IRON DEFFICIENCY ANAEMIASTUDY DESIGN AND INTERPRETATION

PRESENTED BYDR.PRIYANKA R. PHONDE.

ANEMIADefinition

• Decrease in the number of circulating red blood cells.

• Most common hematologic disorder.• Reduction of hemoglobin concentration below

reference value.

ANEMIACauses

• Blood loss• Decreased production of red blood cells (Marrow

failure)• Increased destruction of red blood cells

– Hemolysis• Distinguished by reticulocyte count

– Decreased in states of decreased production– Increased in destruction of red blood cells

IRONCauses of Iron Deficiency

• Blood Loss– Gastrointestinal Tract– Menstrual Blood Loss– Urinary Blood Loss (Rare)– Blood in Sputum (Rarer)

• Increased Iron Utilization– Pregnancy– Infancy– Adolescence– Polycythemia Vera

• Malabsorption– Tropical Sprue– Gastrectomy– Chronic atrophic gastritis

• Dietary inadequacy (almost never sole cause)• Combinations of above

IRON DEFICIENCYSymptoms

• Fatigue - Sometimes out of proportion to anemia• Atrophic glossitis• Pica (Apetite For Non Food Substances Such As An Ice, Clay)• Koilonychia (Nail spooning)• Esophageal Web• Dizzenes• Headache• Irritability• Palpitation• Dry, Pale Skin• Hair Loss• Increased Platelet Count

BLOOD PARAMETERS• Hemoglobin concentration (Hg)

• F: 7,2 –10; • M: 7,8-11,3 mmol Fe/l (12-18 g/dl)

• Erythrocytes count (RBC)• F: 4-5,5; • M: 4,5-6 x1012/l (4-6 x106 /l)

• Hematocrit (Hct)• F: 37-47; • M: 40-54; (37-54%)

• Platelet count (Plt)• 150 – 450 x 103/l (150-450 x 109/l)

• Leukocytes count (WBC)• 4-10 x 109/l (4-10 x 103/ l)

Erythrocytes parameters

– Mean corpuscular volume (MCV)– N: 80-100 fl

– RDW(Red cell Distrubution Width) – Mean corpuscular hemoglobin (MCH)

– N: 27-34 pg

– Mean corpuscular hemoglobin concentration (MCHC)

– N: 310 – 370 g/lRBC (31-37 g/dl)

IRON DEFICIENCY ANEMIACURE

• ORAL– 200 mg of iron daily 1 hour before meal (e.g. 100

mg twice daily)– How long?

• 14 days + (Hg required level – Hg current level) x 4 – half of the dose - 6 – 9 months to restore iron

reserve– Absorption

• is enhanced: vit C, meat, orange juice, fish• is inhibited: cereals, tea, milk• Usually oral; usually 300-900 mg/day

• Requires acid environment for absorption

IRON THERAPY

• Initial response takes 7-14 days• Modest reticulocytosis (7-10%)• Correction of anemia requires 2-3 months• 6 months of therapy beyond correction of anemia

needed to replete stores, assuming no further loss of blood/iron

• Parenteral iron possible, but problematic

IRON DEFICIENCY ANEMIAPrevalence

Country Men (%) Women (%)

Pregnant Women (%)

S. India 6 35 56 N. India 64 80 Latin America 4 17 38 Israel 14 29 47 Poland 22 Sweden 7 USA 1 13

Aim of the study

• To determine the effect of the timing of iron deficiency anemia during pregnancy on fetal growth and birth outcome.

Objectives • To determine the association between

iron deficiency anemia in pregnancy and birth outcomes.

• To assess whether iron deficiency anemia increase risk of fetal growth.

• To assess the effects of routine iron & folate supplementation on haematological, biochemical parameters and on pregnancy outcome.

Hypothesis• There is a Causal

Relationship between Maternal Iron- Deficiency Anemia and Birth Outcome.

Research Questions • Is the maternal anemia,

assessed primarily as hemoglobin concentration, is causally related to babies weight at birth or duration of gestation ?

Study design • Retrospective study use to identify

the effects of maternal- iron deficiency anemia on birth outcome.

Materials and methods

• Simple random sampling method.• The sample size including (69)

pregnant women.

Materials and methods

• Self-designated questionnaire, self reported and filling questionnaire used to collect data.

