Nutritional Anemias

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Nutritional Anemias
K N Agarwal MD (Ped-Hem Sweden),MD DCH FIAP
FAMS FNA President, Health Care Research
Association for Adolescent, Z-18, Hauz Khas,
N-Delhi, 110016 adolcare_at_hotmail.com
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Definition of nutritional anemia.

• Hemoglobin g/dl cut off- . (WHO/UNU-1996)
• 6mo-5yr lt11.0 5-11 yr. - 11.5
• 12-13 yr -12.0g/dl Men 13.0
• Women Non-pregnant - 12.0Pregnant 11.0
• Irrespective of Hb level , if an individual shows
  rise in hemoglobin after hematinics
  administration he/she is anemic (Garby et al
  1969).

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Why adult Child Hemoglobin level differ

• No satisfactory answer-
• Children have 50 more inorganic phosphate,
  associated with
• Elevated RBC adenosine triphosphate and 2,3
  diphosphoglycerate content-
• Thus oxygen affinity is decreased in children as
  compared to adults.

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Nutrients in hemoglobin synthesis.

• Proteins- all essential amino acids are
  necessary methionine deficiency megaloblastic
  anemia
• Vitamins-
• - B12 and folic acid megaloblastic anemia
• -C- Fe to Fe Releases Fe from stores.
• -A- mobilises Fe from stores improves
  utilisation
• -B6- macro/micro anemia,
• -B2- BONE MARROW-hypoplasia----
• ANOREXIA NERVOSA-Affects all cell lines.
• Thus in PEM and other hematopoietic nutrient(s)
  anemia on Fe- suppl alone will have poor
  response.

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Clinical Features-

• Insidious onset- even Hblt8g/dl, child patient may
  be comfortable physical activity may not be
  decreased even lt6g/dl- ADJUSTMENT
• Rapid breathlessness, dizziness, faintness,
  fatigue, CHF, heart murmurs-systolic in timing
  heard at pulmonary area.
• Pallor eyelids, tongue, nail bed (changes less
  common below 6 yr.) PICA
• Psycho neurological changes- B12 and or Folic
  acid deficiency- Megaloblastic anemia.
• Dyspigmentation /pigmentation- megaloblastic
  anemia

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Effects of maternal iron deficiency on feto
placental unit

• Transport of iron from mother to fetus remains
  proportionate to the degree of maternal
  hypoferriemia (Agarwal et al.AJCN 1979, Acta
  Paediatr 1978 1984).
• Placental iron content reduces significantly.
• Fetal brain iron content and neurotransmitters
  are reduced (BJN 2001 Agarwal).
• Fetal Liver iron stores are reduced.
• However, Breast milk iron content is increased
  (Agarwal et al. Acta Paediatr 1985).

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Physiological anemia of infancy

• Normal newborn- High Hb level progressively
  declines by 8-12 wk -9-11g/dl.- Hypoxia
  stimulates Renal and Hepatic oxygen sensors
  erythropoietin production increases.
• Preterm- Hb decline is extreme rapidly falls to
  7-9 g/dl by 3-6 wk of age.- Sampling for Lab
  tests. There are relatively insensitive Hepatic
  oxygen sensors as Renal Oxygen sensors switch on
  at 40 wk of gestation.

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Prevalence of nutritional anemia

• NFI 2002-2003- 7 states (Assam, HP, Hy, Kerala,
  MP, Orissa, TN ) anemia prevalence- Pregnancy
  86.1(Hb lt7.0g/dl- 9.5) Lactation 81.7 (Hb
  lt7.0g/dl - 7.3) Agarwal et al 2005..
• ICMR 1999-2000- 11 states 19 districts 84.6 (Hb
  lt7.0 g/dl- 9.9 ).
• 90 adolescents were also anemic Teoteja et al
  2000.
• gt80 lt 3 yr children are anemic NFHS-II Agarwal
  et al.
• Magnitude and severity of anemia at all ages
  seems to show life cycle with nutritional anemia
  in INDIA.

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Megaloblastic Anemias

• Hypersegmented Neutrophil 98 had one cell with
  gt6 lobes
• Oval macrocytes.
• Bone-marrow- Large Erythrocyte and Leucocyte
  series Megaloblasts have sieve like chromatin-
  dissociation between nucleus and cytoplasm
  maturity.
• Vitamin B12 and folate levels to differentiate.

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Fetal Latent Iron Deficiency- brain iron content
neurotransmitters- irreversible reduction

• Brain iron content was reduced.
• Excitatory and inhibitory neurotransmitters and
  their receptors were reduced.
• MRI-spectroscopyThere was an increase in
  creatinine and aspartate and reduction in
  choline concentration(BJN Agarwal 2001)

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Control Treatment of Anemias
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Feeding in early infancy

• Baby should be breast fed colostrum and mature
  milk, both have 49 absorbable iron this is
  sufficient with available fetal stores till baby
  doubles the birth weight.
• Weaning foods from 6 months onwards should have
  one iron rich dietary item and iron
  supplementation be given as recommended. Cook in
  iron vessels.

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Iron fortified food.

• Iron EDTA has been highly effective in
  fortification trials with Egyptian flat breads,
  curry powder in South Africa, fish sauce in
  Thailand, and sugar in Guatemala.
• In Grenada , flour used in commercial baking is
  enriched with iron and B vitamins,.
• Indian researchers have field tested with success
  iron fortified salt.
• Pasteurized milk (iron 15 mg/ l and Vit. C 100
  mg/l.)-Stekel 1986

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Availability of dietary iron by cooking in cast
iron utensils

• WHO 1992 prevalence of pregnancy anemia report,
  records that lowest, rates of all the subregions
  of the developing world were observed in southern
  Africa, due to wide spread use of iron cooking
  pots by indigenous people.
• Agarwal et al (Lal et al IJMR-1973) had
  demonstrated that cooking in cast iron utensils,
  for boiling milk, cooking vegetables etc,
  provided extra dietary iron. This available
  dietary iron is well absorbed.

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Diagnosis of Deficiency Anemias
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Iron deficiency Diagnosis-

• RBC-hypochromic microcytic, progressive fall in-
  MCV, MCH MCHC .
• Reduction in Reticulocyte Hb content.
• sTfR-soluble transferrin receptor increases in
  iron def. and ineffective erythropoiesis, No
  change in Chr. Inf. anemia.

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Contd.

• TfR index-ratio of sTfR to the log of ferritin,
  value gt1.5 Iron def lt1.5 anemia chronic
  diseases.
• EPP- Erythrocyte Porphyrin increases in iron def,
  lead poisoning and chr. Inflammatory anemia.
• Serum Ferritin with negative CRP.
• Absence of Bone marrow iron content. Low hepatic
  iron content.

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We at all ages live in life cycle with
anemia.Nutritional Anemia is treatable and can
be controlled measures are affordable.