Iron deficiency: to screen

and prevent
Murti Andriastuti
Departement of Child Health
Faculty of Medicine Universitas Indonesia,
Cipto Mangunkusumo Hospital
Outline
• Prevalence of iron deficiency in Indonesia
• Health consequences of iron deficiency
• Iron deficiency screening
• Iron deficiency prevention
• Routine iron supplementation program
• Nutritional counseling
 Global epidemiology of anemia (WHO, 2011)

WHO. Global prevalence of anemia. Geneva: WHO; 2011.

Kassebaum NJ. The global burden of anemia. Hematol Oncol Clin N Am. 2016;30:247–308

Global Etiology of Anemia, 2013

Iron deficiency anemia

Endocrine, metabolic, blood

and autoimune disorder

Other infectious disease

Hookworm disease

Thalassemia trait

Other hemoglobinopathies
 Prevalence of IDA in Indonesian Children
Iron Iron Iron deficiency
Subjects n Anemia
depletion deficiency anemia
2009, Ringoringo et al 211 11.4% 7.6% 47.4%
0 – 12 months
2008, Sekartini et al 55 38.2% 27.3%
4 – 12 months
2016, Widjaja et al 709 53.9% 29.4% (6 – 59 mo)
6 months – 18 years 16% (5 – 11.9 yo)
15.2% (12 – 18 yo)
2016, Ringoringo et al 50 32%
6 – 12 years
 Prevalence of iron deficiency based on researches
in FKUI-RSCM
Iron
Iron Iron
Subjects n Anemia deficiency
depletion deficiency
anemia
2016 115 14% 4.3% 14.8% 5.8%
Elementary student, 6-12 years
2016 107 10% 2% 20% 5%
Adolescent & young adult, 10-21 years
2017 141 8.5% 4.3% 11.1% 2.1%
Preterm & Term Newborn
2016 207 13.1% 4.4% 18.8% 5.8%
School aged children, 6-18 years
 Health consequences of iron deficiency

Anemia Poor cognitive Poor growth Reduced

development physical capacity

Long term and irreversible consequences,

especially in small children

1. Abdullah K, Zlotkin S, Parkin P, Grenier D. Iron-deficiency anemia in children. Toronto: Canadian Pediatric Surveillance Program; 2011.
2. Luo R, Shi Y, Zhou H, Yue A, Zhang L, Sylvia S, et al. Micronutrient deficiencies and developmental delays among infants: evidence from a cross-sectional survey in rural China. BMJ Open. 2015;5(10):1 – 8.
3. Lam LF, Lawlis TR. Feeding the brain: the effects of micronutrient interventions on cognitive performance among school-aged children: A systematic review of randomized controlled trials. Clin Nutr.
2017;36(4):1007 – 14.
Iron deficiency screening
Spectrum of IDA
Major health
consequences
Iron • Long term
depletion Iron • Permanent
deficiency Iron
deficiency
anemia

Early detection and

Iron supplementation
treatment
Kasper D, et al. Harrison’s Principles of Internal Medicine: 19th ed. 2015

Laboratory parameter of IDA stages

 Iron deficiency screening IDA screening
algorithm
Hb < normal, etiology/risk
Hb normal
factors(+), MCV/MCH/MCHC ,
organomegaly (-)
Clinical symptoms are not
specific and a lot are
Ferritin/serum iron not Ferritin/serum iron
iron supplementation assess assess asymptomatic
(dose 1 month)

Hb increased >= 1 Iron supplementation Normal < Normal

g/dL, or Ht increased Response (-)
>= 3 g/dL

Iron therapy until 2

months after
Observe
ferritin/serum iron is
IDA (+) others
normal

Continue therapy
until 2 months after
Hb is normal
 Primary tools for screening are
Challenges in hemoglobin and hematocrit level
ID screening
Ideally, we could identify population
during earlier stage definitely due to iron
deficiency

Gold standard: ferritin and transferrin saturation

(expensive, large blood volume needed, less
available)

Kiudeliene R. et al, Medicina (Kaunas) 2008; 44(9)

Kuehn MAJD et al, Military Medicine 2012; 1:91
 AAP recommendation to diagnose ID &
IDA
IDA ID without Anemia

One/more
Hb
• Serum Ferritin + • Serum Ferritin + CRP OR
CRP • Ret-He/CHr
• Ret-He/CHr
• TfR1

Cheaper
Reticulocyte hemoglobin content as the strongest Require less blood sample
independent predictor and its comparable test with ferritin
and transferrin saturation to detect iron deficiency Theres no universal cut-off value
Nor available in all laboratory
Baker, R.D.; Greer, F.R. Diagnosis and prevention of iron deficiency and iron-deficiency anemia in infants and young children (0–3 years of age). Pediatrics.
2010;126:1040–1050.
Reticulocyte
hemoglobin
content (Ret-
Hb)
 Reticulocyte Hemoglobin Content as
an alternative screening parameter for iron deficiency in children:
(2018)
207 subject aged 6-18 yr-old, cross sectional
Cut-off Sn Sp NPV PPV
Value

Iron depletion 30.65 100% 13.4% 100% 5% • Small blood sample

• Efficient
• Not affected by
Iron deficiency 27.85 63.2% 69.2% 90.5% 28.7% inflamation/diurnal
variation
Iron deficiency
26.95 75% 80% 98.1% 18.7%
anemia

Andriastuti M, Melita unpublished

 Lab
Result
(Example)

