Iron Deficiency Anemia Recommended Guidelines for the Prevention, Detection, and Management Among U.S. Children and Women of Childbearing Age (1993) / Chapter Skim
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B IRON DEFICIENCY ANEMIA: A SYNTHESIS OF CURRENT SCIENTIFIC KNOWLEDGE AND U.S. RECOMMENDATIONS FOR PREVENTION AND TREATMENT
B IRON DEFICIENCY ANEMIA: A SYNTHESIS OF CURRENT SCIENTIFIC KNOWLEDGE AND U.S. RECOMMENDATIONS FOR PREVENTION AND TREATMENT
Pages 41-98
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From page 41... ...
There has been great progress in preventing iron deficiency anemia among infants and children, but the prevalence among pregnant women of childbearing age remains high. The purpose of this appendix is to provide a brief review of the characteristics of iron deficiency anemia and to review recent guidelines for its prevention in primary health care settings.
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From page 42... ...
The serum ferritin concentration provides an estimate of storage iron reserves. Iron Homeostasis Body Iron Regulation Body iron is regulated primarily by modifying the percentage of food iron that is absorbed.
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From page 43... ...
Low iron stores per se indicate that an individual is vulnerable to developing iron deficiency anemia, but as long as the production of essential iron remains intact, there are no known physiologic handicaps from having low iron reserves (Dallman, 1986~. Iron Loss and Absorption Differences Between Women and Men Women have greater iron losses and absorb a greater percentage of iron from food than do men.
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From page 44... ...
are at risk of developing an iron-responsive depression in hemoglobin concentration in the third trimester unless they receive supplemental iron (Table B-2~. Among women who are already iron deficient when they become pregnant, the severity of the deficiency will usually increase as pregnancy progresses unless they take an iron supplement.
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From page 45... ...
FIGURE By Frequency distribution of menstrual blood loss. Although the mean menstrual blood loss is about 30 ml/month, about 10 percent of women lose more than 80 ml/month.
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The control group comprised normal women, the pill group comprised normal women taking the combination variety of oral contraceptives, and the IUD group comprised women using intrauterine devices (IUDs)
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From page 47... ...
47 em ,_ c Hi: u · _ o Ct o V)
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From page 48... ...
At 1 year of age, for example, iron absorption is about four times greater than excretion, the difference being used for growth (Figure B-8~. The risk of developing iron deficiency anemia during this period depends largely on the diet (Penrod et al., 1990; Pizarro et al., 1991; Tunnessen and Oski, 1987~.
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From page 49... ...
that iron-fortified infant cereals also play a significant role in preventing iron deficiency anemia. Low-birth-weight infants may become iron deficient after 2 months of age and possibly earlier unless they are given an iron supplement (Lundstrom et al., 1977; Slimes et al., 1984)
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From page 50... ...
o ~ o ] 175-1 ~3- ~=-~ Age Interval, days FIGURE B~10 The fecal hemoglobin concentrations of infants fed formula (a)
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From page 51... ...
Low-birth-weight infants weighing 1,000 to 2,000 g are likely to develop iron deficiency anemia after 2 months of age if not given iron supplements (a)
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From page 52... ...
. Heme iron is better absorbed than non-heme iron, but non-heme iron makes up about 90 percent of the iron in the diet, and its absorption is strongly influenced by enhancers and inhibitors of iron absorption consumed in the same meal.
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From page 53... ...
Percent absorption from each form of iron is shown for an iron-replete man, a premenopausal woman, and a person with iron deficiency, individuals with assumed serum ferritin concentrations of 100, 30, and 10 ~g/liter, respectively.
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From page 54... ...
A daily diet with low iron bioavailability is one containing less than 30 g of meat, poultry, or fish (lean, raw weight) or less than 25 mg of ascorbic acid.
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From page 55... ...
Absorption of Iron from Iron-Fortified Foods Absorption of iron from iron-fortified foods has been a major factor in the declining prevalence of iron deficiency anemia among infants and children (Bothwell and MacPhail, 1992; Cook and Bothwell, 1984; Hurrell, 1992~. Even the use of fortified cereal products, however, cannot be expected to prevent iron deficiency anemia among women of childbearing age who have unusually high menstrual blood losses (Swiss and Beaton, 1974~.
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From page 56... ...
Calcium and magnesium are the constituents of such tablets that are most likely to inhibit iron absorption (Babior et al., 1985; Seligman et al, 19831. Definitions of Anemia, Iron Deficiency Anemia, and Iron Deficiency Anemia Anemia is defined as a hemoglobin concentration (or hematocrit)
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From page 57... ...
\\~`,_~,~,'/ ~I I ~ 28 32 31; 40 0 4 8 12 16 20 24 Week d Gestation FIGURE m16 Hemoglobin values during pregnancy. The hemoglobin concentration normally declines during the first half of pregnancy and rises during the second half.
