Totem when breastfeeding. Is it possible or not, reviews

Composition and release form

The drug under discussion is a combined modern remedy against anemia. It helps get rid of the deficiency of 3 important minerals in the body at once.

The remedy allows you to cope with the problem in a short time. This is possible thanks to the composition of the drug.

The table will help you understand it in detail:

Only the first 3 substances are the main ones in the drug. The rest are auxiliary components. For example, to improve the taste and consistency of the product.

Totem during breastfeeding

The drug is available in the form of an oral solution. If you open one glass ampoule, you can see a transparent liquid of a dark brown hue. It has a bright odor, characteristic of preparations with a large portion of iron in the composition.

Terms of sale, prices

Totem during breastfeeding can only be prescribed by a doctor. Women are not recommended to make their own decisions about the need to take a drug to eliminate anemia. Uncontrolled use of the solution can lead to negative consequences. For this reason, today you can purchase the drug in a pharmacy only with a doctor’s prescription.

The product is sold in most specialized retail outlets throughout Russia. You can also order it from an online pharmacy, but in this case the prescription will have to be presented to the courier upon receipt of the goods.

The totem is packaged in a small, thick cardboard box of white and red color. Inside there is a substrate with transparent glass ampoules. They resemble an injection drug. In this case, the drug is taken orally.

The standard package contains 10 glass ampoules. Each of them contains 10 ml of the drug. To take the solution, you will need to carefully break off the glass tip of one ampoule. Afterwards, its contents are poured into a glass or other suitable container.

The cost of the product depends on the region in which it is purchased and on each specific retail outlet. On average, its price ranges from 300 to 700 rubles. per package with 10 ampoules of 10 ml of solution.

Pharmacological properties

Totema belongs to the combined iron preparations. It combines the main active ingredient with 2 additional ones. The use of such a remedy allows the patient to compensate for several important deficiencies in the body at once. Most often it is prescribed for anemia.

Iron from the drug is necessary for many important reactions in the body and its normal functioning in general. For example, for heme synthesis. Copper and manganese are combined with it, since these components contain enzymes that improve the process of iron absorption.

Adverse reactions

The medication may cause the development of non-standard symptoms:

• dyspeptic disorders;
• allergic reactions - itching, redness, skin rashes;
• staining of teeth - with dark scattered spots.

Sometimes black stool is observed, which is normal and does not require stopping the medication. If any of these symptoms appear, the patient should visit a doctor and tell in detail about the changes that have occurred.

Pharmacodynamics and pharmacokinetics

When the solution is taken orally, no more than 20% of a single dose is absorbed in the stomach and intestines. Soon after this, the drug begins to act and replenish iron reserves in the body.

Iron begins to be absorbed first in the duodenum, as well as in the upper part of the jejunum. One part of the substance immediately enters the blood. And the other one lingers on the intestinal mucosa. She is deposited there and waits her turn. As required in the future, the substance again enters the plasma.

If you take the drug continuously in the course prescribed by your doctor, then all the symptoms of anemia gradually go away. The patient's well-being improves markedly.

Features of interaction and manufacturer's instructions

The abstract points out the following nuances:

• Totema is not combined with drugs for parenteral administration that contain iron;
• combination with iron-containing medications can lead to fainting and shock;
• It is necessary to observe an interval of 120 minutes between taking the drug and tetracyclines, fluoroquinolones, thyroxine, penicillamine;
• If you drink too much, the rate of iron absorption slows down sharply.

When treating with Totema, you must adhere to the following instructions:

• the medication is not suitable for solving the problem of reduced levels of iron in the blood serum that occur with inflammatory pathologies;
• treatment of vitamin deficiency should be carried out together with the elimination of the sources that provoked it;
• When using the solution, it must be swallowed immediately to avoid darkening of the enamel.

Patients with diabetes mellitus should not forget that 50 ml of the product contains sucrose (3 g) with glucose (0.08 g) and a quarter of XE. Each ampoule of solution contains a small amount of ethanol.

