Anemia

Download as docx, pdf, or txt
Download as docx, pdf, or txt
You are on page 1of 21

Anemia (pronounced / ni mi /, also spelled anaemia or anmia; from Ancient Greek anaimia, meaning "lack of blood") is a decrease in normal

number of red blood cells (RBCs) or less than the normal quantity of hemoglobin in the blood.[1][2] However, it can include decreased oxygen-binding ability of each hemoglobin molecule due to deformity or lack in numerical development as in some other types of hemoglobin deficiency. Since hemoglobin (found inside RBCs) normally carries oxygen from the lungs to the tissues, anemia leads to hypoxia (lack of oxygen) in organs. Since all human cells depend on oxygen for survival, varying degrees of anemia can have a wide range of clinical consequences. The three main classes of anemia include [3 Hs] excessive blood loss (acutely such as a hemorrhage or chronically through low-volume loss), excessive blood cell destruction (hemolysis) or deficient red blood cell production (ineffective hematopoiesis). Anemia is the most common disorder of the blood. There are several kinds of anemia, produced by a variety of underlying causes. Anemia can be classified in a variety of ways, based on the morphology of RBCs, underlying etiologic mechanisms, and discernible clinical spectra, to mention a few. There are two major approaches: the "kinetic" approach which involves evaluating production, destruction and loss[3], and the "morphologic" approach which groups anemia by red blood cell size. The morphologic approach uses a quickly available and cheap lab test as its starting point (the MCV). On the other hand, focusing early on the question of production may allow the clinician more rapidly to expose cases where multiple causes of anemia coexist.

Contents
[hide]
y y y

y y

1 Signs and symptoms 2 Diagnosis 3 Classification o 3.1 Production vs. destruction or loss o 3.2 Red blood cell size  3.2.1 Microcytic anemia  3.2.2 Macrocytic anemia  3.2.3 Normocytic anemia  3.2.4 Dimorphic anemia  3.2.5 Heinz body anemia 4 Cause 5 Possible complications

y y

y y y

6 Anemia during pregnancy 7 Treatments o 7.1 Blood transfusions o 7.2 Hyperbaric oxygen 8 See also 9 References 10 External links

[edit] Signs and symptoms

Main symptoms that may appear in anemia.[4] Anemia goes undetected in many people, and symptoms can be minor or vague. The signs and symptoms can be related to the anemia itself, or the underlying cause. Most commonly, people with anemia report non-specific symptoms of a feeling of weakness, or fatigue, general malaise and sometimes poor concentration. They may also report shortness of breath, dyspnea, on exertion. In very severe anemia, the body may compensate for the lack of oxygen carrying capability of the blood by increasing cardiac output. The patient may have symptoms related to this, such as palpitations, angina (if preexisting heart disease is present), intermittent claudication of the legs, and symptoms of heart failure. On examination, the signs exhibited may include pallor (pale skin, mucosal linings and nail beds) but this is not a reliable sign. There may be signs of specific causes of anemia, e.g., koilonychia (in iron deficiency), jaundice (when anemia results from abnormal break down of red blood cells in hemolytic anemia), bone deformities (found in thalassaemia major) or leg ulcers (seen in sickle cell disease). In severe anemia, there may be signs of a hyperdynamic circulation: a fast heart rate (tachycardia), flow murmurs, and cardiac enlargement. There may be signs of heart failure.

Pica, the consumption of non-food based items such as dirt, paper, wax, grass, ice, and hair, may be a symptom of iron deficiency, although it occurs often in those who have normal levels of hemoglobin. Chronic anemia may result in behavioral disturbances in children as a direct result of impaired neurological development in infants, and reduced scholastic performance in children of school age. Restless legs syndrome is more common in those with iron deficiency anemia. Less common symptoms may include swelling of the legs or arms, chronic heartburn, vague bruises, vomiting, increased sweating, and blood in stool.

[edit] Diagnosis
Generally, clinicians request complete blood counts in the first batch of blood tests in the diagnosis of an anemia. Apart from reporting the number of red blood cells and the hemoglobin level, the automatic counters also measure the size of the red blood cells by flow cytometry, which is an important tool in distinguishing between the causes of anemia. Examination of a stained blood smear using a microscope can also be helpful, and is sometimes a necessity in regions of the world where automated analysis is less accessible. In modern counters, four parameters (RBC count, hemoglobin concentration, MCV and RDW) are measured, allowing others (hematocrit, MCH and MCHC) to be calculated, and compared to values adjusted for age and sex. Some counters estimate hematocrit from direct measurements. WHO's Hemoglobin thresholds used to define anemia[5] (1 g/dL = 0.6206 mmol/L)[citation needed] Age or gender group Hb threshold (g/dl) Hb threshold (mmol/l) Children (0.55.0 yrs) 11.0 6.8 Children (512 yrs) Children (1215 yrs) Women, non-pregnant (>15yrs) Women, pregnant Men (>15yrs) 11.5 12.0 12.0 11.0 13.0 7.1 7.4 7.4 6.8 8.1

Reticulocyte counts, and the "kinetic" approach to anemia, have become more common than in the past in the large medical centers of the United States and some other wealthy nations, in part because some automatic counters now have the capacity to include reticulocyte counts. A reticulocyte count is a quantitative measure of the bone marrow's production of new red blood cells. The reticulocyte production index is a calculation of the ratio between the level of anemia and the extent to which the reticulocyte count has risen in response. If the degree of anemia is significant, even a "normal" reticulocyte count actually may reflect an inadequate response.

