Dr Mansoora. K
Iron deficiency anemia is a condition in which the body lacks enough red blood cell because of deficiency and inadequate bioavailability of dietary iron.
- Iron is an essential mineral that is needed to form hemoglobin, an oxygen carrying protein inside red blood cells.
- In severe anemia, the capacity to maintain body temperature may also be reduced and it is also life-threatening.
In India 5-6% of general population suffer from this disease. It is prevalent in 3% among men and 10-14% among women. About 10% of attendance in the general hospitals is accounted for by anemias. In specific groups like slum dwellers, plantation labourers, and pregnant women the prevalence rate is 30-50% or even more. Iron deficiency is prevalent in 30-50% of the adolescent and young adult women due to their unsatisfactory food habits and moderate or heavy blood loss during menstruation. Even though iron deficiency is mainly caused by inadequate iron intake in food, IDA is not exclusively a disease of the poor. Food fadism and other diseases which cause blood loss account for the majority of anemia cases occurring in the rich.
FUNCTION OF IRON:
Oxygen transport: It serves as a carrier of oxygen to the tissues from the lungs by red blood cells (Most of the iron in the body is present in the erythrocytes as haemoglobin , Haemoglobin transports oxygen in the blood, delivering it through the capillary beds to the tissues). Myoglobin in muscle facilitates the movement of oxygen into muscle cells.
Brain function: Iron plays role in process of myelinization (the development of myelin sheath around nerve fibres).
Enzymes : Iron serves as an integrated part of important enzyme systems in various tissues. Several iron-containing enzymes, the cytochromes, there role in the oxidative metabolism is to transfer energy within the cell and specifically in the mitochondria. Cytochrome P450 plays role in the synthesis of steroid hormones and bile acids. Detoxification of foreign substances in the liver.
Recommended Dietary Allowances (RDAs) of Iron -ICMR, 2010:
Infants: 0-6 months
Children : 1-3 years
There are 2 types of iron in the diet, Heme iron and non-Heme iron:
- Heme iron is present in animal food like meat, liver & spleen. Heme iron is
not affected by ingestion of other food items. It has constant absorption
rate of 5-10% .
- Non-Heme iron is obtained from cereals, vegetables & beans (Green leafy veggies- Spinach, Amaranth, Mustard , Fenugreek, Onion stalks, Colocassia leaves, Mint etc). The absorption of non-Heme iron varies greatly from 2% to100% because it is strongly influenced by: The iron status of the body, Presence of absorption inhibitors or promoters
Promoters: Ascorbic acid, Muscle tissue, Organic acids
Inhibitors: Polyphenols, Phytate/Phytic acid, Tannin Calcium
Daily dietary iron requirement of human body is 10-20mg. Iron once enterered the human body passes through stomach to small intestine where it is absorbed. Cannot absorb iron in ferric form, it is converted to ferrous form. Therefore in the intestinal lumen, an enzyme i.e. vitamin C ferrireductase converts Fe3+ into Fe2+. Also enterocyte have DMT1 (Divalent metal transporter) channel through which iron in ferrous form is absorbed.
After entering enterocyte ,Fe2+ is converted to Fe3+ and stored in form of Ferritin. Fe2+ iron is also transported to other cells of the body such as the liver and bone marrow.
In blood, iron in ferric form bounds to Transferrin and is transported around the body. There are 2 fates of transferrin in the body: a.)75% of absorbed iron is utilized for RBC’s formation in bone marrow (Erythropoesis) This iron is used by Hemoglobin to carry oxygen. b.) 10-20% of absorbed iron is transported to liver by transferrin. Liver stores iron in the form of Ferritin. Iron can also be released back to blood by a Ferroportin mediated mechanism when body needs increase.
Causes of ida:
- Nutritional inadequacy: More than 80% of cases, especially in the poorer groups. Meat, poultry and fish form good dietary sources of iron. Milk is low in its iron content. Among vegetable sources, grapes, dates, prunes, amla (gooseberry), green leafy vegetables, onions, jaggery and betel leaf are moderate sources of iron. Due to the cereal-based dietary habits, the optimum intake of dietary iron recommended by Indian Council of Medical Research (ICMR) is 20 mg for adults.
- Blood losses: Sources of chronic blood loss are ankylostomiasis, hemorrhoids, menstrual losses, repeated pregnancies in women, and ulcerating lesions in the gastrointestinal tract. Normal menstrual blood loss is about 60 mL per period. Periods which are heavy and which occur more frequently than once a month predispose to iron deficiency. About 750 mg of iron is utilised from the mother for each pregnancy and lactation. Successive pregnancies occurring at short intervals without supplementation of iron during pregnancy and lactation are bound to deplete the iron stores of the mother.
