- Anemia Prevalence age <5 years: 6% in U.S. (50% worldwide)
- Low income U.S.: 14.6% (up to 18.2% at ages 12-17 months)
-
Iron Deficiency Anemia
Prevalence age 1-5 years: 1-2% in U.S.
- Iron Deficiency accounts for 40% of childhood Anemia
- U.S. toddlers with nutritional Iron Deficiency (without Anemia): 7-8%
- Anemia (esp. Iron Deficiency Anemia)
- Premature Infants
- Low Birth Weight Infants
- Recent Immigrants from developing countries
- Infants from low-income families
- Feeding problems or poor growth
- Main dietary intake is unfortified cow's milk
- Cow's milk within first year is greatest risk factor
- Infant formula with low or no iron (<6.7 mg/Liter iron)
- Breastfeeding without Iron Supplementation after 6 months
- See Screening Tests under labs below
- Screen newborns with Hemoglobin electrophoresis (see Newborn Screen)
- Screening recommendations differ between CDC, AAP, WHO, and USPTF
- Screening guidelines are similar but not identical between CDC, AAP, USPTF
- Universal screening is recommended at age 12 months by AAP and WHO
- Identify high risk groups for Anemia (see risk factors above)
- See Anemia History
- Prematurity
- Low birth weight
- Dietary history
- Chronic disease
- Ethnicity
- Family History of Anemia
- Signs and Symptoms
- See Anemia Clinical Clues
- Often asymptomatic
- Fatigue
- Apathy
- Growth Delay
- Developmental Delay
- Increased infection rate
- See Anemia Labs
- Indications
- Symptomatic children
- See Anemia Clinical Clues (as well as findings above)
- Screening
- Goal: Diagnose Iron Deficiency prior to Anemia
- Symptomatic children
- Sample acquisition
- Avoid lab draw within 2-3 weeks of fever or infection
- Venipuncture
- Capillary Puncture
- Initial Anemia screening labs
- Hemoglobin
- See Hemoglobin Cutoffs for Anemia (vary by age and condition)
- Complete Blood Count (with indices including MCV) is ideally obtained
- Precaution
- Hemoglobin And Hematocrit have low efficacy as a screening tool
- Poorly detect Iron Deficiency Anemia
- Poor Test Sensitivity and Test Specificity
- Consider Ferritin and TIBC if suspicious for Iron Deficiency Anemia despite normal Hemoglobin
- Serum Ferritin <15 ng/ml is used as cut-off for Iron Deficiency
- Some authors recommend empiric Iron Supplementation for 1 month in mild Microcytic Anemia
- See protocol below
- White (2005) Pediatrics 115:315-20 [PubMed]
- Hemoglobin And Hematocrit have low efficacy as a screening tool
- More accurate Anemia screening measures
- ReticulocyteHemoglobin content
- Iron Deficiency Anemia suggested when <27.5
- Test Sensitivity: 83%
- Test Specificity:72%
- Reference
- ReticulocyteHemoglobin content
- Cutoffs for Anemia
- Hemoglobin
- See Anemia Evaluation
- See Pediatric Anemia Causes
-
Microcytic Anemia (decreased MCV, most common, esp. Iron Deficiency Anemia)
- See Microcytic Anemia
- See Physiologic Anemia of Infancy
- See below for management protocol
-
Macrocytic Anemia (increased MCV)
- See Macrocytic Anemia
- Uncommon in children
- Nutritional Deficiency (Megaloblastic Anemia)
- Megaloblasts are large nucleated Red Blood Cell precursors
- Vitamin B12 Deficiency
- May occur in strict Vegan diet or Breastfeeding mother with B12 Deficiency
- Folate Deficiency
- May occur with infants exclusively fed goat's milk
- Nonmegaloblastic Anemia
- Causes include Thyroid dysfunction, liver dysfunction, Bone Marrow disorders and infection
