IRON DEFICIENCY ANEMIA

Almost 90% of anemia in children and women are scarce, with a substantial portion of them are
iron-. Iron deficiency in varying degrees is present in 30-40% of the planet, with sideropenia
develops in 2 times more likely than anemia, and identify in all pregnant women in last
trimester. In Russia, iron deficiency anemia affects 40% of children of the first 3 years of life, up
to 1 / 3 of adolescents and 44% of female fertilnogo age. In high-risk group includes children
from mothers with unsatisfactory state leaky and / or multiple pregnancy, preterm infants,
children aged 6-12 months, the large and rapidly growing children at any age, children who
receive irrational and unbalanced diet, suffering from dysbiosis, malabsorption and chronic
inflammatory bowel diseases, as well as adolescent girls with hyperpolymenorrhea. Value is not
limited to age and sex, but also quality of life in the country (Table 8-2).

Table 8-2. Prevalence iron anemia in Depending from age, sex and region habitat,% *

Children Men Women

0-4 5-12 15-49 15-49
Developed 12 7 3 11
Developing countries 51 46 26 47
In the world (average) 43 37 18 35

* Information, WHO, 1989

Etiology and pathogenesis

Etiology of anemia is reflected in their title. They usually occur during periods of rapid growth
of the organism (the first years of life, during puberty), when the high requirements of the
organism in the substances needed for hematopoiesis (a complete protein, vitamins, trace
elements, iron) are not covered by food. In addition, the assimilation of these substances may be
disrupted because of immaturity of the enzyme and transport systems of the body of the child.

Pathogenesis depends on the prevalence of deficiency of a factor required for normal

hematopoiesis. When preferential deficiency of protein reduced production of erythropoietin by
kidneys, the activity of enzymes of intestinal absorption of iron and vitamins. As a consequence,
disturbed hematopoiesis. When there is insufficient flow of vitamins in the body (especially
vitamin B 6 and B 12) is slowed down as the inclusion of iron in heme (vitamin B 6), and normal
maturation of erythroid cells of the first series due to a defect in DNA synthesis (vitamin B, 2 ).
However, protein and Vitamin nodefitsitnye anemia occur rarely, usually in flagrant violation of
breastfeeding. Much more likely to develop iron deficiency severely affects the process of blood
formation and the state of the whole organism. This is due to metabolism, distribution and
assimilation of iron, high demand of the growing organism in this element and its low content in
the diet.
Iron deficiency anemia
EXCHANGE OF IRON IN THE ORGANISM OF THE CHILD

Fruit gets iron from the mother through the placenta during pregnancy, most intensively with 28-
32-th week. In the body, full-term baby contains approximately 300-400 mg of iron, premature -
only 100-200 mg. After the birth of iron reserves, obtained from the mother, are replenished by
recycling of hemoglobin in the decay of "extra" red blood cells containing HbF. Neonatal-ing (a
mother and RBC) iron is consumed in the synthesis of hemoglobin, myo-globin, iron-containing
enzymes necessary for maintaining normal metabolism and homeostasis, as well as
compensation for natural losses (with feces, urine, and then), the regeneration of skin cells,
mucous membranes, etc. In addition, a child needs to build up reserves of iron, ie iron balance
must be positive.

Needs full-term baby 3-4 months before being met by endogenous iron and mother's milk, which
contains iron in the average number of 0.5 mg / l, with up to 50% of it (0.25 mg) is absorbed
from the intestine using a special protein lactoferrin. However, by 5-6 months in term and to 3-4
months in the premature child's need for iron, was 1 mg / day, is met through these sources, only
1 / 4. Artificial feeding cow's milk, consumption of cheese, eggs, tea, oxalates, phosphates slows
absorption of iron. Promotes absorption of iron ascorbic, succinic and other organic acids,
fructose, sorbitol, animal protein.

Grown deep in the small intestine with the help of iron transport protein transferrin is transferred
to the red bone marrow and tissue depots. There are heme (80% of iron in the body) and
negemovoe iron (Table 8-3).

