DEFICIENCY ANEMIA

ANEMIA
The literal translation from
Greek is bloodless, i.e. a
condition incompatible with
life.
In clinical understanding -
anemia.
 Age dynamics of
hemoglobin
 In newborns in the first 8 days
of life – 170-240 g/l
 By 4-5 months of life is reduced
to 110-115 g/l
 In the second year of life
increases to 130 g/l
 CLASSIFICATION OF ANEMIAS
CAUSED BY A DEFICIENCY OF
HEMATOPOIETIC FACTORS

1. Iron deficiency
2. Vitamin deficiency
3. Protein deficit
4. Mixed form deficiency
anemia
 According to the content of
hemoglobin and erythrocytes:
1. Mild anemia: hemoglobin within 90-
110 g/l, the number of erythrocyte 3.0-
3.5×1012/l;
2. Anemia of moderate severity: the
hemoglobin in the range of 70-90 g/l,
the number of erythrocytes in the
range of 2,5-3,0×1012/l;
3. Severe anemia: hemoglobin less than
70 g/l, erythrocytes count less than
2.5×1012/l
By the number of reticulocytes
anemia is divided into:
a) Regenerative - reticulocytosis up
to 5%;
b) Hyperregenerative -
reticulocytosis over 5%;
C) Hypo - or aregenerative - low
reticulocytosis, inadequate
severity of anemia or lack of
reticulocytes in peripheral blood.
 By color index value:

- hypochromic
(color index < 0.85),
- normochromic
(color index = 0.85-1.05),
- hyperchromic

(color index > 1.05).

 Iron deficiency anemia

It is anemia, characterized by a
decrease in hemoglobin (per unit
volume of blood), a decrease in
the average concentration of
hemoglobin in one erythrocyte, a
decrease in serum iron
concentration and an increase in
the total iron binding capacity of
blood serum.
 In Russia, iron deficiency
anemia affects 23-43% of
children 1-3 years (2015)
 Perm region - 255 per 1000
(2014)
 Perm - 273 per 1000 (2014)
 Norway - 2-5%
 USA - 2,3-5%
 India – 71,5%
 CAUSES OF IRON DEFICIENCY
ANEMIA IN CHILDREN OF EARLY
AGE

1. Exogenous iron deficiency due to

insufficient intake in the body with
irrational nutrition;
2. Increased need of the body for iron due
to accelerated growth rates (premature
infants, children from multiple
pregnancies, children with high birth
weight);
3. Insufficient supply of iron in а
body at the time of birth;
4. Increased iron loss;
5. Violation of absorption and
transport of iron in the intestine;
6. Discoordination of regulation of
iron metabolism in the body.
7. Increased need for iron in
diseases (pustular, infectious-
inflammatory, allergic).
 Pathogenesis of iron
deficiency anemia
 In cases of body insufficient intake
of iron the iron saturation of
transferrin reduces
 Reduced reserve of iron in tissues
 Enzyme activity decreases
 Disturbed cellular respiration
 Developing hemic hypoxia
 As a result, the functions of the
brain, cardiovascular and
immune systems, gastrointestinal
tract, adrenal glands are
violated.
 In the long course of iron
deficiency anemia functional
disorders due to hypoxia and iron
deficiency, go into irreversible
dystrophic changes in organs and
tissues.
 Clinical implications

 Epithelial syndrome (pallor of the

skin can be combined with facial
puffiness, pasty lower extremities;
at Hb below 90 g/l – perioral
cyanosis and acrocyanosis).
Characterized by trophic skin
disorders and skin appendages.
 Sideropenic enteropathy - disorders
of the digestive tract (change of
taste and smell, decreased appetite,
regurgitation, sometimes vomiting,
constipation).
 Often found hepatomegaly, rarely -
splenomegaly.
 Astheno-vegetative disorders
(increased irritability, fatigue,
mood swings, negativity and loss
of interest in others, lethargy, lack
of mobility. Reduced memory and
concentration).
 In the long course of anemia -
lagging in neuro-psychological
and physical development,
increased susceptibility to
infections.
 Changes in the cardiovascular
system appear at Hb < 70 g/l –
tachycardia, systolic murmur in the
region of the apex of the heart;
ECG – reduction of the t wave and
the deviation of the ST segment
from the contour.
 Additional symptoms: the tendency
to dental caries, muscular
hypotonia, muscle pain due to lack
of myoglobin, sometimes low-
grade fever.
 LABORATORY CRITERIA OF IRON
DEFICIENCY ANEMIA

