Nutritional iron deficiency anemia is a global problem, affecting 58% of pregnant women and 31% of children under 5 in developing countries. It occurs due to insufficient iron intake, absorption or stores to meet the body's needs. Common symptoms include pallor, fatigue, listlessness and poor appetite or growth. Diagnosis is based on microcytic, hypochromic anemia and low serum iron and ferritin levels. Treatment involves oral iron supplementation long-term to replenish stores, along with addressing any underlying causes of insufficient intake or absorption.

1. Nutritional iron deficiency anemia

3. As iron deficiency chiefly influences the synthesis of heme, the production of Hb is decreased, and the red cells become microcyte and hypochromic. this anemia is also named nutritional microcytic anemia. Definition

4. The Hemoglobin Molecule α β

6. Iron source Dietary iron is important source, such as meat, fish, liver, yolk, bean… Recycled From the breakdown of red cells, 80 % iron is reutilized to produce Hb Iron metabolism

7. Iron cycle Fe Fe Fe Fe Fe Ferritin Hemosiderin slow Fe Fe Fe Fe Fe Fe Fe Fe Fe Ferritin Ferritin Transferrin Receptor RBC PRECURSOR CIRCULATING RBCs Fe Fe TRANSFERRIN MONONUCLEAR PHAGOCYTES

12. Plasma Fe 16% 65% 4% 15%

13. two forms of dietary iron: heme meat, fish, and poultry nonheme Flours, cereals, and grain Iron absorption Iron metabolism

15. Iron: Heme vs. Nonheme Copyright 2005 Wadsworth Group, a division of Thomson Learning 10-17%

16. Food Gastrointestinal tract Fe 3+ Phosphates,oxalates (-) (+) ascorbic acid, meat Fe 2+ intestinal mucosa Fe 3+ Fe 3+ + apoferritin blood Fe 3+ +transferrin Ferritin bone marrow liver spleen (storage) heme Fe 3+ +apoferritin ferritin hemoglobin Hemosiderin (storage) Iron absorption

17. Iron in the Body

18. iron absorption is influenced body’s iron stores the type of iron in the diet other dietary factors that either help or hinder iron absorption enhanced by Vitamin C meat diminished by phosphates, oxalates, and tannic acid The greatest influence on iron absorption is the amount stored in your body. Iron absorption

19. Iron Absorption Copyright 2005 Wadsworth Group, a division of Thomson Learning

20. insufficient iron stores insufficient iron intake rapid growth and development failure of iron absorption iron loss Etiology

21. In newborn, the body contains about 0.2-0.5g of iron. Newborn term infants 75 mg/kg A preponderance of iron hemoglobin (75%) first 2-3 months hemoglobin concentration (iron is reclaimed and stored) adult has 5g Insufficient iron stores Etiology

23. premature low birth weight twins infant with perinatal blood loss Insufficient iron stores the premature or low birth weight infant 64 mg/kg Etiology

24. Iron balance during the first year of life Full-term infant Premature infant Birth 1 year Birth 1 year Weight(kg) 3.3 10.5 1.5 9.5 Blood hemoglobin(g/dl) 20.0 12.3 20.0 12.3 Blood volume(ml) 290 800 135 720 Total hemoglobin(g) 58 98 27 89 Hemoglobin iron(mg) 198 335 90 300 Storage tissue iron(mg) 60 73 27 67 Total body iron(mg) 258 408 117 367 Net positive iron balance 0.4 0.7 (mg/day)

25. A diet containing 8-15mg of iron is necessary for optimal nutrition (approximately 10% is absorbed) the normal daily excretion of iron < 1mg/d Insufficient iron intake Etiology

26. 1mg/kg/day to a maximum of 15mg/day is required in a normal full-term infant 2mg/kg/day to a maximum of 15mg/day is required in Premature infants Etiology

28. Iron content of infant foods Food iron(mg) unit Milk 0.5-1.5 liter Eggs 1.2 each Cereal,fortified 3.0-5.0 ounce Vegetables (strained) yellow 0.1-0.3 ounce green 0.3-0.4 ounce Meats (strained) Beef,lamb,beef liver 0.4-2.0 ounce Pork, liver ,bacon 6.6 ounce Fruits (strained) 0.2-0.4 ounce

29. Rapid growth and development The age of 6 months to 2 yrs is a period of rapid growth and development, correspondingly the infant’s blood volume must be proportionately expanded, the requirement of iron also increased Etiology

30. Iron balance during the first year of life Full-term infant Premature infant Birth 1 year Birth 1 year Weight(kg) 3.3 10.5 1.5 9.5 Blood hemoglobin(g/dl) 20.0 12.3 20.0 12.3 Blood volume(ml) 290 800 135 720 Total hemoglobin(g) 58 98 27 89 Hemoglobin iron(mg) 198 335 90 300 Storage tissue iron(mg) 60 73 27 67 Total body iron(mg) 258 408 117 367 Net positive iron balance 0.4 0.7 (mg/day)

32. Iron loss infant during the first 2 months iron loss > iron absorption from the diet intolerance cow’s milk syndrome of sensitivity to cow’s milk 0.7 ml of blood in stool is lost each day (induced by a heat-labile protein in whole cow’s milk) Etiology

33. Iron loss occult bleeding (Chronic iron deficiency anemia) lesion of the gastrointestinal tract peptic ulcer meckels diverticulum polyp hemangioma hookworm infection Etiology

34. Infants at high risk for iron deficiency Increased iron needs Low birth weight High growth rate Chronic hypoxia Low hemoglobin after birth Blood loss Perinatal bleeding Dietary factors Early cow milk intake Early solid food intake Low vitamin C intake Low meat intake Breast-feeding for more than 6 months without iron supplements Low socioeconomic status