If an automated count is not available, a reticulocyte count can be done manually following special staining of the blood film. In manual examination, activity of the bone marrow can also be gauged qualitatively by subtle changes in the numbers and the morphology of young RBCs by examination under a microscope. Newly formed RBCs are usually slightly larger than older RBCs and show polychromasia. Even where the source of blood loss is obvious, evaluation of erythropoiesis can help assess whether the bone marrow will be able to compensate for the loss, and at what rate. When the cause is not obvious, clinicians use other tests: ESR, ferritin, serum iron, transferrin, RBC folate level, serum vitamin B12, hemoglobin electrophoresis, renal function tests (e.g. serum creatinine). When the diagnosis remains difficult, a bone marrow examination allows direct examination of the precursors to red cells.

[edit] Classification
[edit] Production vs. destruction or loss
The "kinetic" approach to anemia yields what many argue is the most clinically relevant classification of anemia. This classification depends on evaluation of several hematological parameters, particularly the blood reticulocyte (precursor of mature RBCs) count. This then yields the classification of defects by decreased RBC production versus increased RBC destruction and/or loss. Clinical signs of loss or destruction include abnormal peripheral blood smear with signs of hemolysis; elevated LDH suggesting cell destruction; or clinical signs of bleeding, such as guiaic-positive stool, radiographic findings, or frank bleeding. The following is a simplified schematic of this approach: Anemia Reticulocyte production index shows inadequate production response to anemia. No clinical findings consistent with hemolysis or blood loss: pure disorder of production. Macrocytic anemia (MCV>100) Clinical findings and abnormal MCV: hemolysis or loss and chronic disorder of production*. Normocytic anemia (80<MCV<100) Reticulocyte production index shows appropriate response to anemia = ongoing hemolysis or blood loss without RBC production problem. Clinical findings and normal MCV= acute hemolysis or loss without adequate time for bone marrow production to compensate**. Microcytic anemia (MCV<80)

* For instance, sickle cell anemia with superimposed iron deficiency; chronic gastric bleeding with B12 and folate deficiency; and other instances of anemia with more than one cause. ** Confirm by repeating reticulocyte count: ongoing combination of low reticulocyte production index, normal MCV and hemolysis or loss may be seen in bone marrow failure or anemia of chronic disease, with superimposed or related hemolysis or blood loss.

[edit] Red blood cell size


In the morphological approach, anemia is classified by the size of red blood cells; this is either done automatically or on microscopic examination of a peripheral blood smear. The size is reflected in the mean corpuscular volume (MCV). If the cells are smaller than normal (under 80 fl), the anemia is said to be microcytic; if they are normal size (80100 fl), normocytic; and if they are larger than normal (over 100 fl), the anemia is classified as macrocytic. This scheme quickly exposes some of the most common causes of anemia; for instance, a microcytic anemia is often the result of iron deficiency. In clinical workup, the MCV will be one of the first pieces of information available; so even among clinicians who consider the "kinetic" approach more useful philosophically, morphology will remain an important element of classification and diagnosis. Here is a schematic representation of how to consider anemia with MCV as the starting point: Anemia Macrocytic anemia (MCV>100) High reticulocyte count Microcytic anemia (MCV<80) Low reticulocyte count Normocytic anemia (80<MCV<100)

Other characteristics visible on the peripheral smear may provide valuable clues about a more specific diagnosis; for example, abnormal white blood cells may point to a cause in the bone marrow. [edit] Microcytic anemia Main article: Microcytic anemia Microcytic anemia is primarily a result of hemoglobin synthesis failure/insufficiency, which could be caused by several etiologies:
y

Heme synthesis defect o Iron deficiency anemia o Anemia of chronic disease (more commonly presenting as normocytic anemia)

Globin synthesis defect o alpha-, and beta-thalassemia o HbE syndrome o HbC syndrome o and various other unstable hemoglobin diseases Sideroblastic defect o Hereditary sideroblastic anemia o Acquired sideroblastic anemia, including lead toxicity o Reversible sideroblastic anemia

Iron deficiency anemia is the most common type of anemia overall and it has many causes. RBCs often appear hypochromic (paler than usual) and microcytic (smaller than usual) when viewed with a microscope.
y

Iron deficiency anemia is caused by insufficient dietary intake or absorption of iron to replace losses from menstruation or losses due to diseases.[6] Iron is an essential part of hemoglobin, and low iron levels result in decreased incorporation of hemoglobin into red blood cells. In the United States, 20% of all women of childbearing age have iron deficiency anemia, compared with only 2% of adult men. The principal cause of iron deficiency anemia in premenopausal women is blood lost during menses. Studies[who?] have shown that iron deficiency without anemia causes poor school performance and lower IQ in teenage girls. Iron deficiency is the most prevalent deficiency state on a worldwide basis. Iron deficiency is sometimes the cause of abnormal fissuring of the angular (corner) sections of the lips (angular stomatitis). Iron deficiency anemia can also be due to bleeding lesions of the gastrointestinal tract. Faecal occult blood testing, upper endoscopy and lower endoscopy should be performed to identify bleeding lesions. In men and post-menopausal women the chances are higher that bleeding from the gastrointestinal tract could be due to colon polyp or colorectal cancer. Worldwide, the most common cause of iron deficiency anemia is parasitic infestation (hookworm, amebiasis, schistosomiasis and whipworm).[7]

