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FACULTY OF MEDICINE
UNIVERSITY OF BRAWIJAYA MALANG
Clinical Competencies
Be able to describe:
- the causes of iron deficiency anemia
- the pathogenesis and pathophysiology of iron
deficiency anemia
- the stages in development of iron deficiency anemia
- the principal management of iron deficiency anemia
Be able to diagnose iron deficiency anemia based on
clinical features and laboratory findings
Faculty of Medicine
University of Brawijaya
Introduction
Iron deficiency is defined as a decreased total iron body
content.
Iron deficiency is the most prevalent single deficiency
state on a worldwide.
If iron deficiency is sufficiently severe to diminish
erythropoiesis of anemia iron deficiency anemia.
Diminished the capability of individuals: to perform
physical labor, growth and development, academic
achievement of children.
Faculty of Medicine
University of Brawijaya
Iron metabolisms
Body iron distribution and transport
Iron absorption
Iron requirement
Andrew NC. Medical Progress: Disorders of Iron Metabolism. N Engl J Med 1999;
341: 1986-95
th
Hoffbrand AV, et al. Essential Hematology. 4 . London:Blackwell Science.2001
Body iron
distribution
Andrew NC. Medical Progress: Disorders of Iron Metabolism. N Engl J Med 1999; 341:
1986-95
Andrew NC. Medical Progress: Disorders of Iron Metabolism. N Engl J Med 1999; 341:
1986-95
Iron absorption
Factors favouring absorption
Hem iron
Ferrous form (Fe2+)
Acids (HCl, vit. C)
Solubilizing agents (sugars,
aminoacids)
Iron deficiency
Increased erythropoiesis
Pregnancy
Hereditary hemochromatosis
Increased expression of DMT-1
&
ferroportin in duodenal
enterocytes
Iron requirements
Estimated daily iron requirements
In children (average):
- Urine, sweat, feces : 0.5 mg/day
- Growth
: 0.6 mg/day
- Total
: 1.1 mg/day
PATHOGENESIS OF IDA
Three pathogenetic and pathophysiologic factors
are implicated in the anemia of iron deficiency :
1. Impaired hemoglobin synthesis, a
concequence of reduced iron supply.
2. A generalized defect in cellular proliferation.
3. Reduced erythrocyte survival, particularly
when the anemia is severe.
Faculty of Medicine
University of Brawijaya
Stage II
Latent/
Iron Deficiency
Stage III
Iron Deficiency
Anemia
Symptoms
Pallor, pica,
epithelial changes
Hemoglobin levels
Normal
Normal
Decreased
Normal
Normal
Decreased
Reticulocyte Hb content
Normal
Decreased
Decreased
Serum iron
Normal
< 60 ug/dl
< 40 g/dl
360-390 g/dl
Transferrin saturation
Normal
< 16%
< 16%
Serum ferritin
< 20 g/L
< 12 g/L
< 12 g/L
Free erythrocyte
protoporphyrin,
zinc protoporphyrin
Normal
Increased
Increased
Decreased
Absent
Absent
Diagnosis
History findings :
- onset & severity of anemia, age
- parasitism, blood loss (acute or chronic)
- inadequate diet (quantity & quality)
- poor absorption
- increased requirements
Clinical features :
symptoms & signs (general & specific)
Laboratory findings :
hematologic & biochemical markers
Koilonikia
&
MANAGEMENT OF IDA
TREATMENT
1. Medication : elemental iron
In adult : 325 mg (60 mg Fe) orally 3x/day
In child : 3-6 mg/kg/day orally divided in 1-3 dosis
2. Dietetic therapy
3. Surgical treatment : to stop bleeding and correct
the underlying defect either neoplastic or nonneoplastic disease of GIT, GUT, uterus, and lungs
4. Consultation : department of surgery, GE, etc
5. Activity : restriction of activity is usually not
required; patients with moderately severe IDA
and significant cardiopulmonary disease should
limit their activities
Treatment
Elemental Fe
- Do: 3-6 mg/kgBW/d (2-3 dosages)
- It may take up to 2 mo after hemoglobin has
been corrected
- Adverse effects : GI tract upset
to reduce the adverse reactions :
- take the medicine after meal
- slow released preparation
- take a dosage then increase gradually
Treat the etiology
Lanzkowsky P. 1995. p. 35-50.
Glader B. Nelson Textbook of pediatrics. 17th ed.; 2004. p. 1614-6.