Hookworms and other soil transmitted helminths lead to chronic blood loss from the upper intestinal region. Though most of this iron is absorbed, a small part is lost in feces. Hence heavy infestations are bound to cause anemia. Ankylostoma duodenale is more pathogenic than Necator americanus. If nutritional status is good, anemia may not occur even with moderate worm loads, but in the majority of cases hookworms act as the most common aggravating factor in the presence of undernutrition. In many states in India hookworm infestation rates have come down considerably due to general improvement in sanitation, provision of sanitary latrines and safe drinking water. In some areas Trichuris trichura (whipworm) which has established as a common intestinal nematode, causes blood loss and even malabsorption states. Bleeding caused by whipworms is considerably less than that due to hookworms.
Loss of iron from surface epithelium increases with excessive sweating. This is a significant source of iron loss in the tropics, especially in the working classes.
STAGES OF IRON DEFICIENCY
Stage I (PreLatent): Decreased stores of iron without any other detectable abnormality (serum ferritin and bone marrow iron reduced.
Stage II (Latent): Iron stores are exhausted but anemia has not occurred yet (serum ferritin, and transferin saturation reduced, bone marrow iron (absent).
Stage III (Iron deficiency anaemia): Decrease in the concentrating Haemoglobin (Hb), and MCV reduced, TIBC incresed, serum ferritin and transferin saturation reduced, bone marrow iron (absent).
- Onset is gradual over months or years.
- Special features include loss of appetite, pica, especially for eating sand, raw cereal, or lime (CaCO3), glossitis, sideropenic dysphagia, and koilonychia.
- About 10% of cases may show mild splenomegaly.
- The tongue is pale and small.
- Dysphagia takes the form of a feeling of obstruction and food sticking at the upper end of the oesophagus especially on swallowing liquids. It is called Plummer-Vinson syndrome or KellyPatterson syndrome. Probably dysphagia is produced by loss of afferent impulses for the swallowing reflex due to degeneration of the lining epithelial cells. Sometimes constriction, spasm, or even bands may be detected, but in general, local examination is unrewarding. In one-third cases barium swallow may reveal the narrowed area. Clinical features and the radiological abnormalities clear up easily within months of iron therapy, but in a few neurotic individuals vague symptoms may persist. There is increased incidence of post-cricoid and oropharyngeal carcinoma in these subjects, especially in women.
- Nail changes are characteristic of iron deficiency anemia of long standing and in many cases these are diagnostic. The initial changes are thinning, cracking, and brittleness of the toe and finger nails, later becoming typically spoon-shaped (koilonychia). With correction of iron deficiency, normal nail grows and replaces the affected nail.
- Pallor is most marked over the mucous membranes, skin and nails. There may be greying of the hair and premature baldness.
Alimentary system: Gastric acid is reduced, but histamine fast achlorhydria is rare. Motility of the alimentary tract is reduced and this results in constipation. Gastric secretion and gastrointestinal motility recover with treatment.
Cardiovascular changes: Tachycardia, cardiomegaly, high volume pulse, prominent third heart sound, ejection systolic murmurs heard over the pulmonary and aortic areas and in advanced cases signs of cardiac failure. Cardiac murmurs are caused due to decreased viscosity of blood and increased cardiac output.
Neurological manifestations: Apathy, loss of mental alertness, paraesthesia over the extremities, brisk tendon reflexes. When severe anemia develops rapidly, signs resembling raised intracranial tension may be rarely encountered. These include headache, papilledema and retinal hemorrhages. In iron deficiency anemia 10% may show mild splenomegaly, in hemolytic anemias it is over 90%.
- The erythrocytes are microcytic and hypochromic.
- Presence of eosinophilia indicates a helminthic etiology and thrombocytosis to a chronic or acute blood loss.
- The MCHC is below 27 g/dL.
- Red cell distribution width is above 17.
- Bone marrow shows normoblastic hyperplasia with absence of stainable iron.
- The serum iron is usually below 80mcg/dL (normal – 60-160 mcg/dL).
- Transferrin levels are normal (280-400 mcg/dL) or increased.
- Total iron binding capacity in both males and females is 340mg/dL with the range of 250-450 mg/dL.
- Estimation of serum ferritin is helpful to asses the iron stores in the body, and therefore, wherever facilities permit, should be done. Values below 15 mcg/L suggests depletion of stores.
- In iron deficiency anemia (IDA) the transferrin saturation is lowered and is often below 15%.
- Iron is present in plasma also as ferritin. The serum levels of ferritin reflect the iron stores of the individual more reliably than either serum iron or transferrin saturation.
- Normal levels of serum ferritin are: Adult male 40-340 microgram/L, Adult female 14-148 microgram/L, Children 7-142 microgram/L
- In iron deficiency states it is below 12 microgram/L.
- Very high levels are reached in siderosis.
- Normally there is stainable iron in the bone marrow. When there is iron deficiency this form of storage iron disappears.
