LEITÃO, Waldeir de Sousa 
OLIVEIRA, Euzébio de 
LEITÃO, Waldeir de Sousa; OLIVEIRA, Euzébio de – Infant iron deficiency anemia in Brazil: a systematic review of the literature. Multidisciplinary Core scientific journal of knowledge. 1 year; Vol. 5; pp-24 36, July, 2016. ISSN 0959-2448
Iron deficiency anemia, especially from the diet, is considered the most prevalent disease in the world, being called iron deficiency anemia, affecting mainly children and women. Studies conducted in different regions of Brazil have shown a high prevalence of the disease in the country, in all ages and economic levels of this class more hit. There are still no national survey studies of the disease, but some of the studies carried out by the higher prevalence of bipolar disorder iron deficiency anemia in children in the southeast of the country. Due to the magnitude of the problem and the scope of its risk factors, developed this study, aimed at systematizing articles published in the year 2000 to 2015 inherent to the topic. Surveys carried out by the World Health Organization indicate that half of the children under five years of age in developing countries, suffer from iron deficiency anemia, and in Brazil studies report an incidence average around 35% between the ages of one and four years. Inadequate intake of iron in heme shape, low socioeconomic status, the precarious conditions of sanitation and the incidence of parasitic diseases are the main causes of iron deficiency anemia in children. On this issue, it is concluded that the iron deficiency anemia in infancy presents multiple causes, which requires joint action of several strategies to combat, including medication supplementation routine actions of iron, iron fortification in foods used in baby food and dietary education programs to better matching of total and bioavailable iron.
Keywords: iron deficiency Anemia. Childhood. Iron deficiency. Brazil.
Anemia is defined by the World Health Organization (who) as "a condition in which the concentration of hemoglobin in the blood is abnormally low as a result of the lack of one or more essential nutrients, whatever the source of this grace period". Have iron deficiency anemia is the result of long period of negative balance between the amount of biologically available iron and the need of this organic trace element (Z; HAWK; PASQUINI, 2004; Jordan; BERNARDI; BARROS FILHO, 2009).
Iron deficiency anemia is the most common nutritional deficiencies, with higher prevalence in women and children, especially in developing countries. Children between six and 24 months feature twice the risk for developing the disease than those between 25 and 60 months. Considered a serious public health problem, anemia may impair the mental and psychomotor development, cause increased morbidity and mortality, maternal and child in addition to the drop in individual performance at work and reduced resistance to infections (OSORIO et al., 2001; OLIVEIRA; OSÓRIO, 2005; Jordan; BERNARDI; BARROS FILHO, 2009).
In Brazil, there is no national survey of prevalence of anemia, only studies in different regions, which show a high prevalence of the disease, estimated that about 4,800,000 of preschoolers are affected by the disease. Despite the lack of comprehensive national studies, regional data have shown a high prevalence of anemia in Brazil, in all ages and socioeconomic levels (BRAZIL, 2004; Jordan; BERNARDI; BARROS FILHO, 2009; Souza, 2011).
Iron deficiency anemia, or only mild or moderate deficiency of the mineral, can cause fatigue, injury on growth and muscle performance, leading to neurological development and also damage in school performance. Other consequences include behavioral and cognitive disorders, such as irritability, lack of attention, lack of interest, difficulty in learning, loss in ability to maintain body temperature on exposure to cold; changes in the skull, in children with iron deficiency anemia; long bone abnormalities; changes in thyroid function, production and metabolism of Catecholamines and other neurotransmitters and increasing the capacity of absorption of heavy metals (oak; BACARATI; SGARBIERI, 2006; SILVA; WEB CALENDAR, 2006; HEIJBLOM; SANTOS, 2007; FABIAN; OLINTO; COSTA, 2007; Cardoso; Saints; CHEN, 2008).
Despite several programs to combat iron deficiency anemia, the growth rates of the disease are still on the rise, mainly due to poor adherence to the method for weak mother-child bond, low level of education and lack of information about the severity of the disease, leading his parents to discontinue the treatment (MATTOS, 2007). Therefore, on the exposed, this review has as main objective to systematize the articles published in the period from 2000 to 2014 on infant iron deficiency anemia in Brazil and its consequences as a result of this disease if not treated properly.
This is a review carried out by means of retrospective survey of scientific articles published over the past fourteen years (2000 to 2015).
