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IRON DEFICIENCY
Anemia is defined as a hemoglobin below the 5th percentile of healthy population.
} Iron deficiency is the most common micronutrient deficiency in the world affecting 1.3 billion people
}Iron deficiency can range from sub-clinical state to severe iron deficiency anemia.
}Different stages are identified by clinical findings & lab tests.
}There are 2 types of iron in the diet; haem iron and non-haem iron
}Haem iron is present in Hb containing animal food like meat, liver & spleen
}Non-haem iron is obtained from cereals, vegetables & beans
}Milk is a poor source of iron, hence breast-fed babies need iron supplements
}Haem iron is not affected by ingestion of
other food items.
}It has constant absorption rate of 20-30%
which is little affected by the iron balance
of the subject.
}The haem molecule is absorbed intact and the iron is released in the mucosal cells.
The absorption of non-haem iron varies greatly from 2% to 100% because it is strongly influenced by:
ØThe iron status of the body
ØThe solubility of iron salts
ØIntegrity of gut mucosa
ØPresence of absorption inhibitors or facilitators
ØMost common global nutrition problem
ØCommon causes of anemia
- Iron deficiency anemia (IDA)
- Infections (malaria, hookworm, HIV)
- Other vitamin deficiencies
- Hemoglobinopathies
ØHealth impact
- Perinatal & maternal mortality
- Delayed child development
- Reduced work capacity
Inhibitors and promoters of iron absorption
Cut-off points for anaemia
}Children 0.5 – 6 Yrs 11g/ dl
}Children 6- 14 Yrs 12g/dl
}Non pregnant Women 12g/dl
}Pregnant women 11g/dl
}Men 13g/dl
Prevalence in Sri Lanka
Aetiology
Major causes
}Low dietary intake
}Poor Bioavailability
}High parasitic infections
Other causes
}Blood loss (heavy menses & use of aspirin & NSAID).
}High fertility rate in womem.
}Low iron stores in newborns.
SIgns and symptoms
}general fatigue
}weakness
}pale skin
}shortness of breath
}dizziness
}strange cravings to eat items that aren’t food, such as dirt, ice, or clay
}a tingling or crawling feeling in the legs
}tongue swelling or soreness
}cold hands and feet
}fast or irregular heartbeat
}brittle nails
}headaches
How to diagnose IDA?
}Clinical: symptoms (fatigue, dizziness , palpitations..etc) & signs (pallor, smooth tongue, Koilonychia, splenomegaly & dysphagia in elderly women).
}Laboratory
}Stainable iron in bone marrow
}Response to iron supplements
Consequences of IDA
}Impaired learning achievement & cognitive development
}Decrease worker productivity
}Increase maternal mortility.
}Increase risk of premature delivery and LBW.
}Learning disabilities & delayed psychomotor development.
}Reduced work capacity.
}Impaired immunity (high risk of infection).
}Inability to maintain body temperature.
}Associated risk of lead poisoning because of pica.
Prevention
}Iron Supplementation
}Dietary modification
}Parasitic control
}Nutrition and Health Education
Dietary modifications to prevent IDA
}Increase Iron Folate rich foods in diet( green leafy vegs and pulses)
}Increase heam Iron in diet ( fish & meat ) as far as possible)
}Increase Vitamin C consumption ( fruits)
}Increase animal protein consumption
}Increase consumption of iron fortified foods.
