Iron deficiency anemia is the most common type of anemia globally. It results from inadequate iron intake or absorption to meet physiological needs. Common symptoms include pallor, weakness, and fatigue. Diagnosis involves blood tests showing microcytic hypochromic anemia, low serum iron and ferritin levels, and high total iron binding capacity. Treatment consists of oral iron supplementation in the form of ferrous salts to replenish iron stores.

1. Anemia, Iron deficiency anemia
Dr. Kalpana Malla
MD Pediatrics
Manipal Teaching Hospital
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2. ANEMIA

3. What is Anemia?
• Reduction of the red blood cell (RBC) volume or
hemoglobin concentration below reference
level for the age and sex of the individual
• Hb < - 2SD or 95th centile for age and sex

4. Anemia Basics
All anemias are either due to….
1. Ineffective RBC production
or
2. Accelerated destruction of the RBC

5. Classification
• By RBC morphology and By Etiological
factors responsible for anemia

6. Microcytic hypochromic anemia
1. Iron deficiency anemia – nutritional,
- posthemohragic
2. Ineffective Erythropoiesis
- hemoglobinopathies, Thalassemia
- Lead poisoning, Sideroblastic anemia
- Cu deficiency, Pyridoxine deficiency
-Chronic ds - infection, inflammations ,
renal ds

7. Macrocytic anemia
• Megaloblastic Erythropoiesis
a) Nutritional - Folate deficiency, B12 deficiency
b) Toxic – Treatment with antifolate compound –
methotrexate,, and drugs that inhibit DNA
replication – zidovudine, phenytoin
c) Congenital disorders of DNA synthesis like
Orotic aciduria etc.
d) Malabsorption - liver ds

8. Macrocytic anemia
Non - Megaloblastic Erythropoiesis
a) Chronic hemolytic anemia
b) Liver ds
c) Hypothyroidism
d) Diamond blackfan syndrome

9. Normocytic, Normochromic anemia
1. Impaired cell production (low reticulocyte count)
- aplastic anemia
- pure red cell aplasia
- physiological anemia of infancy
- infections
- Systemic diseases like endocrinal, renal
and hepatic diseases
- bone marrow replacement – leukemia,
tumors, storage ds, myelofibrosis,
osteopetrosis
2 Hemolytic anemia ( reticulocyte count high)

10. DIMORPHIC ANEMIA
• When two causes of anemia act
simultaneously, e.g : macrocytic
hypochromic due to hookworm infestation
leading to deficiency of both iron and
vitamin B12 or folic acid
• following a blood transfusion

11. ETIOLOGICAL CLASSIFICATION OF ANEMIA
• Blood loss
Acute
Chronic
• Decreased iron assimilation
- Nutritional deficiency
- Hypoplastic or aplastic anemia
- Bone marrow infiltration like leukemia & other
malignancies,
- Myelodysplastic syndrome
- Dyserythropoietic anemia

12. ETIOLOGICAL CLASSIFICATION OF ANEMIA
• Increased physiologic requirement
- Extracorpscular -
- Alloimmune & isoimmune hemolytic anemia
- Microangiopathic anemias
- Infections
- Hypersplenism

13. ETIOLOGICAL CLASSIFICATION OF ANEMIA
- Intracorpsular defect
– Red cell membranopathy i.e. congenital
spherocytosis,elliptocytosis
– Hemoglobinopathy like HbS, C,D,E etc.
Thalassemia syndrome
– RBC enzymopathies like G6PD deficiency, PK
deficiency etc.

14. Follow-up
• Re-check CBC 4-6 weeks (to confirm response)
• Continue iron 3-4 months (to replace stores)
• If no improvement on adequate iron therapy,
consider evaluating the child for lead poisoning or
thalassemia

15. Differential of Anemia
Hgb, indices, retic count and smear
Inadequate response (RPI<2) Adequate response (RPI>3)
r/o blood loss/hemolytic dis
Hypochromic, microcytic Normochromic,normocytic Macrocytic hemoglobinopathy
iron def chronic dis B12/folate def enzymopathy
thalssemia Ca/BM failure Liver disease membranopathy
chronic disease Transient erythroblastopenia Down Syndrome extrinsic factors
of childhood (DIC,HUS,TTP)
lead poisoning Renal disease Drugs (etoh) Immune Hemolytic anemia

16. IRON DEFICIENCY
ANEMIA

17. IDA
• Most common cause of anemia worldwide
• Most important cause of iron deficiency anemia is
parasitic infection - hookworms, whipworms and
roundworms

18. GENERAL FEATURES
 Newborn contains 0.5g of iron, adult contains 5g
 A diet containing 8–10mg of iron daily is necessary for
optimal nutrition
 1mg of iron must be absorbed each day - Absorbed in
the proximal small intestine
 Absorbed 2-3 times more efficiently from human milk
than from cow's milk

19. Iron sources:
• Meat
• Liver
• Kidney
• Egg-yolk
• Green vegetables
• Fruits
**** Cow’s milk- poor source of iron

20. Iron metabolism:
Distribution of body iron: (adults)
- Hemoglobin: 2.3 gm
- Storage (ferritin / haemosiderin) : 1.0 gm
- Non-available tissue iron: 0.5 gm
- Transport iron: 3-4 mg
- Total : ~5 gm

21. Iron absorption:
Depends upon – Body stores of iron
- Rate of erythropoiesis
- Iron needs of the body
 Increased absorption in presence of:
- vitamin C
- fruit juices
- lactose
- amino acids- cystine, lysine ,
histidine,
- gastric Hcl
 Decreased absorption : - phytates
- tannic acid
- calcium salts
- phosphates

