scholarly journals Iron Ladies: Variation in the Identification and Management of Iron Deficiency in Women with Bleeding Disorders

Blood ◽  
2021 ◽  
Vol 138 (Supplement 1) ◽  
pp. 1036-1036
Author(s):  
Meghan McCormick ◽  
Margaret V. Ragni
Keyword(s):  
Iron Deficiency ◽  
Board Of Directors ◽  
Iron Supplementation ◽  
Oral Iron ◽  
Deficiency Anemia ◽  
Bleeding Disorders ◽  
Medical Providers ◽  
Advisory Committees ◽  
Potential Health ◽  
Laboratory Measures

Abstract Background: Iron deficiency (ID) has negative clinical consequences on physical and cognitive abilities in adolescent and adult women. Women with heavy menstrual bleeding (HMB) are at particularly high risk for ID. Guidelines issued by the American College of Gynecology recommend obtaining a CBC and serum ferritin level to screen for ID in young women with HMB. Despite the high frequency of ID in women with HMB, there are no specific recommendations regarding screening in women with bleeding disorders (WBD), though 50% or more of this population may be affected by HMB. Information on the prevalence of ID and iron deficiency anemia in WBD is lacking. In addition, understanding of the optimal practice for iron supplementation has changed, with recent literature indicating less frequent supplementation improves iron absorption. We aimed to describe the screening practices for and management of ID in WBD through a survey of medical providers within hemophilia treatment centers (HTC). Methods: Electronic surveys were distributed by internet mail to medical providers who treat WBD within HTCs, based on membership rosters of the Hemostasis and Thrombosis Research Society and the American Thrombosis and Hemostasis Network. Data collected included indications for ID screening, laboratory measures for ID screening, iron supplementation in patients with ID (including route of administration, dose and dose frequency) and laboratory assessment to confirm iron repletion. Results: Responses were received from 62 medical providers. Providers reported seeing an average of 70 WBD/year (range 1-300), with ID identified in an average of 38 WBD/year (range 2-125). Screening for ID is completed in approximately 84.5% of WBD. Screening is a part of routine practice for 69.4% of providers, only 32.3% of respondents limit screening to women with HMB or other bleeding symptoms. Over 95% of providers utilize ferritin and hemoglobin to screen for ID. When ID is identified, oral supplementation is prescribed by 96.8% of those surveyed. The most used supplement is ferrous sulfate, with daily dosing employed by 54.8% of providers and alternate day dosing employed by 51.6% of providers. Oral iron dosing varies from 15mg to 325mg elemental iron per day (or 1-6mg/kg/day with weight-based dosing). Intravenous supplementation is prescribed by 80.6% of respondents. The most common indications include refractoriness to oral iron (75.8%) and non-compliance with oral iron (69.4%). The most recommended forms of IV iron are iron sucrose (43.5%) and ferric carboxymaltose (40.3%). Repeat labs are obtained to monitor iron repletion by 96.8% of providers, typically after three months of therapy, though the laboratory measures utilized vary widely. Discussion: All medical providers within HTCs report screening for ID in WBD, though not all WBD undergo screening. Notable variation is present in the formulation and dosing of iron supplementation used in patients with ID, as well as in follow-up practices. Given the prevalence of ID and its potential health burden, there is need for standardization of practices in screening of ID and iron replacement in WBD to promote early recognition and reduce the burden of disease in these women. This project was supported by funding through the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of HRSA H30MC2450 Figure 1 Figure 1. Disclosures Ragni: Alnylam (Sanofi): Membership on an entity's Board of Directors or advisory committees; University of Pittsburgh: Research Funding; BioMarin Pharmaceutical: Membership on an entity's Board of Directors or advisory committees; Bioverativ (Sanofi): Membership on an entity's Board of Directors or advisory committees; Spark Therapeutics: Membership on an entity's Board of Directors or advisory committees; Takeda Therapeutics: Membership on an entity's Board of Directors or advisory committees.

scholarly journals Iron supplementation in goitrous, iron-deficient children improves their response to oral iodized oil

