IRON DEFICIENCY ANEMIA

INTRODUCTION
Iron deficiency is defined as a decreased total iron body content. Iron deficiency anemia occurs when iron deficiency is severe enough to diminish erythropoiesis and cause the development of anemia. Iron deficiency is the most prevalent single deficiency state on a worldwide basis. It is important economically because it diminishes the capability of individuals who are affected to perform physical labor, and it diminishes both growth and learning in children.

DEFINITION
Iron deficiency anemia is a common type of anemia a condition in which blood lacks adequate healthy red blood cells. Red blood cells carry oxygen to the body's tissues. As the name implies, iron deficiency anemia is due to insufficient iron. Without enough iron, body can't produce enough hemoglobin, a substance in red blood cells that enables them to carry oxygen.

EPIDEMIOLOGY

United States statistics In North America and Europe, iron deficiency is most common in women of childbearing age and as a manifestation of hemorrhage. Iron deficiency caused solely by diet is uncommon in adults in countries where meat is an important part of the diet. Depending upon the criteria used for the diagnosis of iron deficiency, approximately 4-8% of premenopausal women are iron deficient. In men and postmenopausal women, iron deficiency is uncommon in the absence of bleeding. International statistics In countries where little meat is in the diet, iron deficiency anemia is 6-8 times more prevalent than in North America and Europe. This occurs despite consumption of a diet that contains an equivalent amount of total dietary iron; the reason is that heme iron is absorbed better from the diet than nonheme iron. In certain geographic areas, intestinal parasites, particularly hookworm, worsen the iron deficiency because of blood loss from the GI tract. Anemia is more profound among children and premenopausal women in these environs. Age-related demographics Healthy newborn infants have a total body iron of 250 mg (80 ppm), which is obtained from maternal sources. This decreases to approximately 60 ppm in the first 6 months of life, while the baby consumes an iron-deficient milk diet. Infants consuming cow milk have a greater incidence of iron deficiency because bovine milk has a higher concentration of calcium, which competes with iron for absorption. Subsequently, growing children must obtain approximately 0.5 mg more iron daily than is lost in order to maintain a normal body concentration of 60 ppm. During adult life, equilibrium between body loss and gain is maintained. Children are more likely to develop iron deficiency anemia. In certain geographic areas, hookworm adds to the problem. Children are more likely to walk in soil without shoes and develop heavy infestations. During childbearing years, women have a high incidence of iron deficiency anemia because of iron losses sustained with pregnancies and menses.

Gastrointestinal neoplasms become increasingly more prevalent with each decade of life. They frequently present with GI bleeding that may remain occult for long intervals before it is detected. Usually, bleeding from neoplasms in other organs is not occult, prompting the patient to seek medical attention before developing severe iron depletion. Investigate the etiology of the iron deficiency anemia to evaluate for a neoplasm. Sex-related demographics An adult male absorbs and loses about 1 mg of iron from a diet containing 10-20 mg daily. During childbearing years, an adult female loses an average of 2 mg of iron daily and must absorb a similar quantity of iron in order to maintain equilibrium. Because the average woman eats less than the average man does, she must be more than twice as efficient in absorbing dietary iron in order to maintain equilibrium and avoid developing iron deficiency anemia. Healthy males lose body iron in sloughed epithelium, in secretions from the skin and gut lining, and from small daily losses of blood from the GI tract (0.7 mL daily). Cumulatively, this amounts to 1 mg of iron. Males with severe siderosis from blood transfusions can lose a maximum of 4 mg daily via these routes without additional blood loss. A woman loses about 500 mg of iron with each pregnancy. Menstrual losses are highly variable, ranging from 10 to 250 mL (4-100 mg of iron) per period. These iron losses in women double their need to absorb iron in comparison to males. A special effort should be made to identify and treat iron deficiency during pregnancy and early childhood because of the effects of severe iron deficiency upon learning capability, growth, and development. Race-related demographics Race probably has no significant effect upon the occurrence of iron deficiency anemia; however, because diet and socioeconomic factors play a role in the prevalence of iron deficiency, it more frequently is observed in people of various racial backgrounds living in poorer areas of the world.

