A pale girl who cannot keep up on the hill road
A 13-year-old girl from a village near Koraput is brought to the health worker by her mother. She is pale, including the inside of her lower eyelids and her palms, and she says she cannot keep up with her friends when they climb the hill road to school, stopping to pant while they wait for her. Her mother reports that for two months she has been breaking pieces of clay off the house wall and eating them. The family eats rice with a small amount of dal twice a day and potato, rarely green leafy vegetables or fruit, and the girl drinks tea with both meals. There is no toilet in the house and everyone walks barefoot. A blood test shows haemoglobin 7.8 g/dL with small, pale red cells, and a stool test shows hookworm eggs.
1. Explain step by step why a haemoglobin of 7.8 g/dL makes this girl pant on a slope but not while sitting.
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Each gram of haemoglobin carries about 1.34 mL of oxygen when fully saturated, so a normal 13–14 g/dL gives an oxygen-carrying capacity near 19 mL per 100 mL of blood. At 7.8 g/dL the capacity is only about 10.5 mL per 100 mL - roughly half.
Oxygen delivery to a muscle equals cardiac output multiplied by the oxygen content of arterial blood, so with half the content the heart must roughly double its output to deliver the same oxygen. Climbing a slope raises the muscles' demand several times above resting level. Breathing deepens and quickens and the heart rate rises, but the ceiling has been lowered, so she reaches her limit early and has to stop and pant. The burning in her legs is lactic acid from anaerobic respiration when oxygen runs short.
At rest the demand is small, so the reduced carrying capacity is still enough and she feels no breathlessness.
Small, pale red cells fit the same story: iron is needed for haem synthesis, so with too little iron the red cells are produced in normal numbers but underfilled with haemoglobin (microcytic, hypochromic anaemia). The pallor of the conjunctiva and palms is the visible sign of the same shortage.
2. The health worker prescribes deworming and iron-folic acid tablets. Why are both needed, and what dietary advice matters most in this household?
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Hookworms fasten onto the wall of the small intestine and feed on blood; a moderate load can cost several millilitres of blood a day. That steady loss can be larger than the amount of iron she absorbs from food or tablets, so giving iron alone is like filling a leaking bucket. Deworming stops the loss; iron then rebuilds the stores. Both are needed, and iron should continue for at least three months after haemoglobin returns to normal so that the stores, not just the blood level, are refilled.
Dietary advice, in order of impact:
- Stop tea with meals. Tannins in tea bind iron into insoluble complexes. Tea should be taken at least an hour away from food and from the tablet.
- Add a vitamin C source to every meal - amla, lemon, guava, tomato, papaya, drumstick leaves. Ascorbic acid reduces iron from the ferric to the ferrous form and keeps it soluble, which sharply increases absorption.
- Increase iron-rich foods that are actually available locally: drumstick and amaranth leaves, spinach, jaggery, groundnut, small dried fish, and dal in larger quantity.
- Do not take the tablet with milk, curd or calcium supplements, and keep it away from phytate-heavy rice water.
- Build a toilet and wear footwear, since hookworm larvae enter through bare feet and the soil is contaminated by open defecation. Treatment without sanitation will simply be repeated.
3. Why is she eating clay, and why is it not a harmless habit to be scolded away?
Read the worked answer
Eating clay (pica) is a well-recognised companion of iron deficiency. The exact cause is not settled - it may be an attempt to obtain minerals, or a distortion of taste and smell produced by the anaemia - but it appears with deficiency and usually disappears once the haemoglobin is corrected. So it should be read as a symptom pointing to the diagnosis, not as a bad habit or a behavioural problem.
It is also actively harmful. Clay binds iron and zinc in the gut and reduces their absorption, so the habit deepens the very deficiency that caused it. Clay from a wall may carry worm eggs, and in some districts the clay or the whitewash contains lead, which causes its own anaemia and harms the developing nervous system. Large amounts can cause constipation or, rarely, a blockage.
The right response is to treat the deficiency and deworm, explain to the mother why the child is doing it, and check the haemoglobin again after treatment. Scolding or punishment alone will not stop it while the anaemia persists. This is also a reason to look for pica in any child with unexplained anaemia.