儿科学英文课件：IRON DEFICIENCY ANEMIA

NUTRITIONAL

IRONDEFICIENCYANEMIA

（缺铁性贫血）NUTRITIONAL

IRONDEFICIENCYCasestudyBoy,9monthsPalefor9months,cough3daysPretermtwins,birthweight2.7kg;BreastfeedinguntilnowHEMATOLOGY/ONCOLOGY,CHILDREN’SHOSPITALdateWBCNLRBCHbMCVMCHMCHCPLTRet4.2424.280.750.254.055661.513.82257794.25260.530.423.955561132277350.0224.26160.240.714.31686315276240.022Hypochromicmicrocyticanemia

？CasestudyBoy,9monthsHEMATOCasestudyHypochromicmicrocyticanemiaHbF1.40,HbA21.80%,血红蛋白电泳（-），SI6.15(11-30)umol/L,TIBC85(50-70)umol/L,TS7.2%.4.25CR:双肺纹理增多、紊乱、模糊、中内带见片絮影，双肺充气过度，心影胸腺部分重叠。肺炎。

HEMATOLOGY/ONCOLOGY,CHILDREN’SHOSPITALWhatkindofAnemiaisthis?CasestudyHypochromicmicrocytClassification-Etiology

HEMATOLOGY/ONCOLOGY,CHILDREN’SHOSPITAL造血减少所致贫血Reducedcapacitytoproduceredbloodcells--deficiencysyndrome溶血性贫血：Hemolysis失血性贫血：BloodLossClassification-EtiologyHEMATIronandHemoglobinIronandHemoglobinTheimpactofIDATheimpactofIDACONTENTSINDUCTIONIRONMETABOLISMETIOLOGY/PATHOGENESISMANIFESTATIONSLABORATORYFINDINGSDIAGNOSIS&DIFFERENTIALPREVENTION&TREATMENTCONTENTSINDUCTIONINTRODUCTIONDefinitionoftheirondeficiencyanemia(IDA)由于体内铁缺乏最终导致储存铁减少血红蛋白合成减少所致的贫血N-IDA:Theanemiacausedbyinsufficientdietaryironuptake,inwhichtheironstorageandhemoglobinsynthesisdecreased.HEMATOLOGY/ONCOLOGY,CHILDREN’SHOSPITALINTRODUCTIONDefinitionoftheClinicalcharacteristics(临床特征）铁生化：

serumferritin(SF),serumiron(SI),transferrinsaturation(TS)贫血：hemoglobinconcentration,microcytichypochromicanemia,治疗反应：goodresponsetoirontherapy.年龄：6moto3yrs.Incidence

INTRODUCTIONHEMATOLOGY/ONCOLOGY,CHILDREN’SHOSPITALClinicalcharacteristics(临床特征Theincidence:

InChina(2004)，aninvestigationfrom9118childrenin15provincesand26citiesreveledthattheincidenceis30.1%vs16.8%forthechildrenwith7～12mosand15.5%vs4.4%forthechildrenwith13～36mosIntheUSItisabout9%of1-2yr-oldsareirondeficient;3%haveanemia.Ofadolescentgirls,9%areirondeficientand2%haveanemia.INTRODUCTIONTheincidence:INTRODUCTIONIRONMETABOLISMCOMPARTMENTHemoglobin64%Storageiron30%Ferritin-SFhemosiderinMyloglobin3%Enzymeiron0.4%Serumiron0.4%HEMATOLOGY/ONCOLOGY,CHILDREN’SHOSPITALCONTENTSNewborn75mg/kgChildren35-70mg/kgAdultsM50mg/kgF35mg/kgIRONMETABOLISMCOMPARTMENTHEMAIronsourcesHemoglobinironDietaryironHEMATOLOGY/ONCOLOGY,CHILDREN’SHOSPITALIRONMETABOLISMIronsourcesHEMATOLOGY/ONCOLOGDietaryironHighinironRedmeat/liverkidney/oilyfishAverageironBeans/fortifiedcereals/darkgreenvegetables/driedfruit/nutsandseedsPoorinironMilk(1.5vs0.5mg/L)HEMATOLOGY/ONCOLOGY,CHILDREN’SHOSPITALIRONMETABOLISMDietaryironHEMATOLOGY/ONCOLOGIronabsorption

generalabsorption 1-20%Meat/fish/chicken 10-25%Cereals/vegetables 1%Breast/cow’smilk 50%/10%HEMATOLOGY/ONCOLOGY,CHILDREN’SHOSPITALIRONMETABOLISMIronabsorptionHEMATOLOGY/ONCO 动物食品 非动物食品 (血红蛋白/肌红蛋白)（胶状氢氧化高铁）

