Measures to prevent iron deficiency conditions test. Prevention of iron deficiency conditions in children. The most common causes of iron deficiency anemia in children

Pharmaceutical care:
treatment of iron deficiency anemia

I. A. Zupanets, N. V. Bezdetko, National Pharmaceutical University

Blood is a vital medium of the body. It performs numerous and varied functions: respiration, nutrition, excretion, thermoregulation, maintaining water and electrolyte balance. The protective and regulatory functions of blood are well known due to the presence of phagocytes, antibodies, biologically active substances, and hormones in it.

The most common blood disease is iron deficiency anemia. According to WHO, more than half of the population of various countries suffers from iron deficiency anemia. It affects all age groups of the population, but most often occurs in children, adolescents and pregnant women. In many countries, the issue of preventing and treating anemia is becoming a social problem. The presence of iron deficiency reduces the quality of life of patients, disrupts their ability to work, and causes functional disorders in many organs and systems. To prevent and eliminate iron deficiency conditions, a whole group of iron-containing drugs has been successfully used, the range of which is continuously replenished and updated. The pharmacist’s recommendations on choosing the optimal drug and the conditions for its rational use will help to significantly improve the well-being and quality of life of patients with iron deficiency conditions, as well as contribute to the timely prevention of the development of iron deficiency in “risk groups”.

The role of iron and its metabolism in the human body

The body of an adult contains 2-5 g of iron, and a newborn contains 300-400 mg. However, despite its low content, iron is a unique microelement in its importance, which is presented in various molecular systems: from complexes in solution to macromolecular proteins in the membranes of cells and organelles. In particular, iron is an important constituent of hemoglobin, myoglobin and iron-containing enzymes.

First of all, the role of iron is determined by its active participation in tissue respiration, which is an indispensable condition for the existence of any living cell. Iron is part of chromoprotein proteins that provide electron transfer in biological oxidation chains. These chromoprotein proteins include cytochrome oxidase, an enzyme of the respiratory chain that directly interacts with oxygen, as well as cytochrome components localized in the membranes of mitochondria and the endoplasmic reticulum. As part of heme, iron is one of the components of hemoglobin, a universal molecule that ensures the binding, transport and transmission of oxygen to the cells of various organs and tissues, as well as myoglobin, a heme-containing protein of muscle tissue. In addition, iron is involved in a number of other biologically important processes occurring at the cellular and molecular level, in particular, in the processes of cell division, biosynthesis of DNA, collagen, and the functional activity of various parts of the immune system.

About 60-65% of the total iron reserve in the body is contained in hemoglobin, 2.5-4% in bone marrow, 4-10% in myoglobin, 0.1-0.5% in iron-containing enzymes and 24-26 % in the form of iron depot in the form of ferritin and hemosiderin.

Iron absorption is a complex process. Iron absorption occurs predominantly in the initial part of the small intestine. It is important to note that the greater the iron deficiency in the body, the larger the zone of its absorption in the intestine; in case of anemia, all parts of the small intestine are involved in the absorption process. Iron is transported from the intestinal mucosa into the blood using active cell transport mechanisms. This process occurs only with normal mucosal cell structure, which is supported by folic acid. Transport through the cells of the intestinal mucosa occurs both by simple diffusion and with the participation of a special carrier protein. This protein is most intensively synthesized during anemia, which ensures better absorption of iron. The protein transports iron only once; subsequent iron molecules carry new molecules of the carrier protein. Their synthesis takes 4-6 hours, so more frequent intake of iron supplements does not increase its absorption, but increases the amount of unabsorbed iron in the intestine and the risk of side effects.

There are two types of iron: heme and non-heme. Heme iron is part of hemoglobin. It is contained only in a small part of the diet (meat products), is well absorbed (20-30%), its absorption is practically not affected by other food components. Non-heme iron is found in the free ionic form of ferrous (Fe II) or ferric iron (Fe III). Most dietary iron is non-heme (found primarily in vegetables). The degree of its absorption is lower than that of heme and depends on a number of factors. Only divalent non-heme iron is absorbed from food. To “convert” ferric iron into divalent iron, a reducing agent is needed, the role of which in most cases is played by ascorbic acid (vitamin C).

Iron is absorbed in both heme and non-heme forms. A balanced daily diet contains about 5-10 mg of iron (heme and non-heme), but no more than 1-2 mg is absorbed.

During absorption in the cells of the intestinal mucosa, ferrous iron Fe2+ is converted into oxide Fe3+ and binds to a special carrier protein, transferrin, which transports iron to hematopoietic tissues and sites of iron deposition. Transferrin is synthesized by the liver. It is responsible for transporting iron absorbed in the liver, as well as iron coming from destroyed red blood cells for reuse by the body. Under physiological conditions, only about 30% of the iron-binding capacity of plasma transferrin is used.

Iron is deposited in the body in the form of proteins ferritin (most of it) and hemosiderin. Ferritin is an iron oxide/hydroxide enclosed in a protein shell, apoferritin. It is found in virtually all cells, providing a readily available reserve for the synthesis of iron-containing compounds and presenting iron in a soluble, non-ionic, non-toxic form. The cells richest in ferritin are the precursors of red blood cells in the bone marrow, macrophages and reticuloendothelial cells of the liver. Hemosiderin is found in macrophages of the bone marrow and spleen, and liver cells. It is considered to be a reduced form of ferritin in which the molecules have lost part of the protein coat and clumped together. The rate of iron mobilization from hemosiderin is slower than from ferritin. With an excess of iron in the body, its proportion deposited in the liver in the form of hemosiderin increases.

