Iron Deficiency Anemia

Objectives
Understand the prevalence and
epidemiology of iron deficiency
Describe the consequences of iron
deficiency
Formulate a diagnostic and
therapeutic plan to manage iron
deficiency

Background
Most common nutritional deficiency
in the world
insufficient dietary iron
Infants and toddlers susceptible because
of rapid growth and increased demand
for iron

Most common: 1-3 years of age

9% of children under 3 years of age
have evidence of iron deficiency of
which 1/3 are anemic

Background

Stages:
1) Iron depletion = earliest stage of
diminishing iron stores in the setting of
insufficient iron supply
2) Iron deficiency = no anemia, develops
as iron stores are depleted further and
begin to impair hemoglobin synthesis
3) Iron deficiency anemia = supply is
insufficient to maintain normal levels
of hemoglobin

Background
Anemia of lower prevalence today
and is limited in its use to screen for
iron deficiency
High risk of anemia:
Premature, IUGR infants
Breastfed infants greater than 6 months
not receiving iron supplements
Low socioeconomic status

Iron Requirements &

Factors Contributing to
Deficiency

Iron Storage and

Metabolism
Functional Iron
Heme iron for hemoglobin and
myoglobin
Enzymatic processes involved in
respiration, dopamine synthesis, CNS
myelination

Stored Iron
Ferritin, hemosiderin

Iron Storage and

Metabolism
80% of iron stores accumulated in
3rd trimester stores should last for
4-6 months (requirement 1
mg/kg/day)
Preterm infants
1500-2500 = 2mg/kg/day
<1500 = 4 mg/kg/day

Iron Intake and Absorption

Daily recommendations exceed
actual needs WHY?
The digestive process can alter the
amount of iron actually absorbed!
Variables include: 1) amount of iron in
body, 2) rate of RBC production, 3)
amount and type of iron in diet, 4)
presence of absorption enhancers and
inhibitors in diet

Iron Intake and Absorption

Low iron/high RBC production =
increase iron absorption
Heme iron in meat, poultry, and fish
= 2-3 times more absorbable than
non-heme in plant based foods
Absorption
Enhance = ascorbic acid (vitamin C)
Inhibitors = bran, fiber, calcium, tannins,
polyphenols in some vegetables

Iron Intake and Absorption

Breast milk and cow milk 0.5 mg/L of iron
50% of iron from breast milk is absorbed
10% of cow milk absorbed

5% of iron in fortified formulas absorbed,

but formulas have much higher
concentrations in range of 10-12 mg/L
After 6 months of age supplement
breastfed infants with 1-2 mg/kg/day
of iron!

Iron Intake and Absorption

Others at risk:
Toddlers drinking more than 24 oz/day of
cow milk low iron produce and high
satiation value in place of iron-rich foods
Infants introduced to whole milk prior to
12 months of age low bioavailability
of iron and association with occult GI
bleeding

Clinical Impact of
Deficiency

Clinical Manifestations and

Complications of Iron Deficiency
Usually Asymptomatic
Anemia
Pallor, fatigue, tachycardia, blue sclera,
splenomegaly, anorexia, pica (due to
increased lead absorption)

BEHAVIORAL AND DEVELOPMENTAL

Lower test scores of mental and motor
development among infants

Functions of Iron
o Formulation of hemoglobin
o Formulation of cytochrome myoglobin
o Binding O2 to RBC and transport
o Regulation of Body temperature
o Muscle activity
o Catacholamine metabolism
o Immune system

T cell

o Brain Dev & function

o Depressed thyroid function

antibodies

Iron Deficiency (6-24 months)

o Difficulty with language

o Poor Motor Co-ordination and
balance
o Poorer rating on attention
o Poor Responsiveness
o Poor Performance of motor

Physical Growth and

performance

o Weight gain, growth velocity

o Further compounded associated

with
o infection anorexia
o Poor work capacity
o Endurance, work capability
o Rapid gain of weight &
endurance with

