Class 10 Girl with Hb 7.5 g/dL and Heavy Periods
An adolescent health check in a government higher secondary school finds a 15-year-old girl in Class 10 with haemoglobin 7.5 g/dL. She is pale, gets breathless climbing two floors to her classroom, and has had heavy periods for the past year, five to six days each cycle, soaking eight to ten pads. She is vegetarian; the family eats rice twice a day with rasam and vegetables, green leafy vegetables about twice a week, no fruit most days, and she drinks tea three times a day with meals. She has not been dewormed in two years. Her father earns about 9,000 rupees a month and the family is reluctant to buy tonics. She has never taken iron tablets. She has no bleeding gums, no black stools, and knows of no family history of thalassaemia. The school's weekly iron and folic acid programme was stopped a year ago.
1. Which findings most plausibly explain the anaemia, and what must be investigated before starting long-term iron?
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Hb 7.5 g/dL is severe anaemia for an adolescent girl, and three findings fit together:
- Chronic blood loss - periods lasting 5–6 days and soaking 8–10 pads are heavy menstrual bleeding, the commonest cause of iron deficiency in adolescent girls.
- Low iron intake with strong inhibitors - a rice-based vegetarian diet with leafy vegetables only twice a week, little fruit, and tea three times a day with meals; tannins in tea bind non-haem iron and reduce absorption.
- No deworming for two years - hookworm causes slow, unnoticed blood loss and is common where sanitation is poor.
Before committing her to months of iron, confirm iron deficiency (serum ferritin, low MCV/MCH with a peripheral smear) and exclude thalassaemia trait, which is common in Tamil Nadu and will not respond to iron. Check for bleeding from other sites, and refer her for the heavy periods, because thyroid disease and clotting disorders need to be ruled out.
2. Plan one day of iron-rich vegetarian food using cheap local items, and state exactly when the iron tablet should be taken and why.
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One day, cheap and local (approximate iron):
- Breakfast: ragi porridge with a little jaggery (ragi about 3.9 mg/100 g; jaggery about 11 mg/100 g).
- Mid-morning: guava, amla or lemon water - vitamin C boosts absorption from the same meal.
- Lunch: rice, kollu (horse gram) rasam, drumstick-leaf poriyal, curd.
- Snack: roasted Bengal gram, or groundnut chutney with sesame.
- Dinner: sprouted green gram curry with rice or chapati.
- Replace tea with buttermilk or lime water, and keep tea at least an hour away from meals and from the tablet.
Iron tablet: one hour before a meal with vitamin C (lemon or amla), not with milk, calcium, antacids or tea. If it causes severe nausea, take it with a small snack and accept somewhat lower absorption. Warn her that black stools are harmless, and continue the tablet for 3 months after Hb returns to normal to refill the stores. Use free government iron-folic acid supplies and link her back to the school programme.
3. What will you monitor at follow-up, and which findings would make you refer her urgently?
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Monitor: repeat Hb in 2–4 weeks - a rise of about 1 g/dL suggests good adherence and the correct diagnosis. Ask about tablet intake, tea with meals, and the number of pads per cycle at every visit. Watch for nausea and constipation and treat them rather than letting her stop the tablet.
Refer urgently if: she becomes breathless at rest, has palpitations, fainting, swelling of the feet or a fast pulse with Hb below 7 g/dL - these suggest cardiac decompensation and need hospital assessment, possibly transfusion. Refer to gynaecology if periods become heavier, last longer, or bleed between periods. Refer if Hb does not rise after 4 weeks of supervised iron, or if ferritin is normal. Black stools, gum bleeding or easy bruising suggest a bleeding disorder and need investigation.