AnemiaAnemia

Definition : Definition : Condition in which the concentration of Condition in which the concentration of Hemoglobin Hemoglobin or the red cell mass is or the red cell mass is ggreduced below normalreduced below normal

1

Table 1. Normal red blood cell values in children

Hemoglobin (g/dl)Hemoglobin (g/dl) MCV (fl)MCV (fl)Hemoglobin (g/dl)Hemoglobin (g/dl) MCV (fl)MCV (fl)

AGEAGE MeanMean -- 2 SD2 SD MeanMean -- 2 SD2 SDBirth (cord blood)Birth (cord blood) 16.516.5 13.513.5 108108 989811--3 days (capillary)3 days (capillary)1 week1 week2 weeks2 weeks1 month1 month

18.518.517.517.516.516.514 014 0

14.514.513.513.512.512.510 010 0

108108107107105105104104

95958888868685851 month1 month

2 months2 months33--6 months6 months0.50.5--2 years2 years

14.014.011.511.511.511.512.012.0

10.010.09.09.09.59.510.510.5

104104969691917878

8585777774747070

22--6 years6 years66--12 years12 years1212--18 years, female18 years, female1212--18 years, male18 years, male

12.512.513.513.514.014.014.514.5

11.511.511.511.512.012.013.013.0

8181868690908888

75757777787878781212 18 years, male18 years, male

1818--49 years, female49 years, female1818--49 years, male49 years, male

14.514.514.014.015.515.5

13.013.012.012.013.513.5

888890909090

787880808080

2Hasting, C. Anemia , In: Hematology/oncology handbook, 2002 ; 3

Classification anemia in childrenClassification anemia in children

ETIOLOGYETIOLOGYETIOLOGYETIOLOGY

I.Impaired red cell formation II.Blood loss III.Hemolytic anemiaI.Impaired red cell formation II.Blood loss III.Hemolytic anemiaA.Deficiency A. CorpuscularA.Deficiency A. Corpuscular

Decreased dietary intake 1 Membrane defecDecreased dietary intake 1 Membrane defectstsDecreased dietary intake 1. Membrane defecDecreased dietary intake 1. Membrane defectstsIncreased demand 2. Enzymatic defIncreased demand 2. Enzymatic defectsectsDecreased absorbsion 3. Hemoglobin defDecreased absorbsion 3. Hemoglobin defectsectsIncreased loss a. HemeIncreased loss a. HemeImpairment in red cell formation can result b. GlobinImpairment in red cell formation can result b. Globin

from one of the following deficiencies from one of the following deficiencies -- Qualitative....Qualitative...... Sickle cell.. Sickle cell1. Iron deficiency 1. Iron deficiency -- Quantitative.... ThalassemiaQuantitative.... Thalassemia2. Follate deficiency2. Follate deficiency3. Vitamin B12 deficiency 3. Vitamin B12 deficiency B. ExtracorpuscularB. Extracorpuscular4. Vitamin C deficiency 4. Vitamin C deficiency 1. Immune1. Immune5.Protein deficiency 5.Protein deficiency a. Isoimmunea. Isoimmune6 Vitamin B6 deficiency6 Vitamin B6 deficiency b Autoimmuneb Autoimmune6. Vitamin B6 deficiency 6. Vitamin B6 deficiency b. Autoimmuneb. Autoimmune7. Thyroxine deficiency 7. Thyroxine deficiency ( 1) Idiopatic( 1) Idiopatic

( 2) Secodary( 2) SecodaryB.Bone marrow failure. B.Bone marrow failure. Immunologic disorderImmunologic disorder

1. Failure of single cell line 1. Failure of single cell line One cell lineOne cell linea. Megakaryocitesa. Megakaryocitesb. Red cell precurcors b. Red cell precurcors Multiple cell lineMultiple cell linepp ppc. White cell precorsorsc. White cell precorsors

2. Failure of all cell line 2. Failure of all cell line 2. Nonimmune( Idiopatic, secondary )2. Nonimmune( Idiopatic, secondary )a. Constitutionala. Constitutionalb. Acquiredb. Acquired

