The most common cause of anemia worldwide is iron deficiency anemia, which results in microcytic and hypochromic red cells on the peripheral smear. Nonspecific complaints such as fatigue and dyspnea on exertion are common. Patients with iron deficiency anemia have a longer hospital stay and more adverse events. This activity examines the causes and symptoms of iron deficiency anemia, as well as the role of the interprofessional team in the care of these patients.
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Determine the cause of iron deficiency anemia.
Examine the case of a patient with iron deficiency anemia.
Outline the available treatment and management options for iron deficiency anemia.
Explain why it is critical to improve care coordination among interprofessional team members to improve outcomes for patients suffering from iron deficiency anemia.
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Anemia is hemoglobin levels less than two standard deviations below the mean for the patient’s age and gender. Iron is required for the formation of the hemoglobin molecule. Iron deficiency is the most common cause of anemia worldwide, resulting in microcytic and hypochromic red cells on the peripheral smear. The causes of iron deficiency differ depending on age, gender, and socioeconomic status. Nonspecific complaints such as fatigue and dyspnea on exertion are common. The underlying condition is reversed, and iron supplementation is used as treatment. Iron supplementation is usually done orally, but in some cases, intravenous iron is required. Patients with iron-deficient anemia have a longer hospital stay and more adverse events. 
Various factors, including age, gender, and socioeconomic status, cause iron-deficiency anemia. Inadequate iron intake decreased absorption, or blood loss can all lead to iron deficiency. Iron deficiency anemia is most commonly caused by blood loss, particularly in elderly patients. Low dietary intake, increased systemic iron requirements, such as during pregnancy, and decreased iron absorption, such as in celiac disease, can all cause it. Breastfeeding protects against iron deficiency in neonates because iron is more bioavailable in breast milk than in cow’s milk; iron deficiency anemia is the most common type of anemia in young children on cow’s milk. A parasitic infestation is also a major cause of iron deficiency anemia in developing countries. Green vegetables, red meat, and iron-fortified milk formulas are all good sources of iron.  
Anemia affects approximately 25% of the world’s population. Iron deficiency is the most common cause of anemia, accounting for 50% of all cases. Iron deficiency is more prevalent in developing countries than in the United States, where iron-deficiency anemia affects 1% of men under 50. In the United States, 10% of women of childbearing age are iron-deficient due to menstrual losses, while 9% of children aged 12 to 36 months are iron-deficient, with one-third developing anemia. While the prevalence of iron deficiency anemia in the United States is low, low-income families are particularly vulnerable.  
Pathophysiology is a good place to start.
Iron is required for hemoglobin production. Iron stores may be depleted due to blood loss, decreased intake, impaired absorption, or increased demand. Occult gastrointestinal bleeding can cause iron deficiency anemia. Adults over 50 with iron deficiency anemia and gastrointestinal bleeding should be evaluated for cancer. However, in one-third of patients evaluated, gastrointestinal diagnostic evaluation fails to identify a cause. On a peripheral blood smear, iron deficiency results in microcytic hypochromic anemia. The American Academy of Pediatrics recommends iron supplementation because it is the most common single nutrient deficiency. When to start supplementing and how much to take depends on the child’s age and diet.
A bone marrow sample stained for iron, such as a Prussian blue stain, will reveal low iron levels in macrophages.
Visit the following pages: History and Physical.
The majority of patients are asymptomatic and are diagnosed through a blood test. The most important clinical sign is whiteness, which is usually not visible until hemoglobin drops from 7 g/dL to 8 g/dL. A thorough history may reveal fatigue, diminished workability, shortness of breath, or worsening congestive heart failure. Cognitive impairment and developmental delays in children are possible. Patients should be asked about their diet and any bleeding from menorrhagia or gastrointestinal sources. Pale skin and conjunctiva, resting tachycardia, congestive heart failure, and guaiac-positive stool may be discovered during the physical exam.
Anemia will be discovered through laboratory testing. In iron deficiency, hemoglobin indices will show low mean corpuscular and mean corpuscular hemoglobin volume. Microcytosis, hypochromic, and anisocytosis are revealed by dermatoscopy, as evidenced by a red cell distribution width that exceeds the reference range. Ferritin, iron, and transferrin saturation levels in the blood will fall. Serum ferritin is a measure of the total iron stored in the body. The total capacity for iron binding will be increased. Occult blood in the stool may reveal a gastrointestinal source of bleeding. A simple Mentzer index, or mean corpuscular hemoglobin/RBC index, can help distinguish between the two causes of microcytic/hypochromic anemia. Iron deficiency and thalassemia minor are the causes. A score of 15 or higher indicates an iron deficiency, while a score of 11 or lower indicates thalassemia minor. Hemoglobin electrophoresis is the definitive test for ruling out thalassemia minor. Other tests like an iron profile are necessary for severe anemia or when anemia does not respond to iron therapy. Low ferritin is a reliable marker of iron deficiency. However, a ferritin level within the reference range or elevated is not very useful in patients with inflammatory conditions such as malignancies, infection, and collagen disease. This is because it is an acute-phase reactant. The standard for establishing iron deficiency is a bone marrow aspiration or biopsy followed by iron staining since it is unaffected by inflammation. However, the cost and invasiveness of this test make it less feasible; it is rarely performed for this reason. 