The body's ability to remove iron is limited. Most of the iron from destroyed red blood cells (more than 20 mg daily) reenters hemoglobin. The total loss of iron during desquamation of skin and intestinal cells reaches about 1 mg per day, about 0.4 mg is excreted in feces, 0.25 mg in bile, less than 0.1 mg in urine. These losses are common for men and women. In addition, each woman loses 15-25 mg of iron during one menstruation. During pregnancy and breastfeeding, she requires an additional 2.5 mg of iron per day. Taking into account that the daily intake of iron from food is only 1-3 mg, during these physiological periods women have a negative iron balance. As a result, by the age of 42-45 years, a woman approaches severe iron deficiency.

Iron-deficiency anemia

Iron deficiency occurs as a result of a mismatch between the body's need for iron and its supply (or loss). The development of iron deficiency can be divided into two stages:

latent iron deficiency ferritin iron levels and transferrin saturation are reduced, hemoglobin levels are reduced, there are no clinical signs of iron deficiency;
iron deficiency anemia (clinically pronounced iron deficiency) a disease in which the iron content in the blood serum, bone marrow and depot is reduced; as a result, hemoglobin formation is disrupted, hypochromic anemia and trophic disorders in tissues occur.

The most common causes of iron deficiency anemia in adults

Blood loss repeated and prolonged bleeding of the uterus, gastrointestinal (peptic ulcer, hemorrhoids, ulcerative colitis), pulmonary (cancer, bronchiectasis).
Increased iron consumption pregnancy, lactation, intensive growth, puberty, chronic infectious diseases, inflammatory processes and neoplasms.
Impaired iron absorption gastric resection, enteritis; taking medications that reduce iron absorption.
Reducing the amount of iron received from food.

The most common causes of iron deficiency anemia in children

In children, the need for iron per 1 kg of body weight is much greater than in adults, since the children's body requires iron not only for hematopoiesis processes, but also for intensive tissue growth. Thus, a child in the first half of life should receive at least 6 mg of iron per day (60% of the daily requirement of an adult), in the second half of the year - 10 mg (as an adult), in adolescence (11-18 years) - 12 mg per day.

Due to the greater need, children suffer from iron deficiency much more than adults. According to available data, about 60% of preschool children and a third of schoolchildren suffer from iron deficiency anemia in Ukraine. The main causes of iron deficiency in children of all age groups are:

insufficient intake of iron into the fetus’s body (premature pregnancy, maternal anemia, late toxicosis of pregnancy);
artificial feeding (in children under 1 year);
acute and/or chronic infectious diseases;
unbalanced diet predominance in the diet of flour and dairy dishes, in which the iron content is relatively low;
insufficient consumption of meat products;
intensive growth.

Symptoms of hidden iron deficiency

Hidden iron deficiency occurs most often in childhood, as well as in adolescents and young women. Women lose 12-79 mg of iron per 1 menstrual bleeding (on average 15 mg), losses during each pregnancy, during childbirth and during lactation 700-800 mg (up to 1 g). Early signs of developing iron deficiency are:

weakness, increased fatigue;
anxiety, lack of concentration;
decreased ability to work;
psychological lability;
headaches in the morning;
decreased appetite;
increased susceptibility to infections.

Symptoms of iron deficiency anemia

If measures aimed at preventing the development of iron deficiency in “risk groups” are not taken, iron deficiency is not compensated for in the early stages, and iron deficiency anemia (IDA) develops.

In the clinical picture of IDA, several specific symptoms and syndromes can be identified.

Characteristic specific (sideropenic) symptoms of iron deficiency include:

perversion of taste (consumption of chalk, clay, eggshells, toothpaste, raw cereals, raw meat, ice);
distortion of the sense of smell (attracted by the smells of dampness, lime, kerosene, exhaust gases, acetone, shoe polish, etc.).

Hypoxic syndrome occurs as a result of oxygen starvation of tissues with sufficient severity of anemia. It manifests itself with the following symptoms:

pallor of the skin and mucous membranes;
bluish lips;
dyspnea;
tachycardia;
stitching pain in the heart;
weakness, constant feeling of fatigue;
decreased emotional tone;
children's mental retardation.

Epithelial tissue damage syndrome develops as a result of decreased synthesis of iron-containing enzymes and disruption of tissue metabolic processes. Characteristic manifestations:

dry skin;
fragility, hair loss;
brittleness and striation of nails;
cracks in the skin of the legs and arms;
stomatitis;
decreased muscle tone, muscle weakness;
imperative urge to urinate, urinary incontinence when laughing and sneezing, bedwetting;
damage to the stomach and intestines unstable stool, impaired gastric secretion, in 50% of patients atrophic gastritis.

Hematological syndrome characteristic changes in the clinical blood test.

Diagnostic criteria for iron deficiency anemia are:

reduction in the number of red blood cells to 1.5-2.0 x 1012 / l,
decrease in hemoglobin in children of the first 5 years of life below 110 g/l, in children over 5 years of age and adults - below 120 g/l;
the decrease in color index is less than 0.85.

Frequency of the most common symptoms of IDA in different age groups

Symptoms of IDA	Frequency (%)
Symptoms of IDA	Adults	Children	Teenagers
Muscle weakness	97	82	-
Headache	68	-	21
Memory loss	93	-	8
Dizziness	90	-	30
Brief fainting	17	-	3
Arterial hypotension	87	22	-
Tachycardia	89	-	-
Shortness of breath on exertion	89	48	51
Pain in the heart area	81	-	-
Symptoms of gastritis	78	-	4
Perversion of taste	31	79	-
Perversion of smell	14	27	-

Measures to prevent iron deficiency conditions

A necessary component of the prevention of iron deficiency is a nutritious diet in all age groups with a sufficient content of meat products.

