Treatment of iron deficiency anemia

Treatment of iron deficiency anemia in children should be comprehensive. Etiological treatment involves eliminating the causes that lead to the development of iron deficiency.

Contraindications to the administration of iron preparations

1. Lack of laboratory confirmation of iron deficiency.
2. Sideroachrestic anemia.
3. Hemolytic anemia.
4. Hemosiderosis and hemochromatosis.
5. Infection caused by gram-negative flora (enterobacteria, Pseudomonas aeruginosa, Klebsiella are siderophilic microorganisms and use iron in the processes of growth and reproduction).

Usually, the patients' health improves within a few days after the start of iron therapy. A significant increase in hemoglobin levels with oral iron preparations is observed on average 3 weeks after the start of treatment; with parenteral administration of iron preparations, the increase in hemoglobin levels occurs faster than with oral administration. The drug of choice for the treatment of severe forms of iron deficiency anemia in children is Ferrum Lek, which allows for a quick clinical and hematological effect. In some patients, the time to normalize hemoglobin levels with oral administration is delayed to 6-8 weeks, which may be due to the severity of anemia and the degree of depletion of iron stores, or to the fact that the cause of iron deficiency anemia persists or is not completely eliminated. If the hemoglobin level does not increase after 3 weeks from the start of treatment, it is necessary to find out the reason for the ineffectiveness of the treatment.

In case of iron deficiency anemia, herbal medicine can be used. Prescribe a herbal mixture: leaves of stinging nettle, three-part Bidens, wild strawberry and black currant; mix the dried leaves of the above plants in equal parts, pour a glass of boiling water over 1 tablespoon of crushed leaves, leave for 2 hours, strain and take 1/3 cup 3 times a day on an empty stomach, daily for 1.5 months. It is highly advisable to take an infusion of lungwort leaves, garden spinach, dandelion, and rose hips.

[ 1 ], [ 2 ]

Mode

Important links in complex therapy are the correct organization of the regime and nutrition. An effective therapeutic and preventive measure is a long stay in the fresh air.

Children need a gentle regime: limited physical activity, extra sleep, a favorable psychological climate, they should be exempted from visiting a child care facility, and protected from colds.

Older children are exempt from physical education classes until they recover; if necessary, they are given an additional day off from school.

Diet for iron deficiency anemia in children

Particular attention should be paid to balanced nutrition, normalization of appetite, gastric secretion and metabolism. Without regulation of these processes, one cannot hope for the effectiveness of drug therapy.

Prescribing adequate nutrition to patients with iron deficiency anemia is of great importance. It is necessary to eliminate existing feeding defects and prescribe rational nutrition, with the main food ingredients corresponding to age indicators.

Iron content (mg) in food products (in 100 g)

Poor in iron		Moderately rich in iron		Rich in iron
Less than 1 mg Fe per 100 g		1-5 mg Fe in 100 g		More than 5 mg Fe in 100 g
Product	Fe	Product	Fe	Product	Fe
Cucumbers	0.9	Oatmeal	4.3	Tahini halva	50.1
Pumpkin	0.8	Dogwood	4.1	Sunflower halva.	33.2
Carrot	0.8	Peaches	4.1	Pork liver	29.7
Grenades	0.78	Wheat groats	3.9	Dried apples	15
Strawberry	0.7	Buckwheat flour	3.2	Dried pear	13
Breast milk	0.7	Mutton	3.1	Prunes	13
Cod	0.6	Spinach	3.0	Dried apricots	12
Rhubarb	0.6	Raisin	3.0	Dried apricots	12
Salad	0.6	Beef	2.8	Cocoa powder	11.7
Grape	0.6	Apricots	2.6	Rose hip	11
Banana	0.6	Apples	2.5	Beef liver	9
Cranberry	0.6	Chicken egg	2.5	Blueberry	8
Lemon	0.6	Pear	2,3	Beef kidneys	7
Orange	0.4	Plum	2.1	Beef brains	B
Mandarin	0.4	Black currant	2.1	Oatmeal	5
Cottage cheese	0.4	Sausages	1.9	Yolk	5.8
Zucchini	0.4	Chum salmon caviar	1.8	Beef tongue	5
Cowberry	0.4	Sausage	1.7
Pineapple	0.3	Pork	1.6
Cow's milk	0,1	Gooseberry	1.6
Cream	0,1	Raspberry	1.5
Butter	0,1	Semolina Chicken	1.6-1.5