[edit] Macrocytic anemia Main article: Macrocytic anemia


y

Megaloblastic anemia, the most common cause of macrocytic anemia, is due to a deficiency of either vitamin B12, folic acid (or both). Deficiency in folate and/or vitamin B12 can be due either to inadequate intake or insufficient absorption. Folate deficiency normally does not produce neurological symptoms, while B12 deficiency does. o Pernicious anemia is caused by a lack of intrinsic factor. Intrinsic factor is required to absorb vitamin B12 from food. A lack of intrinsic factor may arise from an autoimmune condition targeting the parietal cells (atrophic gastritis) that produce intrinsic factor or against intrinsic factor itself. These lead to poor absorption of vitamin B12.

y y y

Macrocytic anemia can also be caused by removal of the functional portion of the stomach, such as during gastric bypass surgery, leading to reduced vit B12/folate absorption. Therefore one must always be aware of anemia following this procedure. Hypothyroidism Alcoholism commonly causes a macrocytosis, although not specifically anemia. Other types of Liver Disease can also cause macrocytosis. Methotrexate, zidovudine, and other drugs that inhibit DNA replication.
o

Macrocytic anemia can be further divided into "megaloblastic anemia" or "non-megaloblastic macrocytic anemia". The cause of megaloblastic anemia is primarily a failure of DNA synthesis with preserved RNA synthesis, which result in restricted cell division of the progenitor cells. The megaloblastic anemias often present with neutrophil hypersegmentation (610 lobes). The nonmegaloblastic macrocytic anemias have different etiologies (i.e. there is unimpaired DNA globin synthesis,) which occur, for example in alcoholism. In addition to the non-specific symptoms of anemia, specific features of vitamin B12 deficiency include peripheral neuropathy and subacute combined degeneration of the cord with resulting balance difficulties from posterior column spinal cord pathology.[8] Other features may include a smooth, red tongue and glossitis. The treatment for vitamin B12-deficient anemia was first devised by William Murphy who bled dogs to make them anemic and then fed them various substances to see what (if anything) would make them healthy again. He discovered that ingesting large amounts of liver seemed to cure the disease. George Minot and George Whipple then set about to chemically isolate the curative substance and ultimately were able to isolate the vitamin B12 from the liver. All three shared the 1934 Nobel Prize in Medicine.[9] [edit] Normocytic anemia Main article: Normocytic anemia Normocytic anemia occurs when the overall hemoglobin levels are always decreased, but the red blood cell size (Mean corpuscular volume) remains normal. Causes include:
y y y y

Acute blood loss Anemia of chronic disease Aplastic anemia (bone marrow failure) Hemolytic anemia

[edit] Dimorphic anemia When two causes of anemia act simultaneously, e.g., macrocytic hypochromic, due to hookworm infestation leading to deficiency of both iron and vitamin B12 or folic acid [10] or following a blood transfusion more than one abnormality of red cell indices may be seen. Evidence for

multiple causes appears with an elevated RBC distribution width (RDW), which suggests a wider-than-normal range of red cell sizes. [edit] Heinz body anemia Heinz bodies form in the cytoplasm of RBCs and appear like small dark dots under the microscope. There are many causes of Heinz body anemia, and some forms can be drug induced. It is triggered in cats by eating onions[11] or acetaminophen (Tylenol). It can be triggered in dogs by ingesting onions or zinc, and in horses by ingesting dry red maple leaves.

[edit] Cause
y y y y

y y y y y y

Anemia of prematurity occurs in premature infants at 2 to 6 weeks of age and results from diminished erythropoietin response to declining hematocrit levels. Aplastic anemia is a condition generally unresponsive to anti-anemia therapies where bone marrow fails to produce enough red blood cells. Fanconi anemia is a hereditary disorder or defect featuring aplastic anemia and various other abnormalities. Hemolytic anemia causes a separate constellation of symptoms (also featuring jaundice and elevated LDH levels) with numerous potential causes. It can be autoimmune, immune, hereditary or mechanical (e.g. heart surgery). It can result (because of cell fragmentation) in a microcytic anemia, a normochromic anemia, or (because of premature release of immature red blood cells from the bone marrow), a macrocytic anemia. Hereditary spherocytosis is a hereditary defect that results in defects in the RBC cell membrane, causing the erythrocytes to be sequestered and destroyed by the spleen. This leads to a decrease in the number of circulating RBCs and, hence, anemia. Sickle-cell anemia, a hereditary disorder, is due to homozygous hemoglobin S genes. Warm autoimmune hemolytic anemia is an anemia caused by autoimmune attack against red blood cells, primarily by IgG. Cold agglutinin hemolytic anemia is primarily mediated by IgM. Pernicious anemia is a form of megaloblastic anemia due to vitamin B12 deficiency dependent on impaired absorption of vitamin B12. Myelophthisic anemia or Myelophthisis is a severe type of anemia resulting from the replacement of bone marrow by other materials, such as malignant tumors or granulomas. Anemia of Pregnancy is anemia that is induced by blood volume expansion experienced in pregnancy.

