Childhood ida2010

Khorfakkan Scientific anemia Day 1 st May 2010 Childhood Iron Deficiency Anemia Prof. Dr.Saad S Al-Ani Senior Pediatric Consultant Head of Pediatric Khorfakkan Hospital

Typical Scenario
* 18 month old child
brought in by mom for
check up
Healthy, URTI a few
weeks ago (in daycare)
Picky eater, but drinks
lots of milk
* Growing well, pudgy
Grand-mother thought
he was a bit pale

Physical exam * Pale, chubby, wt at 95%, ht at 60% *HR 140, RR 20, BP 90/50, SPO2 97% *Conjunctiva and mucous membranes slightly pale *Chest clear *No organomegaly, no adenopathy

Lab values * CBC Hgb 5.4, Plt 735, WBC 8.5 with normal diff *MCV, MCHC decreased *Retic count low *Smear Microcytic, hypochromic cells *Ferritin 

Microcytic, hypochromic cells

Why is it important to know how to diagnose and treat IDA?

30% of the world’s population has anemia, 1 billion have IDA Global prevalence is 53.6% in preschool children ANEMIA – A PUBLIC HEALTH PROBLEM McLean E, Egli I, Cogswell M, de Benoist B,Wojdyla D. Worldwide prevalence of anemia in preschool aged children, pregnant women and non-pregnant women of reproductive age .Ch1:1-12.In: Kraemer K, ed. Nutritional Anemia. Sight and Life press. Basel, Switzerland. 2007 .

Anemia is a severe public health problem in Africa, Asia, Latin America and the Caribbean ANEMIA – A PUBLIC HEALTH PROBLEM World Health Organization (WHO). Nutrition. Geneva: WHO, www. who.int /nutrition/en : WHO 2007

Iron deficiency identified as one of ten most serious risk in countries with high infant and adult mortalities ANEMIA – A PUBLIC HEALTH PROBLEM World Health Organization. The world health report 2002: reducing risks, promoting healthy life. Geneva, Switzerland: World Health Organization, 2002.

Anemia as a public health problem by country; preschool children

Anemia prevalence and number of Individuals affected in preschool- age children in each WHO region

~ 2 billion anemic
Severe anemia ->high mortality
Mild to moderate anemia
Impairs child development
Decreases work capacity
Iron Deficiency/ Anemia: A Major Global Problem

Conceptual diagram of the relationship between iron deficiency and anemia in a hypothetical population
Yip R. Iron nutritional status defined. In: Filer IJ, ed . Dietary Iron: birth to two years. New York, Raven Press, 1989:19-36.

Definition
Anemia is defined as:
A decrease in the concentration
of circulating red blood cells or
in the hemoglobin concentration
and a concomitant impaired
capacity to transport oxygen.
ANEMIA McLean E, Cogswell M, Egli I, Wojdyla D, de Benoist B.Worldwide prevalence of anaemia, WHO Vitamin and Mineral Nutrition Information System, 1993-2005.Public Health Nutr. 2009 Apr; 12(4):444-54. Epub 2008 May 23.

WHO Diagnosis
Hemoglobin
below 11gm/dl
in pre school children.
ANEMIA UNICEF/UNU/WHO. Iron deficiency anemia: assessment, prevention and control. A guide for programme managers.WHO/NHD,2001 [report no.01.3]

One of the 15 leading causes of global disease burden
IRON DEFICIENCY ANEMIA Boccio JR, Iyengar V. Iron deficiency: causes, consequences, and strategies to overcome this nutritional problem. Biol Trace Elem Res. 2003 Jul; 94(1):1-32. Review Global picture
25 Million DALYs lost due to IDA
Stoltzfus R., Stiefel H., Iron deficiency and the global burden on disease. Symposium: Integrating programs to move iron deficiency and anemia control forward. Marrakesch, Morocco, 6 February 2003

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
Iron deficiency As defined by the National Health and Nutrition Examination Survey (NHANES)

Prelatent
reduction in iron stores
without reduced serum
iron levels
Latent
iron stores are exhausted,
but the blood hemoglobin
level remains normal
Iron deficiency anemia
blood hemoglobin
concentration falls below
the lower limit of normal
IRON DEFICENCY STAGES

Formulation of
hemoglobin
Binding O2 to RBC
and transport
Formulation of
cytochrome myoglobin
Regulation of Body
temperature
Functions of Iron

Muscle activity
Catecholamine
metabolism
Immune system
Brain Development
& function
Thyroid function
Functions of Iron Cont.

