ABSTRACT

The most severe consequence of iron depletion is iron deficiency anemia, and it is still considered the most common nutrition deficiency worldwide. Although the etiology of iron deficiency anemia is multifactor, it generally results when the iron demands by the body are not met by iron absorption, regardless of the reason. Individuals with iron deficiency anemia have inadequate intake, impaired absorption or transport, physiologic losses associated with chronological or reproductive age, or chronic blood loss secondary to disease. In this review, will be described diverse etiologies into age-related. Distinguishing iron deficiency anemia from anemia of chronic disease using hematologic measures is reviewed as well. The first step in treatment iron deficiency anemia is to find and eliminate, or rule out, sources of blood loss. If this is not done, replacement therapy is ineffective. Iron replacement therapy is required and very effective.

CHAPTER I INTRODUCTION

Iron deficiency is the most common form of nutritional deficiency. The size and number of red blood cells are reduced. There is a spectrum of iron deficiency ranging from iron depletion, which causes no physiological impairments, to iron-deficiency anemia, which affects the functioning of several organ systems. The terms anemia, iron deficiency, and iron-deficiency anemia are often used interchangeably, but are not equivalent. Anemia can only be diagnosed as iron-deficiency anemia when there is additional evidence of iron deficiency. Iron deficiency anemia develops when the intake of iron is inadequate to meet a standard level of demand, when the need for iron expand, or when there is chronic loss of hemoglobin from the body. Iron deficiency affects 20% to 50% of the world's population, making it the most common nutritional deficiency. Young children, whether in developing or developed countries, are at risk of iron deficiency because rapid growth imposes large iron needs and the bioavailability of iron in the diet of infants is low. In children iron deficiency develops slowly and produces few acute symptoms. As the deficiency worsens children become pale and weak, eat less, and tire easily. Beside that, nowdays, anemia is considered to be an important health problem among the elderly. With advancing age, there is a progressive and apparently physiological decrement of marrow hematopoesis. However, anemia in the elderly is due to disease and should never be considered as a normal physiological response to ageing.The causes of anemia in the elderly are diverse, with anemia of chronic disease and iron deficiency anemia being the most common causes. In community studies

CHAPTER II IRON DEFICIENCY ANEMIA

II.1 DEFINITION Iron deficiency is defined as a decreased total iron body content. Iron deficiency anemia (IDA) occurs when iron deficiency is severe enough to diminish erythropoiesis and cause the development of anemia. Iron deficiency is the most prevalent single deficiency state on a worldwide basis. It is important economically because it diminishes the capability of individuals who are affected to perform physical labor, and it diminishes both growth and learning in children.(1) II.2 ETIOLOGY Conditions that increase demand for iron, increase iron loss, or decrease iron intake or absorption can produce iron deficiency.(2) Will be explain in the next chapter of this paper. II.3 EPIDEMIOLOGY(3) In menstruating women, their monthly loss of blood increases their routine need for iron, which is often not met with the standard U.S. diet. Pregnancy and nursing can lead to a loss nearly 900 mg of iron, further depleting iron dtores for women in their childbearing years. In growing children, the increasing need for iron as the child grows can be coupled with dietary inadequacies. Iron deficiency is relatively rare in adult men and postmenopausal women because the body conserves iron so tenaciously, and these groups lose only about 1mg/day. Iron deficiency is associated with infestation with hookworms (Necator americanus and Ancylostoma duodenale). II.4 PATHOPHYSIOLOGY IDA develops slowly, progressing trough stages that physiologically blend one into the other but are useful delineations for understanding disease progression. Iron is distributed between three compartements: the storage compartement, principally as ferritin in the bone
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marrow macrophages and liver cells, the transport compartement of serum transferrin; and the functional compartement of hemoglobin, myoglobin, and cytochromes.(3) In stage I, the bodys iron stores for red cell production and hemoglobin synthesis are depleted. Red cell production proceeds normally with hemoglobin content of red cell also maining normal. In stage II, insufficient amounts of iron is transported to the marrow and iron deficient red cell production begins. Stage II begins when the hemoglobin deficient red cells enter the circulation to replace normal, age erythrocytes that have been destroyed. The manifestations of IDA appear in stage III when there is an insufficient iron supply and diminished hemoglobin synthesis.(4) II.5 CLINICAL MANIFESTATION The onset of symptom is gradual, and individuals usually do not seek medical attention until hemoglobin levels drop to 7 or 8 g/dl. Early symptoms are nonspecific and include fatigue, weakness, shortness of breath, and pale ear lobes, palm, and conjunctiva. As the condition progresses and becomes more severe, structural and functional change occur in ephitelial tissue. The fingernails become brittle and spoon shaped or concave (koilonychia). Tongue papillae atrophy and cause soreness along with redness and burning. These changes can be reversed within 1 or 2 weeks of iron replacement. The corners of the mouth become dry and sore (angular stomatitis), and an individual may experience difficulty with swallowing because of a web that develops from mucus and inflammatory cells at the opening of the esophagus. These lesion have the potential to become cancerous. Iron is component of many enzymes in the body, and lack of iron may alter other physiologic processes and contribute to the clinical manifestations. Individuals with IDA exhibit gastritis, neuromuscular changes, irritability, headache, numbness, tingling, and vasomotor disturbances. Gait disturbances are rare. In the elderly, mental confusion, memory loss, and disorientation may be wrongly perceived as normal events asspoiated with aging.(4) Iron deficiency may have effects on neurologis and intellectual function. Affects attention span, alertness, and learning both infants and adolescent.(5) II.6 TREATMENT (4)
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The first step in treatment IDA is to find and eliminate, or rule out, sources of blood loss. If this is not done, replacement therapy is ineffective. Iron replacement therapy is required and very effective. Initial doses are 150 to 200 mg/day and are continued until the serum ferritin level reaches 50 mg/L, indicating that adequate replacement has occurred. A rapid decrease in fatigue, lethargy, and other associated symptoms is generally seen within the first month of therapy. Replacement therapy usually continues for 6 to 12 months after the bleeding has stopped but may continue for as long as 24 months. Menstruating females may need daily therapy (325 mg/day) until menopause.

