The Pale Kabaddi Hopeful
Simran, 15, is in Class 10 at a government school near Bathinda. Her haemoglobin is 8.2 g/dL. She tells the school doctor she feels tired climbing two flights of stairs, looks pale, and gets breathless during the 800 m warm-up. Her periods last 7–8 days, with heavy flow for the first three days. At home she eats two wheat rotis with tea at 7 am, skips fruit, eats the school midday meal at 2 pm, and drinks tea with both rotis and dal because 'it helps her digest'. She has no fever, no blood in stool, and no family history of thalassaemia. Her BMI is 16.8. She wants to play in the school kabaddi team but feels too weak. The school runs an iron-folic acid supplementation programme and keeps a weekly deworming record.
1. What is the most likely cause of Simran's symptoms, and how would you rule out other explanations using the information given?
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The combination points to iron-deficiency anaemia. Haemoglobin 8.2 g/dL is moderate anaemia; pallor, fatigue on stairs and breathlessness in the warm-up all reflect reduced oxygen-carrying capacity. The two dietary factors are low iron intake and tea with meals: tannins in tea reduce absorption of non-haem iron from roti and dal. Heavy menstrual bleeding for 7–8 days is a likely ongoing iron loss.
Other causes are less likely but must be checked. There is no fever or chills to suggest malaria, no blood in stool to suggest hookworm or gut bleeding, and no family history of thalassaemia. BMI 16.8 shows undernutrition, which supports a dietary cause but does not exclude others. Heavy periods need medical review because menorrhagia itself has causes that a school cannot diagnose. The correct judgement is: probable iron-deficiency anaemia, confirm with a doctor (including ferritin where available), do not self-prescribe high-dose iron tablets, and treat the heavy periods as a separate medical issue.
2. Plan one week of low-cost, locally available diet changes for Simran. Explain the timing rules and why tea matters.
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The principle is to add iron, add vitamin C with it, and separate tea from iron-containing meals.
Additions: green leafy saag, chana or sattu, jaggery, groundnut chikki, sesame seeds, and egg if the family accepts it. Pair these with amla, guava, lemon or tomato, because vitamin C improves non-haem iron absorption. Cook in an iron kadhai where possible. Keep the midday meal but add a small morning snack, such as a groundnut-jaggery chikki, because the gap from 7 am to 2 pm is long.
Timing rule: tea or coffee should be at least one hour after a meal, not with roti and dal. The tea habit is not the only cause, but changing it is free and removes a daily blocker. This plan is realistic because all items are cheap and available in a village. It supports, but does not replace, iron tablets prescribed after medical review.
3. What should the school do over the next month, and what signs mean Simran must be referred urgently?
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The school should supervise the weekly iron-folic acid tablet under its programme, confirm deworming, and ensure clean toilets and a private space for menstrual hygiene. It should record her attendance in PE and allow modified activity until her breathlessness improves. The class teacher should contact the family and explain that she needs a doctor's review for heavy periods and anaemia.
Refer urgently if she has chest pain, fainting, breathlessness at rest, black stools, very heavy bleeding that soaks a pad in an hour, or a fall in haemoglobin despite treatment. These are red flags for severe anaemia or another cause. The school should not simply give her extra iron tablets from a neighbour or treat her as 'lazy'. The judgement is to combine supplementation, diet, menstrual support and medical referral, then recheck after a few weeks.