Nutritional Anemias

1. Nutritional Anemias K N Agarwal MD (Ped-Hem; Sweden),MD DCH FIAP FAMS FNA President, Health Care & Research Association for Adolescent, Z-18, Hauz Khas, N-Delhi, 110016 adolcare@hotmail.com

2. Definition of nutritional anemia. • Hemoglobin g/dl cut off- . (WHO/UNU-1996) • 6mo-5yr <11.0; 5-11 yr.- 11.5; • 12-13 yr-12.0g/dl; Men – 13.0 • Women Non-pregnant - 12.0;Pregnant – 11.0 • Irrespective of Hb level , if an individual shows rise in hemoglobin after hematinics administration he/she is anemic (Garby et al 1969).

3. Why adult & Child Hemoglobin level differ • No satisfactory answer- • Children have 50% more inorganic phosphate, associated with – • Elevated RBC adenosine triphosphate and 2,3 diphosphoglycerate content- • Thus oxygen affinity is decreased in children as compared to adults.

4. Nutrients in hemoglobin synthesis. • Proteins- all essential amino acids are necessary; methionine deficiency – megaloblastic anemia • Vitamins- • - B12 and folic acid – megaloblastic anemia • -C- Fe+++ to Fe++ & Releases Fe from stores. • -A- mobilises Fe from stores & improves utilisation • -B6- macro/micro anemia, • -B2- BONE MARROW-hypoplasia---- • ANOREXIA NERVOSA-Affects all cell lines. • Thus in PEM and other hematopoietic nutrient(s) anemia on ‘Fe- suppl’ –alone – will have poor response.

5. Clinical Features:- • Insidious onset- even Hb<8g/dl, child patient may be comfortable; physical activity may not be decreased even <6g/dl- ADJUSTMENT • Rapid – breathlessness, dizziness, faintness, fatigue, CHF, heart murmurs-systolic in timing heard at pulmonary area. • Pallor eyelids, tongue, nail bed (changes less common below 6 yr.) PICA • Psycho neurological changes- B12 and or Folic acid deficiency- Megaloblastic anemia. • Dyspigmentation /pigmentation- megaloblastic anemia

6. Effects of maternal iron deficiency on feto placental unit: • Transport of iron from mother to fetus remains proportionate to the degree of maternal hypoferriemia (Agarwal et al.AJCN 1979, Acta Paediatr 1978 & 1984). • Placental iron content reduces significantly. • Fetal brain iron content and neurotransmitters are reduced (BJN 2001; Agarwal). • Fetal Liver iron stores are reduced. • However, Breast milk iron content is increased (Agarwal et al. Acta Paediatr 1985).

7. Physiological anemia of infancy • Normal newborn- High Hb level progressively declines by 8-12 wk -9-11g/dl.- Hypoxia stimulates Renal and Hepatic oxygen sensors – erythropoietin production increases. • Preterm- Hb decline is extreme & rapidly falls to 7-9 g/dl by 3-6 wk of age.- Sampling for Lab tests. There are relatively insensitive Hepatic oxygen sensors; as Renal Oxygen sensors switch on at 40 wk of gestation.

8. Prevalence of nutritional anemia • NFI 2002-2003- 7 states (Assam, HP, Hy, Kerala, MP, Orissa, TN )anemia prevalence- Pregnancy86.1%(Hb <7.0g/dl-9.5%);Lactation 81.7%(Hb <7.0g/dl - 7.3%) Agarwal et al2005.. • ICMR –1999-2000- 11 states 19 districts 84.6% (Hb <7.0 g/dl-9.9% ). • 90%adolescentswere also anemic Teoteja et al 2000. • >80% <3 yr childrenare anemic NFHS-II& Agarwal et al. • Magnitude and severity of anemia at all ages seems to show life cycle with nutritional anemia in INDIA.

9. Megaloblastic Anemias • Hypersegmented Neutrophil – 98% had one cell with >6 lobes; • Oval macrocytes. • Bone-marrow- Large Erythrocyte and Leucocyte series; Megaloblasts have sieve like chromatin- dissociation between nucleus and cytoplasm maturity. • Vitamin B12 and folate levels to differentiate.

10. Fetal Latent Iron Deficiency- brain iron content & neurotransmitters- irreversible reduction • Brain iron content was reduced. • Excitatory and inhibitory neurotransmitters and their receptors were reduced. • MRI-spectroscopy:There was an increase in creatinine and aspartate and reduction in choline concentration(BJN Agarwal 2001)

11. Control & Treatment of Anemias

12. Feeding in early infancy • Baby should be breast fed colostrum and mature milk, both have 49% absorbable iron this is sufficient with available fetal stores till baby doubles the birth weight. • Weaning foods from 6 months onwards should have one iron rich dietary item and iron supplementation be given as recommended. Cook in iron vessels.

13. Iron fortified food. • Iron EDTA has been highly effective in fortification trials with Egyptian flat breads, curry powder in South Africa, fish sauce in Thailand, and sugar in Guatemala. • In Grenada , flourused in commercial baking is enriched with iron and B vitamins,. • Indian researchers have field tested with success iron fortified salt. • Pasteurized milk (iron 15 mg/ l and Vit. C 100 mg/l.)-Stekel 1986

14. Availability of dietary iron by cooking in cast iron utensils: • WHO 1992 prevalence of pregnancy anemia report, records that lowest, rates of all the subregions of the developing world were observed in southern Africa, due to wide spread use of iron cooking pots by indigenous people. • Agarwal et al (Lal et al IJMR-1973) had demonstrated that cooking in cast iron utensils, for boiling milk, cooking vegetables etc, provided extra dietary iron. This available dietary iron is well absorbed.

15. Diagnosis of Deficiency Anemias

16. Iron deficiency Diagnosis- • RBC-hypochromic microcytic, progressive fall in- MCV, MCH & MCHC . • Reduction in Reticulocyte “Hb” content. • sTfR-soluble transferrin receptor increases in iron def. and ineffective erythropoiesis, No change in Chr. Inf. anemia.

17. Contd. • TfR index-ratio of sTfR to the log of ferritin, value >1.5 “Iron def”; <1.5 anemia chronic diseases. • EPP- Erythrocyte Porphyrin increases in iron def, lead poisoning and chr. Inflammatory anemia. • Serum Ferritin with negative CRP. • Absence of Bone marrow iron content. Low hepatic iron content.

18. We at all ages live in life cycle with anemia.Nutritional Anemia is treatable and can be controlled – measures are affordable.