Iron Deficiency Anemia

A recent article in PediatricBasics, which is a publication of Gerber foods, dealt with the issue of iron deficiency. (1)This brings to mind how common a problem this is and how frequent it is discussed in the office. For this reason it makes good material for our Web page.

Iron is a necessary element in the production of hemoglobin, which is the oxygen-carrying component of red blood cells. Many associate iron deficiency with anemia or "low blood". This is in fact the case although one may be low in iron stores and not yet exhibit evidence of anemia. Anemia can be manifested by pallor, lethargy and poor appetite. In very severe degrees of anemia cardiac problems such as murmurs, enlargement and failure can occur.(2)This would be a rare and dramatic presentation in our office practice. More typically this diagnosis is made based on history, routine blood work during annual exams and from lab work which from time to time is ordered for evaluation of an illness.

Of concern are some of the non-hematological effects of iron deficiency. These may be related to the anemia or the amount of iron in tissues. Functional difficulties have been described in proportion to the degree of iron depletion. (1)Some studies indicate that there is a vulnerable period in infancy where the effects of iron depletion may cause prolonged effects.(1;3) Studies have shown that iron supplementation may in fact improve psychomotor development in some groups.(4)There are those who still feel that clarification is needed before we are ready to completely accept these findings.(5)It seems reasonable that iron is indeed important as a part of our children’s diets and may in fact be needed to be supplemented in those who may be iron deficient or whose diet cannot maintain iron stores.

As per the recommendations of the American Academy of Pediatrics:(1;6)

Term infants who are breast-fed will need iron as 1mg/kg/day of elemental iron beginning at 4-6 months of age. This can be achieved with two one half ounce servings of iron-fortified cereals daily

If a term breast-fed infant is not or cannot take appropriate amounts of iron in their diets at six months of age one may use an iron supplement of 1mg/kg/day.

Premature or low birthweight infants need iron in larger quantities (2-4mg/kg/day) beginning at one month and continuing through one year of age. This may be given as iron supplement drops.

Only iron fortified formula should be used whether primary or as supplement.

Low iron formula has no indication for the infant’s diet.

Until a child reached twelve months old, cow’s milk, goat’s milk and soymilk (not soy formula) should be avoided.

Excess milk intake should be avoided in children 1-5 years old. Greater than 24 ounces a day in this age group would be considered excessive.

Iron fortified cereals should be introduced at 4-6 months of age if developmentally ready.

As other solid foods are introduced those with high iron should be encouraged.

Vitamin C as present in fruits and juices helps in the availability and absorption of iron. Those foods which are rich in iron include breast milk (readily absorbable iron) , iron-fortified formula,meats, organ meats, iron-fortified cereal, leafy green veggies such as spinach, soy beans and lentils. Variety in diets is the best way to insure good iron intake.(1)

At Pediatric Specialists your child’s blood is checked periodically for hematocrit which is a measure of red blood cell quantity which frequently reflects the iron intake and stores. Being only a screening test we may follow this up with further tests to identify the anemia. These tests may include a hemogram as well as measurements of iron or iron stores. Should a child be determined to be iron deficient therapeutic amounts of iron will be prescribed for a period of time (usually three months). At some point the blood will be rechecked for anemia. Following correction of the iron deficiency it may be necessary for your child to remain on maintenance amounts of iron if dietary sources are not consumed adequately. It has been observed that correcting this anemia also may stimulate growth and a better appetite.(7)

On rare occasions a child’s anemia does not correlate with the history. A parent may report that the child is consuming foods and supplements high in iron. For these situations we are obliged to try and explain this apparent discrepancy. . Normal iron measurement would eliminate iron deficiency as a cause for anemia.

Further blood work may be obtained including electrophoresis to look for abnormal hemoglobin. Stools and urine should be checked for occult blood. Chronic diseases may also cause anemia and they should be ruled out.Remember there are numerous other causes of anemia which are not related to iron deficiency. It would be less than helpful to put a child with normal iron stores on iron. For this reason it is wise to investigate the source of anemia before beginning long term therapy.

Reference List:

(1) Bruner M.D. A. Iron Deficiency and Anemia. PediatricBasics 1999; 87(Spring):2-11.

(2) Oski FA, DeAngelis CD, Feigin RD, Warshaw JB. Principles and Practice of Pediatrics. 1 ed. J.B. Lippincott Co., 1990.

(3) Walter T, DeAndraca I., Chadud P., Perales C.G. Iron deficiency anemia:adverse effects on infant psychomotor development. Pediatrics 1989 July; 84(1):7-17.

(4) Williams J, Wolff A, Daly A et al. Iron supplemented formula milk related to reduction in psychomotor decline in infants from inner city areas: randomised study. BMJ 1999 Mar 13 318;693-7.

(5) Logan S. Commentary: iron deficiency and developmental deficit-the jury is still out. BMJ 1999 Mar.; 318(7185):697-8.

(6) American Academy of Pediatrics, Committee on Nutrition. Pediatric Nutrition Handbook. 4 ed. Elk Grove Village, Illinois: American Academy of Pediatrics, 1998.

(7) Aukett MA, Parks YA, Scott PH, Wharton BA. Treatment with iron increases weight gain and psychomotor development. Arch Dis Child 1986 Sep 1961;849-57.

---