3. Infiltration3. Infiltrationa. De novo ec Leukemiaa. De novo ec Leukemiab Secondary ec : Neuroblastoma Lymfomab Secondary ec : Neuroblastoma Lymfomab. Secondary ec : Neuroblastoma, Lymfomab. Secondary ec : Neuroblastoma, Lymfomac. Dyshematopoitic anemiac. Dyshematopoitic anemia

Lanzkowosky P,Manual of Pediatric Hematology and Oncology 4 th edsLanzkowosky P,Manual of Pediatric Hematology and Oncology 4 th eds

Blood Smear

Hypocromic Macrocytic Normocytic Specific yp

MicrocyticMacrocytic Normocytic Specific

MCV LOW

( Red Cell Size < 70 fl)• Iron deficiency anemia

MCV HIGH

( Red Cell Size > 85 fl )N l b

MCV NORMAL

( Red Cell Size 72-79 fl)Acute blood loss• Iron – deficiency anemia

• Thalassemia

• Sideroblastic anemia

• Chronic disease

(Infection, Cancer,inflamation, renal disease)

5. Lead toxicity

Normal newborn

Increased erythropoisis

Postsplenectomy

Liver disease

Obstructive jaundice

Infection

Renal failure

Conective tissue disorder

Liver desease

Disseminated malignancy6. Hemoglobin E trait

7. Atransferrinemia

8. Inborn errors of iron metabolism

9. Copper deficiency

10. Severe malnutrision

Aplastic anemia

Hypothyroidism

Megaloblastic anemia

Down syndrome

Syndrome with elevatedHigh F

Disseminated malignancy

Early iron deficiency

Aplastic anemia

Bone marrowinfiltration

Dyserytropoitic anemia

Myelodysplastic syndrome

Diamond-Blackfan syndrome

Fanconi anemia

Dyskeratosis Congenital

Pearson syndrome

Hemolysis

RBC enzym deficiency

RBC membrane defects

Hypersplenism

Drugs3Lanzkowsky P,Manual of Pediatric Hematology and

Oncology 4 th eds.

Laboratory Studies often Helpful in Investigation Laboratory Studies often Helpful in Investigation of a patient with anemiaof a patient with anemia

Usual Initial studiesUsual Initial studiesHemoglobin and hematocrit determinationHemoglobin and hematocrit determinationErythrocyte count and red cell indices, including MCV and RDWErythrocyte count and red cell indices, including MCV and RDW

llReticulocyte countReticulocyte countStudy of stained blood smearStudy of stained blood smearLeucocyte count and differential countLeucocyte count and differential countPlateled countPlateled count

Suspected Iron deficiencySuspected Iron deficiencySuspected Iron deficiencySuspected Iron deficiencyFree erytrocyte protoporphyrinFree erytrocyte protoporphyrinSerum ferittin levelsSerum ferittin levelsStool for occult bloodStool for occult blood99m Tc pertechnetate scan for Mechel’s diverticulum99m Tc pertechnetate scan for Mechel’s diverticulum if indicatedif indicated99m Tc pertechnetate scan for Mechel s diverticulum99m Tc pertechnetate scan for Mechel s diverticulum--if indicated if indicated Endoscopy (upper and lower bowel)Endoscopy (upper and lower bowel)-- if indicatedif indicatedSuspected Vitamin B12 or folic acidSuspected Vitamin B12 or folic acidBone MarrowBone MarrowS i i B12 l lS i i B12 l lSerum vitamin B12 levelSerum vitamin B12 levelSerum folate levelSerum folate levelGastric analysis after histamine injectionGastric analysis after histamine injectionVitamin B12 absorption test (radioactive cobalt) (Schilling testVitamin B12 absorption test (radioactive cobalt) (Schilling test))

d h ld h lSuspected hemolytic anemiaSuspected hemolytic anemia

ContinuedContinuedSuspected hemolytic anemiaSuspected hemolytic anemiaEvidence of red cell breakdownEvidence of red cell breakdown

Bl dBl dBlood smearBlood smearSerum billirubin levelSerum billirubin levelUrinary urobilinogenUrinary urobilinogenHemoglobinuriaHemoglobinuriaS h t l biS h t l biSerum haptoglobinSerum haptoglobin

Evidence of red cell regenerationEvidence of red cell regenerationReticulocyte countReticulocyte countBlood smearBlood smearSkl l di hSkl l di hSkletal radiographsSkletal radiographs