Prevention of iron deficiency in children should begin even before birth, for which it is recommended that women take iron supplements throughout the entire period of pregnancy, especially in the last trimester.

Prevention of iron deficiency conditions, especially in children, reduces their risk of infectious diseases and promotes more complete mental and physical development of the child.

Principles of rational therapy of iron deficiency anemia

It is impossible to eliminate iron deficiency, and especially iron deficiency anemia, without iron supplements - only with a diet consisting of iron-rich foods. Iron from medications can be absorbed 15-20 times more than from food.

In the treatment of iron deficiency conditions, preference is given to oral iron supplements. Treatment with iron preparations should begin with small doses, increasing them after a few days to avoid overdose and toxic reactions.

To correct iron deficiency conditions, the body should receive about 0.5 mg of iron/kg of body weight daily. Since normally only 10% of iron is absorbed from the gastrointestinal tract, and in case of anemia up to 25% of iron, about 2 mg/kg of body weight should be prescribed, which is 100-200 mg of Fe (II) per day in adults. Higher doses are pointless (since iron absorption is limited by physiological mechanisms) and only increase side effects.

You should not stop treatment with iron supplements after the content of hemoglobin and red blood cells has normalized: in order to create a “depot” in the body, you should continue taking the medications for another 1-2 months.

Possible side effects when taking iron supplements

A number of side effects may occur when taking oral iron supplements:

gastrointestinal disorders: nausea, vomiting, intestinal colic, diarrhea/constipation;
darkening of teeth;
false reaction to occult blood in the stool;
facial hyperemia, feeling of heat (rarely);
allergic reactions (rare);
decrease in blood pressure;
tachycardia.

The most common dyspeptic disorders (in 50% of patients) are associated with the irritating effect of iron ions on the mucous membrane of the gastrointestinal tract. It should be noted that the severity of side effects from the gastrointestinal tract is related to the amount of unabsorbed drug: the better the drug is absorbed, the better it is tolerated and produces fewer side effects.

Iron poisoning

Acute poisoning with oral iron supplements in adults is extremely rare. However, since many iron preparations have an attractive form, the development of severe poisoning in children is possible if a large amount of the drug is accidentally taken. Taking more than 2 g is fatal; taking less than 1 g (ferrous sulfate) results in hemorrhagic gastroenteritis, necrosis with nausea, hematemesis, bloody diarrhea and vascular shock within one to several hours. Death may occur 8-12 hours after ingestion. Poisoning often leaves sharp scars in the stomach area (pyloric stenosis) and significant liver damage.

Product	Content iron (mg/100 g)	Product	Content iron (mg/100 g)
Pork liver	12	Buckwheat	8
Beef liver	9	Oatmeal	4
Meat	4	Semolina	2
Fish	0,5-1	Bread	3-4
Chicken eggs	2-3	Cocoa powder	12
Peas	9	Vegetables	0,5-1,5
Beans	12	Fruits	0,3-0,5
Soybeans	12

Treatment includes inducing vomiting, taking milk and eggs to form an iron-protein complex, and gastric lavage with a 1% NaHCO3 solution to form sparingly soluble iron carbonate. Subsequently, deferoxamine is given 5-10 g in 100 ml of saline through a gastric tube, as well as 0.5-1 g intramuscularly or, if the patient is in shock, 15 mg/kg/h as a long-term infusion for 3 days.

Deferoxamine is a weak base that is highly selective for iron and forms chelate compounds with it, which are not absorbed in the intestine and are easily removed from the blood through the kidneys.

Criteria for the effectiveness of iron therapy

The effectiveness of iron supplements is judged by laboratory criteria - the results of a blood test over time. By the 5-7th day of treatment, the number of reticulocytes (young red blood cells) should increase by 1.5-2 times compared to the initial data. Starting from the 7-10th day of therapy, the hemoglobin content increases, after 2-4 weeks a positive dynamics of the color indicator is noted.

Clinical signs of improvement appear much earlier (after 2-3 days) compared to normalization of hemoglobin levels. This is due to the supply of iron to enzymes, the deficiency of which causes muscle weakness.

Comparative characteristics of iron preparations for oral use

Numerous iron preparations presented on the pharmaceutical market of Ukraine can be divided into groups depending on their composition and clinical and pharmaceutical properties.