CHAPTER III
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ETIOLOGY OF IRON DEFICIENCY ANEMIA

IDA has many main causes. These etiologies fall into age-related categories,. They are IDA in infancy and childhood, adult, and elderly. III.1 Iron Deficiency Anemia in Infancy and childhood (5) III.1.1 Increased demand of iron Rapid growth(6) Because of their rapid growth, infants need more iron than older children. Sometimes it can be hard for them to get enough iron from their normal diet. Low birthweight and unusual perinatal hemorrhage Low birthweight and unusual perinatal hemorrhage are associated with decreases in neonatal hemoglobin mass and stores of iron. As the high hemoglobin concentration of the newborn infant falls during the first 2-3 month of life, considerable iron is reclaimed and stored. These reclaimed stores are usually sufficient for blood formation in the first 6-9 month of life in term infants. In low-birthweight infants or those with perinatal blood loss, stored iron may be depleted earlier and dietary sources become of paramount importance. Intensive exercise Intensive exercise conditioning, as occurs in competitive athletics in high school, may result in iron depletion in girls : this occurs less commonly in boys. III.1.2 Increased iron loss Blood loss Blood loss must be considered a possible cause in every case of IDA, particularly in older children. Chronic iron defisiency anemia from occult bleeding may be caused by a lession of the gastrointestinal tract, such as a peptic ulcer, Meckel diverticulum, polyp, or hemangioma,
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or by inflammatory bowel disease. In some geographic areas, hook worm infestation is an important cause of iron deficiency. Pulmonary hemosiderosis may be associated with unrecognized bleeding in the lungs and recurrent iron deficiency after treatment with iron. Chronic diarrhea in early childhood may be associated with considerable unrecognized blood loss. III.1.3 Decreased iron intake or absorption Inadequate dietary iron In term infants, anemia caused solely by inadequate dietary iron is unusual before 6 month and usually occurs at 9-24 month of age. Thereafter, it is relatively infrequent. The usual dietary pattern observed in infants with iron-deficiency anemia is consumption of large amount of cows milk and of food not supplemented with iron. Histologic abnormalities mucosa of the gastrointestinal tract Such as blunting of the villi, are present in advanced IDA and may cause leakage of blood and decreased absorption of iron, further compuonding the problem.

III.2 Iron Deficiency Anemia in Adult (3) IDA develops when the intake of iron is inadequate to meet a standard level of demand, when the need for iron expand, or when there is chronic loss of hemoglobin from the body. III.2.1 Increased demand of iron Rapid growth Iron deficiency can also develop when the level of iron intake becomes inadequate to meet the needs of an expanding erythron. This is the case in periods of rapid growth, such as infancy, childhood, and adolescence. Pregnancy
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Pregnancy and nursing place similar demands on the mothers body to provide iron for the developing fetus or nursing infant, as well as herself. What had previously been an adequate intake of iron for the individual becomes inadequate as the need for iron increases III.2.2 Increased iron loss Chronic loss A third way iron deficiency develops is with excessive loss of hemoglobin from the body. This occurs with slow hemorrhage or hemolysis. Any condition in which there is a slow, low level loss of red blood cell may result in iron deficiency. For women, heavy menstrual bleeding can constitute a chronic loss of blood leading to iron deficiency, as can bleeding associated with fibroid tumors. For either women or men, gastrointestinal bleeding from ulcers or tumors can be the cause. Loss of blood via the urinary tract with kidney stones or tumors can also lead to iron deficiency. Individuals with chronic intravascular hemolytic processes, such as paroxysmal nocturnal hemoglobinuria, can develop iron deficiency dur to the loss of iron in hemoglobin passed into the urine. III.2.3 Decreased iron intake or absorption Inadequate Intake IDA can develop as the erythron is slowly starved for iron. Each day, approximately 1 mg of iron is lost from the body, mainly in the mitochondria of desquamated skin and changing the layer of intestinal epithelium. Since the body persevering conserves all other iron from senescent cells, including red blood cells, replacing 1 mg of iron in the diet daily will maintain iron balance and supply the bodys need for red blood cell production. When the diet is consistently inadequate in iron, the bodys stores of iron will continue to be depleted. Ultimately, red blood cell production will slow due to the inability to produce hemoglobin. Since approximately 1% of cells naturally die each day, the anemia will become apparent when the production rate cannot replace lost cell.

