Iron deficiency anemia in children

Iron deficiency anemia in children is a clinico-hematologic syndrome, based on a violation of hemoglobin synthesis due to iron deficiency.

There are 3 iron deficiency states:

1. prelatent iron deficiency;
2. latent iron deficiency;
3. Iron-deficiency anemia.

With the prelatent iron deficiency, the iron content is reduced only in the depot with the transport and hemoglobin funds preserved. The absence of clinical manifestations and clear diagnostic criteria make it impossible to attach this state of practical importance.

The latent iron deficiency, which is 70% of all iron deficiency states, is considered not a disease but a functional disorder with a negative iron balance, it does not have a separate ICD-10 code. With latent iron deficiency, there is a characteristic clinical picture: sideropenic syndrome, but the hemoglobin content remains within the normal range, which does not allow to identify persons with this condition from the general population according to 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. At this disease reveal:

• anemic and sideropenic syndromes;
• decrease in the concentration of hemoglobin and serum iron;
• increased total iron-binding capacity of serum (OZHSS);
• decrease in serum ferritin concentration (SF).

[1], [2], [3],

Epidemiology

An important frequency response: 90% of anemia in children - iron deficiency anemia, in adults this figure reaches 80%. The remaining 10% (in adults 20%) fall on other types of anemia: hereditary and acquired hemolytic anemia, constitutional and acquired aplastic anemia. The true figures of the incidence and prevalence of iron deficiency anemia in children in our country are unknown, but, most likely, are quite high, especially in young children. The magnitude of the problem can be assessed by examining WHO data: 3,600,000,000 people on earth have a latent iron deficiency and 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 one and requires decision-making at the state level.

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

In childhood, iron deficiency anemia accounts for 90% of all anemia. Thus, appointing iron for all anemia, the doctor "guesses" in 9 cases out of 10. The remaining 10% of anemia includes congenital and acquired hemolytic and aplastic anemia, as well as anemia in chronic diseases.

[4], [5], [6],

The causes of iron deficiency anemia in children

There are more than 10 types of iron metabolism disorders leading to the development of iron deficiency states. The most important are:

• iron deficiency in food, important in the development of iron deficiency conditions in children from the earliest to adolescence, and in adults and the elderly;
• violation of absorption of iron in the duodenum and upper parts of the small intestine as a result of inflammation, allergic edema of the mucous membrane, lambliasis, infection of Helicobacter jejuni, with bleeding;

What provokes iron deficiency anemia?

Exchange of iron in the body

Normally, the body of an adult healthy person contains about 3-5 g of iron, so iron can be classified as trace elements. Iron is distributed unevenly in the body. Approximately 2/3 of the iron is contained in the hemoglobin of erythrocytes - it is a circulating iron pool (or pool). In adults, this pool is 2-2.5 g, in full-term newborns - 0.3-0.4 g, and in preterm infants - 0.1-0.2 g.

Exchange of iron in the body

[7], [8]

Pathogenesis of iron deficiency anemia

In the development of anemia, there is a definite sequence:

I stage - iron stores in the liver, spleen and bone marrow decrease .

In parallel, the concentration of ferritin in the blood serum decreases, a latent iron deficiency develops - sideropenia without anemia. Ferritin according to modern ideas reflects the state of the total iron stores in the body, so at this stage iron stores are significantly depleted without reducing the red blood cell (hemoglobin) fund.

What happens during iron deficiency anemia?

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

The idea that reducing the concentration of hemoglobin in a pregnant woman does not affect the development of the fetus, is mistaken. Iron deficiency in the fetus leads to irreversible disorders:

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

These changes are irreversible, they can not be corrected with iron preparations prescribed in the first months of a child's life. Subsequently, the child is noted for a delay in mental and motor development, a violation of cognitive functions. American researchers have shown that even 5 years after iron deficiency anemia, transferred at the age of 12-23 months, the child is noted for a delay in mental and motor development, as well as learning difficulties.

The most intensive growth is observed in children under one year and in adolescents in the puberty period. Pediatricians know that at the age of 3 months, many children have a decreased level of hemoglobin (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 norm of hemoglobin concentration corresponding to 95 g / l was established, since this transient decrease in hemoglobin level is expressed in the majority of children in the population. Reduction of hemoglobin concentration in the majority of children at 3 months is associated with the transition of erythroid cells from the synthesis of fetal hemoglobin (Hb F) to Hb A2 is a "physiological anemia" and does not require treatment. The concentration of hemoglobin should be determined at 6 months: at this age, its values correspond to the norm (110 g / l and more).