Comparative characteristics of iron-containing preparations for internal use

Tradename	Composition of the dosage form		Release form
Ferrous IRON PREPARATIONS
PREPARATIONS CONTAINING IRON SULPHATE
Hemophere prolongatum	Ferrous sulfate	325 mg	Dragee
PREPARATIONS CONTAINING IRON CHLORIDE
Hemofer	Ferric chloride	157 mg/ml
PREPARATIONS CONTAINING IRON FUMARATE
Heferol	Iron fumarate	350 mg	Capsules
PREPARATIONS CONTAINING IRON GLUCONATE
Ferronal	Iron gluconate	0.3 g	Pills
Iron oxide saccharate solution (iron wine)	Iron saccharate	73.9 g/kg	Solution for internal use
Iron oxide saccharate solution (iron wine)	Rafinated sugar	107.8 g/kg	Solution for internal use
COMPLEX PREPARATIONS CONTAINING DIVALENT IRON
Aktiferrin	Iron (II) sulfate	113.85 mg	Capsules
	D, L - serine	129 mg	Capsules
	Iron (II) sulfate	47.2 mg/ml	Drops
	D, L - serine	35.6 mg/ml	Drops
	Iron (II) sulfate	171 mg/5 ml	Syrup
	D, L - serine	129 mg/5 ml	Syrup
Gyno-Tardiferon	Iron (II) sulfate	256.3 mg	Dragee
	Folic acid	0.35 mg
	Ascorbic acid	30 mg
	Mucoproteosis	80 mg
Sorbifer Durules	Iron (II) sulfate	320 mg	Film-coated tablets
Sorbifer Durules	Ascorbic acid	60 mg	Film-coated tablets
Tardiferron	Iron (II) sulfate	256.3 mg	Depot tablets
	Ascorbic acid	30 mg
	Mucoproteosis	80 mg
Fenotek	Iron (II) sulfate	150 mg	Capsules
	Ascorbic acid	50 mg
	Riboflavin	2 mg
	Thiamine mononitrate	2 mg
	Nicotinamide	15 mg
	Pyridoxine hydrochloride	1 mg
	Calcium pantothenate	2.5 mg
Ferroplex	Iron (II) sulfate	50 mg	Dragee
Ferroplex	Ascorbic acid	30 mg	Dragee
Vitafer	Iron(II) fumarate	175 mg	Capsules
	Ascorbic acid	75 mg
	Cyanocobalamin	30 mcg
	Folic acid	200 mcg
	Thiamine chloride	3.5 mg
	Riboflavin	3.5 mg
	Nicotinamide	15 mg
	Pyridoxine hydrochloride	2 mg
	Calcium pantothenate	5 mg
Ranferon	Iron(II) fumarate	305 mg	Capsules
	Folic acid	0.75 mg
	Cyanocobalamin	5 mcg
	Ascorbic acid	75 mg
	Zinc sulfate	5 mg
Totema	Iron(II) gluconate	5 mg/ml	Solution for internal use
	Manganese gluconate	0.133 mg/ml
	Copper gluconate	0.07 mg/ml
FRIVALENT IRON PREPARATIONS
Maltofer		50 mg/5 ml	Drops
	Iron (III) in the form of polymaltose hydroxide complex	10 mg/ml	Syrup
	Iron (III) in the form of polymaltose hydroxide complex	100 mg	Pills
Ferramin-Vita	Iron (III) aspartate (in terms of Fe(III)	60 mg	Pills
	Riboflavin	25 mg
	Nicotinamide	15 mg
	Folic acid	0.2 mg
	Cyanocobalamin	0.025 mg
Ferrostat	Iron(III) carboxymethylcellulose	0.028 g	Pills
Ferrum lek	Iron (III) in the form of polymaltose hydroxide complex	50 mg/5 ml	Syrup
Ferrum lek	Iron (III) in the form of polymaltose hydroxide complex	100 mg	Pills
MULTIVITAMIN PREPARATIONS CONTAINING IRON
Vitrum	Iron	18 mg	Film-coated tablets
Vitrum centuries	Iron	9 mg	Film-coated tablets
Vitrum circus with iron	Iron	15 mg	Pills
Vitrum junior	Iron	18 mg	Film-coated tablets
Vitrum prenatal	Iron	60 mg	Effervescent tablets
Multibionta junior	Iron	3 mg	Effervescent tablets
Multivitamins "Daily with Iron"	Iron	18 mg	Pills
Multivitamins forte	Iron	10 mg	Pills
Multivitamins and minerals	Ferrous sulfate	5 mg	Pills
Multivitamins with iron	Iron fumarate	12, 17 mg	Pills

Preparations containing ferrous iron Fe(II): iron sulfate, iron fumarate, iron chloride, iron gluconate. Different preparations contain different amounts of iron, the ability of which to be absorbed varies: 12-16% for iron sulfate, 7-9% for iron lactate, 5-6% for iron chloride, 14-16% for iron fumarate, 20 -22% for iron gluconate.

A number of Fe(II) complex preparations contain mucoproteosis, prevent irritation of the gastrointestinal mucosa by iron ions, promote the slow release of iron ions, increase its bioavailability and improve tolerability.

Ferrous iron preparations have a number of common disadvantages: they can cause darkening of teeth and gums in patients, dyspeptic symptoms (nausea, vomiting, epigastric pain, constipation or diarrhea), allergic reactions such as urticaria. In case of an overdose of Fe(II) preparations, cases of severe poisoning are possible, especially in children, which is associated with the activation of free radical oxidation processes and hyperproduction of active radicals. This leads to metabolic and functional disorders in the body, primarily the cardiovascular system.

Preparations containing ferric iron Fe(III). Ferric iron is practically not absorbed in the gastrointestinal tract. However, complex organic compounds of Fe(III) with a number of amino acids and maltose are significantly less toxic than Fe(II), but no less effective. Immobilization of Fe(III) on amino acids ensures its resistance to hydrolysis in the gastrointestinal tract and high bioavailability, due to the slow release of the drug and its more complete absorption, as well as the absence of dyspeptic symptoms.

It is rational to highlight multicomponent drugs, containing, along with iron ions, additional substances that promote erythropoiesis (vitamins B B6, B9, B12); stimulating iron absorption (ascorbic acid, succinic acid, amino acids); multivitamin preparations containing iron.

