1. CH 3: BLOOD & NUTRITIONAL CONDITIONS
11/9/2018
CH 3: BLOOD & NUTRITIONAL CONDITIONS
NATIONAL DEPARTMENT OF HEALTH
AFFORDABLE MEDICINES
ESSENTIAL MEDICINES PROGRAMME
DISCLAIMER
This slide set is an implementation tool and should be used alongside the published STG. This information does not supersede or replace the STG itself.
PRIMARY HEALTHCARE 2014
Updates to the 2008 PHC STG & EML

2. 3.1.1 ANAEMIA, IRON DEFICIENCY
There is a paucity of evidence comparing thrice daily vs. once daily dosing of iron, orally:
ADULTS
The Adult Hospital level Expert Review Committee (2012) reviewed the evidence pertaining to dosing regimens in pregnancy. But, the Saving Mothers Report had indicated that maternal anaemia was a risk factor for maternal deaths caused by obstetric haemorrhages.
Cochrane systematic review: Menstruating women receiving intermittent vs. daily iron supplementation developed anaemia more frequently (RR 1.26; 95% CI 1.04 to 1.51, six trials), despite achieving similar haemoglobin concentrations on average (MD g/L; 95% CI to 1.91, eight trials). However, the review did not describe the daily dose as once or thrice daily.
CHILDREN
Studies in paediatrics (6-24 months & 9-12 years) of single vs. thrice daily dose of ferrous sulfate drops over 1-2 months resulted in a similar rate of increase in Hb, with minimal side effects. But, iron administered two to three times a day was better tolerated.
Level of Evidence: I Systematic review, RCT
Dose frequency of oral iron in adults & children retained as:
Three times daily treatment.
Once daily prophylaxis.
Peña-Rosas JP, De-Regil LM, Dowswell T, Viteri FE. Intermittent oral iron supplementation during pregnancy. Cochrane Database of Systematic Reviews 2012, Issue 7. Art. No.: CD
Beard JL. Effectiveness and strategies of iron supplementation during pregnancy. Am J Clin Nutr 2000;71(suppl):1288S–94S.
Ridwan E, Schultink W, Dillon D, and Gross R. Effects of weekly iron supplementation on pregnant Indonesian women are similar to those of daily supplementation. Am J Clin Nutr 1996;63:
Yakoob MY, Bhutta ZA. Effect of routine iron supplementation with or without folic acid on anemia during pregnancy. BMC Public Health 2011, 11(Suppl 3):S21
Pavord S, Myers B, Robinson S, Allard S, Strong J, Oppenheimer C for British Committee for Standards in Haematology. July UK guidelines on the management of iron deficiency in pregnancy.
Haidar J, Omwega AM, Muroki NM and Ayana G. Daily versus weekly iron supplementation and prevention of iron deficiency anaemia in lactating women. East African Medical Journal. January 2003;80(1):11-16.
Fernández-Gaxiola AC, De-Regil LM. Intermittent iron supplementation for reducing anaemia and its associated impairments in menstruating women. Cochrane Database of Systematic Reviews 2011, Issue 12. Art. No.: CD
Zlotkin S, Arthur P, Antwi KY, Yeung G. Randomized, controlled trial of single versus 3-times-daily ferrous sulfate drops for treatment of anemia. Pediatrics.2001 Sep;108(3):613-6.
Gunadi D, Rosdiana N, Lubis B. Comparison of once a day and three times a day iron treatment in 9-12 year old elementary school children with iron deficiency anemia. Paediatrica Indonesiana March 2009;49(2):
SAMF, 2012 edition.
PRIMARY HEALTHCARE IMPLEMENTATION SLIDES 2014: BLOOD & NUTRITIONAL

3. 3.1.1 ANAEMIA, IRON DEFICIENCY
ADULTS
Ferrous sulphate compound BPC, oral: amended
Ferrous fumarate, oral: added
Iron sucrose, IV: not added
Iron polymaltose, IM: not added
Blood transfusions: not added
Ferrous fumarate is available on the current tender.
Medicine interaction of iron tablets with calcium tablets was described in the text of the STG, aligned with the SAMF 10th edition, 2012.
Iron sucrose, IV; iron polymatose IM blood transfusions not considered pragmatic for primary level of care.
Level of Evidence: III Guideline, Expert opinion
Contract circular HP SD
PRIMARY HEALTHCARE IMPLEMENTATION SLIDES 2014: BLOOD & NUTRITIONAL

