Pediatric Anemia

Aka: Pediatric Anemia, Anemia in Children

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II. Epidemiology

  1. Anemia Prevalence age <5 years: 6% in U.S. (50% worldwide)
    1. Low income U.S.: 14.6% (up to 18.2% at ages 12-17 months)
  2. Iron Deficiency Anemia Prevalence age 1-5 years: 1-2% in U.S.
    1. Iron Deficiency accounts for 40% of childhood Anemia
    2. U.S. toddlers with nutritional Iron Deficiency (without Anemia): 7-8%

III. Causes

  1. See Pediatric Anemia Causes

IV. Risk Factors: Anemia (esp. Iron Deficiency Anemia)

  1. Premature Infants
  2. Low Birth Weight Infants
  3. Recent Immigrants from developing countries
  4. Infants from low-income families
  5. Feeding problems or poor growth
  6. Main dietary intake is unfortified cow's milk
    1. Cow's milk within first year is greatest risk factor
  7. Infant formula with low or no iron (<6.7 mg/Liter iron)
  8. Breastfeeding without Iron Supplementation after 6 months

V. Screening

  1. See Screening Tests under labs below
  2. Screen newborns with Hemoglobin electrophoresis (see Newborn Screen)
  3. Screening recommendations differ between CDC, AAP, WHO, and USPTF
  4. Screening guidelines are similar but not identical between CDC, AAP, USPTF
    1. Universal screening is recommended at age 12 months by AAP and WHO
    2. Identify high risk groups for Anemia (see risk factors above)
      1. Anemia screening at 9-12 months and then again 6 months later for children in high risk groups
      2. CDC recommends re-screening high risk groups annually between ages 2-5 years
      3. CDC recommends screening all non-pregnant women every 5-10 years for Anemia starting at Menarche

VI. History

  1. See Anemia History
  2. Prematurity
  3. Low birth weight
  4. Dietary history
  5. Chronic disease
  6. Ethnicity
  7. Family History of Anemia

VII. Findings: Signs and Symptoms

  1. See Anemia Clinical Clues
  2. Often asymptomatic
  3. Fatigue
  4. Apathy
  5. Growth Delay
  6. Developmental Delay
  7. Increased infection rate

VIII. Labs

  1. See Anemia Labs
  2. Indications
    1. Symptomatic children
      1. See Anemia Clinical Clues (as well as findings above)
    2. Screening
      1. Goal: Diagnose Iron Deficiency prior to Anemia
  3. Sample acquisition
    1. Avoid lab draw within 2-3 weeks of fever or infection
    2. Venipuncture
    3. Capillary Puncture
  4. Initial Anemia screening labs
    1. Hemoglobin
      1. See Hemoglobin Cutoffs for Anemia (vary by age and condition)
      2. Complete Blood Count (with indices including MCV) is ideally obtained
    2. Precaution
      1. Hemoglobin And Hematocrit have low efficacy as a screening tool
        1. Poorly detect Iron Deficiency Anemia
        2. Poor Test Sensitivity and Test Specificity
      2. Consider Ferritin and TIBC if suspicious for Iron Deficiency Anemia despite normal Hemoglobin
        1. Serum Ferritin <15 ng/ml is used as cut-off for Iron Deficiency
      3. Some authors recommend empiric Iron Supplementation for 1 month in mild Microcytic Anemia
        1. See protocol below
        2. White (2005) Pediatrics 115:315-20 [PubMed]
    3. More accurate Anemia screening measures
      1. ReticulocyteHemoglobin content
        1. Iron Deficiency Anemia suggested when <27.5
        2. Test Sensitivity: 83%
        3. Test Specificity:72%
      2. Reference
        1. Ullrich (2005) JAMA 294:924-30 [PubMed]
    4. Cutoffs for Anemia
      1. See Hematocrit Cutoffs for Anemia
      2. See Hemoglobin Cutoffs for Anemia

IX. Evaluation

  1. See Anemia Evaluation
  2. See Pediatric Anemia Causes
  3. Microcytic Anemia (decreased MCV, most common, esp. Iron Deficiency Anemia)
    1. See Microcytic Anemia
    2. See Physiologic Anemia of Infancy
    3. See below for management protocol
  4. Macrocytic Anemia (increased MCV)
    1. See Macrocytic Anemia
    2. Uncommon in children
    3. Nutritional Deficiency (Megaloblastic Anemia)
      1. Megaloblasts are large nucleated Red Blood Cell precursors
      2. Vitamin B12 Deficiency
        1. May occur in strict Vegan diet or Breastfeeding mother with B12 Deficiency
      3. Folate Deficiency
        1. May occur with infants exclusively fed goat's milk
    4. Nonmegaloblastic Anemia
      1. Causes include Thyroid dysfunction, liver dysfunction, Bone Marrow disorders and infection
  5. Normocytic Anemia (normal MCV)
    1. See Normocytic Anemia
    2. High Reticulocyte Count (Reticulocytosis)
      1. See Hemolytic Anemia (includes laboratory evaluation)
      2. See Hemolytic Anemia Causes
    3. Low Reticulocyte Count (Reticulocytopenia)
      1. See Reticulocytopenia
      2. Initial labs include Peripheral Smear, renal and hepatic function, TSH and iron studies