Pharmaceutical care when using oral iron supplements

Treatment with iron supplements is recommended under the supervision of a physician.
Treatment with iron supplements should be accompanied by periodic blood tests.
It is recommended to prescribe iron supplements to children after consulting a pediatrician.
Iron deficiency anemia should be treated mainly with drugs for internal use (Fe II).
The use of iron supplements should be combined with optimization of the diet, with the mandatory introduction of meat dishes into the menu.
Iron supplements should not be prescribed to children against the background of inflammatory processes (ARVI, sore throat, pneumonia, etc.), since in this case iron accumulates at the site of infection and is not used for its intended purpose.
The inclusion of ascorbic acid in complex iron preparations improves the absorption of iron (as an antioxidant, ascorbic acid prevents the conversion of Fe-II ions into Fe-III, which are not absorbed in the gastrointestinal tract) and makes it possible to reduce the prescribed dose. Iron absorption also increases in the presence of fructose and succinic acid.
Taking combination drugs that, along with iron, contain copper, cobalt, folic acid, vitamin B12 or liver extract, makes it extremely difficult to control the effectiveness of iron therapy (due to the hematopoietic activity of these substances).
During pregnancy, taking multivitamin preparations containing iron (glutamevit, complevit, oligovit, etc.) is indicated as a prophylactic measure.
You should not simultaneously prescribe medications that form non-absorbable complexes with iron (tetracyclines, chloramphenicol, calcium supplements, antacids).
Iron ions form insoluble salts that are not absorbed and then excreted in feces, with food components such as phytin (rice, soy flour), tannin (tea, coffee), phosphates (fish, seafood).
Since iron forms complexes with phosphates, at excessively high doses in children, the absorption of phosphates can be reduced so much that this will lead to rickets.
It is rational to take iron supplements 30-40 minutes before meals, which promotes better absorption. At the same time, with this regimen, symptoms of irritation to the gastric mucosa are more likely to occur.
Oral iron supplements should be taken at least 4 hours apart.
Do not chew tablets and pills containing iron!
After taking iron supplements, you should rinse your mouth, and liquid preparations (syrups, solutions for internal use) are best administered through a straw.
Taking iron supplements orally leads to darkening of stool and may give false positive results for occult blood tests.
The simultaneous administration of iron preparations orally and parenterally (intramuscularly and/or intravenously) should be completely excluded!
Parenteral administration of iron supplements should only be done in a hospital!
Iron supplements should be stored out of the reach of children.

Literature

Bokarev I.N., Kabaeva E.V. Treatment and prevention of IDA in outpatient practice // Ter. archive. - 1998. - No. 4. - pp. 70-74.
Zmushko E.I., Belozerov E.S. Drug complications. - St. Petersburg: Peter, 2001. - 448 p.
Kazakova L. M. Iron deficiency and prevention in the practice of a pediatrician. Methodological recommendations. - M., 1999. - 23 p.
Compendium 2001/2002 drugs / Ed. V. N. Kovalenko, A. P. Viktorova. - K.: Morion, 2002. - 1476 p.
Krasnova A. Iron is inside us // Pharmacist.- 1998.- No. 19-20.- P. 59-61.
Krivenok V. A necessary component of the treatment of iron deficiency anemia // Pharmacist. - 2002. - No. 18. - P. 44.
Mikhailov I. B. Clinical pharmacology. - St. Petersburg: Foliant, 1998. - 446 p.
Fundamentals of internal diseases / Ed. I. A. Zupanca.- Kh.: Prapor, 1999.- 82 p.
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The primary prevention of iron deficiency is proper, nutritious nutrition.

Secondary prevention is the active detection of latent iron deficiency and iron deficiency anemia during medical examinations and medical examinations.

1. Antenatal prevention: According to WHO recommendations, an iron supplement at a dose of 60 mg/kg per day is used in the 2nd and 3rd trimesters of pregnancy and during 3 months of lactation (supplementation regimen).

A pregnant woman's menu should include foods rich in protein - up to 120 g per day (meat, liver, cheese, fish), fruits, vegetables, vitamins and microelements. Iron absorption is reduced by excessive consumption of large amounts of milk and plant foods.

2. Postnatal prevention:

Nonspecific preventive measures for IDA include: natural feeding with the timely introduction of complementary foods: assorted vegetable puree (potatoes, beets, carrots, cabbage, zucchini, etc.), pureed beef or veal liver mixed with vegetable puree from 5 months, meat minced meat from 7 months, etc. In the diet, you should limit white porridges (semolina, rice, bearberry), giving preference to buckwheat, barley, pearl barley, and millet. Porridge should be cooked in water or, better yet, in vegetable broth.

Specific preventive measures (taking iron supplements) for children at risk (premature babies, those born from multiple pregnancies, etc.) must begin at 2 months of age, continuing until the end of the first year of life; full-term children at risk from 4 months for 3-6 months.

The prophylactic dose of iron supplements for children under 3 years of age is 1-1.5 mg/kg per day, for children over 3 years old - 1/3 - ½ daily therapeutic dose of elemental iron (according to N.P. Shabalov).

Specified terms for monitoring hematological indicators to confirm the effect of therapy: hemoglobin monthly during the period of clinical observation (1 year), after 1, 3, 4 and 6 months from the start of therapy, monitoring the level of serum iron, TCV and ferritin.

Vaccination is carried out after normalization of hemoglobin levels (with reduced hemoglobin, vaccinations are immunologically ineffective).

Forecast. The prognosis of the disease is favorable, cure should occur in 100% of cases. So-called “relapses” of the disease are possible with: the use of low doses of iron supplements; ineffectiveness of oral ferrodrugs; reducing the duration of treatment for patients; treatment of patients with chronic posthemorrhagic anemia with an unknown and unknown source of blood loss.

