Iron Deficiency Anemia

Iron Deficiency Anemia: Excerpt from The 5-Minute Pediatric Consult

Janet L. Kwiatkowski, MD

Iron Deficiency Anemia - BASICS

Iron Deficiency Anemia - description

A reduction in hemoglobin production due to an insufficient supply of iron that results in a microcytic, hypochromic anemia

Iron Deficiency Anemia - general prevention

• Maintain breast-feeding for the 1st 5–6 months of life when possible. Although the concentration of iron is lower in breast milk than in formula, iron in breast milk is more bioavailable (50% vs 10%).
• Iron supplementation (1 mg/kg/d) for infants who are exclusively breastfed beyond 6 months of age
• Iron-fortified formula for the 1st 12 months of life for infants who are not breastfed
• Iron supplementation after 2 months of life for low-birth-weight and premature infants because of decreased iron stores and increased growth rate
• Encourage iron-enriched cereal when infants are started on solid food.
• Avoid whole cow’s milk during the 1st year of life, to prevent occult GI bleeding.
• Screen hemoglobin level at periodic intervals. The American Academy of Pediatrics recommends 9 months, 5 years, and 14 years of age.

Iron Deficiency Anemia - epidemiology

• Leading cause of anemia among infants and children in the US
• Most commonly seen in children ages 9 months to 3 years and in teenage girls

Iron Deficiency Anemia - prevalence

• Prevalence is variable depending on socioeconomic status, availability of iron-fortified formulas, prevalence and duration of breastfeeding, and the way that iron deficiency is defined.
• Prevalence of iron deficiency anemia is generally between 1% and 5% of children in the US.

Iron Deficiency Anemia - risk factors

• Low socioeconomic status
• Certain ethnic groups (such as southeast Asian) may be at increased risk due to dietary practices.

Iron Deficiency Anemia - pathophysiology

• Iron is required for oxygen transport by hemoglobin.
• Iron is absorbed primarily in the duodenum.
• Iron deficiency develops because of an inadequate supply or increased demand for iron, or a combination of these.
• Sequential stages of iron deficiency:
  • Depletion of iron stores: Reflected by low serum ferritin and absent bone marrow stores (Prussian blue staining)
  • Iron-deficient erythropoiesis: Near-normal number of red blood cells produced, but they have abnormal hemoglobin synthesis with wide distribution in RBC size
  • Iron deficiency anemia: Microcytosis evident

Iron Deficiency Anemia - etiology

• Causes of inadequate supply include dietary deficiency and malabsorption:
  • Dietary deficiency in infants and young children results from introduction of cow’s milk prior to age 12 months, exclusive breast-feeding beyond age 6 months without iron supplementation, and excessive cow’s milk intake (>24 oz/d).
  • Malabsorption results from surgical resection of intestine, celiac disease
  • Certain foods impair iron absorption (tannins in tea and coffee, phytates).
• Causes of increased demand include rapid growth and blood loss:
  • Periods of rapid growth include infancy (especially low-birth-weight infants) and adolescence.
  • GI blood loss is most common and includes cow’s milk enteropathy (seen in infants), inflammatory bowel disease (IBD), and bleeding from Meckel diverticulum.
  • Other etiologies of blood loss include perinatal loss, menorrhagia, pulmonary hemosiderosis, and hematuria.

Iron Deficiency Anemia - DIAGNOSIS

Iron Deficiency Anemia - signs & symptoms

• Iron deficiency anemia often develops slowly, and no symptoms may be present.
• When present, signs and symptoms include:
  • Irritability and behavioral disturbances
  • Fatigue, exercise intolerance
  • Pallor
  • Headache
  • Pica

Iron Deficiency Anemia - history

• Evaluate dietary intake of iron, including breast- or formula feeding and type of formula (iron fortified or low iron).
• Age at introduction of cow’s milk
• Daily intake of cow’s milk
• Birth history for prematurity or blood loss
• Pica
• Lead exposure
• Blood loss from urine, stool, menorrhagia

Iron Deficiency Anemia - physical exam

• Often normal
• Pallor, irritability
• Tachycardia, flow murmur if anemia is more severe
• Koilonychia (spoon nails)
• Glossitis or stomatitis