The drug does not affect the reaction rate. During the procedures, patients can drive vehicles and work with complex moving mechanisms.

Indications for use in hepatitis B

Totema during breastfeeding is prescribed to women who have been diagnosed with a lack of iron in the body. The drug is used to treat anemia. Often - as the main and only means.

Sometimes the solution is chosen as a prophylactic agent to prevent possible negative consequences from a lack of iron in the body. This is especially true if a woman’s balance of important substances is disrupted after childbirth. This often happens with a large loss of blood, after a cesarean section.

If a woman had an iron deficiency during pregnancy, then after childbirth its level must be measured again. If the problem is not solved, the young mother is recommended to continue taking anti-anemia medications during lactation. Often it is Totema who is appointed, which allows you to quickly and cost-effectively correct the situation.

If a woman’s iron deficiency is just discovered and it is not critical, then the doctor may suggest waiting until after feeding. It is important that the woman does not have any obvious symptoms of a lack of this substance and does not feel worse.

How does it affect the child?

Totem during breastfeeding is increasingly prescribed to young mothers by modern doctors. But to date, no large-scale studies have been conducted on the effect of the drug on the newborn. There is even no general data on the penetration of the drug into breast milk. For this reason, doctors advise not to take risks and if any doubts arise about the use of the drug by a nursing mother - to abstain from this or simply postpone therapy until the end of the lactation period.

Interestingly, the drug can also be prescribed to newborns. It is approved for use by children from 3 months of age. In this case, the optimal dosage is calculated based on the baby’s weight. For every 1 kg of body weight, it is optimal to prescribe 3 mg of the drug. For newborns to take Totema, it is quite difficult to divide the solution into the required portions.

To do this you should:

1. Break the ampoule with the drug at both ends and pour the contents into a glass.
2. Make sure that no glass chips or other unnecessary particles get into the solution.
3. Pour the product into a measuring spoon or syringe.
4. Calculate the required portion, taking into account the child’s weight.
5. Dissolve the drug in any liquid. For a newborn, this is usually purified water. But it is not recommended to dissolve Totem in milk. This option is allowed only in extreme cases. For example, when the child does not drink any other liquids.

After the first use, it is recommended to closely monitor the child’s condition. An allergic reaction is possible.

The solution is prescribed to a newborn in 2 cases:

• if the baby himself is diagnosed with iron deficiency anemia by an appropriate blood test;
• if the problem is detected in the mother during the last stages of admission.

Possible complications for the fetus

When breastfeeding, Totem should be taken with extreme caution. Despite the fact that there is no data confirming the negative effects of the drug on newborns, you need to be wary of the following possible consequences:

• poisoning of a child with manganese or copper;
• overdose of iron in the body;
• exacerbation of congenital diseases of the stomach or intestines;
• unstable state of the nervous system - anxiety, poor sleep.

If a nursing mother takes a drug containing iron, then for the first few days she should especially carefully monitor the condition and well-being of the newborn. It is advisable to carefully inspect it during hygiene procedures. If allergic reactions to the drug occur on the child’s skin, redness and rashes may be noticed. They often manifest themselves with severe itching.

There is also the possibility of despotic disorders. Among them: pain and discomfort in the stomach, heaviness, painful or difficult digestion. In a newborn, such consequences can be expressed by strong constant uncontrollable crying, problems with sleep, refusal to eat, regurgitation of milk and water.

If such manifestations are noticed, the woman should stop taking the drug as soon as possible and consult a doctor. The specialist will adjust the prescribed therapy and select more suitable means or even postpone treatment for a while.

If a nursing mother uses Totem in large dosages, this can quickly lead to an excess of iron salts in the child. In this case, the drug should be stopped immediately. A newborn may even require medical attention. It consists of gastric lavage.

The nuances of overdose

The instructions for the drug draw attention to the following variants of hypervitaminosis:

1. Excess of iron salts

Exceeding the amount of a component is associated with accidental use of a large volume of medication or regular use of Totema in acceptable dosages. Complex intoxication with the drug is confirmed by the presence of 0.005 mg/l of the element in the bloodstream.

