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Tpa 50 1 11 PDF
Abstract
Iron deficiency is the most common nutritional deficiency worldwide and an important public health problem especially in developing countries.
Since the most important indicator of iron deficieny is anemia, the terms iron deficiency and iron deficiency anemia are often used interchange-
ably. However, iron deficiency may develop in the absence of anemia and the tissues may be affected from this condition. The most common causes
of iron deficiency in children include insufficient intake together with rapid growth, low birth weight and gastrointestinal losses related to excessive
intake of cows milk. If insufficient intake can be excluded and there is insufficient response to oral iron treatment in patients with iron deficiency
especially in older children, blood loss should be considered as the underlying cause. The main principles in management of iron deficiency anemia
include investigation and elimination of the cause leading to iron deficiency, replacement of deficiency, improvement of nutrition and education of
the patient and family. In this article, the practical approaches in the diagnosis and treatment of iron deficiency and the experience of our center have
been reviewed. (Trk Ped Ar 2015; 50: 11-9)
Keywords: Anemia, child, iron deficiency
Address for Correspondence: Nihal zdemir, Department of Pediatric Hematology-Oncology, Cerrahpaa Faculty of Medicine, stanbul,
Turkey. E-mail: gnozdemir@hotmail.com
Received: 14.11.2014 Accepted: 05.01.2015
Copyright 2015 by Turkish Pediatric Association - Available online at www.turkpediatriarsivi.com
DOI:10.5152/tpa.2015.2337
11
zdemir N. Iron deficiency anemia in children Trk Ped Ar 2015; 50: 11-9
children whose requirements are not met adequately be observed in relation with heat-sesitive proteins in
are under risk. cows milk. In addition, the absorption of iron in cows
milk is much lower compared to breastmilk. Cows milk
In this article, the signififcant points in diagnosis and will substitute for iron-rich fooods and in addition cal-
treatment of iron deficiency which is one of the most cium and caseinophosphopeptides in cows milk may
common diseases observed in children have been disrupt the absorption of iron. If infants are fed with
compiled in terms of directing pediatricians, the recent iron-poor foods after the 6th month when they exhaust
studies performed in this area have been reviewed and almost all of their iron stores, iron deficiency develops
the experiences of our center have been explained. easily.
12
Trk Ped Ar 2015; 50: 11-9 zdemir N. Iron deficiency anemia in children
years after treatment (16). ID which has progressed could be diagnosed with a detailed history with a sen-
to iron deficiency anemia may cause to disruption in sitivity of 71% and specificity of 79% (25). Especially
mental and motor functions and these effects may be prenatal period, nutrition, times of starting breastmilk
permanent. The mechanism of action by which iron and solid foods and bleeding history should be inter-
deficiency causes to neurocognitive disorders is not rogated in detail. Signs of anemia and other systemic
fully understood. In some studies, it was shown that ID diseases which may accompany should be searched
decreased expression of dopamin receptors, disrupted for.
myelinization or disrupted the function of various en-
zymes involved in the nerve tissue (17-19). Again, an- The laboratory tests which may be used are summa-
other important yet controversial clinical effect of iron rized in Table 2. The primary action is ordering com-
deficieny is its effects on the immune system (20-22). plete blood count and peripheral blood smear. When
In addition, it was shown that IDA was strongly related complete blood count is assessed well, it may give
with febril convulsions in some recent studies and in a many clues in the diagnosis of many diseases of the
meta-analysis performed in 2010 (23, 24). childhood (26). In complete blood count, it should be
primarily checked if hemoglobin and hematocrit val-
Diagnosis and laboratory findings ues are normal for age and gender (if anemia is pres-
In medicine, a detailed history and physical examina- ent). The lower limits of normal by age and gender
tion is essential in the diagnosis of all diseases as a specified by the World Health Organization may be
general rule. In one study, it was shown that anemia used, since they are practical and values lower than
these limits are considered anemia (Table 3). In infants
Table 1. Iron deficiency findings younger than 6 months, lower values are observed be-
Skin Immune system disorders cause of physiological anemia, but hemoglobin is not
expected to be lower than 9 g/dL in physiological ane-
Pallor Decreased resistance against infections
mia in term infants if there is no other accompanying
T lymphocyte and polymorphonu- factor.
