Iron deficiency anemia in children

Iron deficiency anemia in children is a clinical and hematological syndrome based on a violation of hemoglobin synthesis due to iron deficiency.

Three iron deficiency states have been described:

1. latent iron deficiency;
2. latent iron deficiency;
3. iron deficiency anemia.

In prelatent iron deficiency, the iron content is reduced only in the depot while maintaining the transport and hemoglobin funds. The absence of clinical manifestations and clear diagnostic criteria allow this condition not to be given practical significance.

Latent iron deficiency, which accounts for 70% of all iron deficiency conditions, is not considered a disease, but a functional disorder with a negative iron balance; it does not have an independent code according to ICD-10. With latent iron deficiency, a characteristic clinical picture is observed: sideropenic syndrome, but the hemoglobin content remains within normal values, which does not allow identifying individuals with this condition from the general population using this laboratory parameter.

Iron deficiency anemia in children (ICD-10 code - D50) is a disease, an independent nosological form, accounting for 30% of all iron deficiency conditions. This disease is characterized by:

• anemic and sideropenic syndromes;
• decreased concentration of hemoglobin and serum iron;
• increase in total iron-binding capacity of serum (TIBC);
• decrease in serum ferritin (SF) concentration.

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Epidemiology

An important frequency characteristic: 90% of anemias in children are iron deficiency anemias, in adults this figure reaches 80%. The remaining 10% (in adults 20%) are other types of anemia: hereditary and acquired hemolytic anemias, constitutional and acquired aplastic anemias. The true figures for the incidence and prevalence of iron deficiency anemia in children in our country are unknown, but most likely they are quite high, especially in young children. The scale of the problem can be assessed by examining WHO data: 3,600,000,000 people on earth have latent iron deficiency and another 1,800,000,000 people suffer from iron deficiency anemia.

Iron deficiency anemia can be called a socially significant disease. The prevalence of iron deficiency anemia in children aged 2.5 years in Nigeria is 56%, in Russia - 24.7%, in Sweden - 7%. According to WHO experts, if the prevalence of iron deficiency anemia exceeds 30%, this problem goes beyond the medical and requires decisions to be made at the state level.

According to official statistics from the Ministry of Health of Ukraine, there is a significant increase in the incidence of anemia in children and adolescents in Ukraine.

In childhood, 90% of all anemias are iron deficiency anemias. Thus, when prescribing iron supplements for all anemias, the doctor will “guess” in 9 cases out of 10. The remaining 10% of anemias include congenital and acquired hemolytic and aplastic anemias, as well as anemias in chronic diseases.

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Causes of Iron Deficiency Anemia in Children

There are more than 10 known types of iron metabolism disorders that lead to the development of iron deficiency conditions. The most important are:

• iron deficiency in food, which is important in the development of iron deficiency conditions in children from early childhood to adolescence, as well as in adults and the elderly;
• impaired iron absorption in the duodenum and upper small intestine as a result of inflammation, allergic edema of the mucous membrane, giardiasis, Helicobacter jejuni infection, and bleeding;

What causes iron deficiency anemia?

Iron metabolism in the body

Normally, the body of a healthy adult contains about 3-5 g of iron, so iron can be classified as a microelement. Iron is distributed unevenly in the body. Approximately 2/3 of iron is contained in the hemoglobin of red blood cells - this is the circulating fund (or pool) of iron. In adults, this pool is 2-2.5 g, in full-term newborns - 0.3-0.4 g, and in premature newborns - 0.1-0.2 g.

Iron metabolism in the body

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Pathogenesis of iron deficiency anemia

There is a certain sequence in the development of anemia:

Stage I - iron reserves in the liver, spleen and bone marrow decrease.

At the same time, the concentration of ferritin in the blood serum decreases, and a latent iron deficiency develops - sideropenia without anemia. Ferritin, according to modern concepts, reflects the state of the total iron reserves in the body, thus at this stage the iron reserves are significantly depleted without a decrease in the erythrocyte (hemoglobin) fund.

What happens during iron deficiency anemia?

Iron deficiency conditions in children of the first year of life and early age

The idea that a decrease in hemoglobin concentration in a pregnant woman does not affect fetal development is wrong. Iron deficiency in the fetus leads to irreversible disorders:

• growth of brain mass;
• the process of myelination and the conduction of nerve impulses through synapses.

