Haematological disease in a child: Iron-deficiency anaemia (IDA) Flashcards
Define IDA.
Reduced Hb with low mean cell volume (MCV <80 fl) and depleted iron stores.
Explain the aetiology/risk factors for IDA.
Three stages in the pathogenesis: Fe2 depletion -> Fe2-deficient erythropoiesis -> Fe2 deficiency anaemia.
What are the 4 categories of IDA.
- Decreased Fe2+ store at birth
- Nutritional (inadequate Fe2 supply)
- Increased Fe2+ demand
- Increased Fe2+ loss
What are some causes of decreased Fe2+ stores at birth?
- Prematurity
- Multiple pregnancy
- Perinatal bleeding
- Early umbilical cord clamping
- Maternal Fe2 deficiency
What are some causes of inadequate Fe2+ supply?
- Exclusive breastfeeding>6/12 (insufficient Fe2 in breast milk)
- Early cow’s milk introduction (reduced bioavailability of iron than breast milk and formula milk is fortified with 6 mg iron/l)
- Excessive reliance on milk in the second year of life
- Increased infant fruit juice intake
- Strict vegetarian diet
- Behavioural (food refusal, grazing, dieting, eating disorders)
- Crohn’s disease, coeliac disease (decreased absorption)
What are some causes of increased Fe2+ loss?
- Acute haemorrhage (Meckel’s diverticulum, intestinal duplication cyst, peptic ulcer)
- Chronic haemorrhage (cow’s milk protein intolerance, intestinal duplication, IBD, telangiectasia, intestinal polyp)
- Parasites (hookworm – Ancylostoma duodenale in developing countries); menstruation.
What are some causes of increased Fe2+ demand?
- Growth
- Prematurity
- IUGR
- Post malnutrition
Summarise the epidemiology of IDA.
Inner city centres (UK) and Asian communities. Most common nutritional deficiency disorder worldwide.
Incidence: 5–40% depending on community.
Peak ages: 6 months to 3 years and adolescent girls. Uncommon in non-premature infants <6/12 (fetally acquired iron reserves).
What are the presenting symptoms of IDA?
General: Gradual onset; failure to thrive, poor exercise tolerance, global developmental delay, headaches, and irritability.
Behavioural: Anorexia, pica (ingestion of odd materials with increased Fe2.), irritability, impaired concentration, impaired progress at school.
What are the signs of IDA?
General: Signs of anaemia (pallor of skin and mucous membranes, tachycardia) and systolic flow murmurs.
Rarely: Brittle nails and hair (epithelial cell iron), spoon-shaped nails (koilonychia), glossitis (atrophy of tongue papillae), angular stomatitis, mild hepatosplenomegaly and lymphadenopathy.
What are some appropriate investigations for IDA?
Blood film: Microcytic, hypochromic (central pallor), anisocytosis (variable sizes), poikilocytosis (variable shapes).
Bloods: Low Hb, high serum ferritin, low serum Fe2, high TIBC, low haematocrit, low MCV.
Hb electrophoresis: Exclude b-thalassaemia trait or Sickle cell disease.
Bone marrow (only in complicated cases): Erythroid hyperplasia and decreased bone marrow Fe2+ or total absence of iron.
What is the management for IDA?
Preterm: Fortify breast milk with Fe2. Use Fe2-fortified milk formula.
Infants: Increase highly absorbable haem iron sources (meat, fish) and sources of non-haem iron (such as grains) in vegetarian families. Enhance non-haem iron absorption by eating vitamin C-rich foods at the same meal.
Oral FeSO4: Maximum rise of Hb 0.25–0.4 g/dl/day.
Blood transfusion: Indicated with severe anaemia leading to CHF and cardiovascular compromise. Packed RBCs should be given slowly or partial exchange transfusion.
What are some complications associated with IDA?
Possible impaired mental and psychomotor development. High output cardiac failure in severe cases.
What is the prognosis of IDA?
Good outcome if cause is nutritional or due to increased demand and prompt action is taken. If underlying GI cause, outcome dependent on underlying cause.