4. 3.1.1 ANAEMIA, IRON DEFICIENCY
CHILDREN
Follow up Hb after 14 days.
The following text was amended, as children with uncomplicated anaemia could be followed up a month later rather than 14 days later, if there is a response to oral iron therapy.
If same or higher – continue treatment and repeat after another days.
Level of Evidence: III Expert opinion
PRIMARY HEALTHCARE IMPLEMENTATION SLIDES 2014: BLOOD & NUTRITIONAL

5. 3.1.2 ANAEMIA, MACROCYTIC OR MEGALOBLASTIC
Vitamin B12, IM: not added
Vitamin B12 deficiency is diagnosed and managed at secondary level.
Level of Evidence: III Guidelines
Adult Hospital level STG, 2012 and Paediatric STG, 2013.
PRIMARY HEALTHCARE IMPLEMENTATION SLIDES 2014: BLOOD & NUTRITIONAL

6. 3.2.1.2 UNCOMPLICATED SEVERE ACUTE MALNUTRITION
Vitamin A (retinol), oral: added
Multivitamin, oral: added
Mebendazole, oral: added
The STG was aligned with the Paediatric Hospital level STG, the NDoH Nutrition SAM policy and the IMCI Guidelines.
Level of Evidence: III Guidelines
Paediatric Hospital level STG, 2013.
National Department of Health. IMCI Guidelines,2014.
National Department of Health Nutrition: Severe Acute Malnutrition policy.
PRIMARY HEALTHCARE IMPLEMENTATION SLIDES 2014: BLOOD & NUTRITIONAL

7. 3.4 VITAMIN B DEFICIENCIES
The description of the various vitamin B deficiencies were described as follows:
Vitamin B3/Nicotinic acid deficiency (Pellagra).
Vitamin B6/Pyridoxine deficiency.
Vitamin B1/Thiamine deficiency (Wernicke encephalopathy and beriberi).
PRIMARY HEALTHCARE IMPLEMENTATION SLIDES 2014: BLOOD & NUTRITIONAL

8. 3.4 VITAMIN B DEFICIENCIES
Vitamin B complex, oral: amended (indicated for all forms of vitamin B deficiencies).
As vitamin B deficiencies often co-exist, comprehensive treatment in the form of vitamin B complex was preferred compared to with individual vitamin B components.
Level of Evidence: III Expert opinion
PRIMARY HEALTHCARE IMPLEMENTATION SLIDES 2014: BLOOD & NUTRITIONAL

9. 3.4.1 VITAMIN B3/NICOTINIC ACID DEFICIENCY (PELLAGRA)
Nicotinamide: dose amended
Nicotinamide doses were delineated to manage severe and mild B3 deficiency in adults and children.
Level of Evidence: III Guideline
SAMF 10th edition, 2012.
PRIMARY HEALTHCARE IMPLEMENTATION SLIDES 2014: BLOOD & NUTRITIONAL

10. 3.4.2 PYRIDOXINE (VITAMIN B6) DEFICIENCY
Pyridoxine: dose amended
Dose aligned with SAMF 10th edition, 2012.
Supportive evidence of pyridoxine supplementation with INH is of poor quality. There is no RCT data, but the recommendation is included in most guidelines.
Level of Evidence: III Guidelines
SAMF 10th edition, 2012.
i. Snider DE Jr. Pyridoxine supplementation during isoniazid therapy.Tubercle.1980 Dec;61(4): ii. Carlson HB, Anthony EM, Russell WF jr, MiddlebrookG. Prophylaxis of isoniazid neuropathy with pyridoxine. N Engl J Med Jul 19;255(3):
iii. Zilber LA, Bajdakova ZL, Gardasjan AN, Konovalov NV, Bunina TL, Barabadze EM. The prevention and treatment of isoniazid toxicity in the therapy of pulmonary tuberculosis. 2. An assessment of the prophylactic effect of pyridoxine in low dosage. Bull World Health Organ. 1963;29:
American Thoracic Society, CDC, and Infectious Diseases Society of America. Treatment of Tuberculosis. Morbidity and Mortality Weekly Report. June 20, 2003 / Vol. 52 / No. RR-11.
WHO. Treatment of Tuberculosis guidelines, 4th edition, Available at:
Center for Disease Control and Prevention. Latent Tuberculosis Infection: A guide for primary healthcare providers, 2013.[Online] [Cited November 2014] Available at:
PRIMARY HEALTHCARE IMPLEMENTATION SLIDES 2014: BLOOD & NUTRITIONAL

