Childhood ida2010

1st May 2010 Khorfakkan Scientific Anemia Day 1

Khorfakkan Scientific

anemia Day 1st May 2010


Typical Scenario

*18 month old child brought in by mom for check up•Healthy, URTI a few weeks ago (in daycare)•Picky eater, but drinks lots of milk* Growing well, pudgy•Grand-mother thought he was a bit pale


Physical exam

*Pale, chubby, wt at 95%, ht at 60%*HR 140, RR 20, BP 90/50, SPO2 97%*Conjunctiva and mucous membranes slightly pale*Chest clear*No organomegaly, no adenopathy


Lab values

*CBC Hgb 5.4, Plt 735, WBC 8.5 with normal diff*MCV, MCHC decreased*Retic count low*Smear Microcytic, hypochromic cells*Ferritin


Microcytic, hypochromic

cells


Why is it important to know how

to diagnose and treat IDA?


30% of the world’s population has anemia,

1 billion have IDA Global prevalence

is 53.6% in preschool children

ANEMIA – A PUBLIC HEALTH PROBLEM

McLean E, Egli I, Cogswell M, de Benoist B,Wojdyla D. Worldwide prevalence of anemia in preschool aged children, pregnant women and non-pregnant women of reproductive age.Ch1:1-12.In: Kraemer K, ed. Nutritional Anemia. Sight and Life press. Basel, Switzerland. 2007.


Anemia is a severe public health problem in Africa, Asia, Latin America

and the Caribbean


World Health Organization (WHO). Nutrition. Geneva: WHO, www. who.int/nutrition/en: WHO 2007

http://www.who.int/nutrition/en




Iron deficiency identified as one of ten most serious risk in countries

with high infant and adult mortalities


World Health Organization. The world health report 2002: reducing risks, promoting healthy life. Geneva, Switzerland: World Health Organization, 2002.


Anemia as a

public health

problem by country;

preschool children


Anemia prevalence and number of Individuals affected in preschool-age children in each WHO region


• ~ 2 billion anemic

• Severe anemia →high mortality

• Mild to moderate anemia– Impairs child development– Decreases work capacity

Iron Deficiency/Anemia: A Major Global Problem


Conceptual diagram of

the relationshipbetween iron

deficiency and anemia

in a hypothetical population

Yip R. Iron nutritional status defined. In: Filer IJ, ed. Dietary Iron: birth to two years. New York, Raven Press, 1989:19-36.


ANEMIA

Definition Anemia is defined as:A decrease in the concentration of circulating red blood cells or in the hemoglobin concentration and a concomitant impaired capacity to transport oxygen.

McLean E, Cogswell M, Egli I, Wojdyla D, de Benoist B.Worldwide prevalence of anaemia, WHO Vitamin and Mineral Nutrition Information System, 1993-2005.Public Health Nutr. 2009 Apr; 12(4):444-54. Epub 2008 May 23.


ANEMIAWHO Diagnosis Hemoglobin below 11gm/dl in pre school

children.

UNICEF/UNU/WHO. Iron deficiency anemia: assessment, prevention and control. A guide for programme managers.WHO/NHD,2001 [report no.01.3]


IRON DEFICIENCY ANEMIA

One of the 15 leading causes of global disease burden

Boccio JR, Iyengar V. Iron deficiency: causes, consequences, and strategies to overcome this nutritional problem. Biol Trace Elem Res. 2003 Jul; 94(1):1-32. Review

Global picture

•25 Million DALYs lost due to IDA

Stoltzfus R., Stiefel H., Iron deficiency and the global burden on disease. Symposium: Integrating programs to move iron deficiency and anemia control forward. Marrakesch, Morocco, 6 February 2003


Iron deficiency

Is an abnormal value for at least two of three laboratory indicators of iron status:

1. Serum ferritin 2. Transferrin

saturation 3. Free erythrocyte protoporphyrin

As defined by the National Health and Nutrition Examination Survey (NHANES)


IRON DEFICENCY

STAGES

Prelatent reduction in iron stores without reduced serum iron levelsLatentiron stores are exhausted, but the blood hemoglobin level remains normalIron deficiency anemiablood hemoglobin concentration falls below the lower limit of normal


Functions of

Iron

Formulation of hemoglobin Binding O2 to RBC and transport Formulation of cytochrome myoglobin Regulation of Body temperature


Functions of

Iron

Muscle activity Catecholamine metabolism Immune system Brain Development & functionThyroid function

Cont.