胃酸胃蛋白酶 蛋白酶游离盐酸

血红素 三价铁

血红素分解酶

*VitC

肠： 二价铁

十二指肠空肠上 三价铁 肠黏膜细胞

转运铁蛋白* 入血

脱落入肠道

肝脾储存 骨髓造血

（图1）Ironabsorptionandtransportation 动物食品 非动物食品（图1）Ironabsorp

Ironstoresandutilizing食物铁血红素铁SIliverspleenBonemarrowHb合成肌红蛋白含铁酶Ironstoresandutilizing食物铁血IRONMETABOLISMRequirementandexcretion

demand

excretion

adults 1mg/d1mg/d 4mo-3yr 1mg//kg(15ug/kg/d) premature 2mg/kgHEMATOLOGY/ONCOLOGY,CHILDREN’SHOSPITALIRONMETABOLISMRequirementandHEMATOLOGY/ONCOLOGY,CHILDREN’SHOSPITAL

ETIOLOGY&PATHOGENESISETIOLOGY病因PoorironstoresPoordietaryintakeofiron*

OverdevelopChronicbleedingAbsorptionproblemsHEMATOLOGY/ONCOLOGY,CHILDREN’PoorironstoresPrematurebirthMultiplebirth/LowweightbirthCordbloodMotherironreservePoordietaryintakeofiron*overdevelopBloodlossandirondepletionHEMATOLOGY/ONCOLOGY,CHILDREN’SHOSPITAL

ETIOLOGY&PATHOGENESISPoorironstoresHEMATOLOGY/ONCPoorironstoresPoordietaryintakeofiron*MilkandcerealsFactorsinfluencingabsorptionOverdevelopBloodlossandirondepletionHEMATOLOGY/ONCOLOGY,CHILDREN’SHOSPITAL

ETIOLOGY&PATHOGENESISPoorironstoresHEMATOLOGY/ONC

ETIOLOGY&PATHOGENESISPoorironstoresPoordietaryintakeofiron*Overdevelop3-5mo/1yrPrematurebirthPubertyChronicbleedingHEMATOLOGY/ONCOLOGY,CHILDREN’SHOSPITALETIOLOGY&PATHOGENESISPooriPoorironstoresPoordietaryintakeofiron*overdevelopChronicbleedingCow’smilkHookworminfectionMenstruatingOthers:idiopathicpulmonaryhemosiderosis(肺含铁…）ulcer,gastritis(溃疡、胃炎）hemangioma,meckeldiverticulum.

ETIOLOGY&PATHOGENESISHEMATOLOGY/ONCOLOGY,CHILDREN’SHOSPITALPoorironstoresETIOLOGY&PA

ETIOLOGY&PATHOGENESISPoorironstoresoverdevelopPoordietaryintakeofiron*ChronicbleedingAbsorptionproblemsDiarrhea/Infection

HEMATOLOGY/ONCOLOGY,CHILDREN’SHOSPITALETIOLOGY&PATHOGENESISPoori

ETIOLOGY&PATHOGENESISQA：Girl，llmoths,paleforonemonth,developmentisgood，noblackstool,nodiseasehistory，breast-fedonly.Birthweight3kg,now10kg.Motherisinhealth.DiagnosisisIDA.Thepossiblereason?A.poorironstore先天储铁不足B.poorironintake铁摄入量不足C.overdevelopment生长发育过快D.problemwithironabsorptionE.ironloose铁丢失过多HEMATOLOGY/ONCOLOGY,CHILDREN’SHOSPITALETIOLOGY&PATHOGENESISQA：GirPathogenesisiron