A.G. BLUSHIN 1.4, Doctor of Medical Sciences, Prof., I.N. ZAKHAROV 2, doctor of medical sciences, prof., V.M. CHERNOV 1.4, doctor of medical sciences, prof., I.S. TARASOVA 1.4, doctor of medical sciences, A.L. PATCHERS 2, doctor of medical sciences, prof.. ON THE. COROVIN 2, doctor of medical sciences, prof., T.E. BOROVIK 3.5, doctor of medical sciences, prof., N.G. ZVONKOVA 3.5, Ph.D., E.B. MACHNEVA 2 , S.I. LAZAREV 6 , T.M. VASILIEV 6

1 Federal State Budgetary Institution "Federal Scientific and Clinical Center for Pediatric Hematology, Oncology and Immunology named after. Dmitry Rogachev" of the Russian Ministry of Health
2 GBOU DPO "Russian Medical Academy of Postgraduate Education" of the Ministry of Health of Russia
3 Federal State Budgetary Institution "Scientific Center for Children's Health"
4 State Budgetary Educational Institution of Higher Professional Education "Russian National Research Medical University named after. N.I. Pirogov" of the Ministry of Health of Russia
5 State Budgetary Educational Institution of Higher Professional Education “First Moscow State Medical University named after. THEM. Sechenov" of the Ministry of Health of Russia
6 GBUZ "Children's City Clinic No. 133" of the Moscow Healthcare Department

Iron deficiency conditions (IDC) are widespread in all countries of the world, therefore doctors of almost all specialties need to know about this disease. Knowledge about iron deficiency anemia (IDA) and latent iron deficiency (LDI) is especially important for a practicing pediatrician. The article presents data from domestic and foreign studies on the prevalence of IDA and LVAD. The most significant factors influencing the prevalence of WDN among various population groups are discussed: gender, age, environmental, physiological, socio-economic factors.

Iron deficiency anemia (IDA) is a polyetiological disease, the occurrence of which is associated with iron deficiency (ID) in the body due to impaired intake, absorption or increased losses, characterized by microcytosis and hypochromic anemia. In turn, latent iron deficiency (LID) is an acquired condition in which there is a hidden iron deficiency, a decrease in iron reserves in the body and insufficient iron content in tissues (sideropenia, hyposiderosis), but there is no anemia yet.

Iron deficiency is a widespread pathology among the population throughout the globe. According to the World Health Organization (WHO), iron deficiency (ID) ranks first among the 38 most common human diseases. The risk of developing ID is highest in children (especially the first two years of life) and women of reproductive age. According to S.Osendarp et al. In the world, about 50% of preschool children and pregnant women have anemia. With an anemia frequency of 20%, ID exists in 50% of the population in the population, and with an anemia frequency of 40% and above, the entire population has various types of ID. According to research by D. Subramanian et al., 9% of children in the first two years of life have IDA.

According to WHO experts, iron deficiency still remains one of the most significant malnutrition-related diseases in the world. Iron deficiency negatively affects the cognitive development of children, both young and adolescent, and damages immune mechanisms, which leads to an increase in the incidence of infectious diseases. If ID is present during pregnancy, various adverse outcomes are possible, both for the mother (increased risk of bleeding, sepsis, maternal mortality) and for the fetus (increased risk of perinatal mortality and low birth weight). Even in industrialized countries, most pregnant women have insufficient iron stores in their bodies. The presence of ID affects physical performance and labor productivity of both men and women. WHO experts concluded that the economic consequences of iron deficiency make it clear that it is necessary to prevent this pathology with the use of iron-fortified food supplements.

WHO experts have done a lot of work, as a result of which it was shown that anemia is more common in developing countries; two groups of the population are most susceptible to anemia - young children and pregnant women ( table 1).

Due to its high prevalence, anemia occurs in the practice of doctors in almost any specialty. It is known that IDA accounts for 90% of all anemia in childhood and 80% of all anemia in adults. Previously, it was believed that all anemia in pregnant women was iron deficiency, however, it was later shown that IDA accounts for 60−70% of all anemia in this category of the population, and the remaining anemia has a different origin.

As already noted, iron deficiency anemia is more common in developing countries than in developed countries. In India, for example, up to 88% of pregnant and 74% of non-pregnant women suffer from anemia, in Africa - about 50% of pregnant and 40% of non-pregnant women. In Latin America and the Caribbean, the prevalence of anemia in pregnant and non-pregnant women is about 40% and 30%, respectively.

Data on the prevalence of anemia in different age groups are not available in all countries, however, the prevalence rate among preschool children is usually the same as or even higher than among pregnant women. According to WHO experts, the prevalence of IDA in the population can be moderate – from 5 to 19.9%, moderate – from 20 to 39.9% and significant – 40% or more ( table 2). When the prevalence of anemia is more than 40%, the problem ceases to be only a medical one and requires measures to be taken at the state level.

The prevalence of ID varies significantly depending on factors such as age, gender, physiological characteristics, existing diseases, environmental and socio-economic conditions.

Full-term babies, as a rule, are born with sufficient iron reserves in the liver and hematopoietic tissue. Subsequently, breast milk provides a certain amount of iron into the baby’s body. Despite the fact that breast milk has a relatively low iron content (0.2-0.4 mg/l), it is much better absorbed from breast milk (50% bioavailability) than from cow's milk. ID often develops after 6 months. in case untimely and incorrect introduction of complementary feeding products does not provide sufficient iron intake. Iron requirements based on body weight are proportional to the child's growth rate. This is why iron deficiency is most common during the preschool years and puberty. Another increase in the prevalence of ID may occur in old age, when nutrition often deteriorates in quality and quantity.

The prevalence of ID varies by gender. Gender differences are most noticeable after puberty. After the onset of menarche in adolescent girls, iron losses due to uterine bleeding are often not sufficiently compensated for by an adequate diet. VSD that arises during puberty persists in the future in 10-12% of women of reproductive age.