CLASSIFICATION OF IRON DEFICIENCY ANEMIA

 Mild (hemoglobin 9.5-11 g/dl),  Moderate (hemoglobin 8-9.5 g/dl),  Severe (<8 g/dl).

RISK FACTORS
These groups of people may have an increased risk of iron deficiency anemia: Young children and pregnant women are at higher risk of iron deficiency because of rapid growth and higher iron needs. Adolescent girls and women of childbearing age are at risk due to menstruation. Among children, iron deficiency is seen most often between six months and three years of age due to rapid growth and inadequate intake of dietary iron. Infants and children at highest risk are the following groups: Babies who were born early or small. Babies given cow's milk before age 12 months. Breastfed babies who after age 6 months are not being given plain, iron-fortified cereals or another good source of iron from other foods. Formula-fed babies who do not get iron-fortified formulas. Children aged 15 years who get more than 24 ounces of cow, goat, or soymilk per day. Excess milk intake can decrease your child's desire for food items with greater iron content, such as meat or iron fortified cereal. Children who have special health needs, for example, children with chronic infections or restricted diets.

CAUSES
Iron deficiency has many causes. These causes fall into two main categories:

Increased iron needs Many common conditions can cause people to need additional iron:
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Because of their rapid growth, infants and toddlers need more iron than older children. Sometimes it can be hard for them to get enough iron from their normal diet.

Women who are pregnant have higher iron needs. To get enough, most women must take an iron supplement as recommended by their healthcare provider.

When people lose blood, they also lose iron. They need extra iron to replace what they have lost. Increased blood loss can occur with heavy menstrual periods, frequent blood donation, as well as with some stomach and intestinal conditions (food sensitivity, hookworms.)

Decreased iron intake or absorption (not enough iron taken into the body) The amount of iron absorbed from the diet depends on many factors:
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Iron from meat, poultry, and fish (i.e., heme iron) is absorbed two to three times more efficiently than iron from plants (i.e., non-heme iron).

The amount of iron absorbed from plant foods (non-heme iron) depends on the other types of foods eaten at the same meal.

Foods containing heme iron (meat, poultry, and fish) enhance iron absorption from foods that contain non-heme iron (e.g., fortified cereals, some beans, and spinach).

Foods containing vitamin C also enhance non-heme iron absorption when eaten at the same meal.

Substances (such as polyphenols, phytates, or calcium) that are part of some foods or drinks such as tea, coffee, whole grains, legumes and milk or dairy products can decrease the amount of non-heme iron absorbed at a meal. Calcium can also decrease the amount heme-iron absorbed at a meal. However, for healthy individuals who consume a varied

diet that conforms to the Dietary Guidelines for Americans, the amount of iron inhibition from these substances is usually not of concern.
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Vegetarian diets are low in heme iron, but careful meal planning can help increase the amount of iron absorbed.

Some other factors (such as taking antacids beyond the recommended dose or medicine used to treat peptic ulcer disease and acid reflux) can reduce the amount of acid in the stomach and the iron absorbed and cause iron deficiency

Increased iron needs

 Rapid growth  Pregnancy  Blood loss  Heavy menstrual periods  Frequent blood donation  Some stomach and intestinal

Decreased iron absorption or storage

 Lack of heme iron sources in the diet

(e.g., vegetarian diets)

 Low absorption  Taking antacids beyond the

recommended

dose

or

medicine used to treat peptic ulcer disease and acid reflux can reduce the amount of iron absorbed in the stomach

conditions (food sensitivity, hookworms)

SIGNS AND SYMPTOMS OF IRON-DEFICIENCY ANEMIA

If a person is otherwise healthy, it can take some time for the signs of anemia to appear.
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The first symptoms will be tiredness and palpitations (awareness of heartbeat). Shortness of breath and dizziness (fainting) are also common. If the anaemia is severe, you may experience angina (chest pain), headache or leg pains (intermittent claudication).

Besides these general symptoms of anemia, in pronounced and long-term cases of iron deficiency there may be:
 burning sensation in the tongue  dryness in the mouth and throat  sores at the corners of the mouth  altered sense of touch  brittle, spoon-shaped nails with vertical stripes and a tendency to fray  pica  brittle hair  difficulty swallowing.