}Avoid drinking tea soon after meals
}Avoid taking calcium & iron together. Iron supplements to be taken after a meals( not soon after)
Priority target groups for interventions
}Pregnant or lactating women
}Infant and preschool children
}Adolescent girls and women reproductive age
}The remaining general population
Interventions
ØDietary diversification
- Foods that are rich in iron include:
- Meat
- Fortified cereals
- Spinach
- Cashew nuts
- Lentils and beans
ØFortification
ØIron supplements
}Iron supplementation
}Dietary modification
}Food fortification
}Parasitic control
}Nutrition/ Health Education
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OTHER STUFF TO READ
Iron is important for many biological functions such as production of haemoglobin, cognitive and motor development, growth, immune functions, especially for the development of T helper cells. Iron deficiency leads to increased lead absorption4
Hb% is the sole parameter to decide whether the patient has anemia or not. Therefore the method used to estimate this has to have good specificity and reproducibility. Cyanmethaemoglobin method with spectrophotometric estimation has stood the test of time to be the best. It is also relatively a low cost test and does not need much expertise to perform. A haemoglobin value of 11.5 g/dl for adults. 11.0 g/dl for pregnant female 10.5 g/dl for children between 1-2 yrs for practical purposes, may be considered as lower normal limits, and any value less than this needs to be considered as anemia. At birth, the normal minimum value of Hb is 12.5 g/dl and at 1 year 10.5g/dl ,as a result of the physiological changes taking place in the infancy. It rises gradually to normal adult range by puberty. Therefore age related normal ranges of haemoglobin value need to be available especially in Paediatric practice. Age and sex related reference ranges should be kept available for clinical and laboratory staff to refer often.
The following routine investigations give further diagnostic information.
• Full Blood Count (FBC)
- Blood picture
- Reticulocyte count
The haematological indices like MCV, MCH, RBC, RDW which are readily produced by the analysers make the subclassification of anaemiua easy
Before iron deficiency anaemia develops a patient can be in a state of complete depletion of iron stores with normal Hb and MCV. Often MCH appears to be the first parameter to show a low value when a patient develops iron deficiency anaemia. Iron studies (serum ferritin, serum iron, total iron binding capacity) should be performed, if the cause for anaemia is not clinically obvious like in haemorrhoids, menorrhagia, nutritional deficiency etc.
Serum ferritin may give a falsely high value when there is a coexisting infection or inflammatory disorder,during febrile illnesses, in acute or chronic liver disease, and in acute leukaemias. Serum iron can be falsely high after a blood transfusion, and while on iron therapy, and it can be low in chronic renal failure with or without dialysis. Serum soluble transferrin receptor level helps in differentiating iron deficiency anaemia from anaemia of chronic disorder. A high value (normal 2.5-8.5 mg/l ) is seen in early iron deficiency. Increased red cell protoporphyrin level is a stable measure of iron deficiency over previous few weeks, provided sideroblastic anaemia and Lead poisoning is excluded.
IDA in the child
For primary prevention, counsel parents on the use of iron-fortified formula for non-breastfed infants until the age 12 months , and introduce iron-rich foods between 4 and 6 months to breastfed babies .
Infants and toddlers with suspected iron-deficiency anemia (IDA) should begin treatment with oral ferrous sulfate (3 mg/kg/d of elemental iron). A rise in hemoglobin >1 g/dL after 4 weeks supports the diagnosis of iron deficiency, and supplementation should continue for 2 additional months to replenish iron stores. Recheck hemoglobin at the end of treatment and again 6 months later
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The American Academy of Paediatrics recommended universal screening of infants at 1 year of age with an estimation of haemoglobin levels9 . However, in the local setting with high rates of exclusive and partial breast feeding and low intake of iron rich and fortified food together with higher degrees of maternal anaemia, low haemoglobin levels could occur at a younger age and therefore either screening any time after six months or having medicinal iron supplementation from 4 to 18 months of age could be recommended.
