On this page
Referral and warning signs
When to refer
Refer if: Severe symptomatic anaemia requiring transfusion. Failure to respond to oral iron therapy. Intolerance to oral iron requiring consideration of IV iron. Need for investigations for underlying cause (e.g., endoscopy for GI bleed).
Red flags
- Severe anaemia symptoms (dyspnoea at rest, angina, heart failure)
- Signs of active significant bleeding (melaena, haematemesis)
- Weight loss or other alarm symptoms suggesting malignancy
Signs and symptoms
- General symptoms of anaemia (fatigue, pallor, dyspnoea, headache, dizziness).
- Specific signs/symptoms of iron deficiency:
- - Koilonychia (spoon-shaped nails - chronic severe deficiency).
- - Angular stomatitis / cheilitis (cracks at corners of mouth).
- - Glossitis (sore, smooth tongue).
- - Pica (craving for non-food substances like ice, dirt, clay).
- - Restless legs syndrome.
- - Difficulty swallowing (Plummer-Vinson syndrome - rare, with oesophageal webs).
Risk factors
- Inadequate Dietary Intake: Low intake of iron-rich foods (meat, fortified cereals), vegetarian/vegan diets.
- Increased Requirements: Infants/young children (rapid growth), Adolescents (growth spurt, menstruation), Pregnancy, Lactation.
- Blood Loss:
- - Chronic: Heavy menstrual bleeding (menorrhagia), Gastrointestinal bleeding (hookworm, PUD, gastritis, malignancy, IBD, haemorrhoids, chronic NSAID use), Schistosomiasis, Frequent blood donation.
- - Acute: Trauma, surgery, postpartum haemorrhage.
- Malabsorption: Celiac disease, Gastric surgery (gastrectomy, bypass), Chronic gastritis (achlorhydria), H. pylori infection.
Diagnosis
Clinical assessment
Suspect based on symptoms of anaemia +/- specific signs of iron deficiency, especially with risk factors (menstruating/pregnant women, children, poor diet, history of bleeding).
Investigations
- Complete Blood Count (CBC): Low Haemoglobin (Hb), Low Mean Corpuscular Volume (MCV - microcytic), Low Mean Corpuscular Haemoglobin (MCH) / Mean Corpuscular Haemoglobin Concentration (MCHC - hypochromic). Platelet count may be high (reactive thrombocytosis).
- Peripheral Blood Smear: Microcytic, hypochromic red blood cells, anisocytosis (variation in size), poikilocytosis (variation in shape - pencil cells).
- Iron Studies:
- - Serum Ferritin: Best single test. Low ferritin (<15-30 ng/mL) confirms iron deficiency. Note: Ferritin is an acute phase reactant, can be falsely normal/high in inflammation/infection/liver disease.
- - Serum Iron: Low.
- - Total Iron Binding Capacity (TIBC): High.
- - Transferrin Saturation (Iron/TIBC x 100): Low (<16-20%).
- Reticulocyte count: Usually low or normal (inadequate production).
- Investigate underlying cause: Stool for occult blood/parasites, Endoscopy/Colonoscopy (if GI bleeding suspected), Gynaecological assessment (if menorrhagia).
Diagnostic criteria
Microcytic, hypochromic anaemia with low serum ferritin.
Management
Non-pharmacological management
- Identify and Treat Underlying Cause of iron deficiency (e.g., treat hookworm, manage menorrhagia, investigate GI bleed).
- Dietary Advice: Increase intake of iron-rich foods (red meat, poultry, fish, lentils, beans, fortified cereals, dark green leafy vegetables). Vitamin C enhances iron absorption.
Pharmacological treatment
- Oral Iron Supplementation: First-line treatment.
- - Ferrous Sulphate: 200mg tablet contains ~65mg elemental iron. Dose: 200mg PO BID or TID (Adult). Aim for ~100-200mg elemental iron per day.
- - Child Dose (Elemental Iron): ~3-6 mg/kg/day divided into 1-3 doses.
- - Ferrous Fumarate or Ferrous Gluconate are alternatives.
- - Take on empty stomach if tolerated (absorption better), or with Vitamin C (juice). Can take with food to reduce GI side effects.
- - Continue treatment for 3-6 months AFTER Hb normalizes to replenish iron stores.
- - Common Side Effects: Nausea, constipation, diarrhoea, abdominal cramps, black stools. Manage by taking with food, lower dose, switch formulation, stool softeners.
- Parenteral Iron (IV Iron): Indications - Intolerance or non-response to oral iron, severe malabsorption, significant ongoing blood loss requiring rapid repletion, severe anaemia needing faster response (e.g., pre-op, late pregnancy), CKD patients on ESAs. Requires careful administration due to risk of infusion reactions/anaphylaxis (rare with newer formulations). Specialist use.
- Blood Transfusion: Reserved for severe symptomatic anaemia or haemodynamic instability (See HEM001/Blood Transfusion sections).
Monitoring
Monitor Hb response (should rise ~1 g/dL per week, or 2g/dL over 3-4 weeks). Check Hb after 2-4 weeks, then periodically. Check Ferritin after Hb normalizes to confirm stores replete before stopping iron.
Complications
- Impaired cognitive function/development (children)
- Reduced work capacity / Fatigue
- Increased susceptibility to infection
- Worsening of underlying cardiac conditions
- Restless legs syndrome
- Complications related to underlying cause
Prevention
- Adequate dietary iron intake.
- Iron supplementation for high-risk groups (infants, pregnant women, regular blood donors).
- Deworming.
- Malaria prevention/control.
Patient education
- Explain IDA and its cause.
- Importance of taking oral iron consistently for several months.
- How to take iron (timing, with Vit C, managing side effects).
- Explain black stools are normal with iron.
- Dietary advice on iron-rich foods.
- Need to treat underlying cause.
- Importance of follow-up blood tests.
Uganda-specific notes
Extremely common due to diet, hookworm, malaria, and menorrhagia/pregnancy. Diagnosis often presumptive based on microcytic anaemia. Ferritin testing limited. Oral ferrous sulphate (+/- folic acid) is standard treatment. Treat hookworm concurrently (Albendazole). Antenatal/childhood supplementation programs important.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 11, Section 11.1.1.1