II. Epidemiology
- Anemia Prevalence age <5 years: 6% in U.S. (50% worldwide)
- Low income U.S.: 14.6% (up to 18.2% at ages 12-17 months)
- Iron Deficiency Anemia Prevalence age 1-5 years: 1-2% in U.S.
III. Causes
IV. Risk Factors: Anemia (esp. Iron Deficiency Anemia)
- Premature Infants
- Low Birth Weight Infants
- Recent Immigrants from developing countries
- Infants from low-income families
- Feeding problems or poor growth
- Main dietary intake is unfortified cow's milk
- Cow's milk within first year is greatest risk factor
- Infant formula with low or no iron (<6.7 mg/Liter iron)
- Breastfeeding without Iron Supplementation after 6 months
V. Screening
- See Screening Tests under labs below
- Screen newborns with Hemoglobin electrophoresis (see Newborn Screen)
- Screening recommendations differ between CDC, AAP, WHO, and USPTF
- Screening guidelines are similar but not identical between CDC, AAP, USPTF
- Universal screening is recommended at age 12 months by AAP and WHO
- Identify high risk groups for Anemia (see risk factors above)
VI. History
- See Anemia History
- Prematurity
- Low birth weight
- Dietary history
- Chronic disease
- Ethnicity
- Family History of Anemia
VII. Findings: Signs and Symptoms
- See Anemia Clinical Clues
- Fatigue
- Apathy
- Growth Delay
- Developmental Delay
- Increased infection rate
VIII. Labs
- See Anemia Labs
- Goal: Diagnose Iron Deficiency prior to Anemia
- Sample acquisition
- Avoid lab draw within 2-3 weeks of fever or infection
- Venipuncture
- Capillary Puncture
- Initial Anemia screening labs
- Hemoglobin
- Precaution
- Hemoglobin And Hematocrit have low efficacy as a screening tool
- Poorly detect Iron Deficiency Anemia
- Poor Test Sensitivity and Test Specificity
- Consider Ferritin and TIBC if suspicious for Iron Deficiency Anemia despite normal Hemoglobin
- Some authors recommend empiric Iron Supplementation for 1 month in mild Microcytic Anemia
- See protocol below
- White (2005) Pediatrics 115:315-20 [PubMed]
- Hemoglobin And Hematocrit have low efficacy as a screening tool
- More accurate Anemia screening measures
- ReticulocyteHemoglobin content
- Iron Deficiency Anemia suggested when <27.5
- Test Sensitivity: 83%
- Test Specificity:72%
- Reference
- ReticulocyteHemoglobin content
- Cutoffs for Anemia
IX. Evaluation
- See Anemia Evaluation
- Consider causes above
X. Management: General
- See below for Microcytic Anemia
- See Anemia topics in adults
XI. Management: Microcytic Anemia
- See Iron Deficiency Anemia
- Criteria for empiric treatment in young child
- Mild Anemia AND
- Findings consistent with Iron Deficiency (Microcytic Anemia)
- Protocol
- Ferrous Sulfate 3-6 mg/kg/day before breakfast
- Anticipate Hgb increase 1.0 g/dl by 4 weeks
- Increase appropriate: Continue iron for 2-3 months
- Not appropriate
- Evaluate other causes (blood loss)
- Consider Hemoglobin electrophoresis, lead level, iron studies (Serum Ferritin, TIBC, Serum Iron)
- Consider Differential Diagnosis (See above)
- See Microcytic Anemia
- Thalassemia (See Mentzer Index)
XII. Complications
- Pediatric Anemia may result in life-long deficits
- Effects persist despite correction of Anemia
- Prevent deficits by diagnosing Iron Deficiency early
- Motor Effects
- Decreased gross and fine motor coordination
- Cognitive effects
- Lower scores on Intelligence Testing
- Longterm functional Impairment in school
- Behavioral effects
- Fearfulness and unhapiness
- Early Fatigue, less playful, clingy
- References
XIII. Prevention
- Formula-fed infants should use only full iron formula
- Never use low iron infant formula (no GI benefit)
- Do not use with iron-containing Vitamins
- Limit unfortified cow's milk
- No cow's milk should be given under age 1 year
- Limit cow's milk to <24 ounces ages 1-2 years
- Supplement Breast Feeding
- Term infants need 1 mg/kg/day elemental iron
- Start supplement at 6 months of age
- Preterm and low-weight infants need 2 mg/kg/day
- Start supplement at 2-4 weeks of age
- Options
- Ferrous Sulfate drops
- Infant Vitamin Drops (10 mg elemental iron/dropper)
- Term infants need 1 mg/kg/day elemental iron
- Pregnancy and Delivery
- Prevent and treat maternal Iron Deficiency Anemia during pregnancy
- Iron requirements increase with each trimester
- More than two thirds of fetal iron storage occurs in third trimester
- Unclear evidence regarding impact on fetal outcomes
- Delayed Umbilical Cord clamping (2-3 minutes)
- Improved iron stores at 6 months
- Greatest impact in higher risk infants for Iron Deficiency (e.g. SGA, Premature Infants)
- Prevent and treat maternal Iron Deficiency Anemia during pregnancy
- Other measures
- See Dietary Iron
- See Iron Supplementation
- Maintain varied diet
- Iron fortified cereal
- Avoid excessive juice intake
XIV. Resources
- MMWR Iron Deficiency Anemia Prevention