In rare cases, iron deficiency can cause permanent changes to the soft lining in the throat (Plummer-Vinson syndrome). This condition is a preliminary stage to cancer of the oesophagus.

WHY IRON DEFICIENCY ANEMIA A CONCERN?

Iron deficiency is a concern because it can:
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Iron deficiency can delay normal infant motor function (normal activity and movement) or mental function (normal thinking and processing skills).3,4,5,6

Iron deficiency anemia during pregnancy can increase risk for small or early (preterm) babies.7,8 Small or early babies are more likely to have health problems or die in the first year of life than infants who are born full term and are not small.

Iron deficiency can cause fatigue that impairs the ability to do physical work in adults.9,10 Iron deficiency may also affect memory or other mental function in teens.

DIAGNOSTIC TESTS AND PROCEDURES

Iron-deficiency anemia is diagnosed based on medical history, a physical exam, and the results from tests and procedures.Mild to moderate iron-deficiency anemia may have no signs or symptoms. Thus, you may not know you have it unless your doctor discovers it from a screening test or while checking for other problems. Specialists Involved Primary care doctors often diagnose and treat iron-deficiency anemia. These doctors include pediatricians, family doctors, gynecologists/obstetricians, and internal medicine specialists. A hematologist (a blood disease specialist), a gastroenterologist (a digestive system specialist), and other specialists also may help treat iron-deficiency anemia. Medical History History collection helps to find out the signs and symptoms and any past problems you've had with anemia or low iron. He or she also may ask about your diet and whether you're taking any medicines.If you're a woman, your doctor may ask whether you might be pregnant.

Physical Exam Your doctor will do a physical exam to look for signs of iron-deficiency anemia.
 Look at your skin, gums, and nail beds to see whether they're pale  Listen to your heart for rapid or irregular heartbeats  Listen to your lungs for rapid or uneven breathing  Feel your abdomen to check the size of your liver and spleen  Do a pelvic and rectal exam to check for internal bleeding

Many tests and procedures are used to diagnose iron-deficiency anemia. They can help confirm a diagnosis, look for a cause, and find out how severe the condition is. Complete Blood Count Often, the first test used to diagnose anemia is a complete blood count (CBC). This test checks hemoglobin and hematocrit levels. Hemoglobin is an iron-rich protein in red blood cells that carries oxygen to the body. Hematocrit is a measure of how much space red blood cells take up in your blood. A low level of hemoglobin or hematocrit is a sign of anemia. The CBC also checks the number of red blood cells, white blood cells, and platelets in your blood. Abnormal results may be a sign of infection, a blood disorder, or another condition. Finally, the CBC looks at mean corpuscular volume (MCV). MCV is a measure of the average size of your red blood cells. The results may be a clue as to the cause of your anemia. In irondeficiency anemia, for example, red blood cells usually are smaller than normal.

Other Blood Tests If the CBC results confirm you have anemia, you may need other blood tests to find out what's causing the condition, how severe it is, and the best way to treat it. Reticulocyte count. This test measures the number of reticulocytes in blood. Reticulocytes are young, immature red blood cells. Over time, reticulocytes become mature red blood cells that carry oxygen throughout your body.A reticulocyte count shows whether bone marrow is making red blood cells at the correct rate. Peripheral smear. For this test, a sample of your blood is examined under a microscope. If you have iron-deficiency anemia, red blood cells will look smaller and paler than normal. Tests to measure iron levels. These tests can show how much iron has been used from body's stored iron. Tests to measure iron levels include: Serum iron. This test measures the amount of iron in your blood. The level of iron in your blood may be normal even if the total amount of iron in your body is low. For this reason, other iron tests also are done. Serum ferritin. Ferritin is a protein that helps store iron in your body. A measure of this protein helps your doctor find out how much of your body's stored iron has been used. Transferrin level, or total iron-binding capacity. Transferrin is a protein that carries iron in your blood. Total iron-binding capacity measures how much of the transferrin in your blood isn't carrying iron. If you have iron-deficiency anemia, you'll have a high level of transferrin that has no iron. Other tests. 


