IRON DEFICIENCY ANEMIA

IN INFANCY AND CHILDHOOD

Sony Wicaksono
Susanto Nugroho
Department of Child Health,
Faculty of Medicine-University of Brawijaya/
Dr. Saiful Anwar General Hospital

Objectiveo
To understand the burden of iron
deficiency anemia (IDA)
To understand the IDA diagnosis and
management

Keypoints

Introduction
Iron metabolism
Iron deficiency anemia
Management

Introduction
Iron deficiency anemia is the most common
haematologic disease in infants & children
remains the community health problem
in
Indonesia
Several studies iron deficiency anemia
associated with : - poor cognitive function
- lower achievement scores in school
- impaired psychomotor development
- behavioral problems
Palti H, Meijer A, Adler B. Early Hum Dev 1985 ; 10 : 217-23
Sherriff A, Emond A, Bell JC, Golding J. Arch Dis Child 2001; 84; 480-5

Developmental and Behavioral Effects

of Iron Deficiency Anemia (IDA) in Infants

Holst M-C. Developmental and behavioral effects of iron deficiency anemia in infants. Nutrition Today 19

ASEAN Human Development Index 2002

UNDP Report 2004

Iron deficiency anemia 2001

underfives children in Indonesia

Household Survey, 2001

Untoro R. Peningkatan Kualitas Hidup Anak Melalui Pencegahan Anemia Gizi Besi.
Disajikan pada Kampanye Anti Anemia 2006-2008. Depkes, Jakarta, 1 Maret 2007

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
Hoffbrand AV, et al. Essential Hematology. 4th. London:Blackwell Science.2001

Body iron distribution

Andrew NC. Medical Progress: Disorders of Iron Metabolism.

N Engl J Med 1999; 341: 1986-95

Iron requirements
Estimated daily iron requirements
In childen (average):
- Urine, sweat, feces : 0.5 mg/day
- Growth : 0.6 mg/day
- Total
: 1.1 mg/day

In female (age 12-15 yrs):

- Urine, sweat, feces
: 0.5-1 mg/day
- Menses
: 0.5-1 mg/day
- Growth: 0.6 mg/day
- Total : 1.6-2.6 mg/day
Hoffbrand AV, et al. Essential Hematology. 4th. London:Blackwell Science.2001

Etiology of iron deficiency

Less 1 year
Low iron storage (LBW or gemelli)
Lack of iron supplements in exclusively breastfed infants beyond 6 months of age
Unfortified milk formula
Age 1-2 year
Milkaholics
Increased iron needs due to chronic infection
Malabsorption
Blood loss >> eg. parasitic infection and
Meckels diverticulum

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.

Staging of iron deficiency

Stage I

: Iron depletion (without anemia)

Stage II : Iron deficiency (without anemia)

Stage III : Iron deficiency (with anemia)
IRON DEFICIENCY ANEMIA

Raspati H dkk. Anemia defisiensi besi. Dalam Permono B, dkk. Editor.

Buku Ajar Hemato-onkologi anak 2005: 30-431.

Iron deficiency
with and without anemia
Anemia (Iron Deficiency with Anemia (ID + A)
- Serum hemoglobin : below normal
- Depleted ferritin stores
- Disturbing cognitive & behavior development
Iron Deficiency without Anemia (ID A)
- Serum hemoglobin : normal
- Deplete ferritin stores
- Decrease iron concentrations in some tissues
- Strongly potential disturbing cognitive and
behavior development
- Critical periode : 1 2 years of age
Joyce C McCann JC, Ames BN. Am J Clin Nutr 2007;85:931 45

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

Clinical features
Depend on speed of onset, severity (degrees of iron
deficiency), age & HbO2 dissociation curve
General symptoms and signs
- weakness, lethargy, palpitation
- pallor of mucous membranes (Hb < 9-10 g/dL)
- tachycardia, cardiomegaly, a bounding pulse,
a systolic flow murmur at apex
A painless glossitis, angular stomatitis, brittle,
ridged or spoon nails (koilonychia), dysphagia as
result of pharyngeal web (Paterson-Kelly or
Plummer-Vinson syndrome)

Laboratory findings for identifying iron

deficiency

Raspati H dkk. Anemia defisiensi besi. Dalam Permono B, dkk. Editor.

Buku Ajar Hemato-onkologi anak 2005: 30-431.

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
Diet

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.

Indication for routine iron supplementation

children < 5 yrs old

Lannotti LL, Tielsch JM, Black MM, and Black RE,Am J Clin Nutr
2006;84:126176

Response to iron therapy in

deficiency anemia

iron-

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.

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.

Dept. of Child Health Dr. Saiful Anwar Hospital:

Hb < 7 /dL g/dL
Hb > 7 g/dL, with cardiorespiratory disturbances,
severe infection, dehydration, surgical
procedures

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)
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
Oski FA. N Engl J Med 1993;329:190-3

Primary prevention..

Allen LH. J Nutr 2002;132:813S-9S

Lanzkowsky P. 1995. p. 35-50
Sandoval C, et al. Hematol Oncol Clin N Am 2004;18:1423-38
Oski FA. N Engl J Med 1993;329:190-3

Conclusions
IDA is a major problem in developing countries
Iron supplementation
resulted in a similar rate of successful
treatment
of anemia (Hb & ferritin)
Iron supplementation
- The increases in Hb concentration were
comparable
- Improvement of cognitive function
- Cost effective
- No or fewer side-effect