IRON D E F IC IE N C Y

ANEMIA IN
CHILDREN
BY DR MADIHA SHAFI
• ANEMIA
• ANEMIA IS DEFINED AS A REDUCTION OF THE HEMOGLOBIN CONCENTRATION OR RED BLOOD CELL VOLUME BELOW THE RANGE OF NORMAL VALUES OCCURING IN HEALTHY
PERSON

• NORMAL HEMOGLOBIN AND HEMATOCRIT CONCENTRATION VARY SUBSTANTIALLY WITH AGE AND SEX
IRON DEFICIENCY ANEMIA

MOST COMMON HEMATOLOGIC DISEASE OF INFANCY AND CHILDHOOD

SUSCEPTIBLE AGE GROUPS:

PRESCHOOL CHILDREN

ADOLESCENTS
NORMAL IRON PHYSIOLOGY

• TOTAL BODY IRON CONTENT:

☐ 5 GM IN ADULT VS 0.5 GM IN A NEWBORN INFANT.

TO MAINTAIN POSITIVE IRON BALANCE, 1 MG OF IRON NEEDS TO BE ABSORBED EACH DAY

• SOURCES OF IRON:

- MEAT, LIVER, KIDNEY, EGG YOLK, GREEN VEGETABLES AND FRUITS

■ IRON IN COW’S MILK AND BREAST MILK?

IRON DISTRIBUTION:

IN HEMOGLOBIN – 65 TO 70%

AS FERRITIN, HEMOSIDERIN (STORAGE) – 20 TO 30%

• THE REMAINDER IN MYOGLOBIN AND HEME ENZYME

NORMAL IRON PHYSIOLOGY

IRON ABSORPTION AND REGULATION:

OCCURS PRIMARILY IN THE DUODENUM

READILY ABSORBED IN THE FERROUS FORM

ABSORPTION ENHANCED BY

ASCORBIC ACID, GLUCOSE, FRUCTOSE AND SOME AMINO ACIDS

ABSORPTION INHIBITED BY

PHOSPHATES, TANNINS, CALCIUM AND BICARBONATE

IRON ABSORBED BY MUCOSAL CELLS BIND TO APOFERRITIN TO FORM FERRITIN

. IN STATES OF ENHANCED IRON ABSORPTION, IRON ENTERING THE MUCOSAL CELLS IS DELIVERED DIRECTLY TO PLASMA

IN PLASMA, IRON IS BOUND TO TRANSFERRIN TRANSPORTED TO MARROW FOR USE OR STORAGE

CAUSES OF IRON DEFICIENCY

DIMINISHED IRON STORES:

• LOW BIRTH WEIGHT BABIES, TWINS, EARLY CLAMPING OF CORD, HEMORRHAGE FROM CORD OR PLACENTA DURING DELIVERY

• DIMINISHED IRON INTAKE:

FEEDING WITH COW’S MILK

• BLOOD LOSS:
HOOKWORM INFESTATION, PORTAL HYPERTENSION, RECTAL PROLAPSE ETC.

DIMINISHED IRON ABSORPTION:

MALABSORPTION SYNDROME

INCREASED DEMANDS:- LBW BABIES, DURING PUBERTY

ERRORS OF IRON METABOLISM:

• • SIDEROBLASTIC ANEMIA, IRON REFRACTORY IRON DEFICIENCY ANEMIA

CLINICAL MANIFESTATIONS

• HEMATOLOGICAL MANIFESTATION S
•• PALLOR((<7-8G/DL)

• IN MILD TO MODERATE ANEMIA(6-10HB G/ DL)

