Iron Deficiency

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Iron Deficiency in pediatric

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Iron Deficiency   Anemia Done by: Mohammed A Qazzaz

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Objective INTRODUCTION PREVALENCE IRON BALANCE REQUIREMENTS Causes CLINICAL MANIFESTATIONS Diagnosis Treatment Prevention of iron deficiency

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INTRODUCTION   Iron deficiency (ID) is the most common nutritional deficiency in children. WHO estimates that anemia affects one quarter of the world's population and is concentrated within pre-school age children and women. Iron deficiency anemia ( IDA ) is a microcytic, hypochromic, and hypoproductive state.

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PREVALENCE Iron deficiency  anaemia  is an important public health problem in the Eastern Mediterranean Region . It is estimated that more than one third of the population in the Region is anaemic . Pregnant women and young children are most at risk 50% of pregnant women and 63% of children under-5 have iron deficiency anaemia . 9 % incidence of iron deficiency and a 2 % incidence of anemia among American females between the ages 12 and 15 years. Less than 1% of adolescent males had iron deficiency  

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IRON BALANCE  75% bound in heme proteins (hemoglobin and myoglobin ). In normal subjects - small amount of iron enters and leaves the body on a daily basis. Iron balance is achieved primarily by mechanisms affecting intestinal absorption and transport. In infants and children, 30% of daily iron needs must come from diet.

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Intestinal iron absorption is a function of three principal factors: body iron stores ( transferrin and ferritin ) erythropoietic rate bioavailability of dietary iron. Iron absorption also is increased when there is increased erythropoiesis and reticulocytosis or ineffective erythropoiesis , as in beta thalassemia . Heme dietary sources have a higher bioavailability of iron than do non- heme sources (30 versus 10 percent) Ascorbic acid enhances the absorption of non-animal sources of iron. Tannates (teas), bran foods rich in phosphates , and phytates (plant fiber, especially in seeds and grains) inhibit iron absorption.

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REQUIREMENTS Breast milk contains only 0.3 to 1.0 mg/L iron, but has a high bioavailability (50 percent) Iron-containing formulas with 12 mg/L iron have only 4 to 6 percent bioavailability. Full-term: 1 mg/kg (maximum 15 mg) Children 1 to 3 years old: 7 mg/day Children 4 to 8 years old: 10 mg/day Children 9 to 13 years old: 8 mg/day

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Causes

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Perinatal risk factors   At birth- iron stores ~75 mg/kg , mean hemoglobin concentrations are 15 t 17 g/ dL . First three to six months of life , by reducing the iron stores at birth or through other mechanisms: Maternal iron deficiency Prematurity Fetal-maternal hemorrhage (FMH) Twin-twin transfusion syndrome (TTS) Other perinatal hemorrhagic events Insufficient dietary intake of iron during early infancy

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Dietary factors    Insufficient iron intake Decreased absorption due to poor dietary sources of iron Introduction of unmodified cow's milk (non-formula cow’s milk) before 12 months of age Occult blood loss secondary to cow's milk protein-induced colitis

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Gastrointestinal disease Gastrointestinal malabsorption of iron:   Active celiac disease Crohn’s disease Giardiasis Resection of the proximal small intestine. Conditions that cause gastrointestinal blood loss : Cow’s milk protein-induced colitis Inflammatory bowel disease c hronic use of aspirin or nonsteroidal antiinflammatory drugs, are also associated with iron deficiency.

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CLINICAL MANIFESTATIONS Iron deficiency anemia (IDA) is a microcytic, hypochromic, and hypoproductive state. The most common presentation of IDA is an otherwise asymptomatic , well nourished infant or child who has a mild to moderate microcytic, hypochromic anemia Much less frequent are infants with severe anemia , who present with: Lethargy Pallor Irritability Cardiomegaly Poor feeding Tachypnea .