clear leukocyte dysfunction
Nails
Table 2. Investigations which may be oredered in pati-
Koilonychia ents in whom iron deficiency is considered
Central nervous system
Irritability-malaise Complete blood count
Musculoskletal system Peripheral blood smear
Fainting
Decreased effort capacity Reticulocyte
Papilledema
Exercise limitation Urea, creatinine
Pseudotumor cerebri
Serum iron, total iron binding capacity, transferrin saturation
6th nerve palsy index
Cardiovascular system
Restless leg syndrome Ferritin
Increased cardiac output
Breath holding spell Serum soluble transferrin receptor levela
Tachycardia
Sleep disturbance Free erythrocyte protoporphyrina
Cardiomegaly
Used with a low rate in practice
a
Attention deficit
Heart failure
Learning difficulty Table 3. Lower limits for hemoglobin and hematoctrit
Behavioral disorder values specified by the World Health Organization
Gastrointestinal system by age and gender
Decrease in perception functions
Loss of appetite
Retardation in motor and mental Groups by age Hemoglobin Hematocrit
Angular stomatitis and gender (g/dL) (%)
developmental tests
Atrofic glossitis Children aged between 6-59 months 11 33
Dysphagia Children aged between 5-11 years 11.5 34
Increased absorption of heavy metals
Pica Children aged between 12-14 years 12 36
Lead intoxication
Gluten sensitive enteropathy Girls aged >15 years 12 36
Plummer-Vinson syndrome Boys aged >15 years 13 39
13
zdemir N. Iron deficiency anemia in children Trk Ped Ar 2015; 50: 11-9
Erythrocytes appear pale and smaller than normal younger than 10 years, because the lower limit is 80 fL
when the amount of hemoglobin inside is reduced. in children older than 10 years as in adults.
This is manifested by reduced mean erythrocyte vol-
ume (MCV) and reduced mean eryhtrocyte hemoglobin In anemias related with nutritional deficiencies, there
(MCH) in complete blood count. On peripheral blood is a non-homogeneous erythrocyte volume in contrast
smear, the erythrocytes are microcytic and hypochro- to congenital anemias including thalassemia; erythro-
mic. Mean erythrocyte volume and MCH are parallel cytes may have variable sizes according to the amount
to each other; this means that microcytic erythrocytes of hemoglobin. This is reflected by anisocytosis on pe-
are hypochromic at the same time. If the MCH is below ripheral smear and by increased eryhtrocyte distribu-
tion width (RDW) on blood count. Basically, nutritional
27 pg, it is low. The normal value of mean erythrocyte
deficiency should be considered, if incrased RDW to-
volume ranges between 80 and 99 fL, but normal val-
gether with anemia is present; if reduced MCV is also
ues by age should be considered in children. Formulas
present, iron deficiency is considered and if increased
which may be used simply in busy outpatient clinical
MCV is present, vitamin B12 or folic acid deficiency
practice are also present (Table 4). Here, it is import- may be present. However, it should be kept in mind that
ant to use the formula for the lower limit for children withdrawal or deficiency anemia where all variables are
Table 4. Laboratory findings in iron deficiency disrupted is not observed rarely in most children with
malnutrition. A normal RDW value and microcytosis
Complete blood count: suggest thalassemia carier state rather than iron de-
RDW>14 ficiency anemia. Generally, two seperate RDW results
RBC: low are noted in complete blood count results; RDW-CV
Hb, Hct: low according to age and gender and RDW-SD. This arises from a statistical calculation
MCV: low according to age and gender difference. RDW-SD is the standard deviation of the
erythrocyte and is the mean of deviations from MCV of
When specifying the lower limit of MCV: 70+age
(for >10 years) each erythrocyte; its normal range is 37-54 fL. RDW-CV
(if MCV is <72, generally abnormal)
is the variability coefficient of erythrocyte distribution
volume and the percentage expression of the standard
Upper limit of MCV: 84 + age x 0,6 (for >6 months)
deviation by mean erythrocyte volume. RDW-CV is a
(if MCV>98: always abnormal)
more reliable measurement and is abnormal if it is >14.