Iron Deficiency Anemia - tests

Iron Deficiency Anemia - lab

• Hemoglobin level <2 standard deviations below the age-specific mean defines anemia.
• Low MCV (red cell volume) and MCH (hemoglobin concentration) for age
• High RDW (red cell distribution width):
  • Measures the variation in red cell size
  • Normal is <14.5%
  • Often increased before anemia is present
• Low serum ferritin reflects reduced tissue iron stores:
  • Earliest laboratory abnormality
  • May be normal or increased with concurrent infection or inflammation
• Low serum iron
• Increased total iron-binding capacity
• Low transferrin saturation; measures the iron available for hemoglobin synthesis
• Increased soluble transferrin receptor:
  • Indicator of increased tissue iron demand
  • Also increased in thalassemia syndromes but not in anemia of chronic inflammation
• Decreased reticulocyte hemoglobin content. This test is an early indicator of iron deficiency because reticulocytes have a short (1–2-day) life span.
• Increased free erythrocyte protoporphyrin, a precursor molecule to hemoglobin synthesis. Also increased in lead poisoning and chronic inflammation
• Thrombocytosis
• Peripheral blood smear with microcytosis, hypochromia, poikilocytosis (varying shapes), pencil forms, and anisocytosis (varying sizes)
• Test for occult blood in stool often positive with gastrointestinal blood loss

Iron Deficiency Anemia - diag proced-surgery

Bone marrow examination: Shows decreased iron stores by Prussian blue staining; rarely needed to establish diagnosis

Iron Deficiency Anemia - differencial diagnosis

• Recent infection
• Lead poisoning
• Thalassemia trait
• Anemia of chronic inflammation (e.g., juvenile rheumatoid arthritis, IBD)
• Sideroblastic anemias

Iron Deficiency Anemia - TREATMENT

• Iron supplementation (see below)
• Family education regarding age-appropriate diet and iron-containing foods
• Specific treatment if underlying condition causing blood loss is found (e.g., hormonal therapy for menorrhagia, medications for IBD)
• May require initial inpatient observation in cases of severe anemia
• Red cell transfusion only if evidence of cardiovascular compromise (rarely indicated)

Iron Deficiency Anemia - general measures

Iron Deficiency Anemia - diet

• Milk should be restricted to <24 oz. daily or eliminated from diet in those with milk protein enteropathy.
• Bottle use should be discontinued after 12 months of age.
• Diet should include foods rich in iron such as meats, beans, iron-fortified cereals, strawberries, spinach.

Iron Deficiency Anemia - activity

Usually, no activity restriction is needed. Those with severe anemia resulting in CHF should have limited activity until the anemia is corrected.

Iron Deficiency Anemia - nursing

Family education: Teaching administration of iron and dietary counseling

Iron Deficiency Anemia - medication

Iron Deficiency Anemia - first line

Oral replacement with ferrous iron, 3–6 mg/kg/d of elemental iron divided into 2 or 3 doses. Iron should be given on an empty stomach or with a vitamin C–containing juice to increase absorption.

Iron Deficiency Anemia - second line

Parenteral (IM or IV) iron dextran indicated only for severe noncompliance or malabsorption, or if ongoing loss exceeds absorption capacity. Administration may be associated with pain at injection site or anaphylaxis.

Iron Deficiency Anemia - FOLLOW UP

Iron Deficiency Anemia - disposition

Iron Deficiency Anemia - admission criteria

• Active bleeding
• Severe anemia (hemoglobin level <6 g/dL) especially if symptoms or ongoing blood loss
• Tachycardia, S3 gallop, or other signs of CHF

Iron Deficiency Anemia - discharge criteria

• No signs of CHF
• If blood loss, bleeding is controlled
• Stable hemoglobin level
• Parent demonstrates ability to administer oral iron therapy to young children and demonstrates adequate knowledge about dietary modifications
• Adequate follow-up ensured

Iron Deficiency Anemia - issues for referral

• Evaluation for source of GI blood loss
• Unexplained recurrence after treatment
• Failure to improve with iron supplementation

Iron Deficiency Anemia - prognosis

• Anemia is readily corrected with iron replacement.
• Developmental delay may be long lasting or irreversible.