+protoporphyrin

IDAheme+globinshemoglobinHEMATOLOGY/ONCOLOGY,CHILDREN’SHOSPITALETIOLOGY&PATHOGENESISHEMATOLOGY/ONCOLOGY,CHILDREN’ID.Irondeficiency（铁减少期）decreasedironstore-SFIDE.Irondeficiencyerythropoiesis（红细胞生成铁减少期）decreasedironstore-SFIncreaseFEPIDA.Irondeficiencyanemia（缺铁性贫血期）decreasedironstore-SFIncreasedFEPSI,TIBC,TSHypochromic/microcyticanemiaETIOLOGY&PATHOGENESISID.Irondeficiency（铁减少期）ETIPathogenesisHypochromic/microcyticanemiaID.IrondeficiencyIDE.IrondeficiencyerythropoiesisIDA.IrondeficiencyanemiaEnzymesImmunefunctionSkin/mucosalHEMATOLOGY/ONCOLOGY,CHILDREN’SHOSPITALETIOLOGY&PATHOGENESISPathogenesisHEMATOLOGY/ONCOLOGFeatures特点Age:6mo~3yrsTheonsetoftheIDAThedegreeofanemiaHEMATOLOGY/ONCOLOGY,CHILDREN’SHOSPITALCLINICALMANIFESTATIONSFeatures特点HEMATOLOGY/ONCOLOGYPallor苍白Extramedullaryhematopoiesis髓外造血Theslightsplenomegalyisfoundin10-15%ofthecasesHEMATOLOGY/ONCOLOGY,CHILDREN’SHOSPITALCLINICALMANIFESTATIONSPallor苍白HEMATOLOGY/ONCOLOGY,Moderate/SevereconditionDigestivesystem食欲减低、恶心呕吐、腹泻、舌炎、胃炎Cardiacfunctiontachycardia,cardiacdilatationandsystolicmurmursareoftenpresentNeurology/intellectual神萎或烦躁、头晕、耳鸣、注意力不集中、反应迟钝、学习能力和智力ImmunefunctionHEMATOLOGY/ONCOLOGY,CHILDREN’SHOSPITALCLINICALMANIFESTATIONSModerate/SevereconditionHHemoglobin:belowtheacceptablelevelforageRedcellindices:MCV<80fl,MCH<26ug,MCHC<0.31,highRDWBloodsmear:HypochromicsandmicrocyticwithanisocytosisandpoikilocytosisHEMATOLOGY/ONCOLOGY,CHILDREN’SHOSPITALLABORATORYFINDINGSHemoglobin:HEMATOLOGY/ONCOLO儿科学英文课件：IRONDEFICIENCYANEMIA儿科学英文课件：IRONDEFICIENCYANEMIAReticulocytecount:isusuallynormalbutinsevereIDAassociatedwithbleeding,areticulocytecountof3-4%mayoccurPlateletcountItvariesfromthrombocytopeniatothrombocytosis.ThrombocytopeniaismorecommoninsevereIDA;thrombocytosisispresentwhenthereisassociatedbleedingfromthegut.FreeerythrocyteprotoporphyrinFEPelevationoccursassonasthebodystresofironaredepleted,beforemicrocyticanemiadevelops.AnelevatedFEPlevelisthereforeanincicationforirontherapyevenwhenanemiaandmicrocytosishavenotyetdeveloped.HEMATOLOGY/ONCOLOGY,CHILDREN’SHOSPITALLABORATORYFINDINGSReticulocytecount:HEMATOLOGYSerumferritinItreflectsthelevelofbodyironstores;itisquantitative,reproducible,specificandsensitive.Aconcentrationoflessthan12ng/mlisconsidereddiagnosisofirondeficiency.SerumironandironsaturationpercentageSI：<9-10.7umol/L(12.8-31.3umol/L) or<50-60ug/dl(75-175ug/dl）TIBC：>62.7umol/L(>350ug/dl)TS：<15%（30-50%）HEMATOLOGY/ONCOLOGY,CHILDREN’SHOSPITALLABORATORYFINDINGSSerumferritinHEMATOLOGY/ONCOLSerumtransferrinreceptorlevels(STfR)ItssensitiveandcorrelateswithHbandotherLabparametersofironstatus.ItisincreasedininstancesofhyperplasiaoferythroidprecursorssuchasIDAandthalassemiaItisunaffectedbyinfectionandinflammationBonemarrow:Erythroidhyperplasia;StainableironHEMATOLOGY/ONCOLOGY,CHILDREN’SHOSPITALLABORATORYFINDINGSSerumtransferrinreceptorlevHEMATOLOGY/ONCOLOGY,CHILDREN’SHOSPITAL

