Treatment of iron deficiency anemia

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

Contraindications to the appointment of iron

1. Absence of laboratory confirmation of iron deficiency.
2. Sidero-amphibic 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, patients feel better after a few days of starting iron therapy. A significant increase in hemoglobin levels with the use of iron preparations through the mouth is observed on average 3 weeks from the start of treatment, with parenteral administration of iron preparations, the increase in hemoglobin levels occurs faster than with the administration of drugs inside. The drug of choice for the treatment of severe forms of iron deficiency anemia in children is ferrum lek, which allows you to quickly get a clinical and hematological effect. In some patients, the normalization of hemoglobin with the use of oral medications is delayed up to 6-8 weeks, which may be due to the severity of anemia and the degree of depletion of iron stores or the fact that the cause of iron deficiency anemia persists or is not completely eliminated. If after 3 weeks from the start of treatment the hemoglobin content does not increase, it is necessary to find out the reason for the ineffectiveness of the treatment.

With iron deficiency anemia, phytotherapy can be used. Assign a phytosborus: leaves of nettle dioecious, three-parted, strawberry forest and blackcurrant; dried leaves of these plants are mixed in equal parts, 1 tablespoon of chopped leaves pour a glass of boiling water, insist for 2 hours, filter and take 1/3 cup 3 times a day on an empty stomach, for 1.5 months every day. It is highly desirable to take infusion of leaves of medicinal medicinal herbs, spinach of garden, dandelion, hips.

[1], [2]

Mode

The proper organization of diet and nutrition is an important part of complex therapy. An effective therapeutic and preventive measure is a long stay in the open air.

Children need a sparing regimen: limiting physical exertion, additional sleep, a favorable psychological climate, should be freed from visiting a children's institution, and should be protected from colds.

Older children are exempt from physical education until they recover, if necessary, they are given an extra day free from school.

Diet in iron deficiency anemia in children

Particular attention should be paid to balanced nutrition, normalization of appetite, gastric secretion and metabolism. Without the resolution of these processes, one can not rely on the effectiveness of drug therapy.

The appointment of adequate nutrition to patients with iron deficiency anemia is of great importance. It is necessary to eliminate the existing breastfeeding defects and to prescribe a rational diet, according to the main food ingredients, corresponding to the age indices.

The content of iron (mg) in food (in 100 g)

Poor iron		Moderately rich in iron		Rich in iron
Less than 1 mg of Fe in 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	Groats of oatmeal	4.3	Halva tahini	50.1
Pumpkin	0.8	Dogwood	4.1	Halva sunflower.	33.2
Carrot	0.8	Peaches	4.1	Pork liver	29.7
Grenades	0.78	Groats wheaten	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	Raisins	3.0	Dried apricots	12
Salad	0.6	Beef	2.8	Cocoa powder	11.7
Grapes	0.6	Apricots	2.6	Rosehip	Eleven
Banana	0.6	Apples	2.5	Beef liver	9
Cranberry	0.6	Chicken egg	2.5	Blueberries	8
Lemon	0.6	Pear	2.3	Kidney beef	7th
Orange	0.4	Plum	2.1	Brawns of beef	B
Mandarin	0.4	Blackcurrant	2.1	Oatmeal	5
Cottage cheese	0.4	Sausages	1.9	Yolk	5.8
Courgettes	0.4	Caviar caviar	1.8	Beef tongue	5
Lingonberry	0.4	Sausage	1, 7
A pineapple	0.3	Pork	1.6
Cow's milk	0.1	Gooseberry	1.6
Cream	0.1	Raspberries	1.5
Butter	0.1	Groats manna Chicken	1.6-1.5

Young children with anemia who are naturally breastfed should first of all adjust their mother's nutrition and, if necessary, adjust the baby's nutrition. Children suffering from anemia, the first lure should be introduced for 2-4 weeks earlier, while healthy (that is, from 3, 5 to 4 months). The first lure 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 lure, children with anemia can be fed with veal or beef liver. Hepatic dishes should be given in a garbled form, mixing with vegetable puree. Starting from the bi-monthly, it is possible to introduce meat dishes in the form of minced meat into the diet. From the diet should be excluded white porridge (semolina, rice, tolon), giving preference to buckwheat, barley, pearl barley, millet. Cook porridge should be on the water or, better, on a vegetable broth.