These changes are irreversible and cannot be corrected by iron preparations prescribed in the first months of a child's life. Subsequently, the child experiences delayed mental and motor development, and impaired cognitive functions. American researchers have shown that even 5 years after iron deficiency anemia suffered at the age of 12-23 months, the child experiences delayed mental and motor development, as well as learning difficulties.

The most intensive growth is observed in children under one year of age and in adolescents during puberty. Pediatricians know that at the age of 3 months, many children have a reduced hemoglobin level (105-115 g / l). This phenomenon was also registered by American doctors and served as the basis for the development of relevant recommendations. For children aged 3 months, the lower limit of the hemoglobin concentration norm was established, corresponding to 95 g / l, since this transient decrease in the hemoglobin level is expressed in most children in the population. A decrease in hemoglobin concentration in most children at 3 months is associated with the transition of erythroid cells from the synthesis of fetal hemoglobin (Hb F) to Hb A2, represents "physiological anemia" and does not require treatment. Hemoglobin concentration should be determined at 6 months: at this age, its values u200bu200bcorrespond to the norm (110 g / l and more).

If the child is breastfed and does not belong to any risk group (prematurity, multiple pregnancy, low birth weight), breastfeeding and observation of the child are continued. Prescription of iron preparations in prophylactic doses, usually 50% of the therapeutic dose, is indicated for children from the indicated risk groups for the development of iron deficiency anemia.

Continuous monitoring of hemoglobin levels should be carried out up to 18 months:

• in children with low birth weight;
• in premature babies;
• in children who do not receive iron-containing formulas.

From 6 to 18 months, hemoglobin levels should be monitored if the child:

• receives cow's milk until 12 months;
• when breastfed after 6 months, does not receive enough iron from complementary foods;
• sick (chronic inflammatory diseases, dietary restrictions, heavy bleeding due to injury, taking medications that interfere with iron absorption).

Iron deficiency anemia in adolescents

Adolescents, especially girls aged 12-18, need screening of hemoglobin levels. It is advisable to determine the hemoglobin level annually in girls and women with heavy menstrual or other blood loss, low iron intake with food, and a history of iron deficiency anemia. Non-pregnant women who do not belong to these risk groups do not need frequent monitoring of hemoglobin levels and can be examined once every 5 years if they eat iron-rich foods that enhance its absorption. Young men also need to monitor their hemoglobin levels if they are intensively involved in heavy sports (athletes' anemia). If iron deficiency anemia is detected, it is treated.

Preventive vaccinations for children with iron deficiency anemia are not contraindicated and do not require normalization of hemoglobin levels, since the number of immunocompetent cells is sufficient.

Russia can and should rely on the experience of combating iron deficiency anemia gained in other countries. The most clearly formulated measures for preventing iron deficiency conditions are the national "Recommendations for the Prevention and Treatment of Iron Deficiency in the United States" (1998): primary prevention involves proper nutrition, secondary prevention involves active detection of latent iron deficiency and iron deficiency anemia during medical examinations, medical check-ups and visits to the doctor.

Symptoms of Iron Deficiency Anemia in Children

Men tolerate iron deficiency anemia worse than women; older people are more severely affected than younger people.

The most vulnerable tissues in iron deficiency anemia are those with epithelial cover as a constantly renewing system. There is a decrease in the activity of digestive glands, gastric, pancreatic enzymes. This explains the presence of leading subjective manifestations of iron deficiency in the form of decreased and perverted appetite, the appearance of trophic disorders, the appearance of dysphagia (difficulty in swallowing dense food), a feeling of a food lump getting stuck in the throat.

Symptoms of Iron Deficiency Anemia

Diagnosis of iron deficiency anemia

In accordance with WHO recommendations, the following diagnostic criteria for iron deficiency anemia have been standardized:

• decrease in the level of SF to less than 12 μmol/l;
• increase in TIBC more than 69 μmol/l;
• transferrin iron saturation less than 17%;
• hemoglobin content below 110 g/l at the age of up to 6 years and below 120 g/l at the age of over 6 years.

Diagnosis of iron deficiency anemia

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Treatment of iron deficiency anemia in children

With ID, only iron preparations are effective! You cannot cure IDA with a diet! With other anemias not associated with ID, prescribing ferropreparations is unnecessary, and with prolonged use they can lead to pathological accumulation of iron. Since ID is always secondary, it is necessary to find and, if possible, eliminate the cause underlying ID. But even if it is not possible to establish the cause of ID, it is necessary to restore iron reserves with iron preparations. Ferropreparations (FP) differ in chemical structure, method of administration, and the presence of other components in their composition.

