A Rare Case of Plummer-Vinson Syndrome

Plummer-Vinson syndrome (PVS) is characterized by a triad of symptoms comprising microcytic hypochromic anemia, esophageal webs, and dysphagia. PVS is commonly found in women of middle age especially in the fourth and fifth decade of life and is rarely reported in males. We report a case of a 39-year-old female patient who had a classic presentation of PVS. PVS is precancerous with high malignant potential; early diagnosis is of utmost importance for better prognosis and surveillance endoscopy is recommended. Iron repletion oftentimes improves the dysphagia; seldom esophageal dilatation is used to provide symptomatic relief.

The Effect of a Date Consumption-Based Nutritional Program on Iron Deficiency Anemia in Primary School Girls Aged 8 to 10 Years Old in Zahedan (Iran)

AIM

Iron deficiency anemia (IDA) is one of the most common nutritional problems in students. The best and most cost-effective ways to prevent IDA are changes in people's dietary habits and their nutrition education. The purpose of this study was to determine the effect of nutritional program based on dates consumption on IDA in primary schoolgirls.

MATERIALS AND METHODS

This was a semi-experimental study. The study population consisted of primary school girl students of Zahedan, Iran, during the academic year of 2018-2019. The sampling method was a combination of stratified sampling and multi-stage cluster sampling. Then, 31 female primary school children with IDA were fed with dates for 2 months. Before the intervention and after 2 months of date consumption, hemoglobin, hematocrit, and ferritin blood parameters were measured. Both paired t-test and chi-square test were used to analyze the data using SPSS version 21.

RESULTS

The results were meaningful. The hemoglobin levels at the beginning and the end of the study were 11.19 ± 0.38 and 12.05 ± 0.81 g/dL, respectively (P = 0.001), the hematocrit levels were 34.24 ± 0.41% and 37.17 ±2.36%, respectively, P = 0.001, and the ferritin levels were 47.07 ± 21.89 μg/dL and 53.98 ± 19.77 μg/dL, respectively, P= 0.001.

CONCLUSION

The consumption of date fruit increased hemoglobin, hematocrit, and serum ferritin levels in primary school girl students with IDA; therefore, it is recommended to give dates to school girls.

Thiol-Disulfide Homeostasis, Serum Ferroxidase Activity, and Serum Ischemia Modified Albumin Levels in Childhood Iron Deficiency Anemia

Aim: The aim is to compare the markers of oxidative stress in iron deficient children to that of non-anemic children. Method: Serum thiol-disulfide level, ferroxidase activity and ischemia-modified albumin (IMA) levels were compared between iron deficiency anemia (IDA) and non-anemic children. Results: A total of 117 children, 66 with IDA and 51 non-anemic children were included in the study. Disulfide, disulfide/native thiol, and disulfide/total thiol levels were significantly higher in the IDA group (p: 0.001). Serum ferroxidase levels were significantly lower in the IDA group (p: 0.04); but there was no significant difference between the two groups regarding serum IMA levels (p: 0.42). There was a weak negative correlation between disulfide and serum hemoglobin (p: 0.004), iron (p: 0.041), and ferritin (p: 0.023) levels while there was a weak positive correlation between ferroxidase activity and these parameters. Conclusion: There is an increased protein oxidation in children with IDA compared with non-anemic controls.

Long-term outcomes in patients newly diagnosed with iron deficiency anaemia in general practice: a retrospective cohort study

OBJECTIVES

To describe all iron deficiency anaemia (IDA)-related causes during follow-up of patients newly diagnosed with IDA and to assess whether a delayed colorectal cancer (CRC) diagnosis influences survival.

DESIGN AND SETTING

Retrospective cohort study of patients from general practices in the Dordrecht area, the Netherlands.

PARTICIPANTS

Men and women aged ≥50 years with a new diagnosis of IDA (ie, no anaemia 2 years previously).

METHOD

From February 2007 to February 2018, all relevant data were collected from the files of the referral hospital. Early IDA-related cause was defined as established within 18 weeks after IDA diagnosis. Cox proportional-hazards regression was used to analyse survival of patients with CRC diagnosis.

RESULTS

587 patients with IDA were included with a median follow-up of 4.6 years. Early and late IDA-related causes could be established in 32% and 8% of patients, respectively. Early and late CRC was found in 8% and 2% of patients, respectively, and were located mainly right sided. After adjustment for age, gender and TNM classification, mortality risk was lower in patients with IDA with early CRC diagnosis, but not significantly (HR 0.30, 95% CI 0.09 to 1.02).

CONCLUSION

Even with extended follow-up, the cause of IDA remains elusive in the majority of patients with IDA in general practice. However, patients with IDA are at increased risk for in particular right-sided CRC and a late diagnosis of CRC appears to have a detrimental effect on survival in patients with IDA.

From the Breast to the Bowel: An Unconventional Metastatic Presentation

Breast cancer is the most common cancer in women. The common sites of metastasis include the lungs, liver, and, infrequently, the gastrointestinal (GI) tract. A 72-year-old Caucasian female presented to the hospital with nausea and vomiting, diarrhea, intermittent abdominal pain, and unintentional weight loss. She had had a past medical history of bilateral lobular breast carcinoma and severe iron-deficiency anemia treated with iron transfusions. On arrival, the examination was significant for hypotension and pallor. Laboratory investigations revealed abnormal liver enzymes and raised tumor markers Ca-125 and carcinoembryonic antigen. Imaging studies established a diagnosis of distal small bowel obstruction. The surgical intervention showed the presence of a small bowel tumor, the biopsy findings of which were consistent with metastatic breast cancer, with ER and PR positive but HER-2 negative. She was managed with a selective estrogen receptor degrader and CDK4/6 inhibitor and has been in remission since. Metastasis to the small bowel from the breast is a very rare occurrence. Clinicians should thus maintain a modest amount of suspicion when encountering an uncommon GI presentation of primary breast malignancy. We describe the case of metastatic breast cancer with an atypical GI presentation.

Improvement of Health-Related Quality of Life in Children with Inflammatory Bowel Disease Receiving Routine Intravenous Iron Supplementation

OBJECTIVES

Iron deficiency anemia (IDA) is very common in children with inflammatory bowel disease (IBD). While health-related quality of life (HRQL) is a key outcome measure, no long-term studies have evaluated the effect of correction of IDA on HRQL in children with IBD. Our goal was to prospectively study changes in HRQL in iron-deficient children with IBD receiving routine iron supplementation with periodic intravenous iron sucrose (IVIS).

METHODS

Thirty-eight children with IBD treated with infliximab participated. Hematology and inflammatory markers were assessed before each infliximab treatment. Iron-deficient patients (transferrin saturation below 20% and/or ferritin below 30 ng/mL or 100 ng/mL with normal or elevated C-reactive protein, respectively) received IVIS after each infliximab infusion until iron indices stayed normal for two consecutive measurements. HRQL was assessed with Pediatric Quality of Life Inventory every 4 months. Correlation between changes in mean hemoglobin levels and HRQL scores was analyzed prospectively in 3-month periods over a period exceeding 3 years.

RESULTS

At enrollment, 27 patients had already been established on infliximab; 11 had not started or completed induction. Mean iron indices and hemoglobin normalized after 3 and 6 month of starting IVIS, respectively. Multiple HRQL parameters significantly improved, regardless of the duration of infliximab treatment at the time of enrollment. There was a statistically significant positive correlation between correction of anemia and improvement in parent-reported emotional and physical HRQL scores.

CONCLUSIONS

Periodic IVIS resulted in long-term correction of IDA in children with IBD. Correction of IDA contributed to some improvements in HRQL.

A Novel School-based Intermittent Delivery System of Iron Supplements for Highly Marginalized Tarahumara Indigenous Women of Reproductive Age of Northern Mexico

To develop a novel delivery scheme to bridge the Mexican health system with highly isolated indigenous communities by involving naturally occurring social links: households and boarding schools. This was a school-based placebo-controlled trial with a follow-up period of 16 weeks. Children whose mothers fulfilled the inclusion criteria for anemia acted as iron supplement carriers between schools and homes. Adherence was measured based on teachers' and mothers' records. An effectiveness sub-analysis assessed changes in biochemical profiles according to random allocation to either supplementation or placebo groups. There was an overall high adherence in both groups. Analyses revealed that schooling years, literacy, and walking times played a role in high adherence. Logistic regression showed that women had higher adherence odds on the basis of household size, walking times, and previous inclusion in supplement distributions. Adherence significantly decreased the proportion of anemia by 48.2% in the intervention group. The difference at baseline and endpoint significantly reduced the number of iron-deficient anemic women by 67.7% in the supplementation group. This delivery method is a valid alternative to the conventional efforts used to reach Tarahumara indigenous communities, and could also have the potential to be piloted to tackle other health issues hindering these marginalized communities.