In childhood, poisoning with the component can cause death; a volume of 60 mg per kg is dangerous. Help consists of gastric lavage and the use of activated carbon - 1 tablet for every 10 kg of weight.

2. Excess of manganese salts

Poisoning is manifested by dyspeptic disorders and myalgia. Intoxication provokes problems with muscle tone, memory, causes depression, atrophic changes in muscles, and disturbances of consciousness. Overdose requires symptomatic treatment.

3. Excess copper salts

Intoxication leads to painful sensations in the abdomen, chest area, and muscles. Patients experience unreasonable irritability, a metallic taste in the mouth, and depression. Intoxication is treated by gastric lavage using diuretics, laxatives, and sorbents.

Contraindications

Totema during breastfeeding is often prescribed to women with a lack of iron in the body.

But there are situations in which the drug will have to be abandoned even if this problem exists:

• with exacerbation of duodenal or gastric ulcer;
• with anemia of a different nature (not related to iron levels);
• for serious problems with hematopoiesis.

It is also contraindicated to take the solution if a woman is hypersensitive to any components of its composition. It is strictly prohibited to combine it with other iron supplements. This does not even depend on the method of their entry into the body. You cannot combine, for example, an injection and taking the solution orally.

If a woman is already taking any vitamin complexes, then before adding Totems to them, it is worth carefully studying the composition of the first ones. If they contain iron, you will have to choose only one option.

Contraindications and indications for Totem from the instructions

The drug is prescribed to patients with pathologies identified by diagnostic examination:

• iron deficiency anemia – for patients older than 3 months;
• hypovitaminosis - for people at risk: blood donors, pregnant women, newborns (from mothers with documented iron deficiency).

Totem is contraindicated:

• in anemic conditions not associated with insufficient iron intake;
• exacerbation of gastrointestinal ulcers;
• thalassemia, hemochromatosis, hemosiderosis;
• poisoning with lead, manganese, copper;
• intolerance to the component composition;
• hepatolenticular degeneration, etc.

Increased caution is needed when treating patients with inflammatory processes in the small intestine, colon, diverticulitis, and granulomatous lesions of the gastrointestinal tract.

The medicine is approved for the treatment of pregnant women; it is contraindicated in breastfeeding due to the high probability of the active components passing into milk.

Directions for use and doses

According to the instructions, the drug in question must be used before meals. First, the glass ampoule is broken on both sides, after which its contents are poured into a glass and mixed with any liquid. Slightly sweetened drinking water is perfect for this. Shake the product well before use. It is recommended to drink Totem already diluted in water as soon as possible. It is prohibited to store it longer than 25 hours in this form.

A newborn can only use the drug from 3 months. The dosage is calculated according to the scheme 3 mg per 1 kg of weight. From 1 year to 5 years, a child can take 50 mg of the drug per day.

From 5 to 12 years old, 1-2 ampoules of the drug are allowed daily. And patients after 12 years can drink up to 100 mg per day.

In this case, the dosage of the drug for the patient depends not only on his age, but also on the severity of anemia. If this is the average form, then an adult is prescribed 3 ampoules of the solution per day. If severe - up to 200 mg per day. For children, the optimal dosage is calculated by the attending physician.

For pregnant and nursing mothers, this dosage also changes. In the first case, with a mild degree of anemia, the girl is recommended to drink 2 ampoules per day, with moderate anemia - up to 150 mg, with severe anemia - up to 200 mg. And in the second, regardless of the severity of the problem - 1 ampoule per day.

The dosage chosen for the patient can be consumed in different ways. The first option is 2-3 doses before meals throughout the day. The second option is immediately, for example, before breakfast or before lunch.

How long to take the drug is decided on a case-by-case basis. To do this, the patient must undergo regular blood tests. For example, nursing mothers are advised to take the medicine until the hemoglobin level returns to normal. On average, treatment usually takes 4-6 months. If the drug is prescribed for preventive purposes, then it must be taken for 1-2 months.

