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With the high demands placed on a child’s diet, deficiencies of nutrients like iron can cause considerable effects on his or her growth and ability to perform physically and mentally. Thus it's up to you to make sure children are not suffering the effects of iron deficiency or anemia and that parents have the infomation they need to maintain their child’s health. This article outlines key indicators which may signal an iron deficiency or anemia, including the presence of pallor, a poor diet, heavy menstrual bleeding, behavioral indicators and a family history of anemia.

Starting Out Right

Even before a child is born, a great deal of attention is paid to the nutrient and iron levels of expectant mothers to avoid iron deficiency and anemia in the newborn. Current research shows that when a mother suffers from anemia during pregnancy, the newborn may not be able to store enough iron before birth, is more likely to be born prematurely, and have a lower birth weight. This lack of stored iron may continue well into the baby’s first year of life.¹ Conversely, babies born to a mother with healthy iron levels, children will have received about 4-6 months worth of stored iron. After that however, children will need to rely on their diet alone.

To monitor if children are receiving enough iron in their diet during these crucial developmental stages, Dr. Van Winkle, a Family Practice Physician and Clinical Associate Professor of Medicine at the University of Texas, routinely performs a complete blood count (CBC) around nine months of age. Although the U.S. Preventive Services Task Force (USPSTF) does not recommend for or against screening for anemia in children 6-12 months of age, iron deficiency anemia in young children and adolescents may decrease attention spans, alertness, and subsequent learning.^2,3 Although not definitively proven, iron supplementation has shown to improve learning, memory, and cognitive test performance in select studies.³

To parents, Dr. Van Winkle recommends continuing to provide iron-fortified formula to children through age 12 months and also providing iron-fortified cereals and vitamin C. After 12 months limiting a child’s non-formula milk to 24 ounces daily also helps by decreasing the chances of inhibited iron absorption. For more information you can provide to parents, refer to NAAC’s series of feature articles on Anemia in Children, which discuss a few common causes and strategies for preventing anemia in children of different age groups, including Infants (0-3), School-Aged Children (3-12), and Adolescents (13-19).

General Diet Recommendations

As with all patients, children should consume foods which contain or are enriched with vitamin B12, folic acid (folate) and iron; including breakfast cereals, meat, fish, beans, green leafy vegetables, eggs and nuts, among others. Vitamin C plays a role in preventing anemia by helping to increase the amount of iron absorbed in the stomach. Encouraging parents to provide a healthy diet can reduce the chance of iron deficiency, the most common reason children develop anemia. NAAC has two articles available to help your patients learn more about nutritious, iron-rich diets to help avoid anemia, including Anemia and Nutrition: The Importance of Iron and Anemia and Nutrition: The Importance of Essential Vitamins.

Additionally, some food and beverages – like bran, soy proteins, tea, coffee, and certain kinds of milk – can decrease the absorption of iron when consumed with iron-rich foods, potentially making children susceptible to iron deficiency. Dr. Van Winkle recommends that children drink no more than 24 ounces of cow’s milk, goat’s milk or soy milk daily until 5 years old.

Symptoms and Indicators

Anemia can be characterized by fairly nondescript symptoms like tiredness, fatigue, weakness, dizziness, shortness of breath, chest pain, coldness in the hands or feet, or a desire to chew ice. Some patients with mild or moderate anemia may not experience any reportable symptoms. Presence of symptoms, or of the other possible indicators listed below, should warrant consideration of and possible screening for anemia.

Pallor – For infants who cannot communicate the symptoms they may be experiencing, pallor can indicate a reduced level of circulating red blood cells. Pallor, a reduction in the pink hue of the skin, has also been considered a possible screening tool for anemia in infants and young children. This is a sign which parents may notice and inquire about during regular visits.⁶

Diet and Nutrition – The most common cause of childhood anemia is an iron-poor diet. This may be the result of inadequate intake of iron or the possibility that other agents are inhibiting iron absorption as described above. Either before or after measuring a child’s iron levels, it is important to ask about their dietary history, including what foods they eat or do not eat and if they drink excessive amounts of milk.

Menstrual Blood Loss – Young women who have begun menstruating are also at a much higher risk to develop iron deficiency and anemia due to blood loss. Approximately 10-15% of all women experience heavy bleeding at some point in their life.⁷ It is important to encourage young women to report symptoms of heavy menstrual bleeding to you or to their parents. Feel free to encourage young women and their parents to visit Women & Anemia – Heavy Menstrual Bleeding and Fibroids for more information about anemia and heavy bleeding.

Behavioral Indicators – Parents concerned about their child being anemic may cite that they sleep more than usual, however Dr. Van Winkle stresses that children in growth phases require more sleep than normal and that sleep may not be a true indicator of fatigue. Conversely, some school performance issues associated with learning disabilities or attention deficit disorders – like irritability or lack of attentiveness – may be additional signs that a child is anemic. Dr. Van Winkle recommends that, “Doctors should screen for anemia in children who are acting out or who have displayed evidence which could be considered a learning disability.”

