A condition in which haemoglobin content of blood is lower than normal, as a result of deficiency of one or more essential nutrient, specially iron.

1. NUTRITIONAL ANEMIANUTRITIONAL ANEMIA
AND VITAMIN AAND VITAMIN A
DEFICIENCYDEFICIENCY
PRESENTED BY:
Samjhana Shrestha
M.Sc Nursing 1st
year
Dept Of Community
Health Nursing
PION

2. HIDDEN HUNGER
The term was coined by WHO in 1986 &
refers to the problems associated with
the deficiency of 3 essential
micronutrients:
Iron
 Vitamin A
 Iodine

3. NUTRITIONAL ANEMIA
DEFINITION
 It is a disease syndrome
caused by Malnutrition.
• Acc to WHO –
• A condition in which
haemoglobin content of blood
is lower than normal, as a
result of deficiency of one or
more essential nutrient,
specially iron.

4. Nutritional Anemia
• Deficiency of
A. Iron
B. Folate
C. Vitamin B12
D. Protein
• corrected by
supplementation

5. ANAEMIA
• ANAEMIA - Insufficient Hb to carry out O2
requirement by tissues.
• WHO definition : Hb conc. < 11 gm %
• CDC definition : Hb conc. < 11gm % in 1st
and 3rd
trimesters and < 10.5 gm% in 2nd
trimester
• For developing countries : cut off level suggested is
10 gm %
- WHO technical report Series no. 405, Geneva 1968

6. WHO cut off criteria OF hb%
(in venous blood)
Adult man 13 gm/dl
Adult woman (non
pregnant)
12 gm/dl
Adult woman
(pregnant)
11 gm/dl
Child above 6 yrs 12 gm/dl
Child below 6 yrs 11 gm/dl

7. Prevalence
–Widespread public health problem
with major consequences for
human health and socio-economic
development
–WHO estimates 2 billion people
are affected worldwide
–>50% due to iron deficiency

9. INTRODUCTION
Iron deficiency (ID) is one of the most
frequent nutrition deficiency all round the
world.( In India - 50%)
Its prevalence is higher in children and
childbearing age women.
Iron deficiency anemia (IDA) mainly affects
child behavior and development, work
performance and immunity.

10. • WORLD It is a world wide problem with
highest prevalence in developing countries.
• It affect nearly 2/3 of pregnant and ½ of
non pregnant.
• INDIA-
• Overall , 72.7 % of children up to age of 3
year in urban and 81.2% in rural are
anaemic .
• It was found that , except for Punjab , all
other state had more than 50% prevalence
of anaemia among pregnant women.
PROBLEM STATEMENT

11. % OF IDA IN INDIA IN
VULNERABLE GROUPS
Vulnerable groups % of Population with
Anemia
Adult male 20
children 40
Adolescent girls 56
Adult female 60
Pregnant mothers 60

12. WHO Classification of
Anaemia
Degree Hb% Haematocrit (%)
Moderate 7-10.9 24-37%
Severe 4-6.9 13-23%
Very Severe <4 <13%
Degree Hb% Haematocrit (%)
Moderate 7-10.9 24-37%
Severe 4-6.9 13-23%
Very Severe <4 <13%

13. Iron requirements (RDA)
Females 11 – 14 15
15 – 18 15
19 – 24 15
25 – 50 15
51 + 10
Pregnant 30
Lactating 1st
6
months
15
2nd
6
months
15
Category Age
(years)
RDA – Iron
(mg)
Infants 0 – 0.5 6
0.5 – 1 10
Children 1 – 3 10
4 – 6 10
7 – 10 10
Males 11 – 14 12
15 – 18 12
19 – 24 10
25 – 50 10
51 + 10

14. Sources of Iron
There are 2 types of iron in the
diet; haem iron and non-haem
iron
 Haem iron is present in Hb
containing animal food like
meat, liver & spleen
 Non-haem iron is obtained from
cereals, vegetables & beans
 Milk is a poor source of iron,
hence breast-fed babies need
iron supplements

17. HIGH RISK FACTORS

18. Causes of IDA
• Increased demand for iron
– Rapid growth in infancy
or adolescence
– Pregnancy
– Erythropoietin therapy
• Increased iron loss
– Chronic blood loss
– Menses
– Acute blood loss
– Blood donation
– Phlebotomy as
treatment for
polycythemia vera
•Decreased iron
intake or absorption
-Inadequate diet
-Malabsorption from
disease (sprue,
Crohn's disease)
-Malabsorption from
surgery (post-
gastrectomy)
-Acute or chronic
inflammation

