Iron deficiency


  • Statewide logo

    This guideline has been adapted for statewide use with the support of the Victorian Paediatric Clinical Network

  • See also       

    Anaemia 
    Patient Blood Management in the surgical setting  
    Patient blood Management and surgery algorithm
    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 ( <20μg/L) indicates borderline/low iron stores.
    3. Children with iron deficiency anaemia (IDA), symptomatic iron deficiency and iron deficiency with or without anaemia prior to surgery should be treated.
    4. In most instances, IDA and iron deficiency can be treated safely and effectively with oral iron supplements.  

    Background

    This guideline is adapted from the National Blood Authority (NBA) Patient Blood Management Guidelines: Module 6 Neonatal and Paediatrics (2016)

    Iron deficiency is the most common cause of anaemia in children.

    Iron deficiency in infants and toddlers is predominantly a nutritional disorder; (insufficient red meat or excessive cow milk consumption); rarely due to malabsorption or gastrointestinal bleeding.

    Risk factors include 

    Infants

    • Maternal iron deficiency 
    • Prematurity and/or low birth-weight 
    • Multiple pregnancy 
    • Exclusive breast-feeding after 6 months 
    • Late or insufficient introduction of iron rich solids
    • Excess cow's milk consumption
    • Aboriginal and Torres Strait Islander 

    Children

    • Vegetarian or vegan diet
    • Gastrointestinal disorders e.g. Meckel’s diverticulum, coeliac disease, inflammatory bowel disease, gastric or intestinal surgery or infection 
    • Other chronic blood loss

    Adolescents

    • Vegetarian or vegan diet
    • Heavy menstrual bleeding
    • Gastrointestinal disorders e.g. coeliac disease, inflammatory bowel disease, gastric or intestinal surgery or infection
    • Other chronic blood loss 
    • Extreme athletes

    Assessment

    See Anaemia

    Symptoms of low ferritin:

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

    Serum ferritin is the most useful screening test for assessing iron stores.  A ferritin of <20 μg/L is taken to indicate borderline/low iron stores.

    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.
    • 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. 

    A FBC is needed to diagnose IDA, most commonly the red blood cells are microcytic and hypochromic (reduced MCV and MCH). 

    Management

    Suggest iron supplementation and dietary modification if low ferritin, with or without anaemia.

    Dietary advice

    • Increase iron-rich foods and reduce cow’s milk consumption.
    • See Iron dietary advice
    • Cow’s milk should not be offered to children < 12 months and should be limited to <500ml/day in those older than 12 months.
    • Consider referral to a dietitian.

    See Adolescent gynecology – heavy menstrual bleeding

    Oral iron supplementation

    • 1 - 2mg/kg/day is the preventative dose for iron deficiency
    • 3 - 6 mg/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 <80g/L).
    • 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 point.

    Other Treatment Considerations

    • Parent should be advised 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 and families should consider brushing a child’s teeth following iron administration.
    • Iron is better absorbed if taken with vitamin C (e.g. orange juice)
    • In patients 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 point.
    • Assess for any potential issues with compliance, as poor compliance is the leading reason for treatment failure
    • Transfusion rarely required (e.g. cardiac failure)

    Oral iron formulations

    Formulation Name Elemental iron content Notes
    Ferrous sulphate oral mixture Ferro-liquid 6mg/ml May stain teeth, drink through a straw to prevent teeth discolouration
    and consider brushing teeth with baking soda afterwards.
    Ferrous sulphate delayed release capsules or spansules (270mg) Fefol ® 87.4mg

    Spansules can be opened and the beads sprinkled on food to give lower doses

    They should not be crushed or chewed

    Ferrous sulphate (325mg) Ferro-gradumet 105mg May be appropriate for older children who can swallow them whole

    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 3mg/kg/day

    Weight Ferro-Liquid Fefol Spansules Ferro-Gradumet slow release tablets
    <10kg 0.5ml/kg/day NA NA
    10kg 5mls per day Half a spansule 5 days/week   NA
    20kg 10mls per day One spansule 5 days/week  NA 
    30kg 15mls per day One spansule daily  1 tablet daily
    >40kg 20mls per day One spansule daily  1 tablet daily

    Note: doses in patients > 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 6mg/kg/day

    Weight Ferro-Liquid Fefol Spansules Ferro-Gradumet slow release tablets
    <10kg 1mls/kg/day NA NA
    10kg 10mls per day One spansule 5 days/week  NA
    20kg 20mls per day One  spansule daily   NA 
    30kg 30mls per day One spansule daily   1 tablet daily
    >40kg 40mls per day One spansule daily   1 tablet daily

     Note: doses 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:

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

    Consider consultation with local paediatric team when:

    The cause of iron deficiency is unclear.

    Consider transfer when:

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

    For emergency advice and paediatric or neonatal ICU transfers, call the Paediatric Infant Perinatal Emergency Retrieval (PIPER) Service: 1300 137 650.

    Parent information sheet

    Iron RCH nutrition and food services   

     

     Information specific to RCH and Monash Children’s Hospital 

     Consider discussion with clinical haematology 

    Last updated January 2019