Evidence of type of hemolytic anemia: corpuscularEvidence of type of hemolytic anemia: corpuscularMembraneMembrane

Blood smearBlood smearOsmotic fragility testOsmotic fragility testAutohemolysis testAutohemolysis test

HemoglobinHemoglobinSickle testSickle testHemoglobin electrophoresisHemoglobin electrophoresisHemoglobin F determinitationHemoglobin F determinitationKleihauerKleihauer--Betke smearBetke smearHeatHeat--stability teststability test

EnzymesEnzymesEnzymesEnzymesEnzyme assayEnzyme assay

ContinuedContinued

Evidence of type of hemolytic anemia : extracorpuscularEvidence of type of hemolytic anemia : extracorpuscularyp y pyp y pImmuneImmune

Antiglobulin testAntiglobulin testAcid serum lysis testAcid serum lysis testSucrose lysis testSucrose lysis testSucrose lysis testSucrose lysis testDonathDonath--Landsteiner antibodyLandsteiner antibodyANAANA

Suspected aplastic or leukemiaSuspected aplastic or leukemiaBone marrow (aspiration or biopsy)Bone marrow (aspiration or biopsy)--cytocemistry, immunologic cytocemistry, immunologic markers, cromosome analysismarkers, cromosome analysisSkl t l di hSkl t l di hSkletal radiographsSkletal radiographs

Other test often used espicially to diagnose the primary diseaseOther test often used espicially to diagnose the primary diseaseViral serology e g HIVViral serology e g HIVViral serology, e.g. HIVViral serology, e.g. HIVANA, complemant, CH50ANA, complemant, CH50Blood urea, creatinin, T4,TSH, Tissue biopsy (skin, lympnode,liver)Blood urea, creatinin, T4,TSH, Tissue biopsy (skin, lympnode,liver)

Investigation of AnemiaAnemia

History, physical examination, CBC

MCV

Reticulocyte count

Low Normal or high

Compatible with iron deficiency

Peripheral smear

Peripheral

smear

Low

yesNo

N

high

Response to

Trial of ironNeutrophils,

platelets Investigate

yNo

HemolysisNoHemolysis

I d fi i

Blood loss

Specific tests

Dictated by history Laboratory evaluation

yes NoHemolysis

Iron deficiency Dictated by history, physical, & red cell morphology

Laboratory evaluation of microcytic anemia

Normal or highPure red cell aplasia or megaloblatic anemia

Bone marrow failure

8

Low Normal or high

Table 3. Physical examination of the anemic child

Physical findingsPhysical findings ConsiderConsiderSkinSkin PallorPallor

JaundiceJaundice

Petechiae purpuraPetechiae purpura

Severe anemiaSevere anemiaHemolytic anemia, acute & chronic Hepatitis, aplastic Hemolytic anemia, acute & chronic Hepatitis, aplastic anemiaanemiaAutoimmune haemolytic anemia with thrombocytopeniaAutoimmune haemolytic anemia with thrombocytopeniaPetechiae, purpuraPetechiae, purpura Autoimmune haemolytic anemia with thrombocytopeniaAutoimmune haemolytic anemia with thrombocytopeniaHemolyticHemolytic--uremic syndromeuremic syndromeBone marrow aplasia or infiltrationBone marrow aplasia or infiltration

HeentHeent Cavernous hemangiomaCavernous hemangiomaF t l b i i t l & F t l b i i t l &

Microangiopathic hemolytic anemiaMicroangiopathic hemolytic anemiaE t d ll h t i i (th l i j E t d ll h t i i (th l i j Frontal bossing, prominent malar & Frontal bossing, prominent malar &

maxillary bonesmaxillary bonesIcteric scleraeIcteric sclerae

A l t titiA l t titi

Extramedullary hematopoiesis (thalassemia major, Extramedullary hematopoiesis (thalassemia major, congenital hemolytic anemia)congenital hemolytic anemia)Congenital hemolytic anemia & or hyperhemolytic Congenital hemolytic anemia & or hyperhemolytic crises crises

associated with infectionassociated with infectionAngular stomatitisAngular stomatitisGlossitisGlossitis

associated with infectionassociated with infectionIron deficiency Iron deficiency Vit. B12 or iron deficiencyVit. B12 or iron deficiency

