Nutritional Anaemia | CHAPTER 15 | Pediatric Nursing

Nutritional Anaemia – Health of the children has been considered as the vital importance to all societies because children are the basic resource for the future of humankind. Nursing care of children is concerned for both the health of the children and for the illnesses that affect their growth and development. The increasing complexity of medical and nursing science has created a need for special area of child care, i.e. pediatric nursing.

Pediatric nursing is the specialized area of nursing practice concerning the care of children during wellness and illness. It includes preventive, promotive, curative and rehabilitative care of children. It emphasizes on all round development of body, mind and spirit of the growing individual. Thus, pediatric nursing involves in giving assistance, care and support to the growing and developing children to achieve their individual potential for functioning with fullest capacity.

Nutritional Anaemia

Definition of Anaemia:

It is a clinical condition characterized by the pale colouration of the skin & mucous membrane due to decrease concentration of Hb in the peripheral blood below the normal range for the age & sex of the person.

Or,

Anaemia is a clinical condition characterized by pale coloration of the skin and mucous membrane due to qualitative and quantitative deficiency of haemoglobin below the lower limit în the peripheral blood in respect of age and sex.

Or

Anaemia refers to a state in which the level of haemoglobin in the blood is below the normal range appropriate for age and sex.

Definition of Nutritional Anemia

Nutritional anemia refers to types of anemia that can be directly attributed to nutritional disorders. Examples include Iron deficiency anemia and pernicious anemia

Or

Nutritional anemia in general is defined as a condition that results in a lowering of hemoglobin (Hb) levels below what is considered to be normal for specific demographic groups regardless of the underlying nutritional deficiencies that may be the cause.

Normal Hb level:

• Male: 13-18 gm/dl
• Female: 11.5-16.5 gm/dl
• Children: 16-19 gm/dl
• At birth: 18-20 gm/dl

Site Where Anaemia is seen:

• Lower palpebral conjunctiva
• Dorsum of the tongue
• Buccal mucous membrane
• Palm of the hand
• Nail bed
• Sole of the feet
• Whole skin

Classifications of Anaemia:

A. Morphological classification: (On the basis of absolute values – MCV, MCH, MCHC)

a) Microcytic hypochromic anaemia: (MCV, MCH & MCHC)

• Iron deficiency anaemia.
• Thalassaemias.
• Sideroblastic anaemia.
• Anaemia of chronic disease.

b) Normocvtic normochromic anaemia: (MCV, MCH & MCHC normal, but ↓ RBC & Hb)

• Aplastic anaemia.
• Haemolytic anaemia.
• Acute haemorrhagic anaemia.

c) Macrocytic anaemia: (↑MCV, MCHC normal)

• Megaloblasic anemia due to vtamin B12 deficiency.
• Megaloblastic anaemia due to folic acid deficiency.

B. Aetiological classification:

a) Haemorrhagic anaemia:

• Acute haemorrhage: Trauma, surgical operation.
• Chronic haemorrhage:

✓GIT lesion: PUD, hookworm infestation, haemorrhoids etc.

✓ Gynaecological disturbance: Menorrhagia.

b) Haemolytic anaemia: (Due to excess RBC destruction)

• Intra-corpuscular defect: Thalassaemia.
• Extra-corpuscular defect: Haemolytic disease of newborn.

c) Dyshaemopoietic anaemia:

• Due- to deficiency of essential elements of erythropoiesis:

✓ Iron deficiency anaemia.

✓ Megaloblastic anaemia (due to deficiency of vitamin B12 & folic acid.

✓ Nutritional anaemia in PEM (protein-energy malnutrition). WO

✓ Anaemia with scurvy (due to deficiency of vitamin C).

• Due to bone marrow disturbance:

✓ Aplastic anaemia.

✓ Sideroblastic anaemia.

✓Anaemia with renal failure (due to reduced erythropoietin secretion).

