NUTRITIONAL IRON DEFICIENCY ANEMIA

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NUTRITIONAL IRON DEFICIENCY ANEMIA

• Jie Yu MD. Professor
• The Department of Pediatrics Hematology/Oncology,
  Childrens Hospital

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CONTENTS

• INDUCTION
• IRON METABOLISM
• ETIOLOGY /PATHOGENESIS
• MANIFESTATIONS
• LABORATORY FINDINGS
• DIAGNOSIS DIFFERENTIAL
• PREVENTION TREATMENT

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INTRODUCTION

• Definition / describing
• The anemia caused by insufficient dietary iron
  uptake, in which the iron storage and hemoglobin
  synthesis decreased.

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INTRODUCTION

• Clinical characteristics
• ? iron stores ? serum iron
• ?hemoglobin concentration , hypochromic
  microcytic anemia,
• good response to iron therapy.
• 6mo to 3 yrs.
• Incidence

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IRON METABOLISM

• CONTENTS
• New born 75mg/kg
• Children35-70mg/kg
• Adults
• M 50mg/kg
• F 35mg/kg

• CMOPARTMENT
• Hemoglobin 64
• Storage iron 30
• ferritin
• hemosiderin
• Myloglobin 3
• Enzyme iron 0.4
• Serum iron 0.4

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IRON METABOLISM

• Iron sources
• Hemoglobin iron
• Dietary iron

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IRON METABOLISM

• Dietary iron
• High in iron
• Red meat/ liver kidney/ oily fish
• Average iron
• Beans / fortified cereals/ dark green vegetables/
  dried fruit/ nuts and seeds
• Poor in iron
• milk

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IRON METABOLISM

• Iron absorption
• general absorption 1-20
• Meat/ fish/ chicken 10-25
• Cereals/vegetables 1
• Breast/cows milk 50/10

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ABSORPTION TRANSPORT

• Hemoglobin iron non hemoglobin iron
• gastric juice
  proteinase
• proteolytic
  HCl
• heme ferric
• hemolytic ferric
  reductase
• Vit C
  
  ferrous
• duodenum
• upper jujenum ferric
  mucosal cells
• transferrin circulation
  GI tract liver
  /spleen
  marrow
  (fig2)

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IRON METABOLISM
TfR
Ferritin
transferritin
Fe
Mucous cells
Fe
Fe
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IRON METABOLISM

• Iron stores and utilizing

RBC iron
Liver Spleen Marrow
SI
Food iron
Fe
Fe
heme globin
(fig2)
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IRON METABOLISM

• Requirement and excretion
• demand excretion
• adults 1mg/d 1mg/d 1mg/d
• 4mo-3yr 1mg//kg (15ug/kg/d)
• premature 2mg/kg

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ETIOLOGY PATHOGENESIS

• ETIOLOGY
• Poor iron stores
• Poor dietary intake of iron
• Overdevelop
• Chronic bleeding

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ETIOLOGY PATHOGENESIS

• Poor iron stores
• Premature birth
• Multiple birth /Low weight birth
• Cord blood
• Mother iron reserve
• overdevelop
• Poor dietary intake of iron
• Blood loss and iron depletion

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ETIOLOGY PATHOGENESIS

• Poor iron stores
• Poor dietary intake of iron
• Milk and cereals
• Factors influencing absorption
• Diarrhea and infection
• Overdevelop
• Blood loss and iron depletion

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ETIOLOGY PATHOGENESIS

• Poor iron stores
• Poor dietary intake of iron
• Overdevelop
• 3-5mo/ 1yr
• Premature birth
• Puberty
• Chronic bleeding

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ETIOLOGY PATHOGENESIS

• Poor iron stores
• overdevelop
• Poor dietary intake of iron
• Chronic bleeding
• Cows milk
• Hookworm infection
• Menstruating
• Others

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ETIOLOGY PATHOGENESIS

• Pathogenesis
• iron ? protoporphyrin
• IDA
• ? heme globins
  hemoglobin?

