Anemia in Childhood.

Anemia is a pervasive problem in pediatrics and evaluating for it is considered part of standard care for all pediatric patients. If left untreated, it can cause significant problems for children and many of the detriments can be long lasting. Although iron deficiency anemia is the most common form of pediatric anemia, it is important to keep the broad differential in mind for those in whom the history suggests an alternate diagnosis or who do not respond to standard treatment with iron supplementation. This article gives a basic overview of anemia in children with a focus on iron deficiency. [Pediatr Ann. 2018;47(2):e42-e47.].

The role of preoperative iron deficiency in colorectal cancer patients: prevalence and treatment.

BACKGROUND: In preoperative blood management of colorectal cancer patients, intravenous iron therapy is increasingly used to treat anaemia and prevent red blood cell transfusions. However, while iron deficiency is the most common cause of anaemia, little is known about the prevalence and namely type of iron deficiency in this population, whereas both types of iron deficiency (i.e. absolute and functional iron deficiency) are recommended to be treated differently by international cancer guidelines. OBJECTIVE: The aim of present study is to investigate the prevalence and namely type of iron deficiency in colorectal cancer patients, and to assess its clinical relevance. METHODS: Preoperative iron status, clinical parameters (i.e. age, ASA classification, tumour location, tumour stage) and postoperative complications were retrospectively collected for all newly diagnosed colorectal cancer patients in our institution over a 3-year period. RESULTS: Iron deficiency was observed in 163 (48.1%) of 339 patients. Of these iron-deficient patients, 3.7% had an isolated absolute iron deficiency (AID) and 15.3% a functional iron deficiency (FID), while the rest had a combination of AID and FID. Anaemia was present in 66.1% of iron-deficient patients. Iron deficiency was significantly associated with an increased postoperative complication rate (univariable OR 1.94, p = 0.03, multivariable OR 1.84, p = 0.07), with right-sided tumours (p < 0.001), high ASA classification (p = 0.002), advanced tumour stage (p = 0.01) and advanced age (p = 0.04). In comparing clinical parameters between patients with AID and FID, advanced age was significantly associated with FID (p = 0.03), and the presence of anaemia with AID (p = 0.02). CONCLUSION: In preoperative colorectal cancer patients, there is a high prevalence of iron deficiency, including a high percentage of patients with-a component of-functional iron deficiency, associated with the increased postoperative complication rate. As both types of iron deficiency require a different treatment strategy, our results illustrate the therapeutic potential of especially intravenous iron supplementation in patients with severe iron deficiency and stress the urgency of routinely monitoring preoperative iron status and differentiation between types of iron deficiency. As iron therapy may also be potentially harmful in respect to stimulation of tumour growth, future clinical trials assessing the long-term effect of iron therapy are necessary.

Ferrous gluconate and ferrous sulfate added to a complementary food distributed by the Mexican nutrition program Oportunidades have a comparable efficacy to reduce iron deficiency in toddlers.

OBJECTIVE: To assess the efficacy of ferrous sulfate (FS) and ferrous gluconate (FG) as fortificants for a complementary baby food (Nutrisano) to improve the iron status and to reduce the prevalence of anemia in toddlers. PATIENTS AND METHODS: Toddlers 12 to 30 months old were randomly assigned to receive either of 3 versions of Nutrisano fortified with FS or FG or not fortified (CG) for 6 months. In final blood samples, the concentrations of hemoglobin, serum ferritin, and soluble transferrin receptors (sTfR) were determined. The effects of treatment on final hemoglobin, ferritin, and sTfR were assessed by multivariate analysis. RESULTS: No significant changes in hemoglobin were observed within or among treatment groups. The prevalence of high sTfR decreased 7.1 percentage points in FG, increased 13.1 percentage points in FS, and increased 0.7 percentage points in CG (P>0.05). In an interaction between treatment and total intake of Nutrisano on the concentration of ferritin, sTfR, and total iron body stores, adjusted means of serum ferritin in the medium tertiles of intake of Nutrisano for FS (P=0.05) and in the higher and medium tertiles for FG were higher (P=0.001), and adjusted means of sTfR were significantly lower (P<0.001), than the respective lower tertile of intake. CONCLUSIONS: Fortification of Nutrisano with FG has an acceptable level of beneficial effect on markers of iron status. The satisfactory efficacy and other sensory data has led to the political decision to substitute hydrogen-reduced iron, used formerly as a fortificant, with FG. Studies to assess the effectiveness of the reformulated Nutrisano are in order.