[edit] Possible complications


Anemia diminishes the capability of affected individuals to perform physical activities, a result of one's muscles being forced to depend on anaerobic metabolism. The lack of iron associated with anemia can cause many complications, including hypoxemia, brittle or rigid fingernails, cold intolerance, and possible behavioral disturbances in children. Hypoxemia resulting from anemia can worsen the cardio-pulmonary status of patients with pre-existing chronic pulmonary

disease. Cold intolerance occurs in one in five patients with iron deficiency anemia, and becomes visible through numbness and tingling.[citation needed]

[edit] Anemia during pregnancy


Anemia affects 20 percent of all women of childbearing age in the United States[citation needed]. Due to the subtlety of the symptoms, affected women are often unaware that they have this disorder, as they attribute the symptoms to the stresses of their daily lives. Possible problems for the fetus include increased risk of growth retardation, prematurity, intrauterine death, rupture of the amnion and infection. An expectant woman should be especially aware of the symptoms of anemia, as an adult female loses an average of two milligrams[citation needed] of iron daily. Therefore, she must intake a similar quantity of iron in order to compensate for this loss. Additionally, a woman loses approximately 500 milligrams[citation needed] of iron with each pregnancy, compared with a loss of 4100 milligrams[citation needed] of iron with each period. Possible consequences include cardiovascular symptoms, reduced physical and mental performance, reduced immune function, fatigue, reduced peripartal blood reserves and increased need for blood transfusion in the postpartum period. This may severely affect the health of the child.

[edit] Treatments
There are many different treatments for anemia and the treatment depends on severity and the cause. Iron deficiency from nutritional causes is rare in non-menstruating adults (men and postmenopausal women). The diagnosis of iron deficiency mandates a search for potential sources of loss such as gastrointestinal bleeding from ulcers or colon cancer. Mild to moderate iron deficiency anemia is treated by oral iron supplementation with ferrous sulfate, ferrous fumarate, or ferrous gluconate. When taking iron supplements, it is very common to experience stomach upset and/or darkening of the feces. The stomach upset can be alleviated by taking the iron with food, however this decreases the amount of iron absorbed. Vitamin C aids in the body's ability to absorb iron, so taking oral iron supplements with orange juice is of benefit. Vitamin supplements given orally (folic acid) or subcutaneously (vitamin B-12) will replace specific deficiencies. In anemia of chronic disease, anemia associated with chemotherapy, or anemia associated with renal disease, some clinicians prescribe recombinant erythropoietin, epoetin alfa, to stimulate red cell production. In severe cases of anemia, or with ongoing blood loss, a blood transfusion may be necessary.

[edit] Blood transfusions

Doctors attempt to avoid blood transfusion in general, since multiple lines of evidence point to increased adverse patient clinical outcomes with more intensive transfusion strategies. The physiological principle that reduction of oxygen delivery associated with anemia leads to adverse clinical outcomes is balanced by the finding that transfusion does not necessarily mitigate these adverse clinical outcomes. In severe, acute bleeding, transfusions of donated blood are often lifesaving. Improvements in battlefield casualty survival is attributable, at least in part, to the recent improvements in blood banking and transfusion techniques.[citation needed] Transfusion of the stable but anemic hospitalized patient has been the subject of numerous clinical trials, and transfusion is emerging as a deleterious intervention. Four randomized controlled clinical trials have been conducted to evaluate aggressive versus conservative transfusion strategies in critically ill patients. All four of these studies failed to find a benefit with more aggressive transfusion strategies.[12][13][14][15] In addition, at least two retrospective studies have shown increases in adverse clinical outcomes with more aggressive transfusion strategies.[16][17]

[edit] Hyperbaric oxygen


Treatment of exceptional blood loss (anemia) is recognized as an indication for hyperbaric oxygen (HBO) by the Undersea and Hyperbaric Medical Society.[18][19] The use of HBO is indicated when oxygen delivery to tissue is not sufficient in patients who cannot be transfused for medical or religious reasons. HBO may be used for medical reasons when threat of blood product incompatibility or concern for transmissible disease are factors.[18] The beliefs of some religions (ex: Jehovah's Witnesses) may prohibit the receipt of transfused blood products.[18] In 2002, Van Meter reviewed the publications surrounding the use of HBO in severe anemia and found that all publications report a positive result.[20] Anemia and the Breastfeeding Woman Written by Cheryl Renfree Scott RN, PhD, IBCLC, 2004 Anemia is a common complication for lactating mothers, partly as a result of the high incidence of anemia in pregnancy. It is estimated that 33% of American women are anemic in their pregnancy. A study was conducted at a large private urban hospital in the north central United States, exploring the relationship between anemia and insufficient milk supply with 630 first time mothers. The frequency of anemia was 22% of mothers with postpartum hemoglobin of <10g/dL. Anemic mothers reported a higher level of symptomatology associated with low milk supply and were more frequently classified as having insufficient milk syndrome.