Table 8-3. Allocation and function iron in organism

Connections Function Processes

Heme Hemoglobin, myoglobin, Transport 0 2, Metabolism porphyrin
iron cytochromes electrons, the destruction synthesis of collagen, nor
-
(30 species), peroxides Minimum functioning
catalase etc. tion of lymphocytes
and granulocytes, the
growth
body and nerves
Negemovoe Flavolroteidy, Oxidation-for the
restoration of
iron succinate dehydro - itinerary
dehydrogenase, xanthine cells, oxidative
 ca -
sidaza etc. -- phosphorylation

By negemovomu iron than specified in the table also includes transferrin (the main transport
protein), ferritin and hemosiderin (proteins that serve a backup source of iron in the body). Iron
is involved in many metabolic processes. Without it the normal growth and development of the
child.

Iron deficiency in the body (sideropeniya) passes through three stages.

1. Prelatentnaya - lack of iron in tissues, the concentration of hemoglobin and serum iron did not
change.

2. Latent - concentration of hemoglobin is normal, but serum iron decreased.

3. Iron deficiency anemia - changed all red blood.

The clinical picture of Iron STATES

The clinical picture of iron states (sideropeny) unspecific and includes several syndromes.

Astenovegetativny syndrome - a consequence of functional disorders of the brain. Young

children with iron deficiency anemia are lagging behind in psychomotor development. They
were tearful, irritable, capricious, bad contact with peers. In older children suffer intellectual
development: reduced memory, attention, interest in learning. There are signs of SVD. Possible
muscle pain and hypotension (eg, bladder), enuresis.

Epithelial dystrophy syndrome include atrophy and barrier tissues (mucous membranes, skin
and its derivatives - nails, hair). K trophic disorders easily align inflammatory changes. As a
result of decreased appetite, there are a perversion of taste and smell (pica
chlorotica), dysphagia, dyspeptic disorders, the processes of intestinal absorption, latent
intestinal bleeding. Pallor of the skin and conjunctiva identify only with a significant decrease in
the concentration of hemoglobin.

Immunodeficient acute respiratory syndrome is manifested by frequent and DCI. About 70% of
sickly children suffering sideropeniey. They have been reduced as a non-specific (lysozyme,
Properdin, etc.) and specific immunity. Shown that in the absence of iron IgA loses its
bactericidal activity.

Cardiovascular syndrome observed in severe iron deficiency anemia. The children develop
unusual fatigue, low blood pressure, tachycardia, decreased cardiac muscle tone, muffled tones,
functional, rather rough systolic sound, well listen to the blood vessels ( "the noise of the top")
and associated polyplasmia. May cause dizziness.
 Gepatolienalny syndrome occurs rarely, usually with severe anemia and rickets and anemia
combined.

Laboratory criteria sideropeny presented in Table 8-4. In recent years began to pay attention to
the fact that iron deficiency increases lead absorption in the gastrointestinal tract. This is
especially important for children living in large cities, close to main roads, Expressions
sideropeny in this case may join (especially in young children) lead intoxication, leading to
severe mental and neurological disorders, kidney function and blood formation. Anemia then
becomes refractory to iron therapy.

Table 8-4. Laboratory criteria iron states y Children *

Indicator Norma Latent IDD -

deficit Nye anemia
Hb, g / l
- Up to 6 years > by > 110 <U0
- Over 6 years > 120 > 120 <120
Color index,% 0,86-1,05 0,86-1,05 <0,86
Iron serum (HS), mmol / l 10,6-33,6 <14 <14
The average content of hemoglobin in erythro - 24-33 24-33 <30
tsite ** pg
The average concentration of hemoglobin in erythro - 30-38 30-38 <30
tsite ***,%
Total iron binding capacity 40,6-62,5 <63 > 63
serum (OZHSS), mmol / l
Latent iron-way > 47 > 47 > 47
tions of serum, mmol / l
Transferrin saturation ratio > 17 <17 <17
iron (JS / OZHSS),%
Serum ferritin, ug / l > 12 <12 <12
Desferalovaya siderouriya *** mg / day 0.65 +0.006 <0,4 <0,4

* By Korovino NA et al., 1999.

* The indicators are determined automatically modern analyzers red blood cells.