The Human-Specific BOLA2 Duplication Modifies Iron Homeostasis and Anemia Predisposition in Chromosome 16p11.2 Autism Individuals

Human-specific duplications at chromosome 16p11.2 mediate recurrent pathogenic 600 kbp BP4-BP5 copy-number variations, which are among the most common genetic causes of autism. These copy-number polymorphic duplications are under positive selection and include three to eight copies of BOLA2, a gene involved in the maturation of cytosolic iron-sulfur proteins. To investigate the potential advantage provided by the rapid expansion of BOLA2, we assessed hematological traits and anemia prevalence in 379,385 controls and individuals who have lost or gained copies of BOLA2: 89 chromosome 16p11.2 BP4-BP5 deletion carriers and 56 reciprocal duplication carriers in the UK Biobank. We found that the 16p11.2 deletion is associated with anemia (18/89 carriers, 20%, p = 4e-7, OR = 5), particularly iron-deficiency anemia. We observed similar enrichments in two clinical 16p11.2 deletion cohorts, which included 6/63 (10%) and 7/20 (35%) unrelated individuals with anemia, microcytosis, low serum iron, or low blood hemoglobin. Upon stratification by BOLA2 copy number, our data showed an association between low BOLA2 dosage and the above phenotypes (8/15 individuals with three copies, 53%, p = 1e-4). In parallel, we analyzed hematological traits in mice carrying the 16p11.2 orthologous deletion or duplication, as well as Bola2^+/- and Bola2^-/- animals. The Bola2-deficient mice and the mice carrying the deletion showed early evidence of iron deficiency, including a mild decrease in hemoglobin, lower plasma iron, microcytosis, and an increased red blood cell zinc-protoporphyrin-to-heme ratio. Our results indicate that BOLA2 participates in iron homeostasis in vivo, and its expansion has a potential adaptive role in protecting against iron deficiency.

In Vitro and In Vivo Evaluations of Mesoporous Iron Particles for Iron Bioavailability

Chronic renal failure involving hemodialysis results in blood loss during filtration. Iron deficiency and iron deficiency anemia can result. A compensatory increase in iron dosage has many side effects including discomfort. Elemental iron is a highly-pure iron source, which reduces the frequency of dosages; the solubility decreases with increased particle size or pore size. In this study, synthesized mesoporous iron particles (MIPs) were used to relieve iron deficiency anemia. Their bioavailability was measured in vitro by a Caco-2 cell model and in vivo in iron-deficient rats. In vitro bioavailability of MIPs was examined by measuring ferritin content in the Caco-2 cell model. Iron uptake of MIPs was significantly higher than commercial iron particles, which were less porous. In vivo bioavailability of MIPs was examined by measuring body weight gain and red blood cell-related parameters, compared with the bioavailability of standard drug ferrous sulfate in iron-deficient anemic rats. Finally, average hemoglobin content and hemoglobin regeneration efficiency were significantly higher in anemic rats supplemented with commercial iron particles, compared to anemic controls. In the 28-day oral toxicity test, MIPs were not significantly toxic to rat physiology or tissue histopathology. Thus, MIPs may allow effective recovery of hemoglobin in iron deficiency anemia.

Maltobionic acid accelerates recovery from iron deficiency-induced anemia in rats

In experiments 1 and 2, effect of ingestion of maltobionic acid calcium salt (MBCa) on recovery of rats from a latent iron deficiency and from iron deficiency anemia was examined, respectively. After grouping rats into control and iron-deficiency groups, a latent iron deficiency or iron-deficiency anemia was induced in the latter group. And recovery from these states by MBCa containing diets (0%, 3%, and 6% MBCa in diet, classified into MBCa-0, MBCa-3, and MBCa-6 groups) was compared for convalescence period in light of iron sufficient control group. In experiment 1, MBCa ingestion significantly increased the iron concentration in the serum and liver, and promoted recovery from a latent iron deficiency. In experiment 2, hemoglobin and hematocrit levels increased significantly with MBCa intake, and recovery from iron-deficiency anemia was promoted. MBCa effectively promoted the recovery of rats from a subclinical iron deficiency and iron-deficiency anemia.Abbreviations: ANOVA: analysis of variance; DMT1: divalent metal transporter 1; EDTA-2Na: disodium salt of ethylenediaminetetraacetic acid; Fpn: feroportin; Hb: hemoglobin; Ht: hematocrit; ICP-OES: inductivity coupled plasma optical emission spectrometer; MBCa: maltobionic acid calcium salt; nitroso-PSAP: 2-nitroso-5-[N-n-propyl-N-(3-sulfopropyl)amino]phenol; SE: standard error; SI: serum-iron concentration; TSAT: transferrin saturation; TIBC: total iron-binding capacity; UIBC: unsaturated iron-binding capacity.

Alférez M, Díaz-Castro J. Fermented Goat Milk Consumption Enhances Brain Molecular Functions during Iron Deficiency Anemia Recovery

Iron deficiency anemia (IDA) is one of the most prevalent nutritional deficiencies worldwide. Iron plays critical roles in nervous system development and cognition. Despite the known detrimental consequences of IDA on cognition, available studies do not provide molecular mechanisms elucidating the role of iron in brain functions during iron deficiency and recovery with dairy components. In this study, 100 male Wistar rats were placed on a pre-experimental period of 40 days and randomly divided in two groups: a control group receiving a normal-Fe diet, (45 mg/kg), and an Fe-deficient group receiving a low-Fe diet (5 mg/kg). At day 40, 10 rats per group were sacrificed to anemia control, and 80 rats were divided into eight experimental groups fed with fermented goat or cow milk-based diets, with normal Fe content or Fe overload (450 mg/kg) for 30 days. IDA decreased most of the parameters related to brain molecular functions, namely dopamine, irisin, MAO-A, oxytocin, β-endorphin, and α-MSH, while it increased synaptophysin. These alterations result in an impairment of brain molecular functions. In general, during anemia recovery, fermented goat milk diet consumption increased dopamine, oxytocin, serotonin, synaptophysin, and α-MSH, and decreased MAO-A and MAO-B, suggesting a potential neuroprotective effect in brain functions, which could enhance brain molecular functions.

Challenges in the Treatment of Iron Deficiency Anemia in a Child With Autism Spectrum Disorder: A Case Study

Children with autism spectrum disorder (ASD) face many challenges, including feeding problems due to behavioral issues and food aversions. Therefore, pediatric nurse practitioners need to assess for different mineral deficiencies, including iron deficiency anemia (IDA). The following case study describes a 4-year-old with ASD with persistent IDA despite typical recommendation of oral iron supplementation. Other potential etiologies of IDA are reviewed. Finally, different management approaches for managing IDA in children with ASD are described.

"Tear Drops in the Duodenum": Uncommon Cause of Iron Deficiency Anemia in Adults

A 64-year-old man presented to the internal medicine resident clinic with fatigue and abdominal pain of six-month duration. He did not have diarrhea, hematemesis, melena, or hematochezia. Physical examination was unremarkable. Laboratory findings were consistent with iron deficiency anemia. Upper and lower gastrointestinal (GI) endoscopies revealed normal findings. Duodenal biopsy showed trophozoites (tear-drop-shaped) morphologically consistent with Giardia duodenalis. He was prescribed metronidazole and iron replacement therapy, with a resultant improvement in symptoms as well as lab values at the four-month follow-up visit.

Iron deficiency anemia associated with extracorporeal photopheresis: A retrospective analysis

BACKGROUND

Extracorporeal photopheresis (ECP) is associated with few adverse effects. We have anecdotally noted patients treated with long-term ECP develop iron deficiency anemia (IDA).

METHODS

We performed a retrospective chart review of adult patients who received ECP for any indication at Mayo Clinic Rochester and Mayo Clinic Arizona. The primary objective was to describe the cumulative incidence of IDA at 1 year of ECP therapy.