Iron preparations used to treat and prevent iron deficiency

For internal use (oral)		Parenteral
Single-component Complex in composition
Salt (ionic) ferropreparations
Iron (II)-glucose (Ferronal, Ferronal 35)	Iron, manganese, copper gluconate (Totem)	Iron (III) hydroxide sucrose complex for intravenous administration (Venofer)
Iron (II) sulfate (Hemofer prolongatum)	Iron sulfate and ascorbic acid (Sorbifer Durules, Ferroplex)	Iron (III) hydroxide polymaltose (iron dextrin) for intramuscular injection (Maltofer for intramuscular injections)
Iron (II) fumarate (Heferol)	Multivitamin, mineral salts (Fenuls)
	Iron sulfate (Actiferrin)	Iron (III) hydroxide polyisomaltose (iron dextran) for intramuscular administration (Ferrum Lek for intramuscular injections)
	Iron sulfate (Actiferrin compositum)
	Iron sulfate, folic acid (Gino-Tardiferon)
	Iron sulfate (Tardiferon)
	Iron sulfate, folic acid, cyanocobalamin (Ferro-Folgamma)

Iron(III)-hydroxide sucrose complex and iron(III)-hydroxide polymaltose are manufactured by Vifor (International) Inc., Switzerland.

The iron dose is calculated based on the elemental iron contained in a specific drug. For young children (up to 15 kg), the iron dose is calculated in mg/kg per day, and for older children and adolescents - in mg/day. The use of smaller doses of FP does not provide an adequate clinical effect. The received iron is first used to build hemoglobin, and then it is deposited in the depot, so a full course of treatment should be carried out to replenish iron reserves in the body. The total duration of FT depends on the severity of ID.

The choice of a specific FP depends on its dosage form (oral solution, syrup, tablets, parenteral forms), chemical structure of the drug, degree of iron absorption from the FP. The child's age, severity of ID, concomitant pathology, social status are also important. In most cases, FP for oral administration is used to treat ID, since the enteral route is physiologically more appropriate.

For children under 5 years of age, FP is used in the form of solutions for oral administration or syrup, over 5 years of age - in the form of tablets or dragees, after 10-12 years - in the form of tablets or capsules.

When prescribing oral FPs, it should be borne in mind that 5-30% of the iron prescribed orally is absorbed, and FPs differ

The duration of ferrotherapy and calculation of the dose of alimentary iron for oral administration differ from each other by the degree of absorption. It is highest (15-30%) in sulfate salts of iron and iron (III) hydroxide polymaltose. The degree of absorption of iron from other salt FP (gluconate, chloride, fumarate, succinylate) does not exceed 5-10%. In addition, it is necessary to take into account the interaction of salt FP with other drugs and food products.

Degree J		Age	Basic FT
			FP dose	Duration, weeks
LJ		Up to 3-5 years	3 mg/kg/day)	4-6
		>5 years	40-60 mg/day
IDA	1st degree	Up to 3-5 years	5-8 mg/kg/day)	6-8 (max 10-12)
		>5 years	50-150 mg/day
	II degree	Up to 3-5 years	5-8 mg/kg/day)	8-10 (max 12-14)
		>5 years	50-200 mg/kg/day)
	III degree	Up to 3-5 years	5-8 mg/kg/day)	10-12 (max 14-18)
		>5 years	50-200 mg/day

Treatment of children with IDA and IDA grades I-II is performed on an outpatient basis using oral FPs, except for cases when the family cannot provide the prescribed medication or there are indications for prescribing parenteral FPs. Treatment of children with severe IDA, especially at an early age, is usually performed in a hospital, and therapy can be started with parenterals and then switched to oral FPs, but the entire course of FT can also be performed using drugs for oral administration.

Indications for the administration of parenteral FP:

• cases of adverse effects from oral FP (for example, metallic taste, darkening of teeth and gums, allergic reactions, dyspeptic symptoms: epigastritis, nausea, constipation, diarrhea);
• ineffectiveness of oral administration due to impaired intestinal absorption (lactase deficiency, celiac disease, food allergies, etc.);
• inflammatory or ulcerative diseases of the gastrointestinal tract;
• the need to quickly replenish iron reserves (surgical intervention, diagnostic/therapeutic invasive procedures);
• social reasons (for example, the inability to control the intake of oral FPs).