• Use of 21 questions to determine the effects of maternal-iron deficiency anemia on Birth outcome.

Data analysis

Age of the mother

Percent Frequency Age of the mother

4.3% 3 Less than 20 years

66.7% 46 20-30 years

23.2% 16 31-40 years

5.8% 4 Missing System

100.0% 69 Total

Do you take iron during pregnancy?

Percent Frequency Do you take iron during pregnancy?

89.9% 62 Yes

10.1% 7 No

100.0% 69 Total

Hb level during this pregnancy

Percent Frequency Hb level during this pregnancy

58.0% 40 Grater than> 10g\L

42.0% 29 Less than<10g\L

100.0% 69 Total

Gestational age in the delivery

Percent Frequency Gestational age in the delivery

15.9% 11 Less than 35 wk

84.1% 58 Between 36-42 wk

100.0% 69 Total

Baby weight Percent Frequency Baby weight

30.4% 21 Less than 2.50g

69.6% 48 2.5-4.5 g

100.0% 69 Total

Type of delivery

Percent Frequency Type of delivery

62.3% 43 C\S

37.7% 26 N\D

100.0% 69 Total

Results of the hypothesis

ANOVA test between taking iron during pregnancy and baby weight

Sig. F Mean Square

Df Sum of Squares

.912 .012 .003 1 .003 Regression

- - .218 67 14.606 Residual

- - - 68 14.609 Total

Since the level of significance (0.912) is bigger than 0.05, we accept the hypothesis and conclude that “There exists no significant relationship, in the significance level 0.05, between taking iron during pregnancy and baby weight.

Simple Linear Regression model between taking iron during pregnancy and baby weight.

t B

7.868 1.673 (Constant)

.111 2.074E-02 Do you take iron during pregnancy?

Since the R equal (0.014) and R square equal (0.000) there is no correlation between taking iron during pregnancy and baby weight.

ANOVA test: between taking iron during pregnancy and type of delivery.

Sig. F Mean Square

Df Sum of Squares

.770 .086 .021 1 .021 Regression

- - .242 67 16.182 Residual

- - - 68 16.203 Total

Since the level of significance (0.770) is bigger than 0.05, we accept the hypothesis and conclude that “There exists no significant relationship, in the significance level 0.05, between taking iron during pregnancy and type of delivery.

Simple Linear Regression model: between taking iron during pregnancy and type of delivery.

t B

5.869 1.313 (Constant)

.294 5.760E-02 Do you take iron during pregnancy?

Since the R equal (0.036) and R square equal (0.001) there is a very weak correlation between taking iron during pregnancy and type of delivery.

ANOVA test between: taking iron during pregnancy and gestational age in the delivery.

Sig. F Mean Square

Df Sum of Squares

.230 1.466 .198 1 .198 Regression

- - .135 67 9.048 Residual

- - - 68 9.246 Total

Since the level of significance (0.230) is bigger than 0.05, we accept the hypothesis and conclude that “There exists no significant relationship, in the significance level 0.05, between taking iron during pregnancy and gestational age in the delivery.

Simple Linear Regression model: between taking iron during pregnancy and gestational age in the delivery.

t B

9.831 1.645 (Constant)

1.211 .177 Do you take iron during pregnancy?

Since the R equal (0.146) and R square equal (0.021) there is a very weak correlation between taking iron during pregnancy and gestational age in the deliver

Discussion• No correlation between baby weight and taking iron

supplement during 3rd trimester of pregnancy.• No correlation between type of delivery and gestational

age with mother Hb level during pregnancy.• The correlation between the other variables, is very

weak.• Supplementation of anemic or no anemic pregnant

women with (IDA) does not appear to increase birth weight or the duration of gestation.

• A negative association between anemia and duration of gestation and low birth weight has been reported in the majority of studies, although a causal link remains to be proven.

• Finally; we reject our hypothesis, and found that their was no causal relationship between maternal – iron deficiency anemia & birth outcomes

Limitation of the study• First, there is a chance of recall bias in the process of

gathering data. Given low income and low socioeconomic status of the pregnant women of this study, it was not feasible to carry out longitudinal studies.

• Second, it is difficult to determine the prevalence of maternal iron deficiency in the pregnant women because of the criteria used to define iron deficiency.

