Iron deficiency anemia

1. Anemia , Iron deficiency anemia Download more documents and slide shows on The Medical Post [ www.themedicalpost.net ] Dr. Kalpana Malla MD Pediatrics Manipal Teaching Hospital

2. ANEMIA

3. What is Anemia? Reduction of the red blood cell (RBC) volume or hemoglobin concentration below reference level for the age and sex of the individual Hb < - 2SD or 95 th centile for age and sex

4. Anemia Basics All anemias are either due to…. 1. Ineffective RBC production or 2. Accelerated destruction of the RBC

5. By RBC morphology and By Etiological factors responsible for anemia Classification

6. Microcytic hypochromic anemia I ron deficiency anemia – nutritional, - posthemohragic 2. Ineffective Erythropoiesis - hemoglobinopathies , Thalassemia - Lead poisoning, Sideroblastic anemia - Cu deficiency, Pyridoxine deficiency -Chronic ds - infection, inflammations , renal ds

7. Megaloblastic Erythropoiesis a) Nutritional - Folate deficiency, B12 deficiency b) Toxic – Treatment with antifolate compound – methotrexate, , and drugs that inhibit DNA replication – zidovudine, phenytoin c) Congenital disorders of DNA synthesis like Orotic aciduria etc. d) Malabsorption - liver ds Macrocytic anemia

8. Macrocytic anemia Non - Megaloblastic Erythropoiesis Chronic hemolytic anemia Liver ds Hypothyroidism Diamond blackfan syndrome

9. 1. Impaired cell production (low reticulocyte count ) - aplastic anemia - pure red cell aplasia - physiological anemia of infancy - infections - Systemic diseases like endocrinal, renal and hepatic diseases - bone marrow replacement – leukemia, tumors, storage ds , myelofibrosis , osteopetrosis 2 Hemolytic anemia ( reticulocyte count high) Normocytic , Normochromic anemia

10. DIMORPHIC ANEMIA When two causes of anemia act simultaneously, e.g : macrocytic hypochromic due to hookworm infestation leading to deficiency of both iron and vitamin B12 or folic acid following a blood transfusion

11. ETIOLOGICAL CLASSIFICATION OF ANEMIA Blood loss Acute Chronic Decreased iron assimilation - Nutritional deficiency - Hypoplastic or aplastic anemia - Bone marrow infiltration like leukemia & other malignancies, - Myelodysplastic syndrome - Dyserythropoietic anemia

12. Increased physiologic requirement - Extracorpscular - - Alloimmune & isoimmune hemolytic anemia - Microangiopathic anemias - Infections - Hypersplenism ETIOLOGICAL CLASSIFICATION OF ANEMIA

13. ETIOLOGICAL CLASSIFICATION OF ANEMIA Intracorpsular defect Red cell membranopathy i.e. congenital spherocytosis,elliptocytosis Hemoglobinopathy like HbS, C,D,E etc. Thalassemia syndrome RBC enzymopathies like G6PD deficiency, PK deficiency etc.

14. Follow-up Re-check CBC 4-6 weeks (to confirm response) Continue iron 3-4 months (to replace stores) If no improvement on adequate iron therapy, consider evaluating the child for lead poisoning or thalassemia

15. Differential of Anemia

16. IRON DEFICIENCY ANEMIA

17. Most common cause of anemia worldwide Most important cause of iron deficiency anemia is parasitic infection - hookworms, whipworms and roundworms IDA

18. Newborn contains 0.5g of iron, adult contains 5g A diet containing 8–10mg of iron daily is necessary for optimal nutrition 1mg of iron must be absorbed each day - Absorbed in the proximal small intestine Absorbed 2-3 times more efficiently from human milk than from cow's milk GENERAL FEATURES

19. Meat Liver Kidney Egg-yolk Green vegetables Fruits **** Cow’s milk- poor source of iron Iron sources:

20. Distribution of body iron: (adults) - Hemoglobin : 2.3 gm - Storage ( ferritin / haemosiderin ) : 1.0 gm - Non-available tissue iron: 0.5 gm - Transport iron: 3-4 mg - Total : ~5 gm Iron metabolism:

21. 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

22. Iron Metabolism: Figure 16-8: Iron metabolism

23. Increased physiological demand : - growing children (6-24 months) - adolescence - women during reproductive ages Pathological blood loss: - chronic loss Inadequate intake of diets rich in iron: - nutritional deficiency -decreased absorption- gastroenterostomy / tropical sprue / coeliac disease Pathogenesis of IDA:

24. High Hb conc of the newborn falls during the first 2–3 mo - considerable iron is stored - usually sufficient for blood formation in the first 6–9 mo of life in term