19. Symptoms of anemia

20. Adolescent
Anaemia
Adolescent
Anaemia
Reduced
physical
development
Reduced
physical
development
Reduced
cognitive
development
Reduced
cognitive
development
Impaired sexual
and
reproductive
development
Impaired sexual
and
reproductive
development
Decreased
work output
Decrease
d work
capacity
Diminished
concentration Poor
learning
ability
Disturbance
in
perception
Irregular
menstruation
Low pre-
pregnancy
iron stores
LBW
babies and
preterm
delivery

23. Clinical Presentation
Iron-deficiency anemia can cause:
• brittle nails
• cracks in the sides
of the mouth

24.  Extreme fatigue (tiredness)
chest pain

25. • Pale skin
• Dizziness or lightheadedness

26. • Fast heart rate
• Headache

27. Pale conjunctiva
an enlarged spleen
Cold hands and feet
frequent infections.
shortness of breath
swelling or soreness of the tongue

28. • An unusual craving for non-nutritive substances
such as:
Ice
Dirt
Paint or starch.
This craving is called pica.
• Some people who have iron-deficiency anemia
develop restless legs syndrome (RLS). RLS is a
disorder that causes a strong urge to move the
legs.

29. • Some signs and symptoms of iron-
deficiency anemia are related to the
condition's causes.
 A sign of intestinal bleeding is bright red
blood
in the stools or black, tarry-looking stools.
 Very heavy menstrual bleeding, long
periods,
or other vaginal bleeding may suggest that
a woman is at risk for iron-deficiency
anemia.

30. • Consequences of Iron
Deficiency
Increase maternal & fetal mortality.
Increase risk of premature delivery and LBW.
Learning disabilities & delayed psychomotor development.
Reduced work capacity.
Impaired immunity (high risk of infection).
Inability to maintain body temperature.
Associated risk of lead poisoning because of pica.

31. •Assessment of IDA
I. Clinical and
II. Laboratory indices.
• Laboratory indices are the most
common methods used to assess
iron nutrition status.

32. I. Clinical Indices
•Pallor of the:
•Conjunctiva,
•Tongue,
•Nail bed and palm

33. Unique Physical Exam
findings
– Koilonychia -Cheilosis
..spooning of the ..fissures at the corners
fingernails of the mouth

34. II. Laboratory Indices
1. Low Hemoglobin
2. Low Hematocrit
3. Low Mean Corpuscular Volume
4. Serum Ferritin <10ng/ml
5. Transferrin Saturation<15%
6. TIBC>350µg/dl
7. Increased free erythrocyte
protoporphiryn

35. Checking Haemoglobin Level

37. 1. Adequate nutrition
2. Nutrition education to improve dietary habit
3. Breast feeding and appropriate weaning diet
4. Iron rich food
5. Increase ascorbic acid
6. Health education
7. Periodical deworming specially among children and at
least once during IInd trimester of pregnancy
8. Nutritional supplementation
9. Foot wear use
10. Safe drinking water
• I. HEALTH PROMOTION
Prevention of nutritional anemia

38. Contd…
II. SPECIFIC PROTECTION
1.Food fortification
2.National nutritional anemia prophylaxis
program (NNAPP)
3.National nutritional anemia control program
(NNACP): The elemental iron was increased
from 60 mg to 100 mg per tablet in 1992

41. GRADE (WHO) DEGREE OF
ANAEMIA
TREATMENT
11-14 gm/dl Normal Nothing required
9-11 gm Mild Oral iron therapy
required
7-9 gm Moderate Parenteral iron
therapy
Less than 7 gm Severe Blood transfusion
GRADING & T/t OF ANAEMIA

42. TREATMENT
IRON SUPPLEMENT

43. 1. Treat underlying cause (hook worm etc)
2. Oral iron therapy: 3-6mg/kg in 3 divided doses ( Hb rises
by 0.4g/day)
3. Vit C, empty stomach or in between meals: For 6-8 wks
after Hb is normal
4. Parental iron therapy ( Iron in mg=wt in kg× Hb deficit in
gm/dl×4)
5. Blood transfusion –rarely when Hb<4gm/dl, CCF, severe
infection with poor iron utilisation
Treatment OF IDA

44. B) Folic acid deficiency
1. Necessary for DNA synthesis.
2. SOURCES: Liver, soya bean, dark green leafy vegetables
3. CAUSES: Strict vegetarian, Tape worm anemia, Repeated
Pregnancy, Chronic diarrhea, malabsorption and recurrent
infections
4. Cooking destroys folic acid
5. Deficiency disease: Megaloblastic anemia in children &
pregnant mothers
6. Treatment with phenytoin / antimetabolites
7. T/T: Folic acid 2-5 mg/day
8. RDA: 500 mcg/day for pregnant mother

