As much as 100 ml of fetal blood may remain in the placenta with early clamping of the cord. Cord clamping delayed for only 3 minutes can result in a 58% increase in red cell volume.a similar effect can be achieved by clamping the cord at the placental end, raising the clamp, and allowing gravity to drain the cord depletion of maternal iron has little or no effect on the body iron stores of the newborniron supplementation during pregnancy has no effect on the subsequent development of iron deficiency in the infant, although it may be protective for the mother
A unique disorder termed Bahima disease, described in Uganda, was attributed to the practice of feeding children a diet of cow’s milk almost exclusively
Iron deficiency anemia
Iron Deficiency Anemia
PrevalenceNFHS-3 : 7/10 children aged 6-59 months areanemic. (3%-severely anemic, 40%-moderateanemic, 26%- mildly anemic)65% in preschool childrenAdolescent period -50%Iron deficiency affects 2170 millionworldwide, and 1200 million of them anemic with90% of affected are in developing countries
Total Body IronFull-term infants - approximately 75 mg/kgbody weight of ironAdult males – 50 mg/kg and females – 35mg/kgCan be divided into functional(80%) andstorage(20%) compartments
Iron BalanceMostly lost from shedding of epithelial cells inG.I.Tract.Total average daily loss of iron has beenestimated at ∼1.0 mg in normal adult men andnonmenstruating women.20% of heme iron (in contrast to 1% to 2% ofnonheme iron) is absorbable.
Iron balance is primarily, if notexclusively, achieved by controlof absorption rather than bycontrol of excretion
Role of HepcidinSynthesized and released from the liverInhibits iron transfer from the enterocyte toplasmaRegulator of iron absorptionAlso suppresses iron release frommacrophagesImportant role in anemia of chronic diseasesand hemochromatosis
Very high levels of hepcidin inAnemia of chronic diseases andinappropriately low levels ofhepcidin in hemochromatosis
EtiologyLate manifestation of prolonged negativeiron balanceAs a result of major blood lossIncreased physiologic need for iron
DietBody iron concentration in normal neonates averages∼75 to 100 mg/kg weightPremature infants are at higher risk of iron deficiencyDelayed cord clampingThe fetus is an “effective scavenger of maternal iron”Normal term infant must acquire 135 to 200 mg of ironduring the first year of life. A premature infant mayrequire as much as 350 mg in the same period
Iron stores in the infant are typically depleted by 4 to6 months of age Iron intake of 1 mg/kg/day is recommended for full-term infants, 2 to 4 mg/kg/day for preterm infants Deficiency is relatively uncommon in the first 6months of life in infants exclusively fed breast milk Cow’s milk should not be given to infants <1 year ofage
Blood loss• Lesions of the gastrointestinal (GI) tract - pepticulcer, Meckel diverticulum, polyp, hemangioma, orinflammatory bowel disease• Heat-labile protein in whole bovine milk• Chronic diarrhea and rarely with pulmonaryhemosiderosis• Parasitic infestations and H.pylori infection
Clinical FeaturesPallor, anorexia and irritabilityHyperdynamic circulationSkin and nail changesPica - 70-80% of Children
Consequences of Iron DeficiencyLong term mental impairmentImpaired immune functionPoor physical performanceFebrile seizures, temper tantrums, breathholding spells, restless leg syndrome.
Lab evaluationHemoglobin, HematocritRed cell indicesReticulocyte hemoglobin content (CHr)Mentzer index and RDWSerum ferritinSerum iron, TIBC, Transferrin saturationStainable iron in bone marrowStool for occult blood
Treatment Depends on severity and associated complications 3-6 mg/kg of elemental iron in 3 divided doses isadequate Ferrous sulfate is 20% elemental iron by weightand is ideally given between meals with juice Addition of folic acid and vitamin C (200mg), vitamin B12.
Parenteral Iron Should usually be avoided Severe side effects on oral therapy, noncompliance orgastrointestinal bleeding Total dose infusion (only in hospital) Iron dextran or sucrose complex - most commonly used Iron required=wt (kg)x 2.3x (15-patient hemoglobin)+500-1000 mg
Response to Iron therapyTIME AFTER IRON ADMINISTRATION RESPONSE12-24 hrReplacement of intracellular ironenzymes; subjective improvement;decreased irritability; increasedappetite36-48 hrInitial bone marrow response;erythroid hyperplasia48-72 hr Reticulocytosis, peaking at 5-7 days4-30 days Increase in hemoglobin level1-3 months Repletion of stores
Nonresponders to Iron therapy Incorrect dose or medication Malabsorption of administered iron Ongoing blood loss including gastrointestinal, menstrual, and pulmonary Concurrent infection or inflammatory disorder inhibiting the response toiron Concurrent vitamin B12 or folate deficiency Diagnosis other than iron deficiency • Thalassemias • Anemia of chronic disease • Lead poisoning • Sickle thalassemias, hemoglobin SC disease • Rare microcytic anemias
Prevention• Medicinal iron supplementation• Dietary modificationBalance between inhibitors and promotersVitamin C rich foodsFermentation and germination• Food fortificationDouble fortified salt
Weekly Iron and Folic acidSupplementation (WIFS)