Nutritional Anemia New(s)

NUTRITIONAL ANEMIA
DR SREERAJ R
ANEMIA
Anemia is present when the hemoglobin level is

more than two standard deviations below the
mean for the child's age and sex
CUTOFFS FOR HEMOGLOBIN
(WHO DEFINITION ANEMIA)
Children ,6month -5years<11g/dl
Children,5-11 yrs <11.5

Children,12-13 yrs <12 <12
Men <13
Non pregnant Women <12
Pregnant women <11

ANEMIA GRADING
• Mild – 10 -10.9g/dl
• Moderte- 7-9.9
• Severe -<7
CAUSES OF NUTRTITIONAL ANEMIA
Iron deficiency predominantly.
VitaminB12 and folic acid deficiency in a significant number of

cases.
Deficiency of Vitamin
A ,thiamine ,riboflavin ,pyridoxine ,Vitamin C ,
CAUSES
OF IRON DEFICIENCY ANEMIA(IDA)
•Inadequate intake of iron.

•Reduced bioavailability of dietary iron.
•Decreased absorption of the iron
•Increased need of the iron.
•Chronic blood loss due to worm infestations and other causes
•Nonspecific e.g. chronic infection
DETERMINANTS OF IRON ABSORPTION
Absorption Promoters
•Ascorbic acid
•Heme iron(meat,fish)
•Germination
Absorption Inhibitors
•Phytates(Cereals)
•Tannin(Tea,coffee)
•Calcium
•Soyprotein
DETERMINANTS OF IRON ABSORPTION
• Heme Iron :High bioavailability(20‐30%)
• Non heme Iron :Poor bioavailability(2 ‐5%)

APPROACH TO IDA
•History
•Physical examination
•Laboratory tests
•Management
HISTORY IN NUTRITIONAL ANEMIA
Age of onset:6mo‐36months
Sex : Both sexes equally affected in childhood , after

adolescence females>males
Diet : Lack of breast feeding , Excess of animal milk ,

inadequate weaning food , predominantly vegetarian diet.
Exclusive breastfeeding up to 6mo prevents anemia.

HISTORY IN NUTRITIONAL ANEMIA–
CONTD.
•H/O pica :craving for for mud(geophagia) , chalk, ice(….),
starch, cardboard etc.
•H/O breath holding spells
•Infections :rule out worms infestation esp.
hookworm ,roundworms , giardia
•Symptoms: Irritability , fatigue ,shortness of breath,
Lassitude ,weakness , dyspnea on exertion.
If fall of Hb is gradual the onset of symptoms is insidious , and
symptoms may not be noticed till Hb falls to 4‐5g%.
ANEMIA–PHYSICAL EXAM
•Signs : pallor , puffiness , edema feet, hemic murmur

•Tongue : pallor, bald & shining tongue , loss of papillae
•Angular stomatitis
•Nails : platynychia , koilonychia in iron deficiency
•Hyperpigmented knuckles in megaloblastic anemia
•Plummer‐Vinson syndrome(Patterson ‐ Kelly syndrome):Triad
of dysphagia due to esophageal webs, koilonychia ,
splenomegaly rarely.
ANEMIA–PHYSICALEXAM–CONTD
..Rule out other causes of anemia by looking for: •Abnormal

facies (e.g.Hemolytic facies)
•Spleno hepatomegaly (e.g.Thalassemia)
•Lymphadenopathy(infections , tuberculosis)
•Bony tenderness(e.g.leukemia)
•Petechiae / purpura (aplastic anemia , leukemia)
•Recent weight loss(e.g malignancies)
•Skeletal changes(e.g.Fanconi’s anemia)
LABORATORY INVESTIGATIONS
• The mean corpuscular volume (MCV) denotes the size of the

red cells while the mean corpuscular hemoglobin (MCH) and
mean corpuscular hemoglobin content (MCHC) provide
information on red cell hemoglobinization.•
• The red cell distribution width (RDW) provides an estimate of
the size differences in red blood cells.
• Examination of the peripheral smear reveals red cell
morphology.
• The reticulocyte count helps distinguish between anemia
caused by red cell destruction and decreased production
INVESTIGATION
• •The peripheral blood smear reveals microcytic, hypochromic

red cells with anisocytosis and poikilocytosis
• •Increased red cell distribution width (RDW).
• •The MCV and MCHC are reduced.
• •The serum level of iron and ferritin are reduced while the
total iron binding capacity is increased •The saturation of
transferrin is reduced
TREATMENT OF IDA
• Hb below5g/dl: Risk of cardiac failure;

• Hospitalization is desirable.
• If Hb is below 3g/dl (<4g/dl with infection and in young
children):Blood transfusion is usually required;
• Packedred cell transfusion 2‐3ml/kg at one time.

