Download - Iron deficiency in children
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Iron Deficiency Anemia
Done by:Mohammed A Qazzaz
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Objective
• INTRODUCTION• PREVALENCE• IRON BALANCE• REQUIREMENTS• Causes• CLINICAL MANIFESTATIONS• Diagnosis• Treatment• Prevention of iron deficiency
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INTRODUCTION
• Iron deficiency (ID) is the most common nutritional deficiency in children.
• WHO estimates that anemia affects one quarter of the world's population and is concentrated within pre-school age children and women.
• Iron deficiency anemia (IDA) is a microcytic, hypochromic, and hypoproductive state.
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PREVALENCE• Iron deficiency anaemia is an important public health
problem in the Eastern Mediterranean Region.
• It is estimated that more than one third of the population in the Region is anaemic.
• Pregnant women and young children are most at risk– 50% of pregnant women and – 63% of children under-5 have iron deficiency anaemia.
• 9 % incidence of iron deficiency and a 2 % incidence of anemia among American females between the ages 12 and 15 years.
• Less than 1% of adolescent males had iron deficiency
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IRON BALANCE • 75% bound in heme proteins (hemoglobin and myoglobin).
• In normal subjects - small amount of iron enters and leaves the body on a daily basis.
• Iron balance is achieved primarily by mechanisms affecting intestinal absorption and transport.
• In infants and children, 30% of daily iron needs must come from diet.
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• Intestinal iron absorption is a function of three principal factors: – body iron stores (transferrin and ferritin)– erythropoietic rate– bioavailability of dietary iron.
• Iron absorption also is increased when there is increased erythropoiesis and reticulocytosis or ineffective erythropoiesis, as in beta thalassemia.
• Heme dietary sources have a higher bioavailability of iron than do non-heme sources (30 versus 10 percent)
• Ascorbic acid enhances the absorption of non-animal sources of iron.
• Tannates (teas), bran foods rich in phosphates, and phytates (plant fiber, especially in seeds and grains) inhibit iron absorption.
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REQUIREMENTS
• Breast milk contains only 0.3 to 1.0 mg/L iron, but has a high bioavailability (50 percent)
• Iron-containing formulas with 12 mg/L iron have only 4 to 6 percent bioavailability.
• Full-term: 1 mg/kg (maximum 15 mg)• Children 1 to 3 years old: 7 mg/day• Children 4 to 8 years old: 10 mg/day• Children 9 to 13 years old: 8 mg/day
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Causes
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Perinatal risk factors• At birth- iron stores ~75 mg/kg, mean hemoglobin
concentrations are 15 t 17 g/dL.
• First three to six months of life, by reducing the iron stores at birth or through other mechanisms: – Maternal iron deficiency– Prematurity– Fetal-maternal hemorrhage (FMH)– Twin-twin transfusion syndrome (TTS)– Other perinatal hemorrhagic events– Insufficient dietary intake of iron during early infancy
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Dietary factors
• Insufficient iron intake
• Decreased absorption due to poor dietary sources of iron
• Introduction of unmodified cow's milk (non-formula cow’s milk) before 12 months of age
• Occult blood loss secondary to cow's milk protein-induced colitis
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Gastrointestinal disease• Gastrointestinal malabsorption of iron:– Active celiac disease– Crohn’s disease– Giardiasis– Resection of the proximal small intestine.
• Conditions that cause gastrointestinal blood loss:– Cow’s milk protein-induced colitis– Inflammatory bowel disease – chronic use of aspirin or nonsteroidal antiinflammatory
drugs, are also associated with iron deficiency.
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CLINICAL MANIFESTATIONS• Iron deficiency anemia (IDA) is a microcytic, hypochromic, and
hypoproductive state.
• The most common presentation of IDA is an otherwise asymptomatic, well nourished infant or child who has a mild to moderate microcytic, hypochromic anemia
• Much less frequent are infants with severe anemia, who present with:– Lethargy– Pallor– Irritability– Cardiomegaly– Poor feeding– Tachypnea.
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• A number of abnormalities of epithelial tissues are described in association with iron deficiency anemia. These include:
– Esophageal webbing– Koilonychias– Glossitis– Angular stomatitis– Gastric atroph
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• Neurodevelopmental – Impaired psychomotor and/or mental development. – cognitive impairment can occur in adolescents. – negatively impact infant social-emotional behavior – may contribute to the development of attention deficit
hyperactivity disorder.
