ANEMIA OF IRON DEFICIENCY IN CHILDREN
Although iron deficiency anemia can be seen in all age groups and both sexes, it is the most important cause of anemia especially in infants aged 6-24 months and in adolescence. In our country, iron deficiency anemia can be detected in the rate of 30-40% in preschool period. Unless the mother has very severe anemia, healthy infants born in time have sufficient iron deposition and iron deficiency anemia does not develop in the first 6 months. After six months, the main cause of iron deficiency anemia is rapid growth and insufficient iron in diet and milk-weighted nutrition. In addition to rapid growth during adolescence (12-18 years), blood loss due to menstruation, vegetarian nutrition, inadequate nutrient intake and slimming regimens are important causes, especially in young girls.
Why is iron important?
Iron is a very important element for life. Protein synthesis, oxygen transport, electron transport, cell respiration, is involved in the structure and function of many enzymes. Deficiency does not only result in anemia, but also dysfunction of other systems such as the nervous system.
How does iron deficiency anemia occur?
Only about 10% (1-2mg / day) of iron taken with food is absorbed from the intestines, especially the duodonum; the rest is excreted with feces. The most important iron source in the body is iron (20 mg) which is released by the destruction of old erythrocytes. 12-25% of the liver is stored for use when necessary. 0.5-1 mg of iron per day is lost by shedding of cells on the skin and mucosal surfaces. In menstruating girls, an excess iron of 1 mg per day is lost during bleeding; If the amount of iron taken with food is not increased, it becomes clear after a while. Iron deficiency and associated iron deficiency anemia develop in all individuals if the iron required to be taken with food is taken less, absorption is impaired, iron cannot be transferred in the organism, iron need increases and blood losses are present (Table 1) . Iron deficiency anemia is not a disease but a symptom; it is absolutely necessary to reveal the underlying cause.
What are the clinical signs of iron deficiency?
When anemia develops, complaints such as fatigue, weakness, dizziness, headache, palpitation, fatigue, paleness in the skin, pain in the tongue, decreased sensation of taste, fracture and streaking of the nails, and wound in the corners of the mouth may occur. Soil, ice, salt, paper, lime can be eaten. Irritation, anorexia, failure to concentrate attention, drop in school success, difficulty in understanding and perception, decrease in intelligence level, frequent infection may occur due to the functions of iron other than erythrocytes. Infants may present with difficulty in swallowing, bruising while they cry and a pause in their development. The baby cannot sit while sitting and cannot walk while walking. These findings can be seen in the early stages of iron deficiency before anemia occurs.
Table 1. Causes of iron deficiency anemia in childhood and adolescence
Prenatal causes
Twin and multiple pregnancies
Blood transfer from baby to mother or twin mate
Other causes of bleeding
Stay without oxygen (hypoxia)
Postnatal reasons
Insufficient reception
- Nutritional deficiency
- Late start of supplementary foods
- Excessive use of cow's milk (> 500ml)
- Vegetarian nutrition
- Slimming regimens
- Eating disorders
Absorption disorders
- Chronic diarrhea
- Chronic infections
- Congenital anomalies of the digestive system
- Surgical shortening of intestines
- Diseases leading to absorption disorder
- Anti-acid treatment, high stomach pH
- Excess intake of elements such as zinc
Increased iron requirement
Acute or chronic blood loss
Parasitic infections
Periods of rapid growth
Babies with low birth weight
Preterm babies
Pregnancy
What are the laboratory findings of iron deficiency anemia?
In the event of iron deficiency, the iron in the storage first decreases and serum ferritin decreases. Then serum iron decreases and iron binding capacity increases. Transferrin saturation decreases during this period, but anemia has not yet developed. In the last period iron deficiency becomes evident, there is now anemia and related findings emerge. In iron deficiency anemia, erythrocyte count, hemoglobin and hematocrit values are low; mean erythrocyte volume, mean erythrocyte hemoglobin, mean erythrocyte hemoglobin concentration decreased erythrocyte distribution width increased. Intra-erythrocyte free protoporphyrin levels and serum soluble transferrin receptor levels were increased. When the bone marrow sample is taken and stained with iron dye, it is observed that iron is absent or very low in erythrocyte precursors. Although bone marrow aspiration is used for diagnosis in adults, it is not necessary for diagnosis in children.
What diseases can iron deficiency anemia be confused with?
Iron deficiency anemia is often confused with anemia caused by mediterranean anemia (thalassemia) and some diseases. These include infections, kidney failure, liver diseases and cancers.