46. C) Vitamin B12
deficiency
• Necessary for DNA synthesis.
• SOURCES: Foods of animal origin only (fish,
egg, meat)
• DISEASES: Megaloblastic anemia, parasthesia
of fingers & toes.
• It is observed in breast fed infants of vit. B12
deficient mother & delayed weaning child
• RDA: Vit. B12
1µg/day

47. Clinical features
1. Pale
2. Very sick
3. Irritable
4. Severe anorexia
5. Failure to thrive
6. Knuckle pigmentation (hands and nose)
7. Tremor and developmental regression

49. ANAEMIAANAEMIA
PROPHYLAXISPROPHYLAXIS
PROGRAMMEPROGRAMME

50. 2. National nutritional anaemia2. National nutritional anaemia
Prophylaxis programmeProphylaxis programme
•Initiated in 1970
being taken up by Maternal and Child
Health (MCH) Division of Ministry of
Health and Family Welfare. Now it is
part of RCH programme.
•Available studies on prevalence of
nutritional anemia in India show that
65% infant and toddlers, 60% 1-6 years
of age, 88% adolescent girls and 85%
pregnant women

51. OBJECTIVESOBJECTIVES
1.1. Assess prevalenceAssess prevalence
2.2. Give anti anemic treatmentGive anti anemic treatment
3.3. Give prophylaxisGive prophylaxis
4.4. MonitoringMonitoring
5.5. EducationEducation

52. BENEFICIARIESBENEFICIARIES
Children age group 1 to 10,Children age group 1 to 10,
Pregnant and nursingPregnant and nursing
mother,mother,
Acceptors of familyAcceptors of family
planning,planning,
Adolescent girls.Adolescent girls.
ORGANIGATIONORGANIGATION
PHC and sub centersPHC and sub centers

53. Contd…Contd…
♦ Pregnant women : 100 mg Fe & 0.5mg folic acidPregnant women : 100 mg Fe & 0.5mg folic acid
♦ Children 6 to 60 months : 20mg Fe & 0.1 mg folicChildren 6 to 60 months : 20mg Fe & 0.1 mg folic
acid Should be given 100 daysacid Should be given 100 days
♦ 6 to 10 years of age : 30 mg iron and 0.25 mg folic6 to 10 years of age : 30 mg iron and 0.25 mg folic
acidacid
♦ Adolescent girls : 100 mg Fe & 0.5mg folic acidAdolescent girls : 100 mg Fe & 0.5mg folic acid
♦ Iron fortification in saltIron fortification in salt
♦ Screening test for anaemia done at 6 months,1 andScreening test for anaemia done at 6 months,1 and
2 years of age.2 years of age.

54. IRON FORTIFICATIONIRON FORTIFICATION
 Developed by National Institute of Nutrition, HyderabadDeveloped by National Institute of Nutrition, Hyderabad
 Addition of ferric ortho phoshate or ferrous sulphateAddition of ferric ortho phoshate or ferrous sulphate
with sodium bisulphate was enough to fortify salt withwith sodium bisulphate was enough to fortify salt with
iron.iron.
 When consumed for 12-18 monthsWhen consumed for 12-18 months
--reduce prevalence of anaemia.--reduce prevalence of anaemia.
 Commercial production since 1985.Commercial production since 1985.

55. Improving
human capacity
and productivity
Increase school
attendance &
learning capacity
Increase school
attendance &
learning capacity
Elimination
of gender
disparity in
secondary
education
Elimination
of gender
disparity in
secondary
education
Adequate
infant iron &
Vit A store –
improved
infant survival
and health
Adequate
infant iron &
Vit A store –
improved
infant survival
and health
Reduce anemia
related maternal
deaths
Reduce anemia
related maternal
deaths
Halt and begin to
Reverse the
incidence of
malaria and other
major diseases
Halt and begin to
Reverse the
incidence of
malaria and other
major diseases

57. INTRODUCTIONINTRODUCTION
• Vitamin A deficiency (VAD) is a major nutritional
concern in poor societies, especially in lower
income countries like INDIA.
• Vitamin A is an essential nutrient needed in small
amounts for the normal functioning of the visual
system, and maintenance of cell function for
growth, epithelial integrity, red blood cell
production, immunity and reproduction.