Calculation of the iron dose for parenteral administration: elemental Fe++ (mg) = 2.5 mg x weight (kg) x hemoglobin deficit.

When prescribing parenteral FPs, it should be taken into account that replenishing iron stores in tissues requires 20-30% more iron than the calculated value (this is the amount of iron administered parenterally that is excreted in the urine during the day). However, the initial dose of parenteral FPs should not exceed 5 mg/kg per day. Of the parenteral FPs, drugs are used for intramuscular administration - iron (III) hydroxide polymaltose (Maltofer, Ferrum Lek). There is also a drug for intravenous administration - iron (III) hydroxide sucrose complex (Venofer4), but at present there is insufficient experience with its use in children with IDA. Although true iron deficiency is extremely rare in the neonatal period, when iron deficiency is proven, the drugs of choice for these children are drugs containing iron (III) hydroxide polymaltose complex, approved for use in premature and newborn infants.

In 20-40% of patients with stage II-III IDA, a concomitant deficiency of B12 and/or FC is detected, and against the background of taking FP, their number reaches 70-85%, which requires the prescription of appropriate drugs.

For GI, a diet is recommended that includes foods rich in iron and vitamins B, 2 and FC: meat of mature animals (meat of young animals contains less iron), fish, seafood, buckwheat, legumes, apples, spinach, liver pates. Separate intake of cereals and meat and vegetable dishes is recommended, calcium-rich foods are temporarily limited; girls should refrain from taking oral contraceptives. Long stays in the fresh air are useful.

Treatment of iron deficiency anemia with red blood cell transfusions

It is not recommended to use red blood cell transfusions even in cases of severe IDA, since it develops gradually and the child adapts to anemia.

Transfusions are only justified if:

• this is necessary for vital indications; in case of severe anemic syndrome (Hb below 50 g/l);
• the patient requires urgent surgical intervention or immediate examination under anesthesia.

If necessary, red blood cell mass is administered at a rate of 3-5 mg/kg per day (maximum 10 mg/kg per day) - intravenously slowly, every other day, until a hemoglobin concentration is reached that will reduce the risk of surgical intervention. There is no need to try to quickly correct severe anemia, since this carries a risk of developing hypervolemia and heart failure.

Contraindications to the administration of iron preparations

Absolute contraindications to the appointment of FP are:

• acute viral and bacterial infectious diseases;
• diseases accompanied by iron accumulation (hemochromatosis, hereditary and autoimmune hemolytic anemia);
• diseases accompanied by impaired iron utilization (sideroblastic anemia, alpha- and beta-thalassemia, anemia due to lead poisoning);
• diseases accompanied by bone marrow failure (aplastic anemia, Fanconi anemia, Blackfan-Diamond anemia, etc.).

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Adverse effects and complications when using iron preparations

When using oral FPs, side effects associated with both the chemical properties of iron salts and hypersensitivity to individual components of the drugs are rare.

Manifestations of side effects include:

• metallic taste in the mouth;
• darkening of teeth and gums;
• pain in the epigastrium;
• dyspeptic disorders due to irritation of the gastrointestinal mucosa (nausea, belching, vomiting, diarrhea, constipation);
• dark coloration of stool;
• allergic reactions (usually urticaria);
• necrosis of the intestinal mucosa (in case of overdose or poisoning with saline FP).

These effects can be easily prevented by strictly following the correct dosage regimen and taking the medicine. First of all, this applies to the group of saline FP. It is advisable to start treatment with a dose equal to 1/2 - 2/3 of the therapeutic dose, followed by gradual achievement of the full dose over 3-7 days. The rate of "increasing" the dose to the therapeutic dose depends on both the degree of ID and the child's individual tolerance of a particular medicine. Saline FP should be taken between meals (approximately 1-2 hours after, but not later than 1 hour before meals), washed down with a small amount of fruit juice with pulp. Salt FP should not be washed down with tea or milk, as they contain components that inhibit iron absorption. Darkening of the teeth and gums can also be avoided if the medicine is given diluted (for example, with fruit juice) or on a piece of sugar. Allergic reactions are usually associated with other components included in the complex drugs, in which case it is necessary to change the FP. Necrosis of the intestinal mucosa develops in extremely rare cases of overdose or poisoning with saline FP. Dark coloring of the stool has no clinical significance, but it is necessary to warn the child's parents or the child himself about this if he already performs hygienic procedures independently. By the way, this is a very good and effective way to check whether your patient is taking the FP.