25. The most important cause world-wide is infestation with parasitic worms (hookworms- suck 0.03- 0.2 ml of blood per worm /day ),whipworms, roundworms Dietary insufficiency Malabsorption ETIOLOGY

26. Chronic blood loss - occult bleeding : peptic ulcer, Meckel diverticulum, polyp, hemangioma, inflammatory bowel disease, Intravascular hemolysis and hemoglobinuria Chronic diarrhea Milk allergy ETIOLOGY

27. Demograpghic – Eldery, Teenager, Female Dieatary – low Iron, low Vit C, excess phytate,tea coffee, Social and physical – poverty,alcohol abuse,GIT ds Risk factors for IDA

28. Pallor is the most important sign Look for pallor : FACE , nails, palms, conj, mucus membranes Pagophagia (pica for ice) / pica Anxiety , Poor appetite Below 5g/ dL : irritability and anorexia are prominent Tachycardia and systolic murmurs- dyspnea , Palpitations CLINICAL FEATURES

29. Hair loss and lightheadedness Fainting Sleepiness, Tinnitus Mouth ulcers, Glossitis ,Angular cheilitis Constipation Depression, Twitching muscles, Tingling, numbness or burning sensations CLINICAL FEATURES

30. Koilonychia (spoon-shaped nails) , Platynychia Weak,brittle nails Pruritus Dysphagia due to formation of esophageal webs (Plummer-vinson syndrome CLINICAL FEATURES

31. Koilonychia - spoon shaped nail

32. Neurologic and intellectual function Affects attention span, alertness, Verbal learning and memory Monoamine oxidase (MAO ) , an iron dependent enzyme, has a crucial role in neurochemical reactions in the CNS breath-holding spells CLINICAL FEATURES

33. First: Tissue iron stores represented by bone marrow hemosiderin disappear Serum ferritin decreases Next: Serum iron level decreases Serum transferrin,S . iron-binding capacity of the - increases Percent saturation ( transferrin saturation) falls below normal Free erythrocyte protoporphyrins (FEP) accumulates Response to low Hb:

34. Response to low Hb: Later: Microcytosis, hypochromia, poikilocytosis, and increased RBC distribution width (RDW )

35. 1.complete blood count (CBC) - High RBC distribution width (RDW) - reflecting an increased variability in the size of red blood cells (RBCs). - A low MCV,MCH and MCHC Hemoglobin ( Hb )& hematocrit ( Hct ) value – low Reticulocyte - normal or moderately elevated Diagnosis - LABORATORY INVESTIGATIONS

36. 3.Peripheral blood smear – microcytic hypochromic anemia, target cells, hypochromic pencil-shaped cells, and occasionally small numbers of nucleated RBC Thrombocytosis -activate thrombopoietin receptors in precursor cells which make platelets Diagnosis - LABORATORY INVESTIGATIONS

37. 4. Diagnostic tests – - Serum ferritin- low Serum iron - low Serum transferrin -elevated Total iron binding capacity (TIBC) - high 5.Stool for occult blood 6.Stool R/M/E - hookworm and whipworm LABORATORY INVESTIGATIONS

38. Ratio of serum iron to TIBC (called iron saturation or transferrin saturation index - is the most specific indicator of iron deficiency - < 5% - indicates iron deficiency LABORATORY INVESTIGATIONS

39. Gold standard Bone marrow aspiration, with the marrow stained for iron -Bone marrow is hypercellular, with erythroid hyperplasia Leukocytes and megakaryocytes are normal No stainable iron in marrow reticulum cells DiagnosisLABORATORY INVESTIGATIONS

40. Oral administration - ferrous salts (sulfate, gluconate, fumarate) -4–6mg/kg of elemental iron Consumption of milk should be limited Blood loss from intolerance to cow's milk proteins is reduced The amount of iron-rich foods is increased TREATMENT

41. Incorrect diagnosis (eg, thalassemia) Patient is not taking the medication Not absorbed (enteric coated?) malabsorption syndromes gastrectomy/celiac disease Rapid iron loss? Anemia of chronic disease-impairs bone marrow response Oral iron failure?

42. Parenteral iron preparation (iron dextran) : Intolerance to oral iron, severe gastrointestinal complaints Packed or sedimented RBCs : with Hb values < 4g/dL congestive heart failure: fresh-packed RBCs should be considered TREATMENT

43. 12–24 hr Replacement of intracellular iron enzymes; subjective improvement; decreased irritability; increased Appetite 36–48 h r Initial bone marrow response; erythroid hyperplasia 48–72 h r Reticulocytosis, peaking at 5–7 days 4–30 days Increase in hemoglobin level 1–3 mo Repletion of stores RESPONSES TO IRON THERAPY

44. Thank you Download more documents and slide shows on The Medical Post [ www.themedicalpost.net ]