TREATMENT OF IDA
•For treatment dose of oral iron is 3mg/kg/day; ferrous

sulphate,gluconate and fumarate are most commonly used and
cost effective.
ORAL IRON SIDE EFFECTS
•Nausea,vomiting,pain in abdomen,
diarrhea ,constipation
•Discoloration of stool
•Staining of tongue/teeth
•True intolerance rare

RESPONSE TO IRON THERAPY
•12‐24hrs-Replacementofenzymes
Subjective improvement
Decreased irritability
Increased appetite
•24‐48hrs -Erythroid hyperplasia
•48‐72hrs -Reticulocytosis
•4‐20days -Increase in Hb level
•1‐3months –Repletion of stores
NON RESPONSE TO IRON THERAPY
• Poor compliance
• Poorly absorbed iron preparation
• Use of H2 blockers or PPI
• Interaxn with food & medicines
• Associated B12 or folic acid deficiency
• Underlying hemolytic anemia ,inflamation or infection
• Malabsorption (celiac disease,giardiasis)
• High rate of ongoing blood loss
• Alternative etiology(thalassemia,sideroblastic anemia)
INDICATION FOR PARENTERAL IRON
THERAPY
• Intolerance to oral iron therapy
• Malabsorptive states
• Ongoing blood loss at a rate when oral

replacement can not match iron loss
MEGALOBLASTIC ANEMIA
• Characterized by macrocytic red blood cells &

erythroid precursors which shows nuclear
dysmaturity
• Causes –
• Deficiency of vitamin B12 & folic acid
PATHOPHYSIOLOGY
• Affect all cell lines

- Anemia , thrombocytopenia & leukopenia
DNA synthesis is impaired because of lack of methyl

tetrahydro folate(folic acid derivative)
Vitamin B12 is a cofactor in this reaction

ETIOLOGY
• Folate deficiency
- decreased ingestion
- impaired absorption(celiac
disease,malabsorption)
- impaired utilisation(methotrexate,6MP,Phenytoin)
increased requirement(infancy,hyperthyroidism,c/c
hemolytic disease)
ETIOLOGY
Vitamin B12 deficiency

- decreased ingestion
- impaired absorption(intestinal parasites,intrinsic factor
deficiency)
-impaired utilisation(congenital enzyme deficiencies:orotic
aciduria)
CLINICAL MANIFESTATION
• Anemia , anorexia, irritability & easy fatigability

• signs of thrombocytopenia , neutropenia
• Glossitis , stomatitis
• Hyper pigmentation of the skin on the knuckles & terminal
phalanges
• Hepato splenomegaly(40%)
• Loss of position & vibration sense (earliest neurological
signs)
• Memory loss ,confusion & neuropsychiatric symptoms
INVESTIGATIONS
• Complete hemogram with red cell indices

• -macrocytosis(>110 fl highly suggestive ) & cytopenia
• Hypersegmented neutrophils(nucleus>6lobes)
• Reticulocyte count
• Serum B12& Folic acid levels
• Bone marrow evaluation if more than one cell line affected
( marrow cellular ..& red blood cell precursor shows nuclear -
cytoplasmic asynchrony
• Elevated LDH & bilirubin
DIFFERENTIAL DIAGNOSIS
• Aplastic anemia & other marrow failure syndromes (pure red

cell aplasia , fanconis anemia ,transient erythroblastopenia of
childhood)
• Congenital dyserythropoitic anemia
• c/c liver disease
• Hypothyroidism
• Myelodysplastic syndromes
• HIV infection
TREATMENT
• Depends on underlying cause

• Cause not identified –
therapeutic doses of folate (1-5 mg/day)& vitamin B 12
1000microgram are administered
Only folate supplementation???

Anemia gets corrected but doesn’t correctB12 deficiency
associated neurological disorder
• Parenteral vitamin B12 dose 1mg (1000microgram) given as
IM
RESPONSE- with in few days

• decrease in MCV
• Reticulocytosis
• Higher platelet & neutrophil count
Pernicious anemia & malabsorption-
• vitamin B12 IM daily For 2wks
• weekly until HCT is normal &
• monthly for life
Neurological complication
• vitamin B12 IM daily For 2wks
• weekly for 6months &
• monthly for life
Thank u

Nutritional Anemia New(s)

Uploaded by

Copyright:

Available Formats

Nutritional Anemia New(s)

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Nutritional Anemia New(s)

Uploaded by

Copyright:

Available Formats

NUTRITIONAL ANEMIA

Anemia is present when the hemoglobin level is

Children,5-11 yrs <11.5

Non pregnant Women <12

Pregnant women <11

Iron deficiency predominantly.

VitaminB12 and folic acid deficiency in a significant number of

•Inadequate intake of iron.

• Heme Iron :High bioavailability(20‐30%)

• Non heme Iron :Poor bioavailability(2 ‐5%)

Sex : Both sexes equally affected in childhood , after

Diet : Lack of breast feeding , Excess of animal milk ,

Exclusive breastfeeding up to 6mo prevents anemia.

•Signs : pallor , puffiness , edema feet, hemic murmur

..Rule out other causes of anemia by looking for: •Abnormal

• The mean corpuscular volume (MCV) denotes the size of the

• •The peripheral blood smear reveals microcytic, hypochromic

• Hb below5g/dl: Risk of cardiac failure;

• Packedred cell transfusion 2‐3ml/kg at one time.

•For treatment dose of oral iron is 3mg/kg/day; ferrous

•True intolerance rare

• Intolerance to oral iron therapy

• Ongoing blood loss at a rate when oral

• Characterized by macrocytic red blood cells &

• Affect all cell lines

DNA synthesis is impaired because of lack of methyl

Vitamin B12 is a cofactor in this reaction

Vitamin B12 deficiency

• Anemia , anorexia, irritability & easy fatigability

• Complete hemogram with red cell indices

• Aplastic anemia & other marrow failure syndromes (pure red

• Depends on underlying cause

Only folate supplementation???

RESPONSE- with in few days

You might also like