If the child is breastfeeding and does not belong to any risk group (prematurity, from multiple pregnancies, born with low body weight), breastfeeding and follow-up of the child continue. The appointment of iron preparations in preventive doses, usually 50% of the treatment dose, is shown to children from these groups at risk of developing iron deficiency anemia.

Continuous monitoring of hemoglobin should be performed up to 18 months:

• in children with low birth weight;
• in premature infants;
• in children who do not receive formula containing iron.

From the 6th to the 18th month, the level of hemoglobin should be monitored if the child:

• receives cow's milk up to 12 months;
• on breastfeeding after 6 months of receiving insufficient amount of iron with lure;
• sick (chronic inflammatory diseases, dietary restrictions, heavy blood loss due to trauma, taking medications that interfere with iron absorption).

Iron deficiency anemia in adolescents

Teenagers, especially girls 12-18 years old, need screening for hemoglobin. It is expedient to annually determine the level of hemoglobin in girls and women who have heavy blood loss during menstruation or other nature, low iron intake with food, and iron deficiency anemia in the anamnesis. Non-risk groups that are not at risk are not in need of frequent monitoring of hemoglobin and can be inspected every 5 years if they consume iron-rich foods that enhance their absorption. Young people also need to control the level of hemoglobin if they are intensively engaged in heavy sports (anemia of athletes). If iron deficiency anemia is detected, it is treated.

Conducting preventive vaccinations in children with iron deficiency anemia is not contraindicated, does not require normalization of the hemoglobin level, since the number of immunocompetent cells is sufficient.

Russia can and should rely on the experience of fighting iron deficiency anemia, obtained in other countries. The most clear measures for the prevention of iron deficiency states are formulated in the national "Recommendations for the Prevention and Treatment of Iron Deficiency in the United States" (1998): primary prevention implies proper nutrition, secondary - active detection of latent iron deficiency and iron deficiency anemia in medical examinations, medical examinations and doctor visits.

Symptoms of iron deficiency anemia in children

Men suffer iron deficiency anemia worse than women; the elderly are heavier than the young.

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

Symptoms of iron deficiency anemia

Diagnosis of iron deficiency anemia

In accordance with the recommendations of the WHO, the following criteria for the diagnosis of iron deficiency anemia are standardized:

• decrease in the level of SLC less than 12 μmol / l;
• an increase in OJSS more than 69 μmol / l;
• transferrin saturation with iron less than 17%;
• the hemoglobin content is lower than 110 g / l under the age of 6 years and below 120 g / l - over the age of 6 years.

Diagnosis of iron deficiency anemia

[9], [10], [11]

Treatment of iron deficiency anemia in children

With JE, only iron preparations are effective! Diet can not be cured by IDA! In other anemias not associated with JJ, ferro-preparations are unnecessary, and with prolonged use they can lead to abnormal cumulation of iron. Since JJ is always secondary, it is necessary to find and, if possible, eliminate the cause underlying JJ. But even if you can not establish the cause of JJ, you should restore iron stores with iron preparations. Ferro-preparations differ from the chemical structure, the method of administration, and the presence of other components in their composition.

Iron preparations used to treat and prevent iron deficiency

For oral administration (oral)		Parenteral
Monocomponent Complex in composition
Salt (ionic) ferro-preparations
Iron (II) -gljonat (Ferronal, Ferronal 35)	Gluconate of iron, manganese, copper (Totem)	Iron (III) -hydroxide sucrose complex for intravenous administration (Venofer)
Iron (II) -sulfate (Hemoplast prolongantum)	Iron sulfate and ascorbic acid (Sorbifer Durules, Ferroplex)	Iron (III) -hydroxide polymaltozate (iron dextrin) for intramuscular injection (Maltofer for intramuscular injection)
Iron (II) -fumarate (Heferol)	Multivitamin, mineral salts (Fenulis)
	Iron sulfate (Actyferrin)	Iron (III) -hydroxide polyisomaltozate (iron dextran) for intramuscular injection (Ferrum Lek for intramuscular injection)
	Iron sulfate (Aktiferrin 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 is produced by the company Viphor (International) Inc., Switzerland.