For young children suffering from anemia who are breastfed, the mother's diet should be adjusted first of all, and if necessary, the child's diet should be adjusted. For children suffering from anemia, the first complementary feeding should be introduced 2-4 weeks earlier than for healthy children (i.e. from 3.5 - 4 months). The first complementary feeding must necessarily be dishes rich in iron salts: potatoes, beets, carrots, cabbage, zucchini, etc. The diet should include fruit and berry juices, grated apples. Already with the first complementary feeding, children suffering from anemia can be given veal or beef liver. Liver dishes should be given in a mashed form, mixed with vegetable puree. Starting from 6 months, meat dishes in the form of minced meat can be introduced into the diet. White porridges (semolina, rice, bearberry) should be excluded from the diet, giving preference to buckwheat, barley, pearl barley, millet. Porridges should be cooked in water or, better, in vegetable broth.

When planning a diet for older children, it is necessary to take into account that heme iron contained in meat dishes is best absorbed in the digestive tract. Salt iron contained in vegetables and fruits is absorbed much worse. It is advisable to slightly increase the protein quota in the diet (by about 10% of the age norm) by increasing the amount of protein products of animal origin in the diet; the amount of carbohydrates in the patient's diet should correspond to the age norm, the amount of fats should be somewhat limited. In case of anemia, sufficient introduction of fruit and vegetable juices and decoctions is indicated; in older children, mineral waters can be used. It is advisable to use water from springs with a type of weakly mineralized iron-sulphate-hydrocarbonate-magnesium waters, in which iron is in a well-ionized form and is easily absorbed in the intestine. Sources of this type include mineral springs of Zheleznovodsk, Uzhgorod, Marcial Waters in Karelia. It is necessary to take into account that compensation for iron deficiency and correction of iron deficiency anemia with the help of dietary iron cannot be achieved, which is necessarily reported to the patient’s parents, who often prefer “nutritional correction” to medications.

To improve the functioning of the gastrointestinal tract, enzymes are prescribed.

[ 3 ], [ 4 ], [ 5 ], [ 6 ], [ 7 ]

Pathogenetic treatment of iron deficiency anemia in children

It is carried out with iron preparations, which are administered orally or parenterally.

Iron preparations are the main drugs for the treatment of iron deficiency anemia; they are represented by numerous forms of iron preparations for oral administration (drops, syrup, tablets).

To calculate the required amount of the drug, it is necessary to know the content of elemental iron (Fe ²⁺ or Fe ³⁺ ) in a given dosage form of the drug (drop, tablet, dragee, bottle) and the volume of the packaging.

The choice of iron preparation is the prerogative of the doctor. The doctor chooses the preparation in accordance with the financial capabilities of the patient or his parents, the tolerability of the preparation and his own experience of using the iron preparation.

At the same time, every physician should be informed about the current trend in global practice of replacing iron salt preparations, which often demonstrate low compliance, with new generation preparations - trivalent iron hydroxide polymaltose complex (Maltofer Ferrum-Lek).