-
Normocytic Anemia (normal MCV)
- See Normocytic Anemia
- High Reticulocyte Count (Reticulocytosis)
- See Hemolytic Anemia (includes laboratory evaluation)
- See Hemolytic Anemia Causes
- Low Reticulocyte Count (Reticulocytopenia)
- See Reticulocytopenia
- Initial labs include Peripheral Smear, renal and hepatic function, TSH and iron studies
- See Microcytic Anemia
- See Iron Deficiency Anemia
- Criteria for empiric treatment in young child
- Mild Anemia AND
- Findings consistent with Iron Deficiency (Microcytic Anemia)
- Protocol
- Ferrous Sulfate 3-6 mg/kg/day before breakfast
- Iron Deficiency without Anemia may initially be treated with increased Dietary Iron
- Anticipate Hemoglobin increase 1.0 g/dl by 4 weeks
- Increase appropriate: Continue iron for 2-3 months (up to 3-6 months)
- Not appropriate
- Evaluate other causes (blood loss)
- Labs include Reticulocyte Count, lead level, iron studies (Serum Ferritin, TIBC, Serum Iron)
- Consider Hemoglobin electrophoresis (e.g. Sickle Cell Anemia, Thalassemia)
- Typically performed in the U.S. as part of universal screening
- Consider Differential Diagnosis (See above)
- See Microcytic Anemia
- Thalassemia (See Mentzer Index)
- Ferrous Sulfate 3-6 mg/kg/day before breakfast
- Pediatric Anemia may result in life-long deficits
- Effects persist despite correction of Anemia
- Prevent deficits by diagnosing Iron Deficiency early
- Motor Effects
- Decreased gross and fine motor coordination
- Cognitive effects
- Lower scores on Intelligence Testing
- Longterm functional Impairment in school
- Behavioral effects
- Fearfulness and unhapiness
- Early Fatigue, less playful, clingy
- References
- Formula-fed infants should use only full iron formula
- Never use low iron infant formula (no GI benefit)
- Do not use with iron-containing Vitamins
- Limit unfortified cow's milk
- No cow's milk should be given under age 1 year
- Limit cow's milk to <24 ounces ages 1-2 years
- Supplement Breast Feeding
- Term infants need 1 mg/kg/day elemental iron
- Start supplement at 6 months of age
- Preterm and low-weight infants need 2 mg/kg/day
- Start supplement at 2-4 weeks of age
- Options
- Ferrous Sulfate drops
- Infant Vitamin Drops (10 mg elemental iron/dropper)
- Term infants need 1 mg/kg/day elemental iron
- Pregnancy and Delivery
- Prevent and treat maternal Iron Deficiency Anemia during pregnancy
- Iron requirements increase with each trimester
- More than two thirds of fetal iron storage occurs in third trimester
- Unclear evidence regarding impact on fetal outcomes
- Delayed Umbilical Cord clamping (2-3 minutes)
- Improved iron stores at 6 months
- Greatest impact in higher risk infants for Iron Deficiency (e.g. SGA, Premature Infants)
- Prevent and treat maternal Iron Deficiency Anemia during pregnancy
- Other measures
- See Dietary Iron
- See Iron Supplementation
- Maintain varied diet
- Iron fortified cereal
- Avoid excessive juice intake
- MMWR Iron Deficiency Anemia Prevention
- (1998) MMWR Morb Mortal Wkly Rep 47:1-29 [PubMed]
- Gallagher (2022) Blood 140(6):571-93 +PMID: 35213686 [PubMed]
- Irwin (2001) Am Fam Physician 64(8):1379-86 [PubMed]
- Kazal (2002) Am Fam Physician 66(7):1217-27 [PubMed]
- Janus (2010) Am Fam Physician 81(12): 1462-71 [PubMed]
- Raleigh (2024) Am Fam Physician 110(6): 612-20 [PubMed]
- Wang (2016) Am Fam Physician 93(4): 270-8 [PubMed]