etiology is often multifactorial; even when there is
an obvious cause, investigation of serious underlying
causes (e.g.cancer in adults) is recommended.
 Aim of Treatment
Normalize hemoglobin levels and red cell indices;
replenish iron stores.
Individualize disease-specific management depending
on underlying cause.
 Lifestyle Management
It is recommended that patients with iron deficiency
receive dietary advice .

49. NON PHARMOCOLOGICAL MANAGEMENT
 Tea and coffee inhibit iron absorption when
consumed with a meal or shortly after a meal.
 Vitamin C (ascorbic acid) is also a powerful
enhancer of iron absorption from nonmeat foods
when consumed with a meal. The size of the
vitamin C effect on iron absorption increases with
the quantity of vitamin C in the meal

50. NON PHARMOCOLOGICAL MANAGEMENT
 Germination and fermentation of cereals and
legumes improve the bioavailability of iron by
reducing the content of phytate, a substance in
food that inhibits iron absorption.
 Promote and support exclusive breastfeeding for
about 6 months followed by breastfeeding with
appropriate complementary foods, including iron-
rich through the second year of life.

51. RECOMMENDED DIETARY
ALLOWANCE
Mg/DAY
Men Adult 8 mg
Women Adult (age 50 on) 8 mg
Adult (ages 19 to 50) 18 mg
Pregnant 27 mg
Lactating 9 mg to 10 mg
Adolescents (ages 9 to 18)
Girls
Boys
8 mg to 15 mg
8 mg to 11 mg
Children (birth to age 8) Ages 4 to 8 10 mg
Infants (7 months to 1 year)
Infants (birth to 6 months)
11 mg
0.27 mg

53. MANAGEMENT
Complimentary parasite control measures
 Anti-helminthic therapy with 400 mg of single dose of
ALBENDAZOLE is given to eliminate hook worms
before the initiation of iron and folic acid therapy.
 Child -
<2yrs-200mg/day single dose
 Pregnancy-
Albendazole is contraindicated in first trimester,
Can be administered in second or third trimester.

54. TREATMENT FOR 6-24 MONTHS
Dosage Birth-weight category Duration
12.5 mg iron
+
50 µg
folic acid daily
Normal
Low birth weight
(<2500 g)
6-24 months of age
2-24 months of age

55. GROUP DOSAGE/day
Children 2-5 years 20-30 mg iron
Children 6-11 years 30-60 mg iron
Adolescents and adults 60 mg iron
TREATMENT OF MILD &MODERATE
 Anemia will correct within 2 to 4 months if
appropriate iron dosages are administered and
underlying cause of iron deficiency is corrected.
 Continue iron therapy an additional 4 to 6 months
(adults) after the hemoglobin normalizes to
replenish the iron stores.

56. TREATMENT OF SEVERE ANEMIA
 After completing 3 months of therapeutic
supplementation, pregnant women and infants
should continue preventive supplementation program
3 months
3 months
3 months
AGE GROUP DOSE DURATION
<2 years
2-12 years
Adolescents and adults,
including pregnant
women
25 mg iron + 100-400 µg
folic acid daily
60 mg iron + 400 µg folic
acid daily
120 mg iron + 400 µg
folic acid daily

57. Prevalence of anemia in Dose Duration
pregnancy
>40 % in population 60 mg iron + 400 ug folic
acid daily
6 months in pregnancy,
and continuing to 3
months postpartum
TREATMENT OF PREGNANT WOMEN

58. Injectable IRON therapy
INDICATIONS
 Can’t take iron by mouth
 Can’t absorb iron adequately through the gut
 Can’t absorb enough iron due to blood loss
 Need to increase iron levels fast to avoid medical
complications or a blood transfusion
ROUTE OF ADMINISTRATION:
INTRAMUSCULAR
INTRAVENOUS INFUSION

59. Pre-requisites for parenteral therapy:
 Should be given under proper supervision
 After test dose only
 Close monitoring required
 Inj. Adrenaline, Hydrocortisone and oxygen to be
available for management of anaphylactic reactions.
 Cardiopulmonary resuscitation facility to be available.

60. Calculation of Dose of Parenteral Iron
Required iron dose (mg) = (2.4 × (target Hb-actual Hb) ×
pre-pregnancy weight (kg)) + 1000 mg for replenishment
of stores

61. Injectable IRON therapy
PREPARATIONS AVAILABLE IN INDIA
Intravenous Iron Preparations:
1. IRON DEXTRAN: Test dose is necessary before giving IV iron
dextran as severe anaphylactic reactions reported
2. IRON SORBITOL CITRATE
3. IRON SUCROSE: can be given without test dose, favorable
safety profile, preferred
4. FERRIC CARBOXY MALTOSE
5. SODIUM FERRIC GLUCONATE
6. SODIUM ISOMALTOSIDE
Intramuscular iron preparations:
1. IRON SORBITOL
2. IRON DEXTRAN
3. IRON POLYMALTOSE

62. Anemia Caused by Vitamin B12 Deficiency
Replenish B12 level in serum
Inj Methylcobalamine 1500 µg IM on alternate days for 5-8 days
OR 1500 µg IM /week for 8 weeks
Along with Folic Acid 5mg daily
Followed by B-complex supplements daily for 3 months
Iron Supplements- depends upon level oh hypochromia,
( Risk of overload)

63.  Iron absorption may be decreased by
 Antacids or
 Supplements containing aluminum,
magnesium, calcium, zinc
 proton pump inhibitors.
 Space administration apart by at least 2 hours
 IFA tablets should not be consumed with tea,
coffee, milk or calcium tablets
PRACTICAL TIPS

64. PRACTICAL TIPS
 Oral iron preparations may cause nausea, vomiting,
dyspepsia, constipation, diarrhea or dark stools.
 Strategies to minimize these effects include:
 start at a lower dose and
 increase gradually over 4 to 5 days;
 giving divided doses or
 the lowest effective dose, or
 taking supplements with meals
If constipation occurs, advise to drink more water and add
roughage to diet

65. PRACTICAL TIPS
IFA treatment should always supplemented with diet rich in
iron, vitamins (particularly Vitamin C), protein, minerals and
other nutrients e.g. green leafy vegetables, whole pulses,
jaggery, meat, poultry and fish, fruits and black gram,
groundnuts, ragi, whole grains, milk, eggs, meat and nuts, etc
Ideally, tablets should be taken on empty stomach for better
absorption.

66. BENEFITS OF THERAPY
POPULATION GROUP BENEFITS
Children Improved behaviour and cognitive
development
Where anaemia is common, improved child
survival
Adolescents Improved cognitive development
In girls, better iron stores for later pregnancies
Pregnant women and their infants Decreased low birth weight
Where severe anaemia is common, decreased
maternal mortality and obstetrical
complications
All individuals Improved fitness and work capacity
Improved cognition

67. National Iron+ Initiative
National Iron+ Initiative reach the following age groups for
supplementation or preventive programming:
Bi-weekly iron supplementation for preschool children 6 months
to 5 years
Weekly supplementation for children from 1st to 5th grade in
Govt. & Govt. Aided schools
Weekly supplementation for out of school children (5–10 years) at
Anganwadi Centres
Weekly supplementation for adolescents (10–19 years)
Pregnant and lactating women
Weekly supplementation for women in reproductive age

68. IFA supplementation programme

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