24.1 Anaemia

This is a condition characterised by low haemoglobin concentration, clinically recognised by pallor. It is commonly caused by:

• Nutritional deficiency of iron or folate.
• Chronic systemic diseases such as HIV, TB, malignancy.
• Blood loss (bleeding/haemorrhage) e.g. caused by parasites, ulcers, tumours, abnormal menstruation.

Other causes include:

• Vitamin B₁₂
• Infiltration or replacement of the bone marrow.
• Abnormal Hb or red cells.

Diagnostic Criteria

Class	Hb less than
Women	12gm/dl or 11g/dl in pregnancy
Men	13g/dl
Children 1–5 years of age	10g/dl
Children >5 years of age	11g/dl

Children < 5 years of age:

• Anaemia is most often due to iron deficiency (See Section 24.1.1, iron deficiency Anaemia).

Children > 5 years of age and Adults:

• Request a full blood count.
• If MCV is normal (normocytic), then systemic disease is the most likely cause.
• If MCV is low (microcytic), then iron deficiency is the most likely cause.
• If MCV is high (macrocytic), then folate and/or vitamin B₁₂ deficiency is the most likely cause.

Pregnant women: (See Section 11.5.1, Anaemia in pregnancy).

Referral is recommended if:

• Cause is unknown
• Symptomatic anaemia (e.g. palpitations and shortness of breath).
• Evidence of cardiac failure
• Signs of chronic disease (first investigate for HIV and TB)
• Anaemia is associated with enlargement of the liver, spleen or lymph nodes
• Evidence of acute blood loss or bleeding disorder
• Menorrhagia or dysfunctional uterine bleeding
• Blood in stool or melaena

24.1.1 Iron Deficiency Anaemia (IDA)

Anaemia due to deficiency of iron. Common causes of iron deficiency are chronic blood loss or poor nutritional intake. A common cause of anaemia in younger children and women of childbearing age. A full blood count showing a low MCV suggests the diagnosis of iron deficiency anaemia.

Note: Iron deficiency anaemia in children > 5 years of age, adult males and no menstruating women, is generally due to occult or overt blood loss

General Measures

• Identify and treat the cause. Exclude other causes.
• Lifestyle and dietary adjustment.

Dietary advice:

• Avoid drinking tea/coffee with meals
• Increase vitamin C intake (e.g. citrus fruit, orange juice, broccoli, cauliflower, guavas, and strawberries) with meals to maintain iron in its reduced state
• Increase dietary intake of iron rich foods like liver, kidney, beef, dried beans and peas, green leafy vegetables, fortified wholegrain breads and cereals

Pharmacological Treatment:

Children < 5 years of age:

Iron 1–2 mg/kg/dose of elemental iron (PO) 8 hourly with meals

• Follow-up Hb after 14 days.
• If Hb is lower than before, refer.
• If Hb is the same/higher, continue treatment and repeat after another 28 days.
• Continue treatment for 3 months after Hb normalises

Adults:

A:Ferrous sulphate compound BPC (PO) 170 mg (± 65 mg elemental iron) 8 hourly with food.

OR

A:Ferrous fumarate (PO) 200 mg (± 65 mg elemental iron) 8 hourly with food

• Follow up at monthly intervals
• The expected response is an increase in Hb of ≥ 2 g/dL in 4 weeks.
• Continue for 3–6 months after the Hb normalises in order to replenish body iron stores.
• Do not take iron tablets within 4 hours of taking calcium tablets.

Pregnant women: (See Section 11.5.1: Anaemia in pregnancy)

Prophylaxis

Infants from 6 weeks: If < 2.5 kg at birth:

A:Ferrous lactate (PO) 0.3 mL daily until 6 months of age.

OR

A:Ferrous gluconate syrup (PO) 0.8 mL daily until 6 months of age.

During pregnancy:

B:Ferrous sulphate compound BPC (PO)170 mg (± 65 mg elemental iron), 12 hourly.

Referral: (As in Section 24.1: Anaemia)

Children > 5 years of age, men and non-menstruating women.

• No or inadequate response to treatment

24.1.2 Macrocytic or Megaloblastic Anaemia (Vitamin B₁₂ Deficiency)

Anaemia with large red blood cells is commonly due to folate or vitamin B₁₂ deficiency. Folate deficiency is common in pregnant women and in the postpartum period. Macrocytic anaemia in these women may be assumed to be due to folate deficiency and does not require further investigation (See Section 11.5.1 Anaemia in pregnancy. Vitamin B₁₂ deficiency occurs mainly in middle-aged or older adults, and can cause neurological damage if not treated. Macrocytic anaemia outside of pregnancy or the postpartum period requires further investigations to establish the cause.

Diagnostic Criteria: FBC will confirm macrocytic anaemia.

• Elevated MCV
• White cell count and/or platelet count may also be reduced.
• If there is a poor response to folate, a serum vitamin B₁₂ should be done.

General Measures:

• Dietary advice: Increase intake of folic acid rich foods such as:liver, eggs, fortified breakfast cereals, citrus fruit, spinach and other green egetables, lentils, dry beans, peanuts.
• Reduce alcohol intake.

Vitamin B₁₂ deficiency anaemia:

• High protein diet is recommended (1.5 g/kg/day).
• Increase intake of dietary vitamin B₁₂ sources, including meat (especiallyliver), eggs and dairy products.

Pharmacological Treatment:

Folic acid deficiency:

A:Folic acid (PO) 5 mg daily until Hb is normal

• Check Hb monthly

Folic acid given to patients with vitamin B₁₂ deficiency can mask the situation and eventually lead to neurological damage, unless vitamin B12 is also given.

Referral:

• Patients with suspected vitamin B₁₂ deficiency
• Chronic diarrhoea
• Poor response within a month of treatment
• Macrocytic anaemia, of unknown cause