By: Dr. Deepak Seth, Deptt. Of Paediatrics, Himalayan Institute of Medical Sciences
Guest Editor: Dr Neeraj Jain, Dept. of Paediatrics, HIMS
Editors: Surya Aggarwal and Katyayni Seth
Anaemia (or Pallor in layman’s term) is a condition to all in which our blood is not able to carry oxygen to all our body parts, efficiently. In paediatric age group, the most common cause is nutritional deficiency. Nutritional anaemia is a state where in normal levels of haemoglobin cannot be maintained by red blood cells. And among deficiencies, iron deficiency is most common in
Normally iron levels in the blood vary from person to person depending upon his/her age, sex and even geographical altitude. At birth it is highest; levels fall by the age of 3 months and then gradually increases to adulthood.
Our body has its own iron stores, which are balanced between iron absorption, utilization, and iron excretion.
Iron absorption in our body depends upon factors:
(i) Form of iron salt- ferrous salts and haeme are better absorbed
(ii) Iron absorption is also regulated by duodenal mucosa
(iii) Iron absorption is inversely proportional to iron stores and directly proportional to erythropoiesis.
Iron stores: iron released during the first 8-12 weeks of life is stored in the body and it helps to maintain erythropoiesis up to 4-6months of age in a normal term infant and up to 3 months in a low birth weight baby or pre-term baby.
Iron deficiency causes can be divided as:
- Decreased intake-
Milk is a poor source of iron, although breast milk iron is better absorbed so compensates for its low concentration. Delayed introduction of iron rich food supplements is the major cause for the pathogenesis. Iron in vegetarian diets is predominantly in Non- Haeme form, haeme form is found in non-vegetarian diet. Haeme form is readily absorbed and its absorption is less affected by other components such as phylates, tannates, calcium, fibre and phosphates. These factors reduce the absorption of non- haeme iron. - Increased losses:
Iron losses in the faeces are insignificant in normal conditions, but in the presence of parasitic infestation, diarrhoea and dysentery it may increase manifolds. - Reduced absorption:
absorption of iron is inversely proportional to the amount present in the diet. Ascorbic acid, citrate, alcohol, sugars, aminoacids ( hystidine and cystine) enhance iron absorption. While iron is poor absorbed from wheat and rice as they are rich in phylates. Iron absorption from meat and fish is up to 30%. - Increased demands:
Rapid growth during infancy, and childhood results in increased demands of iron. During pregnancy also mother should take good amount of iron in diets and even supplements to avoid deficiency in the growing fetus in her womb.
Clinical features of Iron Deficiency Anaemia:
Fatigue, headache, dyspnoea, apathy, behavioural problems together with the symptoms secondary to abnormalities of the epithelial surfaces such as koilonychias (i.e. thin spoon shaped nails), glossitits (inflammation of the tongue), papiilay atrophy, dysphagia (difficulty in swallowing), diarrhoea and malabsorption. Koilonychia is characteristic of of iron deficiency anaemia.
Congestive heart failure is produced in severe anaemia even in the absence of pre-existing heart disease. Examination of lips, nails, tongue, and conjunctiva enables to assess the presence and degree of anaemia (pallor). Severe chronic deficiency, may, in addition lead to (i) retardation of physical growth, (ii) delay in language and cognitive development, (iii) clumsiness and poor performance in school, (iv) Attention Deficit Disorder, (v) repeated infections.
Investigations
- Blood picture will show presence of microcytic, hypochromic anaemia. With progressive increase in the severity of anaemia anisocytosis and poikilocytosis (various and abnormal shape red blood cells) may appear.
- Haemogram will show blood hemoglobin levels, packed cell volume and condition of RBCs and WBCs.
- Serum iron, total iron binding capacity and transferrin saturation: These parameters get affected only after a decrease in the ferritin level but before a fall in the haemoglobin level or peripheral smear changes.
Serum iron is variable but fasting levels of less than <75ug/dl> - Serum ferritin: It’s an indirect measure of iron stores and most sensitive indicator of body iron stores. Level less than <15mg/>
- Marrow stainable iron: Prussian blue staining of a marrow aspirate is a measure of iron stores and an absence of stainable iron is the earliest abnormality detected in iron deficient states.
The commonest differential diagnosis of the condition includes thalassemia trait, anaemia of chronic disease sideroblastic anaemia. These conditions should be suspected if a patient fails to respond to adequate iron therapy. It is most important to differentiate IDA from b- thalassemia trait. In thalassemia microcytosis is more marked than hypochromia. Moreover the red cells distribution is more uniform than in IDA and target cells and basophilic slipping is indicative of thalassemia. The diagnosis of thalassemia trait can be made by detecting the elevated levels of HbA2 and diagnosis of thalassemia major is dependant upon fetal haemoglobin levels of
greater than 10 percent. Anaemias secondary to chronic disease frequently have normocytic, normochromic picture on peripheral smear, however a few patients may have a microcytic hypochromic picture. A therapeutic trial with iron is helpful to differentiate between these conditions.
Sideroblastic anaemia can be reliably diagnosed by demonstrating ringed sideroblasts in a bone marrow aspirate.
Management of IDA:
A thrapeutic response of iron therapy is probably the only definitive evidence of IDA. Treatment of a patient with IDA involves two aspects, the first being the iron supplementation and the second aimed at correcting the underlying cause. Important points to keep in mind regarding iron therapy are:
Oral Therapy is the best form of treatment.
Dose of elemental iron for the treatment is 6mg/kg body weight in two or three divided doses on an empty stomach. Ferrous sulphate is the best and cheapest form of therapy. However, since a large number of iron preparations are available, it is important that the paediatricians should be aware of the amount and concentration of elemental iron of products. Iron preparations containing haemoglobin or enteric-coated preparations do no offer any advantage.
Treatment should be continued for at least 6-8 weeks for correction of the haemoglobin levels and to replenish the stores.
Parenteral iron therapy is indicated only when oral iron is either not tolerated or compliance is poor, or in presence of malabsorptive states. The requirement for iron is calculated by the formula:
Elemental iron required (mg) = weight in kg ´ haemoglobin deficit ´ 4 ( as iron dextran) should be given deep intramuscularly.
Prevention of Iron Deficiency: Nutritional Counselling: Milk is poor source of iron and solids such as green vegetables, pulses, and peas should be introduced by 6 months of age. Hookworm infestation should be prevented by footwear or by periodically de-worming. The children health education and hygienic habits should be improved to prevent parasitic infestation. WHO has recommended additional iron and folic acid supplementation during infancy and childhood.
Fortification: Supplementation of biologically active and acceptable form of iron in food is an accepted method of prevention of iron deficiency. Salt, which is produced only in a few centres, but is consumed by all, was considered to be the most suitable vehicle for fortification. The National Institute of Nutrition,
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