ChestChest Rales, gallop rhythmRales, gallop rhythm Congestive heart failure, acute or severe anemiaCongestive heart failure, acute or severe anemiaTachycardiaTachycardia

ExtremitiesExtremities Radial limb dysplasiaRadial limb dysplasiaSpoon nailsSpoon nailsTriphalangeal thumbsTriphalangeal thumbs

Fanconi’s anemiaFanconi’s anemiaIron deficiencyIron deficiencyRed cell aplasiaRed cell aplasiap gp g pp

SpleenSpleen SplenomegalySplenomegaly Congenital hemolytic anemia, infection, hematologic Congenital hemolytic anemia, infection, hematologic malignancies, portal hypertension with resultant malignancies, portal hypertension with resultant hypersplenismhypersplenism 7

Hasting, C. Anemia , In: Hematology/oncology handbook, 2002 ; 5

IRON DEFICIENCY ANEMIAIRON DEFICIENCY ANEMIADefinition : Definition : Definition : Definition :

Anemia resulting from lack of sufficient iron for Anemia resulting from lack of sufficient iron for synthesis of hemoglobin.synthesis of hemoglobin.

Prevalence :Prevalence :The most common cause of anemia worlwideThe most common cause of anemia worlwideAn estimated 30% of the world’s population :An estimated 30% of the world’s population :

4.5 billion 4.5 billion anemicanemic500 500 –– 600 million 600 million Iron def. anemiaIron def. anemia

North American (1970) : 30 North American (1970) : 30 -- 75% of child 1 75% of child 1 –– 2 years 2 years f f of ageof age

Israelli : 25% females (aged 16 Israelli : 25% females (aged 16 -- 17 yrs) 17 yrs) I d i 25 I d i 25 35% ( d 5 )35% ( d 5 )Indonesia : 25 Indonesia : 25 –– 35% (aged 5 yrs)35% (aged 5 yrs)

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Iron cycle 12

Causes of Iron Deficiency AnemiaCauses of Iron Deficiency Anemia

I. Deficient intakeI. Deficient intakeDietary ( milk,0,5Dietary ( milk,0,5--1,5 iron /L)1,5 iron /L)

II. Increased demandII. Increased demandGrowth ( low birth weight, prematury, lowGrowth ( low birth weight, prematury, low--birthbirth--weigh twins or multiple brths, weigh twins or multiple brths, adolecence pregnance) cyanotic congenital heart diseaseadolecence pregnance) cyanotic congenital heart diseaseadolecence, pregnance),cyanotic congenital heart diseaseadolecence, pregnance),cyanotic congenital heart disease

III.Blood lossIII.Blood lossA.A. PerinatalPerinatal

1.Placental (Transplacental bleeding into maternal Circulation,1.Placental (Transplacental bleeding into maternal Circulation,Retroplacental, Intraplacental, Fetal blood loss at before birth)Retroplacental, Intraplacental, Fetal blood loss at before birth)

2.Umbilicus (rupture umbilical cord,In adequat cord tying, post exchange 2.Umbilicus (rupture umbilical cord,In adequat cord tying, post exchange transfusion)transfusion)

B.B. PostnatalPostnatalGastrointestinal tract, Hepatobiliary system,Pulmonary hemocideration,Gastrointestinal tract, Hepatobiliary system,Pulmonary hemocideration,recurent epistaxisrecurent epistaxis

IV.Impaired absorptionIV.Impaired absorptionMalabsorption syndrome celiac disease severe prolongedMalabsorption syndrome celiac disease severe prolongedMalabsorption syndrome, celiac disease, severe prolonged Malabsorption syndrome, celiac disease, severe prolonged diared,postgastrectomy, inflamatory bowel desease, Helicobacter pylori diared,postgastrectomy, inflamatory bowel desease, Helicobacter pylori infection associated chronic gastritisinfection associated chronic gastritis

CLINICAL MANIFESTATIONSCLINICAL MANIFESTATIONS

Consequences of anemia :Consequences of anemia :Mild Mild moderate iron def moderate iron def ( Hb 6( Hb 6 10 g/dl) 10 g/dl) Mild Mild –– moderate iron def. moderate iron def. ( Hb 6( Hb 6--10 g/dl) 10 g/dl) compensatory mechanism (+)compensatory mechanism (+)Severe iron deficiency (Hb < 5 g/dl) :Severe iron deficiency (Hb < 5 g/dl) :Severe iron deficiency (Hb < 5 g/dl) :Severe iron deficiency (Hb < 5 g/dl) :

Fatigue, listlessness, irritability, anorexia, Fatigue, listlessness, irritability, anorexia, tachycardia, cardiac dilatation & systolic murmurs.tachycardia, cardiac dilatation & systolic murmurs.