Mental and psychomor dev

o Poor attentiveness
o Poor memory
o Poor academic performance
vocabulary,
o

reading, writing, arithmetic

o Disruptive, irritable, restlessness

o Poor performance in test

Concentration of Iron in Brain

o Highest at birth
o Decrease at weaning
o Increase at onset of Myelination
o Maximum at expression of mRNA

Iron Concentration In Brain

100%
Myelination

75%

50%
Maximum

25%

Birth

2 Years

10 Years

Adult Human

Iron def, Infection, physical

growth
o T cell and antibodies diminishes
o Cell mediated immunity
defective
o Killing bacteria capabilities poor
o Capacity of leucocyte defense
poor

Iron and Neurotransmitor

o Dopaminergic system dev in early post
natal life
o Rapid increase in number and density of
DA
transporter, receptor
o Monoamine for axonal growth and
synapse
formation

Critical Period
o Irriversible effect on nerve conduction in
iron
deficiency
o Timing of iron deficiency is of great
importance
o Lead to toddler developmental delay if iron
def earlier
o Sequence Cell migration significant
myelination

Iron Value per 100gm for Common

Food

Food
(mg)

Rice
23.8
Rice Pufed
Wheat
Bengal gram
Bengal G Dal
Rajma
Soyaneam
Milk
Gagery
Apple

Iron (mg) Food

6.4
4.6
11.5
10.2
9.1
5.8
11.5
.1-.3
10.5
0.66

Iron

Bengal G Leave
Coriander L 18.5
Mustard L 16.5
Spinach
10.9
Ginger
10.5
Muster Seed 17.9
Date
7.3
Fish Dried
20-25
Fish Fresh
1-4
Egg
2.1

Diagnosis of Anemia
Dont forget your history Are they
at risk?
Remember that anemia is the end
result of iron deficiency!
Start with hematologic (reflect RBC
status) before biochemical markers
(reflect iron metabolism, more
sensitive) as they are cheaper

Diagnostic Testing
Iron Depletion

Iron Deficiency Iron Deficiency

w/o Anemia
Anemia

Ferritin

Normal/Low*

Low

Low

Transferrin
saturation

Normal

High

High

Erythrocyte
Normal
protoporphyrin

High

High

MCV

Normal

Normal

Low
(microcytic)

RDW

Normal

High

High

Hemoglobin

Normal

Normal

Low

Review of the Tests

Biochemic
al

Hematologi
c

Hemoglobin measures the concentration

of oxygen carrying protein
MCV average volume of RBCs
RDW index of variation of RBC size
Ferritin storage compound for iron
Erythrocyte Protoporphyrin immediate
precursor of hemoglobin
Transferrin saturation proportion of
occupied iron binding sites and reflects
iron transport

Diagnosis
In most cases, simple hematologic tests
associated with an appropriate history and
a trial of iron therapy that demonstrates
an increase in hemoglobin by 1.0g/dL or
more in 1 month are sufficient to make the
diagnosis of iron deficiency anemia.
Capillary blood samples should be confirmed
by venous puncture

If there is doubt use the biochemical

makers to help with the diagnosis!

Diagnosis
Mentzer index used to differentiate
iron deficiency anemia from beta
thalasemia; high sensitivity but low
specificity
MI = MCV/RBC count
MI < 13 likely thalasemia
MI > 13 likely iron deficiency
anemia

Treatment

Treatment
Start empiric treatment with oral
elemental iron at 3-6 mg/kg/day and
retest after 4 weeks of therapy
Increase of Hgb by 1g/dL or 3% rise in
hct confirms the diagnosis of iron
deficiency
Continue therapy for 2 months and
recheck
Discontinue if normal and recheck in 6
months

Treatment
If no response to therapy:
Confirm compliance
Intercurrent ilness?
Stool for occult blood
Check MCV, RDW, Serum Ferritin

Screening
Universal screening for populations
at risk
9-12 months
15-18 months

Selective screening based on

individual risk

Prevention
Breastfed
Supplement all breastfed babies by 4-6 months
of age 1 mg/kg/day
Preterm infants 2 mg/kg/day
Only use iron fortified formula for
supplementing (10-12 mg/dL)

Formula
Preterm 1mg/kg/day iron in addition to
preterm formula
Only use iron fortified formula

Thankyou