Iron Deficiency Anemia

M R Lokeshwar*, Nitin Shah**
Prevention Of Iron Deficiency Anemia
The basic approaches for prevention of IDA include:
- Supplementation with medicinal iron
- Increase the dietary iron intake.
- Control of infection and treatment of helminthiasis.
- Fortification of staple food with iron.

Supplementation with medicinal iron: These programs do best when concentrated on high risk groups such as pregnant women, infants and preschool children and captive audiences such as school children or plantation workers who can receive their supplements at school or work place. In infants, promoting breast feeding for as long as possible and encouraging timely introduction of appropriate weaning food is the best method of prevention. Major constraints against the effectiveness of supplementation are:
- Side-effects of oral iron medication
- Continuing iron medication for 2 - 3 months by those who do not perceive themselves as ill.

Iron supplementation should be started in full term infants by 4 months and in pre-term infants by 2 months of age in a dose of 1 mg/kg/day in full term and 2 mg/kg/day in preterm infants.

Dietary Modification: Increase total intake to fulfill energy requirements. The total iron consumption has been shown to increase by 25 -30%. Include heme iron and Vitamin C containing food and reduce inhibitory factors in diet i.e. Tannin and Phytates, etc.

Control of Viral, Bacterial and Parasitic Infections: Feeding and breast-feeding must be continued during illness. Immunization and other preventive public health measures such as safe water, proper sanitation etc. should be ensured. Giardiasis, hookworm and other worm infestations and schistosomiasis should be treated promptly.

Food Fortification: Fortification staple food which will reach the masses at large will virtually eliminate iron deficiency in the world. In India, salt fortification has been successfully tried, but with fortification the cost increased by 20%. Salt contains 3500 ppm of ferric orthophosphate and 5000 ppm of acid sulfate. At this level of fortification each gm of salt will provide 1 mg of elemental iron. However, this was done only in field trials in few places and has to be implemented further. Edta (NaFeEDTA) increased bioavailability of iron in sugar and condiments and the cost increased by 2%. This has been tried in Guatemala and should be explored in India too.

Two major sources of fortification iron in infancy are infant formulas and infant cereals using ferric pyrophosphate and ferric orthophosphate, Ferrous Fumarate and succinate or dried bovine Hemoglobin. Fortification of wheat flour has been done by adding Ferrous Sulphate and elemental iron powder, ferric pyrophosphate, ferric orthophosphate. NaFeEDTA also have been used for fortification of fish sauce, masala (condiments). Dried bovine hemoglobin have been used for fortification of cereals.

Cost and benefits of prevention:
Levin from the world bank has prepared a cost benefit analysis of the impact of fortification and supplementation on iron deficiency anemia. The conclusions drawn are that when it comes to benefit, anemia control produces an immediate increase in physical work output and long term leads to reduced morbidity and mortality, higher productivity, improved quality of leisure time, increased capacity and a greater sense of well being. Apart from many of the benefits, which cannot be measured in material terms, impressive improvement in the earnings occur out of increased labor productivity. He concludes that both iron fortification and supplementation programme represent highly productive investments for developing countries.

Management of iron deficiency anemia can be considered in two parts:
- Treatment of individual patient
- Treatment of IDA-public health problem

Treatment of individual patient: Management of individual patient consists of:
- Replenishment of reduced body iron
- Correction of underlying factors responsible for the deficiency.
In 80-85 % of patients, it is possible to determine the causes of deficiency.

Successful management requires:
- Confirmation of diagnosis
- Through investigation of the underlying cause
- Supplementation of iron

It is important to find out the cause of iron deficiency. In children, it is often due to poor intake rather than blood loss. Therefore the key to success in the management of IDA is proper nutritional counseling. Parents should be made to understand the need for a well-balanced diet, particularly in growing children. Continuation of breast milk should be encouraged beyond 6 months, as bioavailability of iron in the breast milk is high. Restriction of milk to one pint a day, and introduction of iron rich weaning foods like nachani, jaggery, cereals, spinach, beans, meat, fruits etc. and iron-fortified food should be advocated.

Oral iron therapy: This is the treatment of choice, as it is cheap, safe, effective and well tolerated. Parenteral administration is reserved for patient who are completely intolerant to oral iron or when compliance is poor. Various preparations available are shown in Table 5.

PreparationIron compound (mg) per tabElemental iron (mg) per tab% of iron given
Ferrous fumarate2006633
Ferrous gluconate3003612
Ferrous sulphate
Ferrous sulphate

Ferrous salts are absorbed better than ferric salts. Of the ferrous salts, Ferrous Sulphate is most preferred because of its low cost. Various types of preparation available are as follows :
- Uncoated tablets and sugar coated tablets: Least expensive but less effective as they get oxidized
- Enteric-coated tablets: More expensive, disintegrate only partially in gastric acidity. Side-effects are minimal, therefore better compliance. However, if disintegration of the tablet does not take place, than it may not be effective.
- Liquid preparations: They include syrups and drops. Useful for children and infants but are expensive and deteriorate on storage.
- Combination of other nutrients: Ascorbic acid in the dose of 100mg/15mg elemental iron enhances absorption of 30%. But it is expensive and increases side-effects.