Advanced iron deficiency : Advanced iron deficiency : Pale, plump, & petulant .Pale, plump, & petulant .

14

Nonhematologic consequence :Nonhematologic consequence :CLINICAL MANIFESTATIONS

Pica :Pica :Phagophagia (compulsive eating of ice)Phagophagia (compulsive eating of ice)Geophagia : interest in dirt consumption Geophagia : interest in dirt consumption risk risk for parasitic infestation & lead poisoning)for parasitic infestation & lead poisoning)

Ephitelial changes : Koilonychia, atrophy of lingual Ephitelial changes : Koilonychia, atrophy of lingual papilpapilExercise intoleranceExercise intoleranceBehavioral changesBehavioral changesAb l th iAb l th iAbnormal thermogenesisAbnormal thermogenesisAltered host responseAltered host response 15

Koilonychia 16

LABORATORIUM FINDINGSLABORATORIUM FINDINGS

Red blood cells (RBCs)Red blood cells (RBCs)Hb concentration : Hb concentration : Hb concentration : Hb concentration : Chronic iron def. Chronic iron def. red cell indicesred cell indices (MCV, MCH, (MCV, MCH, MCHC) : MCHC) : parallels with Hb concentrationparallels with Hb concentration)) ppReticulocytes : slightly Reticulocytes : slightly Red cell morphology : Red cell morphology : p gyp gy

Mild iron def. Mild iron def. hypochromic, anisocytosishypochromic, anisocytosisChronic iron def. Chronic iron def. poicylocytosis (targets poicylocytosis (targets p y y ( gp y y ( gcells, ovalocytes, mycrocytes & cell cells, ovalocytes, mycrocytes & cell fragments)fragments)

RBCs survival : shortenedRBCs survival : shortened17

Live Blood Cell Analysis

Photos taken with a dark field microscope

Normal Red blood cell Microcytes 18

19

Poikylocytosis Anisocytosis 20

…… Laboratorium findings…… Laboratorium findings

PlateletsPlatelets : : varies trombocytopenia to trombositosisvaries trombocytopenia to trombositosisyyIron metabolism :Iron metabolism :

Serum iron : Serum iron : TIBC : TIBC : Transferrin sat. (ratio SI : TIBC) : Transferrin sat. (ratio SI : TIBC) : Transferrin sat. (ratio SI : TIBC) : Transferrin sat. (ratio SI : TIBC) : Serum ferritin : < 10 Serum ferritin : < 10 --12 µg/dl12 µg/dlFEP (Free erythrocyte porphyrin) : > 100 µg/dlFEP (Free erythrocyte porphyrin) : > 100 µg/dlFEP (Free erythrocyte porphyrin) : > 100 µg/dlFEP (Free erythrocyte porphyrin) : > 100 µg/dl

Factor VIII activity : Factor VIII activity : 2 2 –– 3 fold.3 fold.

21

DIAGNOSISDIAGNOSIS

Based of :Based of :HistoryHistoryPhysical examinationPhysical examinationLaboratorium findingsLaboratorium findings

Diagnostic criterias for iron deficiency anemia (IDA) :Diagnostic criterias for iron deficiency anemia (IDA) :

Criteria of IDA by WHO :Criteria of IDA by WHO :1.1. Hb concentration < normal (age dependent)Hb concentration < normal (age dependent)2.2. Mean Hb concentration < 31% ( N: 32 Mean Hb concentration < 31% ( N: 32 -- 35%)35%)3.3. Serum iron < 50 Ug/dl (N: 80Serum iron < 50 Ug/dl (N: 80--180 ug/dl)180 ug/dl)

T f i t < 15 (N 20T f i t < 15 (N 20 50%)50%)4.4. Transferrin sat. < 15 (N: 20Transferrin sat. < 15 (N: 20--50%)50%)22