2000 ◽  
pp. 217-223 ◽  
Author(s):  
M Zimmermann ◽  
P Adou ◽  
T Torresani ◽  
C Zeder ◽  
R Hurrell
Keyword(s):  
Iron Deficiency ◽  
Iron Deficiency Anemia ◽  
Iron Supplementation ◽  
Thyroid Volume ◽  
Oral Iron ◽  
Deficiency Anemia ◽  
Urinary Iodine Concentration ◽  
Iodized Oil ◽  
Iron Deficient ◽  
Group 2

OBJECTIVE: In developing countries, many children are at high risk for both goiter and iron-deficiency anemia. Because iron deficiency may impair thyroid metabolism, the aim of this study was to determine if iron supplementation improves the response to oral iodine in goitrous, iron-deficient anemic children. DESIGN: A trial of oral iodized oil followed by oral iron supplementation in an area of endemic goiter in the western Ivory Coast. METHODS: Goitrous, iodine-deficient children (aged 6-12 years; n=109) were divided into two groups: Group 1 consisted of goitrous children who were not anemic; Group 2 consisted of goitrous children who were iron-deficient anemic. Both groups were given 200mg oral iodine as iodized oil. Thyroid gland volume using ultrasound, urinary iodine concentration (UI), serum thyroxine (T(4)) and whole blood TSH were measured at baseline, and at 1, 5, 10, 15 and 30 weeks post intervention. Beginning at 30 weeks, the anemic group was given 60mg oral iron as ferrous sulfate four times/week for 12 weeks. At 50 and 65 weeks after oral iodine (8 and 23 weeks after completing iron supplementation), UI, TSH, T(4) and thyroid volume were remeasured. RESULTS: The prevalence of goiter at 30 weeks after oral iodine in Groups 1 and 2 was 12% and 64% respectively. Mean percent change in thyroid volume compared with baseline at 30 weeks in Groups 1 and 2 was -45.1% and -21.8% respectively (P<0.001 between groups). After iron supplementation in Group 2, there was a further decrease in mean thyroid volume from baseline in the anemic children (-34.8% and -38.4% at 50 and 65 weeks) and goiter prevalence fell to 31% and 20% at 50 and 65 weeks. CONCLUSION: Iron supplementation may improve the efficacy of oral iodized oil in goitrous children with iron-deficiency anemia.

Effects of Iron Status and Iron Supplementation on Salmonella Typhimurium and Plasmodium Yoelii Infection In Mice

Blood ◽  
2010 ◽  
Vol 116 (21) ◽  
pp. 2052-2052
Author(s):  
Eldad A. Hod ◽  
Eric H. Ekland ◽  
Shruti Sharma ◽  
Boguslaw S. Wojczyk ◽  
David A. Fidock ◽  
...  
Keyword(s):  
Iron Deficiency ◽  
Salmonella Typhimurium ◽  
Median Survival ◽  
Iron Supplementation ◽  
Iron Status ◽  
Plasmodium Yoelii ◽  
Oral Iron ◽  
Deficiency Anemia ◽  
Iron Deficient ◽  
Deficient Mice

