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Iron deficiency anemia

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Iron deficiency anemia

  1. 1. Anemia, Iron deficiency anemia Dr. Kalpana Malla MD Pediatrics Manipal Teaching Hospital Download more documents and slide shows on The Medical Post [ www.themedicalpost.net ]
  2. 2. ANEMIA
  3. 3. What is Anemia?• Reduction of the red blood cell (RBC) volume or hemoglobin concentration below reference level for the age and sex of the individual• Hb < - 2SD or 95th centile for age and sex
  4. 4. Anemia BasicsAll anemias are either due to….1. Ineffective RBC production or2. Accelerated destruction of the RBC
  5. 5. Classification• By RBC morphology and By Etiological factors responsible for anemia
  6. 6. Microcytic hypochromic anemia1. Iron deficiency anemia – nutritional, - posthemohragic2. Ineffective Erythropoiesis - hemoglobinopathies, Thalassemia - Lead poisoning, Sideroblastic anemia - Cu deficiency, Pyridoxine deficiency -Chronic ds - infection, inflammations , renal ds
  7. 7. Macrocytic anemia• Megaloblastic Erythropoiesisa) Nutritional - Folate deficiency, B12 deficiencyb) Toxic – Treatment with antifolate compound – methotrexate,, and drugs that inhibit DNA replication – zidovudine, phenytoinc) Congenital disorders of DNA synthesis like Orotic aciduria etc.d) Malabsorption - liver ds
  8. 8. Macrocytic anemia Non - Megaloblastic Erythropoiesisa) Chronic hemolytic anemiab) Liver dsc) Hypothyroidismd) Diamond blackfan syndrome
  9. 9. Normocytic, Normochromic anemia1. Impaired cell production (low reticulocyte count) - aplastic anemia - pure red cell aplasia - physiological anemia of infancy - infections - Systemic diseases like endocrinal, renal and hepatic diseases - bone marrow replacement – leukemia, tumors, storage ds, myelofibrosis, osteopetrosis2 Hemolytic anemia ( reticulocyte count high)
  10. 10. DIMORPHIC ANEMIA• When two causes of anemia act simultaneously, e.g : macrocytic hypochromic due to hookworm infestation leading to deficiency of both iron and vitamin B12 or folic acid• following a blood transfusion
  11. 11. ETIOLOGICAL CLASSIFICATION OF ANEMIA• Blood loss Acute Chronic• Decreased iron assimilation - Nutritional deficiency - Hypoplastic or aplastic anemia - Bone marrow infiltration like leukemia & other malignancies, - Myelodysplastic syndrome - Dyserythropoietic anemia
  12. 12. ETIOLOGICAL CLASSIFICATION OF ANEMIA• Increased physiologic requirement- Extracorpscular - - Alloimmune & isoimmune hemolytic anemia - Microangiopathic anemias - Infections - Hypersplenism
  13. 13. ETIOLOGICAL CLASSIFICATION OF ANEMIA- Intracorpsular defect – Red cell membranopathy i.e. congenital spherocytosis,elliptocytosis – Hemoglobinopathy like HbS, C,D,E etc. Thalassemia syndrome – RBC enzymopathies like G6PD deficiency, PK deficiency etc.
  14. 14. Follow-up• Re-check CBC 4-6 weeks (to confirm response)• Continue iron 3-4 months (to replace stores)• If no improvement on adequate iron therapy, consider evaluating the child for lead poisoning or thalassemia
  15. 15. Differential of Anemia Hgb, indices, retic count and smear Inadequate response (RPI<2) Adequate response (RPI>3) r/o blood loss/hemolytic disHypochromic, microcytic Normochromic,normocytic Macrocytic hemoglobinopathy iron def chronic dis B12/folate def enzymopathy thalssemia Ca/BM failure Liver disease membranopathy chronic disease Transient erythroblastopenia Down Syndrome extrinsic factors of childhood (DIC,HUS,TTP) lead poisoning Renal disease Drugs (etoh) Immune Hemolytic anemia
  17. 17. IDA• Most common cause of anemia worldwide• Most important cause of iron deficiency anemia is parasitic infection - hookworms, whipworms and roundworms
  18. 18. GENERAL FEATURES Newborn contains 0.5g of iron, adult contains 5g A diet containing 8–10mg of iron daily is necessary for optimal nutrition 1mg of iron must be absorbed each day - Absorbed in the proximal small intestine Absorbed 2-3 times more efficiently from human milk than from cows milk
  19. 19. Iron sources:• Meat• Liver• Kidney• Egg-yolk• Green vegetables• Fruits**** Cow’s milk- poor source of iron
  20. 20. Iron metabolism:Distribution of body iron: (adults) - Hemoglobin: 2.3 gm - Storage (ferritin / haemosiderin) : 1.0 gm - Non-available tissue iron: 0.5 gm - Transport iron: 3-4 mg - Total : ~5 gm
  21. 21. Iron absorption: Depends upon – Body stores of iron - Rate of erythropoiesis - Iron needs of the body Increased absorption in presence of: - vitamin C - fruit juices - lactose - amino acids- cystine, lysine , histidine, - gastric Hcl Decreased absorption : - phytates - tannic acid - calcium salts - phosphates
  22. 22. Iron Metabolism: Figure 16-8: Iron metabolism
