k11-anemia defisiensi besi

8/6/2019 k11-Anemia Defisiensi Besi

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HEMATOLOGY -ONCOLOGY DiChild Health Depart.- School of Medicine

University of Sumatera Utara


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Anemia

Definition:

reduction in red cell mass or blood

hemoglobin concentration below 2standard deviations (SD)

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T able 1.Normal red blood cell values in children

Hemoglobin(g/dl) MCV(fl)Age Mean -2SD Mean -2SDBirth (cord blood) 16.5 13.5 108 981-3 days(capillary) 18.5 14.5 108 951 week 17.5 13.5 107 882 week 16.5 12.5 105 861 month 14.0 10.0 104 852 month 11.5 9.0 96 773-6 month 11.5 9.5 91 740.5-2 years 12.0 10.5 78 702-6 years 12.5 11.5 81 756-12 years 13.5 11.5 86 77

12-18 years, female 14.0 12.0 90 7812-18 years, male 14.5 13.0 88 7818-49 years, female 14.0 12.0 90 8018-49 years, male 15.5 13.5 90 80

Caroline Hasting,2002

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IRO N DEF I C I ENCY ANEM I A

Definition :Anemia resulting from lack of sufficient iron forsynthesis of hemoglobin.

Pr evalence : The most common cause of anemia worlwide

An estimated 30% of the world s population :4.5 billion @ anemic500 600 million @ Iron def. anemia


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P revalenceP revalence

Anemia Anemia

Developed countries0-4 tahun : 20.1%5-14 tahun: 5.9%

Developing countries0-4 tahun: 39.0%5-14 tahun: 48.1%

WHO, 2001


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P revalenceP revalenceof ID & IDAof ID & IDA

USA:1-2 years ID 9%; IDA 3%adolescent girls ID 9%; IDA 2%UK Infants:

Asian IDA 39% Afro-Caribbean 20%White 16%

Developing countries

Adolescent girls 21-35%

Indonesia (SKRT 2001):


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Etiology of iron deficiency


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ETIOLOGY

I. Deficiency intake :

Dietary (milk 0,5-1.5 mg iron/L)

II. Increased demand :Growth (low birth weight, premarurity, low-birth-weight twins or multiple births, adolescence,pregnancy)Cyanotic Congenital heart disease

III. Blood loss :A. Perinatal

1. PlacentalTransplacental bleeding into maternal circulationRetroplacental (e.g,premature placental separatio )IntraplacentalFetal blood loss or before birth (e.g, placenta previa)Fetofetal bleeding in monochrorionic twinsPlacental abnormalities 8


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. 2.Umbilicus- Ruptured umbilical cord (e.g, vasa previa) and

other umbilical cord abnormalities

- Inadequate cord tying- Postexchange transfusion

B. Postnatal1.Gastrointestinal tract

- Primary iron deficiency anemia resulting in gutalterationwith blood loss agravating existing iron deficiency- Hypersensitivity to whole cows milk?

- Anatomic gut lesions, exudative enteropathycaused by undelying bowel disease

- Gastritis from aspirin, adrenocortical steroids,indomethacin, phenylbutazone

- Intestinal parasites( e.g, hookworm /N ecator Americanus )- Henoch-Scholein Purpura

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2. Hepatobililiary system: hematobilia3. Lung: Pulmonary hemosiderosis, Goodpasture

sydrome, defective iron mobilization with IgA deficiency4. Nose: recurrent epistaxis5. Uterus: menstrual loss6. Heart: intracardiac myxomata, valvular prostheses or

patches7. Kidney: microangiopathic hemolytic anemia, hematuria,

nephrotic syndrome,hemosiderinurias-chronicintravascular hemolysis

8. Extracorporeal: hemodialysis, trauma

IV. Imparied absorptionMalabsorption syndrome, celiac disease, severeprolonged diarrhea, postgastrectomy, inflammatorybowel disease, H elicobacter pylori infection associatedchronic gastritis

Lanzkowsky ,200 5

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K ey Functional of I ron


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I ron Status in Human Body


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History takingP allor,floppiness :time of onsetFatigue,lethargyP oor feedingIrritabilityAbdominal painHeadache ,dizzinessShortness of breathArthralgia

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Clinical Manifestation

P allor ,jaundice T ac h ycardia ,p ostural h ypotension A norexia A ngular stomatitis G lossitis S poon nail

Pica (pago ph agia) E ff ect on neurologic and intellectual f unction: attention s pan , allertness ,learning

N athan Osk i,2003Lanz kow sky P,2005Glade r B, 2007

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CLINICAL MANIFESTATIONS

M ild moderate iron de f. ( Hb 6- 10 g/dl) @ com pensatory mec h anism (+)

S evere iron de f iciency (Hb < 5 g/dl) : F atigue , listlessness , irritability,anorexia , tac h ycardia , cardiac dilatation & systolic murmurs .- A dvanced iron de f iciency :

P ale , p lum p, & p etulant

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N onhematologic con sequence : P ica :

Ph ago ph agia (com pulsive eating of ice) G eo ph agia : interest in dirt consum ption @ risk f or

parasitic inf estation & lead poisoning) E ph itelial c h anges : Koilonyc h ia , atro ph y of lingual pa pil