List of some oral iron preparations

Preparation	Composition of the drug (in one dragee, tablet, in 1 ml of drops or syrup)	Release form	Elemental iron content
Iron sulfate (actiferrin)	Ferrous sulfate 113.85 mg, DL-serine 129 mg in 1 capsule	Capsules, 10 capsules in a blister, 2 and 5 blisters in a package	Fe 2+: 34.5 mg per capsule
Iron sulfate (actiferrin)	Ferrous sulfate 47.2 mg, DL-serine 35.6 mg, glucose and fructose 151.8 mg, potassium sorbate 1 mg in 1 ml drops	Drops for oral administration, 30 ml in a bottle	Fe 2+: 9.48 mg in 1 ml
Iron sulfate (actiferrin)	Ferrous sulfate 171 mg, DL-serine 129 mg, glucose, fructose in 5 ml syrup	Syrup, 100 ml in a bottle	Fe 2+: 34 mg in 5 ml
Iron (III) hydroxide polymaltosate (Maltofer)	Hydroxide-polymaltose complex	Solution for oral administration, 30 ml in a bottle with a dropper	Fe 3+ 50 mg in 1 ml of solution (20 drops)
Iron (III) hydroxide polymaltose + folic acid (Maltofer Fol)	Hydroxide-polymaltose complex, folic acid 0.35 mg in 1 tablet	Chewable tablets, 10 tablets in a blister, 3 blisters in a package	Fe 3+: 100 mg in 1 tablet
Iron (III) hydroxide polymaltosate (Maltofer)	Hydroxide-polymaltose complex	Chewable tablets, 10 tablets in a blister, 3 and 50 blisters in a package	Fe 3+: 100 mg in 1 tablet
Iron (III) hydroxide polymaltosate (Maltofer)	Hydroxide-polymaltose complex	Syrup, 150 ml in a bottle	Fe 3+: 10 mg in 1 ml
Iron sulfate + ascorbic acid (Sorbifer Durules)	Iron sulfate 320 mg, ascorbic acid 60 mg	Film-coated tablets, 30 and 50 tablets per bottle	Fe 3+: 100 mg in 1 tablet
Iron sulfate (tardyferon)	Iron sulfate 256.3 mg, mucoproteose 80 mg, ascorbic acid 30 mg	Film-coated tablets, 10 tablets in a blister, 3 blisters in a package	Fe 2+: 80 mg
Totem	In 10 ml of solution: 50 mg of iron gluconate, 1.33 mg of manganese gluconate, 0.7 mg of copper gluconate, glycerol, glucose, sucrose, citric acid, sodium citrate, etc.	Solution for oral administration, 10 ml ampoules, 20 pcs. per package	Fe 2+: 5 mg in 1 ml
Iron fumarate + folic acid (ferretab coml)	Ferrous fumarate 154 mg, folic acid 0.5 mg	Capsules, 10 capsules in a blister, 3 blisters in a package	Fe 2+ 50 mg in 1 capsule
Iron sulfate + ascorbic acid (ferroplex)	Iron sulfate 50 mg, ascorbic acid 30 mg	Dragee, 100 pcs. in a package.	Fe 2+ 10 mg in 1 tablet
Ferronal	Iron gluconate 300 mg in 1 tablet	Film-coated tablets in a blister of 10 tablets, 1 blister per package	Fe 2+ 30 mg per tablet
Heferol	Ferrous fumarate 350 mg in 1 calsup	Capsules, 30 pcs in a bottle.	Fe 2+ 115 mg per capsule
Iron (III) hydroxide polymaltose (Ferrum Lek)	Hydroxide-polymaltose complex	Chewable tablets, 10 tablets per strip, 3 strips per pack	Fe 3+ 100 mg in 1 tablet
Iron (III) hydroxide polymaltose (Ferrum Lek)	Hydroxide-polymaltose complex	Syrup, 100 ml in a bottle	Fe 3+ 10 mg in 1 ml
Ferlatum	Iron protein succinylate 800 mg in 15 ml	Solution for oral administration, 15 ml in a bottle, 10 bottles in a package	Fe 2+ 40 mg in 15 ml
Multivitamin + mineral salts (fenuls)	Iron sulfate 150 mg, ascorbic acid 50 mg, riboflavin 2 mg, thiamine 2 mg, nicotinamide 15 mg, pyridoxine hydrochloride 1 mg, pantothenic acid 2.5 mg	Capsules, 10 capsules in a blister, 1 blister in a package	Fe 2+ 45 mg in 1 capsule

In most cases, except for special indications, treatment of iron deficiency anemia is carried out with drugs for internal use. It is most advisable to use drugs containing divalent iron. These compounds are well absorbed and provide a high rate of hemoglobin growth. When choosing a drug for young children, it is necessary to take into account the degree of toxicity and the form of release. Preference is given to drugs in liquid form. When prescribing iron drugs orally, it is necessary to take into account some general principles.

1. It is better to prescribe iron preparations between meals. Food leads to dilution and decrease in iron concentration, and, in addition, some food elements (salts, acids, alkalis) form insoluble compounds with iron. These include preparations containing phosphorus, phytin. Iron taken in the evening continues to be absorbed at night.
2. Iron preparations should be used in combination with substances that improve its absorption: ascorbic, citric, succinic acids, sorbitol. The treatment complex includes agents that accelerate the synthesis of hemoglobin - copper, cobalt; vitamins B ₁, B ₂, B ₆, C, A - to improve the regeneration of the epithelium; vitamin E - to prevent excessive activation of free radical reactions. The doses of vitamins B ₁, B ₂, C correspond to the daily requirement, the dose of vitamin B ₆ exceeds the daily requirement by 5 times. The vitamin complex should be taken 15-20 minutes after meals, and iron preparations - 20-30 minutes after taking them.
3. To prevent dyspeptic symptoms, it is recommended, according to indications, to use enzymes - pancreatin, festal.
4. The course of treatment should be long. Therapeutic doses are used until the normal level of hemoglobin in the blood is achieved, i.e. 1.5-2 months, and then for 2-3 months it is possible to prescribe prophylactic doses to replenish iron reserves.
5. It is necessary to take into account the tolerability of the drug. If it is poorly tolerated, the drug can be replaced, treatment can be started with a small dose, gradually increasing it to a tolerable and effective one.
6. Iron preparations should not be prescribed simultaneously with drugs that reduce its absorption: calcium preparations, antacids, tetracyclines, chloramphenicol.
7. It is necessary to calculate the iron requirement for each patient. When calculating the duration of treatment, the content of elemental iron in the drug and its absorption should be taken into account.