Prevalence of celiac disease, Helicobacter pylori and gastroesophageal reflux in patients with refractory iron deficiency anemia.

OBJECTIVE: The aim of this article is to determine the prevalence of celiac disease (CD), Helicobacter pylori (H. pylori) and gastroesophageal reflux (GER) in patients with resistant iron deficiency anemia (IDA). PATIENTS: The study included 25 patients <18 years of age with refractory IDA (not responding to iron therapy for 3 months in a dose of 6 mg elemental iron/kg/day). METHODS: All patients included in the study were subjected to careful history taking and thorough clinical examination. Blood sample was taken for analysis of antibodies for CD including: antigliadin antibody (AGA), antiendomysial antibody (EMA), antireticulin antibody (ARA) and antitissue Transglutaminase (tTg) IgG antibody. Anti-H. pylori IgG antibodies and a (13)C-urea breath test (UBT) was done to all patients to diagnose H. pylori. Upper gastrointestinal tract endoscopy was done for all patients to evaluate for the presence of some etiologies of intractable anemia as chronic blood loss. These included: CD, H. pylori infection and GER. The upper gastrointestinal tract endoscopy was also done to evaluate the presence of bleeding spots, ulcers or angiomatous malformations. In addition, gastric antral biopsies were taken for diagnosis of H. pylori infection by the following tests: rapid urease test, histopathological examination and culture. RESULTS: CD was positive in 11 out of 25 patients (44%), H. pylori infection in 12 out of 25 patients (48%), while GER was diagnosed in 11 out of 25 patients (44%). Patients with CD had age of presentation < or =2 years in two patients (18.2%) while the remaining nine patients (81.8%) had age of presentation >2 years and it was statistically significant (p = 0.05*). Also patients with H. pylori had age of presentation < or =4 years in five patients (41.7%) and the remaining seven patients (81.8%) had age of presentation >4 years and it was statistically significant (p = 0.03*). Logistic regression analysis demonstrated that the risk factors for severity of anemia were age of patients and duration of anemia. On the other hand, other parameters have no significant influence on the severity of anemia. Also risk factors of short stature were age of presentation of anemia, degree of anemia and H. pylori infection. AGA had the highest sensitivity (100%) followed by antiendomysium antibody (81.8%) while the tTG antibody had the highest specificity (85.7%) for diagnosis of CD. UBT and histopathology had the highest sensitivity (100%) for diagnosis of H. pylori while rapid urease test, culture, H. pylori stool antigen and anti-H. pylori IgG antibody had the highest specificity (100%). In conclusion, refractory IDA may be due to clinically unapparent H. pylori gastritis and CD. CD is one of the most common causes of intestinal malabsorption during childhood which leads to impairment of iron absorption. Apart from offering them gluten-free diet rich in iron, early detection and treatment of IDA and prophylactic iron and folic acid supplementation will go a long way to optimize their mental and psychological functions. Eradication of H. pylori infection with concomitant iron therapy should correct the anemia.

Inflammation and iron deficiency in the hypoferremia of obesity.

