IRON DEFFICIENCY ANAEMIA STUDY DESIGN AND INTERPRETATION PRESENTED BY DR.PRIYANKA R. PHONDE.
ANEMIA Definition• Decrease in the number of circulating red blood cells.• Most common hematologic disorder.• Reduction of hemoglobin concentration below reference value.
ANEMIA Causes• Blood loss• Decreased production of red blood cells (Marrow failure)• Increased destruction of red blood cells – Hemolysis• Distinguished by reticulocyte count – Decreased in states of decreased production – Increased in destruction of red blood cells
IRON Causes of Iron Deficiency• Blood Loss – Gastrointestinal Tract – Menstrual Blood Loss – Urinary Blood Loss (Rare) – Blood in Sputum (Rarer)• Increased Iron Utilization – Pregnancy – Infancy – Adolescence – Polycythemia Vera• Malabsorption – Tropical Sprue – Gastrectomy – Chronic atrophic gastritis• Dietary inadequacy (almost never sole cause)• Combinations of above
IRON DEFICIENCY Symptoms• Fatigue - Sometimes out of proportion to anemia• Atrophic glossitis• Pica (Apetite For Non Food Substances Such As An Ice, Clay)• Koilonychia (Nail spooning)• Esophageal Web• Dizzenes• Headache• Irritability• Palpitation• Dry, Pale Skin• Hair Loss• Increased Platelet Count
IRON DEFICIENCY ANEMIA CURE• ORAL – 200 mg of iron daily 1 hour before meal (e.g. 100 mg twice daily) – How long? • 14 days + (Hg required level – Hg current level) x 4 – half of the dose - 6 – 9 months to restore iron reserve – Absorption • is enhanced: vit C, meat, orange juice, fish • is inhibited: cereals, tea, milk • Usually oral; usually 300-900 mg/day• Requires acid environment for absorption
IRON THERAPY• Initial response takes 7-14 days• Modest reticulocytosis (7-10%)• Correction of anemia requires 2-3 months• 6 months of therapy beyond correction of anemia needed to replete stores, assuming no further loss of blood/iron• Parenteral iron possible, but problematic
IRON DEFICIENCY ANEMIA PrevalenceCountry Men (%) Women Pregnant (%) Women (%)S. India 6 35 56N. India 64 80Latin America 4 17 38Israel 14 29 47Poland 22Sweden 7USA 1 13
Aim of the study• To determine the effect of the timing of iron deficiency anemia during pregnancy on fetal growth and birth outcome.
Objectives• To determine the association between iron deficiency anemia in pregnancy and birth outcomes.• To assess whether iron deficiency anemia increase risk of fetal growth.• To assess the effects of routine iron & folate supplementation on haematological, biochemical parameters and on pregnancy outcome.
Hypothesis Research Questions• There is a Causal • Is the maternal Relationship between anemia, assessed primarily Maternal Iron- Deficiency as hemoglobin Anemia and Birth Outcome. concentration, is causally related to babies weight at birth or duration of gestation ?
Study design• Retrospective study use to identify the effects of maternal- iron deficiency anemia on birth outcome. Materials and methods• Simple random sampling method.• The sample size including (69) pregnant women.
Materials and methods• Self-designated questionnaire, self reported and filling questionnaire used to collect data.• Use of 21 questions to determine the effects of maternal-iron deficiency anemia on Birth outcome.
ANOVA test between taking iron during pregnancy and baby weight Sum of Squares Df Mean F Sig. SquareRegression .003 1 .003 .012 .912 Residual 14.606 67 .218 - - Total 14.609 68 - - -Since the level of significance (0.912) is bigger than 0.05,we accept the hypothesis and conclude that “There existsno significant relationship, in the significance level 0.05,between taking iron during pregnancy and baby weight.
Simple Linear Regression model between taking iron during pregnancy and baby weight. B t (Constant) 1.673 7.868 Do you take iron 2.074E-02 .111 during pregnancy? Since the R equal (0.014) and R square equal (0.000) there is no correlation between taking iron during pregnancy and baby weight.
ANOVA test: between taking iron during pregnancy and type of delivery. Sum of Df Mean F Sig. Squares SquareRegression .021 1 .021 .086 .770 Residual 16.182 67 .242 - - Total 16.203 68 - - -Since the level of significance (0.770) is bigger than0.05, we accept the hypothesis and conclude that“There exists no significant relationship, in thesignificance level 0.05, between taking iron duringpregnancy and type of delivery.
Simple Linear Regression model: between taking iron during pregnancy and type of delivery. B t (Constant) 1.313 5.869 Do you take iron 5.760E-02 .294 during pregnancy?Since the R equal (0.036) and R square equal(0.001) there is a very weak correlation betweentaking iron during pregnancy and type of delivery.
ANOVA test between: taking iron during pregnancy and gestational age in the delivery. Sum of Df Mean F Sig. Squares Square Regression .198 1 .198 1.466 .230 Residual 9.048 67 .135 - - Total 9.246 68 - - - Since the level of significance (0.230) is bigger than 0.05,we accept the hypothesis and conclude that “There exists nosignificant relationship, in the significance level 0.05,between taking iron during pregnancy and gestational age inthe delivery.
