Outline the etiology of Iron deficiency in children. Describe the clinical features and approach to diagnosis of a child suspected to be having nutritional anemia.

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iron Deficiency Anemia:

Etiology:

Reduced iron intake:

• Non breastfed infant on cow milk
• Inadequate intake of iron containing foods
• Diet containing no bioavailabile iron

Reduced iron absorption:

• Chronic diarrhoea
• Celiac disease
• Cow milk allergy
• G.I surgery
• Giardiasis
• Loss of function of TMPRSS6 gene (↓ inhibition of hepcidin)

Inadequate transport:

• Atransferrinemia
• Anti transferrin receptor antibodies

Increased requirement:

• Periods of growth- preterms, toddlers, puberty
• Reproductive age female
• Pregnancy & lactation

Increased losses:

• G.I bleeding
• Repeated blood sampling
• Menstruation
• Intestinal parasites

Clinical features:

Asymptomatic - most children

Pallor - when hb below 7-8g/dl

Palms

Palmar creases

Nail beds

Conjunctivae

Cold intolerance

Fatigue

Exercise induced dyspnea

Non hematological systemic effects

• Impaired neurocognitive function in infancy
• Seizures, strokes, breath-holding spells
• Pica, pagophagia(ice)

Approach to Diagnosis in Nutritional Anemia:

Nutritional anemia consists of three major deficiencies

1. Folate deficiency
2. Vitamin B12 deficiency
3. Iron deficiency

History:

Dietary history

Drug history

Surgical history

Symptoms & signs

• Pallor
• Weakness, lethargy, irritability, feeding difficulties
• Neurological complaints
• Seizures
• Sensory defects
• Developmental delay

Microscopy:

Folate/B12 def	Iron def
• Macrocytic RBC • Nucleated RBC • Neutrophils with hyper segmented nuceli	• Microcytic Hypochromic RBC • Anisopoikilocytosis

Lab parameters:

Folate/B12 def	Iron def
MCV High Neutropenia Thrombocytopenia	MCV Low Normal WBC counts Thrombocytosis (oftenly)

Confirmatory tests

1. Folate deficiency

RBC folate levels(150-600ng/ml) are better indicator than serum folate than serum folic acid(5-20ng/ml)

Concomitant B12 deficiency if present should also be treated to avoid worsening of neurological symptoms.

      2. Vit B12 deficiency

• ↓ B12 levels
• ↑ methyl malonic acid (MMA) & homocysteine
• ↑ urinary MMA 
• Anti IF & anti Parietal cell antibodies

      3. Iron deficiency

• >1g/dl increase in hb after iron theory is most practical mean to establish diagnosis
• Iron studies
• ↓ Serum ferritin
• ↑ Total Fe binding capacity
• ↓ Transferrin saturation
• ↑ soluble transferrin receptor