IDA

Presented by:Awatif K. Al-MutairiHind K. Bin-Drees

Sarah N. Al-Gubaisi

Supervised by:Dr. Al-Johara Al- Quaiz

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Red Eye

Iron deficiencyAnaemia

acne

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RED EYEOutlines:• What is red eye?• Red eye in PHC.• DDx.• How to deal with pt. with red eye?

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Anaemia

What is Anaemia ?

It is a Greek word = “ Bloodlessness”

It is a ↓ in the level of Hb in the blood below the reference range for the age and sex of the individual .

Usually there is reduction RCC and PCV

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Normal Blood indices

Hb (g/dl)♂ 13 - 18

♀ 12 - 16

PCV (Hct) (%)♂ 42 - 52

♀ 37 - 47

RCC (1012/ L)♂ 4.7 – 6.1

♀ 4.2 – 5.5

MCV (fL)80 – 94

MCH (Pg)27 – 32

MCHC ( g/dl)32 – 36

RDW (%) 11.5 – 14.5

ESR (mm/hr)0 – 10

Reticulocytes (%)0.2 – 2.0

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Cut Offs for WHO definition of Anaemia

Age or sex groupHeamoglobin

Below (g/dl)

Heamatocrit

Below (%)

Children 0 – 60 months11.033

Childern 5 – 11 years11.534

Children 12 – 15 years12.036

Non-pregnant women12.036

Pregnant women11.033

Men 13.039

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Iron Metabolism

Absorption of iron occur primarily in the duodenum in the form of ferrous(Fe+2) , in a rate of 1-2mg/ dayIn serum Fe is bound to transferrin , & ⅓ is saturated Fe is stored as ferritin and haemosidrin in hepatocyte , Sk. Ms. , reticuloendothelial macrophages 1mg/day is lost through skin , mucosal cells , sweat, urine , faeces and menses

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Daily requirements

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Men 1 mg

Adolescence 2-3 mg

Women (reproductive age)

2-3 mg

Pregnancy 3-4 mg

Infancy 1 mg

Maximum bioavailability from normal diet about 4 mg

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Prevalence of IDA

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Iron deficiency is the most common and widespread nutritional disorder in the world

The World Health Organization estimated that about 40% of the world’s population (more than 2 billion individuals) suffer from anaemia, and that approximately 50% of all anaemia can be attributed to iron deficiency

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Prevalence in Saudi arabia

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Prevalence among women ranged from 20 -50%

in a study of 1,210 primary school girls aged 7-14, in Riyadh, Saudi Arabia, an anaemia level of 55.4% was found. The highest level (71.4%) was found among 14 year-old girls

Anaemia was reported among 20.5% of school students in general

And it is about 36-37% in preschool children

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Epidemiology

Age : very young (6-24m), preschool children , during puberty and in old ages

Gender : adolescent females are more prone than males

Physiology : pregnant & lactating women

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Etiology and Risk factors

Chronic blood loss Uterine Gastrointestinal : peptic ulcer, esophageal varices , aspirin or NSAID ingestion , partial gastictomy , GIT Ca, Hookworm , angiodysplasia , colitis… Heamosidrenosis , self induced blood lossIncrease demand Prematurity Growth Pregnancy

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Malabsorption

Celiac disease , gluten-induced enteropathy , atrophic gastritis ,gasterctomy , chronic diarrhea , IBD

Poor diet

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Clinical Features

Symptoms

Fatigue , feeling tired

Faintness

Breathlessness

Angina pectoris , palpitation

Intermittent claudication

Decreased attention span , behavioral & developmental problems

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Signs

Pale skin & mucus membranes

Spoon nails ( Koilonychias )

Painless glossitis

Angular stomatitis

Brittle hair & nails

Dietary craving (Pica)

Dysphagia

Tachycardia

Systolic flow murmur

Cardiac failure signs

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Investigations & DDx

CBC & indices RBC MCV MCH MCHC RDW

Reduced in relation to severity Of anaemia

Increased

RDW = SD of RBC volume (fL) / MCV x 100

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Iron profile

serum ferritin ( reflects stores )is lowlow

serum iron is lowlow

total iron binding capacity (TIBC) is HighHigh

transferrin saturation < 19%

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Deferential Diagnosis

MCV < 80 fL ( Microcytic )

Anaemia of chronic disease

Thalassaemia

Sideroblastic Anaemia

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Consequences of IDA

Iron deficiency adversely affects the cognitive performance, behaviour, and physical growth , language of infants, preschool and school-aged children; the immune status and morbidity from infections of all age groups; and the use of energy sources by muscles and thus the physical capacity and work performance of adolescents and adults of all age groups.