Test for thyroid hormone level Blood test for a chemical called erythrocyte protoporphyrin. This chemical is a building block for hemoglobin.

Children also may be tested for the level of lead in their blood. Lead can make it hard for the body to produce hemoglobin.

Tests for Gastrointestinal Blood Loss To check whether internal bleeding is causing your iron-deficiency anemia,a fecal occult blood test is done. This test looks for blood in the stools and can detect bleeding in the intestines.

TREATMENT
Treatment for iron-deficiency anemia will depend on its cause and severity. Treatments may include dietary changes and supplements, medicines, and surgery.. The goals of treating iron-deficiency anemia are to treat its underlying cause and restore normal levels of red blood cells, hemoglobin, and iron. IRON SUPPLEMENTS

Treatment of an underlying cause should prevent further iron loss but all patients should have iron supplementation both to correct anaemia and replenish body stores. This is achieved most simply and cheaply with ferrous sulphate 200 mg twice daily.Lower doses may be as effective and better tolerated and could be considered in patients not tolerating traditional doses. Other iron compounds (e.g. ferrous fumarate, ferrous gluconate) or formulations (iron suspensions) may also be tolerated better than ferrous sulphate. Ascorbic acid (250500 mg twice daily with the iron preparation) may enhance iron absorption. We recommend that oral iron is continued until three months after the iron deficiency has been corrected so that stores are replenished. Take iron tablets on an empty stomach. If possible, take your iron tablets when your stomach is empty. However, because iron tablets can upset your stomach, you may need to take your iron tablets with meals. Side effects
Iron supplements can cause side effects, such as dark stools, stomach irritation, heartburn. constipation,

IRON RICH FOODS The best source of iron is red meat, especially beef and liver. Chicken, turkey, pork, fish, and shellfish also are good sources of iron. The body tends to absorb iron from meat better than iron from non meat foods. However, some nonmeat foods also can help you raise your iron levels. Examples of nonmeat foods that are good sources of iron include:
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Iron-fortified breads and cereals Peas; lentils; white, red, and baked beans; soybeans; and chickpeas Tofu Dried fruits, such as prunes, raisins, and apricots Spinach and other dark green leafy vegetables Prune juice

The Nutrition Facts labels on packaged foods will show how much iron the items contain. The amount is given as a percentage of the total amount of iron you need every day. VITAMIN C Vitamin C helps the body absorb iron. Good sources of vitamin C are vegetables and fruits, especially citrus fruits. Citrus fruits include oranges, grapefruits, tangerines, and similar fruits. Fresh and frozen fruits, vegetables, and juices usually have more vitamin C than canned ones.Other fruits rich in vitamin C include kiwi fruit, strawberries, and cantaloupes.Vegetables rich in vitamin C include broccoli, peppers, Brussels sprouts, tomatoes, cabbage, potatoes, and leafy green vegetables like turnip greens and spinach. TREATMENT TO STOP BLEEDING If blood loss is causing iron-deficiency anemia, treatment will depend on the cause of the bleeding.

Bleeding ulcer, doctor may prescribe antibiotics and other medicines to treat the ulcer. polyp or cancerous tumor in intestine is causing bleeding, surgery is needed to remove the growth. heavy menstrual flow, doctor may prescribe birth control pills to help reduce your monthly blood flow. In some cases, surgery may be advised. TREATMENTS FOR SEVERE IRON-DEFICIENCY ANEMIA Blood Transfusion If iron-deficiency anemia is severe, transfusion of red blood cells is required. A blood transfusion is a safe, common procedure in which blood is given through an IV line in one of your blood vessels. A transfusion requires careful matching of donated blood with the recipient's blood.A transfusion of red blood cells will treat anemia right away. The red blood cells also give a source of iron that your body can reuse. However, a blood transfusion is only a short-term treatment. Your doctor will need to find and treat the cause of your anemia. Iron therapy If severe anemia, doctor may recommend iron therapy. For this treatment, iron is injected into a muscle or an IV line in one of your blood vessels. IV iron therapy presents some safety concerns. It must be done in a hospital or clinic by experienced staff. Iron therapy usually is given to people who need iron long-term but can't take iron supplements by mouth. This therapy also is given to people who need immediate treatment for iron-deficiency anemia.

