Iron Deficiency, Vitamin B12 and Folic Acid deficiency anemia in children

1. By
Dr. Imran Mahmood
Associate Professor
Department of Pediatrics
Fazaia Medical College, Islamabad

2. Learning Outcomes
 At the end of the presentation, students should have adequate knowledge
regarding
 Definition of nutritional anemias
 Cutoff values of normal and low hemoglobin
 Types of nutritional anemias
 Its common etiologies
 Important questions in history taking
 Important physical findings
 Important investigations
 And its main principles of treatment

3. Anemia - Definition
Anemia is defined as a reduction in hemoglobin two standard
deviations below the mean, based on age-specific norms (Harriet Lane)
Age of Population Anemia
6-59 months < 11 g/dl
5-11 years < 11.5 g/dl
12 -14 years < 12 g/dl
15 years and above
Males < 13 g/dl
Females < 12 g/dl

4. Types of Nutritional Anemias
 Three types
 Iron deficiency anemia
 Vitamin B-12 deficiency anemia
 Folic acid deficiency anemia

5. Etiologies
Iron Def. Anemia Vit. B 12 Def. Anemia Folic Acid Def. Anemia
Poor dietary intake e.g.
strict vegetarian, delayed
weaning
Poor dietary intake e.g.
Strict vegetarian
Ingestion of goat's
milk
Prematurity Bacterial overgrowth of
small intestine
Prematurity
Decreased absorption e.g.
Celiac disease, Giardiasis
Decreased absorption e.g.
Celiac disease & Crohn's
disease, short gut (NEC)
Impaired absorption e.g.
celiac disease, short gut
Blood Loss e.g. epistaxis,
peptic ulcer
Pernicious anemia Hemolytic anemia e.g.
Thalassemia
Hookworm infestation Fish tape worm
infestation
Medication: PPI
Medications e.g.
Phenytoin, Methotrexate

6. History Taking
 Presenting complaints:
 Irritability
 Easy fatigability
 Shortness of breath
 Pallor
 Chronic diarrhea----- malabsorption (celiac disease)
 Abdominal Pain-----History of worm infestation
 History of Pica---- more common in iron deficiency
anemia

7. Nutritional History
 Type of milk feed
 Cow milk ---- iron deficiency anemia
 Breast fed infant are less likely to develop iron deficiency
anemia.
 Goat milk--- Folic acid deficiency anemia
 Weaning
 Weaning food---- containing iron rich food.

8.  Treatment History:
 Anticonvulsant, methotrexate
 Past History
 History of gut surgery ----- Necrotising enterocolitis
 Birth History:
 Preterm, low birth weight--- more prone to develop anemia
 School History: Poor due to cognitive delay
 Socioeconomic History:
 More common in low socioeconomic status.

9. Physical Examination
 Pallor on palms and conjunctiva

10. Physical Examination
 Koilonychia (Iron deficiency
anemia)
 Glossitis (Vitamin B-12
deficiency)

11.  Look for lymphadenopathy, petechiae, bruises and
hepatosplenomegaly to rule out leukemia, aplastic anemia and
thalassemia
 Anthropometric measures (weight, height, head circumference)---
should be checked to rule out malnutrition.

12. Laboratory Investigations
 Complete Blood Picture:
 Hb level: decrease
 RBCs: decrease
 Pancytopenia in case of folic acid and vitamin B12 deficiency anemia
 MCV
 Increase ( MCV>100fl) in megaloblastic anemia--- Vitamin B12 and
folic acid deficiency
 Decrease ( MCV < 76fl) in Iron deficiency anemia
 RDW: Increased in iron deficiency anemia (Normal Value 12 to 16)
 Platelets: increase in iron deficiency anemia

13. Red Cell Morphology
 Hypochromic Microcytes in iron
deficiency anemia
 Hyper segmented nuclei of
neutrophils (3 to 5 lobes of nuclei
)in folic acid and B-12 deficiency
anemia
 Retics: Normal

14.  Serum Ferritin Levels:
 Serum Iron levels:
 Decrease in iron deficiency anemia
 CRP should also be done along with this to rule out false
negative serum ferritin levels.
 Stool for occult blood: (Iron def. anemia due to blood
loss)

15. Ref: The Harriet Lane Handbook, 21st Edition

16.  Serum Vitamin B-12 levels:
 Decrease
 Intrinsic factor Deficiency
 Anti IF antibodies and anti-parietal cell antibodies
 Schilling test is not available nowadays.
Ref: The Harriet Lane Handbook, 21st Edition

17.  Red cell folate levels: decrease (best measure of
metabolically active folate i.e. 5 methyl
tetrahydrofolate)
 Serum Folic acid levels: Decrease
Ref: The Harriet Lane Handbook, 21st Edition

18. Treatment
 Four main principles
 Deworming
 Dietary counseling
 Nutritional supplementation
 Follow up

19. Deworming
 Mebendazole: (Vermox)
 100mg (5ml) BD for 3 days
 Albendazole: (Zentel)
 200mg (5ml) stat for children less than 2 years of age.
 400mg (10ml) for older children

20. Dietary Counselling
• Meat and liver (Heme iron )
• Fruits (Apple, Peach, Banana, Guava)
Non-Heme iron
• Green vegetables & Red beans etc.
 Bioavailability of heme iron is 10 times higher than nonheme iron
 Vitamin B-12 rich foods: Meat, Egg, Milk.
 Folic Acid rich foods: Cereals, Fruits, green leafy vegetables.

21.  Iron supplementation:
 Elemental Iron: 3-6mg/kg/ day for 4 to 6 months.
 Iron should be given for 3 more months after
normalization of Hemoglobin.
 In Oral Iron refractory Cases:
 Malabsorption
 Poor compliance
 Side effects like diarrhea
 Parenteral Iron: Iron sucrose

22. Parenteral Iron: Venofer
 Formula for calculation.
 (Desired Hb- Current Hb) x weight (kg) x 3
 Maximum 100mg IV iron can be given at one day
 Usually 100mg (1 ampuole of Venofer) in 300ml Normal saline over 3 hours.
 Side effects:
 Hypersensitivity reaction (slow IV infusion for first 15 minutes)
 Hypotension (which can be prevented by normal saline )

23. Ref: Nelson textbook of Pediatrics--- 21st Edition

24. Megaloblastic Anemia
 Folic acid:
 (1-5 mg/day for 3-4 weeks )
 Vitamin B-12:
 Oral: as effective as IM
 Intrinsic factor Deficiency
 IM: 1mg for 2-4 days and then monthly
 Folic acid contraindicated in Vitamin B12 deficiency because it will
aggravate neurological deficit.
 Vitamin B12 is always started before starting folic acid

25. Blood Transfusion
 In case of severe anemia with
signs of heart failure.
 RCC ---15 to 20 ml/kg slowly
to avoid or exacerbate CCF

26. Follow up
 Good follow up is necessary
 To check compliance
 Response to treatment
 Side effects:
 Decreasing the dose
 Change of drug

27. References
 Basis of Pediatric by Dr. Pervez Akbar
 Nelson textbook of Pediatrics--- 21st Edition
 The Harriet Lane Handbook, 21st Edition
 https://emedicine.medscape.com
 https://www.who.int/vmnis/indicators/haemoglobin.pdf

29. Questions and comments?