CONTEXT: Obesity is associated with hypoferremia, but it is unclear if this condition is caused by insufficient iron stores or diminished iron availability related to inflammation-induced iron sequestration. OBJECTIVE: To examine the relationships between obesity, serum iron, measures of iron intake, iron stores and inflammation. We hypothesized that both inflammation-induced sequestration of iron and true iron deficiency were involved in the hypoferremia of obesity. DESIGN: Cross-sectional analysis of factors anticipated to affect serum iron. SETTING: Outpatient clinic visits. PATIENTS: Convenience sample of 234 obese and 172 non-obese adults. MAIN OUTCOME MEASURES: Relationships between serum iron, adiposity, and serum transferrin receptor, C-reactive protein, ferritin, and iron intake analyzed by analysis of covariance and multiple linear regression. RESULTS: Serum iron was lower (75.8+/-35.2 vs 86.5+/-34.2 g/dl, P=0.002), whereas transferrin receptor (22.6+/-7.1 vs 21.0+/-7.2 nmol/l, P=0.026), C-reactive protein (0.75+/-0.67 vs 0.34+/-0.67 mg/dl, P<0.0001) and ferritin (81.1+/-88.8 vs 57.6+/-88.7 microg/l, P=0.009) were higher in obese than non-obese subjects. Obese subjects had a higher prevalence of iron deficiency defined by serum iron (24.3%, confidence intervals (CI) 19.3-30.2 vs 15.7%, CI 11.0-21.9%, P=0.03) and transferrin receptor (26.9%, CI 21.6-33.0 vs 15.7%, CI 11.0-21.9%, P=0.0078) but not by ferritin (9.8%, CI 6.6-14.4 vs 9.3%, CI 5.7-14.7%, P=0.99). Transferrin receptor, ferritin and C-reactive protein contributed independently as predictors of serum iron. CONCLUSIONS: The hypoferremia of obesity appears to be explained both by true iron deficiency and by inflammatory-mediated functional iron deficiency.

Prevalence and severity of anemia and iron deficiency: cross-sectional studies in adolescent schoolgirls in western Kenya.

OBJECTIVE: Anemia is a major public health concern in preschool children and pregnant women in the developing world. While many studies have examined these two at-risk groups, there is a paucity of data on anemia in adolescents living in developing countries in the complex ecologic context of poverty, parasitism, and malnutrition. We evaluated the prevalence, severity, and risk factors of anemia in adolescent schoolgirls in an area with intense malaria transmission in western Kenya. DESIGN: Two cross-sectional surveys were conducted, using a multistage random sample design. SETTING: Public primary schools in an area with intense malaria transmission in western Kenya. SUBJECTS: A total of 648 randomly selected adolescent schoolgirls aged 12-18 y. RESULTS: The prevalence of anemia (Hb <120 g/l) was 21.1%; only one girl had an Hb less than 70 g/l. Ferritin levels were available from a subsample of 206 girls. The prevalence of iron deficiency (ferritin <12 microg/l) was 19.8, and 30.4% of anemic girls were iron deficient. Malaria and schistosomiasis were the main risk factors for anemia in younger girls (12-13 y), while menstruation was the principal risk factor in older girls (14-18 y). CONCLUSIONS: Iron deficiency and anemia in school-attending girls in western Kenya were more prevalent than in developed countries, but considerably less prevalent than in preschool children and pregnant women from the same study area. Our findings are consistent with other recent school-based surveys from western Kenya, but not with recent community- and school-based cross-sectional surveys from other parts of sub-Saharan Africa. It deserves further study to determine if adolescent girls not attending school are at higher risk of anemia.

Anemia in children.

Anemia in children is commonly encountered by the family physician. Multiple causes exist, but with a thorough history, a physical examination and limited laboratory evaluation a specific diagnosis can usually be established. The use of the mean corpuscular volume to classify the anemia as microcytic, normocytic or macrocytic is a standard diagnostic approach. The most common form of microcytic anemia is iron deficiency caused by reduced dietary intake. It is easily treatable with supplemental iron and early intervention may prevent later loss of cognitive function. Less common causes of microcytosis are thalassemia and lead poisoning. Normocytic anemia has many causes, making the diagnosis more difficult. The reticulocyte count will help narrow the differential diagnosis; however, additional testing may be necessary to rule out hemolysis, hemoglobinopathies, membrane defects and enzymopathies. Macrocytic anemia may be caused by a deficiency of folic acid and/or vitamin B12, hypothyroidism and liver disease. This form of anemia is uncommon in children.