The literature search was performed on indexed studies in national and international databases, such as: Latin American literature (LILACS) and in the Scientific Electronic Library Online (SCIELO), Pub Med, Google Scholar, among others.
The descriptors used were: iron deficiency anemia, children, iron deficiency, Brazil.
Selected articles were national and international published in Portuguese and English language in the period mentioned above regarding infant iron deficiency anemia in both Brazil and outside of it. Reference items are available in Brazil via Internet or in national libraries.
2.1. Inclusion criteria:
-articles published in full in the period from 2000 to 2015, in Portuguese and English languages;
-articles that contained some of the selected descriptors;
-items available in Brazil, either via internet or in libraries.
2.2. Exclusion criteria:
-Summary of articles;
-items not available in Brazil;
-articles in other languages that do not Portuguese or English;
Articles were reviewed and categorized with a view to the classification and delineation of the studies, observing: year of publication, source, formation and origin of author/researcher, object of study, the study population, exposure time, instrument rating or data collection and results and discussion thereof.
Since this is a review article, there was no need for this study submission to the Research Ethics Committee, as well as signing an informed consent because you don't treat directly with human beings.
- RESULTS AND DISCUSSION
By definition, the term anemia applies simultaneously to a clinical syndrome, being the most prevalent chronic syndrome in medicine, and a laboratory frame characterized by decrease in hematocrit, hemoglobin concentration in the blood or the concentration of red blood cells per unit volume, compared with peripheral blood parameters of a reference population. In any age group, anemia is not a diagnosis in itself, but only one objective sign of the presence of basic disease that is causing, being one of the most common manifestations of disease worldwide (Z; HAWK; PASQUINI, 2004; COURTEOUS; LIRA; COITINHO, 2009; BORTOLINI; VITOLO, 2010).
Among the nutritional diseases, considered worldwide the most prevalent is anemia, being an important public health problem. There are several types of anemia, but the iron deficiency anemia is the most common type and is caused by iron deficiency, which is one of the main constituents of hemoglobin for oxygen transport to the tissues, because iron is an essential nutrient for life and acts mainly in the manufacture of red blood cells, erythrocytes (OSÓRIO, 2002; WILLIAMS, 2002; BARBOSA, 2003; SILVEIRA, ALBUQUERQUE; Rock, 2008).
Anemia is defined by the World Health Organization (who) (2004) as "a condition in which the concentration of hemoglobin in the blood is abnormally low as a result of the lack of one or more essential nutrients, whatever the source of this grace period". Have iron deficiency anemia is the result of long period of negative balance between the amount of biologically available iron and the need of this organic trace element (OSORIO et al., 2001; STOLTZFUS, 2001).
The iron deficiency anemia, also called ferropênica, may be associated with malnutrition, caused by the diet low in iron, vitamin A, folate, but its etiology is the result of multiple factors, such as the loss of iron, the speed of growth of the child and the parasitic infections (OLIVEIRA, 2005; ANVISA, 2006; Name; RAO, 2006). Iron deficiency anemia is a serious public health problem and is a result of various etiological factors. Among the most important causes include inadequate intake of iron in heme shape due to the low consumption of foods of animal origin and low socioeconomic status, the precarious conditions of sanitation and the incidence of parasitic diseases, especially those that cause chronic blood loss (OSÓRIO, 2002; WILLIAMS, 2002; ZAGO; HAWK; PASQUINI, 2004; Jordan; BERNARDI; BARROS FILHO, 2009).
In January 2004 the who defined the best indicators of iron status in children aged less than five years, and less than 11 g/dL hemoglobin and ferritin of less than 12ug/L (OLIVEIRA, 2005; PATEL, 2008; SILVEIRA; ALBUQUERQUE; Rock, 2008).
3.1. STAGES OF IRON DEFICIENCY ANEMIA
The first stage of iron deficiency anemia, also called latent iron deficiency or iron depletion, occurs when the intake of iron is unable to meet the needs, producing a reduction of their deposits, which is characterized by serum ferritin below 12 micrograms per litre, but no functional changes (AGUILAR, 2006).