X. Management: Microcytic Anemia

  1. See Microcytic Anemia
  2. See Iron Deficiency Anemia
  3. Criteria for empiric treatment in young child
    1. Mild Anemia AND
    2. Findings consistent with Iron Deficiency (Microcytic Anemia)
  4. Protocol
    1. Ferrous Sulfate 3-6 mg/kg/day before breakfast
      1. Iron Deficiency without Anemia may initially be treated with increased Dietary Iron
    2. Anticipate Hemoglobin increase 1.0 g/dl by 4 weeks
      1. Increase appropriate: Continue iron for 2-3 months (up to 3-6 months)
      2. Not appropriate
        1. Evaluate other causes (blood loss)
        2. Labs include Reticulocyte Count, lead level, iron studies (Serum Ferritin, TIBC, Serum Iron)
        3. Consider Hemoglobin electrophoresis (e.g. Sickle Cell Anemia, Thalassemia)
          1. Typically performed in the U.S. as part of universal screening
    3. Consider Differential Diagnosis (See above)
      1. See Microcytic Anemia
      2. Thalassemia (See Mentzer Index)

XI. Complications

  1. Pediatric Anemia may result in life-long deficits
    1. Effects persist despite correction of Anemia
    2. Prevent deficits by diagnosing Iron Deficiency early
  2. Motor Effects
    1. Decreased gross and fine motor coordination
  3. Cognitive effects
    1. Lower scores on Intelligence Testing
    2. Longterm functional Impairment in school
  4. Behavioral effects
    1. Fearfulness and unhapiness
    2. Early Fatigue, less playful, clingy
  5. References
    1. Lozoff (2000) Pediatrics 105:E51 [PubMed]

XII. Prevention

  1. Formula-fed infants should use only full iron formula
    1. Never use low iron infant formula (no GI benefit)
    2. Do not use with iron-containing Vitamins
  2. Limit unfortified cow's milk
    1. No cow's milk should be given under age 1 year
    2. Limit cow's milk to <24 ounces ages 1-2 years
  3. Supplement Breast Feeding
    1. Term infants need 1 mg/kg/day elemental iron
      1. Start supplement at 6 months of age
    2. Preterm and low-weight infants need 2 mg/kg/day
      1. Start supplement at 2-4 weeks of age
    3. Options
      1. Ferrous Sulfate drops
      2. Infant Vitamin Drops (10 mg elemental iron/dropper)
  4. Pregnancy and Delivery
    1. Prevent and treat maternal Iron Deficiency Anemia during pregnancy
      1. Iron requirements increase with each trimester
      2. More than two thirds of fetal iron storage occurs in third trimester
      3. Unclear evidence regarding impact on fetal outcomes
    2. Delayed Umbilical Cord clamping (2-3 minutes)
      1. Improved iron stores at 6 months
      2. Greatest impact in higher risk infants for Iron Deficiency (e.g. SGA, Premature Infants)
  5. Other measures
    1. See Dietary Iron
    2. See Iron Supplementation
    3. Maintain varied diet
    4. Iron fortified cereal
    5. Avoid excessive juice intake

XIII. Resources

  1. MMWR Iron Deficiency Anemia Prevention
    1. https://www.cdc.gov/mmwr/pdf/rr/rr4703.pdf

XIV. References

  1. (1998) MMWR Morb Mortal Wkly Rep 47:1-29 [PubMed]
  2. Gallagher (2022) Blood 140(6):571-93 +PMID: 35213686 [PubMed]
  3. Irwin (2001) Am Fam Physician 64(8):1379-86 [PubMed]
  4. Kazal (2002) Am Fam Physician 66(7):1217-27 [PubMed]
  5. Janus (2010) Am Fam Physician 81(12): 1462-71 [PubMed]
  6. Raleigh (2024) Am Fam Physician 110(6): 612-20 [PubMed]
  7. Wang (2016) Am Fam Physician 93(4): 270-8 [PubMed]

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