anemia%20-%20iron-deficiency%20(pediatric)
ANEMIA - IRON-DEFICIENCY (PEDIATRIC)

Iron deficiency (ID) is the most common nutritional deficiency in children & reportedly 3x more common than iron-deficiency anemia, but does not always develop into anemia.

Neonates & children may have delayed growth & development; adolescents may show decrements of learning such as behavioral abnormalities.

Iron-deficiency anemia is the most advanced stage of iron deficiency resulted from a protracted imbalance between iron intake & demand.

Characterized by low hemoglobin & hematocrit levels, reduction or depletion of iron stores, low serum iron levels & decreased transferrin saturation.

Principles of Therapy

  • The aim of treatment should be restoring hemoglobin and red blood cell indices to normal, and to replenish iron stores
  • If this cannot be achieved, the decision to initiate therapy depends on symptoms, etiology, and severity of anemia, rate of change, comorbidity, and  potential adverse effects of therapy
  • It is important to consider that anemia impairs quality of life even in the absence of specific symptoms from an underlying cause, its treatment must prevent further iron loss, hence supplementation should be initiated immediately if iron-deficiency anemia (IDA) is diagnosed

Pharmacotherapy

  • Patients with iron-deficiency anemia (IDA) have good response to iron therapy
  • The choice between different iron replacement products, oral or intravenous (IV), depends on a number of factors including severity of anemia, costing, availability of the preparation and ability of the patient to tolerate treatment

Oral Iron

  • Preferred route for uncomplicated iron-deficiency anemia due to the ease of administration, is effective, readily available, safe and inexpensive
  • Oral supplements are generally used for infants, children, and adolescents
  • Use of oral Iron avoids the need for IV access as well as monitored infusion
  • Gastrointestinal adverse effects such as epigastric discomfort, nausea, diarrhea, metallic taste, thick, green stool and mild to severe constipation may cause non-compliance to oral iron therapy
  • Recommended pediatric doses are:
    • Infants: 3 mg/kg/day divided 12 hourly
    • Children: 6 mg/kg/day divided 12 hourly 
    • Age Ferritin levels Dosage Duration
      0-2 months <40 ng/ml 2-6 mg/kg/day 3-6 months
      2-6 months <20 ng/ml
      6 months onwards <10 ng/ml
  • Iron eliminates the potential for infusion reactions and/or anaphylaxis
  • Intake of proton pump inhibitors and those that induce gastric acid hyposecretion can reduce iron absorption
  • Iron absorption is enhanced in a mildly acidic medium, thus addition of ascorbic acid (either by tablet or half-glass of orange juice) has been suggested
    • Studies have shown that ascorbic acid can overcome the negative effect of iron absorption of all inhibitors, including phytate, polyphenols and the calcium and proteins in milk products, and it will increase the absorption of both native and fortified Iron
Ferrous Iron
  • Eg Ferrous sulphate, Ferrous fumarate, Ferrous gluconate
  • Most common forms of oral iron used for correction of iron-deficiency anemia
  • Effective, widely distributed, and is readily absorbed due to higher solubility but is associated with more gastrointestinal (GI) side effects
    • Can be minimized by taking oral Iron supplements after meals, although it may cause decreased absorption
  • Most recent advances of oral preparations have led to the development of prolonged-release preparations with new formulations that may improve gastrointestinal tolerability
    • Enhanced Fe2+ bioavailability from a surrounding polymeric complex, controls distribution to parts of GI tract allowing Iron levels in the blood to reach a maximum of 7 hours and remains elevated for 24 hours

Ferric Iron

  • Has a longer period of active absorption
  • Iron polymaltose complex is a ferric compound that is as effective as ferrous salts, only with the advantage of controlled absorption for minimal gastrointestinal adverse events
    • Have reduced gastrointestinal disturbances thus have better tolerance rate due to extremely poor solubility in alkaline media
    • Needs to be transformed into ferrous iron before being absorbed