The physiological characteristics of the body also affect the incidence of anemia. The most noticeable differences are typical for pregnant women. Significant amounts of iron from a woman’s body enter the placenta and fetus during pregnancy. This leads to an increase in iron requirements of about 700 – 850 mg throughout pregnancy. Lactation leads to loss of iron through breast milk (1 mg/day), therefore, for some women, ID that occurs during pregnancy may worsen during lactation. However, from an iron balance perspective, lactational amenorrhea in healthy women compensates for iron losses through breast milk.

Scientists from various countries have conducted studies on the prevalence of WDN among various population groups. The studies varied in scope. In Japan, mandatory screening of school-age children has been carried out for 30 years for the purpose of early detection of IDA. Published in 2012 by Igarashi T. et al. The data showed the prevalence of anemia among schoolchildren in Japan: 0.26% in elementary school among boys, 0.27% in elementary school among girls, 1.21% in middle school among boys. The prevalence of anemia in girls' second and third years of secondary school was lower than in the first year of secondary school. IN table 3 data on the prevalence of IDA in some developed and developing countries is presented.

Table 3. Prevalence of IDA in developed and developing countries
A country	Year of publication, author	Frequency, %	Children's age
China	Zhu Y, Liao Q, 2004	20,8	6 months –1 year
China	Zhu Y, Liao Q, 2004	7,8	1–3 years
WHO	Corapci F. et al., 2010	20–25	First 2 years of life
USA	Baker R., Greer F., 2010	2,1	From 1 year to 3 years
		2,0
		1,6
		0,9
USA	Amy Zhu et al., 2010	7	1–2 years
		5	3–5 years
		4	6–11 years
African Americans USA	Angulo-Barroso R.M. et al.,2011	39,8	9 months
Ghana		55	9 months
Brazil	Cotta R. et al., 2011	55	Children under 5 years old
China	Angulo-Barroso R.M. et al., 2011	31,8	9 months
Japan	Igarashi T. et al., 2012	1,05–7,1	7–15 years

IN table 4 presents data on the prevalence of latent iron deficiency (LDI) in some developed and developing countries.

Table 4. Prevalence of latent iron deficiency in developed and developing countries
A country	Year of publication, author	Frequency, %	Children's age
China	Zhu Y, Liao Q., 2004	65,5	6 months –1 year
China	Zhu Y, Liao Q., 2004	43,7	1–3 years
Norway	Hay G. et al., 2004	4,0	6 months
Norway	Hay G. et al., 2004	12	1 year
USA	Baker R., Greer F., 2010	9,2	1–3 years
		7,3	White non-Hispanic Americans
		6,6	Black non-Hispanic Americans
		13,9	Mexican Americans

Zhu Y.P. et al. In 2004, a large epidemiological study of the prevalence of WDN among children in China was conducted. 9,118 children aged 7 months to 7 years were examined. According to the study results, the prevalence of LID and IDA was 32.5% and 7.8%, respectively. Moreover, the prevalence of LID and IDA was the highest in newborns - 44.7% and 20.8%, respectively. In preschool children aged 4 to 7 years, the prevalence was lower: 26.5% had LID, 3.5% had IDA. A comparison was made of the prevalence of WDN among children living in the city and in rural areas. Urban children had a higher prevalence of LID than rural children, however, rural children had a higher prevalence of anemia.

A. Zhu et al. in their 2010 publication, they provide data on the prevalence of IDA in the United States, taken from the Centers for Disease Control and Prevention for 1999–2000. In the United States, a developed country, the prevalence of IDA was also higher in young children (1-2 years old) - 7% and lower in older children (6-11 years old) - 4%.

Research on the prevalence of VDN is being conducted in various regions of our country. So back in 1988 Yu.E. Malakhovsky et al. The results of a study of the frequency of IDA and LVAD in children were published. It is shown that by the end of the 80s. XX century LDV frequency ( rice. 1) and mild forms of IDA ( rice. 2) among children of the first 6 months. life reached 40%. With age, there was a significant decrease in the incidence of ID (by the end of the 2nd year of life, IDA was registered in more than 10% of children, and LDJ in more than 20%).

Currently, according to various authors, it has been shown that the prevalence of VDV in children depends on the region, for example, VDV in some regions of the Russian Federation (North, Northern Caucasus, Eastern Siberia) reaches 50–60%. According to Yunusova I.M. (2002), the prevalence of IDA among the child population of various districts of Makhachkala was 43%.

Also, the frequency of VDN in our country was studied depending on the age group and gender. According to Tarasova I.S. (2013), the prevalence of anemia and the structure of IDA in adolescents have pronounced gender differences: anemia was detected in 2.7% of boys and 9% of girls, IDA – in 2.1 and 17.2%, respectively, IDA – in 2.7 and 7.3% respectively.

The prevalence of WDN is also influenced by socio-economic conditions. So, according to Malova N.E. (2003), VSD are detected in 80.2% of young children in orphanages. In the structure of sideropenic conditions, the leading place is occupied by IDA - 59.3%, LID occurred in 40.7% of the examined children.

Thus, accumulated global and domestic data on the prevalence of iron deficiency states show that it is high and depends on many factors: gender, age, environmental factors, socio-economic living conditions, and the presence of pathological factors. This should be remembered by a practicing physician of any specialty in order to promptly suspect and diagnose VHD for the purpose of adequate and early therapy. In addition, there is an obvious need for systematic updating of data on the prevalence of WDN based on epidemiological studies among various population groups, since the structure of factors influencing it changes over time.