History of Anemia – A family history of anemia may suggest a genetic predisposition to anemia. This is especially true for patients of African or Mediterranean descent or other ethnic groups, who are more likely to have certain hereditary blood disorders like sickle cell anemia and thalassemia to name two. These may be detected during anemia screening, and their treatment is condition determined.

Screening and Monitoring

In the absence of anemia-related symptoms, the USPSTF has determined that population-based evidence has not established the need to screen asymptomatic children for anemia, with potential harms of screening including false-positives, anxiety for patients and parents, and additional costs. In favor of universal screening, Dr. Van Winkle feels there is a need to “test children for iron deficiency at nine months and again during the pre-adolescent stage around 9-11 years of age,” to ensure that they are not iron deficient prior to the significant developmental changes ahead.³

If anemia-related symptoms are present, both the USPSTF and Dr. Van Winkle recommend using a simple hematocrit screening test to check for a below normal hematocrit level. Inexpensive, quick and easily administered by staff, a hematocrit test can determine if further testing is necessary. Below normal hematocrit levels – as defined in the chart to the right – would warrant further evaluation with a CBC and additional testing based on the CBC findings.

The mean corpuscular volume (MCV) measurement – one component of the CBC – can help classify a patient’s type of anemia when compared with normal-sized RBCs (MCV range of 80-96 fl).⁵ Patients with a decreased MCV will have smaller than normal RBCs (microcytic), potentially caused by an iron deficiency or thalassemia. Patients with an elevated MCV will have larger than normal RBCs (macrocytic), which can indicate a vitamin B12 deficiency.⁹ Results from a peripheral blood smear or reticulocyte count may help diagnose the cause of anemia. The American Academy of Family Physicians provides guidelines with a complete description of deferential diagnosis, diagnosis testing and evaluation, for free on their website, www.aafp.org.

Although much less common than a nutritional deficiency or menstrual blood loss, children and teens can be anemic due to suppressed bone marrow production associated with inflammation or chronic disease, like cancer or kidney disease. More descriptions about other conditions which can cause anemia of chronic disease are found in NAAC’s Information Handouts for patients or the Anemia Monograph written in 2002 as an in-office handbook for professionals.

Treating Anemia

Although anemia can result from a number of conditions, iron deficiency is the most common cause for infants, children and adolescents. As confirmed with a full iron work-up, an iron deficiency is traditionally treated with oral iron supplementation.¹⁰ For many children with iron deficiency or mild iron deficiency anemia, replenishing iron stores may be as simple as recommending parents to provide a daily vitamin containing iron, available over the counter. In other cases with much lower iron stores or severe iron defiency anemia, oral iron supplements or parenteral iron may be necessary.

A Physician’s Guide to Oral Iron Supplements from NAAC has more information about the supplements themselves. For information about treating iron deficiency anemia, consult the article Iron Deficiency Anemia provided by the American Academy of Family Physicians. For proper dosing and administration of iron supplements to children, consult the product labeling and instructions. With your help, children do not have to suffer the effects of anemia and parents can have peace of mind about their child’s health.

References

1. Allen LH. Anemia and iron deficiency: effects on pregnancy outcome. Am J Clin Nutr. 2000 May;71(5 Suppl):1280S-4S. Link.
2. The National Library of Medicine. Medline Plus Medical Encyclopedia. Iron Deficiency Anemia-Children. Link. Accessed: August 12, 2009.
3. U.S. Preventive Services Task Force. Screening for Iron Deficiency Anemia—Including Iron Supplementation for Children and Pregnant Women. Link. Accessed: August 12, 2009.
4. Halterman JS, Kaczorowski JM, Aligne CA, Auinger P, Szilagyi PG. Iron deficiency and cognitive achievement among school-aged children and adolescents in the United States. Pediatrics. 2001 Jun;107(6):1381-6. Link.
5. Irwin JJ, Kirchner JT. Anemia in children. Am Fam Physician. 2001 Oct 15;64(8):1379-86. Link.
6. Yurdakök K, Güner SN, Yalçin SS. Validity of using pallor to detect children with mild anemia. Pediatr Int. 2008 Apr;50(2):232-34. Link.
7. Vercellini P, Vendola N, Ragni G, Trespidi L, Oldani S, Crosignani PG. Abnormal Uterine Bleeding Associated with Iron-Deficiency Anemia. J Reprod Med. 1993 July;38(7):502-04. Link.
8. Worldwide Prevalence of Anaemia 1993-2005: WHO Global Database on Anaemia. Edited by Bruno de Benoist, Erin McLean, Ines Egli and Mary Cogswell. Link.
9. Lab Tests Online. Complete blood count. Link. Accessed: August 12, 2009.
10. Crosby WH. The rationale for treating iron deficiency anemia. Arch Intern Med 1984;144:471-72. Link.

Last Updated: August 26, 2009