The McMaster

at night

Pediatric

Curriculum

Wang, M. (2016). Iron Deficiency and Other Types of

Anemia in Infants and Children. American Family Physician.

93 (4): 270-278.

Objectives

• Recognize common signs and symptoms of anemia

• Develop an approach to the work-up of anemia based on

the differential diagnosis

• Understand the treatment of iron deficiency anemia

Background

• Anemia is both a common presenting complaint (in the

Emergency Department and outpatient pediatric office)

• It is also a common incidental finding on bloodwork

ordered for other reasons

• Anemia in children: Two standard deviations below the

mean for age

The Case

• You are working in a small community hospital as the

pediatrician. You are called to the emergency department

to assess a 2 year old girl who came in with upper

respiratory tract symptoms. The ER physician noted that

she looked pale and did some bloodwork. Her hemoglobin

came back at 55 and you are being consulted for anemia.

History

What would you ask?

History

• HPI:

• OPQRST about the reason they came in (URTI

symptoms)

• Any change in energy, ability to keep up with peers

when active

• Diet history – how much milk, how often and via bottle

or cup

• Any bruising, bleeding, limp, night sweats, fevers,

weight loss?

• Abdominal pain, diarrhea/blood diarrhea?

• Bleeding history - bums, gum, nose, hematemesis?

History

• PMHx:

• Previous hospitalizations, recent surgeries, chronic

diseases

• Previous or known anemia? Previous bloodwork

done?

• Family history:

• Anyone in the family with anemia?

• Anyone with thalassemia/thalassemia trait?

• Anyone with hematologic malignancies?

• Ethnic background

• Birth history:

• Term, pre-term, any sequealae of prematurity?

• Medications:

• Previous treatment with iron? Calcium

supplementation?

• Allergies

History

• Developmental history:

• Important to ascertain whether child is developmentally

appropriate, or delayed

• If delayed, find out what domains and when this

occurred

• Social history:

• Ability to afford food? Use of food banks?

• Access to nutritious food sources (proximity of grocery

stores)

• Parent’s employment

Physical Exam

What would you look for?

Physical Exam

• General appearance – pallor, lethargy

• HEENT: Conjunctival pallor, bleeding gums, nares,

lymphadenopathy

• Respiratory: Tachypnea, increased work of breathing,

crackles

• Cardiac: Tachycardia, flow murmur, delayed capillary refill

• Abdominal: Splenomegaly, hepatomegaly, masses

• Skin: Petechiae, purpura, edema, pallor of palms,

nailbeds

• MSK: Joint swelling

Workup

What would you order?

Workup

• CBC with differential and smear, reticulocyte count

• Ferritin if child is well, serum iron level if unwell

• Depending on history/physical, consider:

• Bilirubin, haptoglobin, LDH (Hemolytic process)

• Lytes, extended lytes, urate, LDH, CXR (Malignancy)

• Fecal occult blood (Ulcer, IBD, polyps)

• CRP, fecal calprotectin (Autoimmune/inflammatory)

• Hemoglobin electrophoresis, DNA alpha-thalassemia

(Hemoglobinopathies)

• Cross and match (If anticipating transfusion)

Differential Diagnosis

Neonates

Microcytic • α-Thalassemia

Normocytic • Acute blood loss • Isoimmunization • Congenital hemolytic anemias

• Spherocytosis • Glucose-6-phosphate dehydrogenase deficiency

• Congenital infections

Macrocytic Congenital Aplasia

Differential Diagnosis Infants and Toddlers

Microcytic • Iron deficiency anemia • Concurrent infection • Thalassemia • Lead poisoning

Normocytic • Concurrent infection • Acute blood loss • Sickle cell disease • Red blood cell enzyme defect

• G6PD • Pyruvate-kinase deficiency

• Red blood cell membrane defects • Spherocytosis • Elliptocytosis

• Hemolytic anemia (acquired, autoimmune) • Hypersplenism • Transient erythroblastopenia of childhood • Bone marrow disorders (leukemia, myelofibrosis)

Macrocytic • Vitamin B12 or folate deficiency • Hypothyroidism • Hypersplenism • Congenital aplasia

Differential Diagnosis

Older Children and Adolescents

Microcytic • Iron deficiency anemia • Anemia of chronic disease • Thalassemia • Menorrhagia (menstruating females)

Normocytic • Acute blood loss • Anemia of chronic disease • Acquired hemolytic anemia • Sickle cell disease • Bone marrow disorders (leukemia,

myelofibrosis)