NormalIDIDEIDAMarrowiron+++0SF(ug%)1006010-20FEP

SITIBCTS

HbMCVMCH

HEMATOLOGY/ONCOLOGY,CHILDREN’DiagnosisImpression6月-24月/36月生产史、喂养史小细胞低色素性贫血Diagnosis：biochemicalchangeSF减低；FEP升高；SI减低，TIBC升高，TS降低ProvenbytherapyHEMATOLOGY/ONCOLOGY,CHILDREN’SHOSPITALDIAGNOSIS&DIFFERENTIALTypicalpictureDiagnosisHEMATOLOGY/ONCOLOGY,HEMATOLOGY/ONCOLOGY,CHILDREN’SHOSPITALTable3-8DiagnosticTestsforIron-deficiencyAnemiaBloodsmearHypochromicmicrocyticredcells,confirmedbyRBCincices:MCVlessthannromalrangeofageMCHlessthan27.0pgMCHClessthan30%RDWgreaterthan14.5%Freeerythrocyteprotoporphyrin:elevatedSerumferritin:decreasedSerumironandironbingdingcapacityDecreasedserumironIncreasedironbindingcapacityDecreasedironsaturation(16%orless)Serumtransferrinreceptorlevel：elevatedBonemarrowDealyedcytoplasmicmaturationDecreasedorabsentstainalbeironTherpeuticresponsestooralironReticulocytosiswithpeak5-10daysafterinstitutionoftherapyFollowingpeakreticulocytosisHblevelrisesonanverageby0.25-0.4g/dl/dyorhematocritrises1%/dayHEMATOLOGY/ONCOLOGY,CHILDREN’Differential地中海贫血alassemia慢性Chronic&inflammatorydiseases肺含铁血黄素沉着症Pulmonaryhemosiderosis铁粒幼细胞贫血SiderblasticanemiaHEMATOLOGY/ONCOLOGY,CHILDREN’SHOSPITALDIAGNOSIS&DIFFERENTIALDifferentialHEMATOLOGY/ONCOLOGDifferential—Thalassemia是血红蛋白珠蛋白肽链合成障碍引起的一组遗传性溶血性贫血。地区性明显，有家族史；轻型临床上难以区别，重型常有特殊面容，肝脾肿大明显；外周血涂片可见靶形红细胞和有核红细胞血红蛋白检查显示胎儿血红蛋白水平异常增高或血红蛋白电泳出现异常成分区带；血清铁增高，骨髓铁粒幼细胞增多HEMATOLOGY/ONCOLOGY,CHILDREN’SHOSPITALDIAGNOSIS&DIFFERENTIALDifferential—ThalassemiaHEMAT

TREATMENTGeneralcareEradicatethecauses*Ironsupplementation*TransfusionHEMATOLOGY/ONCOLOGY,CHILDREN’SHOSPITAL原则去除病因补充铁剂TREATMENTGeneralcareHEMATOLO

治疗

(Treatment)QA哪些因素或病因是可以预防的？哪些因素或病因是可以去除的？治疗(Treatment)QA

治疗

(Treatment)NutritionalCounselingMaintainbreastfeedingforatleast6moUseaniron–fortifiedinfantformulauntil1yearageUseiron–fortifiedcerealfrom6mo-1yearProvidesupplementalironforlowbirthweightinfants:Infants1.5-2.0kg:2mg/kg/dsupplementalironInfants1.0-1.5kg:3mg/kg/dsupplementalironInfants<1.0kg:4mg/kg/dsupplementalironFacilitatorsofironabsorptionsuchasVC-richfoods,meat,fishandpoutryshouldbeincludedinthedietandinhibitorsofironabsorptionsuchtea,phosphateandphytatescommoninvegetariandietsshouldelinminated治疗(Treatment)NutritionalCoIronsupplementation（补铁）Elementaliron：4-6mg/kg/dOralironmedicationTypes-ferrousformAdministrationBetweenmealsVitaminCCourse:6-8weeksafterHbnormalization

HEMATOLOGY/ONCOLOGY,CHILDREN’SHOSPITAL

TREATMENTIronsupplementation（补铁）HEMATFerrousSalts4mg/kg/dFerroussulfate（20%）(硫酸亚铁）20mg/kg/dferrousfumarate

(30%）（富马酸亚铁）13mg/kg/dFerrousgluconate（11%）（葡萄糖酸亚铁）40mg/kg/dHEMATOLOGY/ONCOLOGY,CHILDREN’SHOSPITALTable:FerroussaltsanttheironcontentsFerrousSalts4mg/kg/dFerrouIronsupplementation（补铁）Parenteraliron（胃肠外注射铁）

Indication:intoleranttooralironorabsorptionproblemtypes：HEMATOLOGY/ONCOLOGY,CHILDREN’SHOSPITAL

TREATMENTIronsupplementation（补铁）HEMAT

IRONTHERAPYRESPONSE（fromNelson）timeresponse12-24hrReplacementofironenzymes,subjectiveimprovement36-48hrInitialmarrowresponse:erythroidhyperplasia48-72hrReticulocytespeaking5-7d4-30daysHemoglobinlevel1-3moReplenishofstoresHEMATOLOGY/ONCOLOGY,CHILDREN’SHOSPITALIRONTHERAPYRESPONSE（fromNTREATMENTTransfusion（输血）IndicationsSevereanemiaInfectionPre-operationComponent：redbloodcellsVolume：Hb<30g/L,3-5ml/kg Hb30-60g/L,5-10ml/kgAttentionsHEMATOLOGY/ONCOLOGY,CHILDREN’SHOSPITALTREATMENTTransfusion（输血）HEMATOPREVENTION预防EducationForpregnantwomenFortermBreastmilk/cow’smilkIronrichsupplementaryfoodIron-fortifiedfoodForprematureinfantHEMATOLOGY/ONCOLOGY,CHILDREN’SHOSPITALPREVENTION预防EducationHEMATOLOMegaloblasticAnemia