Iron Deficiency Anemia - complications

• Impaired cognitive and motor development in infants and toddlers
• Impaired immunity
• Short-term memory impairment and poor exercise performance in adolescents

Iron Deficiency Anemia - patient monitoring

• Reticulocyte count begins to increase in 3–4 days.
• Hemoglobin concentration should rise by at least 1 g/dL in 2–3 weeks.
• Continue iron for 2 months beyond correction of anemia to replenish body stores.
• Causes of poor response to oral iron supplementation include:
  • Noncompliance (most common)
  • Ongoing blood loss
  • Insufficient duration of therapy
  • High gastric pH
  • Concurrent lead intoxication
  • Incorrect diagnosis (thalassemia trait and anemia of chronic disease are not iron responsive)

Iron Deficiency Anemia - bibliography

1. Booth I, Aukett MA. Iron deficiency anaemia in infancy and early childhood. Arch Dis Child. 1997;76:549–554.
2. Griffin IJ, Abrams SA. Iron and breastfeeding. Pediatr Clin North Am. 2001;48:401–413.
3. Looker AC. Iron deficiency–United States 1999–2000. Morb Mortal Wkly Rep. 2002;51:897–899.
4. Lozoff B, Jimenez E, Wolf AW. Iron deficiency anemia and infant development: Effects of extended oral iron therapy. J Pediatr. 1996;129:382–389.
5. Lozoff B, Jimenez E, Wolf AW. Long-term developmental outcome of infants with iron deficiency anemia. N Engl J Med. 1991;325:687–694.
Nathan DG, Orkin SH, Ginsburg D, et al., eds. Nathan and Oski’s Hematology of Infancy and Childhood. 6th ed. Philadelphia: WB Saunders; 2003.
6. Oski FA. Iron deficiency anemia in infancy and childhood. N Engl J Med. 1993;129:190–193.
7. Pappas DE. Iron deficiency anemia. Pediatr Rev. 1998;19:321–322.
8. Wharton BA. Iron deficiency in children: Detection and prevention. Br J Haematol. 1999;106:270–280.
9. Wu AC, Lesperance L, Bernstein H. Screening for iron deficiency. Pediatr Rev. 2002;23:171–177.

Iron Deficiency Anemia - CODES

Iron Deficiency Anemia - icd9

280 Iron deficiency anemias

Iron Deficiency Anemia - PATIENT TEACHING-MED

Iron Deficiency Anemia - patient teaching-med_diet

A diet containing iron-rich foods should be encouraged. Milk intake should be limited to <24 ounces daily.

Iron Deficiency Anemia - patient teaching-med_activity

Usually no activity restriction is required.

Iron Deficiency Anemia - patient teaching-med_prevent

Prevention of iron deficiency is preferable. Anticipatory guidance about diet, prolonged bottle use, etc., should be given, and government-sponsored programs such as the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) should be used.

Iron Deficiency Anemia - FAQ

• Q: What dietary changes can help prevent the recurrence of iron deficiency?
• A: Limit milk to not more than 24 oz/d so that your child has a better appetite for iron-containing foods. Heme iron, found in meats, fish, and poultry, is absorbed better than non-heme iron and enhances the absorption of non-heme iron. Other foods that contain iron are raisins, dried fruit, sweet potatoes, lima beans, chili beans, green peas, peanut butter, and enriched foods. Give iron on an empty stomach along with an ascorbic acid–containing juice to increase absorption of iron. Foods that decrease iron absorption include bran, vegetable fiber, tannins found in tea, and phosphates. Antacids may also decrease iron absorption.
• Q: What are the side effects of iron therapy?
• A: Iron may cause temporary staining of the teeth, which can be decreased by diluting the iron with a small amount of juice. Iron will also change the color of bowel movements to greenish black and may be associated with constipation.
• Q: What are the most important tests to do to establish the diagnosis of iron deficiency?
• A: For patients with a history of dietary deficiency or known blood loss, a CBC that shows a low hemoglobin level and MCV and an elevated RDW is very suggestive of iron deficiency. A therapeutic trial of iron without further laboratory testing is an appropriate next diagnostic step. An increase in the hemoglobin concentration of ≥1 g/dL after 1 month of therapy confirms the diagnosis. If this does not occur, further laboratory testing is necessary and other diagnoses should be considered.
• Q: How does a concurrent infection affect the diagnosis of iron deficiency?
• A: Common childhood infections may be associated with a mild microcytic anemia that resembles iron deficiency. Laboratory tests to diagnose iron deficiency may be misleading while a child is acutely ill. Acute infection is associated with a shift of iron from serum to storage sites, causing a decrease in serum iron and an increase in ferritin. It is therefore more helpful to screen a child for iron deficiency 3–4 weeks after an acute infection.

Book Source Details

• Book Title: The 5-Minute Pediatric Consult
• Author(s): M. William Schwartz MD; et al.
• Year of Publication: 2008
• Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: The 5-Minute Pediatric Consult Authors: M. William Schwartz MD; et al. Publisher: Lippincott Williams & Wilkins Copyright: 2008 ISBN: 0-7817-7577-9

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