eMedicine Specialties > Hematology > Red Blood Cells and Disorders

Iron Deficiency Anemia: Follow-up

Author: Marcel E Conrad, MD, (Retired) Distinguished Professor of Medicine, University of South Alabama
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Updated: Aug 4, 2009

Follow-up

Further Outpatient Care

• Monitor patients with iron deficiency anemia on an outpatient basis to ensure that there is an adequate response to iron therapy and that iron therapy is continued until after correction of the anemia to replenish body iron stores. Follow-up also may be important to treat any underlying cause of the iron deficiency.
• Response to iron therapy can be documented by an increase in reticulocytes 5-10 days after the initiation of iron therapy. The hemoglobin concentration increases about 1 g/dL weekly until normal values are restored. These responses are blunted in the presence of sustained blood loss or coexistent factors that impair hemoglobin synthesis.

Transfer

Transfer of a patient rarely is required for treatment of simple iron deficiency anemia; however, it may be necessary to identify the etiology of the anemia, such as occult blood loss undetected with chemical testing of stool specimens, for identification of a source of bleeding that requires endoscopic examinations or angiography or for treatment of an underlying major illness (eg, neoplasia, ulcerative colitis).

Deterrence/Prevention

• Certain populations are at sufficiently high risk of iron deficiency to warrant consideration for prophylactic iron therapy. These include pregnant women, women with menorrhagia, consumers of a strict vegetarian diet, infants, adolescent females, and regular blood donors.
• Pregnant women have been given supplemental iron since World War II. Often, this is administered in all-purpose capsules containing vitamins, calcium, and iron. If the patient is anemic (hemoglobin <11 g/dL), administer the iron at a different time of day than calcium because calcium inhibits iron absorption. The practice of routinely administering iron to pregnant females in affluent societies has been challenged recently; however, provide prophylactic iron therapy during the last one half of pregnancy, except in settings where careful follow-up for anemia and methods for measurement of serum iron and ferritin are readily available.
• Iron supplementation of the diet of infants is advocated. Premature infants require more iron supplementation than term infants. Infants weaned early and fed bovine milk require more iron because the higher concentration of calcium in cow milk inhibits absorption of iron. Usually, infants receive iron from fortified cereal. Additional iron is present in commercial milk formulas.
• Iron supplementation in populations living on a largely vegetarian diet is advisable because of the lower bioavailability of inorganic iron than heme iron.

Complications

• Iron deficiency anemia diminishes work performance by forcing muscles to depend, to a greater extent than in healthy individuals, upon anaerobic metabolism. This is believed to be due to deficiency in iron-containing respiratory enzymes rather than anemia.
• Severe anemia due to any cause may produce hypoxemia and enhance the occurrence of coronary insufficiency and myocardial ischemia. Likewise, it can worsen the pulmonary status of patients with chronic pulmonary disease.
• Defects in structure and function of epithelial tissues may be observed in iron deficiency. Fingernails may become brittle or longitudinally ridged with development of koilonychia (spoon-shaped nails). The tongue may show atrophy of the lingual papillae and develop a glossy appearance. Angular stomatitis may occur with fissures at the corners of the mouth. Dysphagia may occur with solid foods, with webbing of the mucosa at the junction of the hypopharynx and the esophagus (Plummer-Vinson syndrome); this has been associated with squamous cell carcinoma of the cricoid area. Atrophic gastritis occurs in iron deficiency with progressive loss of acid secretion, pepsin, and intrinsic factor and development of an antibody to gastric parietal cells. Small intestinal villi become blunted.
• Cold intolerance develops in one fifth of patients with chronic iron deficiency anemia and is manifested by vasomotor disturbances, neurologic pain, or numbness and tingling.
• Rarely, severe iron deficiency anemia is associated with papilledema, increased intracranial pressure, and the clinical picture of pseudotumor cerebri. These manifestations are corrected with iron therapy.
• Impaired immune function is reported in subjects who are iron deficient, and there are reports that these patients are prone to infection; however, evidence that this is directly due to iron deficiency is not convincing because of the presence of other factors.
• Children deficient in iron may exhibit behavioral disturbances. Neurologic development is impaired in infants and scholastic performance is reduced in children of school age. The IQ of school children deficient in iron is reported as significantly less than their nonanemic peers. Behavioral disturbances may manifest as an attention deficit disorder. Growth is impaired in infants with iron deficiency. All these manifestations improve following iron therapy.

Prognosis

Iron deficiency anemia is an easily treated disorder with an excellent outcome; however, it may be caused by an underlying condition with a poor prognosis, such as neoplasia. Similarly, the prognosis may be altered by a comorbid condition such as coronary artery disease.

Patient Education

• Physician education is needed to ensure a greater awareness of iron deficiency and the testing needed to establish the diagnosis properly. Physician education also is needed to investigate the etiology of the iron deficiency.
• Public health officials in geographic regions where iron deficiency is prevalent need to be aware of the significance of iron deficiency, its effect upon work performance, and the importance of providing iron during pregnancy and childhood. The addition of iron to basic foodstuffs is employed in these areas to diminish the problem.
• For excellent patient education resources, visit eMedicine's Blood and Lymphatic System Center and Esophagus, Stomach, and Intestine Center. Also, see eMedicine's patient education articles Anemia and Celiac Sprue.

Miscellaneous

Medicolegal Pitfalls

• Failure to investigate the etiology of the iron deficiency anemia causing a delayed or missed diagnosis of neoplasm
• Giving iron to patients who have a microcytic iron-overloading disorder (eg, thalassemia, sideroblastic anemia)
• Failure to promptly and adequately treat a patient with iron deficiency anemia who is symptomatic with a comorbid condition such as coronary artery disease
• Anaphylaxis pursuant to the use of parenteral iron therapy in patients who should be treated with oral iron

Special Concerns

• Special effort should be made to identify and treat iron deficiency during pregnancy and early childhood because of the effects of severe iron deficiency upon learning capability, growth, and development.
• The addition of iron to basic foodstuffs in affluent nations where meat is an important part of the diet is of questionable value and may be harmful. The gene for familial hemochromatosis (HFe gene) is prevalent (8% of US white population). Excess body iron is postulated to be important in the etiology of coronary artery disease, strokes, certain carcinomas, and neurodegenerative disorders because iron is important in free radical formation.

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