The dose of iron is calculated by the elemental iron contained in a particular drug. At the same time, for children of early age (up to 15 kg), the calculation of the iron dose is made in mg / kg per day, and for older children and adolescents - in mg / day. The use of smaller doses of AF does not provide an adequate clinical effect. Received iron is used first to build hemoglobin, and then it is already deposited in the depot, so you should conduct a full course of treatment to replenish iron stores in the body. The total duration of FT depends on the severity of the JJ.

The choice of a particular OP depends on its dosage form (oral solution, syrup, tablets, parenteral forms), the chemical structure of the drug, the degree of absorption of iron from the OP. The age of the child, the severity of the JJ, the accompanying pathology, and the social status are also important. In most cases, the use of AF for oral administration is used to treat the JJ, since the enteral route is physiologically more appropriate.

Children under 5 years of age use OP in the form of solutions for ingestion or syrup, older than 5 years - in the form of tablets or dragees, after 10-12 years - in the form of tablets or capsules.

When appointing oral AF, it should be borne in mind that 5-30% of the ingested iron is absorbed, and AF differs

Duration of ferrotherapy and calculating the dose of alimentary iron for ingestion from each other according to the degree of absorption. It is highest (15-30%) in the 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.

Grade G		Age	Basic FT
			The dose of OP	Duration, weeks
LJ		Up to 3-5 years	3 mg / kg xut)	4-6
		> 5 years	40-60 mg / day
IDA	I degrees	Up to 3-5 years	5-8 mg / kg xut)	6-8 (mах 10-12)
		> 5 years	50-150 mg / day
	II degree	Up to 3-5 years	5-8 mg / kg xut)	8-10 (max 12-14)
		> 5 years	50-200 mg / kg xut)
	III degree	Up to 3-5 years	5-8 mg / kg xut)	10-12 (m 14-18)
		> 5 years	50-200 mg / day

Treatment of children with LJ and IDA I-II degree is performed by outpatient with oral AF, except in cases when the family can not provide the prescribed drug intake or there are indications for the appointment of parenteral AF. Treatment of children with severe IDA, especially the early age, is usually performed in the hospital, with the possibility of starting therapy with parenteral, and then switching to oral AF, but it is possible to conduct the entire course of FT with the help of drugs for ingestion.

Indications for the appointment of parenteral AF:

• cases of adverse effects from oral AF (eg, metallic taste, darkening of teeth and gums, allergic reactions, dyspepsia: epigastritis, nausea, constipation, diarrhea);
• inefficiency of oral intake due to impaired intestinal absorption (lactase deficiency, celiac disease, food allergy, etc.);
• inflammatory or ulcerative diseases of the digestive tract;
• the need for rapid replenishment of iron stores (surgical intervention, diagnostic / therapeutic invasive manipulation);
• social reasons (for example, inability to exercise control over oral opioid use).

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

When appointing parenteral AF, it should be borne in mind that to fill iron stores in tissues, 20-30% more iron is required than the calculated value (just such quantity from the parenterally administered iron is excreted in the urine during the day). However, the initial dose of parenteral AF should not exceed 5 mg / kg per day. Parenteral AF is used for intramuscular injection of iron (III) -hydroxide polymaltose (Maltofer, Ferrum Lek). There is also a drug for intravenous administration - iron (III) -hydroxide sucrose complex (Venofer4), but currently there is insufficient experience of its use in children with IDA. Although a true lack of iron is extremely rare in the newborn period, but with the JE-proven drugs of choice for these children, drugs containing the iron (III) -hydroxide polymatcous complex are allowed for use in preterm and newborn babies.

In 20-40% of patients with IDA of II-III degree, concomitant deficiency of B, 2 and / or FC is detected, and on the background of AF reception their number reaches 70-85%, which requires the appointment of appropriate drugs.

The diet with the inclusion of foods rich in iron and vitamins B, 2 and PK is shown in the case of GJ: meat of mature animals (meat of young animals contains less iron), fish, seafood, buckwheat, legumes, apples, spinach, liver pates. It is recommended to separate the reception of cereals and meat and vegetable dishes, temporarily limited to calcium-rich foods; girls should refrain from taking oral contraceptives. It is useful to stay in the open air for a long time.

Treatment of iron deficiency anemia with transfusions of erythrocyte mass

It is not recommended to use Erythrocytic Mass Transfusion even in cases of severe IDA, since it develops gradually, and the child adapts to anemia.

