Iron Deficiency and Iron Deficiency Anemia
Key points
- All newly arrived refugee, internationally adopted and immigrant children from resource-poor countries should have complete blood count (CBC) testing for initial screening of iron deficiency anemia.
- Iron deficiency anemia incidence is high among refugee children, and it is the most common nutritional deficiency worldwide.
- Dietary deficiency is the most common cause of low iron. Chronic infections and disease, notably recurrent malaria and parasitic infections, can compound anemia.
- Iron deficiency can cause delayed cognitive and physical development, poor acquisition of language and learning skills, and increases risk of infection in children and adolescents.
- All children who have iron deficiency anemia should be treated with therapeutic iron, but they must be screened for hemoglobinopathy before starting therapy.
Prevalence
Iron deficiency is the most common nutritional deficiency worldwide.1 It affects one-half of children living in low-resource countries and the reported prevalence of its consequence – anemia – is also high among refugee children.1 Iron deficiency among children who were long-term African refugees has been estimated to be from 23 to 75%.2
Definition
|
Anemia, hemoglobin level g/L |
|||
---|---|---|---|---|
|
Healthy range |
Mild |
Moderate |
Severe |
Children 6 to 59 months |
≥ 110 |
100–109 |
70–99 |
< 70 |
Children 5 to 11 years |
≥ 115 |
110–114 |
80–109 |
< 80 |
Children 12 to 14 years |
≥ 120 |
110–119 |
80–109 |
< 80 |
Non-pregnant women (≥ 15 years) |
≥ 120 |
110–119 |
80–109 |
< 80 |
Men (≥ 15 years) |
≥ 130 |
110–129 |
80–109 |
< 80 |
Pregnant women |
≥ 110 |
100–109 |
70–99 |
< 70 |
Source: Adapted from World Health Organization. Haemoglobin concentrations for the diagnosis of anaemia and assessment of severity. Vitamin and Mineral Nutrition Information System.Geneva, Switzerland: WHO, 2011 (WHO/NMH/NHD/MNM/11.1). |
Etiology
The most common cause of iron deficiency is dietary insufficiency, caused by poor bioavailablity of iron in food or factors relating to poor absorption. Non-dietary factors may play a contributing role for anemia, such as parasitic infections, recurrent malaria, and chronic infections.1 Other chronic conditions, notably hereditary anemias (e.g., sickle cell, thalassemias), are exacerbated by iron deficiency.
Consequences
Iron deficiency can lead to delayed cognitive and physical development, poor acquisition of language or learning skills, and increases risk of infection in children and adolescents.1
Screening
All newly-arrived refugee, internationally adopted and immigrant children from resource-poor countries should have a complete blood count (CBC) test for initial screening of iron deficiency anemia. An infant found to be anemic should have a serum ferritin test, which reflects body iron stores. It is one of the earliest indicators of depleted iron levels,3 but results may be elevated by the presence of inflammatory disease and mask iron deficiency. Children coming from endemic areas or of ethnicities at risk should have hemoglobinopathy testing (high-performance liquid chromatography [HPLC], or hemoglobin analysis [e.g., Hb electrophoresis]) and be screened for G6PD levels if from endemic regions such as the Mediterranean, Africa and Asia.
Treatment
Clinicians need to take a complete dietary history for children with iron deficiency anemia, and offer dietary education to newcomer families on culturally appropriate foods with a high iron content.
All children who have iron deficiency anemia should be treated with therapeutic iron but must be screened for hemoglobinopathy before starting therapeutic levels.
Children with hemoglobinophathies may also have iron deficiency and must be monitored closely to prevent iron loading.
Ferrous sulfate treatment
Children with anemia or low ferritin should receive iron at a treatment dose. Elemental iron is available in several forms such as ferrous sulfate or fumarate. To avoid confusion it should be ordered as elemental iron, specifying the quantity of drops, syrup, or tablets. Dose of elemental iron is 4 mg to 6 mg/kg/day divided q8–24h for 2 to 4 months. CBC and ferritin levels need to be closely monitored during this time.
Weight, kg |
Daily iron dose, mg elemental iron |
Fer-in-Sol drops* (15 mg/mL) |
Fer-in-Sol syrup* |
Tablets* |
PALAFER syrup† |
FeraMAX |
---|---|---|---|---|---|---|
2.5–4 |
15 |
0.5 mL bid |
1 mL bid |
|
0.5 mL bid |
¼ tsp daily |
5–9 |
30 |
1 mL bid |
2.5 mL bid |
|
0.5 mL tid |
½ tsp daily |
10–19 |
60 |
2 mL bid |
5 mL bid |
|
1.5 mL bid |
1 tsp daily |
20–29 |
120 |
|
10 mL bid |
1 tab bid |
3 mL bid |
1 tsp BID |
30–49 |
160–180 |
|
|
1 tab tid |
4 mL bid |
1 capsule daily |
> 50 |
180–240 |
|
|
1 tab tid or qid |
5 mL bid |
2 capsules daily |
*Elemental iron. Ferrous sulfate content: drops 75 mg/mL, syrup 30 mg/mL, tabs 300 mg/tab. †Elemental iron. Ferrous fumarate content: 60 mg/mL. |
Selected resources
- Centers for Disease Control and Prevention. Immigrant and refugee health.
- Health Canada, 2007. Eating well with Canada’s food guide is available in multiple languages.
- U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic Infectious Diseases. Guidelines for evaluation of the nutritional status and growth in refugee children during the domestic medical screening process. Bethesda, MD: CDC, April 2012.
- WHO. Worldwide prevalence of anaemia 1993–2005. Geneva, Switzerland: WHO, 2008.
References
- U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic Infectious Diseases. Guidelines for evaluation of the nutritional status and growth in refugee children during the domestic medical screening process. Bethesda, MD: CDC, April 2012.
- Seal AJ, Creeke PI, Mirghani Z, et al. Iron and vitamin A deficiency in long-term African refugees. J Nutr 2005;135(4):808-13.
- Zlotkin S. Clinical nutrition: 8. The role of nutrition in the prevention of iron deficiency anemia in infants, children and adolescents. CMAJ 2003;168(1):59-63.
Editor(s)
- Anna Banerji, MD
- Andrea Hunter, MD
Last updated: September, 2016