Going on continuity of the negative balance, there is a second phase, called eritropoese iron deficient, which is characterized by decreased bone marrow and serum iron, transferrin saturation below 16%, and elevation of free erythrocyte protoporphyrin, or that the reduction of working capacity. As a consequence of iron deficiency erythropoiesis, medullary ineffective. And finally, when there is restriction in the synthesis of hemoglobin, develops the third and final stage, or iron deficiency anemia, iron deficiency anemia, where haemoglobin is located below the standards for the age and the sex is characterized by the appearance of microcytosis and hipocromia red blood cells (QUEIROZ, 2000, HADLEY, 2002; AGUILAR, 2006).
To Zafar, Hawk and Pasquini (2004), between iron deficiency and iron deficiency anemia itself, there are intermediate situations in which the morphology of RBCs (microcytosis and hipocromia), the serum iron, total iron transport capacity (TIBC), deposits of iron in the bone marrow and serum ferritin not present yet all changes features of iron deficiency anemia. In this case, there is a mild to moderate anemia, with red blood cells still showing normal (oak; BARACATI; SGARBIERI, 2006).
Iron deficiency occurs: when their intake is insufficient, for example, during the period of growth or pregnancy; when iron malabsorption occurs; in cases of losses increased by consequences of uterine blood loss or in the digestive tract; When renal loss of hemosiderin as a result of chronic intravascular hemolysis; in case of iron sequestration in a place inaccessible and even the urinary losses of blood (BAIN, 2007; VERRASTRO, 2005).
The depletion of stocks of iron in the bone marrow and the insufficient supply of iron to eritroblastos lead to a decrease in the synthesis of heme and as a consequence a reduction in the production of hemoglobin and red blood cells (BAIN, 2007; VERRASTRO, 2005; CH; BARACATI; SGARBIERI, 2006).
3.2. PREVALENCE OF CHILD IRON DEFICIENCY ANEMIA
The who estimates that half of the population of children under five years of age in developing countries suffer from iron deficiency anemia. Several studies conducted in different locations and populations indicate a high prevalence of iron deficiency anemia in Brazil. There are an estimated 5,000,000 children under 4 years with iron deficiency anemia in the entire country and, contrary to what occurs with malnutrition, the prevalence of iron deficiency anemia has been increasing in recent decades (CARDOSO; Saints; CHEN, 2008; Jordan; BERNARDI; BARROS FILHO, 2009).
Due to the rapid expansion of red cell mass and the sharp growth of the tissues, the children are more vulnerable to iron deficiency due to the increase of their needs (SILVA; WEB CALENDAR, 2006; CH; BARACATI; SGARBIERI, 2006).
The increasing prevalence of iron deficiency anemia in children may be due to changes in dietary habits, accompanying the nutritional transition in the country. In Brazil, the trend of increasing anaemia in preschoolers was evidenced by two studies in which the prevalence of the disease increased from 35.6% in the Decade of 1980, to 46.9% in the Decade of 1990, in São Paulo, and of 19.3% to 36.4%, in Paraíba (MONTEIRO, 2000; OLIVEIRA; 2002; MOREIRA et al., 2004). Due to its high prevalence and its consequences, the fight against iron deficiency anemia is one of the priorities for professionals who are responsible for planning of public health nutrition programs, finding political support in social commitment assumed by Brazil to reduce iron-deficiency anemia. The Ministry of health has made compulsory the fortification of maize flour and wheat flour with iron and folic acid, for being easily accessible food and population have not updates to its organoleptic characteristics in the process of fortification, in addition to being economically viable in the country. To do so, from 1998, was deployed to the National Program of supplemental iron Drug risk groups (children from six to 18 months, pregnant women and women in postpartum), aiming at the reduction in the number of cases and the improvement in the quality of life of the patient (OSORIO et al., 2001; MOREIRA et al., 2004).
3.3. CONSEQUENCES OF CHILD IRON DEFICIENCY ANEMIA
The reduction of blood hemoglobin concentration compromise oxygen transport to the tissues and have various consequences, including signs and symptoms, alterations of the skin and mucous membranes (pallor, Glossitis), gastrointestinal changes (stomatitis, dysphagia), fatigue, weakness, palpitations, reduced cognitive function, growth and psychomotor development, besides affecting the thermoregulation and the immunity of the child (OLIVEIRA , 2005; Cardoso; Saints; CHEN, 2008).