C. Clinical classification:

✓Anaemia with endocrine disorders.

a) Mild anaemia: When Hb-12 to 9 gm /dl. (‘+’)

b) Moderate anaemia: When Hb = 9 to 6 gm/dl. (++)

c) Severe anaemia: When Hb Less than 6 gm/dl. (+++)

Causes of Anemia in Bangladesh

Blood loss anaemia:

✓Haemorrhoids.

✓ Anal fissure.

✓Bleeding peptic ulcer disease,

✓Carcinoma of stomach, colon etc.

✓Menorrhagia

✓Hook worm infestation.

Nutritional deficiency: Lack of iron and folate in diet, mal-absorption.

• Frequent pregnancy.
• Chronic kidney disease (CKD).
• Haematological malignancy.
• Aplastic anaemia.
• Congenital haemolytic anaemia.
• Anaemia of chronic disease.

Common Nutritional Anaemia:

• Iron deficiency anaemia.
• Folic acid deficiency anaemia. (Megaloblastic anaemia).
• Vitamin B12 deficiency anaemia. (Megaloblasic anaemia).

C/F of Anaemia:

Prevention/Intervention of Anaemia:

An estimation of haemoglobin should be done to assess the degree of anaemia. If the anemia is severe (Hb 10 gm/dl), high dose of iron or blood transfusion may be necessary. If Hb between 10 to 12 gm/dl, the other interventions are –

Iron and folic acid supplementation:

• Mothers: 1 tab of iron & folic containing 60 mg of elemental iron (180 mg of ferrous sulfate) 0.5 mg of folic acid should be given daily up to 2-3 months.
• Children: 1 tab of iron and folic acid containing 20 mg of elemental iron (60 mg of ferrous sulfate) & 0.1 mg of folic acid should be given daily.

Iron fortification: Iron fortification with salt by adding ferric ortho-phosphate or ferrous sulfate with Na bisulfate. Iron fortification has many advantages over implementation a salt is a universally consumed dietary item.

Other strategies: (Long term measures)

• Changing dietary habits
• Control of parasites
• Nutrition education.

Detrimental Effects of Nutritional Anaemia:

The detrimental effects of anaemia can be seen in 3 important areas:

1. Pregnancy: Anaemia increases the risk of maternal and foetal mortality and morbidity Conditions such as abortions, premature births, post-partum haemorrhage and low birth weight were especially associated with low haemoglobin levels in pregnancy.

2. Infection: Anaemia can be caused or aggravated by parasitic diseases, e.g., malaria, intestinal parasites. Further, iron deficiency may impair cellular responses and immune functions and increase susceptibility to infection.

3. Work capacity: Anaemia (even when mild) causes a significant impairment of maximal work capacity.

(Ref-Park/24h/680)

Risk of Nutritional Anaemia:

Some groups of people are more likely to be iron or folate deficient than others. They are ‘at risk’ of anaemia.
High-risk groups arez

• Women, especially during pregnancy or soon after delivery,
• Babies who are low birth weight or not breastfed,
• Young children- especially if they are malnourished, Adolescents, who are growing fast, especially girls.
• Older men and women, especially if they are poor.

Consequences of Anaemia:

Benefits of Anaemia Prevention and Control:

All individuals:

• Increased immunity and low morbidity from infectious diseases.
• Improved cognition.
• Improved quality of life.

In-case of pregnant women (PW) and foetus:

• Decreased risk of complications during delivery, preterm delivery, LBW, maternal and neonatal death.
• Increased iron stores in infants and lower risk of anaemia in infancy and children.

In case of infants and children:

• Improved growth.
• Improved BCD.
• Risk of IDD.
• Improved child survival.
• Better iron store for future pregnancies (adolescent).

Iron Deficiency Anaemia

Definition of Iron Deficiency Anaemia:

Iron deficiency anemia develops when body stores of iron drop too low to support normal red blood cell  (RBC) production. Inadequate dietary iron, impaired iron absorption, bleeding, or loss of body iron in the urine  may be the cause.

