RA Iron Deficiency Anemia
RA Iron Deficiency Anemia
RA Iron Deficiency Anemia
Kawsari Abdullah, MBBS, The Hospital for Sick Children, Toronto Stanley Zlotkin, MD, FRCPC, The Hospital for Sick Children, Toronto Patricia Parkin, MD, FRCPC, The Hospital for Sick Children, Toronto Danielle Grenier, MD, FRCPC, Canadian Paediatric Society, Ottawa
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Although the prevalence of IDA in Canadian children among the general population is low (3.5% to 10.5%), there are certain Canadian Aboriginal populations in whom the prevalence is very high (14% to 50%).12-14 Factors associated with the increased prevalence of IDA in these populations include high consumption of evaporated milk and cows milk after six months of age, prolonged exclusive breastfeeding and significant burden of Helicobacter pylori infection.8 Other high-risk groups include children from families of low socioeconomic status, children of Chinese background, infants of low birth weight, and children who consume whole cow's milk before 12 months of age.4,5,8,15-17.
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investigated through controlled trials; hence, the results cannot be considered conclusive. The Canadian Task Force on Preventive Health Care concluded there was insufficient evidence to recommend screening for infants between six and 12 months of age. However, for all infants in high-risk groups, physicians may consider screening between six and 12 months of age, perhaps optimally at nine months.27 The AAP recommends screening with hemoglobin at 12 months. If the Hb level is less than 110 g/L at 12 months, additional screening tests should include measurement of serum ferritin plus CRP levels, or CHr concentration.18
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When IDA is identified, the family should be counseled regarding the importance of limiting the total daily milk intake and increasing iron-rich foods, including those with vitamin C that improves iron absorption, and avoiding foods that impair iron absorption such as tea. Children with IDA should also receive iron supplementation. The recommended therapeutic dose of oral iron is 6 mg/kg/day of elemental iron, for three to four months. Adequate follow-up is also important.
Conclusion
In Canada, IDA in children remains a public health problem, and certain populations of children are at particularly high risk. IDA is associated with poor developmental outcomes in children; the impact of ID is less well understood. Laboratory investigations include hemoglobin and iron tests, such as serum ferritin. Primary prevention of IDA is recommended; the role of secondary prevention through screening programs remains inconclusive but recommended by some professional organizations. Treatment of children identified with IDA includes both dietary counseling and oral iron supplementation.
References
1. WHO, UNICEF, UNU. Iron deficiency anaemia: assessment, prevention, and control. A guide for programme managers. Geneva, World Health Organization. 2001;WHO/NHD/01.3. 2. Martins S, Logan S, Gilbert RE. Iron therapy for improving psychomotor development and cognitive function in children under the age of three with iron deficiency anaemia. Cochrane Database of Systematic Reviews, 2001(Issue 2). 3. Yip R. The changing characteristics of childhood iron nutritional status in the United States. In: Filer LJ Jr, ed. Dietary iron: birth to two years. New York, NY: Raven Press 1989:3761. 4. Earl R, Woteki CE, d. Iron deficiency anemia: recommended guidelines for the prevention, detection, and management among U.S. children and women of childbearing age. Washington, DC: National Academy Press, 1993. 5. Dallman PR, Siimes MA, Stekel A. Iron deficiency in infancy and childhood. Am J Clin Nutr 1980;33:86-118. 6. Dallman PR, Looker AC, Johnson CL, Carroll M. Influence of age on laboratory criteria for the diagnosis of iron deficiency anaemia in infants and children. In: Hallberg L, Asp N-G, eds. Iron nutrition in health and disease. London, UK: John Libby & Co., 1996:65-74. 7. Looker AC, Dallman PR, Carroll MD, Gunter EW, Johnson CL. Prevalence of iron deficiency in the United States. JAMA 1997;277(12):973-6. 8. Christofides A, Schauer C, Zlotkin SH. Iron deficiency anemia among children: Addressing a global public health problem within a Canadian context. Paediatr Child Health 2005;10(10):597-601.