A young mother during lactation should evaluate her condition before starting to take Totem. Especially if the newborn is still younger than 1 month. If possible, taking the drug should be postponed for at least 30-50 days after birth. During this period, a woman can try to adjust the level of iron in the body through nutrition.

Iron deficiency anemia in infants and young children

Anemia and anemic syndrome, caused by many causes, can be mentioned among the most common pathological conditions that general pediatricians have to deal with every day. This group includes various diseases and pathological conditions characterized by a decrease in the content of hemoglobin and/or red blood cells per unit volume of blood, leading to disruption of the oxygen supply to tissues. The following laboratory criteria for anemia are applied (N.P. Shabalov, 2003). Depending on the age of the children, the hemoglobin level is:

• 0–1 day of life - < 145 g/l;
• 1–14 days of life - < 130 g/l;
• 14–28 days of life - < 120 g/l;
• 1 month - 6 years - < 110 g/l.

Of all anemias, the most common is iron deficiency (IDA), which accounts for approximately 80% of all anemias. According to the World Health Organization (WHO), more than 500 thousand people worldwide suffer from IDA. The prevalence of IDA in children in Russia and developed European countries is: about 50% in young children; more than 20% - in older children.

IDA is a clinical and hematological syndrome characterized by impaired hemoglobin synthesis as a result of iron deficiency, developing against the background of various pathological (physiological) processes, and manifested by signs of anemia and sideropenia.

Iron is one of the main microelements in the human body. Normally, the adult body contains 3–5 g of iron in bound form. 70% of the total amount of iron is part of hemoproteins. The iron in these compounds is bound to porphyrin. The main representative of this group is hemoglobin (58% iron); Iron is also contained in myoglobin (8%), cytochromes, peroxidases, catalases - up to 4%. Iron is also part of non-heme enzymes (xanthine oxidase, nicotinamide adenine dinucleotide (NADH) dehydrogenase, aconitase, localized in mitochondria); transport form of iron (transferrin, lactoferrin). Iron reserves in the body exist in two forms: in the form of ferritin (up to 70%) and hemosiderin (up to 30%). The peculiarity of iron distribution in young children is that they have a higher iron content in erythroid cells and less iron in muscle tissue.

Iron absorption occurs predominantly in the duodenum and proximal jejunum. The daily diet usually contains about 5–20 mg of iron, and only about 1–2 mg per day is absorbed. The degree of iron absorption depends both on its amount in food consumed and bioavailability, and on the state of the gastrointestinal tract (GIT).

Iron is more easily absorbed in heme (meat products) - 9–22%. Absorption of non-heme iron is determined by diet and gastrointestinal secretion patterns.

Iron absorption is especially active from breast milk, although its content is low - only 1.5 mg per liter; The bioavailability of iron in breast milk is up to 60%. This is facilitated by the special form in which it is presented - in the form of the iron-containing protein lactoferrin. In the lactoferrin molecule, two active binding sites for Fe3+ ions are identified. Lactoferrin is found in breast milk in saturated and unsaturated forms. The ratio of lactoferrin forms varies depending on the lactation period. During the first 1–3 months of life, the saturated iron transport form of lactoferrin predominates. The presence of specific receptors for lactoferrin on the epithelial cells of the intestinal mucosa promotes the adhesion of lactoferrin to them and its more complete utilization. In addition, lactoferrin, by binding excess iron that is not absorbed in the intestine, deprives the opportunistic microflora of the microelement necessary for its life and triggers nonspecific bactericidal mechanisms. It has been established that the bactericidal function of immunoglobulin A is realized only in the presence of lactoferrin.

Physiological losses of iron in urine, sweat, feces, through the skin, hair and nails do not depend on gender and amount to 1-2 mg per day, in women during menstruation - 2-3 mg per day. In children, iron loss is 0.1–0.3 mg per day, increasing to 0.5–1.0 mg per day in adolescents.

