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Iron deficiency anaemia

Introduction, etiology

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Iron deficiency anaemia is the most common micronutrient deficiency it in the world today. It affects the lives of many millions of human beings throughout their life cycle, especially women and infants, but also older children, adolescents, adult males and elderly. A major threat to safe motherhood, it contributes to low birth weight, lowered resistance to infection, poor cognitive development, and decreased work capacity. Iron deficiency anaemia (inadequate amount of red blood cells caused by lack of iron) is highly prevalent in less-developed countries but also remains a problem in developed countries. The prevalence of anaemia, defined by low hemoglobin or hematocrit, is commonly used to assess the severity of iron deficiency in a population (table1). Iron deficiency anaemia is a severe stage of iron deficiency in which hemoglobin (or hematocrit) falls below the cutoffs. Iron deficiency anaemia is defined as anaemia with biochemical evidence of iron deficiency. Serum ferritin, transferrin saturation, transferrine receptor, and erythrocyte protoporphyrin are indicators used as biochemical evidence of iron deficiency.

Hemoglobin and hematocrit cutoffs used to define anemia in people at sea level:

Age or sex group
Hemoglobin below (g/dL)
Hematocrit below (%)
Children 6 months to 5 years
11.0
33
Children 5-11 years
11.5
34
Children 12-13 years
12.0
36
Non pregnant women
12.0
36
Pregnant women
11.0
33
Men
13.0
39

Recommended treatments

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Iron supplementation to prevent iron deficiency anaemia
Pregnant women should routinely receive iron supplements in almost all contexts
ferrous salt + folic acid
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tablet equivalent to 60 mg iron + 400 micrograms folic acid

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Prevalence of anaemia < 40%:
60 mg iron + 400 micrograms folic acid daily during 6 months in pregnancy
Prevalence of anaemia ≥ 40%:
60 mg iron + 400 micrograms folic acid daily during 6 months in pregnancy, and continuing to 3 months postpartum
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If a full course of treatment (6 months duration) cannot be achieved in pregnancy, continue to supplement during the postpartum period for 6 months or, increase the dose to 120 mg iron in pregnancy.

Children 6 - 24 months of age
ferrous salt + folic acid
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tablet equivalent to 60 mg iron + 400 micrograms folic acid

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Child with normal birth weight:
12.5 mg iron + 50 micrograms folic acid during 6-12 months of age (prevalence of anaemia < 40%) or, during 6-24 months of age (prevalence of anaemia ≥ 40%)
Low birth weight child: (< 2500 g)
12.5 mg iron + 50 micrograms folic acid during 2-24 months of age
ferrous salt
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tablet, equivalent to 60 mg iron
oral solution equivalent to 25 mg iron (as sulfate)/ml

 
folic acid
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tablet, 1 mg, 5 mg
injection, 1 mg (as sodium salt) in 1-ml ampoule

 

Other population groups (if the prevalence of anaemia is high
ferrous salt
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tablet, equivalent to 60 mg iron
oral solution equivalent to 25 mg iron (as sulfate)/ml

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Children 2-5 years:
2 mg/kg body weight/day

Children 6-11 years:
30-60 mg iron

Adolescent and adults:
60 mg iron (+ 400 micrograms folic acid if the population group includes girls or women of reproductive age)
Treatment or referral of severe anaemia

ferrous salt + folic acid
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tablet equivalent to 60 mg iron + 400 micrograms folic acid

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Children < 2 years:
25 mg iron + 100-400 micrograms folic acid daily for 3 months

Children 2-12 years:
60 mg iron + 400 micrograms folic acid daily for 3 months

Adolescent and adults, including pregnant women:
120 mg iron + 400 micrograms folic acid daily for 3 months
ferrous salt
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tablet, equivalent to 60 mg iron
oral solution equivalent to 25 mg iron (as sulfate)/ml

 
folic acid
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tablet, 1 mg, 5 mg
injection, 1 mg (as sodium salt) in 1-ml ampoule

 
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After completing 3 months of therapeutic supplementation, pregnant women and infants should continue preventive supplementation regimen.

Children with Kwashiorkor or marasmus should be assumed to be severely anaemic. However, oral iron supplementation should be delayed until the child regains appetite and starts gaining weight, usually after 14 days.
Complementary parasite treatments

albendazole
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chewable tablet, 400 mg

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Adults:
400 mg single dose
mebendazole
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chewable tablet, 100 mg, 500 mg

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500 mg single dose or 100 mg twice daily for 3 days
levamisole
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tablet, 50 mg, 150 mg (as hydrochloride)

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2.5 mg/kg single dose, best if second dose is given after 7 days
pyrantel
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chewable tablet 250 mg (as embonate)
oral suspension, 50 mg (as embonate)/ml

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10 mg/kg single dose, best if dose is repeated on next 2 consecutive days
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In areas where hookworms are endemic (prevalence 20-30% or more), if the affected person is older than 2 years, give one of the above anthelminthic treatments in combination with iron.

Universal anthelminthic treatment, irrespective of infection status, is recommended at least annually. High-risk groups, women and children, should be treated more intensively (2 - 3 times per year). If the person is a woman who might be in the first trimester of pregnancy, delay anthelminthic treatment until pregnancy can be ruled out (e.g. menstruation resumes) or until the second trimester of pregnancy (e.g. until the uterus can be easily palpated).

When urinary schistosomiasis is endemic, if the affected person is older than 5 years, check for visual hematuria. If present, give the following treatment:
praziquantel
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tablet, 150 mg, 600 mg

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Adults:
40 mg/kg, single dose
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Where P. falciparum malaria is endemic, if the affected person is a child younger than 5 years with a severe anaemia, give antimalarial treatment according to local recommendations. If the affected person is a pregnant women, give curative antimalarial treatment at the first prenatal visit, followed by antimalarial prophylaxis according to local recommendations. For other affected individuals, examine blood film for malarial infection and treat if the film is positive. If a blood film cannot be made, give presumptive treatment.

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Follow up of treated cases
Individuals diagnosed with severe anaemia and treated with oral iron and folate therapy should be asked to return for evaluation 1 week and 4 weeks after iron supplementation is begun. Individuals should be referred to a hospital if their condition has worsened at the 1 week follow-up visit or if their condition shows no improvement at the 4 week follow-up visit.

References
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Iron deficiency anaemia: documents
   http://www.who.int/nut/publications.htm#ida
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Micronutrient deficiencies: iron deficiency anaemia
   http://www.who.int/nut/ida.htm
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Report of the WHO Informal Consultation on the use of praziquantel during pregnancy/lactation and albendazole/mebendazole in children under 24 months, Geneva, 8-9 April, 2002, WHO/CDS/CPE/PVC/2002.4
   http://www.who.int/wormcontrol/documents/en/pvc_20024full.pdf
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(1) Use of praziquantel in pregnant and lactating women, Essential Medicines, WHO Drug Information, Vol 17, No. 1, 2003
(2) Benzimidazoles: use in children, Essential Medicines, WHO Drug Information, Vol 17, No. 1, 2003
   http://www.who.int/druginformation/vol17num1_2003/vol17-1.pdf

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