Iron deficiency and iron deficiency anaemia

Introduction

Anaemia is common in children and the most common cause of anaemia is iron deficiency. Iron deficiency is primarily a nutritional disorder although it is also caused by physiologically increased requirements in children under 5 and in adolescents. Pathologically defective absorption or chronic blood loss are less common causes. Untreated, iron deficiency anaemia can result in developmental delays and learning difficulties.

Children may present with pallor, lethargy, weakness or listlessness, poor growth, shortness of breath or flow murmur. Older children may present with signs of hyperactivity, poor sleep, and poor concentration.

Risk factors include:

• prematurity
• low birth weight
• low maternal iron during pregnancy
• poor diet
• delayed introduction of solids
• recurrent infections
• heavy menstrual bleeding
• high consumption of cows’ milk
• Aboriginal children or children from a Refugee background.

Pre-referral investigations

Blood tests are required to make this diagnosis.

Perform:

• FBP (Full Blood Picture)
• Iron Studies
• Blood film
• Reticulocyte count 

Consider:

• stool sample for parasites
• serum B12 and folate
• Coeliac Serology if child is taking solid foods without gluten exclusion.

Pre-referral management

• Discuss dietary modifications including advising increased consumption of iron rich foods such as red meat, poultry, fish, pulses and green vegetables. See Iron deficiency diet sheet - Health Fact sheet (PDF).
• If < 1 year, and child is on cow’s milk, replace with infant formula
• If >1 year, reduce cows’ milk consumption to a maximum of 2 cups (500 ml)/day
• Reduce consumption of other foods that inhibit iron absorption such as tea, coffee, cola drinks and unprocessed bran
• Commence Iron supplementation:

• The dose is between 3 – 6 mg of elemental iron /kg per day
• 3 mg/kg is usually effective

*Note: dosing is of elemental iron and can be confusing.

• Advise parents supplement is better absorbed if given with fruit juice which is also useful to disguise flavour
• If constipation/abdominal pain, consider giving on alternate days
• Keep out of reach of children
  • Warn parents to store iron in a safe location such as a locked cupboard as iron overdose in children can be fatal

• Monitor patient’s response to treatment
  • Check ferritin and reticulocyte count after 4 – 6 weeks and again at 3 months
  • Consider changing to a different formulation if no response to treatment
• Intravenous iron therapy is rarely necessary.

When to refer

• Anaemia associated with haemolysis or blood film abnormalities
• Signs of cardiac failure
• If the cause is unclear
• No response to treatment after ensuring compliance
• If no response to treatment after a trial of at least three months of oral therapy and at least two difference formulations as demonstrated by no improvement in ferritin and or haemoglobin.

How to refer

• Routine non-urgent referrals from a GP or a Consultant should go to the Central Referral Service
• Routine non-urgent referrals from private hospitals are made via the PCH Referral Office (Fax: 6456 0097 or email PCH.Referrals@health.wa.gov.au)
• Urgent referrals (less than seven days) should be discussed with the on-call general paediatric registrar
• Please note: Referrals for patients with isolated iron deficiency without anaemia and no other medical concerns will not be accepted. These children should continue with oral iron therapy and remain monitored by their general practitioner.

Essential information to include in your referral

• Birth history
• Growth parameters and percentile chart
• Physical examination findings
• Developmental history
• Dietary history
• Treatments already used
• Blood test results both pre and post commencement of iron treatment.

Useful resources

• Iron Deficiency - The Royal Children’s Hospital Melbourne
• Iron deficiency diet sheet - Health Fact sheet (PDF)
• Paediatric and Neonatal Iron Deficiency Anaemia Guide - National Blood Authority
• Anaemia - Raising Children
• A guide to taking iron tablets and liquids - Queensland Government-Metro North Hospital and Health Services
• Patient information: Iron tablets and liquid - Metro North HHS
• Iron - Nutrition Australia

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