The daily requirement of a child's body for iron is 0.5–1.2 mg per day. In young children, due to rapid growth and development, there is an increased need for iron. During this period of life, iron reserves are quickly depleted due to increased consumption from the depot: in premature infants by the 3rd month, in full-term infants by the 5th–6th month of life. To ensure the normal development of a child, the daily diet of a newborn should contain 1.5 mg of iron, and for a child 1–3 years old - at least 10 mg.

Iron deficiency in children leads to an increase in infectious diseases of the respiratory system and gastrointestinal tract. Iron is necessary for the normal functioning of brain structures; if it is insufficient, the child’s neuropsychic development is disrupted. It has been established that in children who had iron deficiency anemia in infancy, at the age of 3–4 years, disturbances in the transmission of nerve impulses from the centers of the brain to the organs of hearing and vision are determined due to impaired myelination and, as a consequence, impaired nerve conduction.

The causes of iron deficiency in children are very diverse. The main cause of IDA in newborns is considered to be the presence of IDA or hidden iron deficiency in the mother during pregnancy. Antenatal causes also include complicated pregnancy, impaired uteroplacental circulation, fetomaternal and fetoplacental bleeding, fetal transfusion syndrome in multiple pregnancies. Intrapartum causes of iron deficiency are: fetoplacental transfusion, premature or late ligation of the umbilical cord, intrapartum bleeding due to traumatic obstetric care or abnormal development of the placenta or umbilical cord. Among the postnatal causes of sideropenic conditions, the first place is taken by insufficient intake of iron from food. In this case, newborns who are bottle-fed with unadapted milk formulas, cow's and goat's milk suffer the most. Other postnatal causes of IDA are: increased body need for iron; iron losses exceeding physiological ones; gastrointestinal diseases, malabsorption syndrome; deficiency of iron stores at birth; anatomical congenital anomalies (Meckel's diverticulum, intestinal polyposis); consumption of foods that inhibit iron absorption.

Premature children and children born with a very large weight, children with a lymphatic-hypoplastic type of constitution are always at risk.

In children of the first year of life, iron deficiency is most often caused by an unbalanced diet, in particular, feeding exclusively with milk, vegetarianism, and insufficient consumption of meat products.

Bleeding of various etiologies can lead to sideropenia. The source of this may be: hiatal hernia, esophageal varices, gastrointestinal ulcers, tumors, diverticula, ulcerative colitis, hemorrhoids, as well as bleeding from the genitourinary tract and respiratory tract. Taking certain medications, such as nonsteroidal anti-inflammatory drugs, salicylates, coumarins, and glucocorticosteroids, can also lead to iron loss. Iron deficiency always accompanies diseases accompanied by impaired intestinal absorption (enteritis, Crohn's disease, parasitic infestations, etc.). Intestinal dysbiosis also interferes with normal digestion of food and thereby reduces the body's ability to absorb iron. In addition, there may be a disruption in iron transport due to insufficient activity and decreased transferrin levels in the body.

It is extremely important to recognize the cause of the development of IDA in each specific case. Focus on nosological diagnosis is necessary, since in most cases, when treating anemia, it is possible to influence the underlying pathological process.

IDA manifests itself with general symptoms. One of the main and visible signs is pallor of the skin, mucous membranes, and conjunctiva of the eyes. Noteworthy are general lethargy, moodiness, tearfulness, easy excitability of children, decreased overall body tone, sweating, lack or decreased appetite, shallow sleep, regurgitation, vomiting after feeding, decreased visual acuity. Changes in the muscular system are detected: the child has difficulty overcoming physical activity, weakness and fatigue are noted. In children of the first year of life, regression of motor skills may be observed.

In the second half of life and in children older than one year, signs of damage to epithelial tissue are observed - roughness, dry skin, angular stomatitis, painful cracks in the corners of the mouth, glossitis or atrophy of the oral mucosa, fragility and dullness of hair, hair loss, dullness and brittleness of nails, tooth decay (caries), retardation in physical and psychomotor development.

Depending on the severity of the disease, symptoms of damage to organs and systems are identified: cardiovascular - in the form of a functional heart murmur, tachycardia; nervous system - in the form of headaches, dizziness, fainting, orthostatic collapse. Possible increase in the size of the liver and spleen. From the gastrointestinal tract, there is difficulty swallowing, bloating, diarrhea, constipation, perversion of taste - the desire to eat clay, earth.