Iron Concentration In Brain 25% 50% 75% 100% Birth 2 Years 10 Years Adult Human Maximum Myelination

Iron deficiency anemia occurs when iron deficiency is severe enough to reduce hemoglobin levels below normal.
ANEMIA
NHANES 1999-2000

Normal values Harriet Lane Handbook, The John Hopkins Hospital,15th edition 81 (70+ age per yr) 36 (33) 12.5 (11.0) > 6 Months 76 (68) 36 (31) 12.6 (11.0) 6 Months 95 (84) 35 (28) 11.2 (9.4) 2 Months 101 (91) 44 (33) 13.9 (10.7) 1 Month 108 (96) 51 (42) 16.5 (13.5) Newborn MCV Mean/ (-2SD) HCT% Mean/ (-2SD) Hgb Mean/ (-2SD) AGE

http://www.cdc.gov/hemochromatosis/training/ pathophysiology/iron_cycle_popup.htm Iron cycle

Mechanism of development of Anemia Normal Iron deficiency anemia

Factors Contribute To the Development Of Anemia http://www.caribou.bc.ca/schs/medtech/rice/IronDeficiency.html

Iron deficiency Anemia http://www.caribou.bc.ca/schs/medtech/rice/IronDeficiency.html
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

Iron deficiency Anemia (cont.)
Dietary deficiency
Increased demand (growth)
Impaired absorption
Blood loss ( e.g. )
- gut problems
- lung
- nose
- kidney
- menstrual problems
- trauma
Causes

Iron deficiency Anemia (cont.)
Pallor is the most important sign
Mild to Moderate iron deficiency
( hemoglobin levels of 6 -10 g/dL)
few symptoms of anemia;
irritable, Pagophagia
Severe iron deficiency
( hemoglobin levels of 6 -10 g/dL)
Irritability , Anorexia, Tachycardia,
Cardiac dilation, Systolic murmurs
Clinical Manifestation

Iron deficiency Anemia (cont.) Clinical Manifestation (Cont.)
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

Iron deficiency Anemia (cont.) Clinical Manifestation (Cont.) Decreased cognitive performance often accompanies iron deficiency and iron deficiency anemia Murray-Kolb LE, Beard JL. Iron treatment normalizes cognitive functioning in young women. Am J Clin Nutr. 2007; 85:778-787.

Iron deficiency Anemia (cont.) Clinical Manifestation (Cont.) Koilonychia: "spoon nails” Iron deficiency anemia

Iron deficiency Anemia (cont.) Clinical Manifestation (Cont.) Smooth, bald, burning tongue; Iron deficiency anemia

Iron deficiency Anemia (cont.) Clinical Manifestation (Cont.) Angular Cheilosis or Stomatitis

Iron deficiency Anemia (cont.) Bone marrow ABSENT IRON STORES IN BONE MARROW IN IRON DEFICIENCY Normal control Iron deficiency

Laboratory Findings
Prelatent
Hgb (N), MCV (N), iron absorption (  ), transferrin saturation (N), serum ferritin (  ), marrow iron (  )
Latent
Hgb (N), MCV (N), TIBC (  ), serum ferritin (  ), transfe r rin saturation (  ), marrow iron (absent)
Iron deficiency anemia
Hgb (  ), MCV (  ), TIBC (  ), serum ferritin (  ), transfer r in saturation (  ), marrow iron (absent)

Laboratory Findings ( Cont.)
With increasing deficiency ,RBCs become deformed
and misshapen and present characteristic :
- Microcytosis
- Hypochromia
- Poikilocytosis
- Increased RBC distribution width (RDW)
Reticulocyte percentage
may be normal or moderately elevated
Nucleated RBCs occasionally seen
Thrombocytosis (some time)
Normal white blood cells

Laboratory Findings ( Cont.)
Additional diagnostic tests
- Free erythrocyte protoporphyrin
(elevated)
- Serum ferritin (decreased)
- Serum iron (decreased)
- Iron binding capacity (increased)
- Iron saturation (decreased)

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

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)
( Cont.)