Iron (III) hydroxide polymaltosate preparations are virtually devoid of side effects. In addition, due to the absence of interaction with food components in this group of FP, children do not need to adhere to any dietary restrictions, and treatment begins immediately with a calculated therapeutic dose.

If side effects occur, either the dose of FP should be reduced or replaced with another one.

When parenteral FPs are administered, side effects may occur rarely: sweating, iron taste in the mouth, nausea, asthma attacks, tachycardia, fibrillation, which requires discontinuation of FP. Local reactions (hyperemia, soreness, venous spasm, phlebitis, darkening of the skin and abscesses at the injection site), allergic reactions (urticaria, Quincke's edema) may be observed extremely rarely.

The most severe life-threatening complication is poisoning with iron salts (60 mg/kg or more of elemental iron). The severity of the condition and prognosis depend on the amount of absorbed iron. Clinical manifestations of acute overdose of iron salts are sweating, tachycardia, CNS depression, collapse, shock. There are 5 phases of poisoning with iron salts.

Phases of iron salt poisoning

Phase	Duration	Symptoms
1. Local irritation	From 0.5-2 hours to 6-12 hours	Acute gastrointestinal symptoms: nausea, vomiting and diarrhea with blood, drop in blood pressure, necrosis of the intestinal mucosa
2. Imaginary “recovery” (asymptomatic period)	2-6 hours	Relative improvement of the condition. During this time, iron accumulates in the mitochondria of cells
3. Gross metabolic breakdowns	12 hours after poisoning	Acidosis, hypoglycemia, CNS disorders due to severe damage to cells of the brain, liver and other organs - direct cytotoxic effect of iron ions, accompanied by cytolysis of cells
4. Liver necrosis	In 2-4 days (sometimes earlier)	Clinical and laboratory signs of liver necrosis. Hepatocerebral disorders
5. Formation of scars at the site of necrosis of the intestinal mucosa	2-4 weeks after poisoning	Corresponding clinical symptoms depending on the localization and area of damage to the intestinal mucosa

If there is even a suspicion of AF poisoning, the patient should be observed in hospital for at least 24 hours, even if no further symptoms develop. Diagnosis of AF poisoning:

• nausea, vomiting of blood (very important symptoms!);
• areas of intestinal necrosis and/or abdominal fluid levels on ultrasound or radiographic examination;
• FS - above 30 μmol/l, TIBC - less than 40 μmol/l.

Treatment for iron poisoning:

• Milk and raw eggs are prescribed as first aid.

In hospital they prescribe:

• gastric and intestinal lavage;
• laxatives (activated carbon is not used!);
• chelated iron complexes (with iron content over 40-50 μmol/l): deferoxamine intravenously by drip 10-15 mg/kg per day for 1 hour, and intramuscularly at an initial dose of 0.5-1.0 g, then 250-500 mg every 4 hours, gradually increasing the intervals between administrations.

Evaluation of the effectiveness of treatment of iron deficiency anemia in children

In the first days after the appointment of FP, the child's subjective sensations should be assessed, with special attention paid to complaints such as metallic taste, dyspeptic disorders, unpleasant sensations in the epigastric region, etc. On the 5th-8th days of treatment, the number of reticulocytes must be counted. For IDS, their number is typically increased by 2-10 times compared to the initial value, and the absence of a reticulocyte crisis, on the contrary, indicates that the diagnosis of IDS is erroneous.

After 3-4 weeks from the start of treatment, it is necessary to determine the hemoglobin concentration: an increase in hemoglobin content by 10 g / l or more compared to the initial level is considered a positive effect of FT; otherwise, additional examination should be carried out. After 6-10 weeks of FT, iron reserves should be assessed (FP should be discontinued 2-3 days before blood sampling): preferably by the FS content, but it is also possible to use the ISC content. The criterion for curing IDA is the normalization of FS (N = 80-200 μg / l).

Observation of children who have had stage I-II IDA is carried out at the site for at least 6 months, and for those who have had stage III IDA - at least 1 year. The concentration of hemoglobin should be monitored at least once a month, the content of FS (FS, OTZS) - at the end of the FT course and when removed from the dispensary register.

When performing FT, especially saline FT, it is necessary to take into account the interaction of iron salts with other drugs and a number of food components, which can reduce the effect of treatment and/or contribute to the occurrence of undesirable side effects.