The optimal daily dose of elemental iron is 4-6 mg/kg. It should be borne in mind that the increase in hemoglobin in patients with iron deficiency anemia can be ensured by the intake of 30 to 100 mg of divalent iron per day. Considering that with the development of iron deficiency anemia, iron absorption increases by 25-30% (with normal reserves, 3-7% of iron is absorbed), it is necessary to prescribe 100 to 300 mg of divalent iron per day. The use of higher daily doses does not make sense, since the volume of absorption does not increase. Thus, the minimum effective daily dose is 100 mg of elemental iron, and the maximum is about 300 mg orally. The choice of daily dose in this range is determined by the individual tolerance of iron preparations and their availability.

In case of overdose of iron preparations, undesirable effects are observed: dyspeptic disorders (nausea, vomiting, diarrhea) are directly proportional to the amount of unabsorbed iron in the gastrointestinal tract; infiltrate at the site of intramuscular injection; hemolysis of erythrocytes due to activation of free radical reactions, damage to cell membranes.

Disadvantages of using iron salt preparations in the treatment of patients with iron deficiency anemia:

• the risk of overdose, including poisoning, due to inflexible dosing, passive, uncontrolled absorption;
• a pronounced metallic taste and staining of the enamel of the teeth and gums, sometimes persistent;
• interaction with food and other drugs;
• frequent refusal of patients from treatment (30-35% of patients who started treatment).

Doctors are required to warn patients or their parents about possible poisoning with iron salt preparations. Iron poisoning accounts for only 1.6% of all poisoning cases in children, but is fatal in 41.2% of cases.

Properties and advantages of preparations based on hydroxide polymaltose complex:

• high efficiency;
• high safety: no risk of overdose, intoxication or poisoning;
• no darkening of teeth and gums;
• pleasant taste, children like it;
• excellent tolerability, which determines the regularity of treatment;
• no interaction with medications and food;
• antioxidant properties;
• the existence of dosage forms for all age groups (drops, syrup, chewable tablets, single-use ampoules, iron supplement with folic acid for pregnant women).

Parenteral (intramuscular, intravenous) iron preparations are indicated:

• in severe forms of iron deficiency anemia (about 3% of patients);
• in case of intolerance to oral iron preparations;
• in case of peptic ulcer or gastrointestinal surgery, even in history;
• when there is a need to quickly saturate the body with iron.

The total course dose of iron for parenteral administration is calculated using the formula:

Fe (mg) = P x (78 - 0.35 x Hb), where P is the patient's weight in kilograms; Hb is the patient's hemoglobin content in g/l.

Parenterally, no more than 100 mg of iron per day should be administered, which provides complete saturation of transferrin. In children under 2 years of age, the daily dose of parenterally administered iron is 25-50 mg, in children over 2 years of age - 50-100 mg.

Parenteral administration of iron is much more complicated and dangerous than oral administration due to the possible development of allergic reactions and infiltrates (with intramuscular administration), as well as the toxicity of ionized iron and the danger of its excessive deposits in tissues in case of overdose, since it is practically not excreted from the body. Iron is a capillary toxic poison and with parenteral administration, against the background of a reduced level of transferrin in the blood, the fraction of free iron increases, which leads to a decrease in the tone of arterioles and venules, their permeability increases, total peripheral resistance and circulating blood volume decrease, and arterial pressure drops. In case of iron overdose, it is recommended to administer an antidote - desferal (deferoxamine) at a dose of 5-10 g orally or 60-80 mg / kg per day intramuscularly or intravenously by drip.

Characteristics of iron preparations for parenteral use (prescribed only after determining the iron complex of the blood and verifying the diagnosis of iron deficiency anemia)

Iron preparation	Quantity in ampoule, ml	Iron content in 1 ml (in an ampoule)	Route of administration
Ferrum lek	2.0	50 (100)	Intramuscularly
	5.0	20 (100)	Intravenously
Ferbitol	2.0	50 (100)	Intramuscularly
Zhektofer	2.0	50 (100)	Intramuscularly
Ferkoven	5.0	20 (100)	Intravenously
Imferon	1.0	50 (50)	Intramuscular, intravenous
Ferrlecite	5.0	12.5 (62.5)	Intravenously by drip for 60 minutes, dilute in 50-100 ml of 0.9 % NaCl solution

Dose calculation

The dose of the drug is calculated for a specific patient taking into account:

• degrees of anemic state (I, II, III degree);
• the patient's body weight;
• therapeutic plan for the treatment of iron deficiency anemia used in this medical institution.