RESULTS

A total of 123 patients were eligible for analysis. Graft-vs-host disease was the most common indication for ECP (n = 76, 61.8%). At 1 year of ECP therapy, the cumulative incidence of IDA was 24.1% (95% CI, 14.2%-32.9%). At 5 years, the cumulative incidence of IDA was 68.3% (95% CI, 38%-83.8%). Risk factors for the development of IDA included: cumulative number of ECP sessions (HR 1.34, 95% CI, 1.05-1.73 per 10 additional sessions, P = .022), an indication for ECP of solid organ transplant rejection (compared to cutaneous T-cell lymphoma, HR 5.46, 95% CI, 2.06-14.49, P < .001), and proton pump inhibitor use at baseline (HR 2.15, 95% CI, 1.1-4.21, P = .03). Iron supplementation was initiated in 29 of 37 evaluable patients who developed IDA, with a cumulative incidence of supplementation in 77.2% patients within 3 months of recognition of IDA (95% CI, 55.8%-88.3%). Hemoglobin normalized in 50.1% of patients started on iron supplementation for IDA within 7 months (95% CI, 25.2%-66.7%).

CONCLUSIONS

Iron deficiency anemia is common in patients receiving long-term ECP and occurs throughout ECP therapy. IDA resolved with iron supplementation in half of patients.

Plummer-Vinson syndrome: improving outcomes with a multidisciplinary approach

Plummer-Vinson syndrome is a rare condition associated with dysphagia, iron deficiency, and esophageal webs. Data regarding this condition is limited to mostly case reports and a few small cohort studies. Although most cases have a benign and indolent course, the risk of malignancy warrants long-term surveillance. A multidisciplinary approach among healthcare providers is of the utmost importance in the management of this condition.

Importance of Initial Complete Parenteral Iron Repletion on Hemoglobin Level Normalization and Health Care Resource Utilization: A Retrospective Analysis

STUDY OBJECTIVE

Iron deficiency anemia is the most common form of anemia, and parenteral iron therapy is necessary in select patients. The objective of this analysis was to assess the impact of initial complete parenteral iron repletion on serum hemoglobin (Hgb) level normalization and on health care resource utilization in real-world practice.

DESIGN

Retrospective observational study.

DATA SOURCE

Decision Resources Group Real-World Data Repository (United States databases).

PATIENTS

A total of 2966 patients who had a baseline Hgb level below normal (< 12 g/dl for females and < 13.5 g/dl for males) and were treated with parenteral iron between March 2015 and February 2017.

MEASUREMENTS AND MAIN RESULTS

The effect of receiving the required parenteral iron dose to replete the deficit, calculated by a modified Ganzoni formula, within 3 weeks of the first parenteral iron therapy claim (index date) on the likelihood of Hgb level normalization, was estimated by using logistic regression. All analyses were adjusted for sex, age, comorbidities, and use of prescription oral iron therapy. The adjusted mean numbers of all-cause inpatient admissions, outpatient visits, and emergency department (ED) visits within 6 months and 1 year after the index date were compared between patients with and without normalized Hgb levels by using negative binomial regression. Of the 2966 included patients, 33.9% received the required iron dose within 3 weeks of the index date, and 19.6%, 48.2%, and 53.9% had a normalized Hgb level within 8 weeks of the index date, within 1 year of the index date, and until the end of data availability, respectively. Patients who received the required iron dose within 3 weeks of the index date were significantly more likely to have a normalized Hgb level within 8 weeks of the index date and at any time during the study period than those who did not: adjusted odds ratio (OR) (95% confidence interval [CI]) 2.67 (2.20, 3.24) and 2.33 (1.96, 2.77), respectively. Hgb level normalization within 1 year of the index date was associated with fewer inpatient admissions and outpatient visits and a similar number of ED visits compared with no Hgb level normalization 1 year after the index date.

CONCLUSION

The results of these analyses underscore the importance of initial complete parenteral iron repletion for rapidly improving clinical outcomes. Prompt achievement of a normalized Hgb level may also provide an opportunity to reduce health care resource utilization in patients with iron deficiency anemia receiving parenteral iron therapy.

Comparative efficacy and safety of intravenous ferric carboxymaltose and iron sucrose for the treatment of preoperative anemia in patients with menorrhagia: An open-label, multicenter, randomized study

AIM

To compare ferric carboxymaltose (FCM) with iron sucrose (IS) for the effective and timely treatment of preoperative iron deficiency anemia (IDA) in women with menorrhagia.

METHODS

This open-label, multicenter, two-arm study randomized patients to receive either a single dose of FCM or multiple doses of IS. The primary endpoint was the proportion of patients who achieved hemoglobin (Hb) levels ≥10 g/dL within 2 weeks after the first administration. Secondary endpoints included mean Hb levels, time to reach Hb ≥10 g/dL and quality of life (QoL).

RESULTS

In total, 101 patients (FCM n = 52; IS n = 49) were randomized to the study treatments. FCM was as effective as IS in achieving Hb ≥10 g/dL within 2 weeks after the first administration (78.8% vs 72.3%). The time to reach Hb ≥10 g/dL was significantly shorter in the FCM group than in the IS group (7.7 days vs 10.5 days). Mean Hb levels were higher in the FCM-treated patients than in the IS-treated patients with borderline significance. QoL scores did not differ between the two groups.

CONCLUSION

Ferric carboxymaltose is as effective as IS in correcting preoperative IDA among patients with menorrhagia. The added benefits of FCM over IS included significant rapid correction of IDA, replenishment of iron stores and reduced hospital visits.

Impairment of the Developing Human Brain in Iron Deficiency: Correlations to Findings in Experimental Animals and Prospects for Early Intervention Therapy

Due to the necessity of iron for a variety of cellular functions, the developing mammalian organism is vulnerable to iron deficiency, hence causing structural abnormalities and physiological malfunctioning in organs, which are particularly dependent on adequate iron stores, such as the brain. In early embryonic life, iron is already needed for proper development of the brain with the proliferation, migration, and differentiation of neuro-progenitor cells. This is underpinned by the widespread expression of transferrin receptors in the developing brain, which, in later life, is restricted to cells of the blood–brain and blood–cerebrospinal fluid barriers and neuronal cells, hence ensuring a sustained iron supply to the brain, even in the fully developed brain. In embryonic human life, iron deficiency is thought to result in a lower brain weight, with the impaired formation of myelin. Studies of fully developed infants that have experienced iron deficiency during development reveal the chronic and irreversible impairment of cognitive, memory, and motor skills, indicating widespread effects on the human brain. This review highlights the major findings of recent decades on the effects of gestational and lactational iron deficiency on the developing human brain. The findings are correlated to findings of experimental animals ranging from rodents to domestic pigs and non-human primates. The results point towards significant effects of iron deficiency on the developing brain. Evidence would be stronger with more studies addressing the human brain in real-time and the development of blood biomarkers of cerebral disturbance in iron deficiency. Cerebral iron deficiency is expected to be curable with iron substitution therapy, as the brain, privileged by the cerebral vascular transferrin receptor expression, is expected to facilitate iron extraction from the circulation and enable transport further into the brain.

Anemia epidemiology, pathophysiology, and etiology in low- and middle-income countries

Anemia affects a third of the world's population and contributes to increased morbidity and mortality, decreased work productivity, and impaired neurological development. Understanding anemia's varied and complex etiology is crucial for developing effective interventions that address the context-specific causes of anemia and for monitoring anemia control programs. We outline definitions and classifications of anemia, describe the biological mechanisms through which anemia develops, and review the variety of conditions that contribute to anemia development. We emphasize the risk factors most prevalent in low- and middle-income countries, including nutritional deficiencies, infection/inflammation, and genetic hemoglobin disorders. Recent work has furthered our understanding of anemia's complex etiology, including the proportion of anemia caused by iron deficiency (ID) and the role of inflammation and infection. Accumulating evidence indicates that the proportion of anemia due to ID differs by population group, geographical setting, infectious disease burden, and the prevalence of other anemia causes. Further research is needed to explore the role of additional nutritional deficiencies, the contribution of infectious and chronic disease, as well as the importance of genetic hemoglobin disorders in certain populations.