- Absence of stainable iron in the bone marrow is a reliable evidence of iron deficiency state helps to distinguish iron deficiency anemia from hemolytic and hypoplastic anemias in which there is increase in stainable iron.
- Free erythrocyte protoporphyrin (FEP) : Elevation of FEP mainly the erythrocyte zinc protoporphyrin (EZP) is very sensitive index of IDA. In uncomplicated IDA, EZP levels reach 100-1000 mcg/dL.
- Soluble transferrin receptor (STIR): Serum levels of STIR are elevated in iron deficiency. Normal levels of STIR range from 2.8-8.5 mg/dL.
1. Infections – of respiratory, GIT, urinary. TB is more common in them.
2. Chronic anemia reduces the efficiency in work and study. Impairment of cognitive function of brain and retardation of learning ability and motor skills in children.
- Supplementation: Dietary diversification and Food fortification
According to a study daily dose of iron (30 mg iron) during pregnancy improves women’s iron status and seems to protect their infants from iron deficiency anaemia
Food fortification: It has been defined as the addition of one or more essential nutrients to a food, whether or not it is normally contained in the food, for the purpose of preventing or correcting a demonstrated deficiency of one or more nutrients in the population .In India, Tata Salt Plus, priced at an economical rate, is an iodine plus iron fortified salt, developed by the National Institute of Nutrition, Hyderabad through double fortification technology.
Dietary diversification: The manipulation of diets to enhance the content of micronutrients and alter the levels of absorption to improve micronutrient bioavailability like fruits rich in vitamin C improve the absorption of non-heme iron.
- Dietary Modification
- Eat more fruits and vegetable.
- No coffee or tea with meals.
- Reduce phytic content of cereals and legumes by fermentation and sprouting.
- Addition of iron rich foods to the weaning foods of infants.
- Promote home gardening.
- Consume vitamin c with meal.
- Improved health services
- Deworming and prevention and treatment of malaria (parasitic infections cause ID through loss of blood or destruction of RBCs) could help in controlling anemia .
- Education on dietary practices also help in controlling anemia.
Correction of anemia:
- Meat, liver, green vegetables, onions, grapes and jaggery are good sources of iron.
- Ferrous sulphate given as 300 mg tablets thrice daily after food is ideal and least expensive. 10% cases may show side effects like nausea, vomiting etc which can be reduced if the drug is administered after food, but absorption is better if given on empty stomach. The response is evident within a week as improved well being and activity, return of apetite and increase of hemoglobin and reticulocytes. On an average hemoglobin rises at the rate of 1% everyday. Iron salts have to be continued for atleast 6 months after the hemoglobin level reaches normal with a view to replete the iron stores.
- Parenteral iron is indicated when oral medication becomes impossible because of side effects or when the anemia has to be corrected within a shorter period. Parenteral iron rises the hb by 2% everyday.
Formula for calculating total iron requirement:
Total dose of iron required in mg = (weight of patient in kg) x (deficiency in hb%) x (0.66)
- Intramuscular injection: Iron dextran complex is given in doses of 100 mg of elemental iron given in areas usually covered by clothing, once in three days till the dose is reached.
Side effects of parenteral iron include fatal anaphylactic reactions, iron encephalopathy, local thrombophlebitis, tissue necrosis, pyrexia, arthralgia, arthritis, serum sickness like reactions, and pigmentation over injection site.
RUBRICS FOR ANEMIA
- GENERALS – ANAEMIA
- GENERALS – ANAEMIA – haemorrhage,after
- GENERALS – CHLOROSIS
- NOSE – EPISTAXIS – anemia, with
- FACE – ERUPTIONS – acne – girls; in anemic
- FEMALE GENITALIA/SEX – LEUKORRHEA – anemia, with
- CHEST – PALPITATION of heart – anemia, with
- GENERALS – ANEMIA
- GENERALS – WEAKNESS – anemia, in
- VERTIGO – Aggravation – anaemia, in
- HEAD – Internal – aggravation – anaemia, from
- NOSE – Bleeding – anaemia, in
- STOOL – Constipation – anaemia, of
- GENITALIA – Female organs – abortus – anaemia, with
- MENSTRUATION – Concomitants after menses – anaemia
- SENSATIONS AND COMPLAINTS IN GENERAL – Weakness, exhaustion, prostration, infirmity – anaemia of
- CIRCULATION – Palpitation – anaemia in
- CIRCULATION – Congestions – anaemia
- Blood – ANEMIA
- Blood – ANEMIA – pernicious anemia
- Blood – ANEMIA – pernicious anemia – family, in
- Constitutions – ANEMIC, constitutions
- Constitutions – WEAK, constitutions – anemia, in
- Constitutions – WOMEN, general – anemic
- Constitutions – YOUNG people – anemic
- Clinical – HEMOLYTIC anemia, chlorosis
- Clinical – NURSING, of others, agg. – prolonged, with anemia and debility
- Clinical – PERNICIOUS anemia
- Female – BLEEDING, uterus, metrorrhagia – anemia, with
- Generals – NURSING of others, agg. – prolonged, with anemia and debility
- Generals – WEAKNESS, sensation of being – anemia, in
- Headaches – ANEMIC ! Heart – PALPITATIONS, general – anemia, with – anemia, from
- Nerves – CHOREA, general – anemia, from ! Nerves – FAINTING, faintness – anemia, in
- Pregnancy – MISCARRIAGE, general, spontaneous abortion – anemia, with
For persons anaemic and dark complexioned, dark hair and eyes; thin spare subjects, instead of fat. At puberty : acne in anaemic girls with vertex headache and flatulent dyspepsia, >> by eating. Headache of school-girls (Nat. m., Psor.) The anaemias after acute diseases and chronic wasting diseases. Anaemic children who are peevish, flabby, have cold extremities and feeble digestion. Numbness and crawling are characteristic sensations, and tendency to perspiration and glandular enlargement are symptoms it shares with the carbonate. Menses too early, excessive, and bright in girls. After prolonged nursing.