PREVENTIVE MEASURES FOR IRON DEFICIENCY ANEMIA

A healthful iron rich diet includes fruits, vegetables, whole grains, fat free or nonfat milk and milk products, lean meats, fish, dry beans, eggs, nuts, and is low in saturated fat, trans fats, cholesterol, salt, and added sugars. In addition to a healthful diet that includes good sources of iron,patient can eat foods that help body absorb iron better. For example, you can eat a fruit or vegetable that is a good source of

vitamin C with a food or meal that contains non-heme iron (Vitamin C helps your body absorb the non-heme iron foods), especially when the food containing non-heme iron and the vitamin-C rich food are eaten at the same meal. The following recommendations are for specific groups who are at greater risk for iron deficiency. Babies
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If possible, breastfeed the baby for at least 12 months and starting at 4 to 6 months of age, give the baby plain, iron-fortified infant cereal and/or pureed meat. Just two or more servings a day can meet a baby's iron needs at this age. Meats should be home prepared or commercially prepared plain pureed (chopped until smooth in a blender) meats.

When baby is about 6 months of age, include a feeding per day of foods rich in vitamin C with foods that are rich in non-heme iron to improve iron absorption.

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If you can't breastfeed, use iron-fortified formula. Don't give low-iron milks (e.g. cow's milk, goat's milk, and soy milk) until baby is at least 12 months old.

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If baby was born early or small, talk to your doctor about giving iron drops to your baby. If your baby can't get two or more servings per day of iron rich foods (such as ironfortified cereal or pureed meats), talk to your doctor about giving iron drops to your baby.

Children (aged 15 years)

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After the child is one year old, give no more than three 8 ounce servings of whole cow, goat, or soy milk per day. After the child is 2 years old, low fat or nonfat milks should be used in place of whole milks. Vitamin D-fortified milk is a good source of calcium and vitamin D, but not iron.

Give child a diet with iron-rich foods such as iron-fortified breads and iron-fortified cereals and lean meats. See Dietary Sources of Iron

Include fruits, vegetables or juices that are rich in vitamin C. Vitamin C helps your child absorb non-heme iron especially when the food that is a source of non-heme iron and the vitamin C-rich food are eaten at the same meal. See Dietary Sources of Vitamin C.

Adolescent girls and women of childbearing age

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Eat iron-rich foods. See Dietary Sources of Iron. Eat foods that are vitamin C sources. Vitamin C helps your body absorb non-heme iron especially when the food that is a source of non-heme iron and the vitamin C-rich food are eaten at the same meal. See Dietary Sources of Vitamin C.

Eat lean red meats, poultry, and fish. The iron in these foods is easier for your body to absorb than the iron in plant foods.

Pregnant women It is recommended that pregnant women:

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Eat iron-rich foods. Eat foods that are vitamin C sources. Vitamin C helps to absorb non-heme iron especially when the food that is a source of non-heme iron and the vitamin-C rich food are eaten at the same meal. See Dietary Sources of Vitamin C below.

Eat lean red meats, poultry, and fish. The iron in these foods is easier for your body to absorb than the iron in plant foods.

Talk to doctor about taking an iron supplement.

COMPLICATION
Mild iron deficiency anemia usually doesn't cause complications. However, left untreated, iron deficiency anemia can become severe and lead to health problems, including the following:
 Heart problems. Iron deficiency anemia may lead to a rapid or irregular heartbeat. Your

heart must pump more blood to compensate for the lack of oxygen carried in your blood when you're anemic. This can lead to an enlarged heart or heart failure.
 Problems during pregnancy. In pregnant women, severe iron deficiency anemia has

been linked to premature births and low birth weight babies. But the condition is easily preventable in pregnant women who receive iron supplements as part of their prenatal care.
 Growth problems. In infants and children, severe iron deficiency can lead to anemia as

well as delayed growth and development. Additionally, iron deficiency anemia is associated with an increased susceptibility to infections.