……… Diagnosis……… Diagnosis

Criteria of IDA by Cook & MonsenCriteria of IDA by Cook & Monsen ::Criteria of IDA by Cook & MonsenCriteria of IDA by Cook & Monsen ::1.1. Microcytic hypochromic anemiaMicrocytic hypochromic anemia22 Transferrin sat < 16%Transferrin sat < 16%2.2. Transferrin sat. < 16%Transferrin sat. < 16%3.3. FEP levels > 100 ug/dl eritrositFEP levels > 100 ug/dl eritrosit44 Serum ferritin level < 12 u/dlSerum ferritin level < 12 u/dl4.4. Serum ferritin level < 12 u/dlSerum ferritin level < 12 u/dl

Diagnostic to established if 2 from 3 criterias Diagnostic to established if 2 from 3 criterias ….. Diagnostic to established if 2 from 3 criterias ….. Diagnostic to established if 2 from 3 criterias (Transferrin sat. serum ferritin & FEP) are present.(Transferrin sat. serum ferritin & FEP) are present.

23

……… Diagnosis……… Diagnosis

C i i f IDA b L k k C i i f IDA b L k k Criteria of IDA by Lanzkowsky :Criteria of IDA by Lanzkowsky :1. Peripheral smears : 1. Peripheral smears :

-- Microcytic hypochromic Microcytic hypochromic -- MCV, MCH, MCHC : MCV, MCH, MCHC : , ,, ,-- RDW > 17%RDW > 17%

2. FEP : 2. FEP : 2. FEP : 2. FEP : 3. Serum ferritin : 3. Serum ferritin : 4 Serum ferritin 4 Serum ferritin TIBC TIBC Transferrin sat < 16% Transferrin sat < 16%4. Serum ferritin 4. Serum ferritin , TIBC , TIBC , Transferrin sat. < 16%, Transferrin sat. < 16%5. Response to iron preparation 5. Response to iron preparation 6 Bone marrow : Iron (6 Bone marrow : Iron (--) / ) / 6. Bone marrow : Iron (6. Bone marrow : Iron (--) / ) /

24

DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS

ββ Thalassemia traitThalassemia traitββ Thalassemia traitThalassemia traitαα Thalassemia traitThalassemia traitAnemia of chronic diseases & infectionAnemia of chronic diseases & infectionAnemia of chronic diseases & infectionAnemia of chronic diseases & infectionLead poisoningLead poisoning

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Disorders Associated with HypochromiaDisorders Associated with Hypochromia

1 I d fi i1 I d fi i1.Iron deficiency1.Iron deficiency2.Hemoglobinopathies2.Hemoglobinopathies

Thalassemia Thalassemia αα--ββ, Hemoglobin Koln, Hemoglobin Koln--LeoporeLeopore--HH--EE3 Disorders of heme synthesis caused by a chemical3 Disorders of heme synthesis caused by a chemical3.Disorders of heme synthesis caused by a chemical3.Disorders of heme synthesis caused by a chemical

Lead, Pyrazinamide, IsoniazideLead, Pyrazinamide, Isoniazide4.Sideroblastic anemias4.Sideroblastic anemias5 Chronic infections or other inflamatory states5 Chronic infections or other inflamatory states5.Chronic infections or other inflamatory states5.Chronic infections or other inflamatory states6.Malignancy6.Malignancy7.Hereditary orotic aciduria7.Hereditary orotic aciduria8.Hypo8.Hypo-- or a transferrinemiaor a transferrinemiaypyp

CongenitalCongenitalAcquired (e.q,hepatic disorders); malignan disease, protein Acquired (e.q,hepatic disorders); malignan disease, protein

malnutrition (decreased transferin synthesis), nephrotic malnutrition (decreased transferin synthesis), nephrotic syndrome ( urinary loss)syndrome ( urinary loss)syndrome ( urinary loss)syndrome ( urinary loss)

9.Copper deficiency9.Copper deficiency10.Inborn error of iron metabolism10.Inborn error of iron metabolism

Congenital defect of iron transportto red cellsCongenital defect of iron transportto red cellsCongenital defect of iron transportto red cellsCongenital defect of iron transportto red cells

TREATMENTTREATMENTTREATMENTTREATMENT

Treatment of IDA is twofold :Treatment of IDA is twofold :Replenishment of body ironReplenishment of body ironCorrection of the factors responsible for the Correction of the factors responsible for the Correction of the factors responsible for the Correction of the factors responsible for the deficiencydeficiency

Iron can be administered orally, IM, or IV.Iron can be administered orally, IM, or IV.