The preterm infant who is fed on human milk should receive elemental iron supplementations at 2 mg/kg per day starting from 1 month of age and continued up to 12 months of age
Children need to be encouraged to have a diverse diet rich in iron. Parents should be educated about mechanisms of enhancing iron absorption by adding citrus fruit when preparing food and reducing phytate (inositol hexaphosphate) content of diet. Parents should be encouraged to choose iron fortified food in the markets. Diets high in vegetables with phytate and low in haem iron could be optimized through diet diversification and supplementation. However, there could be barriers to iron supplementations such as poor compliance due to ignorance of carers, side effects such as nausea, vomiting, constipation, and teeth staining. It is important to brush and clean the teeth after oral supplementation. Other barriers include cost of the preparations, unavailability of adequately fortified food and risk of iron overload especially in patients with the thalassaemia trait. Thalassaemia minor resembles mild anaemia and needs treatment only if iron deficiency is present. Usually iron stores in thalassaemia minor are normal, and they are not more at risk of iron overload from iron fortified products or public health supplementation programmes than anyone else in the general population2 . Universal anthelminthic treatment, irrespective of infection status, is recommended at least annually in areas where hookworm prevalence is more than 20%, alongside with iron supplementation1
it is recommended to supplement exclusively breast fed infants from 4 months with 1mg/kg/day of elemental iron
The provision of daily iron supplements is a widely used strategy for improving iron status in children and is superior to weekly supplementation18 . However, effectiveness of daily supplementation has been limited by poor compliance due to side effects, especially in older age groups. Therefore, intermittent use of oral iron supplements (i.e. once, twice or thrice a week on non-consecutive days) has been proposed as an effective alternative to prevent anaemia among children19. The notion behind this intervention is that intestinal cells turn over every 5–6 days and have limited iron absorptive capacity. Thus, intermittent provision of iron would expose only the new epithelial cells to this nutrient, which should improve the efficiency of absorption20. This may also minimize blockage of absorption of other minerals especially divalent cations21. This reduced frequency of exposure to iron could also minimize the risk of infections, if it exists at all22. Therefore, intermittent iron supplementation regimens reduce associated sideeffects and increase compliance23. Intermittent iron supplementation reduces the risk of ID and IDA in children compared to placebo or no intervention, but it is less effective than daily supplementation. Intermittent supplementation is therefore a viable public health supplementation option5 . It is recommended to provide 25mg of elemental iron to children 24-59 months and 75mg for 5-12 year old children weekly for 12 weeks and recommence another 12 week cycle after a 3 month gap (total of 24 months). This regimen could improve the compliance as well as biological function of iron metabolism and especially that of other divalent cations7 . No definite iron compound has been shown to be superior in its function5
Micronutrient DIsorders
What is Malnutrition?
Ø Malnutrition = “lack of nutrients / poor nutrition”
Ø Two principle constituents:
- Protein-energy malnutrition
- Deficiency in micronutrients
Overview
Ø Common when dependent on relief food
Ø Preventable, BUT
- Food sources not common and are expensive
- Fortification adds to cost of relief food
Ø Difficult to recognize
- Symptomatic cases often represent tip of iceberg
- Laboratory assessment difficult & expensive
Ø Lack of 1 micronutrient typically associated with deficiencies of other micronutrients
Ø Highest risk groups
- Young children
- Pregnant Women
- Lactating women
4 major nutrient deficiencies?
Ø Iron -> anaemia
Ø Iodine -> iodine deficiency disorders (IDD)
Ø Vitamin A -> Xeropthalmia
Ø Zinc -> Multiple disorders
Anaemia (other card)
Iodine Deficiency DIsorders (IDD)
IDD- risk factors
Ø Low iodine level in food
- products grown on iodine-poor soil
–erosion, floods
–mountainous areas
- distance from sea (low fish intake)
ØNon-availability of iodized food (salt)
IDD- Assessment
ØMeasure urinary iodine excretion (UIE)
ØMeasure levels of thyroid hormones in blood
ØMeasure degree of goitre
Grade 0 No Goitre
Grade 1 Palpable Goitre
Grade 2 Visible Goitre
....
Vitamin A deficiency (VAD)
Leading cause of preventable blindness among pre-school children
Also affects school age children and pregnant women
Weakens the immune system and increases clinical severity and mortality risk from measles and diarrhoea
Supplementation with vitamin A capsules can reduce child mortality by 23%.