When building a diet in older children, it is necessary to consider that the heme iron contained in meat dishes is best absorbed in the digestive tract. Much worse is assimilated salt iron, which is a part of vegetables and fruits. In the diet it is advisable to slightly increase the protein quota (approximately 10% of the norm) due to the increase in the diet of protein products of animal origin; the amount of carbohydrates in the diet of the patient should correspond to the age norm, the amount of fat should be somewhat limited. With anemia, a sufficient introduction of fruit and vegetable juices and decoctions is shown, in older children mineral water can be used. It is advisable to use water from sources with poorly mineralized iron-sulphate-hydrocarbonate magnesium waters, in which the iron is in a well ionized form and is easily absorbed in the intestine. Sources of this type include the mineral springs of Zheleznovodsk, Uzhgorod, and Marcial Waters in Karelia. It should be borne in mind that compensation for iron deficiency and correction of iron deficiency anemia with the help of edible iron can not be achieved, which is informally reported to the parents of the patient who often prefer medicamentous preparations "food correction".

To improve the activity of the digestive tract, enzymes are prescribed.

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

Pathogenetic treatment of iron deficiency anemia in children

It is carried out with iron preparations that 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 ingestion (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 the given drug form of the preparation (drop, tablet, dragee, vial) and the volume of the package.

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

At the same time, every physician should be informed about the trend in the world practice of changing iron salts, often demonstrating low compliance, to new generation preparations - the hydroxide polymetal complex of ferric iron (Maltofer / Ferrum-Lek).

List of some iron preparations for ingestion

A drug	The composition of the preparation (in one tablet, tablet, in 1 ml of drops or syrup)	Form of issue	The content of elemental iron
Iron sulfate (actiferrin)	Ferrous sulfate 113.85 mg, DL-serine 129 mg in 1 capsule	Capsules, blister 10 capsules, 2 and 5 blisters per package	Fe 2+ : 34.5 mg in capsule
Iron sulfate (actiferrin)	Ferrous sulphate 47.2 mg, DL-serine 35.6 mg, glucose and fructose 151.8 mg, potassium sorbate 1 mg in 1 ml drops	Drops for ingestion, 30 ml in a vial	Fe 2+ : 9.48 mg in 1 ml
Iron sulfate (actiferrin)	Ferrous sulfate 171 mg, DL-serine 129 mg, glucose, fructose in 5 ml of syrup	Syrup, 100 ml in a vial	Fe 2+ : 34 mg in 5 ml
Iron (III) hydroxide polymaltozate (maltofer)	Hydroxide-polymaltose complex	Solution for ingestion, 30 ml in a vial with a dropper	Fe 3+ 50 mg in 1 ml of the solution (20 drops)
Iron (III) hydroxide polymaltosate + folic acid (Maltofer Fol)	Hydroxide-polymaltose complex, folic acid 0.35 mg in 1 tablet	Chewable tablets, 10 tablets in a blister, 3 blisters per package	Fe 3+ : 100 mg in 1 tablet
Iron (III) hydroxide polymaltozate (maltofer)	Hydroxide-polymaltose complex	Chewable tablets, blistere 10 tablets, 3 and 50 blisters per package	Fe 3+ : 100 mg in 1 tablet
Iron (III) hydroxide polymaltozate (maltofer)	Hydroxide-polymaltose complex	Syrup, 150 ml in a vial	Fe 3+ : 10 mg in 1 ml
Iron sulphate + ascorbic acid (Sorbifer Durules)	Iron sulfate 320 mg, ascorbic acid 60 mg	The tablets covered with a cover, on 30 and 50 tablets in a vial or flask	Fe 3+ : 100 mg in 1 tablet
Iron sulfate (tardiferone)	Iron sulfate 256.3 mg, mucoproteosis 80 mg, ascorbic acid 30 mg	Tablets coated with a coating, 10 tablets in a blister, 3 blisters in a package	Fe 2+ : 80 mg
Totem	In 10 ml of the 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 ingestion, ampoules of 10 ml, 20 pcs. Packaged	Fe 2+ : 5 mg in 1 ml
Iron fumarate + folic acid (ferretab com)	Iron 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 sulphate + ascorbic acid (ferroplex)	Iron sulfate 50 mg, ascorbic acid 30 mg	Dragee, packed in 100 pcs.	Fe 2+ 10 mg in 1 dragee
Ferronal	Gluconate iron 300 mg in 1 tablet	Film-coated tablets in a blister pack of 10 tablets, 1 blister in a package	Fe 2+ 30 mg in tablet
Heferol	Iron fumarate 350 mg in 1 kalsupe	Capsules, in a bottle 30 pcs.	Fe 2+ 115 mg in capsule
Iron (III) hydroxide polymaltozate (Ferrum Lek)	Hydroxide-polymaltose complex	Chewable tablets, 10 tablets in a strip, 3 strips in a package	Fe 3+ 100 mg in 1 tablet
Iron (III) hydroxide polymaltozate (Ferrum Lek)	Hydroxide-polymaltose complex	Syrup, 100 ml in a vial	Fe 3+ 10 mg in 1 ml
Ferlatum	Protein iron succininate 800 mg in 15 ml	Solution for ingestion, 15 ml in a vial, 10 bottles in a package	Fe 2+ 40 mg in 15 ml
Multivitamin + mineral salts (phenyuls)	Ferrous sulphate 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, iron deficiency anemia is treated with drugs for internal use. It is most expedient to use preparations containing ferrous iron. These compounds are well absorbed and give 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 form of release. Preference is given to drugs in liquid form. When prescribing iron preparations inside, some general principles must be taken into account.