Saturasi transferin 3%
Feritin 2,1 ng/ml
 Iron Indicators and Its Limitations
Indicator Assesses Advantage Limitation
Hb Anemia Commonly available Low Sp and Sn
Easy and cheap
Ferritin (SF) Iron stores Commonly available, has WHO Confounded by inflamation
International Standard Material Need CRP exam
Expensive & more blood sample
Transferrin Iron deficit Commonly available Varies diurnally and prandially
saturation erythropoiesis Considered “gold standard” Expensive & more blood sample
Hepcidin Determinant of iron Relatively sensitive Is experimental & under
needs and utilization development
sTfR Iron deficit Less affected by inflamation Has limited availability
erythropoiesis Expensive
Ret-He Iron deficit Less expensive & small blood Different cut-off values
erythropoiesis sample Requires up-to-date assessment
High Sp and Sn tools
Early detection and efficient
Brannon PM, Taylor CL. Iron supplementation during pregnancy and infancy: Uncertainties and implications for research and policy. Nutrients. 2017;9(12):1327.
Current iron supplementation
recommendations
 Iron supplementation recommendation
Source Dosage Frequency
WHO 10 – 12.5 6–23 months for 3 consecutive months/year
(2016)1 mg/day In settings ≥40% anemia prevalence
AAP (2010)2 1 mg/kg/day infants ≥4 months exclusively breast-fed or consuming >1/2 intake from
breast milk until receiving appropriate iron-containing complementary
foods
CDC (1998)3 1 mg/kg/day Suggest supplement breast-fed infants ≥6 months consuming
insufficient iron from supplementary foods (<1 mg/kg/day)
ESPGHN - No convincing evidence for iron supplements of exclusively breast-fed
(2014)4 term infant <6 months except on individual basis
Canada - Recommend meat, meat-alternatives & iron-fortified cereals for firs
(2015)5 complementary foods at 6 months.
1. World Health Organization. Daily Iron Supplementation in Children 6–23 Months of Age. Available online: http://www.who.int/elena/titles/guidance_summaries/iron_children/en/
2. Baker, R.D.; Greer, F.R. Diagnosis and prevention of iron deficiency and iron-deficiency anemia in infants and young children (0–3 years of age). Pediatrics 2010, 126, 1040–1050.
3. Yip, R.; Parvanta, I.; Cogswell, M.E.; McDonnell, S.M.; Bowman, B.A.; Grummer-Strawn, L.M.; Trowbridge, F. Recommendations to prevent and control iron deficiency in the United States. Morb. Mortal. Wkly. Rep. 1998, 47, 1–29.
4. Domellöf, M.; Braegger, C.; Campoy, C.; Colomb, V.; Decsi, T.; Fewtrell, M.; Hojsak, I.; Mihatsch, W.; Molgaard, C.; Shamir, R.; et al. Iron requirements of infants and toddlers. J. Pediatr. Gastroenterol. Nutr. 2014, 58, 119–129
5. Infant Feeding Working Group. Nutrition for Healthy Term Infants: Recommendations from Birth to Six Months. Available online: http://www.hc-sc.gc.ca/fn-an/nutrition/infant-nourisson/recom/index-eng.php
 WHO recommendation (2016)
Target group Infants and small children Pre-school age children
(6-23 mos) (24-59 mos)
Composition 10-12.5 mg elemental iron 30 mg elemental iron
Form Drop/syrup Drop/syrup/tablet
Frequency 1x daily 1x daily
Duration 3 consecutive months 3 consecutive months
Condition Prevalence of anemia >40% Prevalence of anemia >40%

World Health Organization. Daily iron supplementation in infants and children. Geneva: World Health Organization; 2016.
 ….WHO recommendation (2016)

Target group School-age children (5 – 12 Menstruating women and

years) adolescent girl
Composition 30-60 mg elemental iron 30-60 mg elemental iron
Form Tablet/capsules Tablet/capsules
Frequency 1x daily 1x daily
Duration 3 consecutive months 3 consecutive months
Condition Prevalence of anemia >40% Prevalence of anemia >40%

World Health Organization. Daily iron supplementation in infants and children. Geneva: World Health Organization; 2016.
Recommendation iron supplementation
for Indonesian children (2011)
IDA Task force - Indonesian Pediatric
Society Recommendation 2011
Age (years) Dose (elemental iron) Duration
Infants LBW(<2.500 gr) 3 mg/kgBB/day 1 month – 2 years
Term 2 mg/kgBB/day 4 month – 2 years
2-5 1 mg/kgBB/day 2x/week for 3 consecutive
months, yearly
>5-12 1 mg/kgBB/day 2x/week for 3 consecutive
months, yearly
12-18 60 mg/day with folic acid 2x/week for 3 consecutive
400ug (for girls) months, yearly
 Oral iron preparation
Elixir (Iron Content), mg
Generic Name Tablet (Iron Content), mg
in 5 mL
Ferrous sulfate 325 (65) 300 (60)
195 (39) 90 (18)
Ferrous fumarate 325 (107)
195 (64) 100 (33)
Ferrous gluconate 325 (39) 300 (35)
Polysaccharide ion 150 (150) 100 (100)
50 (50)

1. US Preventive Services Task Force. Screening for Iron Deficiency Anemia in Young Children: Recommendation Statement Summary of Recommendation and Evidence. Am Fam
Physician [Internet]. 2015;92(12):1–3.
2. Short M, Domagalski J. Iron deficiency anemia Evaluation and management. Am Fam Physician. 2013;87(2):98–104.
Vitamin C

Tea, Coffee
Milk
Conclusion
• Anemia including ID and IDA continues to be a major problem of the
world
• IDA could cause long-term effects (e.g. cognitive impairment),
therefore it is important to prevent ID (i.e. detect iron depletion and
deficiency)
• Reticulocyte hemoglobin content as other options to early detection
iron deficiency
• Prevention of ID includes: iron supplementation and nutritional
counseling