Nutritional Anemias

K N Agarwal
MD (Ped-Hem; Sweden),MD DCH FIAP FAMS
FNA
President, Health Care & Research
Association for Adolescent, Z-18, Hauz
Khas, N-Delhi, 110016
adolcare@hotmail.com

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 Definition of nutritional
anemia.
Hemoglobin g/dl cut off- . (WHO/UNU-1996)
6mo-5yr <11.0; 5-11 yr. - 11.5;
12-13 yr -12.0g/dl; Men 13.0
Women Non-pregnant - 12.0;Pregnant 11.0

Irrespective of Hb level , if an individual shows rise in

hemoglobin after hematinics administration he/she is
anemic (Garby et al 1969).

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 Why adult & Child Hemoglobin
level differ
No satisfactory answer-
Children have 50% more inorganic
phosphate, associated with
Elevated RBC adenosine triphosphate
and 2,3 diphosphoglycerate content-
Thus oxygen affinity is decreased in
children as compared to adults.
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 Nutrients in hemoglobin
synthesis.
Proteins- all essential amino acids are necessary; methionine deficiency
megaloblastic anemia
Vitamins-
- B12 and folic acid megaloblastic anemia
-C- Fe+++ to Fe++ & Releases Fe from stores.
-A- mobilises Fe from stores & improves utilisation
-B6- macro/micro anemia,
-B2- BONE MARROW-hypoplasia----
ANOREXIA NERVOSA-Affects all cell lines.
Thus in PEM and other hematopoietic nutrient(s) anemia on Fe-
suppl alone will have poor response.
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 Clinical Features:-
Insidious onset- even Hb<8g/dl, child patient may be
comfortable; physical activity may not be decreased
even <6g/dl- ADJUSTMENT
Rapid breathlessness, dizziness, faintness, fatigue,
CHF, heart murmurs-systolic in timing heard at
pulmonary area.
Pallor eyelids, tongue, nail bed (changes less common
below 6 yr.) PICA
Psycho neurological changes- B12 and or Folic acid
deficiency- Megaloblastic anemia.
Dyspigmentation /pigmentation- megaloblastic anemia
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Effects of maternal iron deficiency
on feto placental unit:
Transport of iron from mother to fetus remains
proportionate to the degree of maternal hypoferriemia
(Agarwal et al.AJCN 1979, Acta Paediatr 1978 & 1984).
Placental iron content reduces significantly.
Fetal brain iron content and neurotransmitters are
reduced (BJN 2001; Agarwal).
Fetal Liver iron stores are reduced.
However, Breast milk iron content is increased
(Agarwal et al. Acta Paediatr 1985).

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Physiological anemia of infancy
Normal newborn- High Hb level progressively
declines by 8-12 wk -9-11g/dl.- Hypoxia
stimulates Renal and Hepatic oxygen sensors
erythropoietin production increases.
Preterm- Hb decline is extreme & rapidly falls
to 7-9 g/dl by 3-6 wk of age.- Sampling for Lab
tests. There are relatively insensitive Hepatic
oxygen sensors; as Renal Oxygen sensors
switch on at 40 wk of gestation.

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 Prevalence of nutritional
anemia
NFI 2002-2003- 7 states (Assam, HP, Hy, Kerala, MP, Orissa,
TN ) anemia prevalence- Pregnancy 86.1%(Hb <7.0g/dl-
9.5%); Lactation 81.7 %(Hb <7.0g/dl - 7.3%) Agarwal et al
2005..
ICMR 1999-2000- 11 states 19 districts 84.6% (Hb <7.0 g/dl-
9.9% ).
90% adolescents were also anemic Teoteja et al 2000.
>80% < 3 yr children are anemic NFHS-II& Agarwal et al.
Magnitude and severity of anemia at all ages seems to show
life cycle with nutritional anemia in INDIA.
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 Megaloblastic Anemias

Hypersegmented Neutrophil 98% had one cell

with >6 lobes;
Oval macrocytes.
Bone-marrow- Large Erythrocyte and
Leucocyte series; Megaloblasts have sieve like
chromatin- dissociation between nucleus and
cytoplasm maturity.
Vitamin B12 and folate levels to differentiate.
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 Fetal Latent Iron Deficiency- brain iron content &
neurotransmitters- irreversible reduction

Brain iron content was reduced.

Excitatory and inhibitory
neurotransmitters and their receptors were
reduced.
MRI-spectroscopy:There was an increase in
creatinine and aspartate and reduction in
choline concentration(BJN Agarwal 2001)
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Control & Treatment of
Anemias

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 Feeding in early infancy
Baby should be breast fed colostrum and
mature milk, both have 49% absorbable
iron this is sufficient with available fetal
stores till baby doubles the birth weight.
Weaning foods from 6 months onwards
should have one iron rich dietary item
and iron supplementation be given as
recommended. Cook in iron vessels.
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 Iron fortified food.
Iron EDTA has been highly effective in fortification
trials with Egyptian flat breads, curry powder in
South Africa, fish sauce in Thailand, and sugar in
Guatemala.
In Grenada , flour used in commercial baking is
enriched with iron and B vitamins,.
Indian researchers have field tested with success iron
fortified salt.
Pasteurized milk (iron 15 mg/ l and Vit. C 100 mg/l.)-
Stekel 1986

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 Availability of dietary iron by
cooking in cast iron utensils:
WHO 1992 prevalence of pregnancy anemia report,
records that lowest, rates of all the subregions of the
developing world were observed in southern Africa,
due to wide spread use of iron cooking pots by
indigenous people.
Agarwal et al (Lal et al IJMR-1973) had
demonstrated that cooking in cast iron utensils, for
boiling milk, cooking vegetables etc, provided extra
dietary iron. This available dietary iron is well
absorbed.

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Diagnosis of Deficiency
Anemias

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 Iron deficiency Diagnosis-
RBC-hypochromic microcytic,
progressive fall in- MCV, MCH & MCHC
.
Reduction in Reticulocyte Hb content.
sTfR-soluble transferrin receptor
increases in iron def. and ineffective
erythropoiesis, No change in Chr. Inf.
anemia.
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 Contd.
TfR index-ratio of sTfR to the log of ferritin,
value >1.5 Iron def; <1.5 anemia chronic
diseases.
EPP- Erythrocyte Porphyrin increases in iron
def, lead poisoning and chr. Inflammatory
anemia.
Serum Ferritin with negative CRP.
Absence of Bone marrow iron content. Low
hepatic iron content.
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We at all ages live in life cycle with
anemia.
Nutritional Anemia is treatable and
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