Correct calculation of the dose of iron preparation is an extremely important principle of treatment. It seems that most cases of ineffective treatment with iron preparations are associated with inadequate (underestimated) dosage of preparations. Calculation of the dose of iron preparations is important in pediatric practice, when the doctor deals with both newborns and adolescents whose body weight corresponds to that of an adult. A therapeutic plan tested in children, adolescents and adults is used.

Therapeutic plan for the treatment of iron deficiency anemia depending on the severity

Severity of anemia (Hb concentration, g/l)	Duration of treatment, months
	1	3	4	6
	Dose of iron preparation, mg/kg per day
Light (110-90)	5	3	-
Average (90-70)	5-7	3-5	3	-
Heavy (<70)	8	5	3

[ 8 ], [ 9 ], [ 10 ], [ 11 ]

Duration of treatment for iron deficiency anemia in children

The criterion for recovery from iron deficiency anemia is considered to be overcoming tissue sideropenia (and not achieving a normal hemoglobin level), which can be recorded by normalizing the SF level. As clinical experience has shown, this requires at least 3-6 months, depending on the severity of the anemia. Ineffective treatment with iron preparations and so-called relapses of the disease may be associated with the cessation of treatment with iron preparations upon achieving a normal hemoglobin level.

[ 12 ], [ 13 ], [ 14 ], [ 15 ]

Monitoring the effectiveness of treatment

The effectiveness of treatment with iron preparations is assessed by several indicators:

• reticulocyte reaction on the 7-10th day from the start of treatment with iron preparations;
• the onset of an increase in hemoglobin concentration after 4 weeks of treatment with iron preparations (it is possible to use the response criteria to treatment with iron preparations recommended by American specialists: an increase in hemoglobin concentration by 10 g/l and an increase in hetocrit by 3% in relation to the initial level);
• disappearance of clinical manifestations of the disease after 1-2 months of treatment;
• overcoming tissue sideropenia, determined by the level of SF, 3-6 months after the start of treatment (depending on the severity of anemia).

[ 16 ], [ 17 ], [ 18 ], [ 19 ]

Blood transfusions for iron deficiency anemia

The results of clinical observations indicate that replacement therapy is inappropriate for this form of anemia. Blood transfusion provides a one-time short-term effect due to the transfused erythrocytes. Blood transfusions have a negative effect on the bone marrow, inhibiting erythropoiesis and suppressing the activity of hemoglobin synthesis in normocytes. Therefore, in iron deficiency anemia, blood transfusions should be used only for vital indications, and the main criterion is not the amount of hemoglobin, but the general condition of the patient. Indications for transfusion of red blood cell mass are severe anemia (hemoglobin < 70 g / l) with pronounced hypoxia, anemic precoma and coma.

Evaluation of the first 3 indicators is especially important in cases where the doctor does not have the opportunity to conduct the most informative laboratory tests confirming iron deficiency in the body (MCV, MCHC, MCH, RDW, SI, TIBC, transferrin saturation with iron, SF).

Replacement therapy with red blood cells should be carried out according to strict indications. Currently, the requirements for determining the indications for transfusion of blood components in a specific patient have been significantly increased. The doctor prescribing the transfusion must take into account the effect and possible harm of the upcoming blood transfusion. Blood transfusions are associated with the risk of transmission of various infections (hepatitis, AIDS), the formation of irregular antibodies, suppression of one's own hematopoiesis - they should be considered as cell transplantation, since the cells are obtained from an allogeneic donor. It is fundamentally important to inform the patient or his parents (guardians) about the patient's condition, the need for transfusion and the associated risk. Sometimes blood transfusions are impossible for religious reasons (Jehovah's Witnesses). The decision to carry out a transfusion (for example, red blood cells) can be made by the doctor currently at the patient's bedside, taking into account:

• nature of the disease;
• severity of anemia;
• threats of further decrease in hemoglobin concentration;
• patient tolerance to anemia;
• stability of hemodynamic parameters.

Asking doctors to name the hemoglobin concentration values at which red blood cell transfusion is necessary is a common mistake, since such an approach does not take into account the above-mentioned parameters. The opinion that there is no indication for red blood cell transfusion in iron deficiency anemia is usually justified. Even severe iron deficiency anemia can be successfully treated with oral, intramuscular, or intravenous iron preparations.

[ 20 ], [ 21 ], [ 22 ]