Anemia - Iron-Deficiency (Pediatric) Signs and Symptoms

Introduction

  • Anemia is defined by the World Health Organization (WHO) as hemoglobin concentration <2 standard deviations below the mean hemoglobin concentration for a normal population of the same age range and gender 
  • Anemia poses a major health issue affecting about one quarter of the world’s population and is concentrated within preschool aged children and women
  • Demographics:
    • Age: Toddlers with picky diets
    • Race: No race predilection in children
    • Socioeconomic status: Higher in those living in chronic poverty

Definition

Iron Deficiency (ID)

  • Most common nutritional deficiency in children and adolescents and reportedly three times more common than iron-deficiency anemia (IDA), but does not always develop into anemia
    • Defined as a reduction in ferritin levels that generally results from a diet in which the bioavailability of iron is inadequate or from an increased need for iron during a period of intense growth
  • Neonates and children may have delayed growth and development; adolescents may show decrements of learning such as behavioral abnormalities
  • Varies accordingly to weight, gender, hemoglobin level as well as size of iron stores of the body
  • Associated with persistent changes in transmission through auditory and visual system, which may be suggestive of a defective myelination

Iron-deficiency Anemia (IDA)

  • Most common form of anemia seen in primary care and clinical hematology, and the most advanced stage of ID
  • Affects two-thirds of all children worldwide
  • Reduced availability of iron is the most important cause of anemia
  • Condition wherein the blood has low levels of red blood cells (RBC), hemoglobin or hematocrit producing a state at which iron stores and serum iron levels are insufficient to maintain normal physiologic function
  • Usually presents as otherwise asymptomatic, well-nourished infant or child who has mild to moderate microcytic, hypochromic anemia
  • The WHO has suggested levels of hemoglobin at which anemia is said to be present:
    • Children 6-59 months: <11 g/dL
    • Children 5-11 years old: <11.5 g/dL
    • Children 12-14 years old: <12 g/dL

Etiology of Anemia

  • Infants born prematurely are at greater risk because of their rapid growth
  • Dietary issues of infancy and early childhood that leads to imbalance of iron metabolism:
    • Insufficient iron intake from infant formulas or transitional foods that are poor dietary sources of iron
    • Introduction of unmodified cow’s milk before 12 months of age
    • Occult blood loss secondary to cow’s milk protein-induced colitis
    • Half of iron is absorbed from maternal milk but only 10% from cow’s milk
    • Unmodified cow’s milk (non-formula cow’s milk) increases intestinal blood loss in infants as compared with formula feeding or breast feeding
  • Gastrointestinal (GI) malabsorption secondary to GI disorders: Active celiac disease, Crohn’s disease, giardiasis, or resection of the proximal small intestine
  • Pharmacological
    • Medicines that cause gastric erosions/ulceration (eg nonsteroidal anti-inflammatory drugs [NSAIDs], corticosteroids)
    • Medicines that interfere with coagulation/platelet function leading to an increased risk of GI hemorrhage (eg anticoagulants, selective serotonin reuptake inhibitors [SSRIs])
  • Others – blood loss from non-GI sources
    • Parasitic infections: Hookworms that feeds on intestinal mucosa are a leading cause of IDA through intestinal blood loss
    • Hereditary hemorrhagic telangiectasia: Recurrent hemorrhage from the nose, GI tract and other sites

Signs and Symptoms

  • Primary symptoms: Dyspnea (exertional or at rest), fatigue, palpitations, headache, faintness or lightheadedness, tinnitus, anorexia, GI disturbance
  • Signs/symptoms suggestive of anemia: Pallor, pale conjunctivae, lethargy, poor growth, weakness, listlessness, shortness of breath
  • Non-specific signs: Decreased papillation of the tongue, cheilosis and prominent defects of nail beds, including Mees lines (discoloration across the nails) and rarely koilonychia (spooning of the nails)

Risk Factors

  • Include low birth weight, history of prematurity, exposure to lead, exclusive breastfeeding beyond 4 months of life and weaning to whole milk and complementary foods without iron-fortified foods