IRON DEFICIENCY ANAEMIA

Clinical Aspect

Dr. dr. Moedrik Tamam,

Sp.A(K)
 IRON DEFICIENCY ANAEMIA

 NUTRITIONAL ANEMIA is a global problem

affecting persons of all ages and economic group
 Its more prevalent in the developing country than
industrialized
Incidence iron deficiency anaemia
- all of the world: 30%
- USA: 9% < 3 yr, 11 % adolescent (girl)
 Table 1. Prevalence of Iron Deficiency Anemia (IDA)
in Several Indonesia Studies
Prevalence (%)
Children 6 months - 5 years
- Low socio-economic groups :
- well-nourished 38 – 73
- with mild protein deficiency 83
- with severe malnutrition 85 – 100
- Medium and higher socio economic group :
- well-nourished 24
Children 5 years - 14 years
- Low socio-economic groups :
- good nutritional status 47 – 64
- with mild protein-caloric malnutrition 38 – 67
- Medium and higher socio-economic groups 20
Pregnant women 21 – 92
Non-pregnant women 35 – 85
Laborers and plantation workers 30 – 65

Source : Soemantri (1997)

Fig 1. Map of Anemia under 5 years in Central Java
IRON
- Essential element of the heme complex
-Facilitate : cell proliferation and defferentiation

DNA synthesis: ribonucleotida reductase enzym

-Neurologic effect:

-proper balance neurotransmitter during brain growth

-essential for oligodendrocytes to ensure myelinationa

Table1. Daily iron requirement

Amount that must Minimum amount

be absorbed for that must be
Hgb synthesis (mg) ingested daily (mg)

Infants 1 10
Children 0.5 5
Young women 2.0 20
Pregnant moms 3.0 30
Men & 1 10
postmenopausal
 Consequences of Iron deficiency Anaemia

1. Impairment in mental and motor development

2. Poor endurance and physical fitness

3. Low score in IQ tes

4. Lack of concentration

5. Short attention span

Iron deficiency Anaemia
may be result of:

1. Increased iron requerements in pregnancy

/ lactation, rapid growth
1. Iron deficient diet
2. Impaired intestinal absorbtion
3. Blood loss ( parasites investation)
REASONS FOR PREVALENCE IRON DEFICIENCY
AMONG 1-2 Y/ O CHILDREN
Rapid growth
Use of non-iron fortified staples and cereals
Picky eating and increased intake of juices
Too early switching to regular cow’s milk
 UNDERLYING CAUSES IMMEDIATE CAUSES
Low food supply
Erroneous feeding
Inadequate diet
practices
Low socio-economic status

Low intake of available iron

Unsuitable meal
Poor absorption
composition
excess of inhibitors

Growth Iron
Increased
Pregnancy & Lactation
requirements
Acute bleeding
Chronic blood loss
Poor sanitation & Blood loss
parasitism

Inadequate health services Infection

Fig 2. The Underlying and Immediate Causes of Iron Deficiency

Figure 3. IRON TRANSPORT PATHWAY
 Enhancers of Iron Absorption
 Organic Acids: ascorbic, citric, lactic,malic,
tartaric
 Animal tissue: meat, fish, poultry
 Sugars: fructose, sorbitol
 Amino acids: cysteine, lysine, histidine
 Alcohol
INHIBITORS OF IRON ABSORPTION

Phenolics: tannins, polyphenols, oxalates

Phosphates
Phytates: (common in vegetarian diets)
Dietary fiber: bran, lignin
Proteins: egg albumin and yolk, legumes
Inorganic elements: Cu, Mn, Cd, Co
 Iron deficiency Anaemia
- Doestn happen suddenly
- Iron deficiency is the end stage of a relatively long drawn
process of deterioration in the iron status of child

A large of group children out there

who are iron deficient
Without being anaemic
Three functionally distinct stages of iron deficiency