Simple Linear Regression model: between taking iron during pregnancy and gestational age in the delivery. B t (Constant) 1.645 9.831 Do you take iron during .177 1.211 pregnancy? Since the R equal (0.146) and R square equal (0.021)there is a very weak correlation between taking ironduring pregnancy and gestational age in the deliver
Discussion• No correlation between baby weight and taking iron supplement during 3rd trimester of pregnancy.• No correlation between type of delivery and gestational age with mother Hb level during pregnancy.• The correlation between the other variables, is very weak.• Supplementation of anemic or no anemic pregnant women with (IDA) does not appear to increase birth weight or the duration of gestation.
• A negative association between anemia and duration of gestation and low birth weight has been reported in the majority of studies, although a causal link remains to be proven.• Finally; we reject our hypothesis, and found that their was no causal relationship between maternal – iron deficiency anemia & birth outcomes
Limitation of the study• First, there is a chance of recall bias in the process of gathering data. Given low income and low socioeconomic status of the pregnant women of this study, it was not feasible to carry out longitudinal studies.• Second, it is difficult to determine the prevalence of maternal iron deficiency in the pregnant women because of the criteria used to define iron deficiency.• Third; our result indicate that the third trimester of pregnancy have no affect on birth outcomes, but it doesn’t measure the effect of the second or first trimester pregnancy
Recommendations • Recommended Guidelines for Preventing And Treating Iron Deficiency Anemia In Pregnant Women• At a scheduled third-trimester visit, or if the first prenatal visit occurs in the third trimester, obtain a blood specimen and determine the hemoglobin concentration. Obtain medical evaluation when the hemoglobin concentration is <9.0 g/dl.
• Prescribe 60-120 mg of supplemental iron per day when the hemoglobin concentration is between 9.0 - 10.9 g/dl.• Prescribe 30 mg of supplemental iron per day when the hemoglobin concentration is 11.0 g/dl.
IRON AND CHILD DEVELOPMENT• FINDING: Increasing evidence that iron deficiency in children impedes development and that supplementation can reverse delays• IMPLICATION: Safe and effective public health interventions are needed to address iron deficiency in children•Sources: Behavioral and developmental effects of preventing iron-deficiency anemia inhealthy full-term infants.•Iron deficiency anemia in infancy: long-lasting effects on auditory and visual systemfunctioning.•Effects of iron supplementation and anthelmintic treatment on motor and languagedevelopment of preschool children, placebo controlled study.• Reversal of developmental delays in iron-deficient anaemic infants treated with iron.
IRON AND GROWTH• FINDING: In India, iron supplementation supported growth in iron-deficient children, but delayed growth in iron-replete children (Growth delay is believed to result from excess iron competing with zinc absorption)• IMPLICATION: Iron supplementation for children is not necessarily a magic bulletSource:. The effect of iron therapy on the growth of iron-replete and iron-deplete children.
IRON SUPPLEMENTATION PROTOCOLS• FINDING: Among lactating women, weekly and daily supplementation had comparable effects on iron status and, in India, weekly supplementation was effective for anemia prevention• IMPLICATION: Intermittent (non-daily) supplementation is an option to be consideredSources: Daily versus weekly iron supplementation and prevention of iron deficiency anaemiain lactating women.Anemia prophylaxis in adolescent school girls by weekly or daily iron-folate supplementation.
FORTIFICATION VEHICLES-1• FINDING: Cereal fortification may improve iron intake but evidence of general effectiveness is still lacking• IMPLICATION: Cereal fortification is not a “magic bullet” for addressing iron deficiency in children Sources: SUSTAIN Guidelines for Iron Fortification of Cereal Food Staples.
FORTIFICATION VEHICLES-2• FINDING: A study in Chile found that just 3% of infants fed iron-fortified milk (ferrous sulfate + ascorbic acid) were anemic versus 26% of those fed non-fortified milk• IMPLICATION: In some cultures, milk fortification may be a viable vehicle for fortification to reduce iron deficiencySource: Prevention of iron deficiency by milk fortification.
FORTIFICATION VEHICLES-3• FINDING: Fortified fish/soy sauce found acceptable.• IMPLICATION: In some cultures, foods such as fish/soy sauce may be viable vehicles for fortification to reduce iron deficiencySources: Combating iodine and iron deficiencies through the double fortification of fish sauce,mixed fish sauce, and salt brine. Regular consumption of NaFeEDTA-fortified fish sauce improves iron status and reduces theprevalence of anemia in anemic women.
IRON SPRINKLES FINDINGS:, sprinkles were shown to be as effective as the standard therapy in treating anemia and, in Zambia, iron+zinc sprinkles did reduce anemia but did not improve zinc status or catch-up growth in infants IMPLICATION: Sprinkles is a promising intervention with high acceptance rates and proven efficacy but cost may be a major constraintSources: Treatment of anemia with micrencapsulated ferrous fumarate plus ascorbic acidsupplied as sprinkles to complementary (weaning) foods.Home-fortification with iron and zinc sprinkles or iron sprinkles alone successfully treatsanemia in infants and young children.
Prevalence of GDM in relation to duration and timing of iron deficiency anemia.Prevalence of GDM in relation to duration and timing of iron deficiencyanaemia. See text for description of anaemic groups. Comparison byPearson’s correlation between incidence of GDM and anaemic groups;P = 0.045.