Literature

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Source: Medical Council, No. 6, 2015

Prevention of iron deficiency anemia in children in the first months of life includes a balanced diet for women during pregnancy and lactation, including a sufficient amount of meat products, fruits and vegetables rich in vitamin C, as well as specialized products containing minerals and vitamins. If the hemoglobin content is below 100 g/l, it is advisable to prescribe the woman oral ferrodrugs or multivitamins fortified with iron.

Natural prevention of IDA in children in the first months of life is exclusively breastfeeding up to 4-6 months of life. It is known that the concentration of iron in human milk is only 0.2-0.4 mg/l, but this is enough to meet the iron needs of a growing child’s body due to its high bioavailability (50%).

When artificially feeding children in the first six months of life, formulas with an iron content of 0.4 to 0.8 mg/100 ml are used, which is quite sufficient, since the “maternal” iron reserves have not yet been depleted. The iron content in “subsequent” adapted milk formulas (for children in the second half of life) increases to 0.9-1.3 mg/100 ml.

By 4–6 months of age, the child’s body is depleted of antenatal iron reserves and its metabolism becomes absolutely dependent on the amount of micronutrients supplied with food in the form of complementary foods. When choosing products to replenish iron deficiency, it is necessary to take into account not only the total amount of iron in products, but also the qualitative form of its compounds.

It is advisable to include industrially produced foods fortified with iron in the diet (fruit juices, fruit and vegetable purees, instant cereals), which increases the amount of iron entering the child’s body with food.

Despite the high iron content in some products of plant origin, they are not able to meet the high iron requirements of a growing child's body. Substances present in products of plant origin (tannins, phytins, phosphates) form insoluble compounds with Fe (III) and are excreted in feces. There is also information about the adverse effect of dietary fiber, which is rich in cereals, fresh vegetables, and fruits, on the absorption of iron. In the intestines, dietary fiber is practically not digested; iron is fixed on their surface and removed from the body. On the contrary, ascorbic and other organic acids, as well as animal protein containing heme iron, increase the bioavailability of iron.

It is important that meat and fish products increase the absorption of iron from vegetables and fruits when used simultaneously. Taking into account the above, as well as the high content of easily accessible iron in meat, it is recommended to introduce meat complementary foods no later than 6 months.

Whole cow's milk is not used in the diet of children under 1 year of age. The concentration of iron in cow's milk is only 0.3 mg/l, and its bioavailability is about 10%. Numerous studies have shown that the use of unadapted products (cow's milk and kefir) in the diet of young children leads to microdiapedetic gastrointestinal bleeding, which is a risk factor for the development of VDN.

Materials for this chapter were also provided by: Ph.D. Rybakova E.P. (Moscow), Ph.D. Bushueva T.V. (Moscow), Ph.D. Stepanova T.N. (Moscow), Ph.D. Kazyukova T.V. (Moscow)

Prevention of VDD should begin in the antenatal period of the child’s development. In the second half of pregnancy, it is advisable for all women in the second half of pregnancy to undergo prophylactic administration of oral ferromedicines or multivitamins enriched with iron (Pharma-Med Ladys formula Iron Plus, Fesovit, Fefol-vit, Natabek F, Irovit, Irradian, Biovital, Materna, Mineravit, Multifit, Nova Vita, Pregnavit , Prenamin, Prenatal, Fenyuls, Stress formula with iron, Vitrum prenatal).

If you are pregnant again, taking iron supplements is strictly necessary during the second and third trimesters. It is best to use ferrous iron supplements with folic acid, which stimulates growth and protects the central nervous system of the fetus. A pregnant woman needs sufficient time in the fresh air and a nutritious, balanced diet.

Postnatal prevention of IDA includes:

Natural feeding with the timely introduction of complementary foods and supplementary foods specially fortified with iron. The choice of the type of complementary foods must necessarily take into account the required content of easily digestible iron in food products (meat puree). It is especially important to timely introduce complementary foods to children with a lymphatic type of constitution, children with large birth weights and excessive weight gain, as well as premature infants.

Maintaining a daily routine with sufficient time in the fresh air, prevention and timely treatment of rickets, malnutrition, and acute respiratory diseases.

For children with an uncomplicated perinatal history at the age of the first 3-4 months, mother's milk is the only physiological food product that ensures the balance of iron metabolism in the body. However, by the 6-7th month of a child’s life, the amount of iron entering the body through breast milk becomes insufficient to maintain its positive balance. Breast milk during this lactation period contains no more than 0.5 mg of iron per liter. Therefore, during this period of life it is necessary to prescribe complementary foods - meat puree.

Formula-fed children should receive adapted formulas containing iron. However, it should be remembered that iron absorption from formulas based on cow's milk is 5 times lower than from human milk. In addition, in children of the first three months, hematopoiesis is carried out mainly through the use of endogenous iron.

Unabsorbed iron can cause increased activity of siderophilic Gram-negative opportunistic microflora. Therefore, children who are bottle-fed with adapted milk formulas are not advised to prescribe iron-fortified formulas and supplementary foods before the age of 4 months.

Premature babies, children from multiple pregnancies, those born with a large body weight or those with rapid rates of weight gain from the 3rd month of life until the end of the first six months are recommended to take prophylactic iron supplements in a dose equal to 1/2 the daily therapeutic dose (2-4 mg/day). kg/day of elemental iron). These children require quarterly hematological monitoring.

Thus, although it is impossible to replenish iron deficiency in the body with diet therapy alone, it should be remembered that a diet that is adequate for age and balanced in terms of the main ingredients is one of the real factors in the prevention of sideropenic conditions.

Pharmaceutical care: treatment of iron deficiency anemia