Transfusions are justified, if only:

• this is necessary for vital indications; with severe anemia syndrome (Hb below 50 g / l);
• the patient needs urgent surgical intervention or an urgent examination under anesthesia.

If necessary, the erythrocyte mass is introduced from the calculation of 3-5 mg / kg per day (max. 10 mg / kg per day) - intravenously slowly, every other day, until reaching a hemoglobin concentration that will reduce the risk of surgical intervention. You should not strive to quickly correct severe anemia, as there is a risk of developing hypervolemia and heart failure.

Contraindications to the appointment of iron

Absolute contraindications to the appointment of AF are:

• acute viral and bacterial infections;
• diseases accompanied by cumulation of iron (hemochromatosis, hereditary and autoimmune hemolytic anemia);
• diseases accompanied by a violation of iron utilization (sideroblastic anemia, alpha and beta-thalassemia, anemia in lead poisoning);
• diseases accompanied by bone marrow insufficiency (aplastic anemia, Fanconi anemia, Blackfin-Diamond, etc.).

[12], [13]

Undesirable effects and complications with the use of iron preparations

When using oral OP, there are few side effects associated with both the chemical properties of iron salts and with increased sensitivity to individual components of the drugs.

Manifestations of side effects are:

• metallic taste in the mouth;
• darkening of teeth and gums;
• pain in epigastrium;
• dyspeptic disorders due to irritation of the mucous membrane of the digestive tract (nausea, eructation, vomiting, diarrhea, constipation);
• dark staining of the stool;
• allergic reactions (more often as a urticaria);
• necrosis of the intestinal mucosa (with overdose or poisoning with salt FP).

These effects can be easily prevented if the correct dosage regimen and drug intake are strictly observed. First of all, this refers to the group of salt FP. It is advisable to begin treatment with a dose equal to 1/2 - 2/3 of the therapeutic dose, followed by a gradual full dose within 3-7 days. The rate of "increasing" the dose to therapeutic depends both on the degree of GI, and on the individual tolerability of the child of a certain drug. Take salted AF follows between meals (about 1-2 hours after, but no later than 1 hour before eating), squeezed a small amount of fruit juice with pulp. Do not drink Salt Ph with tea or milk, as they contain components that inhibit the absorption of iron. Darkening of the teeth and gums can also be avoided by giving the drug in a diluted form (for example, fruit juice) or on a piece of sugar. Allergic reactions are usually associated with other components that make up complex drugs, in which case AF should be changed. Necrosis of the intestinal mucosa develops in extremely rare cases of overdose or poisoning with salt FP. Dark staining of the stool is not clinically important, but it is necessary to warn the parents of the child or himself if he already performs hygiene procedures on his own. By the way, this is a very good and effective way to check if your patient is taking AF.

Preparations of iron (III) -hydroxide polymaltose have practically no side effects. In addition, due to the lack of this group of interaction with food components, children do not need to adhere to any dietary restrictions, and treatment is started immediately with the calculated therapeutic dose.

In case of side effects, either reduce the dose of OP or replace it with another.

With the introduction of parenteral AF rarely, but there may be side effects: sweating, the taste of iron in the mouth, nausea, attacks of suffocation, tachycardia, fibrillation, which requires the abolition of AF. Extremely rare are local reactions (hyperemia, tenderness, venous spasm, phlebitis, skin darkening and abscesses at the injection site), allergic reactions (urticaria, edema Quincke).

The most serious life-threatening complication is poisoning with iron salts (60 mg / kg and more in the elemental gland). The severity of the condition and the 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	0.5-2 hours to 6-12 hours	Acute gastrointestinal symptoms: nausea, vomiting and diarrhea with an admixture of blood, a 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. Coarse metabolic abnormalities	12 hours after poisoning	Acidosis, hypoglycemia, CNS disorders due to severe damage to brain cells, liver and other organs - direct cytotoxic effect of iron ions, accompanied by cell cytolysis
4. Necrosis of the liver	After 2-4 days (sometimes earlier)	Clinico-laboratory signs of liver necrosis. Hepatocerebral disorders
5. Formation of scars at the site of necrosis of the intestinal mucosa	After 2-4 weeks after poisoning	Corresponding clinical symptoms, depending on the location and area of involvement of the intestinal mucosa

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

• nausea, vomiting with blood (very important symptoms!);
• areas of intestinal necrosis and / or fluid levels in the abdominal cavity with ultrasound or X-ray examination;
• ZS - above 30 μmol / l, OJCS - less than 40 μmol / l.