Mothers with the syndrome reported a shorter period of full breastfeeding, and weaned at an earlier age. They identified not having enough milk, baby nursing too often, and baby not gaining enough weight as the main reasons for discontinuing breastfeeding. Anemic mothers reported that not enough milk was the main reason for weaning more often than nonanemic mothers in both groups. The study results suggest that anemia is associated with the development of insufficient milk, which in turn is related to duration of full breastfeeding and to age at weaning (27). The data reported in this study suggests that anemia, an important indicator of maternal health, is associated with the development of insufficient milk. Insufficient milk, in turn, was related to duration of full breastfeeding and even more dramatically to age at weaning. In this study breastfeeding durations were shorter for anemic than for nonanemic mothers. There is a consensus in the literature that breastfeeding women worldwide cite insufficient milk as a primary reason for early weaning and introducing human milk substitutes into their babies diets.

Misconception of Probable Insufficient Milk Supply


In contrast to the above-mentioned consensus in the literature, scientific understanding of insufficient milk reflects diversity of opinion about the nature of the phenomenon. A critical conceptual issue revolves around the veracity of maternal reporting of insufficient milk: Is there really not enough milk, or do womens reports reflect a misperception of insufficiency? This study indicates a belief in the reality of the syndrome since the indicators such as impressive display of hunger cues by the baby or slow infant weight gain suggest that the baby actually receives insufficient milk. Insufficient milk can be considered a continuous variable or a discrete phenomenon reflecting a syndrome. (27) Interestingly, in the study of first time breastfeeding mothers studying the correlation of anemia and insufficient milk supply, mothers without the syndrome listed employment conflicts, infant disinterest and time seemed right as the primary reasons for weaning. The anemic mothers reported that not enough milk was the main reason for weaning more often than nonanemic mothers.

Iron Deficiency Anemia


While there are many causes for anemia, the most common reason for lactating and pregnant women is iron deficiency. Iron deficiency is the most common cause of anemia in women of childbearing age worldwide. Anemia is the reduction in either the number of red blood cells or the amount of hemoglobin (iron containing portion) of the red blood cells. This results in a decrease in the amount of oxygen available to the cells of the body. As a result, they have less energy available to perform their normal functions. Important process such as muscular activity and cell building and repair slow down and become less efficient. Iron deficiency can lead to impaired delivery of oxygen to

the tissues, to anemia, impaired immune function, decreased energy levels, and to decreased physical performance. Anemia is the last stage of iron deficiency. Iron-dependent enzymes involved in energy production and metabolism are the first to be affected by low iron levels. Iron is an important factor in anemia because iron is used to make hemoglobin, which is the component of red blood cells that attaches to oxygen and transports it. Iron deficiency can be caused by insufficient dietary iron intake and or absorption, or by significant blood loss. Iron deficiency is more likely to occur at certain times in life such as infancy, adolescence, pregnancy, and breastfeeding. Pregnant (and consequently lactating) women are amongst the highest groups at risk for iron deficiency. Women become anemic due to the excessive blood losses of menstruation and delivery, increased iron requirements, diminished intake, diminished iron absorption or utilization, or a combination of these factors. Iron deficiency occurs in over 33-58% of young, healthy pregnant women. A mild decrease in hemoglobin is a normal physiologic response to the increases in intravascular volume and demand for erythropoiesis during pregnancy. Anemia occurs with such frequency during pregnancy that it is referred to as the most common medical complication of pregnancy. (28)

Iron Deficiency Anemia and the Breastfeeding Woman


The iron-dependent enzymes involved in energy production and metabolism will be impaired long before anemia occurs. Impaired energy production, lowered energy levels and decreased physical performance may contribute to post-partum depression. Iron deficiency anemia lowers maternal immune response which predisposes the breastfeeding mother to clogged milk ducts, mastitis, thrush, prolonged tissue repair for sore nipple management as well as adversely affecting milk quality and breast milk volume. Anemia is not a disease but actually is a condition that results in a group of symptoms such as weakness, fatigue, vertigo, dizziness, pallor, headache, ringing in the ears, headache, an inability to catch ones breath after physical exertion, and a racing or irregular heart beat. Some women are asymptomatic, but many become tired easily. Anemic mothers are increasingly susceptible to infection, postpartum hemorrhage, and have poor tolerance for even minimal blood loss during birth. (29) For the breastfeeding woman, anemia presents itself as a contributing factor for low milk supply, plugged ducts and mastitis, and delayed healing of sore nipples. Under physiologic conditions, only a small amount of iron is lost from the body each day. The source of these iron losses are: the shedding of epithelial cells from the skin, gastrointestinal tract and the urinary tract; and the excretion of small amounts of iron in the sweat, urine, and bile. Women lose approximately 0.8 mg or iron per day from these sources. (4) Women at the reproductive stage of life are at a higher risk for low iron levels through monthly blood losses. The low level carries over into pregnancy and lactation.

Another group at high risk are women who over-use anti-inflammatories such as aspirin or ibuprofen, as these can cause blood loss through irritation of the digestive tract. The adolescent lactating mother who eats a junk food diet is at an especially high risk for iron deficiency. The daily losses of iron from the body must be replaced by dietary intake of iron.(4) To maintain an adequate iron store, menstruating women need about 1.2-2 mg a day.(5) Lactating women have much greater iron requirements. They need to restore their iron losses from pregnancy and delivery, as well as meet the demands of infant requirement for iron through breast milk. Pregnant women require 5-6 mg of iron per day in the second and third trimester. It is important that a physician for the treatment of anemia perform a thorough clinical evaluation. It is imperative that a comprehensive laboratory analysis of the blood be performed. It is critical that the underlying cause for the anemia be uncovered for appropriate therapy to be instituted.