22. Iron Metabolism:
Figure 16-8: Iron metabolism

23. Pathogenesis of IDA:
Increased physiological demand:
- growing children (6-24 months)
- adolescence
- women during reproductive ages
Pathological blood loss:
-chronic loss
Inadequate intake of diets rich in iron:
-nutritional deficiency
-decreased absorption- gastroenterostomy/
tropical sprue/ coeliac disease

24. • High Hb conc of the newborn falls during the first 2–
3 mo - considerable iron is stored - usually sufficient
for blood formation in the first 6–9 mo of life in term

25. ETIOLOGY
• The most important cause world-wide is
infestation with parasitic worms
(hookworms- suck 0.03- 0.2 ml of blood per
worm /day ),whipworms, roundworms
• Dietary insufficiency
• Malabsorption

26. ETIOLOGY
• Chronic blood loss - occult bleeding : peptic
ulcer, Meckel diverticulum, polyp, hemangioma,
inflammatory bowel disease, Intravascular
hemolysis and hemoglobinuria
• Chronic diarrhea
• Milk allergy

27. Risk factors for IDA
• Demograpghic – Eldery, Teenager, Female
• Dieatary – low Iron, low Vit C, excess
phytate,tea coffee,
• Social and physical – poverty,alcohol
abuse,GIT ds

28. CLINICAL FEATURES
Pallor is the most important sign
Look for pallor : FACE, nails, palms, conj, mucus
membranes
Pagophagia (pica for ice) / pica
Anxiety , Poor appetite
Below 5g/dL: irritability and anorexia are prominent
Tachycardia and systolic murmurs- dyspnea ,
Palpitations

29. CLINICAL FEATURES
• Hair loss and lightheadedness
• Fainting
• Sleepiness, Tinnitus
• Mouth ulcers, Glossitis ,Angular cheilitis
• Constipation
• Depression, Twitching
muscles, Tingling, numbness or burning
sensations

30. CLINICAL FEATURES
• Koilonychia (spoon-shaped nails) ,
• Platynychia
• Weak,brittle nails
• Pruritus
• Dysphagia due to formation of esophageal
webs (Plummer-vinson syndrome

31. Koilonychia - spoon shaped nail

32. CLINICAL FEATURES
Neurologic and intellectual function
Affects attention span, alertness,
Verbal learning and memory
Monoamine oxidase (MAO), an iron dependent
enzyme, has a crucial role in neurochemical
reactions in the CNS
breath-holding spells

33. Response to low Hb:
First:
 Tissue iron stores represented by bone marrow hemosiderin
disappear
 Serum ferritin decreases
Next:
 Serum iron level decreases
 Serum transferrin,S. iron-binding capacity of the - increases
 Percent saturation (transferrin saturation) falls below normal
 Free erythrocyte protoporphyrins (FEP) accumulates

34. Response to low Hb:
Later:
Microcytosis, hypochromia, poikilocytosis,
and increased RBC distribution width (RDW)

35. Diagnosis - LABORATORY INVESTIGATIONS
1.complete blood count (CBC)
- High RBC distribution width (RDW) -
reflecting an increased variability in the size of
red blood cells (RBCs).
- A low MCV,MCH and MCHC
2. Hemoglobin (Hb)&hematocrit (Hct) value –
low
3. Reticulocyte - normal or moderately elevated

36. Diagnosis - LABORATORY INVESTIGATIONS
3.Peripheral blood smear – microcytic
hypochromic anemia, target cells,
hypochromic pencil-shaped cells, and
occasionally small numbers of nucleated RBC
• Thrombocytosis -activate thrombopoietin
receptors in precursor cells which make
platelets

37. LABORATORY INVESTIGATIONS
4. Diagnostic tests –
- Serum ferritin- low
- Serum iron - low
- Serum transferrin -elevated
- Total iron binding capacity (TIBC) - high
5.Stool for occult blood
6.Stool R/M/E - hookworm and whipworm

38. LABORATORY INVESTIGATIONS
• Ratio of serum iron to TIBC (called iron
saturation or transferrin saturation index - is
the most specific indicator of iron deficiency -
< 5% - indicates iron deficiency

39. DiagnosisLABORATORY INVESTIGATIONS
Gold standard
• Bone marrow aspiration, with the marrow
stained for iron -Bone marrow is hypercellular,
with erythroid hyperplasia
• Leukocytes and megakaryocytes are normal
• No stainable iron in marrow reticulum cells

43. TREATMENT
• Oral administration - ferrous salts
(sulfate, gluconate, fumarate) -4–6mg/kg of
elemental iron
• Consumption of milk should be limited
• Blood loss from intolerance to cow's
milk proteins is reduced
• The amount of iron-rich foods is
increased

44. Oral iron failure?
• Incorrect diagnosis (eg, thalassemia)
• Patient is not taking the medication
• Not absorbed (enteric coated?)
malabsorption syndromes
gastrectomy/celiac disease
• Rapid iron loss?
• Anemia of chronic disease-impairs bone
marrow response

45. TREATMENT
• Parenteral iron preparation (iron dextran) : Intolerance
to oral iron, severe gastrointestinal complaints
• Packed or sedimented RBCs : with Hb values < 4g/dL
• congestive heart failure: fresh-packed RBCs should be
considered

46. RESPONSES TO IRON THERAPY
12–24 hr
• Replacement of intracellular iron enzymes; subjective
improvement; decreased irritability; increased Appetite
36–48 hr
• Initial bone marrow response; erythroid hyperplasia
48–72 hr
• Reticulocytosis, peaking at 5–7 days
4–30 days
• Increase in hemoglobin level
1–3 mo
• Repletion of stores

47. Thank you
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