MCH<27 pg In addition, erythrocyte distribution width is the first
MCHC<30% variable which changes in complete blood count in iron
Thrombocytosis deficiency anemia. In parallel, the first finding of IDA
Rarely: Thrombocytopenia, leukopenia on peripheral smear is anisocytosis.
Peripheral smear:
Hemoglobin distribution width (HDW) is a variable
Hypochromia
which is not noted by most individuals in complete
Microcytosis
blood count results. It shows the distribution of the he-
Anisochromia
moglobin in the erythrocytes and is increased in iron
Anisocytosis deficiency. This is reflected as anisochromia on periph-
Pencil cells eral smear. The mean erythrocyte hemoglobin concen-
Rarely: bazophilic stippling, target cells, hypersegmented tration is measured indirectly by hemocounter devices
neutrophils and is classically reduced in iron deficiency. It is also
Serum ferritin<12 ng/mL important to draw attention to the erythrocyte count in
a
Serum iron: <30 mcg/dL complete blood count. While the erythrocyte count is
a
TIBC>480 mcg/dL increased in thalassemias characterized with inefficient
Transferrin saturation (Iron/TBCx100)<16% erythropoesis (production of erythrocytes is increased,
but destruction takes place in the bone marrow before
Metzner index (MCV/RBC)<13
the cells enter the periperal blood), it is reduced in iron
May change by age, gender and other factors. Should be evaluated together.
a
14
Trk Ped Ar 2015; 50: 11-9 zdemir N. Iron deficiency anemia in children
from thalassemia carrier state. While MCV is reduced indicator of the iron stores in the body and the first
both in thalassemia carrier state and IDA, the erythro- biochemical variable to change in ID. A serum ferritin
cyte count is reduced in IDA, but increased in thalas- level below 10-12 g/L strongly supports ID, but ferri-
semia carrier state. In this case, the MCV/RBC ratio is tin is an acute phase reactant and it should be kept in
higher in IDA because RBC is reduced and it is lower mind that it may be increased in infection and inflam-
in thalassemia carrier state because the RBC value is mation. Plasma iron is reduced as the iron in the body
higher. As a result of this formula which is called the is exhausted. Samples should be obtained in the morn-
Metzner index, thallasemia is considered when this ra- ing after one- night fasting, because its value shows
tio is below 13 and IDA is considered when this ratio is variance during the day time and is affected by diet.
above 13. Plasma iron level is not helpful in the differential diag-
nosis from IDA because it is also reduced in anemia of
In addition, thrombocytosis in relation with IDA may chronic disease. Iron binding capacity (total iron bind-
be observed in complete blood count. The reason of ing capacity-TIBC) increased as serum iron decreases.
thrombocytosis is cross-reaction of increased eryth- The value obtained by dividing the serum iron value
ropoetin in IDE with thrombopoetin receptors in the to TIBC shows transferrin saturation and is reduced in
megakaryocytes which leads to increased platelet ID. Iron and TIBC are aslo acute phase reactants and
count. Although rarely, thromobocytopenia may also increase in inflammation/infection.
be observed in IDA (27). The leukocyte count is usually
normal, but leukopenia may also be observed. However, Some new methods have been developed to be used in
other diagnoses should be considered primarily in cases definite diagnosis because of some defects of hemato-
of anemia especially accompanied by leukopenia and/ logical and biochemical tests. Addtional tests including
or thrombocytopenia. Eosinophilia in complete blood zinc protoporphyrine (ZnPP), free erythrocyte protopor-
count or peripheral smear may give a clue in terms of phyrine, serum soluble transferrin receptor (sTfR) and
underlying parasitosis. At this point, treatment can be reticulocyte hemoglobin content may be helpful (28).