For stout, swarthy persons; for systems, once robust, which have become debilitated, “broken down” from exhausting discharges (Carbo v.). Ailments : from loss of vital fluids, especially haemorrhages, excessive lactation, diarrhoea, suppuration (Chin. s.); of malarial origin, with marked periodicity; return every other day. After climacteric with profuse haemorrhages. Face pale, hippocratic; eyes sunken and surrounded by blue margins; pale, sickly expression as after excesses. Face flushed after haemorrhages, or sexual excesses, or loss of vital fluids.
Women who are weak, delicate, chlorotic, yet have a fiery red face. Extreme paleness of the face, lips and mucous membranes which become red and flushed on the least pain, emotion or exertion. Blushing (Amyl., Coca). Erethitic chlorosis, worse in winter. Red parts become white; face, lips, tongue and mucous membrane of mouth. Menses : too early, too profuse, too long lasting, with fiery red face; ringing in the ears; intermit two or three days and then return; flow pale, watery, debilitating. Haemorrhagic diathesis; blood bright red, coagulates easily (Fer. p., Ipec., Phos.). Canine hunger, or loss of appetite, with extreme dislike for all food. Constipation : from intestinal atony.
Adapted to persons of indecisive, slow, phlegmatic temperament; sandy hair, blue eyes, pale face, easily moved to laughter or tears; affectionate, mild, gentle, timid, yielding disposition- the woman’s remedy. Women inclined to be fleshy, with scanty and protracted menstruation (Graph.). The first serious impairment of health is referred to puberic age, have “never been well since”- anaemia, chlorosis, bronchitis, phthisis. Often indicated after abuse of Iron tonics, and after badly-managed measles.
Psoric constitutions; pale, weak, timid, easily tired when walking. Women : menses too early, too profuse. Diseases : arising from defective assimilation. Children crave eggs and eat dirt and other indigestible things; are prone to diarrhoea. Aversion to meat, boiled things; craving for indigestible things – chalk, coal, pencils; also for eggs, salt and sweets. Distention with hardness. Constipation; stool at first hard, then pasty, then liquid.
For the anaemic and cachectic; whether from loss of vital fluids _ profuse menses, seminal losses or mental affections. Headache: anaemic, of school girls (Cal. p.). Constipation: sensation of contraction of anus. Fluttering of the heart; with a weak faint feeling < lying down. The hair falls out when touched, in nursing women (Sep.)
Young people who grow too rapidly are inclined to stoop (to walk stooped, Sulph.); who are chlorotic or anaemic; old people, with morning diarrhoea. Great weakness and prostration; with nervous debility and trembling; of whole body; weakness and weariness from loss of vital fluids (Cinch., Phos. ac.). Constipation : faeces slender, long, dry, tough and hard (Staph.). Haemorrhage : frequent and profuse, pouring out freely and then ceasing for a time; metrorrhagia, in cancer; haemoptysis, vicarious, from nose, stomach, anus, urethra, in amenorrhoea.
After loss of fluids or vitality, particularly in the anaemic (Cinch., Phos. ac., Phos., Psor.). Stomach: distended, sensitive; feels as if it would burst; excessive flatulency, everything she eats or drinks appears to be converted into gas (Iod.). Nosebleed when washing the the face in the morning (Am. c., Arn.). Swallowing difficult; food goes down oesophagus slowly. Large, difficult stools, with stitching pain an hour before. Uterine haemorrhage; constant oozing after copious flow, with violent backache, relieved by sitting and pressure. Palpitation and burning in heart region.
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