Iron Deficiency Anemia for medical students

Iron Deficiency Anemia for medical students

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  Ashan Bopitiya 2022© Iron Deficiency Anemia (Read Anemia Medicine Note) • Definition o Anemia is defined as a HB level bellow the 5th percentile of a healthy population • Iron deficiency is the most common micronutrient deficiency in the world o Commonest is energy-protein malnutrition, but IDA is more widely prevalent • Iron deficiency can have a wide spectrum ranging from a “Sub-Clinical State to Severe Iron Deficiency Anemia” o Different stages are identified by clinical findings and labs • Dietary Iron o There are 2 types of Iron in the Diet § Haem Iron & § Non-Haem Iron o Haem iron is present in Hb containing animal food like meat, liver and spleen o Non-Haem Iron is obtained from cereals , Vegetables and beans o Milk is a poor source of iron. Therefore, breast fed babies need iron supplement § However, the little bit of iron available in the breast milk is highly bioavailable. • Newborn babies have iron in their iron stores which they inherited from the mother and they generally lasts for about 4 months. o It is usually deposited in the last trimester, therefore if a baby is born pre-term their iron stores are less o If there are twins or triplets à The mothers iron stores are shared. o If the mothers own iron stores or Iron Nutrition was less à the iron deposited in the baby also becomes less. • Iron Absorption o Haem Iron § Haem iron is not affected by the ingestion of other food items and has a constant absorption rate of 20-30% • Rarely affected by the iron balance of the subject § The Haem Molecule is absorbed intact and the iron is released in the mucosal cells o Non-Haem Iron § The absorption of Non-Haem iron varies greatly from 2% to 100% as it is strongly influenced by • The iron status of the body • Solubility of iron salts • Integrity of gut mucosa • Presence of absorption inhibitors or facilitators • Inhibitors and Promoter of Iron Absorption o Inhibitors § Cereals like Sorghum and Oats § Veggies like spinach and spices § Beverages like Tea, Coffee, Cocoa and Wine • A Single cup of tea taken with meal reduces iron absorption by upto 11% o Promoters § Foods containing ascorbic acid like citrus fruits § Dark green veggies § Foods containing muscle protein • [From Illustrated] Iron May come from : o Breast Milk § Low iron content but 50% is absorbed (high bioavailability) o Infant formula o Cows milk § High iron content but only 10% is absorbed (low bioavailbility) o Solids introduced at weaning - Cereals (They are supplemented with iron but only 1% is absorbed)
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  Ashan Bopitiya 2022© • Cut-off points for anemia o Children 6 months to 6 years à 11g/dl o Children 6 years to 14 years à 12 g/dl o Non-Pregnant Women à 12 g/dl o Pregnant Women à 11 g/dl o Men 13 g/dl • Aetiology of IDA o Major Causes § Low Dietary Intake • Inadequate intake of iron in infants is common b/c additional iron is needed for the increase in blood volume which occurs with growth and to build up the childs iron stores • A 1 year olf infant requires an iron intake of about 8mg/day • Iron def can occur due to delay in introduction of complementary feeding § Malabsorption : Poor Bioavailability of the iron you take • Iron absorption is markedly increased when eaten with food rich in vit c (fresh fruits and veggies) and decreased when eaten with the inhibitors like tea, coffee § High Parasitic infections • Hook Work infections (Sucks out the blood) and Malaria (Induces a state of hemolysis) o Other causes § Blood Loss • Heavy menses and use of aspirin and NSAIDs § High Fertility rate in women • Women who gets pregnant frequently with less gaps in between goes into a state of Maternal depletion syndrome and their iron stores get depleted with no gap to recover. § Low iron stores in newborns (preterm and malnutrition of mom) • Signs and Symptoms o Feeling of fatigue à One of the most important symptoms o Exertional Dyspnea o Dizziness o Pallor (through the muscous membrane) o Pica § A very unusual symptom àstrange craving to eat items that aren’t food such as Dirt, Ice or clay o Other non-specific symptoms § Cold hands and feet § Tingling sensation or feeling in the legs § Koilonychia à In severe anemia § Headaches • Diagnosis of IDA o Clinical Symptoms à Fatigue, Dizziness, Palpitations o Signs à Pallor, Smooth tongue, Koilonychia, Splenomegaly and Dysphagia in elderly women o Labs o Stainable iron in bone marrow o Response to iron supplements
