Iron Deficiency Anemia

Prevalence

NFHS-3 : 7/10 children aged 6-59 months are anemic. (3%-severely anemic, 40%-moderate anemic, 26%- mildly anemic)

65% in preschool children

Adolescent period -50%

Iron deficiency affects 2170 million worldwide, and 1200 million of them anemic with 90% of affected are in developing countries

Total Body Iron

Full-term infants - approximately 75 mg/kg body weight of iron

Adult males – 50 mg/kg and females – 35 mg/kg

Can be divided into functional(80%) and storage(20%) compartments

Iron Balance

Mostly lost from shedding of epithelial cells in G.I.Tract.

Total average daily loss of iron has been estimated at ∼1.0 mg in normal adult men and nonmenstruating women.

20% of heme iron (in contrast to 1% to 2% of nonheme iron) is absorbable.

Iron balance is primarily, if not exclusively, achieved by control of absorption rather than by control of

excretion

The “Iron cycle”

Since plasma ferritin is derived largely from the

storage pool of body iron, its levels correlate well with body iron stores.

Nutritional Iron Balance

Role of Hepcidin

Synthesized and released from the liver Inhibits iron transfer from the enterocyte to plasmaRegulator of iron absorptionAlso suppresses iron release from macrophagesImportant role in anemia of chronic diseases and hemochromatosis

Very high levels of hepcidin in Anemia of chronic

diseases and inappropriately low levels

of hepcidin in hemochromatosis

Etiology

Late manifestation of prolonged negative iron balance

As a result of major blood loss

Increased physiologic need for iron

Diet

Body iron concentration in normal neonates averages ∼75 to 100 mg/kg weight

Premature infants are at higher risk of iron deficiency

Delayed cord clamping

The fetus is an “effective scavenger of maternal iron”

Normal term infant must acquire 135 to 200 mg of iron during the first year of life. A premature infant may require as much as 350 mg in the same period

Iron stores in the infant are typically depleted by 4 to 6 months of age

Iron intake of 1 mg/kg/day is recommended for full-term infants, 2 to 4 mg/kg/day for preterm infants

Deficiency is relatively uncommon in the first 6 months of life in infants exclusively fed breast milk

Cow’s milk should not be given to infants <1 year of age

Blood loss

• Lesions of the gastrointestinal (GI) tract - peptic ulcer, Meckel diverticulum, polyp, hemangioma, or inflammatory bowel disease

• Heat-labile protein in whole bovine milk

• Chronic diarrhea and rarely with pulmonary hemosiderosis

• Parasitic infestations and H.pylori infection

Clinical Features

Pallor, anorexia and irritability

Hyperdynamic circulation

Skin and nail changes

Pica - 70-80% of Children

Koilonychia

Consequences of Iron Deficiency

Long term mental impairment

Impaired immune function

Poor physical performance

Febrile seizures, temper tantrums, breath holding spells, restless leg syndrome.

Lab evaluation

Hemoglobin, Hematocrit

Red cell indices

Reticulocyte hemoglobin content (CHr)

Mentzer index and RDW

Serum ferritin

Serum iron, TIBC, Transferrin saturation

Stainable iron in bone marrow

Stool for occult blood

Treatment

Depends on severity and associated complications

3-6 mg/kg of elemental iron in 3 divided doses is adequate

Ferrous sulfate is 20% elemental iron by weight and is ideally given between meals with juice

Addition of folic acid and vitamin C (200 mg), vitamin B12.

Parenteral Iron

Should usually be avoided

Severe side effects on oral therapy, noncompliance or gastrointestinal bleeding

Total dose infusion (only in hospital)

Iron dextran or sucrose complex - most commonly used

Iron required=wt (kg)x 2.3x (15-patient hemoglobin) +500-1000 mg

Response to Iron therapy

TIME AFTER IRON ADMINISTRATION RESPONSE

12-24 hrReplacement 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 months Repletion of stores

Nonresponders to Iron therapy

Incorrect dose or medication Malabsorption of administered iron Ongoing blood loss including gastrointestinal, menstrual, and pulmonary Concurrent infection or inflammatory disorder inhibiting the response to

iron Concurrent vitamin B12 or folate deficiency

Diagnosis other than iron deficiency    •    Thalassemias •    Anemia of chronic disease •    Lead poisoning •    Sickle thalassemias, hemoglobin SC disease   •    Rare microcytic anemias

Prevention

• Medicinal iron supplementation

• Dietary modificationBalance between inhibitors and promotersVitamin C rich foodsFermentation and germination

• Food fortificationDouble fortified salt

Weekly Iron and Folic acid Supplementation (WIFS)

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