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Childhood ida2010

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Iron deficiency anemia , presentation , diagnosis ,management

Iron deficiency anemia , presentation , diagnosis ,management


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  • 1. 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
  • 2. 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
  • 3. 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
  • 4. 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 
  • 5. Microcytic, hypochromic cells
  • 6. Why is it important to know how to diagnose and treat IDA?
  • 7. 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 .
  • 8. 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
  • 9. 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.
  • 10. Anemia as a public health problem by country; preschool children
  • 11. Anemia prevalence and number of Individuals affected in preschool- age children in each WHO region
  • 12.
    • ~ 2 billion anemic
    • Severe anemia ->high mortality
    • Mild to moderate anemia
      • Impairs child development
      • Decreases work capacity
    Iron Deficiency/ Anemia: A Major Global Problem
  • 13. 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.
  • 14.
    • 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.
  • 15.
    • 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]
  • 16.
    • 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
  • 17.
    • 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)
  • 18.
    • 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
  • 19.
    • Formulation of
    • hemoglobin
    • Binding O2 to RBC
    • and transport
    • Formulation of
    • cytochrome myoglobin
    • Regulation of Body
    • temperature
    Functions of Iron
  • 20.
    • Muscle activity
    • Catecholamine
    • metabolism
    • Immune system
    • Brain Development
    • & function
    • Thyroid function
    Functions of Iron Cont.
  • 21. Iron Concentration In Brain 25% 50% 75% 100% Birth 2 Years 10 Years Adult Human Maximum Myelination
  • 22.
    • Iron deficiency anemia occurs when iron deficiency is severe enough to reduce hemoglobin levels below normal.
    ANEMIA
            • NHANES 1999-2000
  • 23. 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
  • 24. http://www.cdc.gov/hemochromatosis/training/ pathophysiology/iron_cycle_popup.htm Iron cycle
  • 25. Mechanism of development of Anemia Normal Iron deficiency anemia
  • 26. Factors Contribute To the Development Of Anemia http://www.caribou.bc.ca/schs/medtech/rice/IronDeficiency.html
  • 27. 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
  • 28. Iron deficiency Anemia (cont.)
          • Dietary deficiency
      • Increased demand (growth)
      • Impaired absorption
      • Blood loss ( e.g. )
        • - gut problems
        • - lung
        • - nose
        • - kidney
        • - menstrual problems
        • - trauma
    Causes
  • 29. 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
  • 30. 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
  • 31. 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.
  • 32. Iron deficiency Anemia (cont.) Clinical Manifestation (Cont.) Koilonychia: "spoon nails” Iron deficiency anemia
  • 33. Iron deficiency Anemia (cont.) Clinical Manifestation (Cont.) Smooth, bald, burning tongue; Iron deficiency anemia
  • 34. Iron deficiency Anemia (cont.) Clinical Manifestation (Cont.) Angular Cheilosis or Stomatitis
  • 35. Iron deficiency Anemia (cont.) Bone marrow ABSENT IRON STORES IN BONE MARROW IN IRON DEFICIENCY Normal control Iron deficiency
  • 36. 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)
  • 37. 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
  • 38. Laboratory Findings ( Cont.)
    • Additional diagnostic tests
      • - Free erythrocyte protoporphyrin
      • (elevated)
      • - Serum ferritin (decreased)
      • - Serum iron (decreased)
      • - Iron binding capacity (increased)
      • - Iron saturation (decreased)
  • 39. 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
  • 40. Differential Diagnosis Other hypochromic microcytic anemias
    • 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.)
  • 41. Differential Diagnosis Other hypochromic microcytic anemias
    • 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.)
  • 42. Differential Diagnosis Other hypochromic microcytic anemias
    • 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
    ( Cont.)
  • 43. IRON DEFICIENCY versus ACD Other hypochromic microcytic anemias Serum Iron Transferrin Ferritin Iron Deficiency ACD
  • 44. PRINCIPLES OF TREATMENT 1.Use oral iron 2.Replace iron deficit in total 3.Establish and treat the cause
  • 45. 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.)
  • 46. PRINCIPLES OF TREATMENT ( Cont.) The regular response of iron-deficiency anemia to adequate amounts of iron is an important diagnostic and therapeutic features.
  • 47. PRINCIPLES OF TREATMENT ( Cont.) Oral administration of simple ferrous salts ( sulfate, gluconate, fumartate) provides inexpensive and satisfactory therapy
  • 48. 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
  • 49. Parenteral therapy
      • indications
        • poor compliance
        • severe bowel disease
        • intolerance of oral iron
        • chronic hemorrhage
        • acute diarrhea disorder
  • 50. 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
  • 51. 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.)
  • 52. 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
  • 53. Responses to iron therapy in iron- deficiency 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
  • 54. 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
  • 55. 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)
  • 56. 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)
  • 57. 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
  • 58. Iron obtained from animal products is much more easily absorbed by the body than iron from plant sources ,
  • 59. 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
  • 60. Good to have you with us, Farquhar. We could do with some fresh blood in this place.'
  • 61.