anemia%20-%20iron-deficiency%20(pediatric)
ANEMIA - IRON-DEFICIENCY (PEDIATRIC)

Iron deficiency (ID) is the most common nutritional deficiency in children & reportedly 3x more common than iron-deficiency anemia, but does not always develop into anemia.

Neonates & children may have delayed growth & development; adolescents may show decrements of learning such as behavioral abnormalities.

Iron-deficiency anemia is the most advanced stage of iron deficiency resulted from a protracted imbalance between iron intake & demand.

Characterized by low hemoglobin & hematocrit levels, reduction or depletion of iron stores, low serum iron levels & decreased transferrin saturation.

Diagnosis

  • Diagnosis is confirmed with the presence of low levels of one or more of the major red blood cell (RBC) measurements obtained as a part of the complete blood count (CBC): Hemoglobin concentration, hematocrit or RBC count
  • Obtain a laboratory-confirmed evidence of anemia on a full blood count and low iron stores via measurement of levels of serum ferritin, erythrocyte protoporphyrin, or total iron binding capacity (transferrin)
  • Iron studies (iron, transferrin, ferritin) are useful in excluding iron-deficiency anemia from anemia of chronic disorders as the cause
  • To presume a diagnosis of iron-deficiency anemia, a combination of laboratory examinations and risk assessments must be made
    • A low mean corpuscular volume and an elevated red blood cell distribution width most likely confirms the diagnosis

Classification

  • The mean corpuscular volume (MCV), provided as part of complete blood count (CBC) results (normal 80 - 100 μm3), categorizes anemia into:
    • Microcytic anaemia – MCV < 80 fL
    • Normocytic anaemia – MCV 80 – 95 fL
    • Macrocytic anaemia – MCV > 95 – 100 fL
  • Reduction in mean corpuscular volume is an indicator of hypochromic microcytic anemia, the hallmark of iron-deficiency anemia (IDA) as well as thalassemia, which must be distinguished from each other by Mentzer Index
  • MCV of >13.5 means iron deficiency and <11.5 is suggestive of thalassemia (beta) minor

History

  • History should focus on possible etiologies and may include queries about diet, gastrointestinal (GI) symptoms, history of pica or pagophagia, signs of blood loss, surgical history and family history of gastrointestinal malignancy
  • Note about weight loss and gastrointestinal symptoms such as altered bowel habits, dyspepsia and visible blood in stool
  • Patients with iron deficiency anemia are usually asymptomatic and have limited findings on physical examination

Physical Examination

  • Physical examination: vital signs, pallor, murmur, icterus, hepatosplenomegaly, systemic illness

Laboratory Tests

  • Complete blood count (CBC):
    • Simplest, most cost-effective measurement
    • Includes hemoglobin, hematocrit, mean corpuscular volume (MCV), and red blood cell distribution width
  • Diagnostic work-up may also include peripheral blood smear, serum iron indices:
    • Serum markers of iron-deficiency anemia (IDA) are low ferritin, low transferrin saturation, low iron, raised total iron-binding capacity, raised red cell zinc protoporphyrin, and increased serum transferrin receptor
    • Ferritin is an acute phase reactant and reflects iron stores in otherwise healthy adults
    • It can be elevated in patients with chronic inflammation or infection, thus this test should be done in the absence of inflammation
  • Transferrin level is elevated in patients with iron-deficiency anemia, and is not recommended due to less sensitivity compared to ferritin
  • Total iron-binding capacity is increased in iron deficiency, it reflects the availability of iron-binding sites on transferrin
  • Peripheral blood smear is a test for microcytic hypochromic anemia:
    • Cellular abnormalities (anisocytosis and poikilocytosis) may be of importance in ruling out other diseases, such as hereditary spherocytosis
  • More extensive work-up should be performed if these investigations do not identify the cause of anemia:
    • Tests on several stools for occult blood should always be performed to look for gastrointestinal blood loss as the cause of an iron-deficiency anemia
    • Findings may also include guaiac positive stools
  • Other tests not routinely used but are more reliable measures of iron deficiency status includes soluble transferrin receptor (sTfR) and reticulocyte hemoglobin content
  • Advanced modalities such as reticulocyte hemoglobin content (CHr) provides newer measures of early iron deficient erythropoiesis
  • Bone marrow biopsy is rarely needed for the diagnosis, this would usually show absent iron stores
  • A therapeutic trial of oral iron for 2 weeks is less invasive and may aid diagnosis, but is always dependent on patient’s compliance

Imaging

  • Iron deficiency anemia (IDA) patients with no obvious cause of bleeding should undergo either upper gastrointestinal (GI) endoscopy or colonoscopy, and barium enema

Screening

  • Consistently recommended for infants and children with risk factors such as low birthweight, prematurity, malnutrition and communities with low income levels
  • Most important screening test for detecting iron-deficiency anemia (IDA) is a brief history taking
    • For children with substantial risk factors for iron-deficiency anemia, measuring serum ferritin at the time of the initial screening facilitates the diagnosis
  • Universal laboratory screening for all children, is advised at 9 to 12 months of age
  • For children at high risk for iron-deficiency anemia by dietary history, screen at 15 to 18 months or when risk is identified
  • Repeat screening in early childhood (ages 2-5 years) for children with special health needs such as those with chronic infection, chronic gastrointestinal dysfunction, or inflammatory disorders
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