Iron deficiency – kids

1. Serum ferritin is the most useful screening test for assessing iron stores. 
2. A reduced serum ferritin (<20 μg/L) indicates borderline/low iron stores. 
3. Children with iron deficiency anaemia (IDA), symptomatic iron deficiency and iron deficiency with or without anaemia prior to surgery should be treated. 
4. In most instances, IDA and iron deficiency can be treated safely and effectively with oral iron supplements.   

Background

• Iron deficiency is the most common cause of anaemia in children. 
• Iron deficiency in infants and toddlers is predominantly a nutritional disorder; (insufficient red meat or excessive cow milk consumption); rarely due to malabsorption or gastrointestinal bleeding.
• Anaemia in children in ATSI is nearly always due to iron deficiency, and extensive investigation is rarely warranted.
• Parasites (worms) have been common in the ATSI and routine treatment is recommended in children with anaemia.

Risk factors include  

• Infants
  • Maternal iron deficiency  
  • Prematurity and/or low birth-weight 
  • Multiple pregnancy  
  • Exclusive breast-feeding after 6 months  
  • Late or insufficient introduction of iron rich solids 
  • Excess cow’s milk consumption 
  • Aboriginal and Torres Strait Islander 
• Children
  • Vegetarian or vegan diet
  • Gastrointestinal disorders e.g. Meckel’s diverticulum, coeliac disease, inflammatory bowel disease, gastric or intestinal surgery or infection  
  • Other chronic blood loss 
• Adolescents
  • Vegetarian or vegan diet
  • Heavy menstrual bleeding
  • Gastrointestinal disorders e.g. coeliac disease, inflammatory bowel disease, gastric or intestinal surgery or infection
  • Other chronic blood loss 
  • Extreme athletes

Symptoms of low ferritin: 

• Impaired cognitive function; decreased memory, impaired learning and concentration 
• Behavioural disturbances
• Fatigue
• PICA – eating of non-nutritive substances such as paper, wood and soil 

Investigations

• Serum ferritin is the most useful screening test for assessing iron stores. 
• A ferritin of <20 μg/L is taken to indicate borderline/low iron stores.
• Iron studies or serum iron should not be requested to diagnose iron deficiency. 
• Serum iron reflects recent iron intake and does not provide a measure of the iron stores. 
• Serum ferritin is an acute phase reactant and a normal result does not exclude iron deficiency in the presence of coexisting infection, inflammation or liver disease.  
• A FBC is needed to diagnose IDA, most commonly the red blood cells are microcytic and hypochromic (reduced MCV and MCH).  

Management

Suggest iron supplementation and dietary modification if low ferritin, with or without anaemia. 

Dietary advice 

• Increase iron-rich foods and reduce cow’s milk consumption.
  • IMPORTANT SOURCES OF IRON
    • Infant milk formulas
    • meat (especially red meat, and also fish and chicken)
    • green vegetables and legumes
    • dried fruit
    • juices
    • fortified cereals
    • egg yolk.
• Consider referral to a dietitian.
• Give iron and multivitamin supplements to very premature and low birthweight (<1000 g) infants.
• Introduce iron-containing solids early—at 4 to 5 months, e.g. cereals, vegetables, egg and meat.
• Encourage breastfeeding and avoid cow’s milk in the first 12 months.
• Avoid excessive cow’s milk up to 24 months. – limited to <500 mL/day in those older than 12 months.
• Use iron-fortified formulas and cereals.

Oral iron supplementation 

• 1 – 2 mg/kg/day is the preventative dose for iron deficiency 
• 3 – 6 mg/kg/day is the recommended dose for treatment of iron deficiency and IDA. Higher doses should be considered in those children with severe anaemia (Hb <80 g/L).
• Iron supplements should be continued for a minimum of 3 months after anaemia has been corrected to replenish stores. Hb and ferritin should be checked at this time point. 

Other Treatment Considerations 

• Parent should be advised that iron preparations can make a child’s stool, black in colour and may cause constipation. 
• Oral iron preparations may also stain a child’s teeth and families should consider brushing a child’s teeth following iron administration.
• Iron is better absorbed if taken with vitamin C (e.g. orange juice)
• In patients with severe anaemia, early follow up (within a week) should be arranged to ensure compliance and an appropriate response to treatment (reticulocytosis and increase in Hb).
• Iron supplements should be continued for a minimum of 3 months after anaemia has been corrected to replenish stores. Hb and ferritin should be checked at this time point.
• Assess for any potential issues with compliance, as poor compliance is the leading reason for treatment failure
• Transfusion rarely required (e.g. cardiac failure) 

Oral iron formulations 

Formulation	Name	Elemental iron content	Notes
Ferrous sulphate oral mixture	Ferro-liquid	6 mg/mL	May stain teeth, drink through a straw to prevent teeth discolouration and consider brushing teeth with baking soda afterwards.
Ferrous sulphate delayed release capsules or spansules (270 mg)	Fefol ®	87.4 mg	Spansules can be opened and the beads sprinkled on food to give lower dosesThey should not be crushed or chewed
Ferrous sulphate (325 mg)	Ferro-gradumet	105 mg	May be appropriate for older children who can swallow them whole

Over the counter multi-vitamin or minerals supplements do not contain sufficient iron to treat iron deficiency anaemia and should not be used. 

Quick Dose reference guides 

Mild to moderate IDA – to provide 3mg/kg/day 

Weight	Ferro-Liquid	Fefol Spansules	Ferro-Gradumet slow release tablets
<10 kg	0.5 mL/kg/day	NA	NA
10 kg	5 mL per day	Half a spansule 5 days/week	NA
20 kg	10 mL per day	One spansule 5 days/week	NA
30 kg	15 mL per day	One spansule daily	1 tablet daily
>40 kg	20 mL per day	One spansule daily	1 tablet daily

Note: doses in patients >40 kg are usually limited to one spansule / tablet per day unless no improvement in Hb and reticulocyte count.

Severe IDA (Hb 80 g/L or less) – to provide 6mg/kg/day 

Weight	Ferro-Liquid	Fefol Spansules	Ferro-Gradumet slow release tablets
<10 kg	1 mL/kg/day	NA	NA
10 kg	10 mL per day	One spansule 5 days/week	NA
20 kg	20 mL per day	One  spansule daily	NA
30 kg	30 mL per day	One spansule daily	1 tablet daily
>40 kg	40 mL per day	One spansule daily	1 tablet daily

 Note: doses are usually limited to one spansule / tablet per day unless no improvement in Hb and reticulocyte count.