小儿营养性贫血(NUTRITIONALANEMIA)课件

NUTRITIONALANEMIA1NUTRITIONALANEMIA1NewwordsNutritional营养的Megaloblastic巨幼细胞Hamorrhage出血Irritability激惹Lethargy嗜睡Fatigue疲乏Anorexia厌食Appetite食欲Microcytic小细胞的Hypochromic低色素的Thalassemia海洋性贫血Ferroussulfate硫酸亚铁Hookworm钩虫Epistaxis鼻出血Reticulocyte网织红细胞2NewwordsNutritional营养的2NutritionalanemiaMegaloblasticanemiavitaminB12deficiencyfolicaciddeficiencyIrondeficiencyanemiairondeficiency3NutritionalanemiaMegaloblastiIrondefeciencyanemiaIntroductionCauseofIrondeficiencyanemiaClinicalfeaturesLaboratoryfindingsDiagnosisDefferentialdiagnosisTreatment4IrondefeciencyanemiaIntroducIronDeficiencyAnemia,IDAIncidenceofIDA:10-70%(WHO)40%(6m-6y，China)5IronDeficiencyAnemia,IDAInIDAisthemostcommoncauseofanemiainchildhood.Itusuallyresultsfrominadequatedietary

intakeratherthanlossofironthroughhemorrhage.6IDAisthemostcommoncauseoIroninmilkBothofbreastandcow`smilkarelowinironIronisbetterabsorbedfrombreastmilk(50%)comparedtocow`smilk(10%)Formulamilksarefortifiedwithiron(4%)7IroninmilkBothofbreastandDietarysourcesofiron8Dietarysourcesofiron8DietarysourcesofironRedmeatFortifiedbreakfastcerealsDarkgreenvegetablesBlackbreadabout10-15%ironofdietaryisabsorbed9DietarysourcesofironRedmeaIronrequirementsThefetusabsorbsironfromthemotheracrosstheplacenta.Terminfantshaveadequatereserveforthefirst4monthsoflife.Preterminfantshavelimitedironstoresandbecauseoftheirhigherrateofgrowth,theirironreserveswereusedupby8weeksofage.Adolescentsalsoneedmoreironbecauseof1.Growthspurt2.Dietarydeficiency3.Menstrualbloodloss10IronrequirementsThefetusabsReferencenutrientintakeofironare:6months:4mg/day12months:8mg/dayAdultmale:9mg/dayAdultfemale:15mg/day11Referencenutrientintakeofi（一）thedecreaseofironstoreslowbirthweightpreterminfantshemorrhageCausesofirondeificiency12（一）thedecreaseofironstoresCausesofirondeificiency（二）Nutritionaldeficiencyiscommonincertainat-riskgroupspreterminfantsrequireironsupplementsfrom6-8weeks.Terminfantswilldevelopirondeficiencyafter4monthsif1.mixedfeedingisundulydelayed2.unmodifiedcow`smilkisintroducedearly.Itiscommoninthefirsttwoyearsofage13Causesofirondeificiency（二）Causesofirondeificiency(三）MalabsorptionmaybecomplicatedbyirondeficiencyThechildrenusuallycompanywithanothermalnutrition.14Causesofirondeificiency(三）MCausesofirondeificiency(四）Bloodlossisalesscommoncauseinchildren,butmayoccurwith:MenstruationHookworminfectionRepeatedvenesectioninbabiesMeckel`sdiverticulumRecurrentepistaxisItistheimportantcauseofIDAinolderchildren15Causesofirondeificiency(四）BClinicalfeaturesMildirondeficiencyanemiaisasymptomaticMoreseveremaybeirritabilityLethargyFatigueanorexia16ClinicalfeaturesMildirondefSigns:

palloroftheskinandmucousmembranes.Hb<70g/L,tachycardiaandcardiacdilationoccur,andsystolicmurmursareoftenpresentIDAininfancyandearlychildrenisassociatedwithdevelopmentaldelayandpoorgrowthClinicalfeatures17Signs:Clinicalfeatures17Laboratoryfindings18Laboratoryfindings18Serumiron(SI)<10.7umol/LTatalironbindingcapacity(TIBC)>62.7umol/LSerumFerritin(SF)<16ug/LFreeerythrocyteprotoporphyrin(FEP)>0.9umol/LLaboratoryfindings19Serumiron(SI)<10.7umol/IDA外周血涂片红细胞形态Laboratoryfindings20IDA外周血涂片红细胞形态LaboratoryfindinIrondeficiencyanemia:lowpowerviewofperipheralbloodfilm21Irondeficiencyanemia:lowpow①Microcyticandhypochromicanemia.MCHC<30%,MCV<80fl,MCH<27pg②ThechildrenwiththeclinicalfeaturesofIDAandthecauseofirondeficiency③SI<10.7umol/L④Transferinsaturation<15%⑤Ironstoresdecreaseinbonemarrow⑥Freeerythrocyteprotoporphyrin(FEP)>0.9umol/L⑦SerumFerritin(SF)<16ug/L⑧Goodresponsetoirontherapy①+twoof②~⑧isnecessaryforthediagnosisdiagnosis22①MicrocyticandhypochromicandiagnosisDeterminationofthecauseofIDAismostimportantfordiagnosis23diagnosisDeterminationoftheDifferentialdiagnosis

thalassamieIDAchronicinflammationSI NorTIBC NPercentsaturtion >20% <10%10~20%Ferritin(ug/L) >50 <1020~200Ironstores 3~4+ 0 1~4+TransferrinreceptorNor NHbF N N24DifferentialdiagnosisThalassemiaminorIDAThalassemiaminorSI ↓ Nor↑T IBC ↑ NHbFandA2 N ↑

Differentialdiagnosis25ThalassemiaminorDifferential2626TreatmentManagementwilldependonTheseverityoftheanemiaThecauseoftheirondeficiencyTheabilityofthepatienttotoleratemedicinalironpreparations27TreatmentManagementwilldepenTreatmentOralironpreparations

tablet(ironcontent)Elixir(ironcontent)Ferroussulfate325(65) 300/5ml(60)Ferrousgluconate 325(38) 300/5ml(35)Ferrousfumarate 325(107) 100/5ml(33)Polysaccharide-iron150(150) 100/5ml(100)28TreatmentOralironpreparationTreatmentOraladministrationofsimpleferrousprovidesinexpensiveandsatisfactorytherapy

Ferroussulfateis20%elementalironbyweight.Adailytotalofferroussulfateis4-6mg/kgofelementalironinthreedivideddosesprovides29TreatmentOraladministrationoSerumIrom7AM12N12MN7PMFigure.Oralironabsoption.Whenmedicinalironisgiven3timesaday,eachdoseraisestheSIforseveralhours.AfourthdoseatbedtimecanhelpsustaintheSIduringnighttimehours.30SerumIrom7AM12N12MN7PMFigure.TreatmentBloodtransfusionisindicatedonlywhentheanemiaisverysevereIt`snotnecessarytoattemptrapidcorrectionofsevereanemiabytransfusionThechildrenwithhemoglobinvalueslessthan40g/Lshouldbegivenonly2-3ml/KgofRBCs31TreatmentBloodtransfusionisResponsestoIronTherapyinIDA