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O l i hO l i h

…….. Treatment

Oral iron therapyOral iron therapyFerrous salt : adsorbed 3X better than ferric saltsFerrous salt : adsorbed 3X better than ferric saltsFerrous gluconate, ferrous fumarate, & ferrous Ferrous gluconate, ferrous fumarate, & ferrous sucsinat : well adsorbed but >> expensivesucsinat : well adsorbed but >> expensive

ffDose : 4 Dose : 4 –– 6 mgkg of elemental iron in three divided 6 mgkg of elemental iron in three divided doses.doses.A d t t i th A d t t i th Hb Hb An adequate response to iron therapy : An adequate response to iron therapy : Hb Hb concentration > 1g/dl in 10 days & reticulocytosis concentration > 1g/dl in 10 days & reticulocytosis within 3 within 3 –– 5 days after starting oral iron 5 days after starting oral iron within 3 within 3 –– 5 days after starting oral iron 5 days after starting oral iron supplementation.supplementation.Side effect : >> adults than in infants & childrenSide effect : >> adults than in infants & childrenSide effect : >> adults than in infants & childrenSide effect : >> adults than in infants & children

temporary stainingtemporary staining of the teethof the teeth27

…….. Treatment…….. Treatment

Parenteral iron therapyParenteral iron therapyIndicated : for steadfast noncompliance with oral Indicated : for steadfast noncompliance with oral medication, iron malabsorption, ongoing iron loss medication, iron malabsorption, ongoing iron loss exceed.exceed.P ti i d t P ti i d t l f f i l f f i Preparation : iron dextran Preparation : iron dextran a complex of ferric a complex of ferric hydroxide with hydroxide with molecular weight dextrans.molecular weight dextrans.25% f th i i t th i j ti it f 25% f th i i t th i j ti it f 25% of the iron remains at the injection site for 25% of the iron remains at the injection site for months months staining of the skin.staining of the skin.Dose : weight (kg) x desired increment Hb (g/dl) x 2 5Dose : weight (kg) x desired increment Hb (g/dl) x 2 5Dose : weight (kg) x desired increment Hb (g/dl) x 2.5Dose : weight (kg) x desired increment Hb (g/dl) x 2.5

28

ErythropoietinErythropoietin

…….. Treatment

ErythropoietinErythropoietinRecombinant human erythropoietin (EPO) Recombinant human erythropoietin (EPO) stimulates proliferation & differentiation of erythroid stimulates proliferation & differentiation of erythroid stimulates proliferation & differentiation of erythroid stimulates proliferation & differentiation of erythroid precursors precursors in heme synthesis.in heme synthesis.A typical starting dose : 150 U/kg (3x a week) A typical starting dose : 150 U/kg (3x a week) IV IV A typical starting dose : 150 U/kg (3x a week) A typical starting dose : 150 U/kg (3x a week) IV IV or SQor SQ

Transfusion therapyTransfusion therapyTransfusion therapyTransfusion therapyChildren with very severe anemia (Hb < 5 g/dl)Children with very severe anemia (Hb < 5 g/dl)Blood is best given : packed red cells by a modified Blood is best given : packed red cells by a modified Blood is best given : packed red cells by a modified Blood is best given : packed red cells by a modified exchange transfusion exchange transfusion avoid expansion of the avoid expansion of the blood volume.blood volume.

29

P iP i

…….. Treatment

PreventionPreventionEncouragement of breast Encouragement of breast –– feedingfeedingUse of iron Use of iron -- fortified infant formulas after weaningfortified infant formulas after weaningThe introduction of wholes cow’s milk to 1 years of The introduction of wholes cow’s milk to 1 years of ageageUse of iron Use of iron –– fortified infant cereals & ascorbid acidfortified infant cereals & ascorbid acid--i h f d t 4 i h f d t 4 6 th6 thrich foods at 4 rich foods at 4 –– 6 months6 months

Supplemental iron for preterm infants after the first Supplemental iron for preterm infants after the first monthmonthmonth.month.

30