[Clinical classification of iron deficiency anemia]. / Klinichna klasyfikatsiia zalizodefitsytnoï anemiï.

Symptoms have been analyzed of clinical pleomorphism of iron deficiency anemia (IDA). In the examination of 89 patients with IDA, as example, a complex of secondary abnormalities of metabolism accompanying IDA clinical course is demonstrated. Based on the study of aspects of the clinical course, features of the peripheral blood, indices for iron metabolism, measuring of the blood content of lactic, pyruvic acids, free histamine, free serotonin, free heparin in the blood plasma a clinical classification has been elaborated detailing stages of the condition, basic clinical forms and complications. A classification of IDA is presented. Included in the above classification are stages of the above medical condition, its clinical forms and complications with diagnostic criteria and policy of dealing with IDA outlined. The use of such a classification ensures continuity of work among physicians when they come to deal with problems of diagnosis, treatment and prophylaxis of IDA in patients.

Nutrition and maternal mortality in the developing world.

This review relates nutritional status to pregnancy-related death in the developing world, where maternal mortality rates are typically >/=100-fold higher than rates in the industrialized countries. For 3 of the central causes of maternal mortality (ie, induced abortion, puerperal infection, and pregnancy-induced hypertension), knowledge of the contribution of nutrition is too scanty for programmatic application. Hemorrhage (including, for this discussion, anemia) and obstructed labor are different. The risk of death is greatly increased with severe anemia (Hb <70 or 80 g/L); there is little evidence of increased risk associated with mild or moderate anemia. Current programs of universal iron supplementation are unlikely to have much effect on severe anemia. There is an urgent need to reassess how to approach anemia control in pregnant women. Obstructed labor is far more common in short women. Unfortunately, nutritional strategies for increasing adult stature are nearly nonexistent: supplemental feeding appears to have little benefit after 3 y of age and could possibly be harmful at later ages, inducing accelerated growth before puberty, earlier menarche (and possible earlier marriage), and unchanged adult stature. Deprived girls without intervention typically have late menarche, extended periods of growth, and can achieve nearly complete catch-up growth. The need for operative delivery also increases with increased fetal size. Supplementary feeding could therefore increase the risk of obstructed labor. In the absence of accessible obstetric services, primiparous women <1.5 m in height should be excluded from supplementary feeding programs aimed at accelerating fetal growth. The knowledge base to model the risks and benefits of increased fetal size does not exist.

School-administered weekly iron-folate supplements improve hemoglobin and ferritin concentrations in Malaysian adolescent girls.

BACKGROUND: Iron deficiency and its consequent anemia constitute the commonest micronutrient deficiency in the world. OBJECTIVE: We investigated whether long-term, weekly iron-folate supplements administered at school would improve hemoglobin and ferritin concentrations in adolescent girls, including those with mild-to-moderate anemia and hemoglobin concentrations indicating borderline anemia. DESIGN: Subjects were 266 girls with hemoglobin concentrations of 80-119.9 g/L (group A) and 358 girls with hemoglobin concentrations of 120-130 g/L (group B) who were otherwise healthy. Two hundred sixty-six girls in group A and 268 girls in group B were randomly assigned to receive either 60 or 120 mg Fe plus 3.5 mg folic acid weekly for 22 wk. Ninety of the girls in group B were randomly assigned to receive only 5 mg folic acid weekly. Capillary hemoglobin and plasma ferritin were measured at baseline and after 12 and 22 wk of supplementation. RESULTS: By the end of the study, 2% of the girls had dropped out and > 96% had taken > or = 20 of the 22 tablets; side effects were minimal. Mean plasma ferritin increased significantly in all iron-supplemented groups, independently of initial hemoglobin values and iron doses. Ferritin concentrations decreased in the girls supplemented with folic acid only. As expected, hemoglobin responses to iron were higher in group A than in group B and increases were positively correlated with initial plasma ferritin. Hemoglobin failed to respond to folate supplementation if initial plasma ferritin concentrations were low. Mean hemoglobin increased significantly and consistently in relation to the length of treatment. CONCLUSION: Long-term, weekly iron-folate supplementation was found to be a practical, safe, effective, and inexpensive method for improving iron nutrition in adolescent schoolgirls.

