Screening for Iron Deficiency - Abu Osba Medical

Screening for Iron DeficiencyScreening for Iron Deficiency

Prepared by Maa’n I.Mesmeh,M.D.Prepared by Maa’n I.Mesmeh,M.D.

Moderated by Dr. Yousef Abu-OsbaModerated by Dr. Yousef Abu-Osba

Screening for Iron DeficiencyScreening for Iron Deficiency

DefinitionsDefinitionsEpidemiologyEpidemiologyPathogenesisPathogenesisClinical AspectsClinical AspectsMaking the DiagnosisMaking the DiagnosisLaboratory ParametersLaboratory ParametersDietDietPrevention Prevention

Screening for Iron DeficiencyScreening for Iron Deficiency

IntroductionIntroduction : :

why it is an important health problem ?why it is an important health problem ?

Its serious sequelaeIts serious sequelae

Its prevalenceIts prevalence

Still seen frequentlyStill seen frequently

Screening for Iron DeficiencyScreening for Iron Deficiency

AnemiaAnemia : : Definition Definition CausesCauses CategorizingCategorizing

IronIron : : DepletionDepletion DeficiencyDeficiency Iron deficiency anemiaIron deficiency anemia

Screening for Iron DeficiencyScreening for Iron Deficiency

EpidemiologyEpidemiology : : WHO estimates : most of the world’s WHO estimates : most of the world’s

population are iron deficient , one third population are iron deficient , one third have anemia .have anemia .

High prevalence in the late 1960s led to the High prevalence in the late 1960s led to the introduction of preventive programs .introduction of preventive programs .

WIC actWIC act Iron deficiency remains common in the Iron deficiency remains common in the

developed countries & sever cases still developed countries & sever cases still occur .occur .

0.00%

1.00%

2.00%

3.00%

4.00%

5.00%

6.00%

7.00%

8.00%

1975 1985

Prevalence

Prevalence

0%

2%

4%

6%

8%

10%

12%

14%

1 year 2 year 12-15 years 16-49 years

Iron Deficiency

Series1

0%

1%

1%

2%

2%

3%

3%

4%

4%

Toddlers Adolescent Females Child bearing Age

Iron Deficiency Anemia

Series1

Screening for Iron DeficiencyScreening for Iron Deficiency

Attributable factors are different in the Attributable factors are different in the developing countries from developed countries .developing countries from developed countries .Some sectors of the population are more Some sectors of the population are more susceptible .susceptible .The difference between the infants & toddlers in The difference between the infants & toddlers in regard to fortification of formula , diet & cow milk regard to fortification of formula , diet & cow milk ingestion .ingestion .The difference between the male & the female .The difference between the male & the female .In the first months of life no role for iron In the first months of life no role for iron deficiency .deficiency .

Screening for Iron DeficiencyScreening for Iron Deficiency

PathogenesisPathogenesis : : Site Site Role Role Absorption :Absorption : heme & nonheme heme & nonheme inhibitors of iron absorptioninhibitors of iron absorption enhanced absorptionenhanced absorption absorbability difference between human milk absorbability difference between human milk

(50%) , cow milk (10%) , fortified formula (5%) . (50%) , cow milk (10%) , fortified formula (5%) .

Screening for Iron DeficiencyScreening for Iron Deficiency

TransportTransport

Source & Storage : developing fetus , Source & Storage : developing fetus , depletion of 50% occurs in the first 4 depletion of 50% occurs in the first 4 months , depletion of the stores occur at 2-months , depletion of the stores occur at 2-3 months in the preterm3 months in the preterm

Loss occur in GIT , urine & skin .Loss occur in GIT , urine & skin .

Daily needs ( o.8 mg/d : 0.6 growth , 0.2 for Daily needs ( o.8 mg/d : 0.6 growth , 0.2 for ongoing lossesongoing losses

Screening for Iron DeficiencyScreening for Iron Deficiency

Clinical AspectsClinical Aspects : : S&S depends on the degree of deficiency & S&S depends on the degree of deficiency &

on the rate of development of the deficiencyon the rate of development of the deficiency The most frequent sign is pallorThe most frequent sign is pallor 10-15% splenomegally10-15% splenomegally Irritability & anorexia in infants & toddlersIrritability & anorexia in infants & toddlers 45% of sever cases were asymptomatic45% of sever cases were asymptomatic Developmental delay : ? irreversibilityDevelopmental delay : ? irreversibility

Screening for Iron DeficiencyScreening for Iron Deficiency

Clinical AspectsClinical Aspects : :

Other S&S :Other S&S :

poor growth , blue sclerae , koilonychia , poor growth , blue sclerae , koilonychia , angular stomatitis , increased susceptibility angular stomatitis , increased susceptibility to infections , GIT symptoms , increased to infections , GIT symptoms , increased lead absorption , pica & plumbism .lead absorption , pica & plumbism .