Treatment of iron poisoning:

• as a first aid, milk and raw eggs are prescribed.

In a hospital appoint:

• gastric and intestinal flushing;
• Laxatives (activated charcoal does not apply!);
• chelate complexes of iron (with an LD content of more than 40-50 μmol / L): deferoxamine intravenously drops 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 AF should assess the subjective feelings of the child, special attention should be paid to such complaints as metallic taste, dyspeptic disorders, discomfort in the epigastric region, etc. On the 5th-8th days of treatment, a count of the number of reticulocytes . For LVS, an increase in their number is 2-10 times in comparison with the initial one, and the absence of a reticulocytic crisis, on the contrary, indicates an error in the diagnosis of LVS.

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

Observation on the site after children who have undergone IDA I-II degree is carried out not less than 6 months, who have transferred ZHDA III degree - not less than 1 year. Control hemoglobin concentration should be at least 1 time per month, the content of FS (ZHS, OZHSS) - after the course of FT and when withdrawn from dispensary records.

In carrying out FT, especially salt PF, the interaction of iron salts with other drugs and a number of food components should be taken into account, which may reduce the effect of treatment and / or contribute to the occurrence of undesirable side effects.

Preparations based on iron (III) -hydroxide polymaltose complex are deprived of similar interactions, so their intake is not limited by any dietary or regime restrictions. This makes them more attractive from the point of view of the convenience of admission and, therefore, increases the adherence (adherence) of the therapy to the children and adolescents themselves and their parents.

[14], [15], [16], [17], [18], [19], [20], [21], [22]

Errors and unreasonable appointments

The grossest mistake is the appointment of "anti-anemic" therapy (AF, B12, FC, blood transfusion, and often - all together) to "decipher" the mechanism and causes of anemia. This can radically change the picture of blood, bone marrow, biochemical indicators. Do not prescribe AF until the concentration of FS is determined, since it becomes normal within a few hours after taking the drug. After the introduction of vitamin B12, after 3-5 days, the reticulocytosis rises sharply, leading to overdiagnosis of hemolytic conditions. The appointment of vitamin B12 and FC can normalize the characteristic morphological pattern of the bone marrow, leading to the disappearance of megaloblastic hematopoiesis (sometimes several hours after the injection).

Effects of the interaction of iron preparations with other drugs and food products

Name of substances	Interactions
Chloramphenicol	Slows the response of bone marrow to AF
Tetracyclines, penicillamine, gold compounds, phosphate ions	Reduce iron absorption
Salicylates, phenylbutazone, hydroxyphenylbutazone ZS	Admission together with AF causes irritation of the mucosa of the gastrointestinal tract, which can cause the development (strengthening) of side effects from FT
Cholestyramine, magnesium sulfate, vitamin E, antacids (contain Ca and Al), pancreatic extracts	Inhibit iron absorption, which reduces the anti-anemic effect of AF
Blockers of H2-histamine receptors	Inhibit iron absorption, which reduces the anti-anemic effect of AF
Substances that cause an increase in peroxidation (for example, ascorbic acid)	Contribute to increased bleeding from the mucous membranes of the gastrointestinal tract (a 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)	Slow down the absorption of iron, therefore, when salt salts are prescribed, it is recommended that they be taken 1.5-2 hours after eating
Hormonal contraceptives for ingestion	Slow down the absorption of iron, thereby reducing the therapeutic effect of AF

Do not conduct transfusion of erythrocyte mass in the absence of life indications.

Parenteral AF 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 dietary supplements.

Treatment of iron deficiency anemia

[23], [24], [25]

Prophylaxis of iron deficiency anemia in children

Should be carried out in high-risk groups (premature, children from multiple pregnancies, girls in the first 2-3 years after menarche), an important role in this case belongs to a full-fledged diet, dietary activities, sufficient outdoor activity.

In neonates, the treatment of anemia in mothers during pregnancy plays a crucial role in the prevention of iron deficiency anemia in children. Preventive appointment of AF to pregnant women requires special attention. Thus, when the hemoglobin concentration is higher than 132 g / l, the frequency of premature birth and birth of small children increases, but with a hemoglobin below 104 g / l there is a similar risk. Real prophylaxis of GI is the proper nutrition of pregnant, nursing mothers and children. Confirmed DH in pregnant and lactating women must be corrected by the appointment of AF.