The diagnosis of IDA is made based on the clinical picture, laboratory signs of anemia and iron deficiency in the body: hypochromic (color index < 0.85) anemia of varying severity, hypochromia of erythrocytes, decrease in the average hemoglobin concentration in erythrocytes (less than 24 pg), microcytosis and poikilocytosis of erythrocytes (in peripheral blood smear); decrease in the number of sideroblasts in bone marrow aspirate; decrease in iron content in blood serum (<12.5 µmol/l); an increase in the total iron-binding capacity of serum (TIBC) of more than 85 µmol/l (an indicator of “starvation”); an increase in the level of transferrin in the blood serum, with a decrease in its saturation with iron (less than 15%); decreased serum ferritin levels (<15 µg/L).

Treatment of IDA

Treatment of IDA in young children should be comprehensive and based on four principles: normalization of the child’s regimen and nutrition; possible correction of the cause of iron deficiency; prescription of iron supplements; concomitant therapy.

The most important factor in correcting iron deficiency is a balanced diet, and primarily breastfeeding. Breast milk not only contains iron in a highly bioavailable form, but also increases the absorption of iron from other foods consumed at the same time. However, intense metabolic processes in infants lead to the fact that by the 5th–6th month of life, antenatal iron reserves are depleted even in children with a good perinatal history and babies fed with breast milk.

Among other foods, the greatest amount of iron is found in pork liver, beef tongue, veal kidneys, egg yolk, oysters, beans, sesame seeds, seaweed, wheat bran, buckwheat, pistachios, chick peas, peaches, oatmeal, spinach, hazelnuts and etc. (table).

Iron absorption is inhibited by tannins contained in tea, carbonates, oxalates, phosphates, ethylenediaminetetraacetic acid used as a preservative, antacids, and tetracyclines. Ascorbic, citric, succinic and malic acids, fructose, cysteine, sorbitol, nicotinamide enhance iron absorption.

Long walks in the fresh air, normalization of sleep, a favorable psychological climate, prevention of acute respiratory viral infections (ARVI), and limitation of physical activity are necessary. The child's diet should be balanced and include foods rich in iron and substances that enhance its absorption in the intestines. Children suffering from IDA need to be introduced to complementary foods 2–4 weeks earlier than healthy ones. It is advisable to start introducing meat complementary foods at 6 months. You should avoid introducing cereals such as semolina, rice, and bearberry into your child’s diet, giving preference to buckwheat, barley, and millet.

However, these measures are insufficient and do not lead to the cure of IDA, so the basis of therapy is iron supplements. The main ones used orally include: ferric iron compounds - hydroxide-polymaltose complex (iron polymaltose), maltofer, maltofer foul, ferrum lek and iron-protein complex (iron protein succinylate) - ferlatum; divalent iron compounds - actiferrin, ferroplex, tardiferon, hemofer, totema, ferrous fumarate, ferronate.

Therapy should be started with drugs for oral administration and only if they are poorly tolerated (nausea, vomiting, diarrhea), malabsorption syndrome, resection of the small intestine, etc. - iron supplements are prescribed parenterally. When prescribing oral forms, preference should be given to nonionic iron compounds - protein (ferlatum) and hydroxide-polymaltose Fe3+ complexes (maltofer, maltofer foul, ferrum lek). These compounds have a large molecular weight, which makes it difficult for them to diffuse across the intestinal mucosal membrane. They enter the blood from the intestines as a result of active absorption. This explains the impossibility of overdosing on drugs, unlike iron salt compounds, the absorption of which occurs along a concentration gradient. There is no interaction between them and food components and medications, which allows the use of non-ionic iron compounds without disturbing the diet and treatment of concomitant pathologies. Their use significantly reduces the incidence of side effects usually observed when prescribing oral iron supplements (nausea, vomiting, diarrhea, constipation, etc.). In addition, in young children, the dosage form of the drug is of great importance. At this age, it is convenient to use drops and syrups, which also provides the possibility of precise dosing of drugs and does not cause a negative attitude from the child.

