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.


  • 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) is the most common nutritional deficiency in children 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

  • The most common form of anemia seen in primary care and clinical hematology, and the most advanced stage of iron deficiency
  • A 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 iron-deficiency anemia
  • 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 months - 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 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 [e.g. nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids]
    • Medicines that interfere with coagulation/platelet function leading to an increased risk of GI hemorrhage [e.g. 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, gastrointestinal tract, and other sites

Signs and Symptoms

  • 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)

Risk Factors

  • 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
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