Parenteral Iron

  • Indicated in patients who cannot tolerate or absorb oral preparations
  • Iron dextran, Iron sorbitol, Iron sucrose, and Sodium ferric gluconate are the most common parenteral forms of iron therapy
  • Iron dextran is available in a high molecular weight form, as well in a low molecular weight form
  • Ferric carboxymaltose is a newer generation iron preparation allowing rapid and simplified administration with potentially better safety profile
  • Ferric gluconate complex as well as Iron sucrose preparation are specifically indicated for patients on renal dialysis
  • Ferumoxytol, though associated with severe and even fatal hypersensitivity reactions, is being used more frequently
    • Newest form of commercially available iron for intravenous administration
    • Advantage is that it can be given rapidly
  • IV Iron therapy has risk of serious allergic reactions
    • If the patient has had an anaphylactic reaction to parenteral Iron, further IV Iron supplementation should not be attempted
    • Life threatening adverse events on allergic reactions for IV iron preparations were reported
  • Intramuscular (IM) injection of Iron is discouraged due to associated pain, permanent skin staining and not safer than IV infusion

Non-Pharmacological Therapy

Dietary Therapy
  • The approach to therapy is individualized according to etiology and severity of iron deficiency

Recommended Dietary Allowances by the World Health Organization (WHO)

  • The appropriate use of iron supplements is an important part of anemia control programs against iron-deficiency anemia (IDA)
  • A daily protocol of iron supplementation, recommended for treatment and prevention of its priority target group
    Age Males
    (mg iron/day)
    Females
    (mg iron/day)
    0-6 months 0.27 0.27
    7-12 months 11 11
    1-3 years 7 7
    4-8 years 10 10
    9-13 months 8 8
    14-18 months 11 15
  • Full term
    • Elemental iron 1 mg/kg daily, maximum 15 mg
    • If breastfed, should start Iron supplementation at 4 months
    • Supplementation should be continued until sufficient quantities of iron rich foods are tolerated
  • Premature
    • Elemental iron 2-4 mg/kg daily, maximum 15 mg
    • If breastfed, should start with an Iron supplement at 2 weeks of age
    • Supplementation should be continued through 1st year
  • Low birth weight infants
    • Infants 2000-2500 grams: 1-2 mg/kg/day for 0-6 months
    • Infants 1500-2000 grams: 2 mg/kg/day for 1-12 months
    • Infants <1500 grams: 2-3 mg/kg/day for 0-12 months
  • Female adolescents are as follows:
    • 14-18 years old: 15 mg/day

Nutrition

  • Breastmilk provides sufficient supply of iron for infants <6 months
  • Non-breastfed or partially breastfed infants should be given formula fortified with at least 12 mg/L of iron
  • By 6 months of age, encourage feeding foods rich in vitamin C and to include iron-enriched foods in the diet
    • Ascorbic acid (vitamin C) enhances the absorption of nonheme iron from cereal, breads, fruits, and vegetables
  • At >6 months old, consider introducing pureed meats, heme iron in meats is more bioavailable than nonheme iron
  • Iron-fortified cereals should be given not until 6 months of age
  • Ages 1-5 years old should consume not more than 600 mL (20 oz) of milk per day
  • Diets of infants and young children should include dietary sources of iron such as red meat, liver, shellfish, beans, and leafy green vegetables
Blood Transfusion
  • Will not correct iron-deficiency anemia without other supplementation
  • Rarely necessary, even for severe iron-deficiency anemia of children
  • Indicated in patients who are unstable hemodynamically due to active bleeding, and/or show evidence of end-organ ischemia
  • It is essential to assess the patient’s clinical condition and symptoms in deciding whether blood transfusion is needed
  • Transfusion of red blood cells requires strict medical care and observation, caution must be observed to avoid complications such as volume overload
  • Transfuse one unit at a time of packed red blood cell (RBC) if transfusion is indicated
    • Clinical situation should be reassessed, especially ferritin, serum iron, and total iron binding capacity should be drawn prior to transfusion to help clarify diagnosis once the patient is stable to guide further treatment
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