Or

Iron deficiency anaemia is caused by lack of iron, often because of blood loss or pregnancy. It’s treated with iron tablets prescribed by a GP and by eating iron-rich foods.

Causes of Iron Deficiency Anaemia:

a) Increased physiological demand

• Children during period of growth
• Women during reproductive age:
• Menstruation: 15-30 mg Fe loss
• Pregnancy: 500-600 mg Fe loss
• Parturition
• Lactation

b) Pathological blood loss:

• Injury
• Hookworm infestation
• Bleeding piles
• Peptic ulcer
• Chronic aspirin ingestion
• Haemorrhoids
• Esophageal varices
• Hiatus hernia
• Carcinoma of stomach, colon
• Ulcerative colitis
• Surgical operation

c) Inadequate iron intake:

• Deficient diet
• Gastrectomy or gastro-enterectomy
• Tropical sprue
• Coeliac disease

Clinical Features of Iron Deficiency Anaemia:

a) General feature of anaemia:

• Nonspecific symptoms:

✓ Tiredness

✓Breathlessness

✓ Ankle swelling

• Nonspecific signs:

✓ Mucous membrane pallor

✓ Tachypnea

✓ Raised JVP

✓ Flow murmur

✓ Ankle oedema

✓ Postural hypotension

✓ Tachycardia

b) Features of iron deficiency anaemia: Glossitis, Dysphagia, Koilonychias

Treatment of Iron Deficiency Anaemia:

• Tab. ferrous sulphate 200 mg 3 times daily for 3 to 6 months after the hemoglobin become normal.
• If patient intolerable to ferrous sulphate-Ferrous gluconate 300 mg 12 hourly
• Parenteral iron therapy (in severe anaemia especially in late pregnancy, in mal-absorption, haemosiderinuria, unable to take by mouth)

✓ Iron sorbitol 1.5 mg/kg single dose daily intramuscular injection (never IV)

✓ Iron dextrain IV (anaphylactic reaction may occur) or IM (local irritation)

• Blood transfusion-IDA with angina, HF or evidence of cerebral hypoxia
• Supportive Rx: If infection antibiotic

Investigation of Iron Deficiency Anaemia:

Blood for TC, DC, ESR, Hb%:

• Hb%- Reduced
• ESR-Slightly raised
• TC-Reduced

Peripheral blood film:

• Microcytic and hypochromic anaemia
• Target cell, tear drop cell, pencil cell

Biochemical test: Serum ferritin: < 12 µg/L (most specific), (Normal 15-300 µg/L), TIBC increase, Plasma iron increase

For the diagnosis of cause:

• Occult blood test
• Upper and lower GIT endoscopy, Ba studies
• Stool and urine study for parasites (in tropics)

Prevention Of Iron Deficiency Anaemia:

1. Iron and folic acid supplementation. If haemoglobin is between 10-12 g/dl, dosage for

• a) Mothers: 1 tablet (60mg of elemental iron +0.5 mg folic acid) daily for 2 to 3 months or longer depending upon the progress,
• b) Children (6 months to 1 and 2 years): tablet (20mg of elemental iron +0,1 mg of folic acid) daily.

2. Iron fortification, c.g. Iron Fortified Salt.

3. Others. Changing dietary habits, control of parasites, and nutrition education.

(Ref: K. Park/234/642)

Rickets

Effects of vitamin-D deficiency:

Rickets:

It is a disease of young children (6 months to 2 years) characterized by:

• Growth failure
• Bone deformity
• Muscular hypotonia
• Tetany
• Convulsion due to hypocalcemia.

There is an elevated concentration of alkaline phosphatase in the serum.

Osteomalacia in adults;

• In adult vitamin D deficiency may result in osteomalacia which occurs mainly in women, especially during pregnancy and lactation when requirements of vitamin D are increase.

(Ref: T. K. Indrani/1/78)

Definition of Rickets:

Rickets is a disorder of growing due to deficiency of vitamin D in which there is failure of mineralization of the

epiphyseal growth plate, newly formed bony matrix (osteoid).

