Screening MEN AND POSTMENOPAUSAL WOMEN Asymptomatic men and postmenopausal women should not be screened for iron deficiency anemia. Testing should be performed in patients with signs and symptoms of anemia, and a complete evaluation should be performed if iron deficiency is confirmed.13 PREGNANT WOMEN The American Academy of Family Physicians, U.S. Preventive Services Task Force, and Centers for Disease Control and Prevention recommend routine screening of asymptomatic pregnant women for iron deficiency anemia.4,11,14 The American College of Obstetricians and Gynecologists recommends screening for anemia and implementing iron therapy if iron deficiency anemia is confirmed.15 The defined values consistent with anemia in pregnancy are hemoglobin levels less than 11 g per dL (110 g per L) in the first or third trimester, or less than 10.5 g per dL (105 g per L) in the second trimester.16 Amaternal hemoglobin level of less than 6 g per dL (60 g per L) has been associated with poor fetal outcomes, including death.15 CHILDREN The American Academy of Pediatrics recommends universal hemoglobin screening and evaluation of risk factors for iron deficiency anemia in all children at one year of age.16 Risk factors include low birth weight, history of prematurity, exposure to lead, exclusive breastfeeding beyond four months of life, and weaning to whole milk and complementary foods without iron-fortified foods.16 The Centers for Disease Control and Prevention recommends screening children from low-income or newly immigrated families at nine to 12 months of age, and consideration of screening for preterm and low-birth-weight infants before six months of age if they are not given iron-fortified formula.14 The U.S. Preventive Services Task Force found insufficient evidence for screening in asymptomatic children six to 12 months of age and does not make recommendations for other ages.4 A meta-analysis showed that infants in whom cord clamping was delayed for up to two minutes after birth had a reduced risk of low iron stores for up to six months.17 Larger randomized studies that include maternal outcomes are needed before delayed cord clamping can be recommended for general practice.

3. Penyebab Anemia Menurut Tarwoto, dkk (2010) adalah: a. Pada umumnya masyarakat Indonesia (termasuk remaja putri) lebih banyak mengkonsumsi makanan nabati yang kandungan zat besinya sedikit, dibandingkan dengan makanan hewani, sehingga kebutuhan tubuh akan zat besi tidak terpenuhi b. Remaja putri biasanya ingin tampil langsing, sehingga membatasi asupan makanan c. Setiap hari manusia kehilangan zat besi 0,6 mg yang diekskresi, khusunya melalui feses (tinja) d. Remaja putri mengalami haid setiap bulan, di mana kehilangan zat besi 1,3 mg per hari, sehingga kebutuhan zat besi lebih banyak dari pada pria

Menurut Handayani dan Haribowo (2008), pada dasarnya gejala anemia timbul karena dua hal berikut ini: a. Anoksia organ target karena berkurangnya jumlah oksigen yang dapat dibawa oleh darah kejaringan. b. Mekanisme kompensasi tubuh terhadap Anemia.

Menurut Anie Kurniawan, dkk (1998), Anemia Gizi Besi dapat terjadi karena: a. Kandungan zat besi dari makanan yang di konsumsi tidak mencukupi kebutuhan 13

1) Makanan yang kaya akan kandungan zat besi adalah: makanan yang berasal dari hewani (seperti ikan, daging, hati, ayam) 2) Makanan nabati (dari tumbuh-tumbuhan) misalnya sayuran hijau tua, yang walaupun kaya akan zat besi, namun hanya sedikit yang bisa diserap dengan baik oleh usus. b. Meningkatnya kebutuhan tubuh akan zat besi 1) Pada masa pertumbuhan seperti anak-anak dan remaja, kebutuhan tubuh akan zat besi meningkat tajam. 2) Pada masa hamil kebutuhan zat besi meningkat karena zat besi diperlukan untuk pertumbuhan janin serta untuk kebutuhan ibu sendiri. 3) Pada penderita menahun seperti TBC. c. Meningkatnya pengeluaran zat besi dari tubuh. Perdarahan atau kehilangan darah dapat menyebabkan anemia. Hal ini terjadi pada penderita: 1) Kecacingan (terutama cacing tambang), infeksi cacing tambang menyebabkan perdarahan pada dinding usus, meskipun sedikit tetapi terjadi terus menerus yang mengakibatkan hilangnya darah atau zat besi. 2) Malaria pada penderita Anemia Gizi Besi, dapat memperberat keadaan anemianya.