Iron deficiency and educational deficiency.

Existing data suggest that iron deficiency anemia (IDA) is a risk factor for poor educational performance in schoolchildren. The synergistic effect of IDA in combination with other forms of malnutrition and other risk factors may affect educational performance more strongly. Thus, IDA and its effect on educational performance should be studied in the context of other risk factors.

Use of statistical classifiers as support tools for the diagnosis of iron-deficiency anemia in patients on chronic hemodialysis.

Discriminant analysis, logistic regression and neural network models were applied to the diagnosis of iron-deficiency anemia in hemodialyzed patients. The ability of the three quantitative approaches to distinguish between subjects suffering or not from iron-deficiency anemia was compared by re-substitution and cross-validation testing. Methods performance was evaluated by means of sensitivity, specificity and accuracy. All the methods performed globally well (sensitivity and specificity > 0.85), revealing that the problem is classifiable. Neural networks showed the highest accuracy, both in the re-substitution (models developed and tested on the complete data set) and 3-way cross-validation (data set randomly splitted into 3 developmental and validation data sets) testing. These preliminary results suggest that the correct classification of iron status in the hemodialytic population can be treated as a pattern classification problem, for which neural networks and traditional statistical modelling can be a valuable aid to the clinical diagnosis of iron-deficiency anemia. A better performance of the neural network model must be confirmed through prospective testing on a larger data set.

Iron deficiency anemia in Dubai Medical College for Girls: a preliminary study.

Iron deficiency anemia is still one of the major public health problems all over the world. Particularly in developing countries the complete ecological picture is not well established. All students in the first and second academic years of Dubai Medical College for Girls were included in the present study. The mean Hb was 12.83 +/- 1.49 and that for serum iron was 13.73 micromol/L +/- 4.79. Anemia was detected among 24.62% of the group among which Arab Gulf Nationalities constituted 31.25%. Egyptians showed the highest prevalence of anemia (50%). The study showed a significant effect of chronic blood loss whether menstrual or from any other cause upon the Hb level. Also living in the hostel away from parents and families was reflected upon their diet habits and had a significant reflection upon the prevalence of anemia among the studied group.

No evidence of developmental III effects of low-level lead exposure in a developing country.

Despite substantial controversy regarding the blood levels at which lead adversely affects neurobehavioral development, public health policy in some industrialized countries is prescribing ever more stringent screening criteria for all ages. This study addressed the question of ill effects of lead exposure at the new lower levels, specifically during the late infancy period, which has been targeted for maximum surveillance in pediatric practice. The sample of 184 participants consisted of 12- to 23-month-old healthy infants and toddlers who participated in a community-based study in a developing Central American country (Costa Rica) where extensive family and developmental information was collected. The mean infant blood lead level was 11.0 micrograms/dL, ranging from 5.4 to 37.0 micrograms/dL. Lead levels were not related to the Mental or Psychomotor Developmental Index of the Bayley Scales of Infant Development. When the children were 5 years old, they were reevaluated with complete physical and psychological testing. Blood lead levels in infancy did not predict any of the developmental outcome measures. Thus, among a group of healthy toddlers in a developing country, no ill effects on development of low blood lead levels were observed.