See also

Anaemia 
Patient Blood Management in the surgical setting  
The Australian Red Cross Blood Service – iron deficiency anaemia overview   

Key points

1. Serum ferritin is the most useful screening test for assessing iron stores
2. A reduced serum ferritin (<20 μg/L) indicates borderline/low iron stores
3. For most children, iron deficiency with or without anaemia can be treated safely and effectively with oral iron supplementation and dietary modification

Background

• Iron deficiency is the most common cause of anaemia in children
• Iron deficiency in infants and toddlers is predominantly a nutritional disorder (insufficient iron-rich foods or excessive cow milk consumption) and is rarely due to malabsorption or gastrointestinal bleeding
• Blood transfusion is rarely required

Risk factors for iron deficiency

Assessment

See Anaemia

History

Symptoms of iron deficiency

• Impaired cognitive function, decreased memory, impaired learning and concentration
• Behavioural disturbances
• Fatigue
• Pica (eating of non-nutritive substances such as paper, wood and soil)

Management

Investigations

• Serum ferritin is the most useful screening test for assessing iron stores
• A ferritin of <20 μg/L indicates borderline/low iron stores. Also refer to local guidance as the ferritin threshold for low iron stores may vary eg between 10 and 30 μg/L
• Serum ferritin is an acute phase reactant and a normal result does not exclude iron deficiency in the presence of coexisting infection, inflammation or liver disease 
• Iron studies or serum iron should not be requested to diagnose iron deficiency
• Serum iron reflects recent iron intake and does not provide a measure of the iron stores
• A FBC is needed to diagnose iron deficiency anaemia (IDA). Most commonly the red blood cells are microcytic and hypochromic (reduced MCV and MCH) 

Treatment

Iron supplementation and dietary modification for children with low ferritin, with or without anaemia

Dietary advice

• Increase iron-rich foods and reduce cow milk consumption
• See Iron dietary advice
• Cow milk should not be offered to children <12 months and should be limited to <500 mL/day in those older than 12 months
• Consider referral to a dietitian
• See Adolescent gynaecology – heavy menstrual bleeding

Oral iron supplementation

• 1-2mg/kg/day is the preventative dose for iron deficiency
• 3-6mg/kg/day is the recommended dose for treatment of iron deficiency and IDA Higher doses should be considered in those children with severe anaemia (Hb <80 g/L)
• Practical considerations
  • Advise parents that iron preparations can make a child’s stool black in colour and may cause constipation
  • Oral iron preparations may also stain a child’s teeth. Consider having the child drink the iron preparation through a straw and brush the child’s teeth with baking soda following administration
  • Iron is better absorbed if taken with vitamin C eg orange juice
• In children with severe anaemia, early follow up (within a week) should be arranged to ensure compliance and an appropriate response to treatment (reticulocytosis and increase in Hb)
• Iron supplements should be continued for a minimum of 3 months after anaemia has been corrected to replenish stores. Hb and ferritin should be checked at this time
• Assess for any potential issues with compliance, as poor compliance is the leading reason for treatment failure

 Oral iron formulations

Note: Over the counter multi-vitamin or minerals supplements do not contain sufficient iron to treat iron deficiency anaemia and should not be used

Quick Dose reference guides

Mild to moderate IDA - to provide 3 mg/kg/day

Note: doses in children >40kg are usually limited to one spansule/tablet per day unless no improvement in Hb and reticulocyte count

Severe IDA (Hb 80 g/L or less) - to provide 6 mg/kg/day

Note: doses in children >40 kg are usually limited to one spansule/tablet per day unless no improvement in Hb and reticulocyte count

Intravenous Iron

Intravenous iron should be considered in the following circumstances:

• Contraindications to oral iron or serious issues with compliance or tolerance
• Co-morbidities affecting absorption eg gastrointestinal disease
• Children receiving erythropoietin-stimulating agents
• Ongoing blood loss that exceeds the body’s iron absorptive capacity
• Requirement for rapid iron repletion eg preoperatively for non-deferrable surgery
• Persistent iron deficiency despite adequate oral therapy (3 month trial). Discuss with paediatrician or haematologist

Refer to local guidelines for intravenous iron dosing and administration

Consider consultation with local paediatric team when 

Cause of iron deficiency is unclear
Persistent iron deficiency despite adequate oral therapy (3 month trial)

Consider transfer when 

Children require care beyond the level of comfort of the local hospital

For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services

Parent information sheet

Iron intake (Royal Children’s Hospital) 
Iron for children (Queensland Health)
Iron deficiency and iron therapy (South Australia) with resources in 18 different languages

Last updated Aug 2023