'* Define the content in daily urine desferrioksamina (desferala), introduced by intramuscular
injection at 10 mg / kg.

DIAGNOSIS Iron STATES

Diagnosis of iron deficiency anemia and latent iron deficiency base on the above laboratory
criteria. The main indicator - the content of ferritin in the serum. If you can not get all of the data
can be guided by the following indicators are available in any medical facility.

The concentration of Hb.

The color indicator is calculated as follows: color index = [(concentration of Hb, g / l) HZ ]-*-(
three first digits of the number of red blood cells without the comma). Normally is 0,85-1,05.

Morphology of red blood cells in the peripheral blood smear.

Coefficient Loitski calculated as follows: coefficient Loitski = (hematocrit, hemoglobin %)-*-

(%). In normal - less than 3.1.

The result of treatment with iron ingestion: within 10-14 days, the concentration of hemoglobin
increases daily by 1-4 g / l, the content Ratican-lotsitov increases to 3-4% (retikulotsitarny
crisis).

CLINICAL FORMS OF MAINLY Iron deficiency anemia

Early anemia of prematurity

Early anemia of prematurity is a complex pathogenesis and developing on the 1-2-nd month of
life, more than half of preterm and occasionally at full-term children ( "physiological" benign
anemia), especially under adverse premorbid background. An objective examination noted only
pallor (at lower concentrations of Hb to 80 g / l). In the study of peripheral blood detected
normo-or-ing giperhrom normoregeneratornuyu anemia, often reaching severe.

The main reasons for the development of early anemia consider enhanced "physiologic"
hemolysis of red blood cells containing HbF, the lack of functional and morphological maturity
of the red bone marrow, decreased production of tissue erythropoietin due to hyperoxia, which
occurred at birth. It was also important deficiency of many substances needed for hematopoiesis,
are deposited at the depot just in the last 2 months of pregnancy (protein, vitamins C, E, B group,
copper, cobalt) and provide absorption, transport, exchange and fixation of iron in the heme
molecule, and as the stability of membranes and erythrocyte membranes. Present and iron
deficiency in the depot, to offset ongoing hemolysis, but clearly identified by detecting
mikrotsitoza and gipohromii of red blood cells, reduce the concentration of serum iron and the
amount siderotsitov in punctate red bone marrow. As soon as neonatal iron stores are depleted,
early anemia passes in late anemia of prematurity.

Treatment of early anemia is difficult. Previously, for health reasons of transfused packed cells
than currently successfully used epoetin beta (for example, recombinant human erythropoietin).
Assign 10 injections of erythropoietin at a dose of 200 U / kg s / c 3 times a week. At the same
time prescribe iron supplements (2 mg of elemental iron per day), folic acid (0,001 g / day) and
vitamin E (25 mg / day for 2-3 Mee).

Late anemia of prematurity

Late anemia of prematurity (Constitutional), growing at 3-4-th month of life as a result of

depletion of neonatal iron stores in the depot. Clinical manifestations are usually mild, laboratory
data indicate preferential iron deficiency.

Nutritional and infectious anemia

Nutritional and infectious anemia develops in the second half of life in term infants. At the origin
of nutritional anemia play a role violations of feeding, both causing and dystrophy. Infectious
diseases, mostly from France and ear infections, usually contribute to more severe nutritional
anemia. Clinical and laboratory manifestations are characteristic of the prevalence of iron
deficiency.

Chlorosis

Chlorosis - a rare disease in girls during puberty. Developed against the background of violations
of the regime and endocrine dysfunction. Is manifested by weakness, fatigue, anorexia, taste
perversion, dizziness, sometimes fainting, palpitations, pain in the epigastric region, nausea,
vomiting, constipation. The characters "alabaster", in some cases with a greenish tinge, pale skin,
menstrual irregularities (oligo-or amenorrhea). Recovery is usually spontaneous, possible
relapses. Laboratory studies indicate that the predominant iron deficiency.

DIFFERENTIAL DIAGNOSIS anemia

The differential diagnosis of iron deficiency anemia spend with other deficiency anemia,
thalassemia and sideroblastic anemia - lead and piridoksinzavisimoy in which erythropoiesis
disrupted as a result of violations of the inclusion of iron in heme. Gipohromiya erythrocytes in
the latter case, combined with increased concentrations of serum iron.

