iron deficiency anemia in pediatrics for clinical pharmacy students

1. Prof Dr Hussein Abdeldayem
Professor of Pediatrics,
Alex University

3. By:
Prof.Dr: Hussein Abdeldayem.

4. Definition:
Anemia is defined as a reduction of
the red cell volume (hematocrit) or
hemoglobin concentration below the
range of normal values for age.

5.  World Health Organization (WHO) has
suggested levels of Hb below which
anaemia is said to be present.
*These levels are:
 <11 g/dL in children aged 6 months
-<6Y
 <11.5 g/dL in children aged 6-<12 years
 <12 g/dl in older children (aged 12-14).

6.  Childhood anaemia poses a major public health
issue leading to an increased risk of child
mortality, as well as the negative consequences of
iron deficiency anaemia on cognitive and physical
development.

7.  Dietary sources of iron
 • Rich :liver,dry beans
 • Medium:meat,chicken,fish, spinach, banana,
apple
 • Poor:milk and its products, vegetables

8.  Haeme iron is better absorbed, but forms a
smaller fraction of the dietary iron(6%).
 • Dietary iron :Haeme or non haeme /Inorganic
iron
 • Non haeme iron and iron in inorganic form is
present as ferric iron must be first reduced to
ferrous iron .

9.  • Dietary iron mostly in the ferric form (Fe3+)
 In the stomach Fe3+ - Fe2+
 In the mucosal cells Fe2+ Fe3+ Apoferritin
 Ferritin ( Stored) Iron slowly released
 In the plasma Fe2+ Fe3+ with Transferrin
 Iron bound transferrin Transfers iron to
bone marrow , Liver , Spleen ( Stored)

10.  Absorbed from the duodenum (where most drugs are
absorbed) and upper jejunum.
 Only 10% of dietary iron is absorbed
 In circulation:
iron is carried in ferric form
bound to transferrin (only 35% of transferrin is saturated
with iron)

11.  –Facilitated by • Acidic pH of stomach , Ascorbic
acid •
 –Inhibited by • Excess phosphates, oxalates,
Phytates • Milk, antacids, tetracycline ↓ iron
absorption by forming insoluble complexes

12.  Hemoglobin.
 Heme enzymes, e.g., cytochromes, catalase,
peroxidase
 Myoglobin
 Metalloflavoprotein enzymes such as xanthine
oxidase
 The mitochondrial enzyme alpha-
glycerophosphate oxidase and other
mitochondrial enzymes.
 Other enzymes and processes

13.  FT baby: with store enough for 4 mo
 PMT baby: with store enough for 2 mo
 1mg/kg/day elemental iron for infants and
children (max 15 mg/day)
 2 mg/kg/day elemental iron for low birth weight
and newborns with very low initial Hb values
 6 mg/kg/day elemental iron is needed for tt for 3
mo

14.  Most common nutritional deficiency in
children and is worldwide.
 More common at:
● 6 - 24 months
● artificially fed infants.
● low socioeconomic status

15. !. Inadequate supply of iron.
A. Inadequate iron stores at birth:
 Premature.
 multiple births.
 Severe maternal iron deficiency.
 Fetal blood loss.
B. LOW INTAKE: PERSISTENT MILK INTAKE
II. Impaired absorption of iron:
chronic diarrhea and celiac disease.
III. Excessive demands for iron:
A.Blood loss during infancy:
 Cow milk allergy.
 Acute or chronic hemorrhages.
 Parasitic infestations as hook­ worms.

16. Inadequate dietary intake:
 Early cow milk.
 Exclusive breast feeding after 6 months.
 Low intake
Failure to meet increased demands
for growth:
 premature.
 adolescence.

17.  ↓ iron stores.
 ↓ iron‑storage protein (ferritin)
 ↓ serum iron
 ↑iron binding capacity TIBC.
 Anemia: hypochromia,microcytosis.
 ↓ activity of iron‑containing intra­cellular
enzymes (e.g. CNS -MAO).

18. POSTIVE HISTORY OF THE CAUSE +
1- General manifestations of anemia
2- Particular findings effect of iron def. on
systems:
 GIT: Anorexia, atrophic glossitis,
dysphagia, Pica (ingestion of wall plaster,
clay)
 CNS: Short attention span, irritability,
breath holding, ↓ alertness, ↓ learning
ability and school performance.
 Epithelial structures :in adults such as
spoon shaped or concave nails and brittle
nails.

19. A. (CBC) :
 Hypochromic microcytic anemia
 ↓ Hematocrit.
 Hb< 9 g/dl.
 Red cell count 3 ‑ 5 millions/mm3 (slightly).
 Red blood cell indices : All are ↓: but FEP is ↑
 ↓ MCV: < 78 fl (N 78-95 fl)[fl = 10-15L.
 ↓ MCH: < 26 pg (N 26-32 pg) [pg = 10-12 g]. ,
RDW >14.5%, ↑FEP >40mg/dl
 ↓ MCHC: < 30 g/ dl (N 32-36 g/dl).
 Reticulocytes usually N. Platelets ↑ or ↓

20. B. Plasma:
 Plasma iron ↓ 10 ‑ 50 µg/dl (normally 60-
150 ugm/ dl).
 Serum ferritin: absent (N 10 - 150 ng/ ml)
[ng =10-9 g].
 ↑ TIBC 450 µg/dl (N: 100-400 µg/dl).
 Others: ↑STfR , RBC zinc protoporphyrin /
heme ratio

21.  IRON replacement TREATMENT (oral, IM, IV)
 TREAT THE CAUSE
Treatment of etiology :
correct diet and treat Ancylostoma.

