2. OBJECTIVE
• Introduction
• Prevalence
• Iron balance
• Requirements
• Causes
• Clinical manifestations
• Diagnosis
• Treatment
• Prevention of iron deficiency
DR GRK DSMCH 2
3. Definition
Anemia is defined as:
A decrease in the concentration of circulating
red blood cells or in the haemoglobin
concentration and a concomitant impaired
capacity to transport oxygen
WHO Diagnosis ANEMIA Haemoglobin
below 11gm/dl in pre school children.
Iron deficiency (ID) is the most common
nutritional deficiency in children.
• 50% of adolescent girls are anaemic.
DR GRK DSMCH 3
4. Functions of Iron
Formulation of haemoglobin
Binding O2 to RBC and transport
Formulation of cytochrome myoglobin
Electron transport
DNA synthesis
Catecholamine metabolism
Immune system
Brain Development & function
Thyroid function
DR GRK DSMCH 4
5. IRON BALANCE
• 75% bound in heme proteins (haemoglobin 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.
DR GRK DSMCH 5
7. Intestinal iron absorption is a function of three principal
factors:
– body iron stores (transferrin and ferritin)
– erythropoietin 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)
• Zinc, acidity, 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.
DR GRK DSMCH 7
9. 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
DR GRK DSMCH 9
10. 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
DR GRK DSMCH 10
11. 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
Iron in cows milk low bioavailability
Ca competes for iron absorption
Occult blood loss secondary to cow's milk protein-
induced colitis
PICA- lead poisoning, helminthiasis
DR GRK DSMCH 11
12. Gastrointestinal disease
• Gastrointestinal malabsorption of iron:
– Active celiac disease
– Crohn’s disease
– Giardiasis, Malaria & Hook Worm
– 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 NSAIDs
DR GRK DSMCH 12
15. Dietary iron deficiency is the usual cause
• Iron def. is common in children 9mo-3yr
•Infants less than 6 months generally do not
develop iron def.
•Iron def. anemia in a child over 3yr should
prompt consideration of occult blood loss
DR GRK DSMCH 15
16. CLINICAL MANIFESTATIONS
• Much less frequent are infants with severe anemia,
who present with:
– Lethargy, anorexia
– Pallor
– Irritability, leg cramps
– Cardiomegaly, splenomegaly
– Poor feeding
– Tachypnea
Learning disability( dopaminergic receptors opioid
receptors)
DR GRK DSMCH 16
17. Iron deficiency may have effects on neurologic and
intellectual functions
Iron – deficiency anemia and even iron deficiency
with out anemia affect :
*Attention span
*Alertness
*Learning
DR GRK DSMCH 17
18. A number of abnormalities of epithelial tissues are
described in association with iron deficiency
anemia.
These include:
– Esophageal webbing
– Koilonychias
– Glossitis
– Angular stomatitis
– Gastric atrophy
DR GRK DSMCH 18
19. Causes
•Dietary deficiency
•Increased demand (growth)
•Impaired absorption
•Blood loss (e.g.)
- gut problems
- lung
- nose
- kidney
- menstrual problems
- trauma DR GRK DSMCH 19
21. Is an abnormal value for at least two of three
laboratory indicators of iron status:
1. Serum ferritin
2. Transferrin saturation
3. Free erythrocyte protoporphyrin
DR GRK DSMCH 21
22. Laboratory Findings
Prelatent
Hgb (N), MCV (N), iron absorption (), transferrin
saturation (N), serum ferritin (), marrow iron ()
Latent
Hgb (N), MCV (N), TIBC (), serum ferritin (),
transferrin saturation (), marrow iron (absent)
Iron deficiency anemia
Hgb (), MCV (), TIBC (), serum ferritin (),
transferrin saturation (), marrow iron (absent)
DR GRK DSMCH 22
23. Laboratory Findings (Cont.)
•With increasing deficiency ,RBCs become deformed
and misshapen and present characteristic :
- Microcytosis
- Hypochromia
- Aniso-Poikilocytosis
- Increased RBC distribution width (RDW)
- MCV,MCHC REDUCED
• Reticulocyte percentage may be normal or
moderately elevated
• Nucleated RBCs occasionally seen
• Thrombocytosis (?)
• Normal white blood cells
DR GRK DSMCH 23
24. Laboratory Findings (Cont.)
•Additional diagnostic tests
- Free erythrocyte protoporphyrin (elevated)
precedes anemia
- Serum ferritin (decreased) occurs early in
proportion to iron stores, may falsely elevated in
acute infection
- Serum iron (decreased)
- Iron binding capacity (increased)
- Transferrin Iron saturation (decreased < 16%)
DR GRK DSMCH 24
25. Differential Diagnosis
Other hypochromic microcytic anemias
•1.ß-Thalassemia trait
* mild microcytic anemia
* elevated levels of hemoglobin A2
and/or fetal hemoglobin concentration
* Serum iron, total iron-binding capacity
(transferrin) and ferritin are normal
DR GRK DSMCH 25
26. • 2. a-Thalassemia trait
• * presence of familial hypochromic
• microcytic anemia
• * normal results of iron studies
• * normal levels of Hgb A2 and Hgb F
• *In new born ,3 -10% hemoglobin
• Barts (gamma 4)
DR GRK DSMCH 26
27. 3. Hgb H disease
* a form of a-Thalassemia results
From deletion of three of the four a-globin
Genes * hypochromia and microcytosis
* a mild hemolytic component from
instability of the ß-chian tetramers
(Hgb H)
DR GRK DSMCH 27
28. 4. The anemia of chronic disease (ACD)
* Elevated FPR
* Coarse basophilic stippling of the RBC is frequently
prominent
* Elevations of blood lead. FEP, and urinary
coproporphyrin levels
Serum transferrin receptor (TIR) level
is useful in distinction between iron- deficiency anemia
and anemia of chronic disease
DR GRK DSMCH 28
35. Treatment
• Oral iron therapy is started at a dose of 3-6 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.
DR GRK DSMCH 35
36. • Sulphate(20%), gluconate(12%), fumarate(33%)
• GE side effects-nausea, epigastric discomfort,
vomiting, constipation & diarrhoea
• Reticulocyte count is expected to rise with in 3-4
days after therapy
• Iron continued for 4-6 months to replenish stores
after correction of anemia
DR GRK DSMCH 36
38. 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.
DR GRK DSMCH 38
39. Iron non responders
• Poor compliance
• Enteric coated iron preparations
• H2 Blockers, PPI (achlorohydria)
• Food & drug interaction
• Hemolytic anemia
• Malabsorption –celiac D, giardiasis, H.pylori
infection
• Ongoing blood loss
• Sideroblastic anemia
DR GRK DSMCH 39
40. Parental iron
• Intolerance to oral iron
• Malabsorption
• Ongoing blood loss
• IV> IM
• Iron sucrose for IBD, ESRD, Haemodialysis
• Dose 1-3 mg/kg in 150 ml NS
DR GRK DSMCH 40
41. Blood transfusion
• PCV indicated in
• Acute severe hemorrhage
• Anemia with CCF
• Preoperative
DR GRK DSMCH 41
42. 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.
DR GRK DSMCH 42