3) Kehilangan darah pada waktu haid berarti mengeluarkan zat besi yang ada dalam darah. 4. Dampak anemia Menurut Anie Kurniawan, dkk (1998), dampak anemia pada remaja putri ialah: a. Menurunkan kemampuan dan konsentrasi belajar. b. Mengganggu pertumbuhan sehingga tinggi badan tidak mencapai optimal. c. Menurunkan kemampuan fisik olahragawati. d. Mengakibatkan muka pucat.

Menurut Reksodiputro (2004) yang dikutip oleh Tarwoto, dkk (2010), komplikasi dari anemia yaitu: Gagal jantung kongesif; Parestesia; Konfusi kanker; Penyakit ginjal; Gondok; Gangguan pembentukan heme; Penyakit infeksi kuman; Thalasemia; Kelainan jantung; Rematoid; Meningitis; Gangguan sistem imun. Menurut Moore (1997) yang dikutip oleh Tarwoto, dkk (2010) dampak anemia pada remaja adalah: a. Menurunnya produktivitas ataupun kemampuan akademis di sekolah, karena tidak adanya gairah belajar dan konsentrasi b. Mengganggu pertumbuhan di mana tinggi dan berat badan menjadi tidak sempurna c. Daya tahan tubuh akan menurun sehingga mudah terserang penyakit 15

d. Menurunnya produksi energi dan akumulasi laktat dalam otot 5. Pencegahan anemia

Menurut Tarwoto, dkk (2010), upaya-upaya untuk mencegah anemia, antara lain sebagai berikut: a. Makan makanan yang mengandung zat besi dari bahan hewani (daging, ikan, ayam, hati, dan telur); dan dari bahan nabati (sayuran yang berwarna hijau tua, kacang-kacangan, dan tempe). b. Banyak makan makanan sumber vitamin c yang bermanfaat untuk meningkatkan penyerapan zat besi, misalnya: jambu, jeruk, tomat, dan nanas. c. Minum 1 tablet penambah darah setiap hari, khususnya saat mengalami haid. d. Bila merasakan adanya tanda dan gejala anemia, segera konsultasikan ke dokter untuk dicari penyebabnya dan diberikan pengobatan.

Menurut Anie Kurniawan, dkk (1998), mencegah anemia dengan: a. Makan-makanan yang banyak mengandung zat besi dari bahan makanan hewani (daging, ikan, ayam, hati, telur) dan bahan makanan nabati (sayuran berwarna hijau tua, kacang-kacangan, tempe). b. Makan sayur-sayuran dan buah-buahan yang banyak mengandung vitamin C (daun katuk, daun singkong, bayam,

jambu, tomat, jeruk dan nanas) sangat bermanfaat untuk meningkatkan penyerapan zat besi dalam usus c. Menambah pemasukan zat besi kedalam tubuh dengan minum Tablet Tambah Darah (TTD) Menurut Lubis (2008) dalam referensi kesehatan.html, tindakan penting yang dilakukan untuk mencegah kekurangan besi antara lain: a. Konseling untuk membantu memilih bahan makanan dengan kadar besi yang cukup secara rutin pada usia remaja. b. Meningkatkan konsumsi besi dari sumber hewani seperti daging, ikan, unggas, makanan laut disertai minum sari buah yang mengandung vitamin C (asam askorbat) untuk meningkatkan absorbsi besi dan menghindari atau mengurangi minum kopi, teh, teh es, minuman ringan yang mengandung karbonat dan minum susu pada saat makan. c. Suplementasi besi. Merupakan cara untuk menanggulangi ADB di daerah dengan prevalensi tinggi. Pemberian suplementasi besi pada remaja dosis 1 mg/KgBB/hari. d. Untuk meningkatkan absorbsi besi, sebaiknya suplementasi besi tidak diberi bersama susu, kopi, teh, minuman ringan yang mengandung karbonat, multivitamin yang mengandung phosphate dan kalsium. 17

e. Skrining anemia. Pemeriksaan hemoglobin dan hematokrit masih merupakan pilihan untuk skrining anemia defisiensi besi.

