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close this bookGuidelines for the Use of Iron Supplements to Prevent and Treat Iron Deficiency Anaemia (International Life Sciences Institute, 1998, 46 p.)
View the document(introduction...)
View the documentPreface
View the documentAcknowledgments
View the documentAbout INACG
View the documentBackground
View the documentPurpose of These Guidelines
View the documentOverview of Interventions for Controlling Iron Deficiency Anemia
View the documentSelecting and Prioritizing Interventions
View the documentGuidelines for Iron Supplementation to Prevent Iron Deficiency Anemia
View the documentGuidelines for Treatment or Referral of Severe Anemia in Primary Care Settings
View the documentFrom Guidelines to Programs
View the documentWhere to Go for More Help and Information
View the documentSelected Bibliography
View the documentAppendix A. Percentage and amount of iron in some commonly used iron compounds
View the documentAppendix B. Examples of materials used in iron supplementation programs
View the documentAppendix C. Addresses and World Wide Web sites for international agencies engaged in the control of iron deficiency anemia
View the documentAppendix D. Some sources of supplements and other supplies for iron supplementation programs

Guidelines for Treatment or Referral of Severe Anemia in Primary Care Settings

Severe anemia usually comprises a small proportion of the cases of iron deficiency in a population but may cause a large proportion of the severe morbidity and mortality related to iron deficiency. It is important that primary health care providers are able to recognize these cases and treat or refer individuals with severe anemia. The training and supervision of this activity in primary health care settings becomes a priority activity when the prevalence of severe anemia in population groups (e.g., pregnant women) exceeds 2%.

Iron deficiency is not the only cause of severe anemia. Other possible causes include malaria, folate deficiency, hemoglobinopathies such as sickle cell anemia or thalassemias, and the anemia of chronic disorders such as HIV infection, tuberculosis, or cancer. In primary care settings, health care workers should know when to refer individuals who do not respond to oral iron therapy or who are at urgent risk of serious complications.

Detection of Severe Anemia

Severe anemia is defined clinically as a low hemoglobin concentration leading to cardiac decompensation, that is, to the point that the heart cannot maintain adequate circulation of the blood. A common complaint is that individuals feel breathless at rest. In practical settings, severe anemia may be defined by using a hemoglobin or hematocrit cutoff or by extreme pallor. If the hemoglobin or hematocrit can be determined, cutoffs of hemoglobin below 7.0 g/dL or hematocrit below 20% should be used to define severe anemia. If this is not feasible in the primary care setting, a method is available for evaluating the color of a drop of blood on a special filter paper. This method (formerly called the Talqvist method) requires standard blotting or filter paper and color comparison charts, which are available from the World Health Organization (Haemoglobin Colour Scale). The third choice for detection is assessment of pallor. Three sites should be examined: the inferior conjunctiva of the eye, the nail beds, and the palm. If any of these sites is abnormally pale, the individual should be considered to be severely anemic. This method will detect most but not all of people who are truly severely anemic (i.e., hemoglobin below 7.0 g/L) and will rarely identify a healthy person as severely anemic. Descriptions and pictures of each of these methods can be found in Anemia Detection in Health Services - Guidelines for Program Managers (PATH 1996).

In addition, any child with kwashiorkor or marasmus should be assumed to be severely anemic and treated for severe anemia (Table 8). However, oral iron therapy should not be started until the child regains appetite and is gaining weight. This is usually about 14 days after nutritional rehabilitation has begun.

Treatment or Referral of Cases

Once an individual is determined to have severe anemia, a decision must be made regarding whether to treat in the local setting or refer to a hospital. Treatment should be given in a hospital if the individual is a pregnant woman beyond 36 weeks gestation (i.e., in the last month of pregnancy) or if signs of respiratory distress or cardiac abnormalities (e.g., labored breathing at rest or edema) are present. Other individuals should be treated as indicated in Table 8. Complementary parasite control measures for individuals with severe anemia are given in Table 9.

Table 8. Guidelines for oral iron and folate therapy to treat severe anemia

Age group



< 2 years

25 mg iron + 100-400 µg folk acid daily

3 months

2-12 years

60 mg iron + 400 µg folic acid daily

3 months

Adolescents and adults, including pregnant women

120 mg iron + 400 µg folic acid daily

3 months


· 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 anemic. However, oral iron supplementation should be delayed until the child regains appetite and starts gaining weight, usually after 14 days.

Table 9. Complementary parasite treatments with severe anemia for individuals

· Where hookworms are endemic (prevalence 20-30% or more), if the affected person is older than 2 years, give one of the following anthelminthic treatments:


400 mg single dose


500 mg single dose or 100 mg twice daily for 3 days


2.5 mg/kg single dose, best if second dose is given after 7 days


10 mg/kg single dose, best if dose is repeated on next 2 consecutive days

If the affected 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).

· Where urinary schistosomiasis is endemic, if the affected person is older than 5 years, check for visual hematuria. If present, give the following treatment:


40 mg/kg, single dose

· Where P. falciparum malaria is endemic, if the affected person is a child younger than 5 years, give antimalarial treatment according to local recommendations. If the affected person is a pregnant woman, 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.

Follow-up of Treated Cases

Individuals diagnosed with severe anemia 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. The purpose of this follow-up is to refer individuals who are in need of further medical attention. Specifically, individuals should be refered 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.