Data needed to respond appropriately to anemia when it is a public health problem

Although the proportion of anemia amenable to change varies by population, the World Health Organization (WHO) criteria used to describe the public health severity of anemia are based on population prevalences. We describe the importance of measuring iron and other etiologic indicators to better understand what proportion of anemia could be responsive to interventions. We discuss the necessity of measuring inflammation to interpret iron biomarkers and documenting anemia of inflammation. Finally, we suggest assessing nonmodifiable genetic blood disorders associated with anemia. Using aggregated results from the Global Burden of Disease 2016, we compare population prevalence of anemia with years lived with disability (YLD) estimates, and the relative contributions of mild, moderate, and severe anemia to YLD. Anemia prevalences correlated with YLD and the relative proportion of moderate or severe anemia increased with anemia prevalence. However, individual-level survey data revealed irregular patterns between anemia prevalence, the prevalence of moderate or severe anemia, and the prevalence of iron deficiency anemia (IDA). We conclude that although the WHO population prevalence criteria used to describe the public health severity of anemia are important for policymaking, etiologic-specific metrics that take into account IDA and other causes will be necessary for effective anemia control policies.

Hepcidin as a diagnostic biomarker of iron deficiency anemia during pregnancy

OBJECTIVES

Hepcidin hormone production is suppressed in the case of iron deficiency. The role of hepcidin as a hormone in iron metabolism along with its diagnostic cut-off values and its sensitivity and specificity among pregnant women with iron deficiency anemia (IDA) was examined in this study.

METHODS

In this case-control study, three groups of pregnant subjects were included according to the following criteria: cases/patient group: pregnant women with IDA based on, Hb < 11.5 g/dl, S ferritin < 10 ng/ml, TS%<15%; positive control group: pregnant women with non-IDA based on, Hb < 11.5 g/dl, S ferritin > 10 ng/ml, TS%>15%; and negative control group: included non-anemic apparently healthy pregnant women based on, Hb > 11.5 g/dl, S ferritin > 10 ng/ml, TS%>15%.

RESULTS

The serum hepcidin was significantly lower in pregnant women with IDA (0.34 ng/ml) compared to its level in pregnant women with non-IDA (23.48 ng/l) and apparently healthy pregnant women (13.86 ng/ml; p<.001). The study found a significant correlation between serum hepcidin and iron deficiency-related parameters with adjustment for study groups (p<.01). Moreover, the study found that serum hepcidin has good sensitivity in the range of 0.49-0.76 ng/ml (80.6-83.3%) and good specificity (76.2%) over positive IDA. Similar results were found for serum hepcidin over negative control group (0.49-0.83 ng/ml; sensitivity: 80.6-83.3%; specificity: 75.8-78.8%).

CONCLUSIONS

This study suggests that serum hepcidin is superior to hemoglobin, serum iron, serum ferritin, TS, and TIBC as an indicator of IDA in pregnant women.

STUDY REGISTER

24012018-1 on 24 January 2018.

Salivary Cystatin SN Binds to Phytic Acid In Vitro and Is a Predictor of Nonheme Iron Bioavailability with Phytic Acid Supplementation in a Proof of Concept Pilot Study

BACKGROUND

Acute phytic acid intake has been found to decrease iron bioavailability; however, repeated phytic acid consumption leads to iron absorption adaptation. Salivary proline-rich proteins (PRPs) have been shown to inhibit iron chelation to tannins and may mediate similar iron absorption adaptation with phytic acid intake.

OBJECTIVES

The objectives of this study were to determine whether salivary proteins bind to phytic acid in vitro, and to explore a proof of concept in a pilot study that examined the impact of 4-wk, daily phytic acid supplementation on individuals' iron status, bioavailability, and salivary PRP concentrations.

METHODS

High-performance liquid chromatography (HPLC) and matrix-assisted laser desorption/ionization-time of flight were used to characterize in vitro salivary protein-phytic acid interactions. Nonanemic women (n = 7) consumed 350 mg phytic acid supplements 3 times daily for 4 wk, and meal challenges were employed to determine iron bioavailability, iron status, and salivary protein concentrations before and after supplementation periods. Enzyme-linked immunosorbent assay (ELISA) analysis of purified protein fractions and participant saliva identified proteins bound to phytic acid.

RESULTS

In vitro salivary protein-phytic acid interaction identified cystatin SN, a non-proline rich salivary protein, as the specific bound protein to phytic acid. Iron bioavailability (P = 0.32), hemoglobin (P = 0.72), and serum ferritin (P = 0.08) concentrations were not reduced from week 0 to week 4 after phytic acid supplementation. Basic PRPs and cystatin SN concentrations were positively correlated with iron bioavailability at week 4.

CONCLUSIONS

Overall, results suggest that phytic acid binds to the non-PRP cystatin SN and that salivary protein production may improve iron bioavailability with phytic acid consumption.

Investigation of Nicotianamine and 2' Deoxymugineic Acid as Enhancers of Iron Bioavailability in Caco-2 Cells

Nicotianamine (NA) is a low-molecular weight metal chelator in plants with high affinity for ferrous iron (Fe2+) and other divalent metal cations. In graminaceous plant species, NA serves as the biosynthetic precursor to 2' deoxymugineic acid (DMA), a root-secreted mugineic acid family phytosiderophore that chelates ferric iron (Fe3+) in the rhizosphere for subsequent uptake by the plant. Previous studies have flagged NA and/or DMA as enhancers of Fe bioavailability in cereal grain although the extent of this promotion has not been quantified. In this study, we utilized the Caco-2 cell system to compare NA and DMA to two known enhancers of Fe bioavailability-epicatechin (Epi) and ascorbic acid (AsA)-and found that both NA and DMA are stronger enhancers of Fe bioavailability than Epi, and NA is a stronger enhancer of Fe bioavailability than AsA. Furthermore, NA reversed Fe uptake inhibition by Myricetin (Myr) more than Epi, highlighting NA as an important target for biofortification strategies aimed at improving Fe bioavailability in staple plant foods.

Preventing complications by persistence with iron replacement therapy: a comprehensive literature review

OBJECTIVE

Iron deficiency and particularly iron deficiency anemia (IDA) can lead to negative health consequences. This review describes the importance of adherence and persistence (adhering to treatment for the recommended duration) with iron replacement therapy in the prevention of complications, particularly regarding its recommended dosing schedule.

METHODS

Comprehensive literature searches were performed of Medline and the Cochrane library from 2000 to 2018. Keywords included iron deficiency or IDA, compliance or adherence, persistence, health beliefs, risk factor, complications, dosing cycles, oral iron replacement therapy and recommendations for duration, ferrous compounds, iron supplementation, dietary iron, and delayed-action/slow-release preparations.

RESULTS

Identified articles focused on IDA as a risk factor (particularly for worsened comorbidities or surgical outcomes), guidelines, adherence and persistence, and differences between iron formulations. Current guidelines and expert opinion continue to support oral iron supplementation as first-line therapy. While it is recommended to take iron therapy for 2 months to normalize hemoglobin, then 2-3 months to build up iron stores, many patients face difficulties in adhering to and persisting with the full iron treatment regimen. Patient education and understanding, social support, simple dosing, perceived efficacy including reduced symptoms and tolerability were factors noted to promote medication adherence and persistence. Adherence to iron therapies appears to be facilitated by using ferrous sulfate due to its optimal absorption, and particularly extended-release forms due to their improved tolerability for iron deficiency.

CONCLUSIONS

Proper adherence and persistence with iron supplementation may prevent or reduce the risk of complications of iron deficiency and IDA.

Efficacy of a Novel Food Supplement (Ferfer®) Containing Microencapsulated Iron in Liposomal Form in Female Iron Deficiency Anemia

Introduction

Iron deficiency anemia (IDA) is a highly afflicting condition which affects young children of growing age and reproductive age women in countries of lower economies. Conventional oral iron salts have poor absorption and gastrointestinal side effects. Microencapsulated liposomal iron pyrophosphate is a novel compound with enhanced palatability, higher bioavailability, and consequently increased adherence among people with IDA. This study aims to assess the efficacy of microencapsulated iron pyrophosphate sachets in non-pregnant women with IDA.

