2. Contents:-
• Definition
• Classification
• Role of iron
• Sources of iron
• Iron absorption transport and storage
• Cause of IDA
• Clinical manifestation
• Lab findings
• Treatment
• Prevention
3. Anemia is defined as a reduction of the
hemoglobin concentration or red blood cell
volume below the reference level for age and
sex of the individual.
ANEMIA
Age(yr) Mean value of
Hb(g/dl)
Lower limit of
Hb (g/dl)
MCV(fl)
0.5 - 4 12.5 11 70-73
5 - 7 13 11.5 75
8-11 13.5 12.0 76
12-14(F) 13.5 12.0 78
12-14(M) 14.0 12.5 77
18-49(F) 14.0 12.0 80
18-49(M) 16.0 14.0 80
6. B. Classification based on underlying
physiology
. INADEQUATE PRODUCTION
Diamond-Blackfan Anemia
Acquired pure red cell
aplasia
Anemia of chronic disease
Congenital dyserythropoetic
anemia
Physiological anemia of
infancy
Megaloblastic anemia
Iron deficiency anemia
Increased destruction or loss
Hemolytic anemias:
RBC Mebrane defect
Enzyme dfeciencies
Autoimmune hemolytic anemia
Heoglobinopathies
7. IRON DEFICIENCY ANEMIA
• Iron deficiency is the most widespread and
common nutritional disorder in the world.
• 30% of the global population has iron-
deficiency anemia, and most of them live in
developing countries
8. Salient points
• A full-term newborn contains about 0.5 g of iron,
compared to 5 g of iron in adults.
• It is necessary to absorb approximately 1 mg daily
to maintain positive iron balance in childhood.
• Because <10% of dietary iron usually is absorbed,
a dietary intake of 8-10 mg of iron daily is
necessary to maintain iron levels.
• Breastfed infants have an advantage because
they absorb iron 2-3 times more efficiently than
infants fed with cow’s milk.
9. Role of Iron
Role in transport and storage of oxygen in form
of hemoglobin and myoglobin respectively.
As prosthetic group in no. of
enzymes(cytochromes, cyclooxygense, ETC)
Helps in maintaining healthy immune system.
As a reserve(ferritin and hemosiderin, present
in the liver, spleen and bone marrow) to
maintain iron homeostasis.
10. Body Iron distribution(Adult)
- Hemoglobin: 2.5 gm
- Storage (ferritin / haemosiderin) : 1.0 gm
- Non-available tissue iron: 0.5 gm
- Transport iron: 3-4 mg
- Total : ~5 gm
11. SOURCE OF IRON
• Heme iron – mainly derived animal source
include meat, fish and poultry. Our bodies easily
absorb this type of iron.
• Non heme iron - Plant sources ( include dried
beans, peas and lentils and some fruits and
vegetables)
• Both cow's milk and breast milk are low in iron
(around 0.2-0.5 mg /l), however the iron in breast
milk offers greater bioavailability .Reasons are ;-
high content of lactoferrin
high levels of vitamin C and
lower level of calcium and phosphate
12. 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, prolonged achlorhydria
15. Causes of Iron deficiency
Increased physiological demand:
- growing children (6-24 months)
- adolescence
- women during reproductive ages
Pathological blood loss:
- chronic loss(IBD, Peptic ulcer, meckel’s diverticulum
-Parasitic worm infestation
-Phlebotomy specially in case of preterm new born child
Inadequate iron intake or absorption:
-nutritional deficiency-most important cause worldwide
-decreased absorption- tropical sprue/ coeliac disease/
post gastrectomy
16. • Each gram of Hb contains 3.47 mg of iron, so
loss of each ml of blood from body result in
loss of 0.5 mg of iron
• Hookworms - suck 0.03- 0.2 ml of blood per
worm /day
17. Risk factor in development of IDA
• Age- infants (especially premature);
adolescents
• Sex- increased risk in women
• Drug- aspirin and NSAIDS
• Diet pattern- especially in vegetarians, infant
on cow’s milk.
• Physiological- pregnancy; infancy;
adolescence; at age of weaning
18. A relatively high Hb conc. of the newborn falls
during the first 2–3 month of life, considerable
iron is stored – these stored iron are sufficient for
blood formation in the first 6–9 month of life in
term infant
Stores are depleted sooner in low-birthweight
infants, as their iron stores are smaller.
19. Clinical manifestation
Hematological manifestations
Pallor is the most important sign but usually
not visible until Hb level falls to 7-8g/dl.