Clinical manifestations of acquired sideroblastic anemia caused by lead intoxication, more

manifest than in iron-deficiency anemia: cramping abdominal pain, diarrhea pronounced
manifestations, pallor with an earthy nuance, mental and neurological disorders. The blood
analysis - basophilic granules, gipohromiya red blood cells, increasing the concentration of
serum iron. In urine define aminolevulinic acid.

In piridoksinzavisimoy hereditary sideroblastic anemia synthesis of heme is broken at the last

stage. In hypochromic red blood cells accumulate free protoporphyrin, serum iron concentration
increased in the red bone marrow lot Sideroblasts.
 Belkovodefitsitnaya anemia is accompanied by a more pronounced pallor and
chromatodermatosis and hair, blepharitis, pastoznost tissue or edema, anorexia, vomiting,
diarrhea. The concentration of hemoglobin is reduced to 40-90 g / l, color index in the range of
normal values, expressed as anisotropy and microplania.

Vitaminodefitsitnaya anemia (deficiency of vitamins B 2, C) appears asthenia, paresthesia,

pallor, with lemon-yellow hue, subikterichnostyu sclera, glossitis, aphthous stomatitis, moderate
n-patomegaliey. The concentration of hemoglobin decreased as the content of red blood cells,
normo-and hyperchromic, color index increased (more than 1,0). Emerging macro-poykilo and
anisocytosis, calf Jolly, Cabot rings, me-galoblasty, giant metamyelocytes. In punctate red bone
marrow reveal the type of megaloblastic hematopoiesis.

TREATMENT

Treatment of iron deficiency anemia is carried out in three stages (Table 8-5).

Table 8-5. Stages treatment iron anemia *

Stages Target The length Average daily doses

CONTRACT PERIOD elemental iron
Troubleshooting Restoration 1,5-2 months Up to 3 years - 3-5 mg / kg / day;
anemia normal con - from 3 to 7 years - 100-120 mg /
day;
centration of over 7 years - up to 200 mg / day
Hb
Therapy Restoration 3-6 months Up to 3 years - 1-2 mg / kg / day;
saturation iron stores from 3 to 7 years - 50-60 mg /
day;
the body over 7 years - 50-100 mg / day
Support - Saving Nor When krovoteche - 40-60 mg / day
lation formal level niyah from the digestive
tract --
therapy all funds 7-10 days each
iron month, while girls
adolescents with hyper -
Polymenorrhea --
7-10 days after
each menstrual

* According Arkadieva GV, 1999

Mandatory and most important part of each of the stages - oral iron. Preparations of iron in the
vast majority of cases are inside. In the treatment of iron deficiency anemia and latent iron
deficiency in addition to iron supplementation is necessary to observe the regime, diet, balanced
on the basic ingredients, the normalization of iron absorption when it is violated (for example,
the combined treatment of enzyme preparations with malabsorption syndrome), measured
physical activity.

Treatment pvroralnymi iron preparations

The most frequently used iron compounds include iron (III) hydroxide polimaltozat (maltofer)
and ferrous iron salts - sulfate, fumarate, chloride and gluconate. To improve the absorption of
ferrous iron salts combined with organic acids, amino acids and other compounds.

young children displaying liquid dosage forms, allowing a more precise dosage of iron (Table
8-6).

Table 8-6. Preparata iron used y Children early age

Drug Composition Dosage form The content of elemental iron

Maltofer Iron hydroxytestosterone Drops 1 ml (20 cap) - 50 mg

Seed polimal -
tozny complex
Aktiferrin Iron sulfate Drops 1 ml (18 cap) - 9,5 mg;
Series 1 drop - 0,54 mg
Syrup 1 ml - 6,8 mg
1 teaspoon - 34 mg
Gemofer Iron chloride Drops 1 ml (20 cap) - 44 mg;
1 drop - 2,2 mg

Older children and adolescents prescribed tablets and capsules that contain iron. In recent years
mainly as a prophylactic measure used a combination of drugs that contain besides iron vitamins
and other micronutrients (Table 8-7). Drug of choice is maltofer containing iron in a non-ionic
form, not causing side effects, has a pleasant taste to be adopted immediately after or during
meals. You can add any juices and dishes. Other drugs are taken between meals? High fruit
juices (preferably citrus). At the same time take the age dose of ascorbic acid.