Abstract Abstract 2052 To clarify the interactions between iron status, oral iron supplementation, and bacterial and malarial infections, we examined iron-replete mice and mice with dietary iron deficiency infected with Salmonella typhimurium, Plasmodium yoelii, or both, with and without oral iron administration. These studies were designed to identify potential mechanisms underlying the increased risk of severe illness and death in children in a malaria-endemic region who received routine iron and folic acid supplementation during a randomized, controlled trial in Pemba, Tanzania (Sazawal et al. Lancet 2006;367:133-43). To this end, weanling C57BL/6 female mice were fed an iron-replete or an iron-deficient diet, the latter of which resulted in severe iron deficiency anemia. Groups of mice were then infected by intraperitoneal injection of Salmonella typhimurium strain LT2, Plasmodium yoelii strain 17X parasites, or both. With Salmonella infection alone, iron-deficient mice had a median survival (7.5 days, N=8) approximately half that of iron-replete mice (13 days, N=10, p<0.0001). At death, the mean level of bacteremia was significantly higher in infected iron-deficient mice. In blood cultures performed at death, all iron-deficient mice were bacteremic, but bacteria were detected in only 4 of 10 iron-replete mice. Both iron-deficient and iron-replete Salmonella-infected mice had gross hepatosplenomegaly with hepatitis, distorted hepatic and splenic architecture, massive expansion of the splenic red pulp with inflammatory cells, and Gram-negative bacilli by tissue Gram stain. With P. yoelii infection alone, iron-deficient and iron-replete mice cleared the infection at similar rates (by ~13 days following infection, N=5 in each group) and no deaths due to parasitemia occurred. With Salmonella and P. yoelii co-infection, death was earlier than with Salmonella alone in iron-replete mice (median survival of 10 vs. 13 days; N=10 in each group; p=0.005), but not in iron-deficient mice (median survival of 7 vs. 7.5 days; N=10 and 8, respectively; p=0.8). To examine the effect of short-term oral iron supplementation with Salmonella infection alone, mice received daily iron (ferrous sulfate, 1 mg/kg) by gavage for 4 days before infection with Salmonella, and supplementation continued for a total of 10 days. After gavage, plasma non-transferrin-bound iron (NTBI) appeared at 1–2 hours with a mean peak level of approximately 5 μM. In iron-deficient mice, short-term oral iron supplementation did not fully correct the iron deficiency anemia or replenish iron stores. Oral iron supplementation reduced the median survival of both iron-deficient and iron-replete Salmonella-infected mice by approximately 1 day; the difference was significant only in the iron-replete group (N=5, p<0.05). In summary, these results indicate that iron deficiency decreases the survival of Salmonella-infected mice; the median survival of iron-deficient mice was approximately half that of those that were iron replete. These observations are similar to those in the Pemba sub-study in which iron-deficient children given placebo had a 200% increase in the risk of adverse events relative to iron-replete children. Iron deficiency had no apparent effect on the course of infection with P. yoelii but further studies with more virulent Plasmodium species are needed. Co-infection with Salmonella and Plasmodium significantly increased mortality as compared to single infections, but only in iron-replete mice. Oral iron supplementation of Salmonella-infected mice significantly decreased the median survival, but only of iron-replete animals; however, our study may have had insufficient power to detect an effect on iron-deficient mice. Systematic examination in mice of the effect of iron supplements on the severity of malarial and bacterial infection in iron-replete and iron-deficient states may ultimately help guide the safe and effective use of iron interventions in humans in areas with endemic malaria. Disclosures: No relevant conflicts of interest to declare.

Investigation of ischemia modified albumin levels in iron deficiency anemia

2017 ◽  
Vol 42 (3) ◽  
Author(s):  
Sibel Bilgili ◽  
Giray Bozkaya ◽  
Funda Kırtay Tütüncüler ◽  
Murat Akşit ◽  
Mehmet Yavuz
Keyword(s):  
Iron Deficiency ◽  
Iron Deficiency Anemia ◽  
Iron Supplementation ◽  
Binding Capacity ◽  
Oral Iron ◽  
Deficiency Anemia ◽  
Control Group ◽  
Ischemia Modified Albumin ◽  
Before And After ◽  
Anemia Group

AbstractObjective:The aim of this study was to evaluate the levels of ischemia-modified albumin (IMA), before and after oral iron supplementation in iron deficiency anemia and to determine the correlations between IMA and hemoglobin values.Study design:IMA, hemoglobin, hematocrit, mean corpuscular volume, ferritin, iron, total iron binding capacity and albumin levels were measured in 140 female patients with newly established as iron deficiency anemia before and after treatment and in 84 female healthy controls.Results:IMA levels were higher in the anemia group [0.340±0.082 absorbance units (ABSU)] compared to control group (0.291±0.077 ABSU). After oral iron therapy we saw that IMA values (0.392±0.080 ABSU) were higher than the IMA levels of the anemia group and the control group (p<0.05). Only in the anemia group there were negative correlations between IMA and hemoglobin, hematocrit.Conclusion:We conclude that the high levels of IMA in the anemia group might be attributed to hypoxia due to low hemoglobin levels. Iron is an oxidant element and oral iron supplementation may be associated with oxidative stress and may increase IMA levels by changing the albumin molecule. We thought that, IMA can be demonstrative of the severity of anemia since it was correlated with hemoglobin in the anemia group.