Methods

It was a 12-week long, open label clinical trial conducted with 558 IDA women. Participants were advised one sachet of microencapsulated liposomal iron pyrophosphate (Ferfer®) twice daily. At baseline, and every four-week interval, serum hemoglobin levels and taste tolerability were assessed. Data was entered and analyzed using SPSS v. 24 (IBM Corp, Armonk, NY, USA).

Results

Four hundred and thirty-seven women completed the trial. The mean serum Hb level at baseline was 8.71 ± 2.24 which increased to 10.47 ± 1.69 by the end of 12 weeks (p < 0.001).

Conclusion

Treatment of IDA with microencapsulated liposomal iron pyrophosphate sachets significantly increases serum hemoglobin levels in non-pregnant women of reproductive age.

Recognizing the unusual findings: Cases of desiderosmia

Iron deficiency anemia may cause a desire to smell. This has not been well defined by clinicians. In the cases we present, we have shown that there may be a desire to smell in iron deficiency anemia. We wanted to attract the attention of clinicians.

Prevalence of iron deficiency anemia in Iranian children under 6 years of age: a systematic review and meta-analysis

Background: Iron deficiency anemia is a prevalent condition among children in developing and developed countries that leads to impaired development, activity intolerance, behavioral changes, irritability, and reduced learning ability. The studies conducted in Iran have reported different prevalence rates for this condition. This systematic review and meta-analysis were aimed at estimating the prevalence of iron deficiency anemia in Iranian children under 6 years of age.

Methodology: Persian and English articles published from 2001 to 2018 were collected. The search process was conducted in national and internationals databases, including SID, MagIran, PubMed, Scopus, and Web of Science, using the following keywords and their combinations: Iron, Iron deficiency, Iron deficiency anemia, Ferritin, Child, Children, and Iran. The data were analyzed using the meta-analysis and random effects model. Heterogeneity was assessed using the I² statistic. All analyses were performed using the STATA software, version 12.

Results: Analysis of six selected articles with a total sample size of 1,700 showed that the prevalence rates of iron deficiency and iron deficiency anemia in the Iranian children under 6 years of age were 27.7% (95% CI: 11.9–43.5) and 18.2% (95% CI: 14.3–22), respectively. In addition, the prevalence of iron deficiency anemia was higher in boys (17.7% with 95% CI: 5.9–29.5) than in girls (14.4% with 95% CI: 4.5–24.2).

Conclusion: About one-fifth of Iranian children under the age of 6 years suffer from iron deficiency anemia. Identification of those at risk of developing this condition with the goal of prevention, diagnosis, and treatment seems to be an important and necessary task.

Feralgine™ a New Approach for Iron Deficiency Anemia in Celiac Patients

Background: Celiac disease (CD) is an immunologically-mediated disorder characterized by duodenal mucosa villi atrophy. Iron absorption is usually reduced in celiac patients making every kind of oral iron treatment unhelpful because of malasorption. Feralgine™ is a new product that has been demonstrated to be more bioavailable. As such, the aim of our study was to evaluate the absorption of Feralgine™ in adult patients with CD. Methods: Twenty-six adults affected by Iron Deficiency Anemia (IDA), of which 14 were also affected by CD and 12 were not affected by CD, were enrolled. An oral iron absorption test (OIAT) was performed in each patient by administrating Feralgine™, and serum iron was evaluated at baseline (T0) and after 2 h (T1) from the oral iron ingestion. Results: The OIAT was well tolerated in all patients, and, surprisingly, an equivalent statistically significant improvement in serum iron occurred in the two groups of patients (IDA plus CD: T0 = 28.21 µg/dL vs. T1 = 94.14 µg/dL p = 0.004 and IDA without CD: T0 = 34.91 µg/dL vs. T1 = 118.83 µg/dL, p = 0.0003). Conclusions: These results demonstrated the high absorption of Feralgine™ in celiac patients, confirming our previous data obtained with Ferrous Bysglicinate in children with CD.

The effect of therapy on plasma ghrelin and leptin levels, and appetite in children with iron deficiency anemia

Background It is known that iron deficiency anemia effects appetite and growth negatively. The aim of this study was to investigate the effect of iron therapy on appetite, growth and plasma ghrelin and leptin levels in children aged between 12 and 24 months with isolated nutritional iron deficiency anemia. Methods Iron deficiency anemia was diagnosed by clinic and laboratory findings. All 19 cases were given 5 mg/kg/day iron therapy for 3 months. Results The mean plasma ghrelin level was 936.7±428.8 pg/mL before therapy and it increased to 1284.7±533.3 pg/mL (p<0.001) while the mean plasma leptin level decreased from 3.4±1.6 ng/mL to 1.9±1.0 ng/mL (p<0.01) after therapy. The amount of daily caloric intake, carbohydrate and protein intake were significantly increased after therapy (p<0.001). Δ body weight was correlated with plasma ghrelin levels before and after therapy significantly. Conclusions In conclusion, the findings of this study indicate that plasma ghrelin level increases and leptin level decreases and growth accelerates because of an increase in appetite and daily calories, carbohydrate and protein amount in children with nutritional iron deficiency anemia after iron therapy. The increase in appetite and acceleration on growth in iron deficiency anemia might result from decreased leptin and increased plasma ghrelin levels. The most important finding of this study is significantly increased plasma ghrelin levels after iron therapy, and this finding might be related to both the improved appetite and catch-up growth.

Fe3O4@ Astragalus Polysaccharide Core-Shell Nanoparticles for Iron Deficiency Anemia Therapy and Magnetic Resonance Imaging in Vivo

Iron deficiency anemia (IDA) is a common nutritional disease suffered by 1 billion people. To develop a new drug which avoids the side effects of traditional oral iron supplementation for IDA treatment, we have designed Fe₃O₄@ Astragalus polysaccharide core-shell nanoparticles (Fe₃O₄@APS NPs) and demonstrated them to be an efficient therapeutic drug for IDA treatment in vivo. The Fe₃O₄@APS NPs have been successfully synthesized with good water solubility and stability, especially in imitated digestion. Cytotoxicity assessment in cells and pathological tests in mice justify their good biocompatibility and low toxicity. The IDA treatment in rats shows that they have efficient therapeutic effect, which is contributed to both the iron element supplement from Fe₃O₄ and the APS-stimulated hematopoietic cell generation. Moreover, the superparamagnetic Fe₃O₄@APS NPs are capable for use as a magnetic resonance imaging contrast agent. This study presents the possibility of nanocomposites involving purified natural products from Chinese herb medicine for biomedical applications.

Reticulocyte hemoglobin equivalent in a thalassemia-prevalent area

BACKGROUND

Reticulocyte hemoglobin equivalent (Ret-He), a direct measure of the hemoglobin (Hb) in the young red blood cells, has been reported to be useful in the diagnosis of iron deficiency anemia (IDA) but may have some limitations in thalassemia trait. This study evaluated the differences in Ret-He in school-aged children, and assessed the diagnostic value of Ret-He in identifying IDA in a thalassemia-prevalent area.

METHODS

Blood samples underwent complete blood count analysis, including Ret-He, ferritin, serum iron and total iron binding capacity. Blood samples also underwent Hb typing and a molecular study for α-thalassemia. Receiver operating characteristic analysis was performed to determine the predictive capacity of Ret-He in the diagnosis of IDA. ID was defined as serum ferritin <30 ng/mL and/or transferrin saturation (TSAT) <16%; IDA was defined as serum ferritin <12 ng/mL and/or TSAT <16% with low Hb for age. Normal healthy children (normal controls: NC) had normal iron study, without the thalassemia trait.

RESULTS

Ninety-eight children with a mean age of 12.9 ± 0.6 years were included. Ret-He in the thalassemia trait group (26.7 ± 2.4 pg), ID group (29.0 ± 2.9 pg), IDA group (25.4 ± 2.7 pg), ID + thalassemia trait group (26.6 ± 2.8 pg), and the IDA + thalassemia trait group (24.6 ± 2.3 pg) was significantly lower than in the NC group (30.8 ± 1.7 pg; P < 0.001, 0.01, 0.006, 0.002 and <0.001, respectively). Ret-He had an area under the curve of 0.904 in diagnostic ability for IDA, while a cut-off ≤27 pg had a sensitivity of 91.7% and a specificity of 81%.

CONCLUSION

Ret-He was lowest in subjects with IDA + thalassemia trait. A Ret-He cut-off ≤27 pg was suggestive of IDA in the present study.