1. General blood test:

a) the concentration of hemoglobin of
venous blood below 110 g/l in children
of the first 6 years of life and less than
120 g/l - older than 6 years; the red
blood cell content may remain normal
or decrease below 4,0×1012/l;
b) the color index is lower than
0.8 unit or 28 pictograms; with 1
degree of anemia, the red blood
indicators can be normal;
c) the presence of hypochromic
red blood cells;
d) anisocytosis or more often
microcytosis;
e) poikilocytosis; more often
detected at hemoglobin
concentrations below 90 g/l;
e) the number of reticulocytes may
be within the norm (0.5-1.0%) or
increased (1.8-2.0%, but not more
than 5%).
Possible thrombocytosis and
elevated erythrocyte sedimentation
rate.
2. Biochemical analysis of blood:
a) reduction of serum iron below
11.0 µmol/l;
b) increase in the total iron-binding
capacity of blood serum over 75.0
µmol/l in children of the first 2
years of life and above 70.0 µmol/l
at the age of over 2 years;
c) reduction of iron transferrin
saturation below 16%;
d) dysproteinemia by reducing β -
globulins and increasing α -
globulins
3. The study of the myelogram:
A) reduction in the number of
sideroblasts to 10% and below
(normally 20-30%);
b) changing the ratio of different
forms of normocytes (increasing the
number of basophilic ,
polychromatophilic normocytes and
reducing oxyphilic).
 4. Additional methods of iron
metabolism study
(determination of serum ferritin
and erythrocyte protoporphyrin,
evaluation of absorption of
radioactive iron in the intestine,
desferal test to evaluate iron stores
in the body).
 Prevention of iron
deficiency anemia
 Antenatal prevention
 Postnatal prevention
ANTENATAL RISK FACTORS OF
ANEMIA IN CHILDREN

1. Short interval (less than 1

year) between the previous
birth and the present
pregnancy, long and abundant
menstruation, blood donation,
frequent pregnancies (more than
3);
2. Umbalanced nutrition of a
pregnant woman;
3. Chronic extragenital
inflammatory diseases
(pyelonephritis, rheumatism,
etc.);
4. Frequent abortions before
this pregnancy;
5. Late toxicosis of а pregnant
woman;
6. Multiple pregnancy;
7. Hemoglobin concentration is
less than 100 g/l, serum iron is
less than 11.0 µmol/l and total
iron binding capacity of blood
serum is more than 85%.
The complex of medical and preventive
measures carried out by pregnant women
at risk:

1. Observance of the rational regime of

the day
2. Good nutrition
3. Administration of three two-week
courses of treatment with oxygen
cocktails in combination with vitamins C
and group B
The first course of preventive therapy is
carried out from the 14th week of
pregnancy.
The second - from the 24th week of
pregnancy.
The third course of vitamin therapy is
from the 36th week of pregnancy.
Iron preparations are added at a
hemoglobin level below 120 g/l.
The daily need for iron in
women during
pregnancy is
25-30 mg.
 RISK GROUPS FOR THE
DEVELOPMENT OF IRON DEFICIENCY
ANEMIA AMONG NEWBORNS

1) premature
2) children born from multiple
pregnancies
3) “large fetal” for gestation
period
4) with high rate of physical
development
5) those who are on artificial
feeding
6) having eating disorders
7) ill with severe infections,
hemolytic disease of newborns
and diseases with hemorrhagic
syndrome
8) children with allergic diseases
 Therapeutic and preventive
measures for newborns at
risk:
1. Prophylaxis of hypogalactia the
mother
2. Rational feeding and the mode of
the day
3. The purpose of micronutrients,
adaptogens and vitamins
 Treatment of iron deficiency
anemia
 Conducted on an outpatient basis
 Indications for hospitalization:

- Hb concentration less than 60 g/l

- the presence of other background
diseases
- adverse social environment
- the need to clarify the diagnosis
BASIC PRINCIPLES OF TREATMENT
OF IRON DEFICIENCY ANEMIA