A Survey of the Etiology of Immune Thrombocytopenia (ITP).

Blood ◽  
2012 ◽  
Vol 120 (21) ◽  
pp. 2239-2239
Author(s):  
Valerie Arias ◽  
Ehsan Shabbir ◽  
Daniel Victorio ◽  
Emily Sperling ◽  
Naznin Haq ◽  
...  
Keyword(s):  
Statistical Analysis ◽  
Family History ◽  
Iron Deficiency ◽  
Board Of Directors ◽  
Research Funding ◽  
Pediatric Patients ◽  
Deficiency Anemia ◽  
Advisory Committees ◽  
Formal Statistical Analysis ◽  
History Of

Abstract Abstract 2239 Introduction: Socioeconomic, environmental, lifestyle and genetic factors play a role in the etiology of ITP but are poorly understood. A self-reported questionnaire was designed to study these relationships and how these factors prior to the diagnosis of ITP relate to treatment response and disease progression in order to gain insight into the etiology of ITP. Methods: To design the questionnaire that would address topics of interest: 1) 60 ITP patient interviews were performed and 2) the questionnaire was reviewed by project coordinators, nurse practitioners, Platelet Disorder Support Association (PDSA) members, and hematologists. The input was incorporated into a further-revised questionnaire, which was then administered to both “pediatric” (patients <18 years of age at the time of diagnosis) and adult ITP patients from the Platelet Disorders Center at Weill Cornell - New York Presbyterian Hospital. Formal statistical analysis to relate responses to one question to responses of another to define sub-groups of patients is ongoing. Results: 109 patients were enrolled. Ages ranged from 2–78 years of age; median age was 55 years, with 21 females and 33 “pediatric” patients. The most frequent environmental exposures in adults were automotive exhaust (n=14) and Teflon (n=12). In pediatrics, preservatives and insecticides (n=8) and Teflon (n=7) were most common. The most prevalent hazardous substances in both groups were cleaning supplies (n=16 adults, n=9 “pediatric”) and chlorinated water (n=13 adult, n=9 “pediatric”). 13 adults also had exposure to gasoline or diesel fumes. Refer to figure 1. 51(47%) patients reported at least one infection prior to diagnosis with ITP. The most common were Strep throat (n=12); influenza (n=9), and respiratory tract infections (n=8). Twenty-four (22%) patients reported at least one autoimmune disease, including celiac (n=2) and discoid lupus (n=2).Twenty-one patients reported a family history of Type II diabetes, 12 Type I diabetes, 13 osteoarthritis and 10 rheumatoid arthritis. Eight (7%) patients reported at least one inflammatory disease including: Crohn's disease (n=3), Inflammatory bowel disease (n=7), Systemic lupus erythematous and Vitiligo(each n=1). Thirty-seven (34%) patients reported surgeries prior to diagnosis of ITP, especially: appendectomy (n=8) and tonsil removal (n=8). Twenty-three patients traveled close to date of diagnosis, 58 patients reported more stress than usual (i.e. death of a relative, loss of employment); 13 patients reported a drastic change in diet (i.e. decreasing calories (n=7) or becoming vegetarian (n=5)). Vitamin supplementation for vitamin C and D (each n=17), E (n=12) and B (n=11) were common. In addition, 11 vitamin deficiencies were reported, vitamin D (n=5), vitamin B12 (n=3) and other (n=3). The most frequent allergic reactions included: 31 (28%) patients with hay fever, 9 patients with allergies to milk, 7 patients with poison ivy or skin irritation, 6 patients with eczema, and 4 with allergic rhinitis. Other medical conditions reported were: hypothyroidism (n=10), hyperthyroidism (n=9), high blood pressure (N=16), high cholesterol (N=14), and anemia (N=13) [9 additional patients included 4 with iron deficiency anemia and 5 with a family history of iron deficiency anemia]. Seven patients reported a lack of prenatal care in their mothers' pregnancy and 7 were premature. Medications reported include: acetaminophen (n=53), antibiotics (n=36), antihistamines (n=22), and hormone therapy (n=17). Vaccinations received close to date of diagnosis include: flu vaccine (n=10) and T-dap (n=9). Prednisone was reported most frequently as both the best therapy to minimize symptoms (n=18) and the worst (n=16). Conclusion: Our pilot study intended to capture critical information and to further development of the questionnaire. We can see if there are groups of patients in whom onset and other characteristics relate to outcomes including response to treatment. Following formal statistical analysis of the material acquired (in progress and anticipated by early September), the next step will be for a final updated version of the questionnaire to be posted on the PDSA web site in order to accrue responses from a much larger number of patients. The questionnaire will also be given to a non-ITP patient population to serve as controls. Disclosures: Bussel: Amgen: Family owns Amgen stock Other, Membership on an entity's Board of Directors or advisory committees, Research Funding; Cangene: Research Funding; GlaxoSmithKline: Family owns GSK stock, Family owns GSK stock Other, Membership on an entity's Board of Directors or advisory committees, Research Funding; Genzyme: Research Funding; IgG of America: Research Funding; Immunomedics: Research Funding; Ligand: Membership on an entity's Board of Directors or advisory committees, Research Funding; Eisai: Membership on an entity's Board of Directors or advisory committees, Research Funding; Shionogi: Membership on an entity's Board of Directors or advisory committees, Research Funding; Sysmex: Research Funding; Portola: Consultancy. Off Label Use: The use of romiplostim in pediatric patients was examined in this study.