11. PRIMARY HEALTHCARE IMPLEMENTATION SLIDES 2014: BLOOD & NUTRITIONAL
3.4.3 VITAMIN B1/THIAMINE DEFICIENCY (WERNICKE ENCEPHALOPATHY & BERIBERI)
Thiamine, IM, 100 mg: deleted
Dextrose 5 %, IV: deleted
Wernicke’s encephalopathy is not a common condition.
Patients that present with encephalopathy, eye muscle paralysis or cardiac failure require referral to secondary level facilities. Diagnosis and management is done at secondary level, and thus patients are down referred.
The irrational use of parenteral B12 and B1 was a concern at primary level.
Level of Evidence: III Expert opinion
PRIMARY HEALTHCARE IMPLEMENTATION SLIDES 2014: BLOOD & NUTRITIONAL

12. 12 Slide Ref # Reference 3.1 ANAEMIA 2 1 IRON
Peña-Rosas JP, De-Regil LM, Dowswell T, Viteri FE. Intermittent oral iron supplementation during pregnancy. Cochrane Database of Systematic Reviews 2012, Issue 7. Art. No.: CD
Beard JL. Effectiveness and strategies of iron supplementation during pregnancy. Am J Clin Nutr 2000;71(suppl):1288S–94S.
Ridwan E, Schultink W, Dillon D, and Gross R. Effects of weekly iron supplementation on pregnant Indonesian women are similar to those of daily supplementation. Am J Clin Nutr 1996;63:
Yakoob MY, Bhutta ZA. Effect of routine iron supplementation with or without folic acid on anemia during pregnancy. BMC Public Health 2011, 11(Suppl 3):S21
Pavord S, Myers B, Robinson S, Allard S, Strong J, Oppenheimer C for British Committee for Standards in Haematology. July UK guidelines on the management of iron deficiency in pregnancy.
Haidar J, Omwega AM, Muroki NM and Ayana G. Daily versus weekly iron supplementation and prevention of iron deficiency anaemia in lactating women. East African Medical Journal. January 2003;80(1):11-16.
Fernández-Gaxiola AC, De-Regil LM. Intermittent iron supplementation for reducing anaemia and its associated impairments in menstruating women. Cochrane Database of Systematic Reviews 2011, Issue 12. Art. No.: CD
Zlotkin S, Arthur P, Antwi KY, Yeung G. Randomized, controlled trial of single versus 3-times-daily ferrous sulfate drops for treatment of anemia. Pediatrics.2001 Sep;108(3):613-6.
Gunadi D, Rosdiana N, Lubis B. Comparison of once a day and three times a day iron treatment in 9-12 year old elementary school children with iron deficiency anemia. Paediatrica Indonesiana March 2009;49(2):
SAMF, 2012 edition. 3
FERROUS SULPHATE COMPUND BPC
Contract circular HP SD
FERROUS FUMARATE 5
VITAMIN B12
Adult Hospital level STG, 2012 and Paediatric STG, 2013.
3.2 CHILDHOOD MALNUTRITION, INCLUDING NOT GROWING WELL 6 4
VITAMIN A (RETINOL)
Paediatric Hospital level STG, 2013.
National Department of Health. IMCI Guidelines,2014.
National Department of Health Nutrition: Severe Acute Malnutrition policy.
MULTIVITAMIN 12

13. Slide
Ref #
Reference
3.2 CHILDHOOD MALNUTRITION, INCLUDING NOT GROWING WELL 6 4
MEBENDAZOLE
Paediatric Hospital level STG, 2013.
National Department of Health. IMCI Guidelines,2014.
National Department of Health Nutrition: Severe Acute Malnutrition policy.
3.4 VITAMIN B DEFICIENCIES 9 5
NICOTINAMIDE
SAMF 10th edition, 2012. 10
PYRIDOXINE
Snider DE Jr. Pyridoxine supplementation during isoniazid therapy.Tubercle.1980 Dec;61(4): ii. Carlson HB, Anthony EM, Russell WF jr, MiddlebrookG. Prophylaxis of isoniazid neuropathy with pyridoxine. N Engl J Med Jul 19;255(3):
Zilber LA, Bajdakova ZL, Gardasjan AN, Konovalov NV, Bunina TL, Barabadze EM. The prevention and treatment of isoniazid toxicity in the therapy of pulmonary tuberculosis. 2. An assessment of the prophylactic effect of pyridoxine in low dosage. Bull World Health Organ. 1963;29:
American Thoracic Society, CDC, and Infectious Diseases Society of America. Treatment of Tuberculosis. Morbidity and Mortality Weekly Report. June 20, 2003 / Vol. 52 / No. RR-11.
WHO. Treatment of Tuberculosis guidelines, 4th edition, Available at:
Center for Disease Control and Prevention. Latent Tuberculosis Infection: A guide for primary healthcare providers, 2013.[Online] [Cited November 2014] Available at: 13