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From page 58... ...
58 ·f Ct m so .~ C)
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From page 59... ...
Iron Deficiency Anemia Iron deficiency anemia refers to an anemia that is associated with additional laboratory evidence of iron depletion, such as a low serum ferritin concentration, transferrin saturation, or mean corpuscular volume (MCV) or an elevation in e~ythrocyte protoporphyrin or transferrin receptor levels.
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From page 60... ...
Other laboratory tests used in the diagnosis of iron deficiency anemia include MCV, serum iron concentration and iron-binding capacity, and transferrin receptor concentration. MCV is one of the red blood cell indices that is provided by many laboratories when a hemoglobin concentration is ordered.
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From page 61... ...
If such tests are to be used in large populations, they must be relatively inexpensive and should preferably provide a result rapidly enough to allow initiation of treatment on the same visit. Tests that are widely used for this purpose are determination of erythrocyte protoporphyrin and serum ferritin concentrations.
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From page 62... ...
There thus remains some degree of uncertainty about the usefulness of serum ferritin concentration determination in distinguishing iron-supplemented from unsupplemented and potentially iron-deficient individuals in the last half of pregnancy. In nonpregnant women and children, a serum ferritin concentration of less than 12-15 pa/liter indicates that iron stores are very low, and a value in this range in combination with anemia provides strong evidence that the anemia is due to iron deficiency.
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From page 63... ...
. This conclusion was based on data showing that newborns of mothers with mild iron deficiency anemia at term were not anemic and had normal or only slightly diminished iron stores, as estimated on the basis of the serum ferritin concentration.
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From page 64... ...
Developmental indices (mean ~ standard error of the mean) were lower in 12-month~ld infants with iron deficiency anemia (hemoglobin concentration, <10.5 g/dl)
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From page 65... ...
Group 1 (n = So) consisted of infants with iron deficiency anemia (hemoglobin concentration, <10.5 g/dl; transferrin saturation, <10 percent; serum ferritin concentration, <10 ~g/liter)
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From page 66... ...
for pregnant women on the basis of a carefi~1 evaluation of currently available evidence. As in the case of infants, the weight of evidence leads to the conclusion that anticipation and prevention of iron deficiency anemia deserve a high priority.
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From page 67... ...
Iron-binding proteins in plasma and tissues offer protection against such damage by binding ionic iron, but there are reasons to suspect that this protection is incomplete (Cross et al., 1987; Weinberg, 19841. Specific conditions in which there may be an association of clinical disease with high iron stores include ischemic heart disease (Salonen et al., 1992~.
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From page 68... ...
In general, the same hemoglobin criteria have been used for all races when screening women and children for anemia. This raises the problem that the percentage of black women and children who are erroneously suspected of having iron deficiency anemia is high enough to pose practical difficulties
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From page 69... ...
Use of the same hemoglobin concentration criterion for women and children of all races is the simplest approach and recognizes the fact that not all blacks have low hemoglobin concentrations. However, many normal black individuals are incorrectly suspected of having iron deficiency anemia.
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From page 70... ...
(1983) found that iron absorption almost doubled when calcium as calcium carbonate was decreased from 350 to 250 mg and magnesium as magnesium oxide was decreased from 100 to 25 ma.
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From page 71... ...
The consistently higher prevalence of anemia among blacks than among Hispanics or whites (about 8 percent in the first trimester, 10 percent in the second trimester, and 15 to 20 percent in the third trimester) is partly due to the lower hemoglobin concentrations in blacks, even those with normal iron status.
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From page 72... ...
The recent studies associating iron deficiency anemia or anemia in early pregnancy with low birth weight will also foster increased and earlier use of iron supplements. Between 1976 and 1980, 38 percent of women between the ages of 18 and 50 reported taking a vitamin supplement, a mineral supplement, or both (Laplan et al., 1986~.
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From page 73... ...
Compliance can be improved by using strong motivational techniques and frequent follow-up. Under ordinary circumstances, however, especially in busy and understaffed clinics, it seems likely that poor compliance is frequently responsible for a failure to treat or prevent iron deficiency anemia.
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From page 74... ...
As mentioned above, iron-fortified foods have been remarkably effective in reducing the prevalence of iron deficiency anemia among infants and preschool children, thereby decreasing the vulnerability to lead poisoning. Environmental exposure to lead has decreased since leaded gasoline has been removed from the market (Annest et al., 1983~; removal of additional lead from the environment will be much more costly.
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From page 75... ...
that yielded a prevalence of 5 percent among women during their childbearing years. Since then, the prevalence of iron deficiency anemia in infants and preschool children has been declining drastically on the basis of the prevalence of anemia in clinics that participate in the U.S.