Analysis Of TMPRSS6 Polymorphisms In Patients With Iron Deficiency Anemia Partially Responsive To Oral Iron Treatment

Blood ◽  
2013 ◽  
Vol 122 (21) ◽  
pp. 3438-3438 ◽  
Author(s):  
Erika Poggiali ◽  
Fabio Andreozzi ◽  
Isabella Nava ◽  
Paola Delbini ◽  
Lorena Duca ◽  
...  
Keyword(s):  
Iron Deficiency ◽  
Iron Deficiency Anemia ◽  
Iron Supplementation ◽  
Rare Variants ◽  
Hematological Parameters ◽  
Oral Iron ◽  
Deficiency Anemia ◽  
Healthy Donors ◽  
New Variant ◽  
Parenteral Iron

Abstract Introduction Iron Refractory Iron Deficiency Anemia (IRIDA) is an autosomal recessive form of iron deficiency anemia (IDA) caused by mutations in TMPRSS6 gene, and characterized by unresponsiveness to oral iron supplementation and low effectiveness of parenteral iron administration (Finberg 2009). So far 50 cases from 32 families have been reported and 40 mutations have been identified (De Falco 2013). Although mutations are extremely rare, recent insights have revealed that highly frequent polymorphisms of TMPRSS6 gene may influence iron absorption, being associated with increased risk of IDA (An 2012). Patients and Methods Between January 2009 and May 2013, 88 subjects (11 males, 77 females) with mean age 39+/-14 years were referred to the Hereditary Anemia Centre of “Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico di Milano” for persistent IDA poorly responsive to oral iron. All the patients (pts) were investigated for celiac disease, gastrointestinal bleeding, and HP infection. Hematological parameters, iron status, inflammatory markers, and thyroid function were tested. Sequence variation in TMPRSS6 gene was evaluated by PCR and direct sequencing in genomic DNA isolated from peripheral lymphocytes. Thalassemia trait was suspected and investigated in 27/88 (31%) pts (3 males, 24 females) using HPLC and genetic analysis of globin chains. Fifty healthy donors (15 females, 35 males) with mean age 28±9 yrs were used as control group. Results Frequency of SNP-120, SNP-113, P33P, K253E, Y418Y, D521D, Δ15accc and V739Y results significantly different between pts and controls. Association study revealed that in pts homozygosis for V736A is frequently associated with homozygosis for D521D and Y739Y, while polymorphic alleles F5F, P33P, K253E, S361S, Δ15accc are linked to V736A trans-allele. Based on the observation that homozygosis for V736A is not present in healthy control, we analyzed the hematological parameters in anemic pts homozygotes, heterozygotes, and wild type for V736A. No significant differences were found (table 1). Considering only the thalassemia pts, the combination of thalassemia trait and V736A is associated with a more severe anemia (Hb 10.3±1.4 g/dL, MCV 62.9±6.7 fL median ferritin 30 ng/mL), requiring blood transfusion in particular circumstances (pregnancy, surgery). Moreover, one new variant (H448R) was identified in a pt with IDA requiring parenteral iron supplementation. Two rare variants, A719T and V795I (estimated frequency 0.000/1 and 0.004/9), were detected respectively in two sisters, causing the IRIDA phenotype only in one, and in two patients, who require parenteral iron therapy. Discussion and Conclusion Several TMPRSS6 polymorphisms are more frequent in anemic pts than in healthy donors, suggesting their role in the refractoriness to oral iron. No significant differences were observed in hematological data related to V736A genotype. This is not surprising because all the pts were previously treated with iron therapy, which contribute to partially reduce the degree of anemia. In this study we found peculiar haplotypes, a new variant (H448R) and two rare variants (A719T and V795I), which may account for impairment in TMPRSS6 activity. Further studies are necessary to clarify the role of TMPRSS6 polymorphysms, which will allow identifying individuals at risk for more severe IDA, particularly in thalassemia pts, driving to correct diagnosis and management of iron supplementation, sparing to the patient inadequate therapeutic choices and diagnostic procedures. Disclosures: Cappellini: NOVARTIS: Membership on an entity’s Board of Directors or advisory committees.