  23. 23. Pathogenesis of IDA:Increased physiological demand: - growing children (6-24 months) - adolescence - women during reproductive agesPathological blood loss: -chronic lossInadequate intake of diets rich in iron: -nutritional deficiency -decreased absorption- gastroenterostomy/ tropical sprue/ coeliac disease
  24. 24. • High Hb conc of the newborn falls during the first 2– 3 mo - considerable iron is stored - usually sufficient for blood formation in the first 6–9 mo of life in term
  25. 25. ETIOLOGY• The most important cause world-wide is infestation with parasitic worms (hookworms- suck 0.03- 0.2 ml of blood per worm /day ),whipworms, roundworms• Dietary insufficiency• Malabsorption
  26. 26. ETIOLOGY• Chronic blood loss - occult bleeding : peptic ulcer, Meckel diverticulum, polyp, hemangioma, inflammatory bowel disease, Intravascular hemolysis and hemoglobinuria• Chronic diarrhea• Milk allergy
  27. 27. Risk factors for IDA• Demograpghic – Eldery, Teenager, Female• Dieatary – low Iron, low Vit C, excess phytate,tea coffee,• Social and physical – poverty,alcohol abuse,GIT ds
  28. 28. CLINICAL FEATURESPallor is the most important signLook for pallor : FACE, nails, palms, conj, mucus membranesPagophagia (pica for ice) / picaAnxiety , Poor appetiteBelow 5g/dL: irritability and anorexia are prominentTachycardia and systolic murmurs- dyspnea , Palpitations
  29. 29. CLINICAL FEATURES• Hair loss and lightheadedness• Fainting• Sleepiness, Tinnitus• Mouth ulcers, Glossitis ,Angular cheilitis• Constipation• Depression, Twitching muscles, Tingling, numbness or burning sensations
  30. 30. CLINICAL FEATURES• Koilonychia (spoon-shaped nails) ,• Platynychia• Weak,brittle nails• Pruritus• Dysphagia due to formation of esophageal webs (Plummer-vinson syndrome
  31. 31. Koilonychia - spoon shaped nail
  32. 32. CLINICAL FEATURESNeurologic and intellectual functionAffects attention span, alertness,Verbal learning and memoryMonoamine oxidase (MAO), an iron dependent enzyme, has a crucial role in neurochemical reactions in the CNSbreath-holding spells
  33. 33. Response to low Hb:First: Tissue iron stores represented by bone marrow hemosiderin disappear Serum ferritin decreasesNext: Serum iron level decreases Serum transferrin,S. iron-binding capacity of the - increases Percent saturation (transferrin saturation) falls below normal Free erythrocyte protoporphyrins (FEP) accumulates
  34. 34. Response to low Hb:Later:Microcytosis, hypochromia, poikilocytosis,and increased RBC distribution width (RDW)
  35. 35. Diagnosis - LABORATORY INVESTIGATIONS 1.complete blood count (CBC) - High RBC distribution width (RDW) - reflecting an increased variability in the size of red blood cells (RBCs). - A low MCV,MCH and MCHC2. Hemoglobin (Hb)&hematocrit (Hct) value – low3. Reticulocyte - normal or moderately elevated
  36. 36. Diagnosis - LABORATORY INVESTIGATIONS3.Peripheral blood smear – microcytic hypochromic anemia, target cells, hypochromic pencil-shaped cells, and occasionally small numbers of nucleated RBC• Thrombocytosis -activate thrombopoietin receptors in precursor cells which make platelets
  37. 37. LABORATORY INVESTIGATIONS4. Diagnostic tests –- Serum ferritin- low- Serum iron - low- Serum transferrin -elevated- Total iron binding capacity (TIBC) - high5.Stool for occult blood6.Stool R/M/E - hookworm and whipworm
  38. 38. LABORATORY INVESTIGATIONS• Ratio of serum iron to TIBC (called iron saturation or transferrin saturation index - is the most specific indicator of iron deficiency - < 5% - indicates iron deficiency
  39. 39. DiagnosisLABORATORY INVESTIGATIONS Gold standard• Bone marrow aspiration, with the marrow stained for iron -Bone marrow is hypercellular, with erythroid hyperplasia• Leukocytes and megakaryocytes are normal• No stainable iron in marrow reticulum cells
  40. 40. TREATMENT• Oral administration - ferrous salts (sulfate, gluconate, fumarate) -4–6mg/kg of elemental iron• Consumption of milk should be limited• Blood loss from intolerance to cows milk proteins is reduced• The amount of iron-rich foods is increased
  41. 41. Oral iron failure?• Incorrect diagnosis (eg, thalassemia)• Patient is not taking the medication• Not absorbed (enteric coated?) malabsorption syndromes gastrectomy/celiac disease• Rapid iron loss?• Anemia of chronic disease-impairs bone marrow response
  42. 42. TREATMENT• Parenteral iron preparation (iron dextran) : Intolerance to oral iron, severe gastrointestinal complaints• Packed or sedimented RBCs : with Hb values < 4g/dL• congestive heart failure: fresh-packed RBCs should be considered
  43. 43. RESPONSES TO IRON THERAPY12–24 hr• Replacement of intracellular iron enzymes; subjective improvement; decreased irritability; increased Appetite36–48 hr• Initial bone marrow response; erythroid hyperplasia48–72 hr• Reticulocytosis, peaking at 5–7 days4–30 days• Increase in hemoglobin level1–3 mo• Repletion of stores
  44. 44. Thank youDownload more documents and slide shows on The Medical Post [ www.themedicalpost.net ]