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Adolescent
Definition
Hemoglobin concentration is abnormally low
age, gender, sea-level altitude
as a result of several situation
chronic infection
hereditary blood conditions
deficiency :
folic acid, B12, B6, C,
protein, iron, zinc etc.
Prevalenc
e
USA
o
3 % toddlers
IDA*
3 % adolescent
females
< 1% adolescent
The Indonesian National Household
Health Survey
males
in 2001
: of adolescent girls (10-19 yrs) were
30**%
anemic (Hgb level < 120 g/L)
smaller studies : 22 44%
9% toddlers
:
o 11% adolescent femalesIron def.*
o < 1% adolescent males
Dietary iron
1. Iron is present in food as ferric hydroxides,
ferric-protein and heme-protein complexes.
2. Both the iron content and the proportion of
iron absorbed differ from food to food; in
general, meat-in particular liver-is a better
source than vegetables, eggs or diary foods.
3. The average Western diet contains 10 15 mg
iron daily from which only 5 - 10% is normally
absorbed. The proportion can be increased to
20 30% in iron deficiency or pregnancy but
even in these situations most dietary iron
remain unabsorbed.
Iron absorption
__________________________________________________________________________
DMT
1
Fe2+
Enterocyte
Apical
Fe2
+
Fe
Dcyt
b
3+
Fe2
+
Hem
e
Hem
e
Basolater
al
Hephaes
tin
Ferriti
n
Intracellul
ar iron
pool
Heme
oxygenase
Fe2
+
Bloo
d
Fe3+
Transferri
Fe2n
Fe2
+ Ferroportin
+
FeDMT Endocyto
HF transferrin
1
sis
E Fetransferrin
Fe2
+
TfR Transferrin
1
Heme
TfR2
recepto
The figure shows uptake of ionic iron and heme iron from the gut lumen and
r transfer of iron to blood. DMT1, divalent metal transporter 1; HFE,
hemochromatosis protein, TfR 1, transferrin receptor 1; TfR2, transferrin
receptor 2.
Total
Menses Pregnancy
sweat, feces
Adult male
0.5 1
Postmenopausal
female
0.5 1
0.5 1
Menstruating
female*
0.5 1 0.5 1
Pregnant female*
0.5 1
12
1.5 3
Children (average)*
0.5
1.1
Female (age 1215)*
0.5 1 0.5 1
1.6 2.6
Growth
0.5 1
12
0.6
0.6
*These groups are more likely to develop iron deficiency. Therefore these
groups are particularly likely to develop iron deficiency if there is
additional iron loss or prolonged reduced intake.
Puberty: Dietary, Bleeding, Increased demands (i) menstruation; (ii) each
1 kg of weight gain = 80 mL blood and requires 45 mg of iron
Diagnosis
The degrees of iron
deficiency
Iron sufficient
Normal
Iron depletion
Iron deficiency
(without anemia)
Iron deficiency
anemia
Clinical Aspects
The signs & symptoms depend on the
degree of deficiency and the rate at which
the anemia develops.
Iron deficiency or mild-to-moderate anemia
may show few, if any, signs or symptoms.
- Pallor
Iron Deficiency Anemia-- Fatigue
-Even severe anemia
- Exercise intolerance
may be asymptomatic
- Tachycardia
- Cardiac dilatation
- Systolic murmurs
-45 % were diagnosed
- Splenomegaly
incidentally!
- Irritability, anorexia
11
Consequences
systematic condition
anemia
impaired exercise capacity
functional alteration
behavior and cognitive performance
lower mental and motor
(early childhood)
developmental test
School-aged
scores
cognitive achievement children*
adolescent*
lower standardized
math scores
12
Mechanisms
Uncertain
Several hypothesis:
altered neurotransmitter
function
diminished activity of several
enzymes (monoamine oxidase,
aldehyde oxidase)
reduced activity of dopamine
Dd2 receptor
myelination may also be
a brief period of ID during the brain growth spurt
affected
causes a lasting deficit in brain iron, which persists
into adulthood despite correction of the anemia !!