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From page 76... ...
Preterm Infants Studies comparing the concentration of hemoglobin and other iron status measures in iron-supplemented and unsupplemented infants show that those with a birth weight of less than 2,000 g are at very high risk of developing iron deficiency anemia after 2 months of age unless they receive an iron supplement, iron-fortif~ed formula, or both (Lundstrom et al., 1977) (Figure B-11~.
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From page 77... ...
77 Anemia (percent)
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From page 78... ...
Anemia and low to normal hemoglobin concentration are more common among healthy 1-year-old infants with a history of recent mild infection than among those who have been entirely well. ESR is erythrocste sedimentation rate.
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From page 79... ...
Iron supplementation for low-birth-weight infants should start when the infant reaches a body weight of about 2,000 g or goes home. Infants fed human milk should receive 2 to 3 mg of elemental iron (per kg/day)
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From page 80... ...
IRON DEFICIENCY IN WOMEN OF CHILDBEARING POTENTIAL: PREVALENCE AND RECENT RECOMMENDATIONS Magnitude of the Problem In contrast to children in whom inadequate iron intake is usually responsible for iron deficiency, excessive iron losses via menstrual blood and pregnancy play major roles among women of childbearing age. Also in contrast to children, there is no evidence that the prevalence of iron deficiency among women of childbearing age has declined substantially during the past two decades.
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From page 81... ...
, and about 3 percent had iron deficiency anemia (anemia plus two or three abnormal hemoglobin values)
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From page 82... ...
The discrepancy increases progressively from the first to the second and third trimesters. The high prevalence is partly related to the lower hemoglobin concentrations in blacks, even when iron status is normal.
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From page 83... ...
that contains enhancers of iron absorption (ascorbic acid, meat)
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From page 84... ...
Anemia accompanied by a serum ferritin concentration of less than 12 ,uglliter can be presumed to be iron deficiency anemia and requires treatment with 60 to 120 mg of ferrous iron daily (no more than about 60 mg per dose)
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From page 85... ...
I _ . 120 mg ,~ 30mg On ~ placebo 20 25 30 35 40 Week of Gestation 30 mg ~ 1 20 mg -to placebo 20 25 30 35 Week of Gestation 40 FIGURE s-26 Serum iron and hemoglobin levels in groups of 46 to 49 randomly assigned women receiving either a placebo or various doses of elemental iron as ferrous fumarate given orally on a daily basis.
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From page 86... ...
. Iron absorption increased during the progression of pregnancy.
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From page 87... ...
of Prenatal Daily Vitamin Mineral Supplements for Use by Women Identified To Be At High Nutritional Riska Nutrient Amount Iron Zinc Copper Calciumb Vitamin D Vitamin C Vitamin B6 Folate Vitamin B12 a If vitamin A is included, ,B carotene is preferred over retinal, to reduce the risk of toxicity or other adverse reactions. b Since calcium and magnesium may interfere with iron absorption, upper limits of 250 and 23 ma per 30 60 mg 15 mg 2mg 250 mg 10 fig (400 IU)
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From page 88... ...
Women with iron deficiency anemia should therefore be detected by laboratory screening, and intervention with iron supplements should be recommended for women with iron deficiency anemia.
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From page 89... ...
60 mg of elemental iron is equivalent to: 300 mg of ferrous sulfate about 190 mg of exsiccated ferrous sulfate 180 mg of ferrous fumarate 500 mg of ferrous gluconate What to tell the patient to improve compliance and safety 1. Taking iron to prevent or treat iron deficiency anemia helps to reduce fatigue and increase your ability to adapt to delivery.
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From page 90... ...
Hibbard (1988) proposed screening pregnant women and treating those in low-risk categories with iron only if they have a low serum ferritin concentration or anemia, but Horn (1988)
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From page 91... ...
World Health Organization The document Preventing and Controlling Iron Deficiency Anemia Through Primary Health Care (DeMaeyer, 1989) noted the need for supplementation in situations such as pregnancy, in which rapid improvement in iron status is important.
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From page 92... ...
1989. Nutritional iron requirements and food iron absorption.
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From page 93... ...
1984. The effect of high ascorbic acid supplementation on body iron stores.
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From page 94... ...
1992. Serum transfemn receptor distinguishes the anemia of chronic from iron deficiency anemia.
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From page 95... ...
1991. Calcium: Effect of different amounts on nonheme- and heme-iron absorption in humans.
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From page 96... ...
Hemoglobin difference between black and white women with comparable iron status: Justification for race-specific criteria?
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From page 97... ...
1987. Red blood cell zinc protoporphyrin testing for iron-deficiency anemia in pregnancy.
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From page 98... ...
1989. Iron deficiency anemia: Adverse effects on infant psychomotor development.
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