(营养性巨幼细胞贫血)MegaloblasticAnemia

(营养性巨幼细胞贫INTRODUCTIONDefinition:AkindofanemiawithlargerRBC,causedbythedeficiencyoffolicacidand/orvitaminB12Clinicalfeatures:macrocyticanemia,neuropsychiatricchanges,megaloblasticRBCinthebonemarrow,responsetovitaminB12andfolicacidwell.Theincidence:changingfromcommontorare

HEMATOLOGY/ONCOLOGY,CHILDREN’SHOSPITALINTRODUCTIONDefinition:AkinETIOLOGY

Inadequateintake

DecreasedabsorptionDruginducedabnormalitiesCongenitalabnormalitiesHEMATOLOGY/ONCOLOGY,CHILDREN’SHOSPITALETIOLOGYInadequateintakeHEMAETIOLOGYInadequateintake

AllweneedofB12andfolateisfromfood;Therequirement:forB12:1ug/d;forfolate:60-100ug/d(WHO)Underclinicalconditionswherethereareincreasedvitaminrequirements(pregnancy,growthininfancy,chronichemolysis).HEMATOLOGY/ONCOLOGY,CHILDREN’SHOSPITALETIOLOGYInadequateintakeHEMATETIOLOGYInadequateintakeFolatesabundantinmanyfoodsincludinggreenvegetables,fruits,andanimalorgans(liver,kidney).Humanbreastmilk,pasteurizedcow'smilk.andinfantformulasprovideadequateamountsoffolicacid.Goat'smilkisdeficient;folicacidsupplementationmustbegivenwhenitisthemainfood.Unlesssupplemented,powderedmilkmayalsobeapoorsourceoffolicacid.HEMATOLOGY/ONCOLOGY,CHILDREN’SHOSPITALETIOLOGYInadequateintakeHEMATETIOLOGYInadequateintakeVitaminB12VitaminB12(cobalamin)ispresentinmanyfoods,mostlyinanimalfoods,VitaminB12deficiencymayoccurinthecasesofextremedietaryrestriction(strictvegetariansorvegans)

occursinbreast-fedinfantswhosemothersarevegansorthemselveshaveperniciousanemiaHEMATOLOGY/ONCOLOGY,CHILDREN’SHOSPITALETIOLOGYInadequateintakeHEMATETIOLOGYDecreasedabsorptionChronicdiarrheaInflammatorydiseasesNeonatalnecrotizingenterocolitisSurgeryininterestine/terminalileumHEMATOLOGY/ONCOLOGY,CHILDREN’SHOSPITALETIOLOGYDecreasedabsorptionHEETIOLOGYDruginducedabnormalitiesCertainanticonvulsantdrugs(e.g.,phenytoin,primidone,phenobarbital)canimpairabsorptionoffolicacid

Anumberofdrugshaveanti–folicacidactivity:MethotrexateHEMATOLOGY/ONCOLOGY,CHILDREN’SHOSPITALETIOLOGYDruginducedabnormaliETIOLOGYCongenitalabnormalitiesCcongenitaldihydrofolatereductasedeficiencyLackofintrinsicfactor-CongenitalperniciousanemiaTranscobalaminII(TC-II)deficiency

HEMATOLOGY/ONCOLOGY,CHILDREN’SHOSPITALETIOLOGYCongenitalabnormalitiPATHOGENESIS

HEMATOLOGY/ONCOLOGY,CHILDREN’SHOSPITALVitamin12↓Folicacid↓FolicacidreductaseDNASynthesis↓

TetrahydrofolicacidNucleotidePATHOGENESISHEMATOLOGY/ONCOLOPATHOGENESISInfluenceonhematopoiesis(造血）MegaloblasticRBCDecreasedDNAsynthesisdelaysthematurationofthenucleusoferythrocytesNeutrophilandMegakaryocytehypersegmentedneutrophils(manyneutrophilswithmorethanfourtofivelobes).Ineffectiveerythropoiesis（无效造血）thatdescribesactiveerythropoiesiswithprematuredeathofcells,adecreasedoutputofRBCfromthemarrow,and,consequently,anemia.HEMATOLOGY/ONCOLOGY,CHILDREN’SHOSPITALPATHOGENESISInfluenceonhematPATHOGENESISInfluenceonneurological

systemVitaminB12playsimportantroleinkeepingtheintactofthenervefiberscontainingmyelinsheathThedeficientresultinneuropsychiatricchangesHEMATOLOGY/ONCOLOGY,CHILDREN’SHOSPITALPATHOGENESISInfluenceonneuroCLINICALMANIFESTATION

