Nutritional Anemias

Introduction & Overview - Anemia Unveiled

• Anemia: ↓ Hb or RBC count below age/sex norms, impairing oxygen delivery.

  ⭐ WHO defines childhood anemia by Hb: <11 g/dL (6mo-5yr), <11.5 g/dL (5-11yr), <12 g/dL (12-14yr).

• Morphological Types:
  • Microcytic (MCV <80 fL)
  • Normocytic (MCV 80-100 fL)
  • Macrocytic (MCV >100 fL)
• General Symptoms: 📌 Pallor, fatigue, irritability, weakness, dyspnea on exertion, tachycardia.

Iron Deficiency Anemia - The Iron Thief

• Etiology:

  • Dietary: Inadequate intake (cow's milk <1yr), exclusive breastfeeding >6 months.
  • Increased Demand: Rapid growth (infancy, adolescence), prematurity.
  • Blood Loss: Chronic GI (hookworm), heavy menses.
  • Malabsorption: Celiac disease.

• Pathophysiology - Stages:

  Stage	Ferritin	Serum Iron	TIBC	Transferrin Sat.	Hb	RBC Morphology
  1. Store Depletion	↓	Normal	N/↑	Normal	N	Normal
  2. Def. Erythropoiesis	↓	↓	↑	↓ (<16%)	N	Normal / slight changes
  3. IDA	↓ (<15 ng/mL)	↓	↑	↓ (<16%)	↓	Microcytic, Hypochromic

  ⭐ Serum ferritin (<15 ng/mL) is the most sensitive & specific test for iron deficiency, reflecting iron stores; first to fall.

• Clinical Features (📌 Mnemonic: IRON):

  • Irritability, Inattention, poor scholastic performance.
  • Ridges on nails (Koilonychia).
  • Oral changes (Atrophic glossitis, angular stomatitis).
  • Not enough energy (Pallor, fatigue), Pica, behavioral issues.

• Lab Diagnosis:

  • CBC: ↓Hb, ↓MCV (<80 fL), ↓MCH, ↓MCHC, ↑RDW (>15% - early sign).
  • Iron Studies: ↓Serum Iron, ↓Ferritin, ↑TIBC, ↓Transferrin Saturation (<16%).

• Treatment:

  • Oral Iron: Elemental iron 3-6 mg/kg/day (divided doses).
    • Duration: 2-3 months post-Hb normalization (replenish stores).
    • Side effects: GI upset, black stools.
  • Parenteral Iron: Severe anemia, malabsorption, non-compliance.

• Prevention:

  • Iron for preterm/LBW infants. Iron-rich foods, fortified cereals. Delayed cord clamping. Avoid early cow's milk.

Megaloblastic Anemias - Giant Cell Saga

Impaired DNA synthesis → large, immature RBC precursors.

• Vitamin B12 (Cobalamin) Deficiency:
  • Causes: Maternal deficiency, vegan diet, pernicious anemia, Crohn's, ileal resection.
  • Clinical: Anemia, glossitis, 📌 B12 affects BRAIN: neurological (SCD, developmental regression, paresthesias).
• Folate (Vitamin B9) Deficiency:
  • Causes: Goat's milk, malnutrition, malabsorption, drugs (phenytoin, methotrexate).
  • Clinical: Anemia, glossitis. NO neurological symptoms.
• Diagnosis:

  • CBC: ↑MCV >100 fL.

  • Peripheral Smear: Macro-ovalocytes, hypersegmented neutrophils (≥5% with ≥5 lobes or ≥1 with ≥6 lobes).

  • Labs:

    • B12 Def: ↓Serum B12, ↑MMA, ↑Homocysteine.
    • Folate Def: ↓Serum/RBC Folate, Normal MMA, ↑Homocysteine.
• Treatment:
  • B12 (IM/oral) or Folic acid supplementation. Correct underlying cause.

⭐ Subacute combined degeneration of the spinal cord is a serious and potentially irreversible neurological complication specific to Vitamin B12 deficiency, not seen in folate deficiency.

Other Nutritional Anemias - The Hidden Deficits

• Copper Deficiency
  • Causes: Prematurity, malabsorption, TPN.
  • Features: Sideroblastic anemia, neutropenia, osteoporosis, neurological issues.
  • Dx: ↓Serum copper & ceruloplasmin.
  • Rx: Copper supplementation.
• Vitamin E Deficiency
  • Features: Hemolytic anemia in preterms.
  • Dx: ↓Serum tocopherol, ↑H₂O₂ hemolysis test.
  • Rx: Vitamin E supplementation.
• Protein-Energy Malnutrition (PEM) Anemia
  • Features: Normocytic anemia; due to ↓EPO & marrow hypoplasia.
  • Dx: Clinical signs of PEM, normocytic anemia.
  • Rx: Nutritional rehabilitation.

⭐ Acquired copper deficiency can present with sideroblastic anemia and neutropenia, sometimes mimicking myelodysplastic syndrome.

High‑Yield Points - ⚡ Biggest Takeaways

• Iron Deficiency Anemia (IDA): Most common nutritional anemia. Features: microcytic hypochromic cells, ↓ ferritin, ↑ TIBC.
• IDA Risk Factors: Exclusive breastfeeding >6 months (without iron), early cow's milk, poor dietary intake.
• Megaloblastic Anemia: Due to Vitamin B12 or Folate deficiency. Smear: macro-ovalocytes, hypersegmented neutrophils.
• Vitamin B12 Deficiency: Presents with megaloblastic anemia AND neurological symptoms (e.g., SCD).
• Folate Deficiency: Causes megaloblastic anemia WITHOUT neurological symptoms. Goat's milk is a key dietary risk.