58. EPIDEMIOLOGYEPIDEMIOLOGY
• Is a major public health problem in developing
countries
• 250,000 preschool children become blind each
year worldwide due to vit.A deficiency
• Improving vit.A status reduce young child
mortality by 23% or more
• Infants and young children under 5 year of age
are at highest risk because
- poor stores at birth
- milk and supplementary food( low vit.A)
- infection including diarrheal disease and
- growth sets requirement high

59. SourcesSourcesSources

62. • Inadequate consumption of vitamin A rich food
• Problem of absorption, like disorders associated
with fat malabsorption, such as cystic fibrosis,
cholestatic liver disease, small bowel crohn’s,
and pancreatic insufficiency
• Problem in conversion or utilization of vitamin A
• Repeated infections or diseases such as
measles or diarrhea
• Absence of food containing oil or fat in the diet

63. • Night blindness.
• Keratomalacia.
• Conjunctival dryness, corneal
dryness, xerophthalmia.
• Bitot’s spots.
• Corneal perforation.
• Blindness due to structural
damage to the retina.

64. • Conjunctival dryness
owing to vitamin A
deficiency.
• Follows chronic
conjunctivitis and
vitamin A deficiency
diseases.
• Eyes fail to produce
tears in this condition.

65. Classification of xerophthalmiaClassification of xerophthalmia
• XN Night blindness
• X1A Conjunctival Xerosis
• X1B Bitot’s spot
• X2 Corneal Xerosis
• X3A Corneal ulceration/keratomalacia
(< 1/3 corneal surface)
• X3B Corneal ulceration/keratomalacia
(≥ 1/3 corneal surface)
• XS Corneal scar
• XF Xerophthalmic fundus

66. Night BliNdNess
• Lack of vitamin A causes
night blindness or inability to
see in dim light.
• night blindness occurs as a
result of inadequate pigment
in the retina.
• It also called tunnel vision.
• Night blindness is also found
in pregnant women in some
instances, especially during
the last trimester of
pregnancy when the vitamin
A needs are increased.

67. Night blindness

68. Bitot’s spot
• These are foamy and
whitish cheese-like
tissue spots that
develop around the
eye ball, causing
severe dryness in the
eyes.
• These spots do not
affect eye sight in the
day light.

69. CoNjuNCtival
Xerosis• Conjunctiva
becomes dry and
non wettable.
• Instead of looking
smooth shiny it
appears muddy
&wrinkled.

70. KeratomalaCia
• One of the major cause
for blindness in India.
• Cornea becomes soft
and may burst
• The process is rapid
• If the eye collapses
vision is lost.

71. • An anomaly in the
cornea due to a
damage in the corneal
surface.

72. Other Symptoms of VAD
• Alteration of skin and mucous membrane
• Hepatic dysfunction
• Headache
• Drowsiness
• Peeling of skin about the mouth and
elsewhere

73. Follicular hyperkeratosis

74. • Treatment for subclinical
vitamin A deficiency
includes the consumption
of vitamin A-rich foods.
• For clinically evident
vitamin A deficiency,
treatment includes daily
oral vitamin A
supplements.

76. Eating at least 5 servings of
fruits and vegetables per
day is recommended in
order to provide a
comprehensive
distribution of
carotenoids.
A variety of foods, such as
breakfast cereals,
pastries, breads, etc., are
often fortified with
vitamin A.

77. • Increase consumption of dark green leafy
vegetables. Egg, livers, fat of fish and meat and
cod liver oil can be provided
• Vitamin A should be supplemented in
malnutrition, diarrhea, measles and acute
respiratory infection.
• Distribution of vitamin A capsule should be given
to the community.
– One capsule every 6 months up to 6 year of age
• One drop of vitamin A (25,000IU) for every child
with immunization schedule

80. vitamiN a prophylaXisvitamiN a prophylaXis
programmeprogramme
• Initiated in 1970
• Implemented through RCH Programme.
• Age group 6 months-6 year
• Priority to Vitamin A deficient geographical
area
• OBJECTIVE
Prevent blindness due to Vitamin A Deficiency
• ORGANIGATION
PHC and subcenter

81. • Beneficiary group
–preschool children
(6 months to 6 years)
• A single massive dose of oily preparation of
Vitamin A 200,000 IU (retinol palmitate
110mg) orally every 6 months for every
preschool child above 1 year
half the amount in < than 1 year children

82. Sick Children:
• All children with xerophthalmia are to be
treated at health facilities.
• All children having measles, to be given 1 dose
of Vitamin A if they have not received it in the
previous month.
• All cases of severe malnutrition to be given
one additional dose of Vitamin A.