started directly, if complete blood count and peripheral The diagnosis will be delayed when the hemoglobin
smear strongly suggest IDA. If there is suspicion, treat- content of the erythrocytes are measured, because the
ment itself is a good diagnostic tool. However, ordering life span of normal erythrocytes is 120 days. Reticulocyte
iron variables at the baseline is a better scientific ap- hemoglobin content reduces earlier, because the reticu-
proach; further it will be valuable for differential diag- locyute life span is 24-48 hours. In some studies, it was
nosis and if anemia will not respond to iron treatment. shown to be the most sensitive variable in the diagnosis
In fact, hemogram may be sufficient in the diagnosis of of IDA, but its most important limitation for Turkey is
IDA, but it may be normal in the early stages of iron de- the fact that it is also reduced in thalassemia carrier state.
ficiency. Iron deficiency develops in the body in three Serum transferrin receptor can be tested by immunoas-
stages. say method in some laboratories. This receptor is found
on reticulocytes and an increase is observed in trasferrin
1. Prelatent stage: Iron stores are lowered or absent, receptors in IDA. Zinc protoporphyrine is produced with
serum iron concentration, hemoglobin and hematocrit substitution of zinc instead of iron when iron is absent
are normal. This stage of iron deficiency is manifested and thus is increased in IDA. Since bone marrow is the
with reduction or absence of bone marrow iron stores first place where serum iron is reduced, bone marrow
and reduced serum ferritin level. aspiration is gold standard in IDA, but is not used rou-
2. Latent stage: serum iron (SI) and trasferrin saturation tinely. In some cases, a definite diagnosis can be made
are reduced in addition to reduced iron stores. Hemo- only by combined use of multiple tests. The reticulocyte
globin and hemoctrit are within normal limits. count may be normal or low. Urea and creatinine values
3. Marked IDA: In addition to the depletion of iron should be checked in terms of accompanying renal fail-
stores, serum iron and transferin saturation hemoglob- ure especially in patients who do not adequately respond
ulin and hematocrit levels are reduced. to treatment. The laboratory findings in iron deficiency
are summarized in Table 4 (29-32).
All variables may not change at the same time because
of development of these stages in children with iron Prevention
deficiency. One should be very careful when evaluat- The American Academy of Pediatrics, the World Health
ing iron variables. The serum ferritin level is the best Organization and other well-known pediatrics orga-
15
zdemir N. Iron deficiency anemia in children Trk Ped Ar 2015; 50: 11-9
16
Trk Ped Ar 2015; 50: 11-9 zdemir N. Iron deficiency anemia in children
is high, but it may have side effects including irritation retardation, delayed wound healing and frequent infec-
in the gastrointestinal system, constipation, nausea, tions because of immune system disorder even serum
vomiting and epigastric pain. In our country, drop and zinc levels could not be measured due to insufficient
suspension forms are present : Ferrosanol 1 drop: 1 laboratory opportunities.
mg, 1 spoon: 20 mg elementary iron. In addition, pill
(40 mg elementary iron) and capsule (100 mg elemen- The rate of iron absorption also depends on the sever-
tary iron) forms are also present for older children. ity of anemia. It reaches the highest values in the first
month of treatment. Signs observed in patients includ-
The most commonly used treatment dose is 3-6 mg/ ing restlessness, loss of appetite and fatigue rapidly
kg/day. There are different recommendations releated disappear with initiation of treatment. An increase in
to the dose, in the literature and textbooks. For exam- the reticulocyte count is expected on the 7-19th days of
ple, the recommended dose is 3 mg/kg in Nathan and treatment. If an increase of 1 g/dL or more is observed
Oskis hematology testbook, 4.56 mg/kg/day in Lanz- in Hb after ten days, the diagnosis is correct. In this
kowskys Pediatric Hematology Oncology testbook case, treatment can be continued for at least 2 months
and 6 mg/kg/day in Williams Hematology testbook. to fill iron stores. The treatment period should not ex-
The Centers for Disease Control in USA recommend- ceed 5 months. If there is an insufficient increase after
ed use of 3 mg/kg/day elementary iron in 1998 in or- one-month treatment, incompliance, continuing blood
der to simplify the dose and increase compliance, but loss despite iron replacement, disruption in absorption
this recommendation is based on expert opinion rath- of iron, high gastric pH (use of antacids or H2 receptor
er than clinical studies. In our own center, we give 3-4 antagonists), wrong diagnosis or inefficient iron prepa-
mg/kg/day ferrous iron in two doses 1 hour before or ration should be considered.