• Exercise capacity
• Pica and pagophagia
• Thrombosis — cerebral vein thrombosis
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Diagnosis
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• Birth -Mean Hb = elevated, but highly variable
• 2 mos –“physiologic” anemia
– -2 SD Hb = 9.4 g/dL
• 6 mos to 24 mos
– -2.5 SD Hb 11.0 g/dL
• American Academy of Pediatrics
–Hb <11.0, Hct < 33% defines anemia
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• For infants up to 24 months
• The most cost effective strategy is a therapeutic trial of iron .
• Ferrous sulfate this is given at 3 mg/kg of elemental iron, given once or twice daily between meals (ie, 3 to 6 mg/kg/day total).
• If four weeks of this treatment produces a hemoglobin rise of greater than 1 gm/dL, this confirms the diagnosis
of iron deficiency.
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• 2 years and adolescence, we suggest slightly more evaluation.
• This is because IDA is somewhat less common in otherwise-healthy children than in infants.
• Therefore, in addition to evaluating CBC (with indices for MCV and RDW), we suggest performing a reticulocyte count and reviewing a blood smear, and screening several stools for occult blood.
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Normal Fe deficiency without anemia
Fe deficiency with mild anemia
Severe Fe deficiency with severe anemia
Marrow reticulo- endothelial iron 2+ to 3+ None None None
Serum iron (SI), µg/dL 60 to 150 60 to 150 <60 <40
Total iron binding capacity (transferrin, TIBC), µg/dL
300 to 360 300 to 390 350 to 400 >410
Transferrin saturation (SI/TIBC), percent 20 to 50 30 <15 <10
Hemoglobin, g/dL Normal Normal 9 to 12 6 to 7
Red cell morphology Normal Normal Normal or slight hypochromia
Hypochromia and microcytosis
Plasma or serum ferritin, ng/mL 40 to 200 <40 <20 <10
Erythrocyte protoporphyrin, ng/mL RBC
30 to 70 30 to 70 >100 100 to 200
Other tissue changes None None None Nail and epithelial changes
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TestExpected value in patients with iron deficiency anemia
Confounding factors
Hemoglobin <11 g/dL Viral infections may cause a transient decrease in hemoglobin
Mean corpuscular volume MCV <70 Thalassemia trait
Red cell distribution width RDW >15 Infection or inflammation, hemolysis
Erythrocyte protoporphyrin >70-80 µg/dL Lead poisoning
Total iron-binding capacity >450 µg/dLLiver disease, inflammation, or hemolysis may lower TIBC; pregnancy or hormonal contraceptives may increase TIBC
Transferrin saturation <12-15 percent Infection or inflammation
Serum ferritin <12 ng/mL Infection or inflammation; liver disease
Transferrin receptor Increased Increased in high turnover states
Serum iron <30 µg/dL Diurnal variation; iron intake; infection or inflammation
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Test Iron deficiency anemia
Alpha/beta thalassemia
Anemia of chronic disease
Hemoglobin
MCV
RDW
Erythrocyte protoporphyrin
Total iron-binding capacity
Transferrin saturation
Serum ferritin
Transferrin receptor
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Microcytic hypochromic red cellsNormal peripheral blood smear
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Treatment
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Treatment• Oral iron therapy is started at a dose of 3 mg/kg of elemental
iron, given once or twice daily. It should be given 30 to 45 minutes before meals or two hours after meals, and only with juice or water, rather than with food or milk.
• <12 months:– iron-fortified formula – A cow’s milk-based formula – Unmodified cow’s milk (non-formula cow’s milk) should not be given
to infants.
• >12 months of age, intake of cow's milk should be limited to less than 20 oz per day and bottle feeding should be discontinued.
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• CBC is reevaluated in 4 weeks when the child is healthy. If the hemoglobin (Hgb) has increased by 1 g/dL, therapy is continued and a CBC is retested every 2 to 3 months until the Hgb reaches the age-adjusted normal range.
• Oral iron is continued for an additional two months after the Hgb reaches the normal range for age.
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Prevention of iron deficiency
• Encourage breastfeeding exclusively for 4-6 MO. • > 4MO an additional source of iron should be added, first as an
iron supplement, then transitioning to iron-fortified infant cereals.
• <12 MO who are not breastfed or are partially breastfed, use only iron-fortified formulas (12 mg of iron per liter).
• 6 MO encourage one feeding per day of foods rich in vitamin C.• > 6 MO pureed meats. • Avoid feeding unmodified (nonformula) cow's milk until age 12
months. • 1-5 y should also consume an adequate amount of iron-
containing foods to meet daily requirements.
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Thank you