When prescribing any iron supplements, it is necessary to calculate the individual need for it for each patient, based on the fact that the optimal daily dose of elemental iron is 4–6 mg/kg. The average daily dose of iron in the treatment of IDA is 5 mg/kg. The use of higher doses does not make sense, since the amount of iron absorption does not increase.

The use of parenteral iron supplements is indicated to quickly achieve an effect in severe anemia; gastrointestinal pathology combined with malabsorption; nonspecific ulcerative colitis; chronic enterocolitis; with severe intolerance to oral forms of drugs. Today in the Russian Federation, only one drug is approved for intravenous administration - venofer (iron sucrose), while ferrum lek can be used for intramuscular administration.

It must be remembered that in young children, iron deficiency is never isolated and is often combined with a deficiency of vitamins C, B12, B6, PP, A, E, folic acid, zinc, copper, etc. This is due to the fact that nutritional deficiency and impaired intestinal absorption, leading to iron deficiency, also affects saturation with these micronutrients. Therefore, it is necessary to include multivitamin preparations in complex therapy for IDA.

The effectiveness of IDA therapy can be judged after 7–10 days by an increase in reticulocytes by 2 times compared to the initial number (the so-called reticulocyte crisis). The increase in hemoglobin is also assessed, which should be 10 g/l or more per week. Accordingly, achievement of the target hemoglobin level is observed on average 3–5 weeks from the start of therapy, depending on the severity of anemia. However, treatment with iron supplements should be carried out in sufficient doses and for a long time (at least 3 months) even after normalization of hemoglobin levels in order to replenish iron reserves in the depot.

If within 3-4 weeks there is no significant improvement in hemoglobin levels, then it is necessary to find out why the treatment was ineffective. Most often we are talking about: an inadequate dose of iron supplement; ongoing or unknown blood loss; the presence of chronic inflammatory diseases or neoplasms; concomitant vitamin B12 deficiency; incorrect diagnosis; helminthic infestation and other parasitic infections.

Contraindications to the use of iron supplements are:

• lack of laboratory confirmation of iron deficiency;
• sideroachrestic anemia;
• hemolytic anemia;
• hemosiderosis and hemochromatosis;
• infection caused by gram-negative flora (enterobacteria, Pseudomonas aeruginosa, Klebsiella).

With the development of severe anemia, accompanied by inhibition of erythropoiesis and a decrease in erythropoietin production, the administration of recombinant human erythropoietin (rhEPO) preparations is indicated. The use of rhEPO is of particular importance in the development of early anemia of prematurity, which develops in the second month of life and occurs, according to various authors, in 20–90% of cases. The administration of rhEPO drugs (Recormon, Eprex, Epocrine) leads to a sharp activation of erythropoiesis and, as a consequence, to a significant increase in iron requirements.

Therefore, the use of rhEPO is an indication for the administration of iron supplements, usually parenteral. Currently, a- and b-epoetins are approved for use in the Russian Federation and are included in the list of additional medicinal products. Prescribing rhEPO allows, in most cases, to avoid blood transfusions, in which there is a high probability of complications (transfusion reactions, sensitization, etc.). The preferred route of administration of rhEPO preparations, especially in early childhood, is subcutaneous. The subcutaneous route of administration is safer and more economical, since smaller doses are required to achieve an effect than with intravenous administration. Until recently, in the countries of the European Union and in the Russian Federation, mainly β-erythropoietins were used for the treatment of hyporegenerative anemia in children, which, when administered subcutaneously, did not cause significant adverse reactions, unlike a-erythropoietins, when administered subcutaneously, there was a high risk of developing red cell aplasia. The most widely used drug among β-erythropoietins is Recormon (F. Hoffmann-La Roche), which is easy to use and leads to a rapid increase in the level of erythrocytes and reticulocytes without affecting leukopoiesis, increases the level of hemoglobin, as well as the rate of incorporation of iron into cells.