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)
( Cont.)

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 irondeficiency anemia
and anemia of chronic disease
( Cont.)

IRON DEFICIENCY versus ACD Other hypochromic microcytic anemias Serum Iron Transferrin Ferritin Iron Deficiency ACD

PRINCIPLES OF TREATMENT 1.Use oral iron 2.Replace iron deficit in total 3.Establish and treat the cause

PRINCIPLES OF TREATMENT 4.The therapeutic dose should be calculated in terms of elemental iron 5. A daily total of 4 -6 mg/kg of elemental iron in three divided doses provides an optimal amount of iron 6.A parenteral iron preparation (iron dextran) is an effective form of iron ( Cont.)

PRINCIPLES OF TREATMENT ( Cont.) The regular response of iron-deficiency anemia to adequate amounts of iron is an important diagnostic and therapeutic features.

PRINCIPLES OF TREATMENT ( Cont.) Oral administration of simple ferrous salts ( sulfate, gluconate, fumartate) provides inexpensive and satisfactory therapy

Elemental iron (EI) in various forms of iron tablets 1.Ferrous sulfate (20%EI) (300 mg tablets) 60 mg 2.Ferrous gluconate (12 %EI) (300 mg tablets) 34 mg 3.Ferrous fumarate (33 %EI)(200 mg tablets) 66 mg

Parenteral therapy
indications
poor compliance
severe bowel disease
intolerance of oral iron
chronic hemorrhage
acute diarrhea disorder

Parenteral therapy Iron dextran : (IM-IV) 50 mg iron/mL Low and high molecular weight Ferric gluconate complex (IV) less incidence of allergic reactions Iron sucrose : (IV) safe even with sensitivity to iron dextran

Parenteral therapy Ferumoxytol : safe and effective as a rapid intravenous infusion up to 510 mg in patients with chronic kidney disease and on dialysis. Ferric carboxymaltose : (IV) given at single doses of up to 1000 mg iron per week over of 15 minutes ( Cont.)

Blood transfusion
Is indicated only when
1.Anemia is very severe
2.Superimposed infection may interfere with the response
Packed or sedimented RBCs should be administered slowly
In severely anemic children with hemoglobin values less than 4 g/dL
should be given only
2 -3 mL/kg of packed cells at any one time

Responses to iron therapy in irondeficiency anemia Repletion of stores 1 -3 mo Increase in hemoglobin level 4 -30 days Reticulocytosis, peak at 5 -7 days 48 -72 hr Initial bone marrow response 36 -48 hr Subjective improvement; decreased irritability, increased appetite 12 -24 hr Response Time after Iron Administration

Failure of iron therapy
occur when :
A child does not receive the
prescribed medication
2. Iron is given in a form that is
poorly absorbed
3. There is continuing unrecognized blood loss such as :
* intestinal or pulmonary loss
* loss with menstrual periods
4. An incorrect original diagnosis

Short term Prevention of IDA In infancy
Avoid gestational ID
Try to prevent premature
delivery and low birth weight
Increase birth spacing
Delay pregnancy beyond
teens
Delay ligation of umbilical
cord (by 30-60 seconds)

Short term prevention of IDA In children and adolescents
Avoid gestational ID
Try to prevent premature
delivery and low birth weight
Increase birth spacing
Delay pregnancy beyond
teens
Delay ligation of umbilical
cord (by 30-60 seconds)

Sustainable approaches to elimination of micronutrient deficiency e.g. iron
Iron fortification of foods, foods in the target group:
Foods consumed regularly
Consumed in sufficient
quantities
Consumed in stable amounts
Centrally processed foods
Foods that are easy to fortify

Iron obtained from animal products is much more easily absorbed by the body than iron from plant sources ,

Home Message
Anemia is a sign , not a disease.
Anemias are a dynamic process .
Its never normal to be anemic.
The diagnosis of iron deficiency anemia mandates further work-up

Good to have you with us, Farquhar. We could do with some fresh blood in this place.'

Childhood ida2010

by saad alani

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