Guts, Germs, and Iron: A Systematic Review on Iron Supplementation, Iron Fortification, and Diarrhea in Children Aged 4-59 Months

BACKGROUND

The impact of iron supplements and iron fortification on diarrhea in children is controversial, with some studies reporting an increase and others reporting no effect.

OBJECTIVE

The aim of the study was systematically assess the published literature on oral iron supplementation and fortification to evaluate its impact on diarrhea incidence among children aged 4-59 mo.

METHODS

Randomized controlled trials of oral iron supplementation or iron fortification that reported diarrheal outcomes in children aged 4-59 mo were identified from a systematic search of 5 databases.

RESULTS

Of the 906 records identified, 19 studies were found to fit the inclusion criteria for this systematic review. However, variable case definitions for diarrhea made meta-analysis impossible. Of the 19 studies, 7 (37%) studies showed a significant increase, either in overall diarrhea incidence or within a specific subgroup of the population, between iron-supplemented and control groups. Subgroups included children who were iron-replete and children undergoing their first month of iron intervention. Two studies reported an increase in bloody diarrhea. The remaining 12 (63%) studies showed no difference between iron-supplemented and control groups.

CONCLUSIONS

Studies on iron supplementation and fortification use divergent case definitions for diarrhea. A number of studies (37%) showed an increase in overall diarrhea incidence or within a specific subgroup of the population, between iron-supplemented and control groups, but the majority (63%) did not. In addition, there was no clear relation between diarrhea and type of intervention or amount of iron administered observed. In future studies, we recommend that diarrhea be clearly defined and consistently recorded as a secondary outcome. Antibiotic status of participants receiving iron should also be collected to help assess possible drug interactions resulting in a "red stool effect." Finally, further microbiome research is required to better understand the effects of oral iron on specific bacterial species in the colon.

Ethnic prevalence of anemia and predictors of anemia among chronic kidney disease patients at a tertiary hospital in Johannesburg, South Africa

INTRODUCTION

Anemia is a complication of chronic kidney disease (CKD) that can greatly impact on its prognosis. However, the risk factors for anemia, including the influence of ethnicity, are not well established among the CKD population in Johannesburg.

METHODS

This was a cross-sectional study of 353 adult CKD patients attending the renal outpatient clinic of the Charlotte Maxeke Johannesburg Academic Hospital (Johannesburg, South Africa) from June 1, 2016 to December 30, 2016. Sociodemographic and clinical characteristics were obtained using a proforma. Blood samples were collected for serum electrolytes and hematological parameters. Predictors of low hemoglobin and iron deficiency anemia (IDA) were evaluated using multivariable binary logistic regression.

RESULTS

The mean age and prevalence of anemia among the CKD participants were 55.3±15.0 years and 43.18% (95% CI: 38.1%-48.4%), respectively. Blacks had the highest prevalence of anemia (46.9%), while Indians/Asians had the lowest (18.2%). Although the odds of anemia was 3.8-fold higher (odds ratio =3.8, P-value =0.059) among CKD stage V participants as compared to CKD stage I, the relationship between anemia and stages of CKD was non-linear. Diabetes mellitus (odds ratio =2.31, P-value =0.005) had a strong association with anemia among the CKD participants.

CONCLUSION

Almost half of the CKD participants were anemic, and the odds of anemia did not increase linearly with increasing severity of CKD. There was a marked ethnic disparity in anemia prevalence. Our study highlights the need for risk-based management of anemia among CKD patients.

Iron Deficiency Anemia Due to High-dose Turmeric

Turmeric is increasingly studied as an anti-inflammatory and anti-neoplastic agent. It binds to ferric iron in the gut and causes iron deficiency in mice. We report here a possible case of iron deficiency anemia in a human taking turmeric.

A 66-year-old physician treated himself for an osteoarthritis flare after steroids with six turmeric extract capsules (538 mg) daily, to help with inflammation. During this time, his hemoglobin never rose above 12 and his iron and ferritin levels were consistent with iron deficiency. Upper and lower endoscopy and Hemoccult™ studies were negative. Two weeks after stopping the turmeric and continuing his usual iron supplement, his hemoglobin had returned to normal, with normalizing iron studies. Turmeric was associated with significant iron deficiency anemia, consistent with the binding of available iron in the gut and the prevention of absorption. This resolved after the turmeric was stopped, consistent with animal studies.

This may be the first case of documented iron deficiency anemia in people due to turmeric supplements. Given the widespread use of turmeric and curcumin supplements across many illnesses, further attention is warranted.

Association of Zinc Deficiency with Iron Deficiency Anemia and its Symptoms: Results from a Case-control Study

Iron deficiency anemia (IDA) is the most common type of anemia. Impaired iron absorption can be caused by a decrease in trace elements as zinc, which is found in the structure of enzymes that coordinate or catalyst iron metabolism. The aim of this study is to detect if zinc deficiency is associated with IDA and to determine the effect of associated zinc deficiency on symptoms of IDA in adult IDA patients. This case-control study included 30 IDA patients with matched healthy control group (n = 30) for age and sex. For each subject, the parameters were evaluated: hemoglobin (Hb); mean corpuscular volume (MCV), total iron binding capacity (TIBC), serum iron, serum ferritin (SF). Serum zinc levels were measured by atomic absorption method with the PerkinElmer Analyst. Symptoms attributed to iron deficiency or depletion, defined as fatigue, cardiopulmonary symptoms, mental manifestations, epithelial manifestations, and neuromuscular symptoms were recorded. Serum zinc levels were lower in IDA patients (43.4 ± 7.9 mg/dL) than in the control subjects (94.7 ± 16.75 mg/dL; p < 0.0001). Zinc deficiency was associated with worse cardiovascular symptoms (p = 0.04), epithelial symptoms (p = 0.027), and restless leg syndrome (p < 0.001) in patients with IDA. Measurement of zinc levels should be considered for IDA patients. With the help of our study, iron and zinc supplementation instead of only iron replacement may be considered in cases of iron deficiency particularly, in patients with severe epithelial dysfunctions. Further studies are still needed to evaluate the benefit of zinc and iron supplementation in IDA patients.

Clinical characteristics and prognosis of idiopathic pulmonary hemosiderosis in pediatric patients

OBJECTIVE

This study aimed to analyze the clinical characteristics and prognosis of pediatric idiopathic pulmonary hemosiderosis (IPH).

METHODS

Pediatric IPH cases that were diagnosed at West China Second University Hospital, Sichuan University between 1996 and 2017 were reviewed. Follow-up data from 34 patients were collected.

RESULTS

A total of 107 patients were included (42 boys and 65 girls). The median age was 6 years at diagnosis. The main manifestations of the patients were as follows: anemia (n = 100, 93.45%), cough (n = 68, 63.55%), hemoptysis (n = 61, 57%), fever (n = 23, 21.5%), and dyspnea (n = 23, 21.5%). There were relatively few pulmonary signs. The positive rates of hemosiderin-laden macrophages in sputum, gastric lavage fluid, and bronchoalveolar lavage fluid were 91.66%, 98.21%, and 100%, respectively. Seventy-nine patients were misdiagnosed. A total of 105 patients were initially treated with glucocorticoids, among whom 102 survived and three died. Among the followed up patients, two died and 32 survived, among whom 10 presented with recurrent episodes.

CONCLUSIONS

The classic triad of pediatric IPH is not always present. The rates of misdiagnosis and recurrence of IPH are high. Early recognition and adequate immunosuppressive therapy are imperative for improving prognosis of IPH.

Breath-Holding Spells in Pediatrics: A Narrative Review of the Current Evidence

BACKGROUND

Breath-holding spells are common, frightening, but fortunately benign events. Familiarity with this condition is important so that an accurate diagnosis can be made.

OBJECTIVE

To familiarize physicians with the clinical manifestations, diagnosis, evaluation, and management of children with breath-holding spells.

METHODS

A PubMed search was completed in Clinical Queries using the key term "breath-holding spells". The search strategy included meta-analyses, randomized controlled trials, clinical trials, observational studies, and reviews. Only papers published in the English literature were included in this review. The information retrieved from the above search was used in the compilation of the present article.