1) elimination of causes of iron deficiency

anemia;
2) the observance of a day regimen of
the child (a walk in the fresh air,
hydrotherapy, massage and
gymnastics);
3) rational nutrition;
4) administration of iron preparations.
 Dietotherapy

 Important are products containing

trace elements - iron, copper,
cobalt, manganese, nickel, as well
as vitamins (beef, liver, cottage
cheese, egg yolk, vegetables and
fruits: green peas, beets,
tomatoes, apples, apricots, black
currants).
 The iron content in foods of
animal origin
Products Total iron content Basic iron-
(mg / 100 g) containing
compounds
Liver 9 Ferritin,
hemosiderin
Beef tongue 5 heme
Rabbit meat 4,4 heme
Chicken meat 3 heme
Beef 2,8 heme
Mackerel 2,3 Ferritin
 Enhance the  Reduce the
absorption of iron: absorption of iron:
1. organic acids 1. calcium,
(ascorbic, succinic, 2. oxalates,
pyruvic), 3. phosphates,
2. fructose, 4. phytates,
3. sorbitol, 5. tannin,
4. amino acid 6. tetracyclines,
7. penicillins,
8. antacids
TREATMENT OF ANAEMIA WITH
IRON PREPARATIONS

 Therapy should be carried out mainly

with iron preparations for oral
administration
 Young children should be administred
iron preparations in liquid form
(hemofer, maltofer, aktiferrin, ferrum
Lek, ferlatum)
Hemofer
Maltofer
 Ferlatum

Composition and form of

production: oral
Solution transparent,
brown, with a pleasant
characteristic smell.
1 FL. ((15 ml) iron
proteinsuccinylate 800
mg, which corresponds
to the content of Fe3 +
40 mg,
 Ferronal

Syrup - in 5 ml 35 mg of
serumal iron
Aktiferrin
Composition and form of
production: iron-2-sulfate.
Capsules (1 capsule contains
0,11385 g of ferric sulfate and
0,129 g of D,L serine) at 20 or 50
pack.
Syrup (1 ml contains 0.0342 g
of iron sulfate and 0.00258 g D, l
serine) 100 ml in a bottle.
Drops (1 ml contains 0.0095 g)
of 30 ml in the bottle.
 Daily therapeutic dose

- for children under 3 years - 3 mg/kg,

– for children over 3 years - 45-60 mg/
day,
- for adolescents - up to 80-150
mg/day.
The course of treatment is 6-10
weeks, depending on the severity of
anemia.
To determine the individual duration of
therapy we should focus on blood
hemoglobin levels and serum iron.
To stop the treatment, the concentration
of serum iron should be at least 14
µmol/l.
If it is impossible to control the level of
serum iron, the therapy is continued in a
half dose of the drug for another 3-4
weeks after the normalization of
hemoglobin.
 THE TERMS OF
ADMINISTRATION OF IRON
PREPARATIONS PER OS
1) it is necessary to correctly calculate the
daily dose of the drug, taking into
account the content of elemental iron in
it;
2) treatment starts with minimal doses
(1.5-2.5 mg/kg/day of elemental iron),
gradually increasing them to a
therapeutic dose to 7-10 day treatment;
3) take the drug for 0.5-1 hour
before meals, in the presence of
dyspepsia - during or after meals;
4) the daily dose is evenly distributed
during the day for 3-4 admissions.
 Indications for parenteral
administration of iron
preparations:
 Intolerance to iron preparations taken
orally (persistent diarrhea, vomiting).
 Malabsorption syndrome.
 Diseases of the gastrointestinal tract.
 Severe forms of iron deficiency anemia,
requiring an urgent increase in the
concentration of hemoglobin.
 Daily doses of drugs for parenteral
administration (calculation of the
elemental iron)
The weight of the baby Daily dose of elemental
iron
Up to 5 kg 25 mg / day