Iron Concentration

In Brain

25%25%

50%50%

75%75%

100%100%

BirthBirth 22 YearsYears

10 10 YearsYears

Adult Adult HumanHuman

MaximumMaximum

MyelinationMyelination


ANEMIAIron deficiency anemia occurs when iron deficiency is severe enough to reduce hemoglobin levels below normal.

NHANES 1999-2000


Normal values

Harriet Lane Handbook, The John Hopkins

Hospital,15th edition

AGE HgbMean/ (-

2SD)

HCT%Mean/ (-

2SD)

MCVMean/ (-2SD)

Newborn 16.5 (13.5) 51 (42) 108 (96)

1 Month 13.9 (10.7) 44 (33) 101 (91)

2 Months 11.2 (9.4) 35 (28) 95 (84)

6 Months 12.6 (11.0) 36 (31) 76 (68)

> 6 Months 12.5 (11.0) 36 (33) 81 (70+ age per yr)


http://www.cdc.gov/hemochromatosis/training/pathophysiology/iron_cycle_popup.htm

Iron cycle


Mechanism

of developmen

t of

Anemia Normal Iron deficiency anemia


Factors

Contribute

To the

Development

Of

Anemia

http://www.caribou.bc.ca/schs/medtech/rice/IronDeficiency.html


Iron deficiency

Anemia

http://www.caribou.bc.ca/schs/medtech/rice/IronDeficiency.html

•Dietary iron deficiency is the usual cause• Iron def. is common in children 9mo-3yr•Infants less than 6 months generally do not develop iron def. •Iron def. anemia in a child over 3yr should prompt consideration of occult blood loss


Iron deficiency

Anemia

(cont.)

•Dietary deficiency

•Increased demand (growth)

•Impaired absorption

•Blood loss (e.g.) - gut problems - lung - nose - kidney - menstrual problems - trauma

Causes


Iron deficiency Anemia

(cont.)

•Pallor is the most important sign •Mild to Moderate iron deficiency ( hemoglobin levels of 6 -10 g/dL) few symptoms of anemia; irritable, Pagophagia•Severe iron deficiency ( hemoglobin levels of 6 -10 g/dL) Irritability , Anorexia, Tachycardia, Cardiac dilation, Systolic murmurs

Clinical Manifestation



(cont.)

Clinical Manifestation (Cont.)

Iron deficiency may have effects on neurologic and intellectual functionsIron – deficiency anemia and even iron deficiency with out anemia affect : *Attention span *Alertness *Learning



(cont.)


Decreased cognitive performance often accompanies iron deficiency and iron deficiency anemia

Murray-Kolb LE, Beard JL. Iron treatment normalizes cognitive functioning in young women. Am J Clin Nutr. 2007; 85:778-787.



(cont.)


Koilonychia: "spoon nails” Iron deficiency anemia



(cont.)


Smooth, bald, burning tongue; Iron deficiency anemia



(cont.)


Angular Cheilosis or Stomatitis



(cont.)

Bone marrow

ABSENT IRON STORES IN BONE MARROW IN IRON DEFICIENCYABSENT IRON STORES IN BONE MARROW IN IRON DEFICIENCY

Normal control Iron deficiency


Laboratory Findings

Prelatent Hgb (N), MCV (N), iron absorption (), transferrin saturation (N), serum ferritin (), marrow iron ()

LatentHgb (N), MCV (N), TIBC (), serum ferritin (), transferrin saturation (), marrow iron (absent)

Iron deficiency anemia Hgb (), MCV (), TIBC (), serum ferritin (), transferrin saturation (), marrow iron (absent)


Laboratory Findings (Cont.)

•With increasing deficiency ,RBCs become deformed and misshapen and present characteristic : - Microcytosis

- Hypochromia

- Poikilocytosis - Increased RBC distribution width (RDW)• Reticulocyte percentage may be normal or moderately elevated • Nucleated RBCs occasionally seen• Thrombocytosis (some time) • Normal white blood cells


Laboratory Findings (Cont.)

•Additional diagnostic tests - Free erythrocyte protoporphyrin (elevated) - Serum ferritin (decreased) - Serum iron (decreased) - Iron binding capacity (increased) - Iron saturation (decreased)


Differential Diagnosis

Other hypochromic microcytic anemias

•1.ß-Thalassemia trait * mild microcytic anemia * elevated levels of hemoglobin A2 and/or fetal hemoglobin concentration * Serum iron, total iron-binding capacity (transferrin) and ferritin are normal




2. a-Thalassemia trait * presence of familial hypochromic microcytic anemia * normal results of iron studies * normal levels of Hgb A2 and Hgb F *In new born ,3 -10% hemoglobin Barts (gamma 4)

(Cont.)