scholarly journals Variability in Oral Iron Prescription and the Effect on Spanish Mothers’ Health: A Prospective Longitudinal Study

2021 ◽  
Vol 10 (21) ◽  
pp. 5212
Author(s):  
Regina Ruiz de Viñaspre-Hernández ◽  
José Antonio García-Erce ◽  
Francisco José Rodríguez-Velasco ◽  
Vicente Gea-Caballero ◽  
Teresa Sufrate-Sorzano ◽  
...  
Keyword(s):  
Iron Deficiency ◽  
Iron Supplementation ◽  
Perceived Health ◽  
Oral Iron ◽  
Deficiency Anemia ◽  
Lower Probability ◽  
Iron Intake ◽  
Prospective Longitudinal Study ◽  
Wide Variability ◽  
Prospective Longitudinal

Background: No consensus exists regarding the hemoglobin (Hb) values that define postpartum anemia. Knowledge is currently lacking regarding prescription and consumption practices, which prevents evaluating the rational use of iron supplementation postpartum. Aim: In this study, our objective was to describe this practice and analyze its association with maternal health outcomes. Methods: A prospective observational study was conducted with 1010 women aged between 18 and 50. The hemoglobin value on the first postpartum day; the prescription schedule at hospital discharge; iron consumption; and data on hemoglobin, serum ferritin, maternal fatigue, type of breastfeeding, and perceived health six weeks after delivery were collected. Findings: Oral iron was prescribed to 98.1% of mothers with anemia and 75.8% without anemia. At the same Hb value, the maximum amount of total iron prescribed was between 8 and 10 times greater than the minimum amount. Iron intake was significantly lower than prescribed (p < 0.01). At six weeks, anemic mothers who took iron presented a 3.6-, 3-, and 2.4-times lower probability of iron deficiency, anemia, and abandoning breastfeeding, respectively. Discussion: Postpartum iron intake shows a protective effect on iron deficiency and anemia at six weeks, but not on fatigue or self-perceived health level. Conclusion: We conclude that there is wide variability in the prescription regimen. Oral iron supplementation can benefit mothers with anemia and harm those without. Subsequent studies should further explore the Hb figure that better discriminates the need for postpartum iron.

