The Journal of the Arkansas Medical Society Med Journal Aug 2019 Final 2 | Page 14

SCIENTIFIC ARTICLE
Iron Deficiency Anemia for the Pediatric Primary Care Provider
Morgan Coleman, DO; Kimo C. Stine, MD; Jason E. Farrar, MD
Pediatric Hematology Oncology, Department of Pediatrics, UAMS
Arkansas Children’s Hospital, Little Rock
Abstract
I
ron deficiency anemia (IDA) is
prevalent in the pediatric popu-
lation in the U.S. Early identifi-
cation and initiation of treatment is
crucial in preventing adverse out-
comes associated with IDA. Hence,
it is critical that providers are able to identify
at-risk patients, obtain and interpret the ap-
propriate laboratory studies and prescribe
oral iron therapy in the primary care setting.
Referral to a pediatric hematologist is indi-
cated if the etiology of anemia is unclear or
if the patient remains resistant to oral iron
despite adequate dosing and administration.
Introduction
Iron deficiency is the most common nutri-
tional deficiency worldwide. Fortunately, the ad-
dition of iron-fortified infant formulas and foods
has decreased the prevalence of iron deficiency
in the U.S. 1 The 2007 to 2010 National Health
and Nutrition Examination Survey estimates that
in the U.S., 2.7% of children ages 1 to 2 years
and 2.4% of adolescent females ages 12 to 21
years have iron-deficiency anemia. 1,2
Iron is an essential ingredient for effec-
tive red cell production, myoglobin formation,
collagen and neurotransmitter production, im-
mune function, and numerous other biochemical
pathways. 3 Seventy percent of the body’s iron
stores are used to manufacture hemoglobin. 4 A
microcytic, hypochromic anemia develops from
insufficient iron delivery during heme synthesis. 5
Anemia impairs oxygenation of tissues and can
manifest as poor energy, pallor, headache, dizzi-
ness, and shortness of breath. In severe anemia,
children may have tachycardia; a systolic flow
murmur; or conjunctival, palmar, or oral muco-
sal pallor. However, physical signs of anemia
typically do not present until hemoglobin drops
significantly.
Several observational studies suggest
that iron deficiency, even without anemia, is
associated with neurocognitive and behavioral
delays in younger children. 1 Iron-deficient
adolescents may also experience negative
effects on cognition, audiovisual reaction
time, and physical endurance. 2 Therefore, it is
critical that primary care providers identify at-
risk children, perform appropriate diagnostics,
and initiate treatment to prevent poor health
outcomes associated with severe and chronic
IDA. Uncomplicated IDA can be managed
effectively by the primary care provider.
Risk factors
In children, IDA presents in a bimodal
distribution occurring in the late infant/toddler
population and then later in adolescents. 1 These
two stages of rapid growth have increased
physiologic iron requirements and are frequently
periods of poor nutrition. 3
In infants/toddlers, iron deficiency most
commonly develops following the transition to
Along with initial CBC and
reticulocyte count, the newborn
screen should be reviewed since
the presence of hemoglobin
Barts in a neonate suggests
alpha thalassemia.
38 • THE JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
cow’s milk. Infants who drink cow’s milk before
the age of 1, and those who consume more than
24 ounces per day, are at increased risk. Cow’s
milk is a poor source of iron, and high volumes
of milk often replace other iron-rich foods in the
diet. 4 Cow’s milk may also inflame and damage
the intestinal mucosa, leading to microvascular
bleeds and chronic blood loss. 3
There are multiple other risk factors for
iron deficiency: a history of prematurity (80%
of iron stores are transferred in the third
trimester of gestation), low birth weight, lead
exposure (causes iron malabsorption), exclusive
breastfeeding beyond 4 to 6 months of age,
low socioeconomic status, children of Mexican-
American descent, and prolonged bottle
feeding. 1,3 The American Academy of Pediatrics
(AAP) recommends a complete blood count
(CBC) for all children at 1 year of age. Additional
screening should be repeated as needed
throughout childhood if risk factors or symptoms
are present. 1 The prevalence of IDA peaks again
during adolescence. Additional risk factors
in this age group include obesity, alternative
diets (i.e. vegetarian), eating disorders, new
onset chronic illnesses, strenuous athletic
training, and menarche. Anovulatory cycles
leading to dysfunctional uterine bleeding are
common within the first two years of menarche. 4
IDA is more common in females due to this
chronic blood loss. Although the AAP does not
recommend routine screening of all adolescents,
the Centers for Disease Control recommends
that all women of childbearing age be screened
every five to 10 years. 2
Diagnosis of IDA
A CBC provides valuable information on the
etiology of anemia. Anemia is defined as a he-
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