Macrocytic • Vitamin B12 or folate deficiency • Hypothyroidism

Featured Diagnosis

• Iron deficiency anemia

• Most common type of childhood anemia

• Dietary history of poor iron intake, often exacerbated by

excess milk intake (>18-20 oz. per day)

Featured Diagnosis

• Risk factors for iron deficiency and iron deficiency anemia:

• Race/ethnicity

• Low socioeconomic status

• Prematurity and low birth weight

• Excessive milk intake

• Early introduction of whole cow’s milk

• Prolonged bottle feeding

• Prolonged exclusive breastfeeding

• Overweight and obesity

• Non-attendance at daycare

Featured Diagnosis

• Ferritin is the most sensitive test for iron deficiency

anemia

• Ferritin is less accurate in children who are ill or have

inflammatory conditions because it is an acute phase

reactant

• Order serum iron level in children who are ill or who have

inflammatory conditions

Featured Diagnosis

• Treatment: Infants and toddlers

• Iron supplementation:

• 3-6 mg/kg elemental iron per day for 3-4 months

• Many of the iron supplements have metallic taste,

not well tolerated

• Consider using Feramax (powder, can be sprinkled

in food/drink, better tolerated)

• Side effects include black stools, constipation

• Consider prophylactically starting children on PEG

3350 to avoid constipation

Featured Diagnosis

• Treatment: Adolescents

• Iron supplementation:

• Weight >40 kg

• 150-200 mg/day elemental iron, can dosed daily or

BID

• Non-pharmacologic treatments:

• Increase iron-rich food in diet (red meats, beans,

legumes, green leafy vegetables, cooking with cast

iron)

• Consume vitamin C containing foods with iron-

supplement or high iron foods to promote absorption

• For toddlers:

• Limit milk to 18 oz/day

• Get rid of bottles!

Featured Diagnosis

• Follow-up

• Repeat bloodwork at 1 month

• Anemia should improve by 10 g/L after one month of

treatment with iron supplementation

• If not improving – need to determine, treatment

compliance and consider alternative diagnoses

Featured Diagnosis

• Important to treat because iron is important for:

• Myelination

• Neurogenesis

• Differentiation of brain cells (sensory, learning,

memory, behaviour)

• Cofactor for neurotransmitters

• Iron deficiency anemia has long-term developmental

impacts

Test Your Knowledge

• In addition to a CBC with a differential, what is one

additional test you would order to confirm your diagnosis

of iron deficiency anemia?

A. Serum iron

B. Ferritin

C. Transferrin saturation

D. Total iron binding

capacity

The Answer

• Ferritin

• Unless the child is unwell or has an inflammatory

condition, in which case serum iron is indicated

Test Your Knowledge

• Anemia is defined as…

A. Hb <120 g/L

B. Hb more than 1 standard deviation below the mean

for age

C. Hb more than 2 standard deviations below the mean

for age

D. Hb <100 g/L

The Answer

• Anemia is defined as a hemoglobin more than 2 standard

deviations below the mean for age

Test Your Knowledge

• List 4 risk factors for iron deficiency and iron deficiency

anemia

Test Your Knowledge

• List 4 risk factors for iron deficiency and iron deficiency

anemia. Four of:

1. Race/ethnicity

2. Low socioeconomic status

3. Prematurity and low birth weight

4. Excessive milk intake

5. Early introduction of whole cow’s milk

6. Prolonged bottle feeding

7. Prolonged exclusive breastfeeding

8. Overweight and obesity

9. Non-attendance at daycare

Summary

• Iron deficiency is the most common cause of anemia in

infants and young children

• Have a high index of suspicion if there is high milk

consumption, low dietary iron intake

• Important to treat because of long-term developmental

impact

• Low ferritin is the most sensitive test for iron deficiency

• Repeat CBC, ferritin 1 month into treatment and reassess

the diagnosis if patient is compliant with treatment and

there is no improvement

• In teenagers, particularly boys, iron deficiency is

uncommon, have a high index of suspicion for alternative

diagnoses such as inflammatory bowel disease

References

• Abdullah K, Zlotkin S, Parkin P, Grenier D. (2011). Iron-

deficiency anemia in children. Canadian Paediatric

Surveillance Program.

http://www.cpsp.cps.ca/uploads/publications/RA-iron-

deficiency-anemia.pdf

• Abrams SA. (2017). Iron Requirements and iron

deficiency in adolescents. UpToDate. Feb. 21, 2017.

• Wang, M. (2016). Iron Deficiency and Other Types of

Anemia in Infants and Children. American Family

Physician. 93 (4): 270-278.

• Wu AC, Leperance L, Bernstein H. (2002). Screening for

Iron Deficiency. Pediatrics in Review. 23 (5): 171-177.