35. Causes of Iron Deficiency

36. iron depletion (store) iron deficiency erythropoiesis iron deficiency anemia Clinical manifestation

37. Predisposing age 6 months 3 years Clinical manifestation

38. General manifestation Pallor the most common symptom palpebral conjunctivas mucous membranes of the oral cavity, the nails, palms, the rest of the skin also become pale. Dyspnea on exertion failure to thrive listlessness irritability fatigue dizziness vertigo The nails clubbing and koilo’nychia. Clinical manifestation

40. Manifestation of extramedullary hematopoiesis hepatosplenomegaly lymphonodes enlarged Clinical manifestation

41. Others Gastrointestinal symptom : Anorexia, dysphagia, pica Cardiovascular symptom : A systolic murmur Tachycardia cardiomegaly congestive cardiac failure There is an increased incidence of infections tuberculosis chest gastrointestinal infections Nervous system : Irritability , decreased attentiveness shorter attention span, associated with behavioural and intellectual deficiencies. Clinical manifestation

42. Behavioural Change Lack of energy ， irritability, poor concentration Nervous system Of course these are common problems associated with children that may not always becaused by iron deficiency Clinical manifestation

43. Learning Difficulties Learning difficulties can be present in anemic children, and there is some evidence to suggest that intellectual and physical development may not always be completely reversed when the child’s iron status has been corrected. Nervous system Clinical manifestation

44. red cells microcytic and hypochromic. Laboratory findings

46. Iron Deficiency Anemia:

47. Iron Deficiency Anemia

49. IDA

50. Mean corpuscular volume (MCV)<80fl Mean corpuscular hemoglobin (MCH) <26pg Mean corpuscular hemoglobin concentration (MCHC)<31% Red blood cell indices Laboratory findings

52. Serum irons below 9-10.7 umol/L ( normal range is 12.8-31.3) Serum ferritin less than 12ug/l The total iron-binding capacity(TIBC) more than 62.7 umol/L Free erythrocyte protoporphyrin (FEP) more than 0.9umol/L Laboratory findings

55. The highest incidence age 6m-3yrs A history of inadequate intake of iron History of chronic malabsorption or infections The clinical manifestation The peripheral blood smear microcytic and hypochromic red cells A good hematopoietic respons after 3-7 days of adminstration of iron. then the red cells and Hb other laboratory examinations : bone marrow serum iron or serum ferritin Diagnosis

56. Anemia of infection Protein of malnutrition Thalassemia acquired hemolytic anemia Pyridoxine deficiency Sideroblastic anemia lead poisoning Differential Diagnosis

58. b -Thalassemia HbA2

64. lead ≥10ug/dl

67. Iron Content Of Some Common Foods Food Quantity Milligrams Of Iron Lean beef 100 grams 4.1 Chicken Breast 100 grams 0.6 Fish 100 grams 0.4 1 medium egg 60 gram 0.8 Baked beans 1/2 cup 1.9 Lentils 1/2 cup 2.5 Wholemeal 1 slice 0.7 Boiled spinach 1/2 cup 2.2 Broccoli 1/2 cup 0.7 Iron fortified baby cereal 15 grams 7.5

69. Oral preparation of iron It is convenient to give iron in the form of an oral preparation a doses of 4-6mg/kg/day of elemental iron Treatment

71. Dose of oral iron preparation Kind of iron infant children elemental iron Dose/day in 1g Ferrous sulfate 0.15-0.3g 0.3-0.6g 200mg Ferrous fumarate 0.1-0.2g 0.2-0.4g 330mg Ferrous gluconate 0.3-0.6g 0.6-1.2g 115mg ( Ferrous salts are absorbed better than ferric salts) therapy is generally continual 2-3 months after restoration of the Hb to normal.

72. Failure to respond to oral iron: the following reasons should be considered Failure or irregular administration of oral iron; administration verifiable by change in stool color to gray-black Inadequate iron dose Ineffective iron preparation Persistent or unrecognized blood loss, with the patient losing iron as fast as it is replaced. Incorrect diagnosis Coexistent disease that interferes with absorption or utilization of iron (infection , hepatic or renal disease …) Impaired GI absorption (e.g. concurrent administration of large amounts of antacids, which bind iron, as treatment of peptic ulcer )

73. Parenteral iron therapy indicated in children showing intolerance to oral iron reduced iron absorption persistent blood loss their parents are unreliable Treatment

74. The requirement of iron dextran milligrams is calculated as fellows: Total doses (mg) (elemental iron) · kg: body weight · 12.5 is the normal Hb in infant · 3.4 is elemental iron(mg) in 1 gram of Hb · 1.2 means an additional iron supplement of 20% for serum iron. 75 x kg x (12.5-Hb) x 3.4 x 1.2 100 Treatment

75. Iron dextran complex intramuscular ampoule containing 100mg elemental iron in 2ml. administer daily, on alternate days, biweekly. Treatment

76. The good response reticulocyte 48 ～ 72h a peak during the 5th to 7th days falls the normal level after 2-3 weeks Treatment

77. . Iron supplementation should be continued for a minimum of 3 months , not only to correct the hemoglobin but also to replenish the iron stores. Treatment

78. Therapeutic effect observation Response to iron supplements Replenish iron stores 1-3 mo Hemoglobin  4-30 days Reticulocyte  , 5-7d peak 48-72 hr Bone marrow reaction; hyperplasia 36-48 hr Enzyme activity improve 12-24 hr reaction Time

79. Blood transfusion are rarely indicated in iron deficiency anemia, except for severe cases (Hb<60g/l) . Treatment

81. I ron deficiency anemia definition I ron’s storage I ron’s absorption I ron deficiency anemia’s etiology T he first good response to iron medication T herapy time QUESTIONS