1. It is better to prescribe iron preparations between meals. Food leads to dilution and a decrease in the concentration of iron, and, in addition, certain elements of food (salts, acids, alkalis) form insoluble compounds with iron. These include preparations containing phosphorus, phytin. Iron, taken in the evening hours, continues to be absorbed at night.
2. Use iron preparations should be combined with substances that improve its absorption: ascorbic, citric, succinic acid, sorbitol. The therapeutic complex includes the means 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. 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. A complex of vitamins should be taken 15-20 minutes after eating, and iron preparations - after 20-30 minutes after taking them.
3. To prevent dyspeptic phenomena, it is recommended, according to indications, to use enzymes - pancreatin, festal.
4. The course of treatment should be long. Treatment doses are applied until the normal level of hemoglobin in the blood is reached, that is, 1,5-2 months, and then within 2-3 months, the administration of preventive doses for replenishment of iron reserves is possible.
5. It is necessary to consider the tolerability of the drug. With poor tolerance, you can replace the drug, start treatment with a small dose, gradually increasing it to a tolerable and effective.
6. Do not prescribe iron preparations simultaneously with drugs that reduce its absorption: calcium preparations, antacids, tetracyclines, levomycetin.
7. It is necessary to calculate the need for iron for each patient. When calculating the duration of treatment, account should be taken of the content of elemental iron in the preparation and its absorption.

The optimal daily dose of elemental iron is 4-6 mg / kg. It should be borne in mind that the increase in hemolobin in patients with iron deficiency anemia can be ensured by the ingestion of 30 to 100 mg of ferrous iron per day. Given that with the development of iron deficiency anemia, iron absorption increases by 25-30% (with normal stores absorbed 3-7% of iron), it is necessary to assign 100 to 300 mg of ferrous iron per day. The use of higher daily doses does not make sense, since the amount 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 a daily dose in this range is determined by the individual tolerability of iron preparations and their availability.

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

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

• danger of overdose, up to poisoning, due to inflexible dosing, passive, uncontrolled absorption;
• pronounced metallic taste and staining of enamel of 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 obliged to warn patients or their parents about possible poisoning with salt preparations of iron. Iron poisoning accounts for only 1.6% of all cases of poisoning in children, but in 41.2% of cases end in a lethal outcome.

Properties and advantages of preparations based on the hydroxylpolymaltose complex:

• high efficiency;
• high safety: there is no risk of overdose, intoxication and poisoning;
• absence of darkening of teeth and gums;
• pleasant taste, like children;
• excellent tolerance, determining the regularity of treatment;
• lack of interaction with medicines and food;
• antioxidant properties;
• the existence of medicinal forms for all age groups (drops, syrup, chewable tablets, single ampoules, iron preparation with folic acid for pregnant women).

Parenteral (intramuscular, intravenous) iron preparations are shown:

• with a severe form of iron deficiency anemia (about 3% of patients);
• with intolerance of iron preparations for ingestion;
• with peptic ulcer or GI surgery, even in the anamnesis;
• if necessary, rapid saturation of the body with iron.

The total exchange rate of iron for parenteral administration is calculated by the formula:

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

Parenteral should not be administered more than 100 mg of iron per day, giving complete saturation of transferrin. In children under 2 years, the daily dose of parenterally administered iron is 25-50 mg, in children older than 2 years, 50-100 mg.