Absorption of Iron from the Diet


The amount of iron absorbed from the diet depends on the form of iron in the food and the presence of other foods and substances in the diet. Dietary iron is present in two forms: heme and nonheme iron. Heme iron is more readily absorbed than nonheme iron (5,6) and its absorption is not affected by dietary factors. The amount of iron absorbed from heme iron is 5-10 times greater than the amount of iron absorbed from non-heme iron. (7) Heme iron is present in meat, poultry and fish. (8) The absorption of nonheme iron is much more variable than the absorption of heme iron found in meats, and depends on dietary factors. Nonheme iron is found in grains, cereals, eggs, and dairy products. (5,9) Absorption of nonheme is influenced by the presence of other substances in the food.

Substances that inhibit the absorption on noneheme iron include:


y y y y y y y y y y y

Tannins in tea and some vegetables (10,11) Calcium and phosphorus in milk (12) Casein and whey protein in bovine dairy products (13) Polyphenols in some vegetables and legumes, and coffee Phosphoprotein in eggs Phytates in grains, eggs and some vegetables and lentils Presence of other minerals such as calcium, zinc, and cadmium Soy products Wheat and maize flour EDTA, a food preservative (beer, soda, soft drinks, candy bars Foods containing oxalic acid. Oxalic acid interferes with iron absorption. Eat foods containing oxalic acids in moderation or omit them from the diet. Foods high in oxalic

y y

acid include almonds, cashews, chocolate, cocoa, kale, rhubarb, soda, sorrel, spinach, Swiss chard, and most nuts and beans. Avoid using wheat bran as a source of fiber when eating nonheme iron. Iron is removed through the stool, so it is best to not eat foods high in iron take or iron supplements with bran since it will be removed through the stools. Antacids and overuse of calcium supplements also decrease iron absorption. All of these dietary factors can interfere with iron absorption, so that even if a diet is high in iron content, the actual bioavailablility of the iron can be quite low. If a lactating woman is suffering from symptoms associated with iron deficiency anemia, it is advisable for her to avoid these foods for approximately 6 weeks as she rebuilds her iron stores through iron supplementation and dietary practices.(2) The absorption of nonheme iron can be increased by the presence of meat, poultry, fish, and vitamin C in the diet. (14,15,16)

Risk factors for Iron Deficiency


Risk factors for iron-deficiency anemia include these factors: 1. 2. 3. 4. 5. 6. 7. 8. Low dietary intake of iron Low dietary intake of ascorbic acid (Vitamin C) Low dietary intake of meat Blood loss per month or use of more than 12 sanitary pads or tampons per menstrual cycle. Chronic use of aspirin Low socio-economic status: African-American, Hispanic, Native American, Adolescence High parity and multiple gestation (17, 18,12)

Assessment of Anemic Breastfeeding Mother


A thorough assessment of possible anemia is an important breastfeeding history tool for all lactation consultants to incorporate.. Many of the breastfeeding problems that bring a lactating woman to the lactation consultants office or her physicians office are related to iron-deficiency anemia -- sore nipples, exhaustion, plugged ducts, low milk supply, thrush, all these breastfeeding challenges can occur if a lactating mother is experiencing anemia. A thorough health history and a complete physical examination are an essential component of the evaluation of the anemic woman. The purpose of the history and physical exam is to: 1) Determine whether there are signs and symptoms of anemia, 2) determine if the anemia is affecting the womans current health status, 3) refer the woman to her health care provider to determine whether signs and symptoms of possible medical disorders may be causing the anemia, and 4) to determine if there are familial, environmental dietary or medical disorders that may be the cause of the anemia. Suggested questions to include in the breastfeeding history intake questionnaire to determine iron-deficiency anemia and its cause should include:

y y y y

Determine average daily iron intake Determine are there dietary practices that may decrease iron absorption Is excessive blood loss a possible cause of iron deficiency? Gastrointestinal disorders causing blood loss? Intestinal parasites?

It is best to have a complete blood test to determine if you have an iron deficiency before taking iron supplements. Excess iron can damage the liver, heart, pancreas and immune cell activity, and has been linked to cancer. Iron supplements are to be used only under the supervision of a qualified health care provider. Inorganic iron supplements are coming under sever attack as the potential cause of many health problems. Nutritional research journals are showing interesting facts and studies about the side effects of iron tablets. Not only can excess iron accumulate in the body to toxic levels, it may also interfere with immunity and promote cancer. Iron is an important mineral for pregnancy and lactation, the question is only how much iron and in what form.

