1. IRON DEFICIENCY ANAEMIA BY DR. KAMAL E. HIGGY CONSULTANT HAEMATOLOGIST

2. PER CENT OF INFANTS 20 10 0 FORMULA Percentage of infants with iron deficiency, defined as serum ferritin below 10µ g/l. after feeding iron-supplemented formulas, breast milk and cow’s milk. 20 10 0 0 20 BREAST MILK COW’S MILK AGE IN MONTHS 469 12

3. Factors which affect iron content at birth -------------------------------------------------------------------------------------------------------------------------------------------------------------- Iron content ----------------------------------------------------------------------------------------------------- IncreasedDecreased -------------------------------------------------------------------------------------------------------------------------------------------------------------- Tissue ironHigh birth weightLow birth weight Haemolytic disease Blood VolumeHigh birth weightLow birth weight Late cord clampingEarly cord clamping Haemorrhage from cord or placenta Materno-fetal transfusionFeto-material transfusion Feto-fetal transusionFeto-fetal transfusion Cord haemoglobinGrowth retardationPre-term infant Maternal anaemiaHaemolytic disease Maternal hypoxia

4. Daily Iron Losses and Requirements (mg) ----------------------------------------------------------------------------------------------------------------------------------------------------------------- Daily Loss Requirement Total Loss for Growth (= Requirement) Urine, skin, menses Faeces, etc. ---------------------------------------------------------------------------------------------------------------------------------------------------------------- Infant (0-4 months)0.50.5 (5-12 months)0.50.51.0 Child0.50.51.0 Adolescent male0.90.91.8 Adolescent female0.9 1.00.92.4 Menstruating female0.9 1.92.8 Adult male0.90.9 Post menopausal female0.90.9 -------------------------------------------------------------------------------------------------------------------------------------------------------------- N.B: Average daily requirement during pregnancy is 3.0 – 4.0 mg.

7. IRON ABSORPTION Favored by Dietary factors: Increased Haem iron Increased animal iron Ferrous iron salts Luminal factors: Acid pH (e.g. gastric HCl) Low molecular weight soluble chelates (e.g. Vit. C, sugars, amino acids) Ligand in meat (unidentified) Systemic factors: Iron deficiency Increased erythropoiesis Ineffective erythropoiesis Pregnancy Hypoxia Reduced by Decreased haem iron Decreased animal iron Ferric iron salts Alkalis (e.g. pancreatic secretions) Insoluble iron complexes (e.g. phytates, tannates in tea, bran) Iron overload Decreased erythropoiesis Inflamatory disorders

11. Latent Iron Deficiency Normal Iron Deficiency Anaemia Red cell iron (peripheral film And indices) Normalnormalhypochromic, microcytic MCV↓MCH↓MCHC↓ Iron stores (bone marrow Macrophage iron +++ - + 0 0 The development of iron deficiency anaemia. Reticuloendothelial (macrophage) stores are lost completely before anaemia develops.

12. serum iron Serum iron binding capacity normal iron deficiency anaemia of chronic disorders iron overload 0 10 20 30 40 50 60 70 80 90 100 µ mol/l The serum iron and unsaturated serum iron binding capacity in normal subjects, iron deficiency, the anaemia of chronic disorders and iron overload. The total iron binding capacity (TIBC) is made up by the serum iron and the unsaturated iron binding capacity.

13. Normal Iron Iron Iron Depletion Deficient Deficiency Erythropoiesis Anaemia Iron Stores Erythron Iron RE Marrow Fe (O-6)2-3+ 00 Transferrin IBC (µmol/l)60±5 70 75 Plasma Ferritin (µg/l)100±60 10 <10 Iron AbsorptionNormal ↑↑ Plasma Iron (µmol/l)20±9 20<7 Transferrin Saturation (%) 35±15 30 <10 Sideroblasts (%) 40 – 60 40-60 <10 RBC Protoporphyrin 30 30 200 (µg/dl RBC) Erythrocytesnormal normal normal The sequence of changes induced by a gradual reduction in the iron content of the body. 0-|+ 65 20 ↑ <10 <15 <10 100 Microcytic and hypochromic

14. IRON PROTOPORPHYRIN (a) Iron deficiencySideroblastic anaemia (b) Chronic inflammation or malignancy HAEM + GLOBIN Thalassaemia ( α or β ) HAEMOGLOBIN The causes of a hypochromic microcytic anaemia include: lack of iron (iron deficiency) or of iron release from macrophages to serum (anaemia of chronic inflammation or malignancy) Failure of protoporphyrin synthesis (sideroblastic anaemia) Failure of globin synthesis (α or β–thalassaemia). Lead also inhibits haem and globin synthesis.

15. Hypochromic and/or Microcytic Anaemia Serum Fe Serum Fe Increased Hyperferraemia Serum Fe Reduced Hypoferraemia Serum Fe Normal Bone Marrow Macrophage Iron Serum Ferritin Hemoglobin Electrophoresis, etc Bone marrow Sideroblast Fe Increased OR Absent IRON DEFICIENCY Low THLASSEMIA SIDEROBLASTIC ANAEMIA Increased ANAEMIA OF CHRONIC DISORDERS Normal or Increased HEMOGLOBINOPAT HIES (S,C,D,E) CONGENITAL ACQUIRED

16. Failure of response to oral iron -------------------------------------------------------------------------------------------------------------------------------------------------------------- Continuing haemorrhage Failure to take tablets Wrong diagnosis – especially thalassaemia trait,sidroblastic anaemia Mixed deficiency – associated with folate or vitamin B 12 deficiency Another cause for anaemia – e.g. malignancy, inflammation Malabsorption – this must be extremely severe Use of slow – release preparation