Iron deficiency anemia, or only mild or moderate deficiency of the mineral, can cause fatigue, injury on growth and muscle performance, leading to neurological development and also damage in school performance. Other consequences include behavioral and cognitive disorders, such as irritability, lack of attention, lack of interest, difficulty in learning, loss in ability to maintain body temperature on exposure to cold; changes in the skull, in children with iron deficiency anemia; long bone abnormalities; changes in thyroid function, production and metabolism of Catecholamines and other neurotransmitters and increasing the capacity of absorption of heavy metals (CANÇADO; CHIATTONE, 2002; CH; BARACATI; SGARBIERI, 2006).
Anemic children present a delayed neuromotor development that even after prolonged treatment, no one gets installed framework improvement. The most obvious consequence of iron deficiency is anemia and all its sequels and evidence indicate that this deficiency can affect metabolic processes, such as DNA synthesis, metabolism of several enzymes and transport of electrons, causing changes in the immune response and the cognitive functions of the infant and child (oak; BARACATI; SGARBIERI, 2006; UMBELINO; ROSSI, 2006).
As iron is involved in cellular respiration, low hemoglobin levels interfere with energy metabolism and may affect the level of physical activity; so in the central nervous system it can be associated with delay in cognitive ability of children and on the skin and mucous membranes falling hemoglobin is reflected by skin and mucous membrane discoloration, used to assess the presence of anemia in children (PALOMBO; FUJIMORI, 2006). This fact proved by studies conducted in children under the age of five years have shown that iron deficiency anemia is related, among other changes, the low scores on tests of mental and motor activity, and may lead to irreversible sequel, even in the presence of adequate treatment (SILVA, 2006; CARDOSO, 2008).
Several haematological and biochemical parameters reflect the stages of iron depletion. For the early diagnosis of depletion of stocks of iron in vitro for a parameter considered gold standard, is the bone marrow hemosiderin, which will determine the absence of Medullary indicating the iron depletion. However, this procedure is invasive, it is not suitable as a screening exam (AGUILAR, 2006). The diagnosis of iron deficiency anemia can be accomplished through a correlation between laboratory values, checking the blood levels of hemoglobin and iron stock (P; RONDO; SHINOHARA, 2000).
Currently the haemoglobin concentration is considered to be the most commonly used parameter as indicative of the physiopathological consequences of anemia, but does not show good specificity and sensitivity to assess the nutritional status of iron, since it can meet changed in inflammatory and infectious processes, bleeding, protein-calorie malnutrition, drug use and smoking (ARAÚJO, 2006; BARBOSA; CARDOSO, 2003).
The determination of serum ferritin is considered to be the most appropriate specific biochemical parameter as a real indicator of body iron reserves and is considered a useful method for using peripheral blood and present strong correlation with tissue iron deposits. Transferrin saturation, protoporfirinas free eritrocitárias and the calculation of hematimétricos indices are also used for the diagnosis of iron deficiency anemia (ARAÚJO, 2006; UMBELINO; ROSSI; 2006; MATTOS, 2007).
Changes in the size and color of the red blood cells provide a useful information in relation to the nutritional status of iron, and the use of electronic counters has improved the reliability of the diagnosis. Hematimétricos indexes based on mean corpuscular volume (MCV) and amplitude of variation in the size of the red blood cells (RDW) are important elements in the diagnosis of iron deficiency anemia already installed. The Association of morphological classification of anemia from hematimétricos indices with the characterization of anemia according to the medullar response AIDS in the differential diagnosis and the likely etiology of anemia (P; RONDO; SHINOHARA, 2000; ARAÚJO, 2006; GROTTO, 2009).
Iron depletion causes the red blood cells are produced, on average, small and with great variation in size (anisocytosis), which is measured by the RDW. In iron deficiency anemia, the RED BLOOD CELL DISTRIBUTION WIDTH increases early even of significant decrease of VCM, fact that allows to detect the incipient iron deficiency (AGUILAR, 2006).
Reduced values on concentration of serum iron is a strong indicator of iron depletion. In iron deficiency anemia occurs decreased hemoglobin, hematocrit reduction, the Total transport Capacity (TIBC) is normal or increased, leading to decreased saturation of transferrin to levels lower than 10%. In the examination of the blood smear stained erythrocytes are microcíticas and hypochromic (Z; HAWK; PASQUINI, 2004; ADAM; Fields; SANTANA, 2007).
