Chẩn đoán điều trị thiếu máu thiếu sắt trẻ em 2019

CHẨN ĐOÁN VÀ ĐIỀU TRỊ
THIẾU MÁU THIẾU SẮT
Hội nghị Khoa học Nhi khoa Bệnh viện Nhi Đồng 1
TPHCM, 20-21/9/2019

TS BS Nguyễn Minh Tuấn
Bệnh viện Nhi Đồng 1
Khoa Y – Đại học Quốc gia TPHCM
Đơn vị Nghiên cứu Lâm sàng Đại học Oxford


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Definition of iron deficiency anemia
Epidemiology
Iron metabolism
Etiology
Diagnosis
Management


Contents
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Definition of iron deficiency anemia
Epidemiology
Iron metabolism
Etiology
Diagnosis
Management


ANEMIA
Defined as an insufficient RBC mass to adequately
deliver oxygen to peripheral tissues.
-- Wintrobes
Defined as a decrease in the amount of red blood cells
(RBCs) or the amount of hemoglobin in the blood. It
can also be defined as a lowered ability of the blood to
carry oxygen.
-- Wikipedia
Anemia is defined as a reduction of the total circulating
red cell mass below normal limits
-- Robbins


ANEMIA
Theo Tổ chức Y tế thế giới, gọi là thiếu máu khi lượng
hemoglobin (Hb) dưới giới hạn sau đây:
Hb bình thường

Thiếu máu

Trẻ sơ sinh (đủ tháng)

(g/dL)
13.5 – 18.5

(Hb ≤ giới hạn)
13.5 (Hct 34%)

Trẻ từ 2 – 6 tháng

9.5 – 13.5

9.5 (Hct 28%)

Trẻ từ 6 tháng đến 2 tuổi

10.5-13.5

10.5 (Hct 33%)

Trẻ từ 2 – 6 tuổi

11.0 – 14.4

11.0 (Hct 33%)

Trẻ từ 6 – 12 tuổi

11.5 – 15.5

11.5 (Hct 34%)

Nam trưởng thành

13.0 – 17.0

13.0 (Hct 39%)

Nữ trưởng thành (không mang
thai)

12.0 – 15.0

12.0 (Hct 36%)

Tuổi / giới tính


IRON DEFICIENCY ANEMIA
Anemia with biochemical evidence of iron
deficiency based on following laboratory findings:
• serum ferritin,
• total iron binding capacity (TIBC),
• transferrin saturation,
• or transferrin receptor

Contents
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Definition of iron deficiency anemia
Epidemiology
Iron metabolism
Etiology
Diagnosis
Management


EPIDEMIOLOGY
• Globally, anemia affects 1.62 billion people ,
which corresponds to 24.8% of the population
• IDA occurs across all populations and is
associated with
✓ Diminished QOL
✓ Physical and cognitive performance, and
✓ Unfavorable clinical outcomes


Classification of anemia as a problem
of public health significant

Anemia prevalence


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Definition of iron deficiency anemia
Epidemiology
Iron metabolism
Etiology
Diagnosis
Management


IRON DISTRIBUTION



IRON DISTRIBUTION
• Most body iron is present in haemoglobin in
circulating red cells
• The macrophages of the reticuloendotelial
system store iron released from haemoglobin
as ferritin and hemosiderin
• Small loss of iron each day in urine, faeces,

skin and nails and in menstruating females as
blood (1-2 mg daily)


IRON ABSORPTION


IRON ABSORPTION
• Food sources supply: 10 - 25 mg / day
• Absorbed in the brush border of the upper small
intestine
– Enhanced by gastric acid
– Inhibited by tannins, systemic inflammation

• Most dietary iron is nonheme form, <5%
bioavailability
• < 10% dietary iron is heme form, >25%
bioavailability


Iron absorption from food
Rice
Spinach
Black beans
Corn
Lettuce
Wheat
Soy beans
Ferritin
Veal liver

Fish muscle
Hemoglobin
Veal muscle

Non-heme
iron

Heme
iron

0

5

10

15

20

Iron Absorption (% of dose)

25


Contents
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Definition of iron deficiency anemia
Epidemiology
Iron metabolism
Etiology
Diagnosis
Management


ETIOLOGY
• IDA results from prolonged negative iron balance
• Mainly due to following factors:
1. Inadequate iron intake: infancy, inappropriate diet
2. Decreased iron absorption:
3. Increased iron demand or hematopoiesis:
prematurity, low-birth weight, cyanotic congenital
heart diseases, polycythemia
4. Increased iron loss: GI bleeding, menorrhagia,
recurrent bleeding of hematologic diseases, etc.
Matthew W. et al. Am Fam Physician. 2013;87(2):98-104


PROGNOSIS
IDA adversely effects:
• Cognitive performance, behavior, and physical
growth of infants, preschool, and school-aged
children
• The immune status and morbidity from infections

of all age groups
• The use of energy sources by muscle and thus the
physical capacity and work performance of
adolescents and adults of all age groups
• Increase perinatal risks for mothers and neonates
and overall infant mortality during pregnancy


Contents
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Definition of iron deficiency anemia
Epidemiology
Iron metabolism
Etiology
Diagnosis
Management


Preliminary findings
Chief Complaints
Fatigue, lassitude, palpitation, and
generalized weakness
History
Chronic blood loss, deficient diet

Clinical Features
1. Palor: skin, nailbed, conjunctiva
2. Koilonychia (brittle, spoon shaped nails)
3. Atrophic glossitis (atrophy of tongue papilla;
making the tongue smooth and shiny)
4. Pica (compulsive eating of nonfood items)
or pagophagia (compulsive eating of ice)


Symptoms and Signs
Symptoms
Decreased exercise
tolerance
Fatigue
Dizziness
Irritability

Weakness
Palpitations
Vertigo
Shortness of breath
Chest pain

Signs
Tachycardia
Pale appearance (most
prominent in
conjunctiva)
Decreased mental acuity
Increased intensity of some

cardiac valvular murmurs


Laboratory evaluation
• Complete blood count (CBC), erythrocyte
sedimentation rate (ESR), and peripheral
blood film (PBF)
• Serum Iron profile
• Bone marrow study (if needed)
• Investigations to determine other causes of
IDA (e.g. fecal occult blood test, colonoscopy,
gastroscopy, etc.)


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