Menurut De Maeyer (1995) yang dikutip oleh Tarwoto, dkk (2010), pencegahan adanya anemia defisiensi zat besi dapat dilakukan dengan tiga pendekatan dasar yaitu sebagai berikut: a. Memperkaya makanana pokok dengan zat besi, seperti: hati, sayuran berwarna hijau dan kacang-kacangan. Zat besi dapat membantu pembentukan hemoglobin (sel darah merah) yang baru b. Pemberian suplemen zat besi. Pada saat ini pemerintah mempunyai Program Penanggulangan Anemia Gizi Besi (PPAGB) pada remaja putri, untuk mencegah dan menanggulangi masalah Anemia gizi besi melalui suplementasi zat besi c. Memberikan pendidikan kesehatan tentang pola makan sehat. Kehadiran makanan siap saji (fast food) dapat mempengaruhi pola makan remaja. Makanan siap saji umumnya rendah zat besi, kalsium, riboflavin, vitamin A, dan asam folat. Makanan siap saji mengandung lemak jenuh, kolesterol dan natrium yang tinggi. 6. Pengobatan anemia

Menurut Handayani dan Haribowo (2008), pada setiap kasus anemia perlu diperhatikan prinsip-prinsip sebagai berikut ini:

a. Terapi spesifik sebaiknya diberikan setelah diagnosis ditegakkan. b. Terapi diberikan atas indikasi yang jelas, rasional, dan efisien. Jenis-jenis terapi yang dapat diberikan adalah: a. Terapi gawat darurat

Pada kasus anemia dengan payah jantung atau ancaman payah jantung, maka harus segera diberikan terapi darurat dengan transfusi sel darah merah yang dimampatkan (PRC) untuk mencegah perburukan payah jantung tersebut. b. Terapi khas untuk masing-masing anemia

Terapi ini bergantung pada jenis anemia yang dijumpai, misalnya preparat besi untuk anemia defisiensi besi. c. Terapi kausal

Terapi kausal merupakan terapi untuk mengobati penyakit dasar yang menjadi penyebab anemia. Misalnya, anemia defisiensi besi yang disebabkan oleh infeksi cacing tambang harus diberikan obat anti-cacing tambang. d. Terapi ex-juvantivus (empiris)

Terapi yang terpaksa diberikan sebelum diagnosis dapat dipastikan, jika terapi ini berhasil, berarti diagnosis dapat dikuatkan. Terapi hanya dilakukan jika tidak tersedia fasilitas diagnosis yang mencukupi. Pada pemberian terapi jenis ini, penderita harus diawasi dengan ketat. Jika terdapat respons 19

yang baik, terapi diteruskan, tetapi jika tidak terdapat respons, maka harus dilakukan evaluasi kembali. Menurut Yayan Ahyar Israr (2008) Setelah diagnosis ditegakan maka dibuat rencana pemberian terapi, terapi terhadap anemia difesiensi besi dapat berupa a. Terapi kausal: tergantung penyebabnya, misalnya, pengobatan cacing tambang, pengobatan hemoroid, pengobatan menoragia. Terapi kausal harus dilakukan, kalau tidak maka anemia akan kambuh kembali. b. Pemberian preparat besi untuk mengganti kekurangan besi dalam tubuh 1) Besi per oral merupakan obat pilihan pertama karena efektif, murah, dan aman. preparat yang tersedia, yaitu: a) Ferrous sulphat (sulfas ferosus): preparat pilihan pertama (murah dan efektif). Dosis: 3 x 200 mg. b) Ferrous gluconate, ferrous fumarat, ferrous lactate, dan ferrous succinate, harga lebih mahal, tetepi efektivitas dan efek samping hampir sama. 2) Besi parenteral

Efek samping lebih berbahaya, serta harganya lebih mahal. Indikasi, yaitu : a) Intoleransi oral berat b) Kepatuhan berobat kurang c) Kolitis Ulcerativa

d) Perlu peningkatan Hb secara cepat (misal preoperasi, hamil trimester akhir). c. Penatalaksanaan yang juga dapat dilakukan 1) Mengatasi penyebab perdarahan kronik, misalnya pada ankilostomiasis diberikan antelmintik yang sesuai. 2) Pemberian preparat Fe : Pemberian preparat besi (ferosulfat/ferofumarat/feroglukonat) dosis 4-6 mg besi elemental/kg BB/hari dibagi dalam 3 dosis, diberikan di antara waktu makan. Preparat besi ini diberikan sampai 2-3 bulan setelah kadar hemoglobin normal. 3) Bedah : Untuk penyebab yang memerlukan intervensi bedah seperti perdarahan karena diverticulum Meckel. 4) Suportif : Makanan gizi seimbang terutama yang megandung kadar besi tinggi yang bersumber dari hewani (limfa, hati, daging) dan nabati (bayam, kacang-kacangan).