For the diagnosis of nutritional status of iron there is a great, being the choice of the same, dependent on several factors, such as: some characteristics inherent to the individual or population group (age, pregnancy); prevalence and severity of iron deficiency; inflammatory and infectious disease incidence and frequency of hematologic diseases. Factors such as volume of the blood sample required, cost, complexity of the methodology and laboratory errors, susceptibility cannot be disregarded (P; RONDO; SHINOHARA, 2000; AGUILAR, 2006).
3.5. TREATMENT OF CHILD IRON DEFICIENCY ANEMIA
To combat and prevent iron-deficiency anemia there are several important strategies such as: food education; medical prophylactic supplementation; food fortification and improving the quality of the diet offered; encouraging exclusive breastfeeding in the first six months of life, which is of fundamental importance; don't use cow's milk in the first year of life; fortification of foods; infection control; access to clean water and proper sewage system; and the stimulus to consumption of foods that contain high iron bioavailability in the introduction of complementary feeding (QAZI; TORRES, 2000; SILVA; WEB CALENDAR, 2006; MATTOS, 2007).
The main treatment of iron deficiency anemia involves oral administration of iron in the ferrous form and associated with drug treatment, must guide the consumption of food with quantity and high bioavailability of iron (Williams, 2002; TRINITY et al., 2009).
Osório (2002) explains that there needs to be a special assistance to the rural areas and risk where the low socioeconomic conditions and the difficulties of access to food even more aggravate the problem of iron deficiency anemia.
Another important measure to decrease the prevalence of anaemia, especially among preschoolers, is the use of fortified foods or iron-enriched, as the wheat and corn meal and milk used in baby food, in addition to the fortification of their own drinking water, considered a good vehicle for being washed (OSÓRIO, 2002; CH; BARACATI; SGARBIERI, 2006).
The Ministry of health has made compulsory the fortification of maize flour and wheat flour with iron and folic acid, for being easily accessible food and population have not updates to its organoleptic characteristics in the process of fortification, in addition to being economically viable to the country by deploying the National Program to combat anemia, iron deficiency Anaemia risk groups comprising children from six to 18 months , pregnant women and postpartum women (OSÓRIO, 2002; Jordan; BERNARDI; BARROS FILHO, 2009).
Ferrous sulfate is recommended for the treatment and prevention of iron deficiency anemia whose absorption becomes better when it is administered along with a source of vitamin C, such as orange juice, associating the treatment the food consumption with quantity and high bioavailability of iron (MONTEIRO; SZARFARC; MONDINI, 2000; MOREIRA et al., 2004; MATTOS, 2007).
The rapid expansion of red cell mass and the sharp growth of tissues make children more vulnerable to iron deficiency as a result of the increase of your needs. Anemia, mainly due to lack of food bio-available iron, represents a nutritional problem in collective health in developing countries, especially in Brazil, being a consequence of various etiological factors. Among the most vulnerable segments of the population to the problem of iron deficiency anemia are infants, children under five and women of childbearing age, including gestational period.
Iron deficiency anemia is a public health problem that presents far-reaching consequences for human health and the social and economic development.
The infant iron deficiency anemia is distinguished, not only by the frequency with which manifests itself, especially the age group, but also by the effects.
A study conducted by the World Health Organization points out that half of the children under five years of age in developing countries, suffer from iron deficiency anemia and in Brazil studies report an incidence average around 35% between the ages of one and four years.
The brazilian prevalence of iron deficiency anemia in children is high in many regions and is one of the most important nutritional deficiencies by the occurrence of errors, especially in the period of weaning, when breast milk is now replaced by iron or foods that feature very low bioavailability.
Inadequate intake of iron in heme shape, low socioeconomic status, the precarious conditions of sanitation and the incidence of parasitic diseases, especially those that cause chronic blood loss, are the main causes of iron deficiency anemia in children. On this issue, it is concluded that the iron deficiency anemia in infancy presents multiple causes, which requires joint action of several strategies to combat, including medication supplementation routine actions of iron, iron fortification in foods used in baby food and dietary education programs to better matching of total and bioavailable iron; along with the intensification of campaigns aiming at the prevention and treatment of this type of anemia considered high prevalence and various consequences for the child's body.
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 Biologist, MSC in biology. Doctor of medicine/Tropical Diseases. Professor and researcher at the Federal University of Pará – UFPA. And researcher in Tropical Medicine core Developer of the UFPA. Email: email@example.com (corresponding author).