RESULTS

Breath-holding spells affect 0.1 to 4.6% of otherwise healthy young children. The onset is usually between 6 and 18 months of age. The etiopathogenesis is likely multifactorial and includes autonomic nervous system dysregulation, vagally-mediated cardiac inhibition, delayed myelination of the brain stem, and iron deficiency anemia. Breath-holding spells may be cyanotic or pallid. The former are usually precipitated by anger or frustration while the latter are more often precipitated by pain or fear. In the cyanotic type, the child usually emits a short, loud cry, which leads to a sudden involuntary holding of the breath in forced expiration. The child becomes cyanosed, rigid or limp, followed by a transient loss of consciousness, and a long-awaited inspiration and resolution of the spell. In the pallid type, crying may be minimal or "silent". The apneic period in the pallid type is briefer than that in the cyanotic type prior to the loss of consciousness and posture. The episode in the pallid type then proceeds in the same manner as a cyanotic spell except that the child in the pallid type develops pallor rather than cyanosis. In both types, the entire episode lasts approximately 10 to 60 seconds. The spells usually disappear spontaneously by 5 years of age.

CONCLUSION

Although breath-holding spells are benign, they can be quite distressing to the parents. Confident reassurance and frank explanation are the cornerstones of treatment. Underlying cause, if present, should be treated. Interventions beyond iron supplementation may be considered for children with severe and frequent breath-holding spells which have a strong impact on the lifestyle of both the child and family.

Corrigendum: Prevalence of Anemia and Its Associated Risk Factors Among 6-Months-Old Infants in Beijing

[This corrects the article DOI: 10.3389/fped.2019.00286.].

Prevalence of Anemia and Its Associated Risk Factors Among 6-Months-Old Infants in Beijing

Objective: The worldwide prevalence of anemia is ~24.8%. Iron deficiency anemia is common in children and women and associated with sensory, motor, cognitive, language, and socioemotional deficits. Therefore, detection and early intervention strategies for anemia in infants are urgently needed. To prevent the occurrence of iron deficiency anemia, we aimed to identify risk factors associated with anemia in infants. Methods: This investigation involved a cross-sectional study of 6-months-old infants discharged between April 2014 and September 2017 from Peking University First Hospital. We assessed birth information, maternal age, and maternal educational level as well as data on feeding style, complementary foods and primary caregivers. The infants were assessed with the Denver Developmental Screening Test (DDST). Results: A total of 1,127 6-months-old infants were enrolled at the hospital. We found that the prevalence of anemia among infants in Beijing was ~11.8%. Premature infants had a higher rate of anemia than full-term infants (χ² = 40.103, P < 0.001). Infants born in autumn or winter were at an elevated risk of developing anemia (χ² = 22.949, P < 0.001). Birth weight had no effect on the rate of anemia in infants (χ² = 0.023, P = 0.568). Infants who were exclusively breastfeeding had higher anemia rates than those who were fed formula (χ² = 38.466, P < 0.001). Infants whose caregivers added no complementary foods had higher anemia rates (24.7%) than those whose caregivers added more than two kinds of complementary food (8.2%). The type of caregiver had no effect on the anemia rate in infants (χ² = 0.031, P = 1.000). Conclusions: The following factors resulted in a higher prevalence of anemia in our study a gestational age at birth of <37 weeks, exclusive breastfeeding, a lack of supplementation with complementary foods and a spring birth date. No significant differences in DDST pass rates were evident between infants with and without anemia.

Recognizing missed opportunities to diagnose and treat iron deficiency anemia: A study based on prevalence of anemia among children in a teaching hospital

Background

In developing world, anemia is a significant cause of mortality and morbidity in children under 5 years of age. Iron deficiency anemia (IDA) is a very important causative factor for childhood anemia. The aim of this study was to find the prevalence of anemia in different age group, sex, and its pattern of severity in hospitalized children.

Materials and Methods

A cross-sectional study was carried out in a teaching hospital in Kolkata between April 2016 and September 2016. Children 1-168 months of age were included in the study.

Results

Of 697 children, 296 (42.5%) had anemia as per the World Health Organization criteria. Males outnumbered the females with a ratio of 1.6:1. The median age of presentation was 29.6 months. The majority were from 1-5 years of age. About 73.3% of children had moderate anemia, whereas 21.3% had severe anemia and only 5% had mild anemia. The mean hemoglobin, mean mean corpuscular volume, mean mean corpuscular hemoglobin concentration, and mean red cell distribution width were 9.3 ± 1.4 g/dL, 73.6 ± 8.8 (fL), 32.2 ± 2.6, and 16.3 ± 3.4 (%), respectively. Microcytic hypochromic anemia (71.3%) was the most common morphological type in all age groups, whereas macrocytic anemia was the least common among them. Prevalence of IDA was 69%. IDA was documented in close to 80% of children with microcytic hypochromic anemia. Interestingly, IDA was also documented in almost half of the children with normocytic normochromic anemia.

Conclusion

The high prevalence of IDA among these hospitalized children indicates the role of early screening for IDA in all children with anemia. This early diagnosis and prompt management can prevent the mortality and morbidity related to IDA.

Iron Treatment May Be Difficult in Inflammatory Diseases: Inflammatory Bowel Disease as a Paradigm

Iron plays a key role in many physiological processes; cells need a very exact quantity of iron. In patients with inflammatory bowel disease, anaemia is a unique example of multifactorial origins, frequently being the result of a combination of iron deficiency and anaemia of chronic disease. The main cause of iron deficiency is the activity of the disease. Therefore, the first aim should be to reach complete clinical remission. The iron supplementation route should be determined according to symptoms, severity of anaemia and taking into account comorbidities and individual risks. Oral iron can only be used in patients with mild anaemia, whose disease is inactive and who have not been previously intolerant to oral iron. Intravenous iron should be the first line treatment in patients with moderate-severe anaemia, in patients with active disease, in patients with poor tolerance to oral iron and when erythropoietin agents or a fast response is needed. Erythropoietin is used in a few patients with anaemia to overcome functional iron deficiency, and blood transfusion is being restricted to refractory cases or acute life-threatening situations.

Iron deficiency anemia-related gut microbiota dysbiosis in infants and young children: A pilot study

Nutritional iron deficiency (ID) causes not only anemia but also malfunction of the entire human organism. Recently, a role of the gut microbiota has been hypothesized, but limited data are available especially in infants. Here, we performed a pilot study to explore the gut microbiota in 10 patients with iron deficiency anemia (IDA) and 10 healthy controls aged 6-34 months. Fresh stool samples were collected from diapers, and the fecal microbiota was profiled by next-generation sequencing of the V3-V4 hypervariable region of the 16S rRNA gene. Except for diet diversity, the breastfeeding status at the enrollment, the exclusive breastfeeding duration, and the introduction of complementary foods did not differ between groups. Distinct microbial signatures were found in IDA patients, with increased relative abundance of Enterobacteriaceae (mean relative abundance, patients vs. controls, 4.4% vs. 3.0%) and Veillonellaceae (13.7% vs. 3.6%), and reduced abundance of Coriobacteriaceae (3.5% vs. 8.8%) compared to healthy controls. A decreased Bifidobacteriaceae/Enterobacteriaceae ratio was observed in IDA patients. Notwithstanding the low sample size, our data highlight microbiota dysbalance in IDA worth for further investigations, aimed at unraveling the ID impact on the microbiome trajectory in early life, and the possible long-term consequences.

Current practice of iron prophylaxis in preterm and low birth weight neonates: A survey among Italian Neonatal Units

BACKGROUND

Preterm babies are at high risk of iron deficiency.

METHODS

We investigated current practices regarding iron prophylaxis in preterm and low birth weight newborns among Local Neonatal Units (LNUs, n = 74) and Neonatal Intensive Care Units (NICUs, n = 20) of three Italian Regions (Piemonte, Marche and Lazio).

RESULTS

Birth weight is considered an indicative parameter in only 64% of LNUs and 71% of NICUs, with a significant difference between LNUs in the three regions (86%, 20% and 62%, respectively; p < 0.001). Iron is recommended to infants with a birth weight between 2000 and 2500 g in only 25% of LNUs and 21% of NICUs, and to late-preterm (gestational age between 34 and 37 weeks) in a minority of Units (26% of LNUs, 7% of NICUs).

CONCLUSIONS

Our pilot survey documents a great variability and the urgent need to standardize practices according to literature recommendations.