Classification:

A. Nutritional rickets:

• Lack of vitamin D
• Other factors: Decreased exposure to the sun due to dark skin pigmentation, urban living conditions and the winter season.

B. Rickets associated with abnormal metabolism of vitamin D:

• Vitamin D dependent rickets
• Chronic renal disease
• Chronic anticonvulsant therapy
• Chronic liver disease

C. Rickets due to mineral deficiency:

• Familial hypophosphatemic rickets or vitamin D resistant rickets
• Rickets of prematurity

D. Related conditions resembling rickets:

• Hypophosphatasia
• Metaphyseal dysostosis

clinical features, investigation and management of rickets

A. Clinical features:

1. Vary with the age of onset of rickets

2. Skeletal deformity

• Dwarfism, frontal bossing, craniotabes, philosophers head
• Genu varum (bow leg): genu valgum (knock knee)

3. Swelling of wrist (deformity of forearm)

4. Rachitic rosary- Swelling of costochondral junction of ribs

5. Harrison’s sulcus – Depression of lower ribs along the attachment of diaphragm

6. Delayed closure of anterior fontanelle

7. Spinal deformity eg. kyphoscoliosis

8. Protuberance of abdomen, pelvic deformity

9. Hypotonia with delay in motor development

10.Tetany and convulstion

B. Investigation:

1. Calcium: Normal or decreased

2. Phosphate: Decreased

3. Alkaline phosphatase: Increased

4. Parathyroid hormone (PTH): increased

5. 1.25 (OH)2 D3: Normal or decreased

6. X-ray of knee, ankle, wrist: Cupping, fraying and widening of the distal ends of the long bone with generalized rarefaction.

C. Management:

1. Vitamin D supplementation and intake of calcium (milk)

• Vitamin D 25-125 µg (1000-5000 IU) daily for 6-8 weeks
• Stoss therapy with 3 Lac IU as a single dose for rapid healing calciferol 6 tablets at once (one tablets 50000 IU)

2. Then daily allowance of 10 µg (400 IU) daily

3. Treatment of underlying cause

4. Biochemical checkup monthly

5. If tetany develops: injection calcium gluconate

6. Surgical correction of deformity

Prevention of Vitamin D Deficiency:

Educating parents to expose their children regularly to sunshine.
Periodic dosing (prophylaxis) of young children with vitamin D; and Fortification of foods, especially milk.

(Ref by: T. K. Indrani/1/32)

Scurvy

Clinical Manifestations of Scurvy in Infants and Young Children:

Most frequent symptoms

• General irritability
• Tenderness of the limbs, especially of the legs
• Pseudo paralysis, usually involving the lower extremities
• Involvement of costochondral junctions: changes such as beading of ribs
• Haemorrhage around erupting teeth (in infants without teeth gums appear normal)
• Anaemia

Possible symptoms:

• Anorexia
• Low-grade fever
• Mild diarrhoea, sometimes bloody
• Petechial haemorrhages in the skin

Prevention of Scurvy/Vitamin C Deficiency in Children:

The main approaches to preventing the onset of scurvy in emergency situations affecting large populations are as follows:

1. Providing food rations containing adequate amounts of vitamin C by increasing the variety of the food basket and regularly including fresh fruit and vegetables.

2. Providing sufficient food in the ration to allow refugees to sell the surplus for other purposes.

3. It has been found that refugees with the highest value of rations received did, in fact, consume the greatest amounts of fruit and vegetables (Hansch, 1992)

4. Fortifying current relief commodities with vitamin C, e.g. providing fortified blended cereallegume food in the general ration in sufficient amounts to cover vitamin C requirements.

5. Providing vitamin C supplements in the form of tablets at least weekly,

6. Encouraging and facilitating, where feasible, cultivation by refugees of fruits and vegetables in home gardens

(Ref: WHO)

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• Protein Energy Malnutrition | CHAPTER 15 | Pediatric Nursing