Date of Award
Doctor of Nursing Practice Final Manuscript
Doctor of Nursing Practice
Sharon Boothe-Kepple PhD, MSN, FNP-C, PHN
Purpose: The purpose of this pilot project is to screen for iron-deficiency anemia in pediatric patients (ages 1-17) in a primary school in Gonaïves, Haiti. Patients with anemia will be treated with oral supplemental iron for a period of four weeks according to WHO guidelines (WHO, 2011). All students will be treated empirically for helminths per WHO guidelines, unless treated elsewhere in the last six months (WHO, 2017). Nutritional status will also be assessed using MUAC according to WHO guidelines (2017).
Background Summary: Malnutrition contributes significantly to the problem of iron-deficiency anemia, with one in four children exhibiting stunting of growth due to moderate or severe malnutrition (USAID, 2018). Iron-deficiency anemia is a huge problem in Haiti, with a reported prevalence of 65% of children between the ages of six months- five years of age having the disease (EMMUS-V, 2012). Over the past 10 years in Haiti, the prevalence of iron-deficiency anemia in the pediatric population has increased from 61% to 66% (USAID, 2018).
Some of the causes of iron-deficiency anemia can include malnutrition, chronic bleeding, helicobacter pylori or an absorption problem in the gastrointestinal tract (NIH, 2016). Iron-deficiency anemia is a disease that occurs when the body has a lower than normal number of red blood cells in the body. There is a reduction in both red blood cell mass and a drop in hemoglobin (Hgb) level (NIH, 2016). The World Health Organization defines anemia as a Hgb level of less than 11 for children 6-59 months of age, Hgb less than 11.5 for children 5-11, Hgb less than 12 for children 12-14 and non-pregnant women, and Hgb less than 13 for men ages 15 and older (WHO, 2011). Severe anemia includes Hgb level of less than 7 for children 6-59 months of age and Hgb level of less than 8 for children 5-14, non-pregnant women, and men ages 15 and older (WHO, 2011). It generally takes an extended period of time for iron-deficiency anemia to occur. The body needs iron to build healthy red blood cells. When the body is lacking in iron, it begins using up the iron stores and less red blood cells are produced (NIH, 2016).
Infants, young children, and women of childbearing age are at highest risk for iron-deficiency anemia (NIH, 2016). Signs and symptoms can include fatigue, restless leg syndrome, cold hands and feet, pale skin, fatigue, shortness of breath and chest pain (NIH, 2016). Other symptoms can also include brittle nails, cracks in oral mucosa, tongue swelling, swelling of the spleen, and frequent infections (NIH, 2016). Infants and young children frequently exhibit behavioral problems, delayed growth and development, pica, and lack of appetite (NIH, 2016). If severe iron-deficiency anemia persists over an extended period of time, patients can also exhibit arrhythmias, enlarged heart, or heart failure (NIH, 2016).
As discussed previously, the main causes of iron-deficiency anemia include malnutrition, chronic bleeding, helicobacter pylori or an absorption problem in the gastrointestinal tract (NIH, 2016). Currently, the environmental and lifestyle factors have affected increased rates of anemia. After the earthquake in 2010 in Haiti, the average number of meals per person has decreased from 2.46 meals per day to 1.58 meals per day (USAID, 2014). This is due to destruction of crops, inflation due to political instability, poor infrastructure, poor resource management, and increasing price of food. Due to the decreased number of meals there has been a decline in nutritional health and well-being. With the unemployment and underemployment rate hovering at 67% and the average yearly income of $1,800 USD it is very challenging for families to afford food (CIA, 2016).
Intestinal parasites are a secondary environmental and lifestyle factor that can be treated. Intestinal parasites can create an absorption problem of micronutrients including iron in the gastrointestinal tract. An average of 50-70% of Haitian children suffer from intestinal parasites (USAID, 2013). These parasites are transmitted through contaminated food, water, soil, and produce. The most common parasites in Haiti include ascaris lumbricoides (large roundworm), necator americanus (hookworm), and trichuris trichiura (whipworm) (Karabanow, 2017). These parasites can directly affect the absorption of iron. This, in turn, affects the availability of iron stores and alters the production of healthy red blood cells which can contribute to iron-deficiency anemia.
Project Plan: I propose a primary and secondary screening plan that will be used in pediatric health clinics or schools in Haiti with parental consent. It is essential that all patients be screened due to the enormous prevalence of iron-deficiency anemia in Haiti. The reported prevalence of 65% of children between the ages of six months- five years of age in Haiti have the disease (EMMUS-V, 2012). An average of 50-70% of Haitian children also suffer from intestinal parasites (USAID, 2013). All patients will be screened by using a WHO color scale Hgb paper test by using capillary blood obtained by a finger stick test. These finger-stick tests can be obtained by trained non-essential healthcare personnel. This test can be performed and analyzed in minutes and has relatively high sensitivity and specificity for their cost of less than $0.01 complete. The personnel will be trained on the device and educated about the cost of the supplies.
Pediatric patients will be assessed by a nurse practitioner or medical doctor and treated for iron-deficiency anemia using the WHO guidelines criteria. The pediatric patient will receive liquid suspension or iron tablets for a period of four weeks as well as treatment for intestinal parasites should they meet the criteria for having iron-deficiency anemia. Education will be completed with the pediatric patient and their parent. They will be educated that they have the right to refuse medication at any time. Benefits of Hgb level screening for iron-deficiency anemia in developing countries and iron supplementation was proven in a recent meta-analysis to outweigh potential risks (Neuberger, et al., 2016). All pediatric patients will be treated empirically for helminths using broad-spectrum benzimidazoles per WHO guidelines, unless treated elsewhere in the last six months (WHO, 2017).
Results: Benchmarking measures used were appropriate for this project. MUAC proved to be an appropriate screening tool. Of the 129 pediatric patients screened, no children were at risk for acute malnutrition (middle upper arm circumference 13.5 or greater). All receive an extra meal, five days a week while in school for free through The Rosemila Project Feeding Program. This could have contributed to this number. 104 out of 129 pediatric patients (80%) received preventative chemotherapy for helminths. The remaining 27 patients either did not return to clinic, already received treatment within the past six months, or refused. 10 pediatric patients either refused or were unable to obtain Hgb levels. Of the 119 pediatric patients where Hgb levels were obtained, 58% (n=69) were diagnosed with iron deficiency anemia and subsequently treated with oral iron supplementation for a period of four weeks. 4% (n=5) of the pediatric patients in this pilot study were diagnosed with severe anemia. The average Hgb level was 10.23 (n=119).
Digital USD Citation
Fratianni, Cara Rose, "Screening for Iron-Deficiency Anemia in the Pediatric Population (Ages 1-17) in Gonaïves, Haiti" (2020). Doctor of Nursing Practice Final Manuscripts. 133.
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