2 hours after meals in order to increase compliance.
There are also different recommendations in relation Parenteral iron treatment can be administered when
with dividing the dose. Studies have shown that a sin- oral iron treatment can not be tolerated, in cases where
gel daily dose was also efficient especially in children anemia should be corrected rapidly and in gastrointes-
who developed gastrointestinal side effects (41). Fur- tinal absorption disorders including celiac disease or
ther, different administration methods are also being inflammatory bowel disease. There are not many stud-
discussed. It is thought that iron consumed one day be-
Table 5. Cerrahpaa Medical Faculty intravenous iron
fore disrupts the absorption of iron consumed next day, treatment protocol
makes mucosal inhibition. Therefore, every other day
or weekly treatments is also being discussed. In a study Iron to be given: kg x (desired Hb-patients Hb g/L) x 0.24 +
performed in our center in recent years, no difference depot iron
was found between the efficiencies of daily and weekly Note: multiply the result with 10 because Hb is taken as g/L
iron treatments (42, 43). Desired Hb up to 35 kg: 130 g/L
Iron store: 15 mg/kg
It is known that ascorbic acid increases absorption of Desired Hb above 35 kg: 150 g/L
iron, but use of preparation containing vitamin C in Iron store: 500 mg
combination with iron has a high cost. In Turkey, fer-
Number of venofer ampoules to be given=total iron deficiency
rous fumarate is included in another preparation con- (mg)/100
taining +2 iron for children. It has two forms one of Minimum amount to be given daily 0.15 mL/kg=3 mg/kg
which contains zinc, vitamin C, folic acid and iron and
Maximum 0,35 mL/kg=7 mg/kg
the other one which contains only zinc and iron (Fer-
rozinc, Ferrozinc-G, respectively 1 spoon: 40 mg el-
ementary iron). In a thesis study performed in our cen- 1 ampoule venofer=100 mg iron. One box contains 5 ampoules.
ter, we showed that zinc deficiency accompanied iron The drug should be kept away from light.
deficiency with a rate of 9% (44). However, there are no
sufficient studies related with routine addition of zinc After the dose of iron to be given is calculated, the drug is given
to iron preparations. We think that use of preparations by extending over days (5-7 days).
containing iron and zinc will be beneficial in areas Treatment response should be examined by performing com-
where malnutrition is present and in children with iron plete blood count after the drug and on the 21st day of treat-
ment.
deficiency together with growth and developmental
17
zdemir N. Iron deficiency anemia in children Trk Ped Ar 2015; 50: 11-9
ies conducted with children comparing parenteral and ramme managers. Geneva (Switzerland): World Health
oral iron treatment in IDA related with nutritional de- Organization; 2001.
ficieny and more studies are needed in this area. Since 2. etin E. stanbulda yaayan ocuk ve adolesanlarda ane-
adverse effects were observed with a high rate with the mi prevelansnn aratrlmas (Tez). stanbul niversitesi
first parenteral iron preparations which came onto the Tp Fakltesi, 1997.
3. Gkay G, Kl A. ocuklarda demir eksiklii anemisi-
market, a hesitancy occured among physicians, but the
nin epidemiyolojisi. ocuk Sal ve Hastalklar Dergisi
iron preparations which have been available on the
2000; 43: 3-13.
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side effects are considerably few. However, it should be formula mamalarla beslenenlerde demir durumu. Turki-
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Conflict of Interest: No conflict of interest was declared by ment for iron deficiency in infancy. Pediatrics 2000; 105:
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