Iron Deficiency and Anemia in Children

Although not as common as it once was, thanks to the increased availability of foods with iron in the 1980s and 1990s, iron deficiency is still a common cause of anemia in young children.

Our bodies need a certain amount of iron to help the hemoglobin in our blood cells carry oxygen. Iron is also a part of many enzymes and is needed for them to work properly, for example, to help digest food and regulate cell growth, etc., and it helps our muscles use oxygen.

Children can develop an iron deficiency because they don't get enough foods with iron in their diet, which is the most common way, or because they are chronically losing blood and iron for some reason.

Overview

To help detect all children with iron deficiency anemia, the American Academy of Pediatrics recommends that all children be screened or tested for iron deficiency anemia when they are about 12 months old (universal screening).

Infants, toddlers, and older children might also be screened at other times if they are thought to be at risk for iron deficiency anemia, including:

• Premature babies
• Exclusively breastfed babies who don't start eating an iron-fortified cereal or get another source of iron by about six months
• Infants who are given cow's milk or unfortified goat's milk instead of breast milk or baby formula before they are 12 months old
• Drinking more than 20 ounces of milk each day, a common cause of iron deficiency in toddlers
• Children of low socioeconomic status
• Children with chronic blood loss, such as from chronic diarrhea, nosebleeds, an ulcer, or inflammatory bowel disease.
• Children with chronic medical problems or special healthcare needs and/or those on restricted diets, such as a gluten-free diet or elimination diets for food allergies
• Vegetarians and vegans who don't get enough foods with iron or an iron supplement
• Teen girls who are competitive athletes and/or have heavy periods

Testing

If the initial screening test for iron deficiency anemia, which is usually a simple hemoglobin blood test, is low, additional tests for iron deficiency might be done. This might include testing of:

• Serum ferritin (SF) and C-reactive protein (CRP) levels, or
• Reticulocyte hemoglobin (CHr) levels

In general, kids with iron deficiency anemia will have low hemoglobin, low serum ferritin, normal CRP, and a low reticulocyte hemoglobin level, which is a measurement of the iron available for cells to use.

For children with mild anemia, further testing is not usually required, though, and they will simply be treated with extra iron (therapeutic iron trial) and have their hemoglobin retested in a month. Further testing can then be done if they don't improve.

Symptoms

Many children don't have any signs or symptoms of iron deficiency anemia symptoms and instead are detected on a routine screening test.

Others do have iron deficiency anemia symptoms or signs, which can include:

• General paleness, including pale skin, lips, nail beds, and lining of the eyes (pallor)
• Irritability
• Pounding or racing heartbeat (palpitations)
• Headaches
• Feeling weak
• Dizziness
• Getting tired easy
• Poor school performance
• Trouble maintaining a normal body temperature
• Having an inflamed tongue (glossitis)
• Cracking or splits in the corners of the lips (angular stomatitis, cheilitis, or cheilosis)
• Chewing on non-food items, such as clay, paper, dirt, etc., which is called pica, or chewing on ice (pagophagia)
• Having thin and brittle fingernails, which become spoon-shaped (koilonychia)
• Developing a bluish tinge to the sclera or white part of the eye (blue sclera)
• Increased risk of infections

Recognizing and treating iron deficiency anemia is important, as it can also affect a child's motor development and mental development.

Even without causing anemia, it is thought that iron deficiency may affect a teenager's memory and mental functions. In adults, it can also cause fatigue and impair their ability to do physical work.

The AAP even states that "iron deficiency without anemia may also adversely affect long-term neurodevelopment and behavior and that some of these effects may be irreversible."

Supplementation

Treatment for iron deficiency anemia typically involves giving the child or teen an iron supplement and reversing the cause of the iron deficiency, such as getting toddlers to drink less than 20 ounces of milk and getting kids to eat more foods with iron.

Popular iron supplements for kids include:

• Fer-In-Sol Iron Supplement Drops (ferrous sulfate)
• Feosol Tablets (ferrous sulfate)
• ICAR Pediatric Suspension and Chewables (carbonyl iron)

It is thought by some people that the ferrous sulfate form of iron is better absorbed than carbonyl iron, but others think that carbonyl iron is safer and has fewer gastrointestinal side effects.

Talk to your pediatrician about the best iron supplement, dose, and how long your child will need to take their iron supplement. Keep in mind that although many multivitamins for kids may contain iron, it is usually not enough to treat a child with iron deficiency.

Side effects of iron supplements can sometimes include temporary staining of the teeth, nausea, vomiting, constipation, diarrhea, dark-colored stools, and/or stomach aches.

Dietary Sources

In addition to taking an iron supplement, to help prevent your child from again developing iron deficiency, it is important that they eat plenty of foods with iron. This can also help prevent iron deficiency anemia in the first place.

Foods with iron include those with heme iron, such as lean red meats (beef, pork, lamb), poultry, and seafood. This form of iron is absorbed two to three times better than the iron that is in plants and fortified foods, which is non-heme iron. Meat proteins and vitamin C can help our bodies absorb non-heme iron though.

Some drinks are also fortified with iron (non-heme iron), including Carnation Instant Breakfast Mix, Ovaltine, and most toddler or next-step formulas.

What You Need to Know

• Iron supplementation of formula is not thought to cause colic or any gastrointestinal symptoms.
• Foods with vitamin C, including foods such as strawberries, red pepper, and citrus fruits, can help with iron absorption, so it is a good idea to pair non-heme iron foods and supplements together with foods that are high in vitamin C.
• Iron supplements should usually be given between meals to help make sure as much iron as possible is absorbed from the iron supplement.
• Tannins in tea, calcium, and phytates in legumes and whole grains can decrease the absorption of non-heme iron. It's best to allow a 1 to 2 hour gap between these products and iron supplements.