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13. Christofides A, Schauer C, Zlotkin SH. Iron deficiency and anemia prevalence and associated etiologic risk factors in First Nations and Inuit communities in northern Ontario and Nunavut. Can J Public Health 2005;96:304-7. 14. Harfield D. Iron deficiency is a public health problem in Canadian infants and children. Paediatr Child Health 2010;15:347-50. 15. Greene-Finestone L, Feldman W, Heick H, et al. Prevalence and risk factors of iron depletion and iron deficiency anemia among infants in Ottawa-Carlton. Can Diet Assoc J 1991;52:20-3. 16. Chan-Yip A, Gray-Donald K. Prevalence of iron deficiency among Chinese children aged 6 to 36 months in Montreal. Can Med Assoc J 1987;136:373-8. 17. Tunnessen WW Jr, Oski FA. Consequences of starting whole cow milk at 6 months of age. J Pediatr 1987;111:813-6. 18. Baker RD, Greer FR, and the Committee on Nutrition, American Academy of Pediatrics. Diagnosis and prevention of iron deficiency and iron deficiency anemia in infants and young children. Pediatrics 2010;126:1040-50. 19. Kalantri A, Karambelkar M, Joshi R, Kalantri S, Jajoo U. Accuracy and reliability of pallor for detecting anaemia: a hospital-based diagnostic accuracy study. PLoS ONE 2010;5(1):e8545. 20. Dallman PR. Manifestations of iron deficiency. Semin Hematol 1982;19:19-30. 21. Dallman PR. Biochemical basis for the manifestation of iron deficiency. Annu Rev Nutr 1986;6:13-40. 22. Grantham-McGregor S. Ani C. A review of studies on the effect of iron deficiency on cognitive development in children. J Nutr 2001;131:649S-68S. 23. Sachdev HPS, Gera T, Nestel P. Effect of iron supplementation on mental and motor development in children: systematic review of randomised controlled trials. Public Health Nutrition 2004;8(2):11732. 24. Akman M, Cebeci D, Okur V, Angin H, Abali O, Akman AC. The effects of iron deficiency on infants developmental test performance. Acta Paediatrica 2004;93(10):1391-6. 25. Feightner JW. Prevention of iron deficiency anemia in infants. In: Canadian Task Force on the Periodic Health Examination. Canadian Guide to Clinical Preventive Health Care. Ottawa: Health Canada, 1994:244-55. 26. Nutrition Committee, Canadian Pediatric Society: Meeting the iron needs of infants and young children: an update. Can Med Assoc J 1991;144:1451-4. 27. Bogen DL, Krause JP, Serwint JR. Outcome of children identified as anemic by routine screening in an inner-city clinic. Arch Pediatr Adolesc Med 2001;155:366-71. 28. James J A, Laing GJ, Logan S. Changing patterns of iron deficiency anaemia in the second year of life. BMJ 1995;311:230.
Quiz
1. Iron-deficiency anemia (IDA) is characterized by: a) hemoglobin level of <110 g/L plus serum ferritin <10 g/L (provided CRP is normal) b) hemoglobin level of >110 g/L plus serum ferritin <10 g/L (provided CRP is normal) c) hemoglobin level of <110 g/L d) All of above
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2. The iron stores of full-term, normal birth-weight infants can meet an infants iron requirements: a) b) c) d) until 28 days of age until ages four to six months until six years of age until 12 months of age
3. The most reliable indicator of iron deficiency: a) b) c) d) serum ferritin transferrin saturation bone marrow histopathology erythrocyte protoporphyrins
4. Which one of the following is not an evidence-based clinical predictor of IDA? a) b) c) d) Obesity Bottle use Daycare attendance School attendance rate
5. IDA is treated with: a) b) c) d) iron therapy of 6 mg/kg/day elemental iron for three to four months iron therapy of 6 mg/kg/day elemental iron for three to four weeks bone marrow transplant iron-chelating agent
5. The American Academy of Pediatrics recommends screening for IDA at: a) b) c) d) one month of age three months of age nine months of age twelve months of age
01/2011