Preparations based on iron (III)-hydroxide polymaltose complex are free of such interactions, so their use is not limited by any dietary or regime restrictions. This makes them more attractive in terms of ease of use and therefore increases compliance (adherence) to the therapy of both children and adolescents themselves and their parents.

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Errors and unjustified appointments

A grave mistake is to prescribe "antianemic" therapy (FP, B12, FC, blood transfusion, and often all together) before "decoding" the mechanism and causes of anemia. This can radically change the picture of the blood, bone marrow, and biochemical parameters. FP should not be prescribed before determining the concentration of FS, since it becomes normal within a few hours after taking the drug. After the introduction of vitamin B12, reticulocytosis increases sharply within 3-5 days, leading to hyperdiagnosis of hemolytic conditions. Prescription of vitamin B12 and FC can normalize the characteristic morphological picture of the bone marrow, leading to the disappearance of megaloblastic hematopoiesis (sometimes within a few hours after the injection).

Interaction effects of iron preparations with other drugs and foods

Name of substances	Interactions
Chloramphenicol	Slows down the bone marrow response to AF
Tetracyclines, penicillamine, gold compounds, phosphate ions	Reduces iron absorption
Salicylates, phenylbutazone, oxyphenylbutazone ZhS	Taking it together with FP causes irritation of the gastrointestinal mucosa, which can cause the development (intensification) of side effects from FT
Cholestyramine, magnesium sulfate, vitamin E, antacids (contain Ca and A1), pancreatic extracts	Inhibit iron absorption, which reduces the anti-anemic effect of FP
H2-histamine receptor blockers	Inhibit iron absorption, which reduces the anti-anemic effect of FP
Substances that cause increased peroxidation (eg, ascorbic acid)	They promote increased bleeding from the mucous membranes of the gastrointestinal tract (the benzidine test will always be positive)
Phytates (cereals, some fruits and vegetables), phosphates (eggs, cottage cheese), tannic acid (tea, coffee), calcium (cheese, cottage cheese, milk), oxalates (leafy greens)	They slow down the absorption of iron, therefore, when prescribing salt FPs, it is recommended to take them 1.5-2 hours after meals.
Hormonal contraceptives for oral use	Slows down the absorption of iron, thereby reducing the therapeutic effect of FP

Red blood cell transfusions should not be performed unless there is a vital indication.

Parenteral FPs should be prescribed only for special indications, in a hospital, under medical supervision.

Do not try to treat iron deficiency anemia in children with diet or supplements.

Treatment of iron deficiency anemia

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Prevention of iron deficiency anemia in children

It should be carried out in high-risk groups (premature babies, children from multiple pregnancies, girls in the first 2-3 years after menarche), an important role in this belongs to adequate nutrition, regimen measures, and sufficient time spent in the fresh air.

In newborns, the treatment of maternal anemia during pregnancy plays a decisive role in the prevention of iron deficiency anemia in children. Preventive prescription of FP to pregnant women requires special attention. Thus, with a hemoglobin concentration above 132 g / l, the frequency of premature births and the birth of low-weight children increases, but with hemoglobin below 104 g / l, a similar risk arises. Real prevention of ID is proper nutrition of pregnant women, nursing mothers and children. Confirmed ID in pregnant and nursing women must be corrected by prescribing FP.

In infants, 95% of cases of diarrhea are associated with improper feeding, so this problem is easy to solve.

It is also necessary to take into account the anamnesis data, since peri- or postnatal bleeding, acute or hidden gastrointestinal bleeding, hemorrhagic diseases, early ligation of the umbilical cord (when it is still pulsating) increase the risk of developing IDA in infants. Potential inhibitors of iron absorption are cow's milk proteins and calcium, therefore, infants receiving whole cow's milk (in the absence of other sources of iron in the diet) have a high risk of developing IDA. In this regard, children in the first year of life are not recommended to consume whole cow's milk, non-adapted fermented milk mixtures, products not enriched with iron (juices, fruit and vegetable purees, meat and vegetable purees).

Modern adapted formulas (“follow-on formulas”) are enriched with iron and fully meet the needs of infants for iron, do not reduce appetite, do not cause gastrointestinal disorders and do not increase the incidence of respiratory and intestinal infections in children.