• • WITH HB < 5GM/DL

• • IRRITABILITY

• • ANOREXIA

• • TACHYCARDIA, CARDIAC DILATATION AND SYSTOLIC MURMURS

• NON HEMATOLOGICAL MANIFESTATIONS

• • DECREASED ATTENTION SPAN, ALERTNESS AND LEARNING ABILITY

• SEIZURE, STROKE , BREATH HOLDING SPELL

• PICA, PAGOPHAGIA, PLUMBISM

• • ATROPHY OF TONGUE PAPILLAE AND INTESTINAL VILLI

• • KOILONYCHIA,CHEILOSIS
LABORATORY DIAGNOSIS OF IRON DEFICIENCY
• HEMOGLOBIN/HEMATOCRIT/RED CELL COUNT – DECREASED
MCV/MCH – DECREASED
RBC MORPHOLOGY:
MICROCYTIC AND HYPOCHROMIC
ANISOCYTOSIS, POIKILOCYTOSIS
INCREASED RED CELL DISTRIBUTION WIDTH (RDW)
RETICULOCYTES – NORMAL OR MODERATELY INCREASED
SERUM FERRITIN (50-200UG/DL)_ DECREASED(<12 FOR AGE<5 YR:<15FOR AGE>5YR)
SERUM IRON( N 50-150UG/DL)_DECREASED(<30UG/DL)
• TOTAL IRON BINDING CAPACITY(300- 360UG/DL)_ INCREASED(>400UG/DL)
• TRANSFERRIN SATURATION (30-50%)_DECREASED(<16%)
• • FREE ERYTHROCYTE PROTOPORPHYRIN – INCREASED
• SLOUBLE TRANSFERRIN RECEPTOR- INCREASED
• RETICULOCYTE HEMOGLOBIN CONCENTRATION (SENSITIVE INDICATOR –FALL WITHIN DAYS)
• STOOL FOR OCCULT BLOOD
• STOOL EXAMINATION –HOOK WORM , WHIPWORM
IRON DEFICIENCY ANEMIA

• SEQUENCE OF EVENTS DURING IRON DEFICIENCY

DECREASED STORAGE IRON, WHICH PRODUCES.
• DECREASED SERUM FERRITIN
DECREASED BONE MARROW IRON ON PRUSSIAN BLUE STAINS
- DECREASED CIRCULATING IRON, WHICH CAUSES.

DECREASED SERUM IRON

INCREASED TIBC’
DECREASED % SATURATION
FORMATION OF MICROCYTIC / HYPOCHROMIC ANEMIA.
DECREASED MCV
DECREASED MCHC
• • HIGH RDW
TREATMENT
• DIETARY COUNSELING
• • ORAL ADMINISTRATION OF SIMPLE FERROUS SALTS
• 4-6 MG/KG OF ELEMENTAL IRON IN THREE DIVIDED DOSES BETWEEN MEAL WITH VITAMEN C RICH JUICES

• TO CONTINUE FOR 8 WEEKS AFTER BLOOD VALUES NORMALIZE

• PARENTRAL IRON IRON DEXTRANWHEN NECESSARY, PARENTERAL IRON SUCROSE AND FERRIC GLUCONATE COMPLEX HAVE A LOWER RISK OF SERIOUS

REACTIONS THAN IRON DEXTRAN.•

• RESPONSE OF THE ANEMIA TO IRON THERAPY SERVES AS AN IMPORTANT DIAGNOSTIC AND

THERAPEUTIC TOOL

• BLOOD TRANSFUSION IS RARELY NEEDED. (IMMINENT HEART FAILURE, ONGOING BLOOD LOSS, SEVERE ANEMIA)

• TREATMENT OF THE UNDERLYING CAUSE

• E.G. HOOKWORM INFESTATION

RESPONSES TO IRON THERAPY IN IRON-DEFICIENCY ANEMIA
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
• DIFFERNTIAL DIAGNOSIS
• 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)

• ➤DISORDER OF IRON METABOLISM(ACERULOPLSMINEMIA)

PREVENTION OF IRON DEFICIENCY
• EXCLUSIVE BREASTFEEDING UP TO 6 MONTHS OF AGE

• • WEANING WITH FOODS RICH IN IRON 6 MONTH OF AGE)

• AVOID COW MILK IN INFANTS

• IRON SUPPLEMENTATION OF PRETERM AND LBW BABIES

• >12 MONTHS OF AGE, INTAKE OF COW’S MILK SHOULD BE LIMITED TO LESS THAN 20 OZ PER DAY AND BOTTLE FEEDING SHOULD BE DISCONTINUED.

• • PREVENTION OF HOOKWORM INFESTATION – DEWORMING, SHOES

• IRON SUPPLEMENTATION OF ADOLESCENT GIRLS

• FOOD FORTIFICATION WITH IRON

CASE SCENARIO – HISTORY
PARENTS BRING THEIR 3 YEAR GIRL CHILD TO YOUR CLINIC WITH COMPLAINTS OF INADEQUATE SLEEP, EXCESSIVE CRYING AND POOR EATING, FOR THE LAST 6 MONTHS
•

• THEY COMPLAIN THAT SHE TRIES TO EAT WALL PAINT, DUST AND CLAY
HISTORY OF BIRTH AND DEVELOPMENT ARE UNREMARKABLE
. NUTRITIONAL HISTORY –
-- CHILD WAS BREAST FED FOR SIX MONTHS
-- ANIMAL MILK WAS STARTED FROM SIX MONTHS OF AGE.
-- NOW SHE TAKES ANIMAL MILK MORE THAN A LITER IN DAY AND NIGHT.
-- SHE TAKES JUICES AND FEW BITES OF BREAD OR BISCUITS
•ON EXAMINATION,
-- SHE IS MARKEDLY PALE,
-- THERE IS A SHORT SYSTOLIC MURMUR AUDIBLE IN HEART,
-- LYMPH NODES, LIVER AND SPLEEN ARE NOT PALPABLE
• WHAT IS THE MOST LIKELY DIAGNOSIS?