Anemia%20-%20iron-deficiency%20(pediatric) Signs and Symptoms

• 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

Iron Deficiency (ID)

• Most common nutritional deficiency in children and adolescents and reportedly 3x 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)

• The most common form of anemia seen in primary care and clinical hematology, and the most advanced stage of ID
• 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
• Affects two-thirds of all children worldwide
• Reduction in iron stores may be caused by inadequate iron intake, poor absorption, or blood loss
• Usually presents as otherwise asymptomatic, well-nourished infant or child who has mild to moderate microcytic, hypochromic anemia
• In children up to 5 years of age, ferritin levels <12 mcg/L and Hgb <11 g/dL is diagnostic of IDA
• The World Health Organization (WHO) has suggested levels of hemoglobin at which anemia is said to be present at these levels:
  • Children (12-14 years old): <12 g/dL
  • Children (5-11 years old): <11.5 g/dL
  • Children (6-59 months): <11 g/dL

Anemia etiologies include: 

• 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 gastrointestinal 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, is a leading cause of iron deficiency anemia through intestinal blood loss and a moderate infection which doubles the iron losses of a child
  • Hereditary hemorrhagic telangiectasia: Recurrent hemorrhage from the nose, GI tract, and other sites

• Primary symptoms: Dyspnea (exertional or at rest), fatigue, palpitations, headache, faintness or lightheadedness, tinnitus, anorexia, gastrointestinal (GI) disturbance
• Symptoms/signs suggestive of anemia: Pallor, pale conjunctivae, lethargy, poor growth, weakness, listlessness, shortness of breath
• Nonspecific 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)

• Includes 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