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  Ashan Bopitiya 2022© • Consequences of Anemia [Important] o Impaired learning achievement and cognitive development + delayed psychomotor development § Especially when it occurs in infants o Decrease worker productivity (mainly in adults) o Increased maternal mortality o Increase risk of premature delivery and LBW o Impaired immunity (High risk of infection) o Inability to maintain body temperature o Associated ris of lead poising d/t pica • Prevention of IDA o Iron Supplementation o Dietary modification o Parasitic control o Nutrition and health education • Dietary modifications to prevent IDA o Increase Iron folate rich foods in diet à Green leafy vegs and pulses o Increase haem iron in diet as much as possible à Fish and Meat o Increase Vit C consumption (fruits) o Increase animal protein consumption o Increase consumption of iron fortified foods o Avoid drinking tea soon after meals o Avoid taking calcium and iron together. • Priority target groups for interventions o Pregnant or actating women o Infant and reschool children o Adolescent girls and women of reproductive age o The remaining general population • Interventions o Iron Supplemntation o Dietary modification o Food fortification o Control of parasitic diseases o Nutrition and health education Management [Illustrated] • Dietary advice and supplantation with oral iron o Best combination would be Sytron (Sodium Iron) or Niferex (Polysaccharide iron complex) : These do not stain the teeth o Iron supplements should be continued for a minimum of 3/12 to restore the Hb to normal levels and restore the iron stores o With good compliance Hb will rise about 1g/dl per week • Investigate for other causes if the patient is compliant but not responding or Hx is suggestive of a non- dietary cause o Ix for malabsorption d/t celiac disease or chronic blood loss d/t meckels diverticulm • Blood transfusion should NEVER be necessary for dietary IDA as kids with 2-3g/dl can tolerate it as it has been going on for quite some time • Q/ A 4y old previously well child presented to the OPD with Pica and lethargy for 1/12 duration. The child was pale O/E What is the diagnostic approach ? – if this was 10-15 years ago A/ Probably Hookworm infection leading to anemia
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  Ashan Bopitiya 2022© Any other causes of pica: 1. Can be psychological à In neglected kids and kids with developmental delay or mental retardation 2. Zinc def can also cause pica What are the questions that you would want to ask ? 1. About the dietary pattern of the kid 2. SOB on exertion? a. Indicates the severity of anemia 3. In hookworm infections a. You will not get malena or fresh blood à but you might get occult blood b. This is somewhat of a protein loosing enteropathy à with the blood they loose proteins i. The symptom they develop is generalized edema à by the time they present these kids are kinda swollen. ii. Kids with chronic severe anemia develop CHF and they become edematous. (So this is another Differential of an edematous kid) 4. Syncope - A dramatic symptom of severe anemia 5. LOA The mother also says that this boy has on and off abdominal pain. What may be the cause of this? • There are 2 worms where abd. Pain is a symptoms o Round worm à ascaris lumbricoides § It causes obstruction to the intestinal flow and causes pain (partial intestinal obstruction) § So this kid maybe having a roundworm infection apart from the hook worm infection o Whip Worm à Causes a lower abdominal pain § The most dramatic symptom produced by a whipworm is à Blood and mucous diarrhea (this is one of the causes of a chronic dysentery) • They get colics as the colon is getting irritated due to the worms which results in peristalsis of the colon leading to pain • Rectal prolapse is also a dramatic symptom of whip worms Generalized lymphadenopathy, Splenomegaly, Petichial rash, Bleeding from gums and Sternal Tenderness and all that for leukemia should be excluded Some basics • The main sites of hematopoiesis in: o Fetal life à Liver o Post-Natal life à BM • k