Screening for Iron DeficiencyScreening for Iron Deficiency

Making the DiagnosisMaking the Diagnosis : :

DDx narrows once classified as microcytic :DDx narrows once classified as microcytic :

IDAIDA

ThalassemiaThalassemia

Lead poisoningLead poisoning

Chronic diseaseChronic disease

Sideroblastic anemiaSideroblastic anemia

Screening for Iron DeficiencyScreening for Iron Deficiency

Making the DiagnosisMaking the Diagnosis : : The gold standard for identifying iron deficiency is The gold standard for identifying iron deficiency is

bone marrow biopsy with Prussian blue bone marrow biopsy with Prussian blue staining .staining .

Otherwise no single best test to diagnose iron Otherwise no single best test to diagnose iron deficiencydeficiency

Hematological & biochemical tests are based on Hematological & biochemical tests are based on RBCs features & iron metabolismRBCs features & iron metabolism

Biochemical tests detect early iron deficiencyBiochemical tests detect early iron deficiency CHr is a new testCHr is a new test

Screening for Iron DeficiencyScreening for Iron Deficiency

Laboratory ParametersLaboratory Parameters : : 1) Hematological Markers:1) Hematological Markers: The changes through the spectrum from normal to The changes through the spectrum from normal to

IDA in :IDA in : * Hgb & MCV are late markers & less specific* Hgb & MCV are late markers & less specific * RDW is highly sensitive but has low specificity* RDW is highly sensitive but has low specificity * Reticulocytes : for assessing response to Rx .* Reticulocytes : for assessing response to Rx . * CHr : is the best predictor of iron deficiency * CHr : is the best predictor of iron deficiency

among Hgb , MCV , s.iron , RDW & transferrin among Hgb , MCV , s.iron , RDW & transferrin saturation .saturation .

Screening for Iron DeficiencyScreening for Iron Deficiency

Screening for Iron DeficiencyScreening for Iron Deficiency

Laboratory ParametersLaboratory Parameters : :

2) Biochemical Markers :2) Biochemical Markers :

*S.ferritin is the earliest marker of iron deficiency *S.ferritin is the earliest marker of iron deficiency with high specificitywith high specificity

*S.iron is not accurate because it is affected by iron *S.iron is not accurate because it is affected by iron absorption , infection , inflammation & diurnal absorption , infection , inflammation & diurnal variation .variation .

*TIBC measures iron-binding sites but affected by *TIBC measures iron-binding sites but affected by malnutrition , inflammation , chromic infection & malnutrition , inflammation , chromic infection & cancer .cancer .

*Transferrin saturation (%) = s.iron ÷ TIBC*Transferrin saturation (%) = s.iron ÷ TIBC

Screening for Iron DeficiencyScreening for Iron Deficiency

Laboratory ParametersLaboratory Parameters : :

2) Biochemical Markers :2) Biochemical Markers :

*TfR by immunoassay . It presents in *TfR by immunoassay . It presents in immature reticulocytes . It is early marker immature reticulocytes . It is early marker & can differentiate between IDA & chronic & can differentiate between IDA & chronic illnessillness

*ZPP/heme is an early marker but not *ZPP/heme is an early marker but not specificspecific

Screening for Iron DeficiencyScreening for Iron Deficiency

Screening for Iron DeficiencyScreening for Iron Deficiency

DietDiet : :

The dietary history is suggestiveThe dietary history is suggestive

IDA in one study defined as :IDA in one study defined as :

1) < 5 servings per week1) < 5 servings per week

2) > 16 oz milk per day2) > 16 oz milk per day

3) Daily fatty snacks , sweets & > 16 oz soda.3) Daily fatty snacks , sweets & > 16 oz soda.

In this case the history was 71% sensitive , 79% In this case the history was 71% sensitive , 79% specific , 97% negative predictive valuespecific , 97% negative predictive value

Screening for Iron DeficiencyScreening for Iron Deficiency

PreventionPrevention : : PrimaryPrimary SecondarySecondary AAP recommendation : Hgb & Hct once AAP recommendation : Hgb & Hct once

between 9-12 months & again after 6 between 9-12 months & again after 6 months ( consider risk factor & prevalence months ( consider risk factor & prevalence in the population ) also all adolscence in the population ) also all adolscence once between 11-21 years in addition to once between 11-21 years in addition to all mensruating females annuallyall mensruating females annually

Screening for Iron DeficiencyScreening for Iron Deficiency

Screening for Iron DeficiencyScreening for Iron Deficiency

TreatmentTreatment : :

oral iron saltsoral iron salts

parenteral ironparenteral iron

PRBCsPRBCs

Follow upFollow up : increase of 10 g /L after one : increase of 10 g /L after one month of Rx confirms the diagnosismonth of Rx confirms the diagnosis

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