Iron Deficiency Anemia in Infants and Toddlers – Role of Milk and Constipation

Blood ◽  
2012 ◽  
Vol 120 (21) ◽  
pp. 5171-5171
Author(s):  
Madhavi Lakkaraja ◽  
Lesley Small ◽  
Maura Frank ◽  
Aliza Solomon ◽  
Nicole Kucine ◽  
...  
Keyword(s):  
Iron Deficiency ◽  
Board Of Directors ◽  
Research Funding ◽  
Deficiency Anemia ◽  
Infants And Toddlers ◽  
Iron Intake ◽  
Advisory Committees ◽  
Phone Calls ◽  
History Of ◽  
Equity Ownership

Abstract Abstract 5171 Introduction: One of the most common nutritional deficiencies in the world is iron-deficiency anemia and young children are at high risk of developing it. In spite of fortification of foods in the United States, there is a high prevalence of anemia in infants and toddlers increasing their risk of neuro-developmental effects. Constipation is defined as delay or difficulty in defecation ≥ 2 weeks. Around one year of age, various changes are commonly implemented in a child's diet including introduction of whole milk and solids. Children may then present with sub-clinical colitis, constipation and anemia secondary to blood loss in stool or develop anemia due to increased consumption of milk. The American Academy of Pediatrics (AAP) recommends screening for anemia at 1 year and 2 year visits. The only clue to intolerance to milk may be symptomatic constipation and treating the anemia and switching the type of milk often helps to resolve this problem. This study explores the relation between iron deficiency, constipation and milk. Methods: This is an ongoing prospective study, which has been extended from Cornell to different centers. Data presented here is only from the Cornell principal site. Children between 6 months and 30 months visiting the resident's pediatric clinic and having routine blood work drawn as a part of their visit were included in the study. The National Health Sciences (NHS) Constipation questionnaire was administered to the parents of these children; ≥ 2 was considered Constipation. In addition, a detailed diet history of the child, and history of medicines and illness was taken and questions were asked about family history of anemia, constipation and allergies. If the mother was breast feeding, questions were asked about her dairy intake. Comparisons were made between children with and without constipation/iron deficiency. If the child had Hemoglobin (Hgb) <11, the child was started on Iron as per clinic policy, and phone calls were made to check for compliance with Iron. In addition letters including a printed calendar and a note on Iron rich foods were mailed out to the parents. Results: Two hundred five children, 92 females and 113 males between 8 and 30 months mean age 16. 7 months, are enrolled in the study. Seventy-two children (35 %) were constipated (score ≥2). Forty-two children (20. 5%) had Hgb <11. Children who had Hgb < 11 were not more constipated (45%) than those who had Hgb ≥11 (35%). In the Hgb <11 group, there was no significant difference in Hgb between children with and without constipation (p = 0. 19), however there was a difference in Hgb between infants with a Constipation score 0 and score 1 (p = 0. 03). Of the 42 children who had Hgb <11, 3 were later found to have sickle trait or alpha thalassemia trait, which were identified when iron intake did not improve the Hgb level. Compliance with Iron: Of the 39 children who were on Iron, 9 parents could not be reached via phone. Only 6 parents gave no Iron at all but another 12 did not give Iron properly resulting in 18/30 or 60% of infants/toddlers not receiving an adequate trial of replacement Iron. Among the side effects of Iron, one parent felt Iron caused rash on back and wanted multivitamin with Iron after finishing a month's course, one child had discoloration of teeth, so the parent gave it with juice. Two parents with infants with apparent true milk protein allergy colitis said constipation improved with diet change and iron. Conclusions: The prevalence of mild anemia is high in infants and toddlers. There was no clear association of constipation and anemia. Compliance is one of the key factors for Iron replacement therapy and in view of how erratic compliance was, it is imperative to give proper instructions to the parent while prescribing Iron. Material to better indicate which foods were rich in iron and follow-up phone calls were included in the management to optimize iron intake of anemic children. We will include more patients, more closely monitor the change in the diet of the child, and monitor responses to Iron therapy in children with low Hgb. In addition, different practices at other involved centers e. g. Brooklyn hospital Center may allow comparison of the time of screening (9 months v/s 1 year) and testing with Hemoglobin/Hematocrit versus a full Complete Blood Count with indices. Disclosures: Bussel: Amgen: Equity Ownership, Membership on an entity's Board of Directors or advisory committees, Research Funding; Cangene: Research Funding; GlaxoSmithKline: Equity Ownership, Membership on an entity's Board of Directors or advisory committees, Research Funding; Genzyme: Research Funding; IgG of America: Research Funding; Immunomedics: Research Funding; Ligand: Membership on an entity's Board of Directors or advisory committees, Research Funding; Eisai, Inc: Membership on an entity's Board of Directors or advisory committees, Research Funding; Shinogi: Membership on an entity's Board of Directors or advisory committees, Research Funding; Symphogen: Membership on an entity's Board of Directors or advisory committees; Sysmex: Research Funding; Portola: Consultancy.