WHO (2002) estimates that 21% of all children suffer from VAD, mostly in Africa and Asia
VAD - Signs and symptoms
ØClinical deficiency is defined by:
- night blindness
- Bitot’s spots
- corneal xerosis and/ or ulcerations
- corneal scars caused by xerophthalmia
VAD - Risk factors
- Low availability of vitamin A-rich foods
- Lack of breastfeeding
- High rates of infection (measles, diarrhoea)
- Malnutrition
VAD - assessment
VAD - Treatment
ØSupplementation
- Capsules given during immunization days
ØFood Forms
- As pre-formed vitamin A in foods from animals
- Liver, fish
- As pro-vitamin A in some plant foods
- red palm oil, carrots, yellow maize
- Fortified blended foods (CSB or WSB)
ZInc deficiency
Ø Zinc essential for the function of many enzymes and metabolic processes
Ø Zinc deficiency is common in developing countries with high mortality
Ø Zinc commonly the most deficient nutrient in complementary food mixtures fed to infants during weaning
Ø Zinc interventions are among those proposed to help reduce child deaths globally by 63% (Lancet, 2003)
ZInc deficiency - SIgns and Symptoms
Zinc deficiency - Assessment
Ø No simple, quantitative biochemical test of zinc status
Ø Serum Zinc
- Can fluctuate as much as 20% in 24-hour period
- Levels decreased during acute infections
- Expensive
Ø Hair zinc analysis
Zinc deficiency - Treatment
Ø Regular zinc supplements can greatly reduce common infant morbidities in developing countries
- Adjunct treatment of diarrhea
20mg /day x 10 days
- Pneumonia
- Stunting
Ø Zinc deficiency commonly coexists with other micronutrient deficiencies including iron, making single supplements inappropriate
Ø Dietary diversification
- Animal protein (oysters, red meat)
Micronutrient deficiencies in emergencies
Deficiencies of:
ØVitamin C - scurvy
ØNiacin (vitamin B3) - pellagra
ØThiamin (vitamin B1) - beriberi
…usually associated with situations where populations are fully dependent on limited commodities for their food needs.
Vitamin C - Ascorbic Acid
Ø Humans are among the few species that cannot synthesize vitamin C and must obtain it from food
Ø Manufacture of collagen
- Helps support and protect blood vessels, bones, joints, organs and muscles
- Protective barrier against infection and disease
- Promotes healing of wounds, fractures and bruises
Ø Sources
- Citrus fruits, strawberries, kiwifruit, blackcurrants, papaya, and vegetables
scurvy - signs and symptoms
ØSmall blood vessels fragile
ØGums reddened and bleed easily
ØTeeth loose
ØJoint pains
ØDry scaly skin
Ølower wound-healing, increased susceptibility to infections, and defects in bone development
in c
Thiamin - Vitamin B1
Ø What it does in the body
- energy production and carbohydrate and fatty acid metabolism
- vital for normal development, growth, reproduction, healthy skin and hair, blood production and immune function
Ø Deficiency due to diets of polished rice
Beri beri - Signs and Symptoms
Ø Develop within 12 weeks
Ø Dry Beriberi à peripheral neuropathy
- Difficulty walking and paralysis of the legs
- Reduced knee jerk and other tendon reflexes, foot and wrist drop
- Progressive, severe weakness and wasting of muscles
Ø Wet Beriberi à cardiopathy
- Edema of legs, trunk and face
- Congestive heart failure (cause of death)
Riboflavin Deficiency
Ø Deficiency is rare and often occurs with other B vitamin deficiencies
Ø Several months for symptoms to occur
- Burning, itching of eyes
- Angular stomatitis
- Cheilosis
- Swelling and shallow ulcerations of lips
- Glossitis
Niacin - Vitamin B3
Ø Essential for healthy skin, tongue, digestive tract tissues, and RBC formation
Ø Processing of grains removes most of their niacin content so flour is enriched with the vitamin
Pellagre - Signs and Symptoms
Ø‘ three Ds’: diarrhea, dermatitis and dementia
Ø Reddish skin rash on the face, hands and feet which becomes rough and dark when exposed to sunlight (pellagrous dermatosis)
- acute: red, swollen with itching, cracking, burning, and exudate
- chronic: dry, rough, thickened and scaly with brown pigmentation
Ødementia, tremors, irritability, anxiety, confusion and depression
Summary
ØMajor risk factors for micronutrient deficiency diseases include poor dietary intake, infection, disease and sanitation
ØThe 4 major MDD are anemia, iodine deficiency, vitamin A deficiency, and zinc deficiency
ØTreatment for MDD include dietary diversification, supplementation, and food fortification
Newborn care guidelines