Sandoval C, et al. Hematol Oncol Clin N Am 2004;18:1423-38.
Killip S, et al. Am Fam Physician 2007;75:671-8.
Segel GB, et al. Pediatr Rev 2002;23:75-84.
Grantham-McGregor S & Ani C. J Nutr 2001;131:649S-68S.
Iron preparation
Preparation
Available strength
Elemental Fe
Ferrous fumarate
300 mg/cap
99 mg/cap
Ferrous gluconate
300 mg/tab
35 mg/tab
300-325 mg/tab
60-65 mg/tab
160 mg/tab
65 mg/tab
Polysaccharide-iron complex
150 mg/tab
150 mg/cap
Ferrous fumarate
60 mg/ml
20 mg/ml
Ferrous sulphate
Drops : 75 mg/ml
Syrup : 30 mg/ml
Drops : 15 mg/ml
Syrup : 6 mg/ml
Iron dextran
--
50 mg/ml
--
12.5 mg/ml
Iron sucrose
--
20 mg/ml
Tablets/capsules
Ferrous sulphate
Parenteral
http://www.freece.com/FreeCe/Article.asp?dbArticleID=105.
Transfusion
Indication :
If hemoglobin levels < 4 g/dL
Lanzkowsky P. 1995. p. 35-50.
Glader B. Nelson Textbook of pediatrics. 17th ed.; 2004. p.
1614-6.
Diet
Milk : 24 oz/day
Iron rich food (fish, liver, meat) rather than rice,
spinach, wheat, soybean
absorption: tanin, calsium, phytates
absorption: vitamin C, HCl, amino acid,
fructosa,
meat
Lanzkowsky P. 1995. p. 35-50.
Glader B. Nelson Textbook of pediatrics. 17th ed.; 2004. p.
1614-6.
Sandoval C, et al. Hematol Oncol Clin N Am 2004;18:142338.
Prevention
Primary prevention
Exclusive breastfeeding
- The absorption of iron from breast milk is
higher than that from whole cows milk (50% vs
10%)
- Iron-fortified cows milk : 4%
Milk consumption : 24 oz/day (other: 16 oz/day)
Primary prevention..
Secondary prevention
SCREENING
CBC, serum ferritin and transferrin
saturation
Secondary prevention.
Age 1-3 years
History of iron deficiency anemia (+)
Milk consumption > 24 oz/day
Poor intake of iron and vitamin C
Imigrant from the developing countries
THANK YOU
Etiology
Age 2-5 year
Poor intake of iron-rich food
Increased iron needs due to chronic infection
Blood loss >> eg. Parasitic infection and
Meckels diverticulum
Age 5 year adolescence
Blood loss >> eg. Parasitic infection or
polyposis
Adolescence adult
Woman : eg. menorrhagia
Lanzkowsky P. 1995. p. 35-50.
Glader B. In: Nelson Textbook of pediatrics. 17th ed.; 2004. p. 1614-6.
Sandoval C, et al. Hematol Oncol Clin N Am 2004;18:1423-38.
Killip S, et al. Am Fam Physician 2007;75:671-8.
Segel GB, et al. Pediatr Rev 2002;23:75-84.
UNDERLYING CAUSES
Low food supply
Erroneous feeding
practices
Low socio-economic status
Low intake of available iron
Unsuitable meal
composition
excess of inhibitors
IMMEDIATE CAUSES
Inadequate diet
Poor absorption
Growth
Pregnancy & Lactation
Increased
requirements
Acute bleeding
Chronic blood loss
Poor sanitation &
parasitism
Blood loss
Infection
Iron
deficiency
Controversies
A single vs 3-times-daily dose iron
supplementation
resulted in a similar rate of successful
treatment
Zlotkin et al. Pediatrics 2001;108:613-6
of anemia (Hb & ferritin) (p= 0,25 and p=0,99)
Iron supplementation 1-2 weekly vs daily
- The increases in Hb concentration were
comparable
- Improvement of cognitive function
- Cost effective
- No or fewer side-effect
Sungthong et al. J Nutr 2004;134:2349-54
Siddiqui et al. J Trop Pediatr 2004;50:276-8
Awasthi et al. J Trop Pediatr 2005;51:67-71
Controversies..
Several micronutrients can improve the
hemoglobin response to iron.
Iron absorption may be inhibited by nutrients
such calsium, magnesium and zinc.
Allen LH. J Nutr 2002;132:813S-9S