Menurut Ahmad Syafiq, dkk (2008) screening diperlukan untuk mengidentifikasi kelompok wanita yang harus diobati dalam mengurangi mordibitas anemia. CDC menyarankan agar remaja putri dan wanita dewasa yang tidak hamil harus di-screening tiap 5-10 tahun melalui uji kesehatan, meskipun tidak ada faktor risiko anemia seperti perdarahan, rendahnya intake Fe, dan sebagainya. 21

Namun, jika disertai adanya faktor risiko anemia, maka screening harus dilakukan secara tahunan. Penderita anemia harus mengkonsumsi 60-120 mg Fe per hari dan meningkatkan asupan makanan sumber Fe. Satu bulan kemudian harus dilakukan screening ulang. Bila hasilnya menunjukkan peningkatan konsentrasi Hb minimal 1 g/dl atau hematokrit minimal 3%, pengobatan harus diteruskan sampai tiga bulan.

goes untreated? A: Some types of anemia may be life page 4 Fr equent l y As k e d Qu e s t i o n s U.S. Department of Health and Human Services, Office on Womens Health http://www.womenshealth.gov 1-800-994-9662 TDD: 1-888-220-5446 threatening if not diagnosed and treated. Too little oxygen in the body can damage organs. With anemia, the heart must work harder to make up for the lack of red blood cells or hemoglobin. This extra work can harm the heart and even lead to heart failure

Q: How do I prevent anemia? A: There are steps you can take to help prevent some types of anemia. Eat foods high in iron: cereal/breads with iron in it (100% iron-fortified is best. Check food label.) liver lentils and beans oysters tofu green, leafy vegetables such as spinach red meat (lean only) fish dried fruits such as apricots, prunes, and raisins For more sources of iron, visit www.cc.nih.gov/ccc/supplements/iron.html. Eat and drink foods that help your body absorb iron, like orange juice, strawberries, broccoli, or other fruits and vegetables with vitamin C. Don't drink coffee or tea with meals. These drinks make it harder for your body to absorb iron. Calcium can hurt your absorption of iron. If you have a hard time getting enough iron, talk to your doctor about the best way to also get enough calcium. Make sure you consume enough folic acid and vitamin B12. Make balanced food choices. Most people who make healthy, balanced food choices get the iron and vitamins their bodies need from the foods they eat. Food fads and dieting can lead to anemia. Talk to your doctor about taking iron pills (supplements). Do NOT take these pills without talking to your doctor first. These pills come in two forms: ferrous and ferric. The ferrous form is better absorbed by your body. But taking iron pills can cause side effects, like nausea, vomiting, constipation, and diarrhea. Reduce these side effects by taking these steps: Start with half of the recom mended dose. Gradually increase to the full dose. Take the pill in divided doses. For example, if you are pre scribed two pills daily, take one in morning with breakfast and the other after dinner. Take the pill with food. If one type of iron pill is causing problems, ask your doctor for another brand. It is important to keep iron pills tightly capped and away from childrens reach. In children, death has occurred from ingesting 200 mg of iron. If you are a non-pregnant woman of childbearing age, get tested for anemia every five to 10 years. Thisexam. Testing should start in adolescence. If you are a non-pregnant woman of childbearing age with these risk factors for iron deficiency, get tested every year: heavy periods low iron intake have been diagnosed with anemia in the past Follow your doctors orders for treating the underlying cause of your anemia. This will prevent the anemia from coming back or becoming serious.Q: How much iron do I need every day? A: Most people get enough iron by making healthy, balanced food choices and eating iron-rich foods. But some groups of people are at greater risk for low iron levels: teenage girls/women of childbearing age (who have heavy bleeding during their period, who have had more than one child, or use an intrauterine device [IUD]) older infants and toddlers (mainly those who drink a lot of milk or are having a growth spurt) pregnant women (about half of pregnant women have iron-deficiency anemia) Female athletes who engage in regular, intense exercise These groups of people should be screened at times for iron deficiency. If the tests show that the body isn't getting enough iron, iron pills (supplements) may be prescribed. In extreme cases of iron deficiency, your doctor might prescribe iron shots. Many doctors prescribe iron pills during pregnancy because many pregnant women don't get enough iron. Iron pills can help when diet alone can't restore the iron level back to normal. Talk with your doctor to find out if you are getting enough iron through the foods you eat or if you or your child needs to be taking iron pills. Please see the chart below to see how many milligrams (mg) of iron you should consume every day. Q: How much iron do I need if I am pregnant? A: Pregnant women need to consume twice as much iron as women who are not pregnant. But about half of all pregnant women do not get enough AgeInfants & ChildrenWomenPregnantBreastfeeding