Iron content in some infant formulas

Milk mixtures	Iron content in finished product, mg/l
Gallia-2 (Danone, France)	16.0
Frisolak (Friesland Nutrition, Holland)	14.0
Nutrilon 2 (Nutricia, Holland)	13.0
Bona 2P (Nestle, Finland)	13.0
Similac with iron (Abbott Laboratories, Denmark/USA)	12.0
Enfamil 2 (Mead Johnson, USA)	12.0
Semper Baby-2 (Semper, Sweden)	11.0
Mamex 2 (International Nutrition, Denmark)	10.8
NAS 2 (Nestlé, Switzerland)	10.5
Agusha-2 (Russia)	10.0
Nutrilak-2 (Nutricia/Istra, Holland/Russia)	9.0
Lactofidus (Danone, France)	8.0
Nestozhen (Nestlé, Switzerland)	8.0

After 4-6 months, it is necessary to introduce iron-enriched complementary foods of industrial production (instant porridges, fruit and vegetable juices and purees), and in the second half of the year - meat-vegetable and fish-vegetable purees. After 6-8 months, you can introduce special baby sausage (sausages, ham), made with the addition of potato starch, which does not reduce the absorption of iron. It is better not to give tea to a breastfed baby (it contains tannins, which inhibit the absorption of iron), and use special baby water and juices for drinking.

If the children's diet is perfectly balanced, they do not need to be prescribed FP, with the exception of premature, underweight and multiple births. Nursing mothers are advised to include meat, liver, fish, freshly prepared citrus and vegetable juices, iron-fortified cereals (grains), legumes, and yolk in their diet.

To meet physiological needs, children should receive the following amount of iron from food:

• at the age of 1-3 years - 1 mg/kg per day;
• at the age of 4-10 years - 10 mg/day;
• over 11 years of age - 18 mg/day.

During puberty, girls require special attention in the first 2-3 years after menarche, when prophylaxis of ID should be carried out using FP at a rate of 50-60 mg/day for 3-4 weeks (at least 1 course per year).

The diet of children and adolescents should be varied, healthy and tasty; it is necessary to ensure that it always includes products of animal and plant origin containing sufficient amounts of iron.

Foods High in Iron

Foods containing heme iron	Iron (mg/100 g product)	Foods Containing Non-Heme Iron	Iron (mg/100 g product)
Mutton	10.5	Soybeans	19.0
Offal (liver,		Poppy	15.0
Kidneys)	4.0-16.0	Wheat bran	12.0
Liver pate	5.6	Assorted jam	10.0
Rabbit meat	4.0	Fresh rose hips	10.0
Turkey meat	4.0	Mushrooms (dried)	10.0
Duck or goose meat	4.0	Dry beans	4.0-7.0
Ham	3.7	Cheese	6.0
Beef	1.6	Sorrel	4.6
Fish (trout, salmon, chum salmon)	1,2	Currant	4.5
Pork	1.0	Oat flakes	4.5
		Chocolate	3.2
		Spinach**	3.0
		Cherry	2.9
		"Grey" bread	2.5
		Eggs (yolk)	1.8

Iron bioavailability (absorption) from animal products reaches 15-22%, iron is absorbed worse from plant products (2-8%). Animal meat (poultry) and fish improve iron absorption from other products.

** Spinach has the highest content of folic acid of all foods, which improves not so much the absorption of iron as the process of hemoglobin formation.

Drug prevention of iron deficiency anemia in children

Liquid dosage forms are used to prevent ID in infants: these can be solutions or drops for oral administration containing iron sulfate (Actiferrin), iron (III) hydroxide polymaltose (Maltofer, Ferrum Lek), iron gluconate, manganese, copper (Totema), (Ferlatum); these same drugs are available in the form of syrups (Actiferrin, Maltofer, Ferrum Lek). Parenteral FPs are not used to prevent ID.

The prophylactic dose of FP depends on the child's birth weight:

• for weight <1000 g - 4 mg/kg per day;
• for weight 1000-1500 g - 3 mg/kg per day;
• for weight 1500-3000 g - 2 mg/kg per day.

In other cases, the prophylactic dose of FP is 1 mg/kg per day. Full-term infants who are exclusively breastfed, aged 6 months to 1 year, are also recommended to be prescribed FP at a rate of 1 mg/kg per day.

How is iron deficiency anemia prevented?

Prognosis of iron deficiency anemia in children

After treatment of iron deficiency anemia in children, the prognosis is usually favorable, especially in cases where the cause of ID can be quickly identified and eliminated. If treatment is undertaken later than 3 months from the clinical manifestation of IDA, the consequences can persist for many months, years, and even life.