In infants, GI is associated with improper feeding in 95% of cases, therefore, it is easy to solve this problem.

It is also necessary to take into account the history of the patient, because peri-or postnatal bleeding, acute or latent blood flow from the gastrointestinal tract, hemorrhagic diseases, early cord ligation (when it is still pulsating) increases the risk of GVD in infants. Potential inhibitors of iron absorption are cow's milk proteins and calcium, therefore, in infants receiving whole cow's milk (in the absence of other sources of iron in the diet), there is a high risk of IDA. In this regard, the children of the first year of life are not recommended to consume whole cow milk, unadapted fermented milk mixtures, foods not enriched with iron (juices, fruit and vegetable purees, pulp and mash).

Modern adapted mixtures ("subsequent formulas") are enriched with iron and fully meet the needs of infants in iron, do not reduce appetite, cause gastrointestinal disorders and do not increase the incidence of children with respiratory and intestinal infections.

The content of iron in some infant formula for artificial feeding of children

Milk mixture	The content of iron in the finished product, mg / l
Gallium-2 (Danone, France)	16.0
Frisolac (Friesland Newtryn, Holland)	14.0
Nutrilon 2 (Nutricium, Holland)	13.0
Bona 2R (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 (Nestle, Switzerland)	10.5
Agusha-2 (Russia)	10.0
Nutrilak-2 (Nutricia / Istra, Holland / Russia)	9.0
Lactofidus (Danone, France)	8.0
Nestozhen (Nestle, Switzerland)	8.0

After 4-6 months necessarily introduce complementary foods enriched with iron, industrial production (instant cereals, fruit and vegetable juices and mashed potatoes), and in the second half of the year - meat and vegetable purees. After 6-8 months, you can enter a special children's 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 the baby (it contains tannins, which inhibit the absorption of iron), and for drinking use special children's water, juices.

If the nutrition of the children is perfectly balanced, they do not need to prescribe AF, except for prematurity, small babies and children born from multiple pregnancies. It is recommended that breastfeeding mothers include meat, liver, fish, freshly prepared juices from citrus and vegetables, iron-fortified cereals (cereals), legumes, yolks in the diet.

To cover physiological needs, children should receive the following amount of iron with food:

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

In the period of puberty, girls need special attention in the first 2-3 years after menarche, when prophylaxis of J with AF should be carried out 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, useful and tasty; it is necessary to watch, that in it always there were products of animal and vegetable origin containing a sufficient amount of iron.

Products with high iron content

Products containing heme iron	Iron (mg / 100 g of product)	Products containing non-heme iron	Iron (mg / 100 g of product)
Mutton	10.5	Soybean	19.0
By-products (liver,		Poppy	15.0
Kidney)	4.0-16.0	Wheat bran	12.0
Liver paste	5.6	Jam Assorted	10.0
Rabbit meat	4.0	Fresh briar	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)	1.2	Currant	4,5
Pork	1.0	Oat flakes	4,5
		Chocolate	3.2
		Spinach**	3.0
		Cherry	2.9
		"Gray" bread	2.5
		Eggs (yolk)	1.8

Bioavailability of iron (absorption) from animal products reaches 15-22%, from iron products iron is absorbed worse (2-8%). Meat of animals (birds) and fish improve the absorption of iron from other products.

** In spinach, the highest of all products is the content of folic acid, this improves not so much the absorption of iron as the process of hemoglobin formation. 

Medical prophylaxis of iron deficiency anemia in children

For the prevention of JE in infants use liquid dosage forms: it can be solutions or drops for ingestion, containing iron sulfate (Aktiferrin), iron (III) -hydroxide polymaltose (Maltofer, Ferrum Lek), iron, manganese, copper (Totem gluconate ), (Ferlatum); the same drugs are available in the form of syrups (Aktiferrin, Maltofer, Ferrum Lek). Parenteral AF is not used to prevent JE.

Prophylactic dose of AF depends on the weight of the child's body at birth:

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

In other cases, the preventive dose of FP is 1 mg / kg per day. For pre-natal children who are exclusively breastfed, at the age of 6 months to 1 year, it is also recommended that AF is given 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 it is possible to quickly establish and eliminate the cause of JE. If treatment is undertaken after 3 months from the clinical manifestation of IDA, the consequences can persist for months, years and even for life.