III.3 Iron Deficiency Anemia in Elderly (7)

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In the absence of any history of hemorrhage, IDA in older people is sometimes related to diet, but is usually a result of digestive disorder. Focusing on digestive disorders, the etiology of IDA of gastrointestinal origin can be divided into two groups: situations with increased loss of iron and those with decreased iron absorption. III.3.1 Increased demand of iron Blood loss In post menopausal women the commonest cause blood loss from the gastrointestinal (GI) tract. III.3.2 Increased iron loss There could be a hidden bleeding, which might be more difficult to diagnose. Common causes include NSAID use, colonic cancer or polyp, gastric cancer, angiodysplasia, and inflammatory bowel disease. Rare causes include previous gastrectomy, intestinal teleangiectasia, lymphoma, leiomyoma and other small bowel tumour. The possible existence of a malignancy as the source of anemia, which leads to early completion of endoscopic examinations is a great concern. III.3.3 Decreased iron intake or absorption In the second category of etiology, reduced iron absorption can be caused by celiac disease, atrophic gastritis, and postsurgical status (gastrectomy, intestinal resection). In a study on patients referred to gastroenterologists because of IDA, celiac disease was the diagnosis in at least 2-3% of cases. Microscopic alterations in the duodenal mucosa in nontreated celiac disease will lead to a refractory condition in oral iron treatment. Gastroscopy with biopsy allowed detection of gastritis with or without H.pylori. The positivity of autoantibodies (anti-intrinsic factor or anti-parietal cell) supports the diagnosis of autoimmune atrophic gastritis. A recent meta-analysis concluded that the infection of H.pylori is associated with depleted iron deposits. The mechanism is not clear, but it appears

to involve gastrointestinal blood loss, diminished iron absorption from the diet, and increased consumption of iron by the bacteria.

CONCLUSION

Iron deficiency is one of the most prevalent forms of malnutrition. Generally causes of IDA are conditions that increase demand for iron, increase iron loss, or decrease iron intake or absorption. In this paper explain about the etiology of IDA into age-related categories, in infancy and childhood, adult, and elderly. In each age-related there are many causes. Such as in infancy
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and childhood we can found IDA in infant with low birthweight and unusual perinatal hemorrhage, and unusual caused by inadequate dietary iron. In order that, inadequate dietary iron, blood loss, histologic abnormalities mucosa of the gastrointestinal tract, and intensive exercise usually happened in older child. Beside that IDA can occurs in adult and elderly. In adult caused by inadequate intake, increases need such as a pregnant woman, and chronic loss. In older people IDA usually happen because of digestive disorder, such as increased loss of iron and decreased iron absorption.

REFFERENCES
1. Conrad M. Iron Deficiency Anemia. Available at: http://emedicine.medscape.com/article/202333overview. Accessed May 17, 2012.

2. Adamson JW. Iron Deficiency and Other Hypoproliferative Anemias. In : Harrisons Principles of Internal Medicine. 18th ed. United State of America : The McGraw-Hill Companies, 2012.
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3. Rodak BF. Hematology: Clinical Principles and Applications. 2nd ed. United State : Saunders, 2002. 4. Mansen TJ, McCance KL. Alteration of Hematologic Function. In : Understanding Pathofphysiology. 3rd ed. Missouri : Mosby, 2004.
5. Behrman, et al. Iron Deficiency Anemia. In: Nelson Textbook of Pediatric. 17 th ed.

Philadelphia : Saunders, 2005

6. Centers for Disease Control and Prevention. Iron deficiency United States, 19992000. Available at: http://www.cdc.gov/nutrition/everyone/basics/vitamins/iron.html. Accessed May 18, 2012 7. Kurniawan I. Iron Deficiency Anemia in Elderly. Med J Indones 2011; 20: 71-77.

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