In mild to moderate anemia(Hb level of 6-
10 g/dl) only few symptoms of anemia is
noted due to compensatory mechanism.
In severe anemia(Hb level<5g/dl, irritability
anorexia and lethargy developed.
Tachycardia and systolic flow murmur are
often present and may lead to high output
cardiac failure.
20. Non Hematological Manifestation
Impaired neurocognitive function in infancy.
Some studies suggest an increased risk of seizures,
strokes, breathholding spells in children, and
exacerbations of restless leg syndrome in adults.
Others include:-
pica, the desire to ingest nonnutritive substance
pagophagia, the desire to ingest ice.
The pica can result in the ingestion of lead-
containing substances and result in concomitant
plumbism .
Cheilosis and koilonychia are signs of advanced iron
deficiency
21. Dysphagia due to formation of esophageal webs
(Plummer-vinson syndrome)
22.
23. LAB FINDINGS
Tissue iron stores represented by bone
marrow hemosiderin disappear
Serum ferritin decreases(stored form)
Serum iron level decreases
• Serum transferrin, S. iron-binding capacity of the -
increases
Percent saturation (transferrin
saturation) falls below normal
Free erythrocyte protoporphyrins
(FEP) accumulate
24. At this point iron deficiency progresse to IDA
PBS- Microcytosis, hypochromia, Anisopoikilocytosis
with increased RDW. Elliptocyte and cigar shaped red
cells are often seen
Detection of isoluble transferrin receptor and
decreased reticulocyte Hb conc are very
usefull and early indicator of IDA
25. Diagnosis
A presumptive D/g of IDA is made by;
1.CBC showing microcytic hypochroic anemia
with High RDW and low MCV, MCH and MCHC.
Normal WBC count with normal or elevated
platelet count
2. Hb & Hct value – low
OTHER TEST :-
3.Reticulocyte % - normal or moderately
elevated .but absolute retic count is inadequate.
4. Reduced serum ferritin, reduced
serum iron, and Elevated transferrin increased
total iron-binding capacity.
26. Transferrin saturation index:- Ratio of serum iron to
TIBC(< 16% - indicates iron deficiency)
5. Bone marrow aspiration, with the marrow
stained for iron - No stainable iron in marrow
reticulum cells in IDA
6.Stool for occult blood
7.Stool R/M/E - hookworm and whipworm
“An increase in hemoglobin ≥1 g/dL after a month of
iron therapy is usually the most practical means to
establish the diagnosis.”
27. INDICES NORMAL IDA (CUTOFF VALUE)
S. FERRITIN 50-200µg/L <12 µg/L IN AGE <5 YR
<15 µg/L In age > 5yr
TIBC 300-360 µg/dl >400 µg/dl
S. Iron 50-150 µg/dl <30 µg/dl
Transferrin saturation 30-50 % <16 %
Erythrocyte
protoporphyrin level
<30 µg/L < 5yr age->70 µg/L
>5yr age- >80 µg/L
Marrow iron store 1-3 + 0
•
30. Treatment
Oral administration - ferrous salts (most often sulfate) -
3–6mg/kg /d of elemental iron.
Ferrous sulphate contain 20% elemental iron by wt and
ideally given b/w meals with juice.
31. Differential Diagnosis of Microcytic Anemia
That Fails to Respond to Oral Iron
Poor compliance (true intolerance of Fe is uncommon)
Incorrect dose or medication
Malabsorption of administered iron
Ongoing blood loss
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
Iron refractory iron deficiency anemia (IRIDA)
32. Parenteral iron preparations(iron dextran) are only
used when malabsorption is present, or persistent
ongoing blood loss or when compliance is poor,
because oral therapy is otherwise as fast, as effective,
much less expensive and less toxic.
Red cell transfusion : should only be used when
heart failure is imminent or if the anemia is severe
with evidence of substantial ongoing blood loss.
Unless there is active bleeding, transfusions must be
given slowly to avoid precipitating congestive heart
failure.
33. 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
34. Take home message
Iron deficiency is best prevented to avoid both its systemic
manifestations and the anemia
Routine screening using Hb or Hct is done at 12 mo of age,
or earlier at 4 mo of age, if the child is assessed to be at high
risk for iron deficiency.
Breastfeeding should be encouraged, with the addition of
supplemental iron at 4 month of age.
Infants who are not breastfed should only receive iron-
fortified formula (12 mg of iron /L) for the 1st year, and
thereafter cow’s milk should be limited to <600-720 ml/d.
Iron medication should be continued for 2-3 mo after blood
values normalize to reestablish iron stores.
Good follow-up is essential to ensure a response to therapy.