Since 2004, European countries have allowed subcutaneous administration of a-erythropoietins, among which in our country the most commonly used are Eprex (Jansen-Silag) and Epocrine (Sotex-GosNII OCHB).

The goal of rhEPO treatment is to achieve hematocrit levels of 30–35% and eliminate the need for blood transfusions. The target hemoglobin concentration values ​​may vary depending on the days and months of the child’s life, but cannot be lower than 100–110 g/l. Depending on the dose, target hemoglobin concentrations and hematocrit are achieved after approximately 8–16 weeks of rhEPO treatment.

To prevent iron deficiency anemia, rhEPO is prescribed to premature newborns born weighing 750–1500 g before the 34th week of pregnancy.

Treatment with erythropoietin should begin as early as possible and continue for 6 weeks. The drug Recormon is administered subcutaneously at a dose of 250 IU/kg 3 times a week. However, it must be taken into account that the younger the child is, the higher doses of erythropoietin he requires, so the dose can be increased.

As mentioned above, rhEPO therapy leads to a sharp increase in iron intake, therefore, in most cases, especially in premature infants, along with an increase in hematocrit, serum ferritin levels decrease. Rapid depletion of iron reserves in the body can lead to IDA. Therefore, all patients receiving rhEPO therapy are prescribed iron supplements. Therapy with iron supplements should continue until serum ferritin levels are normalized (at least 100 mcg/ml) and transferrin saturation (at least 20%). If serum ferritin concentration remains persistently below 100 mcg/ml or there are other signs of iron deficiency, the dose of iron should be increased, including the use of parenteral drugs.

Prevention of IDA in young children includes: antenatal (correct regimen and nutrition of the pregnant woman, timely detection and treatment of anemia in the pregnant woman, preventive administration of iron supplements to women at risk for developing IDA); postnatal (observance of hygienic living conditions for the child, long-term breastfeeding and timely introduction of complementary foods, adequate choice of formula for children on mixed and artificial feeding, prevention of the development of rickets, malnutrition and ARVI in the child). The following people need prophylactic administration of iron supplements:

• women of reproductive age suffering from heavy and prolonged menstrual bleeding;
• regular donors;
• pregnant women, especially repeat pregnancies following a short interval;
• women with iron deficiency during lactation.

Preventive administration of iron supplements is indicated for children at risk for developing IDA:

• premature babies (from 2 months of age);
• children from multiple pregnancies, complicated pregnancies and childbirths;
• large children with high rates of weight gain and height;
• children with constitutional anomalies;
• suffering from atopic diseases;
• those who are artificially fed with unadapted formulas;
• with chronic diseases;
• after blood loss and surgical interventions;
• with malabsorption syndrome.

The dose of iron prescribed for preventive purposes depends on the degree of prematurity of the child:

• for children with birth weight less than 1000 g - 4 mg Fe / kg / day;
• for children with birth weight from 1000 to 1500 g - 3 mg Fe/kg/day;
• for children with birth weight from 1500 to 3000 g - 2 mg Fe/kg/day.

The significance of the problem of IDA in young children is due to its high prevalence in the population and its frequent development in various diseases, which requires constant vigilance among doctors of all specialties. Nevertheless, at the present stage, the doctor’s arsenal has enough diagnostic and therapeutic capabilities for early detection and timely correction of sideropenic conditions.

Literature

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L. A. Anastasevich , Candidate of Medical Sciences A. V. Malkoch , Candidate of Medical Sciences, Russian State Medical University, Moscow

Analogues for hepatitis B

Any iron supplements should be taken with caution during lactation. This also applies to all modern analogues of Totem. Most often, this drug for nursing mothers is replaced with Actiferrin drops or Ferretab capsules. Both of them can be prescribed exclusively by a doctor and if the potential benefit to the mother outweighs the possible harm to the child.

Totema is not prohibited during breastfeeding. But its effect on the newborn and penetration into mother’s milk has not yet been fully studied and proven. Therefore, young mothers should use the drug with caution.