General一般情况6～18moWeakness,fatigue,orirritability,failuretothrive,glossitis,vomiting,diarrheaHair:lessandyellowish.Anemia血液系统:Paleandpuffyicterus;PetechiaHepatomegaly/splenomeaglyHEMATOLOGY/ONCOLOGY,CHILDREN’SHOSPITALCLINICALMANIFESTATIONGeneralCLINICALMANIFESTATION

Neurologicalinvolvement（神经系统）developmentaldelay,developmentalregressionTrembles,seizuresparesthesias,sensorydeficits,hypotonianeuropsychiatricchanges.

HEMATOLOGY/ONCOLOGY,CHILDREN’SHOSPITALNeurologicproblemsfromvitaminB12deficiencycanoccurintheabsenceofanyhematologicabnormalitiesCLINICALMANIFESTATIONNeuroloLABFINDINGS

MacrocyticnormochromicanemiaNeutrophilsmaybelargeandhypersegmented,Neutropeniawith/thrombocytopeniaMarrowfilm:megaloblasticformsofnucleatedRBCSerumVitB12and/orfolicacidHEMATOLOGY/ONCOLOGY,CHILDREN’SHOSPITALLABFINDINGSMacrocyticnormoc儿科学英文课件：IRONDEFICIENCYANEMIA儿科学英文课件：IRONDEFICIENCYANEMIADIAGNOSIS

Clinicalmanifestation:anemiaPeripheralbloodmacrocyticanemia,fragmentedneutrophils,BonemarrowmegaloblasticformsofnucletedRBCSerumB12levelandFolicacidconcentration

HEMATOLOGY/ONCOLOGY,CHILDREN’SHOSPITALDIAGNOSISClinicalmanifestatiDIAGNOSIS

HEMATOLOGY/ONCOLOGY,CHILDREN’SHOSPITALAnemiawithLargeMCV/MCHBM:MegaloblasticformsofnucleatedRBChistoryTremblesSerumB12FolicacidVitaminB12deficiencyFolicaciddeficiencyMADIAGNOSISHEMATOLOGY/ONCOLOGY,TREATMENTGeneralcareDrugtherapyVitaminB1225-100ug/次，2-3times/w，weeksortoHbnormal；Onehighdose：500ug

imFolicacid：5mg,tid,2-3w，

Otherdrug：VitaminC；B6；ironinrecovery

TransfusionHEMATOLOGY/ONCOLOGY,CHILDREN’SHOSPITALTREATMENTGeneralcareHEMATOLOGPREVENTIONGoodnutritionformotherAvoidstrictdietrestrictionProvidesolidfoodforinfantsTreattheGIdisordersthedruginducedMA

HEMATOLOGY/ONCOLOGY,CHILDREN’SHOSPITALPREVENTIONGoodnutritionformCASESTUDY男孩，11月，流涕、轻咳2天，发热1天就诊。体温38度，咽充血，R40次/分，肺音清，HR120次/分，有力，律齐；肝肋下2cm,脾未扪及血常规RBC300X1012/L,MCV72fl,MCH21pg,MCHC29,Hb81g/LWBC8.0X109/L,N0.28,L0.70,PLT230X109/L外周血红细胞大小不均，苍白区扩大。CASESTUDY男孩，11月，流涕、轻咳2天，发热1天就CASESTUDYQ1:进一步询问病史？A1：生产史：产重2.8kg，出生时无明显大失血情况；喂养史：单纯母乳喂养，6月加稀饭，偶尔鸡蛋、肉食过去史：1月前腹泻5-6天Q2：进一步检验？A2：血清铁：4.3umol/L铁结合力:70umol/L转铁蛋白饱和度：6%Q3A3：诊断：营养性缺铁性贫血CASESTUDYQ1:进一步询问病史？HEMATOLOGY/ONCOLOGY,CHILDREN’SHOSPITALReviewthesecontentsafterclass,trytomakethesummaryon:TheetiologyofIDAandpersonalhistoryLaboratoryfindingsaccordingtothestagesDiagnosisandDifferentials:espwiththalassemiaImportanttreatment:oralironrelatedMAdiagnosisCasestudyHEMATOLOGY/ONCOLOGY,CHILDREN’

