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
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
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
Only iron fortified formula should be used whether primary or
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
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
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.
(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
(5) Logan S. Commentary: iron deficiency and developmental
deficit-the jury is still out. BMJ 1999 Mar.;
(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.