7 to 12 months11 mg

1 to 3 years7 mg

4 to 8 years10 mg

9 to13 years8 mg

14 to18 years15 mg27 mg10 mg

19 to 50 years18 mg27 mg9 mg

51+ years8 mg

iron. During pregnancy, your body needs more iron because of the growing fetus, the higher volume of blood, and blood loss during delivery. If a pregnant woman does not get enough iron for herself or her growing baby, she has an increased chance of having preterm birth and a low-birth-weight baby. If you're pregnant, follow these tips: Make sure you get 27mg of iron every day. Take an iron supplement (pill). It may be part of your prenatal vitamin. Start taking it at your first prenatal visit. Get tested for anemia at your first prenatal visit. Ask if you need to be tested for anemia 4 to 6 weeks after delivery. Q: I am taking menopausal hormone therapy (MHT). Does that affect how much iron I should take? A: It might. If you are still getting your period while taking MHT, you may need more iron than women who are postmenopausal and not taking MHT. Talk to your doctor. Q: Does birth control affect my risk for anemia? A: It could. Some women who take birth control pills have less bleeding during their periods. This would lower their risk for anemia. But women who use an intrauterine device (IUD) may have more bleeding and increase their chances of getting anemia. Talk to your doctor. Q: I am a vegetarian. What steps should I take to make sure I get enough iron? A: It depends on the food choices you make. Since meat, poultry, and seafood are the best sources of iron found in food, some vegetarians may need to take a higher amount of iron each day than what is recommended for other people. Follow the tips above to prevent anemia, and try to take vitamin C with the iron-rich foods you eat. Q: What happens if my body gets more iron than it needs? A: Iron overload happens when too much iron builds up in the body over time. This condition is called hemochromatosis (HEE-moh-kroh-muh-TOH-suhss). The extra iron can damage the organs, mainly the liver, heart, and pancreas. Many problems can cause iron overload. Most people with hemochromatosis inherit it from their parents. It is one of the most common genetic (runs in families) diseases in the United States. Some other diseases also can lead to iron overload. It also can happen from years of taking too much iron or from repeated blood transfusions or dialysis for kidney disease. Signs of early hemochromatosis may include: fatigue weakness weight loss abdominal pain joint pain fluttering in chest

As iron builds up in the body, common symptoms include: arthritis missed periods early menopause loss of sex drive impotence (repeated inability to get or keep an erection firm enough for sexual intercourse) heart problems like shortness of breath, chest pain, and changes in rate or rhythm Signs of advanced hemochromatosis include: arthritis liver disease, including an enlarged liver, cirrhosis, cancer, and liver failure damage to the pancreas, possibly causing diabetes chronic (ongoing) abdominal pain severe fatigue weakening of the heart muscle heart failure changes in skin color, making it look gray, yellow or bronze (not caused by sun) Treatment depends on how severe the iron overload is. The first step is to get rid of the extra iron in the body. Most people undergo a process called phlebotomy (fluh-BOT-uh-mee), which means removing blood. It is simple and safe. A pint of blood will be taken once or twice a week for several months to a year, and sometimes longer. Once iron levels go back to normal, you will give a pint of blood every 2 to 4 months for life. People who cannot give blood can take medicine to remove extra iron. This is called iron chelation (kuh-LAY-shuhn) therapy. Although treatment cannot cure the problems caused by hemochromatosis, it will help most of them. Arthritis is the only problem that does not improve after excess iron is removed.Preventing or Controlling AnemiaYou can take steps to prevent or control anemia. These actions can give you greater energy and improve your health and quality of life. Here are a few simple things you can do.Follow a Healthy DietFollowing a healthy diet ensures that you get enough of the nutrients that your body needs to make healthy blood cells. These nutrients include iron, vitamin B12, folate, and vitamin C. These nutrients are found in a variety of foods. Healthy eating also is good for your overall health. The basics of healthy eating: Focus on nutrient-dense foods and beveragesvegetables, fruits, whole grains, fat-free or low-fat dairy products, seafood, lean meats and poultry, eggs, beans and peas, and nuts and seeds. Limit your intake of salt, solid fats, added sugars, and refined grains. Maintain a healthy weight by balancing the calories you get from foods and beverages with the calories you use through physical activity. Follow food safety guidelines when preparing and eating foods to reduce the risk of foodborne illnesses. n n n Make following a healthy diet a family goal. Infants, young children, and teens grow rapidly. A healthy diet supports growth and development and can help prevent anemia. Have n