Thalassemia trait in the overall prevalence of 5% in Izmir, Turkey Although 2%, from place to place in the Mediterranean area is over 10%. The incidence of immigration from the Aegean islands and Thrace is more common. If there is no response to iron deficiency treatment, if your doctor's attention draws attention to the findings of the carriage of mediterranean anemia, a hemoglobin electrophoresis test may confirm this diagnosis. Although a diagnosis of carriage of Mediterranean anemia is diagnosed, it should be known that this is not a disease, but that the marital anemia can be seen in children in the same way as marriages with a carrier and the couple should be evaluated by the blood diseases specialist before pregnancy. Iron deficiency anemia may also be associated with carriage of Mediterranean anemia, in which case iron deficiency should be treated first and then hemoglobin electrophoresis should be examined.
Anemia caused by infections affects children, especially in the first two years of age. It has long been known that severe infections have been associated with anemia. In recent years, it has been emphasized that anemia can be seen in mild and widespread infections. Hemoglobin values may decrease by 1.5 g / dl.
How is iron deficiency anemia treated?
Drugs containing iron in the form of drops or syrup are taken orally. Medications are usually given twice a day and preferably between meals when the child is hungry. It is not supplied with milk and foods containing milk, it must be at least half an hour past. Beverages and foods containing vitamin C increase iron absorption.
It is very important that iron medications are used regularly and adequately. Together, the family and the patient are informed about balanced and iron-rich diet. Treatment of intramuscular or intravenous injections of iron drugs is only necessary in certain special cases. These include the absence of iron from the intestines, bowel diseases such as colitis, and renal failure.
In the event of signs of severe heart failure due to severe anemia in children, erythrocyte suspension 5 ml / kg is given by monitoring vital signs in 3-4 hours. Then iron treatment is continued. If there are no signs of heart failure, the patient is not transfused with blood.
Few of iron can be harmful. Therefore, it is important to use iron medications at the dose and time recommended by the physician. It is also important that you follow your physician's recommendations regarding the dose and duration of use of iron therapy.
How long should the treatment be?
The duration of treatment is approximately three months. After the first month of treatment, it is necessary to see that the hemoglobin level is within normal limits. If the hemoglobin level is normal, the dose of iron is reduced and treatment continues for 6-8 weeks. Thus, the iron tanks are filled. The child should be reassessed three months after cessation of iron therapy; If anemia occurs again, there is an underlying cause, which should be discovered.
If the hemoglobin level has not reached normal in the first month, there is a problem; whether the child is receiving the correct treatment, the presence of additional losses, and whether the diagnosis is correct or not.
What should be considered in the use of iron-containing drugs?
Because the taste of iron-containing drugs is not very sweet, some children may experience resistance to drug intake. In these children, administration of the drug with orange juice is beneficial in terms of both taste and absorption.
Some children may develop constipation or diarrhea, abdominal pain and burning sensation in the stomach. If you have abdominal pain, the drug can be given in the evening when hungry. Burning in the stomach can be controlled by taking the drug on a full stomach at least half an hour after a meal. During the use of the drug it can be observed that the color of the feces of the child is darkened to black.
What happens if iron deficiency anemia is not treated?
If the iron deficiency anemia developed in infancy is not diagnosed and treated early, the level of intelligence decreases due to the role of iron element in brain development even if the blood values reach to normal with iron treatment in the future. Children with iron deficiency anemia may develop developmental delay, delay in sorting and walking, perception retardation and distraction. School success falls. In addition, if iron deficiency anemia persists, progressive weakness, fatigue and loss of appetite make daily life difficult. Severe iron deficiency anemia may cause heart failure.
How can iron deficiency anemia be prevented?
In order to prevent iron deficiency, it is important to give low-dose protective iron medicine to infants at the end of the fourth month if they are born on time and to complete the first month if they are born prematurely, and to give supplementary iron-rich foods when the time comes. The Ministry of Health supports the application of protective iron therapy. After the sixth month, the development of iron deficiency anemia can be prevented by adding additional foods such as red meat and eggs with high iron content. The fact that families with good economic conditions use infant formula containing iron instead of cow's milk in the first year reduces the risk of iron deficiency anemia. Children should not be given more than 500 ml of cow's milk per day.
Figure. A study of the Ministry of Health on the issue of protective iron therapy
What is iron-rich nutrition?
Iron-rich foods include red meats such as beef and mutton, liver, egg yolks, legumes such as lentil-chickpeas, and grape molasses. In children, consuming at least three to four times a week each of these foods in appropriate portions ensures adequate nutrition from iron. Green leafy vegetables such as spinach do not have much iron and the absorption of iron is low due to its plant structure.
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