6 - 10 kg 25-50 mg / day

11 - 20 kg 100 mg / day
The calculation of the dose
for a course of treatment :
Number of drug in ml =
[0,66×body weight in kg×(100 –
Hb patient in g/l)] : the amount of
elemental iron in 1 ml of the drug.
Iron preparations for
parenteral administration

 ferrum-Lek - 100 mg in 2 ml
 farbital - 100 mg in 2 ml

 ferrlecide - 62.5 mg in 5 ml
 Iron preparations containing a full
dose of course

 Imferon (England)
 Dextrafen (Russia)
 Ferral (Russia)
These medications are administered
once, used in adults
 Blood transfusion for iron
deficiency anemia
 Severe condition of the patient with
severe anemia (Hb less than 60 g/l)
and hypoxia
 Anaemic precoma or coma
 Iron intolerance and urgent
preparation of the child for surgical
treatment
SIDE EFFECTS OF IRON
SUPPLEMENTS
When administered orally:
- moderate side effects (nausea,
regurgitation);
- more severe (vomiting, diarrhea,
anorexia, temperature elevation, pain in
the abdomen and in the chest, cramps,
allergic rash).
 With intramuscular
administration - headache, pain
in muscles and joints, weakness.
 When intravenous - there may
be an allergic reaction such as
anaphylactic shock.
 Locally, at the injection site, it is
possible to develop infiltration,
sometimes - abscess.
 Poisoning with iron preparations
 Intoxication, drop in blood pressure, in
severe cases – shock, hepatic coma
 Specific antidote – Desferal. The daily
dose - 10 mg/kg, in severe cases - 20-
25 mg/kg.
 Treatment is carried out to normalize
the level of serum iron
 CRITERIA OF RECOVERY

 Hemoglobin not less than 120 g/l;

 Serum iron - from 14 to 18
mmol/l;
 Total iron binding capacity of
blood serum - no more than 60
µmol/l;
 The saturation factor of
transferrin is more than 17%.
 Protein-deficient anemia
 Accompanies kwashiorkor - disease
protein calorie fasting
 Pathogenesis: reduced production of
erythropoietin by the kidneys, which
leads to a decrease in erythropoiesis
 Protein deficiency affects the activity of
enzymes (disturbed absorption of iron
and vitamins in the intestine)
 Clinical implications
 More common in children 1-4 years
 Growth lag
 Anorexia, vomiting, diarrhea
 Skin pale, pasty, foci of
depigmentation,
hyperpigmentation, dryness
 Brittle hair, blepharitis
 Tissue turgor is reduced
 Hepatomegaly, rarely splenomegaly
 Hemoglobin levels are 40-90 g/l
 Life expectancy of red blood cells
reduced by 2 times
 The number of reticulocytes is not
increased
 Treatment
 Dietotherapy
 Rational mode with sufficient stay in the
fresh air
 Appointment of iron preparations
 Appointment of b vitamins (B1, B6,
B12, folic acid), C
 The forecast is favorable
 B12-deficiency anemia
Megaloblastic anemia, characterized
by the appearance of megaloblasts in
the bone marrow and macrocytes in
the blood, premature intraosseous
destruction of erythro-and
normoblasts, accompanied by
moderate leukopenia and
thrombocytopenia
 Etiology
 Insufficient intake of vitamin from food
(less than 1 mg per day)
 Insufficient absorption due to hereditary
or acquired enzyme deficiency or
malabsorption
 Vit B12 is found only in foods of animal
origin
 Pathogenesis
 When vitamin B12 deficiency is a
violation of DNA synthesis, slows down
the process of maturation of
hematopoietic cells, which is expressed
in megaloblastic hematopoiesis
 Suffers not only erythropoiesis, but
granulocyte and thrombocytopoiesis
 Clinical implications
 Asthenia
 Pale skin with lemon-yellow tint
 Subicteric sclera
 Moderate hepatomegaly, less often
- splenomegaly
 Glossitis, aphthae, the formation of
a “lacquered tongue”
 In the long course of anemia -
functional myocardial insufficiency
due to eating disorders of the heart
muscle and its fat degeneration
 Acidity of gastric juice and pepsin
content in it are sharply reduced
 In the period of exacerbation of the
disease due to increased hemolysis
may increase the temperature
 Laboratory diagnosis of B12-
deficiency anemia

