2. Dr Goudarzipour

3.  MCV:HCT/RBC,fl  MCH:Hb/RBC,pg  MCHC:HCT/Hb,gd  RDW:anisocytosis

8.  Neutropenia?  Anemia?  Physiologic anemia?

9.  NL PLT?  WHATS MPV?

15.  2 Y/O male  WBC:6700:PMN:60,L:40 RBC:4.700.000 Hb:11.7 MCV:76 PLT:135000

16.  3 month years,female  WBC:6500,L:30,P:70 Hb:8.7 MCV:90 PLT:400.000

17.  7 y/o,female  WBC:5390,P:63,L:37 RBC:5.900.000 Hb:10.5 MCV:64 MCH:23 PLT:433.000

18.  2 y/o male  WBC:14500,P;78,l;22 RBC:5400 Hb;8 HCT:13 MCV:99 MCH:32 MCHC:36 PLT:78000

20. Iron deficiency is the most common nutritional deficiency in children and is worldwide in distribuiotion. The incidence of iron-deficiency anemia is high in infancy. 40–50% of children under 5 years of age in developing countries.

21.  Babies are born with iron stored in their bodies. Because they grow rapidly, infants and children need to absorb an average of 1 mg of iron per day.  Since children only absorb about 10% of the iron they eat, most children need to receive 8-10 mg of iron per day. Breastfed babies need less, because iron is absorbed 3 times better when it is in breast milk

24.  I. Gastrointestinal tract  Anorexia-common and an early symptom  Pica-pagophagia (ice) geophagia  Atrophic glossitis  II. Central nervous system  Irritability  Fatigue and decreased activity

25.  III. Cardiovascular system  Cardiac hypertrophy  IV. Musculoskeletal system  Deficiency of myoglobin and cytochrome C  Adverse effect on fracture healing  V. Immunologic system  Evidence of increased propensity for infection

29.  Peak prevalence occurs during late infancy and early childhood  Rapid growth with exhaustion of gestational iron  Low levels of dietary iron  Complicating effect of cow’s milk-induced exudative enteropathy

30.  A second peak is seen during adolescence due to rapid growth and suboptimal iron intake.  This is amplified in females due to menstrual blood loss

31.  I. Deficient intake  Dietary (milk, 0.75 mg iron/l)  II. Inadequate absorption  Poor bioavailability: absorption of heme Fe.Fe2.Fe3; breast milk iron.cow’s milk  Antacid therapy or high gastric pH (gastric acid assists in increasing solubility of inorganic iron)  Cobalt, lead ingestion

32.  III. Increased demand  Growth  pregnancy  IV. Blood loss

34.  The best sources of iron include:  Baby formula with iron  Breast milk (the iron is very easily used by the child)  Infant cereals and other iron-fortified cereals  Liver

41.  Blue-tinged or very pale whites of eyes  Blood in the stools  Brittle nails Brittle nails  Decreased appetite (especially in children) Decreased appetite  Fatigue Fatigue  Headache Headache  Irritability  Pale skin color (pallor)pallor  Shortness of breath Shortness of breath  Sore tongue  Unusual food cravings (called pica)pica  Weakness Weakness  Note: There may be no symptoms if anemia is mild.

42.  1. Hemoglobin: Hemoglobin is below the acceptable level for age  2. Red cell indices: Lower than normal MCV, MCH and MCHC for age.  3.Increase RDW Blood smear: Red cells are hypochromic and microcytic with anisocytosis hemoglobin level falls below 10 g/dl.

43.  Basophilic stippling can also be present but not as frequently  The RDW is high (.14.5%)  Reticulocyte count: The reticulocyte count is usually increase in bleeding).)normal  Platelet count: The platelet count varies from thrombocytopenia to thrombocytosis.  free erythrocyte protoporphyrin (FEP) levels. increase

44.  The normal FEP level is 15.56 +-8.3 mg/dl. The upper limit of normal is 40 mg/dl  Serum ferritin: The level of serum ferritin reflects the level of body iron stores (below than 12).  Normal ferritin levels, however, can exist in iron deficiency when bacterial or parasitic infection, malignancy or chronic inflammatory conditions co-exist.because ferritin is an acute-phase reactant

45.  Serum iron and iron saturation percentage:  limitations:  Wide normal variations (age, sex, laboratory methodology)  Time consuming  Subject to error from iron ingestion  Diurnal variation  Falls in mild or transient infection.

46. 1. Iron depletion: tissue stores are decreased  without a change in  hematocrit or serum iron level 2. Iron-deficient erythropoiesis Iron decrease reticuloendothelial macrophage

47.  TIBC increase  With out change in HCT 3. Iron-deficiency anemia:  Anemia  Increase RDW  Increase FEP

50.  Oral Iron Medication  Dose: 1.5–2.0 mg/kg elemental iron three times daily.  In children with gastrointestinal side effects, iron once every other day  Duration: 6–8 weeks after hemoglobin level and the red cell indices return to normal.

51.  Peak reticulocyte count on days 5–10 following initiation of iron therapy.  Following peak reticulocyte level, hemoglobin rises on average by 0.25–0.4 g/dl/  hematocrit rises 1%/day during first 7–10 days.  Thereafter, hemoglobin rises slower: 0.1–0.15 g/dl/day.

52.  Poor compliance – failure or irregular administration of oral iron;  Inadequate iron dose  Ineffective iron preparation  Insufficient duration  Persistent or unrecognized blood loss  Incorrect diagnosis – thalassemia, sideroblastic anemia  Coexistent disease that interferes with absorption or utilization of iron  Impaired gastrointestinal absorption due to high gastric pH

53.  Noncompliance or poor tolerance of oral iron.  Severe bowel disease (e.g., inflammatory bowel disease)  Chronic hemorrhage  Rapid replacement of iron stores is needed.  Erythropoietin therapy is necessary, e.g. renal dialysis.

54. In children with sever infection specially with cardiac dysfunction or Hb less than 4 g/dl.

60.  References  Glader B. Iron-deficiency anemia. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF, eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, Pa: Saunders Elsevier; 2007: chap 455.  Heird WC. The feeding of infants and children. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF, eds. Nelson Textbook of Pediatrics. 18th Ed. Philadelphia, Pa: Saunders Elsevier; 2007: chap 42.  O'Connor NR. Infant formula. Am Fam Physician. 2009;79:565-570.