Dosage
Treatment for iron-deficiency anemia should begin with 60-120mg of elemental iron daily during pregnancy. The supplements should be started gradually, because tolerance to side effects is improved when iron is initiated at a lower dose. The dose should be increased gradually over several days until the full therapeutic dose is achieved. (19) Many clinicians recommend higher dosages of elemental iron but these higher dosages can be problematic with gastrointestinal side effects. The use of high dosages of iron can also decrease the absorption of other important nutrients, such as zinc. (20)

Iron Preparations
There are many types of iron preparations available. When selecting an iron preparation it is good to remember these things:
y y y y

The amount of elemental iron present in the supplement The form of the iron (ferrous or ferric) in the supplement Whether other supplements (vitamins and minerals) are present Whether the preparation is enteric coated or in a delayed-release form

Form of iron
Iron comes in two forms: ferrous or ferric salts. Absorption of iron form the ferrous form is three times greater than the absorption of the ferric. There are several types of ferrous salts available: sulfate, gluconate, fumerate, and succinate. The absorption of each of these salts is roughly equivalent. A recent survey determined that the cost of these varying products were approximately the same.

Handy tips to remember for selection and dosing of iron supplements

y y

y y

y y

Iron is best absorbed when given in a tablet that contains only iron salt. Anemia should not be treated with prenatal vitamin/mineral supplement because the absorption of iron from these supplements is variable and less efficient than the absorption of iron from simple iron preparations. It is best not to take iron supplements that are enteric coated. The enteric-coated preparations are less effective because exposure to gastric juices plays an important role in iron absorption. It is best not to take a time-released iron supplement since the majority of iron absorption occurs in the upper part of the small intestine. The effectiveness of these delayed release forms varies widely. And they are expensive. For the most efficient absorption of iron, it should be taken in a naturally biochelated form, the form that nature supplies. Its best to take the iron supplement on an empty stomach so food components will not interfere with the absorption (as mentioned earlier). When iron supplements are taken with meals, absorption is decreased by 40-50% (19) Dont take iron supplement with coffee, tea or soft drinks since these beverages interfere with iron absorption. If iron assimilation is poor, and iron defiency results, it is best to use a good herbal liver tonic to stimulate digestion and absorption. The Iron-Plus-Calcium Tincture below is one suggestion. Natural iron supplements such as Iron-Plus-Calcium Tincture or spirulina. Floridax Herbs with Iron or Nature Works Herbal Iron, liquid iron supplements made from wildcrafted and organic herbs are available in natural food stores. Women who have trouble swallowing tablets and capsules can be given liquid iron supplements. Since liquid iron supplements can cause staining of teeth, to prevent staining of the teeth these preparations should be diluted in a full glass of water and sipped with a straw.. Avoid swishing before swallowing. Caution mothers to keep iron supplements out of reach of children. In 1991 there were 5,144 cases of pediatric iron poisoning in the US. Iron poisoning can be fatal and there are reports of toddler deaths caused by consumption of prenatal iron supplements. (21) The two best times to take iron supplementation is upon waking up after the night fast and before bedtime. Iron is better tolerated if it is taken at bedtime. (12) And last but not least, cooking foods in the good old-fashioned iron skillet provides maternal blood with an extra boost of iron.

Iron-Plus-Calcium Tincture
Also a Tincture for the Liver and Digestion 3 parts nettle 2 parts yellow dock root 1 part watercress 2 parts spirulina 1 part kelp 1 part lambs quarter

Easing Side Effects of Supplemental Iron


Side effects of oral iron therapy include heartburn, diarrhea, bloating, abdominal cramping, nausea and gastrointestinal upset. About 12% of patients experience side effects from oral iron therapy. (19) These tips will help offset these discomforts:
y y y

Take iron supplement at bedtime, it is better tolerated at bedtime. Reduce the dose of elemental iron since the side effects are related to the dose. Switch to a supplement with a lower concentration of elemental iron in the supplement such as ferrous gluconate or ferrous lactate. (22)

Maintenance of Iron Replacement Therapy


Even though most iron deficiency anemias are usually resolved in six to eight weeks (23), iron therapy should be continued after the hemoglobin returns to normal to replenish iron stores. After the resolution of the anemia, iron is usually supplemented for three to six months. (19, 24) Another option is to have the mothers primary physician monitor serum ferritin levels monthly and continue treatment until the serum ferritin is greater than 50g/ L. (24)

Nutritional Support
Increasing iron levels in the food a breastfeeding mother eats may help partially or completely overcome poor iron absorption. Iron is readily available in dark, leafy vegetables and in dark-red vegetables such as red chard, beets and red cabbage. It is found abundantly in black strap molasses, apples, dried apricots, asparagus, bananas, broccoli, egg yolks, organ meats, lean meat, shell fish, kelp, leafy greens, okra, parsley, peas, plums, prunes, purple grapes, raisins, rice bran, squash, turnip greens, whole grains, and yams. It is good to eat foods high in Vitamin C to enhance iron absorption. Vitamin C supplementation has been shown to greatly enhance the absorption of dietary iron. (1) Vitamin C alone will often increase body iron stores. 500mg of vitamin C with every meal will assist with the absorption of dietary iron. Calf liver: Probably one of the best sources of natural iron available, it is rich not only in iron but also in the B-vitamins that stimulate red blood cell production, in addition to other vitamins and minerals. 4 to 6 oz of calf liver per day is recommended. Liquefied liver extracts are an even better source of highly bioavailable nutrients than regular liver. These extracts have the benefits of liver but are free of fats, cholesterol, and fat-soluble vitamins. The recommended dosage for a high-quality aqueous (hydrolyzed) liver extract would be 4 to 6 mg of heme iron content. Green Leafy Vegetables: Green leafy vegetables are a benefit for any type of anemia. These vegetables contain natural fat-soluble chlorophyll as well as other important nutrients, including iron and folic acid. The chlorophyll is similar to the hemoglobin. Black Strap Molasses: 1 Tablespoon of Black Strap Molasses twice daily is highly recommended because it is a good source of iron and B vitamins.