Dose/ duration: 4-6 mg/kg/day of elemental iron is started and continued for three months after Hb returns to the normal so as to also replenish the deficiency of storage. For children effective dosage is 1.5-2.0mg. of elemental iron/kg/body weight 3 times per day.

Difficulty encountered with oral iron: Sub-optimal response may be due to:
- Poor compliance
- Preparation with poor content and absorption of iron
- Malabsorption
- Loss greater than intake as seen in telangiectasia, portal hypertension, piles, etc.
- Discontinuation of treatment after initial 3 - 4 weeks because of a feeling of well - being or due to gastrointestinal adverse side effects.
- Concurrent protein, folic acid, B12 or other nutrients deficiencies
- Incorrect diagnosis

Response to Treatment: A positive response to treatment can be defined as a daily increase in Hemoglobin concentration of 0.1 - 0.3 g/dl or 1% rise in Hematocrit daily from fourth day onwards. Reticulocytes increase within 3 to 5 days of initiation of treatment, reaching a peak at 7 - 10 days. Hemoglobin is virtually normalized after two months of therapy. With onset of treatment, patient shows rapid subjective improvement with disappearance of fatigability, lassitude, pica and other non-specific symptoms even before there is increase in hemoglobin level.

Side-effects: Side-effects are probably related to dose and amount of elemental iron. They include gastrointestinal symptoms - heart burn, nausea, abdominal cramps, diarrhea, constipation, Blackish discoloration of tongue and teeth, etc.

Parenteral Iron Therapy:
This mode of administration should be resorted to only in cases where anemia persists due to the factors causing failure of oral iron therapy like :
- Intolerance to oral iron therapy
- Non-compliance
- Loss of iron at a rate too rapid for the oral intake to compensate for the loss (eg. hereditary hemorrhagic telangiectasia)
- Disorders of GI tract like ulcerative colitis, malabsorption, unable to maintain iron balance on treatment or hemodialysis.
- Donating large amounts of blood for autotransfusion programme.

It includes both intramuscular and intravenous iron therapy. The preparation most popularly used is iron dextran, which contains 50 mg/ml of elemental iron.

Intramuscular iron administration:
It is very painful and may cause serious allergic reactions. Hence, it is not used in children. IM injections are best given deep into the upper outer quadrant of gluteal region and skin should be laterally displaced before injection (Z tract technique) to prevent iron staining of the skin. A dose of 0.25 cc should be given as a test dose IM, and if there are no reactions after 1 hour, then full dose can be given.

Intravenous iron therapy: There are two methods employed -
- Infusion of iron Dextran (diluted in ratio of 5 ml iron Dextran complex in 100 ml of saline solution). Initially flow rate should be kept at 20 drops per minute for 5 minutes, if there are no side-effects, then the rate may be increased to 40-60 drops per minute.
- Bolus iron Dextran (diluted in a small volume).

Both are however given only after a prior sensitivity testing with intravenous test dose injection. Infusion therapy is associated with a higher incidence of adverse effects as compared to bolus treatment. Nevertheless, both forms of treatment are not spared from anaphylactic reactions. This must be taken as a word of caution against use of intravenous iron therapy.

Side Effects: Reactions to both IM and IV therapy are either immediate or delayed.
Immediate: This includes pain in vein injected, flushing, metallic taste. Such reactions are brief in duration and often are relieved immediately by slowing the rate of injection. Other immediate side-effects include hypotension, anaphylaxis with cardiac arrest, headache, malaise, vomiting, nausea, etc.
Delayed reactions: They include regional lymphadenitis which may be tender for several weeks, myalgia, arthralgia, fever, etc. Most of the reactions though are mild and transient, the anaphylactic reactions may be life-threatening. Hence one should keep ready Inj adrenaline, Inj Hydrocortisone and measures of resuscitation handy before injection is started. Reported incidence of reaction varies from 13 - 26%.

Total dose of iron to be given intravenously is calculated by follows:

Dose of iron (mg) = Wt (kg) x Desired increment of Hb (gm/dl) x 3.

We tried this modality of treatment in 100 of our patients. The results were as follows :
- Certainty of dose was established.
- Administration was assured - i.e. compliance by patient eliminated.
- Hematological response was achieved more rapidly though there was no statistical difference as compared to oral iron therapy.
- Adverse reactions commonly encountered in our series were as follows :
* Fever in 50% of patients
* Arthralgia in 19%
* Vomiting 5%
* Allergic reactions causing skin rash, flushing with sweating 3%
* Local pain along the vein 2%
* 3 patients had anaphylaxis or vasogenic shock, needing resuscitation and hence we do not recommend total dose iron therapy parenterally in children routinely.

In conclusion, iron deficiency anemia is the commonest type of anemia seen in as high as 70 - 80% of children in India. The commonest causes of this are : faulty dietary habits with recurrent infections and infestations. It is easily preventable and treatable by simple, safe and cheap oral iron therapy.

Iron Deficiency Anemia Iron Deficiency Anemia 02/08/2001
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