scholarly journals E-Iron: Rethinking the Way We Deliver Intravenous Iron. Report of a Pilot Telemedicine Initiative

Blood ◽  
2020 ◽  
Vol 136 (Supplement 1) ◽  
pp. 16-17
Author(s):  
Mark Chaitowitz ◽  
Sharon Rikin
Keyword(s):  
Iron Deficiency ◽  
Iron Supplementation ◽  
Conflicts Of Interest ◽  
Intravenous Iron ◽  
Pilot Project ◽  
Lessons Learned ◽  
Oral Iron ◽  
Deficiency Anemia ◽  
Due Dates ◽  
Face To Face

Introduction Iron deficiency is common in the community, affecting upwards of a third of females in their childbearing years. The majority of patients with iron deficiency anemia (IDA) will be successfully managed with simple oral iron supplementation. However, a substantial proportion will only achieve normal hematocrits after protracted courses of treatment, often entailing significant GI toxicity. In recent years, with the availability of formulations that allow for total dose infusion, the role of intravenous iron (IVI) has become increasingly appreciated as a rapid, reliable, and safe strategy in addressing IDA. Historically, at our institution and at many others, the path to IVI treatment entails initial referral to hematology, a face-to-face evaluation at a hematology clinic, followed by scheduling for infusion on another visit. The median time from referral to infusion is approximately 35 days, with timing of infusions determined not by clinical considerations, but by chair availability and the whims of non-clinical personnel entrusted with the scheduling. Inappropriate delays are common, and of practical import when occurring, say, in pregnant women approaching their due dates, or patients scheduled for surgery. With the purpose of expediting the above process, capitalizing on a robust e-consult platform already operational at our institution, e-IRON was made available to referring providers as a function in the EPIC EMR, that facilitates an 'electronic' referral to hematology, for consideration for IVI. A template-based design ensures that all information required (indication, experience with oral iron, current lab-work, etc.) is included. Following the institutional protocol for e-consults, e-IRON referrals are 'chart-reviewed' by a specialist hematologist within 3 business days, and a determination regarding IVI is made. If deemed appropriate, the patient is scheduled for infusion within 10 business days. The specialist also specifies whether a face-to-face hematology appointment is required, and in cases where IVI is not deemed appropriate, will provide guidance as to alternate management. Results During the initial 75 day evaluation period 81 e-IRON referral were received. Indications are listed in table 1, and responses in table 2. The largest subgroup of referrals was from the prenatal clinics, likely as a result of a proactive protocol for management of IDA in pregnancy adopted by the department of obstetrics in conjunction with hematology. Of note, IVI was approved and scheduled for 60 of 81 (74%) patients, of which only 2 were required to be seen by hematology. Reasons for non-approval of IVI varied, but the most common reason cited was an inadequate trial of oral iron, in which case specific instructions were provided for oral iron supplementation. In one notable case, wherein a referred patient's anemia was felt to be discordant with his degree of iron deficiency, a more extensive workup was recommended resulting in a diagnosis of previously unsuspected myeloma. Recommendations were generated within 3 business days for 77 (95%) consults and in 1 day for 47 (58%). Recommended IVI regimens all entailed 1 or 2 infusion days, depending on the estimated iron deficit, and all first infusions were scheduled within 2 weeks of the request. Conclusion The e-IRON pilot project demonstrates the feasibility and efficacy of a telemedicine approach in triaging, and expediting the management of patients requiring IVI. Using a template-based e-consult platform, reviewing hematologists are in the vast majority of cases able to rapidly determine appropriate management, and facilitate IVI when appropriate. The platform ensures effective supervision by specialist hematologists, but dispenses with the laborious, costly, and time consuming traditional requirement of a face-to-face visit to the hematology clinic. The value of this paradigm shift in patient care is underscored by lessons learned during the ongoing COVID19 pandemic. Disclosures No relevant conflicts of interest to declare.

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