22.  The ability of the patient to tolerate and absorb
medicinal iron is important
 Gastrointestinal tolerance to oral iron is
limited
 Mainly absorbed only in the upper small
intestinal (delayed-release preparations ?)
 Heme iron better absorbed (as part of
myoglobin)
 Nonheme iron not well absorbed - bulk of
dietary iron

23. can be given in 2 routes
– Orally –
Parenterally

24.  These preparation are mostly available as
ferrous(Fe+2) and some in ferric(Fe+3)form
  Ferrous salt are better absorbed than ferric
salts

25.  Iron is poorly absorbed in the form of carbonate,
citrate and pyrophosphate, colloidal iron and iron
carbohydrate complex
 FORMS :
Tablets, capsules
Sugar coated & uncoated tablets •
Slow release tabs
chewable tabs •
Drops &syrups—used by children's

26.  1. Ferrous sulphate: 20 – 32% iron
 2. Ferrous fumarate: 33% elemental iron
 3. Ferrous gluconate : 12% elemental iron
 4. Colloidal ferric hydroxide:50% elemental iron •
 Other oral preparations are ferrous choline
citrate , ferric ammonium citrate , iron calcium
complex, iron hydroxy polymatose.
FERRIC
HYDROCHLORIDE
POLYMALTOSE

27.  It is rapidly absorbed, with a high rate of iron utilization
and produces an effective increase in Haemoglobin. Due
to its favourable nonionic nature it has the following
properties unlike ionised iron salt preparations: · Ferose
does not give rise to irritation of the intestinal mucosa
and does not stain the teeth. · Ferose has palatable, non
metallic taste (Ferose chewable tablets have chocolate
flavour and are acceptable even by the most resistant
patients of all ages). · Ferose has excellent tolerance.

28. Oral Iron salts: 6 mg/kg/day elemental for 3 ms/3
doses.
 Ferrous sulfate drops for infants
 Ferrous gluconate drops ( 12 % elemental iron).
 ferrous fumarate tablets or syrup for older
children.
 Iron better between meals.
 AVOID FOOD DECREASE ABSORPTION: fibers
(e.g. whole bread and cereals), tannate (like
tea), phosphates (in bread, cow's milk and egg
yolk) and phytic acid ↓ absorption of iron.
 absorption ↑ by vitamin C (e.g. citrous fruits),
sugar and amino acids (meat, poultry, fish).

29.  • Important points to remember ;Elemental iron
content and not quantity of iron compound per unit
dose to be considered
 Sustained released preparations expensive and
irrational
 Liquid formulations: should be put on back of
tongue and swallowed

30.  Ferrous sulfate –least expensive – treatment
of choice
 Ferrous salts (sulfate, fumarate, gluconate,
succinate) are absorbed about three times as
well as ferric salts.
 Vitamin C increases absorption - Ascorbic
acid, 200 mg or more, increases absorption
by at least 30% (with increased incidence of
side effects too)
 Carbonyl iron: microspheres of pure iron –
less gastrointestinal toxicity than iron salts

31.  • Constipation (BLACK) is common than diarrhea
 • Epigastric pain
 • Vomiting
 • Heart burn
 • Metallic taste
 • Nausea
 • Staining of teeth.

32.  • Oral iron is not tolerated
 • Failure to absorb oral iron
 • Non compliance to oral iron
 • In presence of severe deficiency with chronic
bleeding

33.  • Parenteral iron therapy needs calculation of total
iron requirement of the patient –
Iron requirement (mg) = 4.4 X Body wt (Kg) X Hb
deficit g/dL

34.  1. Iron dextran (Imferon): I.V/ I.M
 2. Iron sorbitol citric acid complex: Only I.M 3. Iron
carbohydrate complex : I.M
 4. Sodium ferric gluconate: Recently approved
preparation for I.V use has much lower risk of
anaphylactic reaction than iron dextran

35.  • Iron dextran and iron sorbitol both contain 50
mg/mL recommended dose is 100 mg daily 2 mL
on alternate days until total required dose is
administered or maximum 2 g .
 To prevent staining to skin given deep I.M in
buttock using z track technique
Elemental iron 100 mg (As Ferric
hydroxide polymaltose complex)

36.  • Intramuscular: – Local pain at site , pigmentation
of skin , sterile abcess
 – Systemic: headache, fever, arthralgia,
backache, tachycardia, flushing hemolysis and
collapse these effects are probably due to
excessive amount of free iron in plasma
 – Iron sorbitol may cause disorientation and
temporary loss of taste, urine turns black on
standing

37.  • Iron dextran after test dose 0.5 mL iron dextran
injected I.V over 5 to 10 min
 • Total dose required diluted in 500 mL NS &
infused slowly over 6 to 8 hours under supervision
 • If required amount greater than 50 mL given on
two consecutive days

38. 1- Systemic reaction:
 severe form : anaphylactoid reaction
severe chest pain
 respiratory distress
 circulatory collapse
2- local: skin coloration

39.  1. Stomach wash with 1% NaHCO3 to render it
insoluble and remove undissolved iron tablets
 2. Desferrioxamine Mesylate 5 to 10 g in 100 mL
isotonic saline or calcium sodium edetate 35 to 40
mg/Kg to retard the absorption from GIT
 3. Early replacement of fluids and electrolytes,
correction of metabolic acidosis and hypotension by
vasopressors
 4. I.v desferrioxamine infusion
 5. Diazepam and other anticonvulsants if epileptic

40.  • Potent specific chelator of iron binds ferric iron to form
ferrioxamine a stable water soluble chelate
 • Ferrioxamine is excreted 2/3 in urine and 1/3 in bile
colors urine reddish brown
 • Removes iron from hemosiderin except that in bone
marrow
 • Well tolerated rapid I.V may cause hypotension,
anaphylactic reactions and tachycardia
 • Allergic reactions and cataract known with chronic
administration
 • Contraindicated in renal disease anuria