 General blood test: basophilic

granularity of erythrocytes,
poikilocytosis and macrocytosis,
nuclear forms of erythroblasts -
megaloblasts, moderate
leukocytopenia and
thrombocytopenia are possible.
Giant forms of neutrophils with
hypersegmentation of nuclei are
characteristic.
 Bone marrow puncture - content
of myelokaryocytes in bone marrow
punctate elevated, dominated by
erythroid elements.
 Increased urinary excretion of
methylmalonic acid,
 Increase in serum
concentration of unconjugated
bilirubin (up to 50 µmol/l),
 5. Reduction of haptoglobin
content,
 6. Increased serum activity of
many red blood cell enzymes.
 7. The concentration of iron in the
blood serum increases to 46 µmol/l;
the concentration of vitamin B12 in
the blood serum is reduced (less than
100 pg/ml).
 Treatment of B12-
deficiency anemia
 Elimination of the cause of B12-
insufficiency: the appointment of an
adequate diet containing vitamin B12,
the exclusion of food products that cause
diarrhea in celiac disease, antibacterial
treatment for gastrointestinal diseases,
the appointment of bifidum- or
lactobacillus to restore normal intestinal
flora, treatment of diseases that led to a
violation of the absorption of vitamin B12
 Intramuscular administration
of vitamin B12 in the dose of
saturation: daily intramuscular
injection of cyanocobalamin 100-
200 mg for 5-7 days before the
appearance of reticulocytic crisis,
and then a day later - before
receiving hematological remission.
 The duration of the course is 2-4
weeks.
Hematological remission criteria:
1) appearance reticulocytes reaction;
2) normalization of bone marrow
hematopoiesis;
3) normalization of peripheral blood
pattern;
4) normal serum levels of vitamin
B12.
 Folio-deficiency anemia

 Megaloblastic anemia,
characterized by a violation of
erythro-, granulo- and
thrombocytopoiesis
 The body receives folic acid from
food, partially synthesized by the
flora of the gastrointestinal tract
The reasons for the development
folio-deficiency anemia
 Inadequate nutrition (feeding goat
milk, improper heat treatment of
food, the appointment of specific
diets in phenylketonuria without
correction of folic acid)
 Malabsorption: hereditary,
acquired, due to medication
 Increased need (for sepsis,
thyrotoxicosis, malignant tumors,
pneumonia and other infections)
 Metabolic disorder
 Increased excretion (chronic
dialysis, liver and heart disease,
vitamin B12 deficiency)
 Clinical picture
 Symptoms are similar to
manifestations in B12-deficiency
anemia
 The lag in physical development
 With congenital folic acid deficiency
- mental retardation
 Diagnostics

 The morphological picture of

peripheral blood and bone marrow
is similar to that of vitamin B12
deficiency
 Leukopenia and thrombocytopenia,
moderate
 The concentration of folic acid in
blood serum and erythrocytes is
reduced
 Treatment

 Diet correction (introduction of

products containing folic acid:
liver, green leafy vegetables)
 Treatment of the underlying
disease
 Administration of folic acid
preparations at a dose of 2-4 mg/
kg per day for at least 3-4 weeks
(fefol, ferrograd folic, leucovorin)
 Vitamin E-deficiency anemia

 Vitamin E is found mainly in plants,

vegetable oil, as well as in milk,
eggs, meat products
 The concentration of vitamin E in
breast milk is 10 times higher than
in cow's milk
 The absorption of vitamin E is
disturbed in children born in
asphyxia, with CNS injury, with
infectious diseases
 Chronic vitamin E deficiency occurs
in patients with hypotrophy, cystic
fibrosis, extended resection of the
small intestine, heart failure, liver
disease and biliary atresia
 Vitamin E - antioxidant
 Causes stabilization of the cell and
subcellular membranes, protects
them from oxidation
 Stimulates the synthesis of heme
and heme-containing enzymes
 As a result, oxidative and synthetic
processes in tissues are improved
 laboratory diagnostics
 Characterized by a decrease in the
number of red blood cells and
hemoglobin
 Moderate anisocytosis, poikilocytosis
 Reticulocytosis
 Shortening the life expectancy of red
blood cells
 Reduced concentration of alpha-
tocopherol in blood plasma
 Elevated hemolytic test of red blood
cells with hydrogen peroxide
 Treatment

 Vitamin E is prescribed in the form of

a 5% solution of tocopherol acetate
in oil through the mouth or in/m for
5-10 mg per day for 1.5-2 weeks
 Hematological improvement - 5-7
days after the start of treatment
 The course and prognosis of vitamin
E-deficiency anemia favorable