• Third; our result indicate that the third trimester of pregnancy have no affect on birth outcomes, but it doesn’t measure the effect of the second or first trimester pregnancy

Recommendations

• Recommended Guidelines for Preventing And Treating Iron Deficiency Anemia In

Pregnant Women

• At a scheduled third-trimester visit, or if the first prenatal visit occurs in the third trimester, obtain a blood specimen and determine the hemoglobin concentration. Obtain medical evaluation when the hemoglobin concentration is <9.0 g/dl.

• Prescribe 60-120 mg of supplemental iron per day when the hemoglobin concentration is between 9.0 - 10.9 g/dl.

• Prescribe 30 mg of supplemental iron per day when the hemoglobin concentration is 11.0 g/dl.

IRON AND CHILD DEVELOPMENT• FINDING: Increasing evidence that iron deficiency

in children impedes development and that supplementation can reverse delays

• IMPLICATION: Safe and effective public health interventions are needed to address iron deficiency in children

•Sources: Behavioral and developmental effects of preventing iron-deficiency anemia in healthy full-term infants. •Iron deficiency anemia in infancy: long-lasting effects on auditory and visual system functioning.•Effects of iron supplementation and anthelmintic treatment on motor and language development of preschool children, placebo controlled study. • Reversal of developmental delays in iron-deficient anaemic infants treated with iron.

IRON AND GROWTH

• FINDING: In India, iron supplementation supported growth in iron-deficient children, but delayed growth in iron-replete children (Growth delay is believed to result from excess iron competing with zinc absorption)

• IMPLICATION: Iron supplementation for children is not necessarily a magic bullet

Source:. The effect of iron therapy on the growth of iron-replete and iron-deplete children.

IRON SUPPLEMENTATION PROTOCOLS

• FINDING: Among lactating women, weekly and daily supplementation had comparable effects on iron status and, in India, weekly supplementation was effective for anemia prevention

• IMPLICATION: Intermittent (non-daily) supplementation is an option to be considered

Sources: Daily versus weekly iron supplementation and prevention of iron deficiency anaemia in lactating women. Anemia prophylaxis in adolescent school girls by weekly or daily iron-folate supplementation.

FORTIFICATION VEHICLES-1

• FINDING: Cereal fortification may improve iron intake but evidence of general effectiveness is still lacking

• IMPLICATION: Cereal fortification is not a “magic bullet” for addressing iron deficiency in children

Sources: SUSTAIN Guidelines for Iron Fortification of Cereal Food Staples.

FORTIFICATION VEHICLES-2

• FINDING: A study in Chile found that just 3% of infants fed iron-fortified milk (ferrous sulfate + ascorbic acid) were anemic versus 26% of those fed non-fortified milk

• IMPLICATION: In some cultures, milk fortification may be a viable vehicle for fortification to reduce iron deficiency

Source: Prevention of iron deficiency by milk fortification.

FORTIFICATION VEHICLES-3

• FINDING: Fortified fish/soy sauce found acceptable.

• IMPLICATION: In some cultures, foods such as fish/soy sauce may be viable vehicles for fortification to reduce iron deficiency

Sources: Combating iodine and iron deficiencies through the double fortification of fish sauce, mixed fish sauce, and salt brine. Regular consumption of NaFeEDTA-fortified fish sauce improves iron status and reduces the prevalence of anemia in anemic women.

IRON SPRINKLES

Sources: Treatment of anemia with micrencapsulated ferrous fumarate plus ascorbic acid supplied as sprinkles to complementary (weaning) foods. Home-fortification with iron and zinc sprinkles or iron sprinkles alone successfully treats anemia in infants and young children.

FINDINGS:, sprinkles were shown to be as effective as the standard therapy in treating anemia and, in Zambia, iron+zinc sprinkles did reduce anemia but did not improve zinc status or catch-up growth in infants

IMPLICATION: Sprinkles is a promising intervention with high acceptance rates and proven efficacy but cost may be a major constraint

Prevalence of GDM in relation to duration and timing of iron deficiency anemia.

Prevalence of GDM in relation to duration and timing of iron deficiency anaemia. See text for description of anaemic groups. Comparison by Pearson’s correlation between incidence of GDM and anaemic groups; P = 0.045.

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