3. Hgb H disease * a form of a-Thalassemia results from deletion of three of the four a-globin genes * hypochromia and microcytosis * a mild hemolytic component from instability of the ß-chian tetramers (Hgb H)

(Cont.)




4. The anemia of chronic disease (ACD) * Elevated FPR * Coarse basophilic stippling of the RBC is frequently prominent * Elevations of blood lead. FEP, and urinary coproporphyrin levels Serum transferrin receptor (TIR) level is useful in distinction between irondeficiency anemia and anemia of chronic disease

(Cont.)


IRON DEFICIENCY versus ACD


Serum Iron Transferrin Ferritin

Iron Deficiency

ACD


PRINCIPLESPRINCIPLES OFOF

TREATMENTTREATMENT

1.Use oral iron

2.Replace iron deficit in total

3.Establish

and treat

the cause



TREATMENTTREATMENT

4.The therapeutic dose should be

calculated interms of

elemental iron

5. A daily total of 4 -6 mg/kg of elemental iron in

three divided doses provides

an optimal amount of iron

6.A parenteral iron

preparation (iron dextran) is an effective form of iron

(Cont.)



TREATMENTTREATMENT

(Cont.)

The regular

response of iron-deficiency anemia

to adequate amounts of iron is

an important diagnostic and

therapeutic features.



TREATMENTTREATMENT

(Cont.)

Oral administration of simple ferrous

salts ( sulfate, gluconate, fumartate) provides inexpensive

and satisfactory therapy


Elemental iron (EI) in various forms of iron

tablets

1.Ferrous sulfate (20%EI) (300 mg tablets) 60 mg

2.Ferrous gluconate (12 %EI) (300 mg tablets) 34 mg

3.Ferrous fumarate (33 %EI)(200 mg tablets)66 mg


Parenteral therapy

indications•poor compliance•severe bowel disease•intolerance of oral iron•chronic hemorrhage•acute diarrhea disorder


Parenteral therapy

Iron dextran: (IM-IV) 50 mg

iron/mL Low and high

molecular weight

Ferric gluconate complex (IV) less incidence of allergic reactions

Iron sucrose: (IV) safe even with sensitivity to iron dextran


Parenteral therapy

Ferumoxytol: safe and effective

as a rapid intravenous infusion up to 510 mg

in patients with chronic kidney disease and on

dialysis.

Ferric carboxymaltose: (IV) given at single doses of up to 1000 mg iron per week over of 15

minutes

(Cont.)


Blood transfusion

•Is indicated only when •1.Anemia is very severe 2.Superimposed infection may interfere with the response

Packed or sedimented

RBCs should be

administered slowly

In severely anemic children with

hemoglobin values less than 4 g/dL

should be given only2 -3 mL/kg of packed cells at any one time


Responses to iron therapy in irondeficiency anemia

Time after Iron Administration

Response

12 -24 hr Subjective improvement; decreased irritability,

increased appetite

36 -48 hr Initial bone marrow response

48 -72 hr Reticulocytosis, peak at 5 -7 days

4 -30 days

Increase in hemoglobin level

1 -3 mo Repletion of stores


Failure of iron therapy

occur when:

1. A child does not receive the prescribed medication2. Iron is given in a form that is poorly absorbed 3. There is continuing unrecognized

blood loss such as : * intestinal or pulmonary loss * loss with menstrual periods 4. An incorrect original diagnosis


Short term Prevention of IDA In infancy

•Avoid gestational ID • Try to prevent premature delivery and low birth weight• Increase birth spacing• Delay pregnancy beyond teens• Delay ligation of umbilical cord (by 30-60 seconds)


Short term prevention of IDA In children and adolescents

•Avoid gestational ID • Try to prevent premature delivery and low birth weight• Increase birth spacing• Delay pregnancy beyond teens• Delay ligation of umbilical cord (by 30-60 seconds)


Sustainable approaches to elimination of micronutrient deficiency e.g. iron

Iron fortification of foods, foods in the target group:• Foods consumed regularly• Consumed in sufficient quantities• Consumed in stable amounts• Centrally processed foods• Foods that are easy to fortify


Iron obtained from animal products is much more easily absorbed by the body than iron from plant sources,


Home Message

•Anemia is a sign, not a disease. •Anemias are a dynamic process. •Its never normal to be anemic.•The diagnosis of iron deficiency anemia mandates further work-up

1st May 2010 Khorfakkan Scientific Anemia Day 60Good to have you with us, Farquhar. We could do with some fresh blood in this place.'


Documents

Childhood ida2010