13
To describe
the degrees
of Iron
Deficiency
Transport iron
transferrin
saturation
Serum iron
Hematologic
markers
Biochemical markers
14
Hematologic
Normal
Iron
Iron
deficiency Iron
marker
depletion
without anemia
deficiency
Hemoglob N : 11
N : 11
N : 11
Danemia
:<
in
11
(g/dL)
N : 70
N : 70
N : 70
MCV (fL)
100
100
100
D:<
70
RDW (%)
N : < 15
N : < 15
N : < 15
I : 15
CHr (pg)
N : 29
N : 29
D : < 29
D:<
N: 1 5
Reticuloc
N:15
N:15
29
ytes
MCV: mean corpuscular volume; RDW: red blood cell
D:<1
distribution width; CHr: reticulocyte hemoglobin content;
N=normal; I=increased; D=decreased
16
N
100
60
N
115
50
N
330
30
N
35
15
N
< 35
depletion
D
< 20
N
< 115
N
360
390
N
< 30
I
35
Dwithout anemia
D
10
< 10
D
D
< 60
< 40
N/I
I
390
410
410
D
D
< 10
< 20
I
I
35
35
N
< 40
I
40
I
70
Zinc
N = normal; I = increased; D = decreased
protoporphyrin/Hem
N
e (mcmol/mol)
< 40
17
Sideroblast
ic anemia
Thalasse
mia trait
Microcytic
Iron
deficienc
y
The
results
of
these
tests
diurnal
variation
recent iron
intake
Chronic
disease:
inflammatio
n, infection,
cancer
Lead
poisonin
g
18
Too
invasive
routine use.
for
Iron def.
Chronic
Lead poisoning
Inflammation
Combination
R
R
R
R
R
R
I
N
I
N
R
R
R
N/I
I
R
N
R
N/I
R/N
I
I
N
N/I
I/N
I
R
I
I
N
N
N
I
I
N
I
I
N
Both
N
N
N
I
N
N
N
N
N
A
20
The diagnosis of
moderately severe
iron-deficiency anemia
is easy
MCV
Serum ferritin
Serum iron
Serum iron-binding
capacity
Red-cell
protoporphyrin
Red-cell distribution
width
Hemoglobin after
the laboratory tests
the
of iron
mayinstitution
be less reliable
therapy
the values of irondeficient and ironsufficient persons
overlap considerably
21
an abnormally low
Hb/Ht
+
a dietary history of
low iron intake
an abnormally low
Hb/Ht
+
a normal diet
history of adequate
iron intake
Ferriti
n
Strongly
suggest IDA
Response to a
therapeutic
trial
To look for blood
loss e.g., occult
rectal bleeding
22
Therapeutic
trial
Presumpti
ve IDA
Children: 3 to
6 mg/kg per
day (qd or tid)
Adolescents:
60 mg/dose
(qd or bid)
IDA
nutritional
The
response to
iron
typically
rapid
Hb increase
1 g/dL
after 1
month of
therapy
23
Preventi
on PRIMARY
PREVENTIO
N
Sufficient dietary iron
must be available from 4
months of age and
through the weaning
period.
SECONDA
RY
PREVENTI
ON
SUPPLEMENTARY IRON
FORTIFICATION OF
FOODS
DIETARY EDUCATION
REGULAR SCREENING
PROMPT DIAGNOSIS
TREATMENT OF IRON
DEFICIENCY
24
Treatment of Iron
Deficiency
Iron
Supplementation
RBC Transfusion
Determining the cause and
correcting the abnormality
Growth spurts, poor dietary
patterns, menstrual losses,
and benign gastrointestinal
bleeding
Oral iron supplementation
usually replaces stores most
efficiently
25
Oral
Supplementation
Oral
Diagnose :
Supplementation
IDA
Oral iron
supplementati
on for 1 month
Hb
measureme
nt
No improvement in
Hb
further
evaluation : MCV,
RDW, serum
ferritin, search for
possible sources of
blood loss
Hb should
be
remeasure
d
An increase of 1
g/dL (10 g/L) or
greater
Iron
therapy
Hb has returned
to a normal level
Iron
6
therapy :
m
Iron 2 3
o
months
therapy:
STOP
27
Parenteral iron
Erythrocyte
transfusion
should be used
only if the
anemia is
causing severe
cardiovascular
compromise;
hypervolemia
and cardiac
dilatation may
result from
rapid
correction of
the anemia !!
29
Parental Iron
Replacement
iron dextran, iron gluconate, iron sucrose
Indication
1. Oral iron is poorly tolerated
2. rapid replacement of iron stores is
needed
3. gastrointestinal iron absorption is
compromised
4. erythropoietin
therapy is necessary
An anaphylactic
reaction
(in renal dialysis patients)
Dose (mL) = 0.0442 x (Desired Hb
Observed Hb) x Lean body weight + (0.26 x
Lean body weight)
30
Regular
screening
Adolescents
AAP : screening all adolescents once
between ages 11 and 21 years
screening menstruating females
annually
CDC :
annual screening of adolescent
females if their risk is increased;
otherwise, anemia should be
screened for every 5 to 10 years
31
33