Specifically, iron deficiency anaemia during pregnancy increases perinatal risks for mothers and neonates; and increases overall infant mortality.

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Management of IDA

Find and treat the underlying cause

Oral iron

ferrous sulfate 200 mg/3/day/6m →

↑ reticulocytes count , then

↑ Hb 1 g/ dl / week

Others ferrous fumarate, gluconate

Liquid preparation → infants & children

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Parentral iron IM or IV (iron dextran) → rarely used , when the patient cannot tolerate oral iron , OR poor response to oral e.g. sever malabsorption

Blood transfusion ( Hb < 3mg/dl )

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Possible side-effects associated with iron medication Epigastric discomfort, nausea, diarrhoea, or constipation may appear with a daily dose of 60 mg or more. If these symptoms occur, supplement should be taken with meals. Faeces may turn black, which is not harmful. Treatment should continue. All iron preparations inhibit the absorption of tetracyclines, sulphonamides, and trimethoprim. Thus, iron should not be given together with these agents.

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Referral

When ?

Sever anaemia with

pregnancy beyond 36 weeks

respiratory distress + cardiac abnormalities

no improvement or worsening with Rx

Blood in stool or melena

Evidence of chronic disease (TB , hepatosplenomegaly )

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Prevention

Supplementation with medical iron

Education and associated measures to increase dietary iron intake

Control of infections

Fortification of food with iron

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Preventive measures is given mostly to pregnant women and young children

Others : schoolchildren, adolescent , and non-pregnant women( WHEN?)

The best way to prevent IDA is . . . .?

Iron is found in meat , liver , cereals , raw green vegetables, fortified food .

It is best to eat food that contain vit. C with non-meat source of iron

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For more information about IDA

WHO

http://www.who.int/ar/index.html

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Case 1

Nora is a 25 years Saudi lady , a mother of 2 children aged 1.5 years , 3 monthsShe came to the clinic complaining of decrease of her energy , weakness , and headacheshe is breast feeding her baby and there is no history of nausea ,vomiting , diarrhea or blood in her stoolReview of other systems was not significant

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on examination she was underweight with

BP 120/70

Pulse 92 / min

Temperature 37.0 C

Pale mucus membranes,

And no other significant findings

What is your next step?

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Nora’s lab results were: RBC 4*10.012/L Hb 77 g/dl Hct 25.5% MCV 61.1 fLMCH 18.5 pgMCHC 303 g/lRDW 20.1 %

What is her diagnosis ? And how would you manage Nora ?

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Case 2

Waleed is a 22 years old Saudi gentleman , a student Waleed is complaining of mild fatigue that gradually worsen over the last 6 months , he also noticed a decrease in his studying & working toleranceThere is no Hx of change of sleep , mood ,appetite , concentration No diarrhea , vomiting , blood in the stool .

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On his examination he was pale and had a

BP 110/85Pulse 82/ min Temp 37.1 COther systems were normal

What else you will do ?

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Waleed’s lab results were

RBC 3.8 *10.012/L

Hb 110 g/ l

Hct 37%

MCV 75 fL

MCH 30 pg

MCHC 321 g/L

RDW 13.4 %

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• After 2 weeks • There was no improvement in his

condition • His iron profile was Ferritin level was normal 200 ng/ml Serum iron , normal 60ng/ml TIBC , normal 320 ng/dl

What is next ?

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Acknowledgment

I am grateful to all the Haematology Lab team who provided me with the materials that I need for my presentation , especially Dr. Laila Al-Quaiz .

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References

INACG 1998 .Guidelines for the use of iron supplement to prevent and treat IDA. WHO, GENEVA 1989 .Preventing and controlling IDA through primary health care , a guide for health administrators and programme managers . Cook J.D.Defining optimal body iron . Proceeding of the Nutrition Society 1999 ; 58,489-495Al-Quaiz J.M. IDA : a Study of risk factors. Saudi Med J 2001; vol. 22 (6):490-496WHO 2001.IDA assessment , prevention , and control : a guide for programme managersGuidelines and Protocol Advisory Committee 2004 . Investigations and Management of IDUNICEF/ WHO Regional Consultation 1999 . Prevention and Control of IDA in Women and ChildrenWHO 2004 .Focusing on anaemia , Towards an integrated approach for effective anaemia control

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