In addition to black strap molasses, Brewers yeast is another good food supplement. Use as directed on the label. Brewers yeast is rich in basic nutrients, is an excellent source of protein and a good source of B vitamins, amino acids and minerals. It is one of the best immune-enhancing supplements available in food form. It helps speed wound healing through an increase in the production of collagen. It has antioxidant properties to allow the tissues to take in more oxygen for healing. (3) Brewers Yeast also contains naturally occurring nucleic acids (DNA and RNA), that are said to enhance the activity of the immune system. Brewers yeast is not toxic and can be taken daily without any side effects. Brewers yeast comes in tablets and powder form. It can be sprinkled on food or drink. Other tips to remember that enhances iron absorption include:
y y y

Eat low-mercury fish at the same time as vegetables containing iron (this increases iron absorption) Omitting all sugar from the diet increases iron absorption as well. Avoid drinking black tea, coffee or soda at mealtimes as this interferes with iron absorption.

Recommended Vitamin and Mineral Supplementation


The following supplements can be used by breastfeeding mothers to treat iron deficiency: Use Ferrous Gluconate, Iron Succinate or Iron fumarate twice per day between meals. If this results in abdominal discomfort, take 30 mg with meals three times per day. Or: Floridax Iron, or +Herbs from Salus Haus contains a readily absorbable form of iron that is nontoxic and a natural source. Vitamin C: 3,000 to 10,000 mg daily (1,000mg 3X a day with meals) Use it with iron supplement to enhance absorption. Folic Acid: 800 mcg to 1,200mg daily. Is needed for red blood cell formation. Vitamin B12: 2,000mcg 3 times daily. Vegetarians should take extra B12 daily. It is essential for red blood cell production. It breaks down and prepares protein for cellular use. Vitamin B complex: Take 50 mg 3 times daily Vitamin B5 100mg daily. It is important in red blood cell production. Vitamin B6 (pyridoxine) Take100 mg daily. It is involved with cellular reproduction.

The following herbs are all good for anemia: Alfalfa, bilberry, cherry, dandelion, grape skins, hawthorn berry, mullein, nettle, Oregon grape root, red raspberry, shepherds purse, watercress Nettle tea is rich in iron; drink it daily. Beet and carrot juice are excellent to help treat anemia.

Homeopathic Remedies
Ferr.phos. (Ferrum phosphoricum, iron phosphate) helps assimilation of iron from food. Nat.mur.(Natrum muriaticum) Take for anemia with constipation, headache and a tendency to cold sores.

Post Partum Anemia


by Pattie Hughes | More from this Blogger 19 Nov 2008 06:10 PM Post partum anemia is a relatively common problem. According to research by the Guttmacher Institute, approximately 27 percent of women experience post partum anemia. The condition may be diagnosed shortly after your baby's birth or later at the post partum visit. Fatigue is the most common symptom of post partum anemia. All new mothers are tired, but most are feeling better by the post partum checkup. Women with post partum anemia are still exhausted at the six week mark. If you are still experiencing extreme tiredness and it is affecting your ability to go about your daily routine, mention it to your midwife or doctor at your post partum visit. Two factors that may increase the likelihood of post partum anemia are anemia in late pregnancy and excessive blood loss during the birth. Like many complications of pregnancy, the best treatment for post partum anemia is to prevent it from occurring in the first place. If you are pregnant and have been diagnosed with anemia, your health care provider may have you increase your intake of iron rich foods and possibly take a supplement. Iron rich foods include beef, turkey, clams, oysters, asparagus, beans and baked potato with the skin. Certain foods enhance the absorption of iron, including strawberries, grapefruit and oranges. Your doctor may recommend taking your iron supplements with orange juice to enhance the absorption. Don't take it with milk, since this will reduce the absorption. I had been taking my pill at breakfast with a big glass of milk, until a nurse gave me that tip.

All pregnant women should work to build up their iron during pregnancy, even if you are not diagnosed with anemia during pregnancy. This can help prevent problems in late pregnancy, after the birth and can reduce your risk of post partum anemia after your baby is born. If you have anemia during pregnancy or experience blood loss during the birth of your baby, your doctor will check your hemoglobin and iron level to determine the best course of treatment. In extreme cases, a blood transfusion may be necessary. In most cases, supplements, injections or intravenous iron treatment may be given. I had IV iron with my last baby was born via c section. It brings up the iron level much faster than supplements, although you may be told to continue to take these as well. Related Articles: New Survey Offers Startling Insight into the Postpartum Period What is a Postpartum Doula? Natural Remedies to Aid in Postpartum Healing

Share and Enjoy:


y y y y y y

Learn more about Pattie Hughes

Pattie Hughes is a freelance writer and mother of four young children. She and her husband have been married since 1992. Pattie holds a degree in Elementary Education from Florida Atlantic University. View Full Profile | More from this Blogger

Relevantpregnancy tags

children | baby | sex | holidays | pregnancy | relationships | christmas | parenting | Kids | family

User Comments

No comments on this article yet. Be the first to comment!

You might also like