Table 8-7. The most often used drugs Iron *

Drug Composition Dosage form The content of elemental iron, mg

Maltofer-FOUL Iron hydroxide Tablets 100

polimaltozny (chewing)
Complex + Folic
acid
Aktiferrin Iron sulfate, a series Capsules 34.2
Aktiferrin - Same + folic acids and
compositum lot + cyanocobalamin Capsules 35

316 Wing of Chapter 8 Table 8-7. End

Drug Composition Dosage form The content of elemental iron, mg

Gemofer Iron sulfate Capsules 105

prolongatum
Konferon Iron sulfate + Sodium Capsules 50
dioktilsulfosuktsinat
Ferropleks Iron sulfate + Drops 50
ascorbate
Sorbifer Iron sulfate + Tablets 100
ascorbate
Ferrograd C Iron sulfate + Tablets 100
ascorbate
Tardiferon Iron sulfate + Tablets 80
mukoproteaza
Ferrogradumet Iron sulfate Tablets 65
Heferol Ferrous fumarate Capsules 115
Pregnavit Ferrous fumarate + Tablets 30
multivitamins
Mathern Iron sulfate + Tablets 60
multivitamins
Fenyuls Iron sulfate + Capsules 45
multivitamins

* According Arkadieva GV, 1999

The daily dose of all drugs are distributed in three stages. At the beginning of treatment within a
few days medications prescribed dose in half to clarify their individual tolerance. In the absence
of dispeptiches-cal phenomena and other side effects pass to the age dose. Combination drugs
designated as a prophylactic measure, take 1 time a day.

Iron preparations for parenteral administration

Parenteral iron supplementation is introduced only in the presence of relevant evidence.

States after operations on the gastrointestinal tract.

Syndrome of malabsorption in the small intestine.

Chronic enterocolitis and ulcerative colitis.

Lactose iron ingestion.

Main drug for parenteral administration - iron (III) hydro-ksid poliizomaltozat (Ferrum
lek). Average daily doses are presented in Table 8-8.

Table 8-
8. Medium DSA dose drugs iron for parenteral introduction (calculation on elementary ir
on) *

Age children Daily dose of elemental iron, mg / day

1.12 months 25
1-3 years 25-40
Over 3 years 40-50

* By Korovino NA et al., 1999

Calculation of exchange rate dose of elemental iron for parenteral administration conducted by
the formula:

Number of elemental iron = M x (78 - 0,35 x Hb),

where: M - mass of the patient's body, kg Hb - Hb concentration, g / liter.

Exchange rate dose for parenteral administration is calculated using the formula:

Number of drug on the course - KJ / SZHP,

where: KJ - Heading dose of iron, mg; SZHP - the iron content in mg in 1 ml.

When parenteral administration of iron preparations often experience side effects: dyspeptic
disorders, allergic reactions (up to the development of anaphylactic shock),
haemosiderosis. Blood transfusions and packed red blood cells carry only at lower
concentrations of Hb less than 60 grams per liter.

PREVENTION

Antenatal prophylaxis. Throughout pregnancy a woman should be prolonged or complex iron

supplementation with multivitamins (tardiferon, ferrogradumet, obscene, etc.). These drugs
should be continued during breast-feeding. In addition, the relevant prevention and treatment of
miscarriage and gestosis, nutrition, dosed physical load.

Postnatal prophylaxis:

breastfeeding with the timely introduction of juices and meat products;

prevention of other diseases, early age;

adequate treatment, good care, adequate exposure to fresh air;

monthly analysis of peripheral blood;

an at-risk groups of courses with the appointment of preventive iron supplementation in half-
dose (1-2 mg / kg / day).

FORECAST

Forecast for iron deficiency anemia in a timely initiated and sequential treatment favorable.