Stage 1: DEPLETION OF STRORAGE IRON

- Small or absent iron stores

- Reduced plasma ferritin level

- Hb concentration within normal limits

- No evidence of functional impairment

Three functionally distinct stages of iron deficiency

Stage II: IRON-DEFICIENT ERYTHROPOIESIS

- Hb level within 95% reference range for sex and age

- Elevated RBC protoporphyrin levels

- Low plasma ferritin and reduced transferrin saturation

- Reduced work of capacity and performance

 Three functionally distinct stages of iron deficiency

STAGE III: IRON DEFICIENCY ANAEMIA

-The flow iron of erythroid marrow is impaired leading to:

reduced Hb concentration

- Progressive microcytic hypochromic anaemia

- Reduced plasma iron, transferin saturation and ferritin levels

Fig 5.Stages in the Development of Iron Deficiency
 Clinical feature
-There is nothing specific
-Majority of patient have symptom and sign anaemia
-Very poor corelation between degree of anaemia and
severity symptoms
- Subclinical iron deficiency is an unrecognized
 fatigue, malaise, GIT disfunction

Three clinical feature wich suggest Iron deficiency anaemia

1. PICA (perverted appetite, geophaghia)
2. Koillonychia (spoon shaped nail)
3. Plummer vinson syndrom (upper oeshophageal dysphagia)
FIG 6. Clinical feature of Iron deficiency anaemi
 Diagnosing Iron deficiency anaemia

1. Red cell morphology

( micrositosis, hypochrom, pencill cel)
2. RBC indices and histogram HB ↓ , low MCV,
low MCHC, low RBC
3. Biochemical parameter: serum iron ↓ , TIBC ↑ ,
serum ferritin ↓
4. Bone marrow iron stainning ( gold standar)
5. Therapeutic trial respon to iron therapy:
by the end of 2 weeks Hb must be show rise
MORPHOLOGY IN IRON DEFICIENCY
ANAEMIA

moderate Severe

Normal
 TREATMENT

It basically requires

Treatment of individual patient trough

1. Confirmation of the diagnosis

2. Through investigation of the cause of negative iron balance

3. supplementation of iron
 Treatment
Nutritional counselling:
- Iron deficiency Is often due to poor intake rather than
blood loss
- The key success in the management of iron deficiency

is propper nutritional counseling

- Prolonged breast feeding
- Introduction / consumption of iron rich weaning food
 - Most iron – deficiency respond well to treatment with oral iron
- iron states present at birth and highly bioavailable iron
in breastfeeding protect an infant from iron deficiency
anaemia up to 6 month (3 month in preterm baby )

Suplementation with medicinal iron recommended by WHO:

1. For infants and children :3-6 mg elemental iron/kg/day
2. For preterm infants: 2 mg elemental iron/kg/day
( from 3 month)
 Duration therapy must be 4-6 month
 Positive Response to Therapy

- 3-5 days: 1. Reticulocyte increase

2. Increased appetite
- 5 -10 days 3. Decreased irritability
4. Improved well being
5. Increase in HB level > o,1 gr/ dl
per day from 5th day
- 60 days : Hb concentration virtually becomes normal
- 90-180 days: Repletion of iron states
FAILURE TO RESPOND TO IRON THERAPY
MAY BE due:
1. Associated infection
2. Concurrent protein deficiency
3. Concurrent deficiencies of other vital nutrients
– folic acid, cooper, zinc, vit B6, Vit C
4. Associated bleeding
5. Wrong diagnosis_ thalassemia minoir, etc

DEFFERENTIAL DIAGNOSIS
1. Beta thalassemia trait
2. Anemia of chronic disease
3. Sideroblastic anemia
Deferentiating iron deficiency anaemia from beta thalasemia

Disease Hb RBC RDW MCV MCHC

COUNT
Iron deficiency ↓↓ ↓ ↑ ↓ ↓
anaemia
thalassemia minor ↓ ↑ n ↓↓ ↓↓

Deferentiating iron deficiency anaemia from anemia of chronic disease

Disease HB S iron TIBC S ferritin sTFR

Iron deficiency ↓↓ ↓ ↑ ↓ ↑
anaemia
Anemia of ↓ ↓ ↓ N↑ N
chronic disease
 SUMMARY

1. Nutritional anemia is a global problem affecting persons

of all ages and economic group
2. iron deficiency anaemia may be result of: increased iron
requerements (rapid growth), iron deficient diet, impaired
intestinal absorbtion, blood loss ( parasites investation)
3. Consequences of iron deficiency anaemia is impairment
in mental and motor developmenent in children
4. Iron deficiency is the end stage of a relatively long drawn
process of deterioration in the iron status of child
5. Iron deficiency is better treated with improved dietary intake
and moderate level suplementation
Gee, mom!
I need my iron
today.