NUTRITIONAL

IRONDEFICIENCYANEMIA

（缺铁性贫血）NUTRITIONAL

IRONDEFICIENCYCasestudyBoy,9monthsPalefor9months,cough3daysPretermtwins,birthweight2.7kg;BreastfeedinguntilnowHEMATOLOGY/ONCOLOGY,CHILDREN’SHOSPITALdateWBCNLRBCHbMCVMCHMCHCPLTRet4.2424.280.750.254.055661.513.82257794.25260.530.423.955561132277350.0224.26160.240.714.31686315276240.022Hypochromicmicrocyticanemia

？CasestudyBoy,9monthsHEMATOCasestudyHypochromicmicrocyticanemiaHbF1.40,HbA21.80%,血红蛋白电泳（-），SI6.15(11-30)umol/L,TIBC85(50-70)umol/L,TS7.2%.4.25CR:双肺纹理增多、紊乱、模糊、中内带见片絮影，双肺充气过度，心影胸腺部分重叠。肺炎。

HEMATOLOGY/ONCOLOGY,CHILDREN’SHOSPITALWhatkindofAnemiaisthis?CasestudyHypochromicmicrocytClassification-Etiology

HEMATOLOGY/ONCOLOGY,CHILDREN’SHOSPITAL造血减少所致贫血Reducedcapacitytoproduceredbloodcells--deficiencysyndrome溶血性贫血：Hemolysis失血性贫血：BloodLossClassification-EtiologyHEMATIronandHemoglobinIronandHemoglobinTheimpactofIDATheimpactofIDACONTENTSINDUCTIONIRONMETABOLISMETIOLOGY/PATHOGENESISMANIFESTATIONSLABORATORYFINDINGSDIAGNOSIS&DIFFERENTIALPREVENTION&TREATMENTCONTENTSINDUCTIONINTRODUCTIONDefinitionoftheirondeficiencyanemia(IDA)由于体内铁缺乏最终导致储存铁减少血红蛋白合成减少所致的贫血N-IDA:Theanemiacausedbyinsufficientdietaryironuptake,inwhichtheironstorageandhemoglobinsynthesisdecreased.HEMATOLOGY/ONCOLOGY,CHILDREN’SHOSPITALINTRODUCTIONDefinitionoftheClinicalcharacteristics(临床特征）铁生化：

serumferritin(SF),serumiron(SI),transferrinsaturation(TS)贫血：hemoglobinconcentration,microcytichypochromicanemia,治疗反应：goodresponsetoirontherapy.年龄：6moto3yrs.Incidence

INTRODUCTIONHEMATOLOGY/ONCOLOGY,CHILDREN’SHOSPITALClinicalcharacteristics(临床特征Theincidence:

InChina(2004)，aninvestigationfrom9118childrenin15provincesand26citiesreveledthattheincidenceis30.1%vs16.8%forthechildrenwith7～12mosand15.5%vs4.4%forthechildrenwith13～36mosIntheUSItisabout9%of1-2yr-oldsareirondeficient;3%haveanemia.Ofadolescentgirls,9%areirondeficientand2%haveanemia.INTRODUCTIONTheincidence:INTRODUCTIONIRONMETABOLISMCOMPARTMENTHemoglobin64%Storageiron30%Ferritin-SFhemosiderinMyloglobin3%Enzymeiron0.4%Serumiron0.4%HEMATOLOGY/ONCOLOGY,CHILDREN’SHOSPITALCONTENTSNewborn75mg/kgChildren35-70mg/kgAdultsM50mg/kgF35mg/kgIRONMETABOLISMCOMPARTMENTHEMAIronsourcesHemoglobinironDietaryironHEMATOLOGY/ONCOLOGY,CHILDREN’SHOSPITALIRONMETABOLISMIronsourcesHEMATOLOGY/ONCOLOGDietaryironHighinironRedmeat/liverkidney/oilyfishAverageironBeans/fortifiedcereals/darkgreenvegetables/driedfruit/nutsandseedsPoorinironMilk(1.5vs0.5mg/L)HEMATOLOGY/ONCOLOGY,CHILDREN’SHOSPITALIRONMETABOLISMDietaryironHEMATOLOGY/ONCOLOGIronabsorption

generalabsorption 1-20%Meat/fish/chicken 10-25%Cereals/vegetables 1%Breast/cow’smilk 50%/10%HEMATOLOGY/ONCOLOGY,CHILDREN’SHOSPITALIRONMETABOLISMIronabsorptionHEMATOLOGY/ONCO 动物食品 非动物食品 (血红蛋白/肌红蛋白)（胶状氢氧化高铁）