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ETIOLOGY PATHOGENESIS

• Pathogenesis
• Hypochromic / microcytic anemia
• ID. Iron deficiency
• IDE. Iron deficiency erythropoiesis
• IDA. Iron deficiency anemia
• Enzymes
• Immune function
• Skin/mucosal

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CLINICAL MANIFESTATIONS

• Features
• Age
• The onset of the IDA
• The degree of anemia

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CLINICAL MANIFESTATIONS

• Pallor
• Extramedullary hematopoiesis
• Mild/ Severe condition
• Digestive system
• Cardiac function
• Neurology/ intellectual
• Immune function

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LABORATORY FINDINGS

• IDA microcytic/hypochromic SI?
• Peripheral blood
• Hemoglobin level
• RBC MCV lt 80fl,
• MCH lt 26ug,
• MCHC lt 0.31
• Bone marrow
• Erythroid hyperplasia
• Stainable iron?

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LABORATORY FINDINGS

• IDA hypochromic/microtytic anemia SI?
• SI lt 9-10.7umol/L (12.8-31.3umol/L)
• or lt 50-60ug/dl (75-175ug/dl )
• TIBCgt 62.7umol/L (gt350ug/dl)
• TS lt 15 (30-50)
• IDE SF?,FEP?(gt0.9umol/L orgt 50ug/dl)
• ID SF lt 12ug/L / marrow iron

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DIAGNOSIS DIFFERENTIAL

• Diagnosis
• Impressionage, feeding, PBL
• Diagnosisbiochemical change
• Proven by therapy

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DIAGNOSIS DIFFERENTIAL

• Differential
• Chronic inflammatory diseases
• Thalassemia
• Pulmonary hemosiderosis
• Siderblastic anemia

Magaloblastic anemia
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Megaloblastic Anemia

• Similar aspects to IDA
• Age
• Anemia by inadequate dietary intake

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Megaloblastic Anemia
Pathogenesis
Nucleotide
Vitamin12?
Tetrahydrofolic acid
Folic acid?
Folic acid reductase
DNA Synthesis?
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Megaloblastic Anemia

• Manifestation Differential
• Pale and puffy
• Neurological involvement
• Lab findings
• Macrocytic normochromic anemia
• Neutropenia with/ thrombocytopenia
• Marrow film megaloblastic forms of nucleated RBC
• Serum Vit B12 and /or folic acid

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Megaloblastic Anemia

• TREATMENT
• General care
• Drug therapy
• Vitamin B12 25-100ug/?,2-3 times/w,weeks or to
  Hb normalOne high dose500ug im
• Folic acid 5-10mg, tid, 2-3w,
• Effect
• Other drug Vitamin C B6iron in recovery
• Transfusion

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TREATMENT

• General care
• Eradicate the causes
• Iron therapy
• transfusion

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TREATMENT

• Iron therapy
• Elemental iron 4-6mg/kg/d
• Oral medication
• Types
• Administration
• Between meals
• Vitamin C
• Course

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Table Ferrous salts ant the iron contents
Ferrous Salts 4mg/kg/d
Ferrous sulfate (20) 20mg/kg/d
ferrous fumarate (30) 13mg/kg/d
Ferrous gluconate(11) 40mg/kg/d
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TREATMENT

• Iron therapy
• Infusion iron
• indication
• types

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IRON THERAPY RESPONSE(from Nelson)
time response
12-24 hr Replacement of iron enzymes,subjective improvement
36-48 hr Initial marrow response erythroid hyperplasia
48-72 hr Reticulocytes peaking 5-7
4-30 days Hemoglobin level ?
1-3 mo Replenish of stores
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TREATMENT

• Transfusion
• Indications
• Severe anemia
• Infection
• Pre-operation
• Component red blood cells
• VolumeHb lt30g/L, 3-5ml/kg
• Hb 30-60g/L, 5-10ml/kg
• Attentions

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PREVENTION

• Education
• For pregnant women
• For interm
• Breast milk/cows milk
• Iron rich supplementary food
• Iron-fortified food
• For premature infant

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• Review these contents after class, try to make
  the summary on
• The characteristics of iron metabolism in fetus
  and infants
• The etiology of IDA
• Laboratory findings according to the stages
• Differentials esp with thalassemia
• Important treatment

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IRON METABOLISM

• Factors influencing iron absorption
• Positive factors
• Ascorbic acid/ gastric acid/amino acid
• Negative factors
• Phosphate/phytate/
• Tea / coffee

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IRON METABOLISM

• Concepts
• SI
• serum iron
• TIBC
• total iron binding capacity
• TS
• transferrin saturation