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A number of abnormalities of epithelial tissues are described in association with iron deficiency anemia. These include: Esophageal webbing Koilonychias Glossitis Angular stomatitis Gastric atroph

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Neurodevelopmental  Impaired psychomotor and/or mental development. cognitive impairment can occur in adolescents. negatively impact infant social-emotional behavior may contribute to the development of attention deficit hyperactivity disorder . Exercise capacity Pica and pagophagia   Thrombosis  —  cerebral vein thrombosis

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Diagnosis

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Birth -Mean Hb = elevated, but highly variable 2 mos –“ physiologic” anemia - 2 SD Hb = 9.4 g/ dL 6 mos to 24 mos - 2.5 SD Hb 11.0 g/ dL American Academy of Pediatrics Hb <11.0, Hct < 33% defines anemia

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For infants up to 24 months The most cost effective strategy is a therapeutic trial of iron . Ferrous sulfate   this is given at 3 mg/kg of elemental iron, given once or twice daily between meals ( ie , 3 to 6 mg/kg/day total ). If four weeks of this treatment produces a hemoglobin rise of greater than 1 gm / dL , this confirms the diagnosis of iron deficiency .

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2 years and adolescence , we suggest slightly more evaluation. This is because IDA is somewhat less common in otherwise-healthy children than in infants. Therefore , in addition to evaluating CBC (with indices for MCV and RDW), we suggest performing a reticulocyte count and reviewing a blood smear, and screening several stools for occult blood.

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  Normal Fe deficiency without anemia Fe deficiency with mild anemia Severe Fe deficiency with severe anemia Marrow reticulo - endothelial iron 2+ to 3+ None None None Serum iron (SI), µg/ dL 60 to 150 60 to 150 <60 <40 Total iron binding capacity (transferrin, TIBC), µg/ dL 300 to 360 300 to 390 350 to 400 >410 Transferrin saturation (SI/TIBC), percent 20 to 50 30 <15 <10 Hemoglobin, g/ dL Normal Normal 9 to 12 6 to 7 Red cell morphology Normal Normal Normal or slight hypochromia Hypochromia and microcytosis Plasma or serum ferritin, ng /mL 40 to 200 <40 <20 <10 Erythrocyte protoporphyrin , ng /mL RBC 30 to 70 30 to 70 >100 100 to 200 Other tissue changes None None None Nail and epithelial changes

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Test Expected value in patients with iron deficiency anemia Confounding factors Hemoglobin <11 g/ dL Viral infections may cause a transient decrease in hemoglobin Mean corpuscular volume MCV <70 Thalassemia trait Red cell distribution width RDW >15 Infection or inflammation, hemolysis Erythrocyte protoporphyrin >70-80 µg/ dL Lead poisoning Total iron-binding capacity >450 µg/dL Liver disease, inflammation, or hemolysis may lower TIBC; pregnancy or hormonal contraceptives may increase TIBC Transferrin saturation <12-15 percent Infection or inflammation Serum ferritin <12 ng/mL Infection or inflammation; liver disease Transferrin receptor Increased Increased in high turnover states Serum iron <30 µg/ dL Diurnal variation; iron intake; infection or inflammation

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Test Iron deficiency anemia Alpha/beta thalassemia Anemia of chronic disease Hemoglobin MCV RDW Erythrocyte protoporphyrin Total iron-binding capacity Transferrin saturation Serum ferritin Transferrin receptor

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Microcytic hypochromic red cells Normal peripheral blood smear

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Treatment

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Treatment Oral iron therapy is started at a dose of 3 mg/kg of elemental iron, given once or twice daily . It should be given 30 to 45 minutes before meals or two hours after meals, and only with juice or water, rather than with food or milk. <12 months: iron-fortified formula A cow’s milk-based formula Unmodified cow’s milk (non-formula cow’s milk) should not be given to infants. >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.

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CBC is reevaluated in 4 weeks when the child is healthy. If the hemoglobin ( Hgb ) has increased by 1 g/ dL , therapy is continued and a CBC is retested every 2 to 3 months until the Hgb reaches the age-adjusted normal range. Oral iron is continued for an additional two months after the Hgb reaches the normal range for age.

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Prevention of iron deficiency Encourage breastfeeding exclusively for 4-6 MO. > 4MO an additional source of iron should be added, first as an iron supplement, then transitioning to iron-fortified infant cereals. <12 MO who are not breastfed or are partially breastfed, use only iron-fortified formulas (12 mg of iron per liter ). 6 MO encourage one feeding per day of foods rich in vitamin C . > 6 MO pureed meats. Avoid feeding unmodified (nonformula) cow's milk until age 12 months . 1-5 y should also consume an adequate amount of iron-containing foods to meet daily requirements.

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Thank you

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