TimeAfterIronAdministrationResponse12–24hrReplacementofintracellularironenzymes;decreasedirritability;increasedAppetite36-48hrInitialbonemarrowresponse;erythroidhyperplasia48-72hrReticulocytosis,peakingat5–7days4-30daysIncreaseinhemoglobinlevel1-3moRepletionofstores32ResponsestoIronTherapyinIThecase8yearsoldboyfromcountrysideDiagnosisisIDAandHookworminfection(Hb=65g/L)ThreeweekslateaftertreatmentwithFerroussulfate:Hb=70g/L33Thecase8yearsoldboyfrom婴儿期缺铁性贫血最常见的原因是A胎儿期储铁不足B饮食中铁的缺乏C出血下列哪项是鉴别缺铁性贫血与海洋性贫血的重要依据A临床表现B细胞形态CHbF和HbA2检查缺铁性贫血铁剂治疗后，最先改善的是A食欲B网织红细胞CHb量34婴儿期缺铁性贫血最常见的原因是34病例10个月男孩面色苍白两个月，不发烧，不咳嗽，无皮肤黏膜出血，无血便及肉眼血尿，大小便正常。出生史：第一胎，第一产，孕36周早产喂养史：生后母乳喂养至今，6个月开始添加辅食。平素食欲较差。体检：皮肤黏膜苍黄，肝右肋下2CM，脾左肋下2CM实验室检查：35病例10个月男孩35项目结果参考值红细胞(RBC)2.683.5-5.0×1012/L血红蛋白(HGB)67110-150g/LMCV6282-92flMCH2227-31pgMCHC280320-360g/LRET4.5%血小板(PLT)275100-300×109/L白细胞(WBC)10.24.0-10×109/L36项目肝功能：GPT39U，GOT40U，TB，DB正常红细胞脆性降低，HbF56%37肝功能：GPT39U，GOT40U，TB，DB正常3THANKS38THANKS38NUTRITIONALANEMIA39NUTRITIONALANEMIA1NewwordsNutritional营养的Megaloblastic巨幼细胞Hamorrhage出血Irritability激惹Lethargy嗜睡Fatigue疲乏Anorexia厌食Appetite食欲Microcytic小细胞的Hypochromic低色素的Thalassemia海洋性贫血Ferroussulfate硫酸亚铁Hookworm钩虫Epistaxis鼻出血Reticulocyte网织红细胞40NewwordsNutritional营养的2NutritionalanemiaMegaloblasticanemiavitaminB12deficiencyfolicaciddeficiencyIrondeficiencyanemiairondeficiency41NutritionalanemiaMegaloblastiIrondefeciencyanemiaIntroductionCauseofIrondeficiencyanemiaClinicalfeaturesLaboratoryfindingsDiagnosisDefferentialdiagnosisTreatment42IrondefeciencyanemiaIntroducIronDeficiencyAnemia,IDAIncidenceofIDA:10-70%(WHO)40%(6m-6y，China)43IronDeficiencyAnemia,IDAInIDAisthemostcommoncauseofanemiainchildhood.Itusuallyresultsfrominadequatedietary

intakeratherthanlossofironthroughhemorrhage.44IDAisthemostcommoncauseoIroninmilkBothofbreastandcow`smilkarelowinironIronisbetterabsorbedfrombreastmilk(50%)comparedtocow`smilk(10%)Formulamilksarefortifiedwithiron(4%)45IroninmilkBothofbreastandDietarysourcesofiron46Dietarysourcesofiron8DietarysourcesofironRedmeatFortifiedbreakfastcerealsDarkgreenvegetablesBlackbreadabout10-15%ironofdietaryisabsorbed47DietarysourcesofironRedmeaIronrequirementsThefetusabsorbsironfromthemotheracrosstheplacenta.Terminfantshaveadequatereserveforthefirst4monthsoflife.Preterminfantshavelimitedironstoresandbecauseoftheirhigherrateofgrowth,theirironreserveswereusedupby8weeksofage.Adolescentsalsoneedmoreironbecauseof1.Growthspurt2.Dietarydeficiency3.Menstrualbloodloss48IronrequirementsThefetusabsReferencenutrientintakeofironare:6months:4mg/day12months:8mg/dayAdultmale:9mg/dayAdultfemale:15mg/day49Referencenutrientintakeofi（一）thedecreaseofironstoreslowbirthweightpreterminfantshemorrhageCausesofirondeificiency50（一）thedecreaseofironstoresCausesofirondeificiency（二）Nutritionaldeficiencyiscommonincertainat-riskgroupspreterminfantsrequireironsupplementsfrom6-8weeks.Terminfantswilldevelopirondeficiencyafter4monthsif1.mixedfeedingisundulydelayed2.unmodifiedcow`smilkisintroducedearly.Itiscommoninthefirsttwoyearsofage51Causesofirondeificiency（二）Causesofirondeificiency(三）MalabsorptionmaybecomplicatedbyirondeficiencyThechildrenusuallycompanywithanothermalnutrition.52Causesofirondeificiency(三）MCausesofirondeificiency(四）Bloodlossisalesscommoncauseinchildren,butmayoccurwith:MenstruationHookworminfectionRepeatedvenesectioninbabiesMeckel`sdiverticulumRecurrentepistaxisItistheimportantcauseofIDAinolderchildren53Causesofirondeificiency(四）BClinicalfeaturesMildirondeficiencyanemiaisasymptomaticMoreseveremaybeirritabilityLethargyFatigueanorexia54ClinicalfeaturesMildirondefSigns:

palloroftheskinandmucousmembranes.Hb<70g/L,tachycardiaandcardiacdilationoccur,andsystolicmurmursareoftenpresentIDAininfancyandearlychildrenisassociatedwithdevelopmentaldelayandpoorgrowthClinicalfeatures55Signs:Clinicalfeatures17Laboratoryfindings56Laboratoryfindings18Serumiron(SI)<10.7umol/LTatalironbindingcapacity(TIBC)>62.7umol/LSerumFerritin(SF)<16ug/LFreeerythrocyteprotoporphyrin(FEP)>0.9umol/LLaboratoryfindings57Serumiron(SI)<10.7umol/IDA外周血涂片红细胞形态Laboratoryfindings58IDA外周血涂片红细胞形态LaboratoryfindinIrondeficiencyanemia:lowpowerviewofperipheralbloodfilm59Irondeficiencyanemia:lowpow①Microcyticandhypochromicanemia.MCHC<30%,MCV<80fl,MCH<27pg②ThechildrenwiththeclinicalfeaturesofIDAandthecauseofirondeficiency③SI<10.7umol/L④Transferinsaturation<15%⑤Ironstoresdecreaseinbonemarrow⑥Freeerythrocyteprotoporphyrin(FEP)>0.9umol/L⑦SerumFerritin(SF)<16ug/L⑧Goodresponsetoirontherapy①+twoof②~⑧isnecessaryforthediagnosisdiagnosis60①MicrocyticandhypochromicandiagnosisDeterminationofthecauseofIDAismostimportantfordiagnosis61diagnosisDeterminationoftheDifferentialdiagnosis

thalassamieIDAchronicinflammationSI NorTIBC NPercentsaturtion >20% <10%10~20%Ferritin(ug/L) >50 <1020~200Ironstores 3~4+ 0 1~4+TransferrinreceptorNor NHbF N N62DifferentialdiagnosisThalassemiaminorIDAThalassemiaminorSI ↓ Nor↑T IBC ↑ NHbFandA2 N ↑

Differentialdiagnosis63ThalassemiaminorDifferential6426TreatmentManagementwilldependonTheseverityoftheanemiaThecauseoftheirondeficiencyTheabilityofthepatienttotoleratemedicinalironpreparations65TreatmentManagementwilldepenTreatmentOralironpreparations

tablet(ironcontent)Elixir(ironcontent)Ferroussulfate325(65) 300/5ml(60)Ferrousgluconate 325(38) 300/5ml(35)Ferrousfumarate 325(107) 100/5ml(33)Polysaccharide-iron150(150) 100/5ml(100)66TreatmentOralironpreparationTreatmentOraladministrationofsimpleferrousprovidesinexpensiveandsatisfactorytherapy

Ferroussulfateis20%elementalironbyweight.Adailytotalofferroussulfateis4-6mg/kgofelementalironinthreedivideddosesprovides67TreatmentOraladministrationoSerumIrom7AM12N12MN7PMFigure.Oralironabsoption.Whenmedicinalironisgiven3timesaday,eachdoseraisestheSIforseveralhours.AfourthdoseatbedtimecanhelpsustaintheSIduringnighttimehours.68SerumIrom7AM12N12MN7PMFigure.TreatmentBloodtransfusionisindicatedonlywhentheanemiaisverysevereIt`snotnecessarytoattemptrapidcorrectionofsevereanemiabytransfusionThechildrenwithhemoglobinvalueslessthan40g/Lshouldbegivenonly2-3ml/KgofRBCs69TreatmentBloodtransfusionisResponsestoIronTherapyinIDA

TimeAfterIronAdministrationResponse12–24h