胃酸胃蛋白酶 蛋白酶游离盐酸

血红素 三价铁

血红素分解酶

*VitC

肠： 二价铁

十二指肠空肠上 三价铁 肠黏膜细胞

转运铁蛋白* 入血

脱落入肠道

肝脾储存 骨髓造血

（图1）Ironabsorptionandtransportation 动物食品 非动物食品（图1）Ironabsorp

Ironstoresandutilizing食物铁血红素铁SIliverspleenBonemarrowHb合成肌红蛋白含铁酶Ironstoresandutilizing食物铁血IRONMETABOLISMRequirementandexcretion

demand

excretion

adults 1mg/d1mg/d 4mo-3yr 1mg//kg(15ug/kg/d) premature 2mg/kgHEMATOLOGY/ONCOLOGY,CHILDREN’SHOSPITALIRONMETABOLISMRequirementandHEMATOLOGY/ONCOLOGY,CHILDREN’SHOSPITAL

ETIOLOGY&PATHOGENESISETIOLOGY病因PoorironstoresPoordietaryintakeofiron*

OverdevelopChronicbleedingAbsorptionproblemsHEMATOLOGY/ONCOLOGY,CHILDREN’PoorironstoresPrematurebirthMultiplebirth/LowweightbirthCordbloodMotherironreservePoordietaryintakeofiron*overdevelopBloodlossandirondepletionHEMATOLOGY/ONCOLOGY,CHILDREN’SHOSPITAL

ETIOLOGY&PATHOGENESISPoorironstoresHEMATOLOGY/ONCPoorironstoresPoordietaryintakeofiron*MilkandcerealsFactorsinfluencingabsorptionOverdevelopBloodlossandirondepletionHEMATOLOGY/ONCOLOGY,CHILDREN’SHOSPITAL

ETIOLOGY&PATHOGENESISPoorironstoresHEMATOLOGY/ONC

ETIOLOGY&PATHOGENESISPoorironstoresPoordietaryintakeofiron*Overdevelop3-5mo/1yrPrematurebirthPubertyChronicbleedingHEMATOLOGY/ONCOLOGY,CHILDREN’SHOSPITALETIOLOGY&PATHOGENESISPooriPoorironstoresPoordietaryintakeofiron*overdevelopChronicbleedingCow’smilkHookworminfectionMenstruatingOthers:idiopathicpulmonaryhemosiderosis(肺含铁…）ulcer,gastritis(溃疡、胃炎）hemangioma,meckeldiverticulum.

ETIOLOGY&PATHOGENESISHEMATOLOGY/ONCOLOGY,CHILDREN’SHOSPITALPoorironstoresETIOLOGY&PA

ETIOLOGY&PATHOGENESISPoorironstoresoverdevelopPoordietaryintakeofiron*ChronicbleedingAbsorptionproblemsDiarrhea/Infection

HEMATOLOGY/ONCOLOGY,CHILDREN’SHOSPITALETIOLOGY&PATHOGENESISPoori

ETIOLOGY&PATHOGENESISQA：Girl，llmoths,paleforonemonth,developmentisgood，noblackstool,nodiseasehistory，breast-fedonly.Birthweight3kg,now10kg.Motherisinhealth.DiagnosisisIDA.Thepossiblereason?A.poorironstore先天储铁不足B.poorironintake铁摄入量不足C.overdevelopment生长发育过快D.problemwithironabsorptionE.ironloose铁丢失过多HEMATOLOGY/ONCOLOGY,CHILDREN’SHOSPITALETIOLOGY&PATHOGENESISQA：GirPathogenesisiron

+protoporphyrin

IDAheme+globinshemoglobinHEMATOLOGY/ONCOLOGY,CHILDREN’SHOSPITALETIOLOGY&PATHOGENESISHEMATOLOGY/ONCOLOGY,CHILDREN’ID.Irondeficiency（铁减少期）decreasedironstore-SFIDE.Irondeficiencyerythropoiesis（红细胞生成铁减少期）decreasedironstore-SFIncreaseFEPIDA.Irondeficiencyanemia（缺铁性贫血期）decreasedironstore-SFIncreasedFEPSI,TIBC,TSHypochromic/microcyticanemiaETIOLOGY&PATHOGENESISID.Irondeficiency（铁减少期）ETIPathogenesisHypochromic/microcyticanemiaID.IrondeficiencyIDE.IrondeficiencyerythropoiesisIDA.IrondeficiencyanemiaEnzymesImmunefunctionSkin/mucosalHEMATOLOGY/ONCOLOGY,CHILDREN’SHOSPITALETIOLOGY&PATHOGENESISPathogenesisHEMATOLOGY/ONCOLOGFeatures特点Age:6mo~3yrsTheonsetoftheIDAThedegreeofanemiaHEMATOLOGY/ONCOLOGY,CHILDREN’SHOSPITALCLINICALMANIFESTATIONSFeatures特点HEMATOLOGY/ONCOLOGY