Iron Supplementation in Suckling Piglets: An Ostensibly Easy Therapy of Neonatal Iron Deficiency Anemia

In pigs, iron deficiency anemia (IDA) is the most prevalent deficiency disorder during the early postnatal period, frequently developing into a serious illness. On the other hand, in humans, only low-birth-weight infants, including premature infants, are especially susceptible to developing IDA. In both human and pig neonates, the initial cause of IDA is low birth iron stores. In piglets this shortage of stored iron results mainly from genetic selection over the past few decades for large litter sizes and high birth weights. As a consequence, pregnant sows cannot provide a sufficient amount of iron to the increasing number of developing fetuses. Supplementation with iron is a common practice for the treatment of IDA in piglets. For decades, the preferred procedure for delivering iron supplements during early life stages has been through the intramuscular injection of a large amount of iron dextran. However, this relatively simple therapy, which in general, efficiently corrects IDA, may generate toxic effects, and by inducing hepcidin expression, may decrease bioavailability of supplemental iron. New iron supplements are considered herein with the aim to combine the improvement of hematological status, blunting of hepcidin expression, and minimizing the toxicity of the administered iron. We propose that iron-deficient piglets constitute a convenient animal model for performing pre-clinical studies with iron supplements.

A Randomized, Placebo-Controlled, Pilot Clinical Trial to Evaluate the Effect of Supplementation with Prebiotic Synergy 1 on Iron Homeostasis in Children and Adolescents with Celiac Disease Treated with a Gluten-Free Diet

Iron deficiency anemia (IDA) occurs in 15–46% of patients with celiac disease (CD), and in some cases, it may be its only manifestation. Studies in animal models have shown that prebiotics, including inulin, may help to increase intestinal absorption of iron. The aim of this study was to evaluate the effect of a prebiotic, oligofructose-enriched inulin (Synergy 1), on iron homeostasis in non-anemic children and adolescents with celiac disease (CD) in association with a gluten-free diet (GFD). Thirty-four CD patients (4–18 years old) were randomized into two groups receiving Synergy 1 (10 g/day) or a placebo (maltodextrin) for three months. Before and after intervention, blood samples were collected from all patients for assessment of blood morphology, biochemical parameters and serum hepcidin concentration. We found that serum hepcidin concentration after the intervention was significantly decreased by 60.9% (p = 0.046) in the Synergy 1 group, whereas no significant difference was observed in the placebo group. No differences in morphological and biochemical blood parameters (including ferritin, hemoglobin and C-reactive protein (CRP)) were observed after intervention in either group. Given that hepcidin decrease may improve intestinal iron absorption, these results warrant further investigation in a larger cohort and especially in patients with IDA.

A Social Ecological Approach to Develop a Nutrition Education Program for Preventing Iron Deficiency Anemia in Young Children in Rural Pakistan

Inappropriate feeding practices puts infants and young children at risk of iron deficiency anemia. Maternal complementary feeding (CF) behavior is determined by influences at various levels, including knowledge and attitude about feeding, inter-personal interaction with family/friends, community norms and support. The aim of this study is to understand the various influences on maternal CF behavior in order to develop a culturally appropriate nutrition education program to improve iron status of children aged 9-24 months. Using a social ecological approach, in-depth interviews with stakeholders revealed restraining factors that prevented behavior change. Culturally appropriate nutrition education messages were developed to address these constraints.

Auditory brainstem response in full-term neonates born to mothers with iron deficiency anemia: relation to disease severity

Background: Iron is crucial for fetal brain development; however, there are insufficient data regarding the effects of maternal iron deficiency anemia (IDA) on auditory neural maturation.Aim: We evaluated the effect of maternal IDA on auditory brainstem response (ABR) in full-term neonates.Methods: Out of 223 pregnant women, 50 were diagnosed as having IDA and 50 healthy mothers were enrolled as controls. ABR test was done for the studied neonates within 48 hours after birth and at 3 months.Results: We found that hemoglobin and iron profile were lower in neonates born to anemic mothers compared with controls. Of 100 neonates screened for ABR, 25 failed the test (all of them were born to anemic mothers). The majority of neonates who failed the screening ABR test (88%) had latent iron deficiency (cord blood ferritin 11-75 µg/L). After 3 months, 85 neonates underwent diagnostic ABR test which revealed significantly prolonged interpeak latencies I-III, III-V, and I-V among neonates born to IDA mothers compared with the control group. Within the IDA group, all interpeak latencies were more prolonged in neonates with latent iron deficiency and in those born to mothers with serum ferritin <15 µg/L. Logistic regression analysis showed that maternal hemoglobin and mean corpuscular volume could predict neonatal ABR results.Conclusions: IDA during late pregnancy adversely affects cord blood iron and hearing status. ABR results are closely related to the severity of maternal and neonatal iron status. Antenatal screening of pregnant mothers is needed to improve fetal iron status and prevent abnormal auditory maturation.

Associations between iron deficiency anemia and clinical features among pregnant women: a prospective cohort study

Background

Iron deficiency anemia (IDA) during pregnancy is a common and preventable disorder. It remains a contributing factor to maternal morbidity and mortality and is associated with high perinatal mortality rates.

Objective

To determine the prevalence of IDA and its associated clinical features among pregnant women.

Methods

This analytical prospective cohort study included 1,579 pregnant women who attended an antenatal clinic, Women’s Specialized Hospital, King Fahad Medical City, Riyadh, Saudi Arabia, between January 2018 and April 2018. The type of anemia and its associated maternal and fetal outcomes were determined.

Results

About 702 women were confirmed to have IDA, with a prevalence of 44.5 %. Most women (79.8%) were younger than 35 years. A low hemoglobin concentration was reported in 45 % of participants. The major type of anemia was microcytic hypochromic anemia (98.7%). More than half of the participants (57.3%) reported use of iron supplementation during pregnancy. IDA anemia was highest in pregnant women with gravidity >8 in 40 (56.3%) compared to normal pregnant women 31 (43.7%), and lowest in those with gravidity ≤2 in 281 (41.4%) compared to normal pregnant women 397 (58.6%). The difference was statistically significant, P=0.024. Similarly, this type of anemia was highest in those with parity of >3 (53.3%) and lowest in nulliparous women (39.3%) compared to normal pregnant women (46.7%) and (60.7%), respectively. This was statistically significant P=0.002. IDA had significantly (P=0.012) lower spontaneous vaginal delivery rates compared with normal pregnant women (44.5% vs 55.5%, respectively). IDA had significantly (P=0.017) lower antenatal fetal distress rates compared with normal pregnant women (68.5% vs 31.5%, respectively).

Conclusion

Anemia in general and microcytic hypochromic anemia in particular were significantly associated with higher gravidity and parity. The significant outcome associated with IDA during pregnancy was a lower rate of spontaneous vaginal delivery and antenatal fetal distress. Compliance with iron supplementation in order to prevent maternal and fetal adverse outcomes was observed.

Ferumoxytol for the treatment of iron deficiency anemia

INTRODUCTION

Ferumoxytol is a superparamagnetic molecule originally developed as a contrast agent for magnetic resonance imaging. Elemental iron is contained within the carbohydrate core and is released slowly after infusion allowing a large dose of iron to be administered in a short period of time. Ferumoxytol, originally approved for iron deficiency in chronic kidney disease, received a broad label for any cause of iron deficiency after oral iron intolerance or in those circumstances when oral iron is ineffective or harmful. Areas covered: The chemistry, pharmacology and pharmacokinetics of ferumoxytol were reviewed. Retrospective, observational, and prospective phase II and III trials were reviewed. When appropriate, comparative safety and efficacy parameters were reported. Differentiation between minor infusion reactions and more severe hypersensitivity reactions that may lead to anaphylaxis is described. Expert commentary: Ferumoxytol is a safe and effective iron formulation providing a means of iron repletion in persons with iron deficiency with or without anemia. Relative to iron sucrose, ferric gluconate, and iron dextran and similar to ferric carboxymaltose and iron isomaltoside, ferumoxytol yields relatively low quantities of labile free iron. Hypersensitivity and anaphylaxis is extremely rare. Hypophosphatemia with ferumoxytol's administration is extremely rare. Optimal strategies for application of ferumoxytol-enhanced imaging and full replacement dosing in a single setting remain to be determined.