Parenteral administration of iron is much more difficult and more dangerous than oral because of the possible development of allergic reactions and infiltrates (with intramuscular injection), as well as the toxicity of ionized iron and the danger of its excessive deposition in tissues during overdose, since it is practically not excreted from the body. Iron is a capillarotoxic poison and when 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 the arterioles and venules, increases their permeability, decreases the overall peripheral resistance and the volume of circulating blood, and drops blood pressure. When iron overdosage is recommended, the administration of an antidote - desferal (deferoxamine) in a dose of 5-10 g or 60-80 mg / kg per day intramuscularly or intravenously drip.

Characteristics of iron preparations for parenteral use (prescribed only after determination of the iron-complex of blood and verification of the diagnosis of iron deficiency anemia)

The preparation of iron	Quantity in ampoule, ml	Content of iron in 1 ml (in ampoule)	The route of administration
Ferrum lek	2.0	50 (100)	Intramuscularly
	5.0	20 (100)	Intravenously
Ferbitol	2.0	50 (100)	Intramuscularly
Jectofer	2.0	50 (100)	Intramuscularly
Ferkoven	5.0	20 (100)	Intravenously
Imferon	1.0	50 (50)	Intramuscularly, intravenously
Ferrelcit	5.0	12.5 (62.5)	Intravenous drip for 60 minutes, dilute in 50-100 ml of 0.9 % NaCl solution

Calculation of doses

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

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

Correct calculation of the dose of iron is an extremely important principle of treatment. One gets the impression that most cases of ineffective treatment with iron preparations are associated with inadequate (underestimated) dosage of drugs. Calculation of the dose of iron preparations is important in pediatric practice, when the doctor deals with both newborn children and adolescents whose body weight corresponds to the body weight of an adult. Use a therapeutic plan, tested in children, adolescents and adults.

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

The severity of anemia (concentration of Hb, g / l)	Duration of treatment, month
	1	3	4	6th
	Dose of iron preparation, mg / kg per day
Easy (110-90)	5	3	-
The 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 curing iron deficiency anemia is the overcoming of tissue sideropenia (and not the achievement of a normal hemoglobin level), which can be fixed by normalizing the level of SF. Clinical experience has shown that this requires at least 3-6 months, depending on the severity of the anemia. Ineffective treatment with iron preparations and so-called relapse of the disease can be associated with the cessation of treatment with iron preparations after reaching the normal level of hemoglobin.

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

Control of treatment effectiveness

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

• reticulocyte reaction on the 7-10th day from the beginning of treatment with iron preparations;
• the beginning of an increase in the concentration of hemoglobin after 4 weeks of treatment with iron preparations (it is possible to use the criteria for the response to treatment with iron preparations recommended by American specialists: an increase in the hemoglobin concentration by 10 g / l and an increase in hectrites by 3% relative to the baseline 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 transfusion with iron deficiency anemia

The results of clinical observations indicate the inexpediency of substitution therapy for this form of anemia. Hemotransfusion gives a momentary short-term effect due to transfused erythrocytes. The bone marrow of blood transfusion has a negative effect, inhibiting erythropoiesis and suppressing the activity of hemoglobin synthesis in normal cells. Therefore, in iron deficiency anemia, hemotransfusions should be used only for vital indications, the main criterion being not the amount of hemoglobin, but the general condition of the patient. Indications for transfusion of erythrocyte mass are a severe degree of anemia (hemoglobin <70 g / l) with pronounced hypoxia, anemic precoma and coma.

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

Substitution therapy with erythrocyte mass should be carried out according to strict indications. At present, the requirements for determining indications for transfusion of blood components in a particular patient have been significantly increased. The doctor who prescribes transfusion, must take into account the effect and possible harm of the forthcoming blood transfusion. With blood transfusions, the risk of transmission of various infections (hepatitis, AIDS), the formation of irregular antibodies, suppression of their own hemopoiesis - they should be considered as a cell transplantation, since cells are obtained from an allogeneic donor. It is of fundamental importance 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 not possible for religious reasons (Jehovah's Witnesses). The decision to perform transfusion (for example, erythrocyte mass) can be taken by a doctor who is currently at the patient's bed, taking into account:

• the nature of the disease;
• severity of anemia;
• threats of further reduction of hemoglobin concentration;
• tolerability of anemia in patients;
• stability of hemodynamic parameters.

The request of doctors to name indicators of hemoglobin concentration, in which transfusion of erythrocyte mass is necessary, is a common mistake, since this approach does not take into account the above indicators. The opinion that there is no indication for transfusion of erythrocyte mass in iron deficiency anemia is, as a rule, justified. Even severe iron deficiency anemia can be successfully treated with iron preparations for ingestion, intramuscular or intravenous iron preparations.

[20], [21], [22]