IRON DEFICIENCY ANEMIA - MEDICINE (Youtube - Med it )

Anemia

-          When hemoglobulin concentration in the blood is less 2 SD below the mean for particular age

-          Leads to tissue hypoxia due to inadequate O2 transport

Physiological Adaptations

-          Decreased oxygen-carrying capacity which will lead to compensatory physiological adjustments

-          Increase in the volume of the plasma and redistribution of blood flow

-          Increased volume – increased stroke volume – increased cardiac output

-          Diversion of blood from tissue with lesser O2 requirements to those with greater needs

-          Blood flow – skin decreased, Brain and muscle increased

-           

 

Clinical Feature

-          Appearance of manifestations depends on the rate of development and compensatory mechanism of Cardiovascular system

Early symptoms - Easy Fatiguability, tiredness, generalized muscular weakness

                                        (In children = poor feeding, irritability, poor school performance)

Signs – pallor of nail beds, oral mucous membrane and conjunctivae

 

Late Symptoms – Dyspnea on exertion, tachycardia, palpitations

Severe symptom – Hemic murmur (mid systolic flow murmur – increased velocity of blood passing through the heart valves) , systolic bruits , postural hypotension and congestive heart failure

Heard over Pulmonary Area

Nervous symptoms- dizziness, headache, humming in ears, fainting, tinnitus, lack of concentration, drowsiness.

With severity, clouding of consciousness

Signs of severe anemia- elevated pulse pressure, collapsing character

If hb less than 6mg/dl , ECG changes in 30% of people

·         Normal QRS wave

·         Depressed ST segment

·         Flattened or inverted T waves

Approach

Children

·         Obstetrics history of maternal infections, anemia or Collagen vascular disease, prematurity, blood loss, jaundice (secondary to Rh incompatibility), G6PD deficiency, Sepsis, Hemangioma or cephalhematoma

·         Dietary history- diet, type and quality of milk, time of weaning, intake of vitamins and hematinic

·         Iron deficiency

at 6 months and 2 year – inadequate weaning, chronic diarrhea, cow milk allergy

At adolescent, growing phase, menstruating and pregnant teens

History of pica, drug intake, chronic diarrhea, prior surgery, acute or prolonged infections, liver and renal disease, transfusion

·         A vegetarian diet, goat milk intake – megaloblastic anemia

·         Thalassemia - presents at 4-6 months, 70% Symptomatic by one year

·         Diamond Black fan (pure red cell) anemia, presents at 3 month (90 days)

-          Low retics, absence of erythroid precursor in the marrow

 

·         Fanconi Anemia – presents at 3-4 years

·         Chronic hemolytic anemia – Hx of anemia, gall stones, blood transfusion

Examination

-          Radial limb anomalies                                             (Bone marrow failure)

-          Splenomegaly                                                         (Hemolytic anemia, infection, storage disease)

-          Lymphadenopathy + Hepatosplenomegaly           (Tuberculosis, malaria, malignancy)

Investigation

• -          Direction of investigations depends upon age and detailed history
• -          Complete Hemogram (for isolated Anemia or other cells lines also affected)

 

Red cell indices

-          MCV (Mean corpuscular volume), MCH (mean corpuscular Hemoglobulin), MCHC (Mean Corpuscular Hemoglobin Content)

-          MCV – microcytic, normocytic, macrocytic anemia

-          Low (MCV, MCH, MCHC) = Iron deficiency, Thalassemia

-          High MCV = megaloblastosis

RDW (Red cell distribution)

-          Value proportional to the variation in the RBC morphology

Peripheral Smear

-          Red cell morphology, present of schistocytes, polychromasia, specific red cell morphology

Or parasites

-          Retics count (if Anemia due to RBC destruction or Less RBC production)

Ø  Low retics count – Bone marrow failure syndromes and infiltrating conditions (Malignancy), Transient Erythroblastopenia of infancy or infection (Pure red cell aplasia, Parvo virus B19)

Ø  High retics count – Hemorrhage, Hemolytic anemia (Coombs’s test for differentiating immune or hereditary), splenic sequestration

If nutritional anemia, measurement of serum iron, Vitamin B12 level, Folic acid level

 

IRON Deficiency Anemia

-          Decrease in total iron body content (enough to decrease erythropoiesis)

Pathophysiology

• -         Diminished intake, poor absorption, excessive loss
• -          Can lead to diminish growth and intellectuality
• -          Dietary Constituents like -phytates, phosphates, tannates (nonheme iron unabsorbable)
• -          Healthy born Infants (250 mg = 80 PPM)
• -          At First 6 months, 60 PPM
• -          Human milk iron more bioavailable than Bovine milk

( Cow milk has more calcium which competes with the iron during absorption , also in some , GI blood loss due to Milk allergy)

 

Approach

Clinical Evaluation

-          Dietary History ,weaning foods and supplement

-          Pica – can lead to infestations and lead poisoning

Early symptoms

•      Behavioral symptoms ( irritability , fatiguability , anorexia, leg cramps ,breathlessness , tachycardia )

Late Symptoms

• -          Angular stomatitis, glossitis, koilonychia and platynychia
• -          Congestive heart failure, splenomegaly

 

 

Laboratory Diagnosis

PBS( Peripheral Blood Smear )  

§   microcytic , hypochromic with anisocytosis, poikilocytosis

§  Increased Red cell distribution  

• Reduced MCV and MCHC
• Red cell number decreased (increased in Thalassemia )
• Serum Fe decreased, transferrin decreased up to 16% ( normal 25-50% )
• TIBC ( Total iron binding capacity ) increased
• Ferritin also decreased but can be increased in a sick child because it is acute phase reactant
• High free erythroprotoporphyrin is seen before anemia develops

 

 

 Treatment 

- Cause should be treated along with manifestations 

- Hookworm infestation treatment

- Dietary counseling 

- Oral iron should be taken on an empty stomach or in between meals for best absorption

-10-20% develop GI symptoms such as nausea ,vomiting epigastric discomfort, vomiting , constipation and diarrhea.(enteric coated fewer side effects but less efficacious and more expensive

-Dose of treatment 3-6mg/kg/day elemental iron.( Ferrous sulphate 20% elemental iron )

-Response ( retics count increases within 72 to 96 hours after initiating therapy .After correction of Anemia, Oral iron should be continued for 4-6 months to replenish iron stores .

Indications for Parenteral Iron ( IV preferred over IM)

- Intolerance of Oral Iron

- ongoing blood loss which cant be tackled by Oral iron

- malabsorptive states

( Iron sucrose IV preparations are safe and effective ( can be used in Children with ESRD on dialysis and IBD)

Dose calculation of Parenteral Iron

Total dose = ( Target Hb - Actual Hb ) *weight * 2.4 /( 15* weight )

Blood transfusion not suggested in Young, stable patients 

Used in Urgent surgery ,hemorhhage or severe anemia with CCF( only in emergency condition ) 

- Transfusion slow at 2-3ml/Kg with monitoring and diuretic therapy