Go to:\sTreatment / Management
The treatment of iron-deficiency anemia includes treating the underlying cause, such as gastrointestinal bleeding and oral iron supplementation. Iron supplementation should be taken without food to increase absorption. Low gastric pH facilitates iron absorption. Rapid response to treatment is often seen in 14 days. The rise in hemoglobin levels manifests it. Iron supplementation is needed for at least three months to replenish tissue iron stores and should proceed for at least a month even after hemoglobin has returned to normal levels. Ferrous sulfate is an inexpensive and effective therapy, usually given in two to three divided doses daily. The adverse effects of oral iron include constipation, nausea, decreased appetite, and diarrhea. Intravenous iron may be required if the patient is intolerant to oral iron, has malabsorption such as celiac disease, post-gastrectomy, or achlorhydria, or the losses are too high for oral therapy. Although intravenous iron is more reliably and quickly distributed to the reticuloendothelial system than oral iron, it does not provide for a more rapid increase in hemoglobin levels.
The most common adverse effect of intravenous iron is nausea. While rare, anaphylaxis may occur with intravenous iron infusions. Extravasation of iron solutions into the subcutaneous tissue causes brownish stains that can be permanent and aesthetically unpleasant for the patient. Dietary counseling is usually necessary for management. Teenage girls experiencing excessive menstrual blood loss may benefit from iron and hormonal therapy.  
Go to:\sDifferential Diagnosis
The differential diagnosis of iron deficiency anemia includes:
Anemia of chronic disease
Hemoglobin CC disease
Hemoglobin DD disease
Autoimmune hemolytic anemia
Hemoglobin S-beta thalassemia
The short-term prognosis for most patients is excellent. However, if the underlying cause is corrected, the prognosis is better.
Chronic iron deficiency can lead to death from an underlying lung or heart disorder.
The complications of iron deficiency anemia include:
Increased risk of infections
Developmental delay in children
Go to:\sPostoperative and Rehabilitation Care
Those with severe iron deficiency anemia should limit physical activity until the anemia has been corrected.
March hemoglobinuria can also lead to iron deficiency anemia and may require some modification in either shoe wear or physical activity.
The following should be consulted in iron deficiency anemia:
Surgeon, if there is a surgical gastrointestinal cause
Gastroenterologist for endoscopy and localization of the gastrointestinal tract bleeding
Radiologist if the bleeding is brisk and can be managed by embolization
Deterrence and Patient Education
Populations at high risk should be considered for prophylaxis with iron therapy. These groups include women with heavy menstrual cycles, frequent blood donors, adolescent girls, and people who eat strict vegetarian diets. Empirical iron supplements for everyone are not recommended as there is no evidence that this is beneficial but may be harmful.
Go to:\sPearls and Other Issues.
Patients often have nonspecific symptoms of anemia, and a careful history and physical examination are needed. In the pediatric population, routine screening starting at 9 to 12 months and annually after that has helped prevent the development of severe anemia. Evaluating the gastrointestinal system as a potential cause of iron-deficient anemia in the adult population can be a diagnostic challenge. The emerging role of less invasive testing for celiac disease, autoimmune atrophic gastritis, and Heliobacter pylori infections has improved disease recognition and diagnosis. While there is always the potential for relapse after iron supplementation, there is a lack of guidance regarding when to stop iron supplementation. An additional pitfall of iron deficiency anemia is worse outcomes with many medical conditions. Some adverse effects of iron-deficient anemia patients are higher mortality, more extended hospital stays, and more cardiovascular events.
Go to:\sEnhancing Healthcare Team Outcomes.
Although iron deficiency is one of the oldest and most common medical disorders, the condition still has not received adequate clinical attention and evaluation. Many children, elderly patients, and pregnant women continue to have undiagnosed iron deficiency anemia or remain under-treated. Evidence from an interprofessional panel of clinicians reveals that iron-deficiency anemia has a high prevalence in hospitalized patients. It is associated with worse outcomes, including extended hospital stays and poor quality of life. There are also risks for those who receive blood transfusions. The panel has recommended several strategies for early diagnosis, treatment, and follow-up of these patients.  The most critical recommendation is a prompt referral to a specialist; not all causes of iron deficiency anemia are merely due to gastrointestinal bleeding or heavy menstrual cycles. The primary care healthcare provider plays a vital role as they are almost always the first to note the presence of iron deficiency anemia. Others who are essential in detecting iron-deficiency anemia include the following:
Laboratory technologists determine serum ferritin, transferrin, vitamin levels, and the entire system’s function.
Hematologists determine the cause.
Pharmacists determine the best formula for iron and the presence of adverse effects. Replacement therapy is either intravenous or oral iron formulas, with red cell transfusions reserved for emergencies. Each has its benefits and limitations.
Nurses ensure compliance with treatment and educate patients on symptoms and signs of anemia.
Internists follow and monitor patients.
The United States Preventive Services Task Force has concluded that the evidence is not sufficient to assess the balance of benefits and harms of screening for iron deficiency anemia in pregnant women and children ages 6 to 24 months.
Most studies on iron replacement therapies were done several decades ago. Many of these studies were not randomized, and the follow-up appointments needed longer. Reports of treatment of iron deficiency anemia are all based on expert opinion, but there is a clear benefit of treatment during the short term.  [Level V] There remain significant gaps in how long the treatment should be done, ethnic differences in response to iron, and who is at risk for developing adverse reactions.
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