E xercise intolerance B e h avioral ch anges

A bnormal th ermogenesis A ltered h ost res ponse

M iller Rd,Baehner RL,edisi ke 7

CLINICAL M ANIFESTATIONS

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LABORATORIUM FINDINGS

Hemoglobin(Hb) is below the acceptable level for ageRed cell indices :- / normal MCV ,MC HC and MC HC for age- RDW

Blood smear :- Red cells : hypochromic, microcytic with anisocytosisand poikilocytosis Hb concentration

Reticulocyte count: N/slightly increasedP leated count : Thrombocytopenia, thrombocytosisFree erythrocyte protoporphyrin: > 100 g/dl


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Lab .finding

Consentration Ferritin <

12 mg/dl S erum iron and iron saturation percentage iron

metabolism : S erum iron : TI BC :

T

rans f errin sat . (ratio SI

: TI

BC

) : S erum trans f errin rece ptor levels ( ST fR )Red blood cell zinc proto por ph yrin/ h eme ratio - Bone marrow iron is insu ff icient to su pp ort h eme synt h esis

- Zinc proto por ph rin relative to h eme increases- Zinc substituses f or iron in proto por ph yrin IX

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T he diagnosis of microcitic anemia usingMCV and R DW

MCV

Low

RDW

Narrow Wide

Hb elektroforesis FE P*MCV on P arents Ferritin

Trial of Iron* Also elevated in lead poisonin. Do serum lead level (if clinical indicated)

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2 5P oikylocytosis Anisocytosis


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DIFFERENTIAL DIAGNOSIS

1.Thalassemia trait

2.Anemia of chronic diseases3.Lead poisoning


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Diffrential Diagnosis Hypochrom MicrocyticAnemia

Lab finding s IDA Thala ss emia Mino r Anemia ch r onic di sea se

MCV N/Serum iron N

TIBC NTransferrin saturation N N/FEP NSerum ferritin N

Lukens,1995


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Criteria of IDA by WHO :1. Hb concentration < normal (age dependent)2. Hematocrit < 31% ( N: 32 - 35%)3. Serum iron < 50 Ug/dl (N: 80-180 ug/dl)4. Transferrin sat. < 15 (N: 20-50%)


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...Diagnosis

Alternative way to determine IDA:

Tr ial of ir on supplementation

Important to know subclinical IDA with monitorhemoglobin respons (increased hemoglobin level).This procedure is very practical, sensitive daneconomical especially for children at high risk of IDA

If with iron supplementation 3 mg iron/kgBW/day, 3-4weeks, Hb level is increased 1-2 g/dL it is confirmedfor IDA.


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Classification of A nemia

S creening Hb CBC:

M CV- M CH

M icrocytic, h ypoc h romic

MCV


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C linical management

D iagnosis Assessment of underlying cause : dietary h istory ,birth h istory , p resence of abnormal bleeding ,

f amily h istory , p ast medical/surgery h istoryInvestigation and treatment : dietary advice ,endosco pyIron therapy

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Ir on the r ap y

Oral therapyD ose: 3 mg/kg/day (2 devided doses) max 180 mgD uration: 6-8 weeks a f ter Hb and th e red cell indices return normalTh e f ollowing pre parations provide 3 mg of elemental iron: 1 5 mg of f errous sul f ate ,

9 mg of f errous f umarate ,2 6 mg of f errous gluconate ,

9 mg of f errous succinate ,1 7 mg of f errous glycine sul f ate ,21 mg of sodium iron edetate

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Parenteral Therapy

1 .Intramuscular Iron dextran ( 50 mg elemental iron/ml) /im , with dose :

Normal Hb - initial Hb x Blood volume (ml)x 3 .4 x 1 .5100

2 .Intravenous.S odium f erric gluconate (Ferrlecit)

.Iron (III) h ydroxyde sucrose com ple (Veno f er)A nemia associated with renal f ailure and h emodialysisD ose: 1 4 mg/ Kg/week

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Tr an sfu sion the r ap y

P acked red cell S

evere anemia (Hb < 5 g/dl) requiring correction more ra pidly es pecially wh en signs of cardiac dys f unction are present

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Factors affecting iron absorption of nonhemeiron from the gastrointestinal tract

Increased absorptionVit C: citrus, tomatoes, potatoes,SolutesSugarsmeat, fish,poultryHydrochloric acidD ecreased absorptionAntacidsP ancreatic secretionsHypochlorhydriaP hytatesP hosphates

Blackwell,2006

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Prevention

1 .E ncouragement of breast f eeding (BF )2 .Use of iron- f ortif ied inf ant f ormula a f ter weaning

BF or non- BF3 .D elay in th e introduction of wh ole cows milk to 1

year of age4 .Use iron f orti f ied inf ant cereals and ascorbic

acid-rich

f ood solid f ood are introduced at 6 mont h s5. S upp lemental iron

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.. Pr evention

Ir on supplemental :

E xclusive breast f eeding beyond 6 mont h : 1 mg/ Kg/d

Low birth weig h t inf ants:a . 1 .5 -2 .0 kg : 2 mg/kg/dayb. 1 .0 -1 .5 kg : 3 mg/kg/dayc.

k11-anemia defisiensi besi

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