Immigrant Health Service

Iron deficiency and anaemia

  • Background

    Please see clinical practice guideline for anaemia.

    Anaemia and iron deficiency are common in children of refugee background.  Australian data suggest the prevalence of anaemia is 10–30% in refugee background children,[1-4] with similar prevalence in children from Africa, Middle East or Asia. Iron deficiency affects a similar proportion,[1,3,4] and is associated with tiredness, irritability and adverse effects on cognitive development.[5]

    Definitions 

    Age Lower limit of normal range of Hb (g/l)
    2 months 90
    2 - 6 months 95
    6 - 24 months 105
    2 - 11 years 115
    > 12 years girls - 120 boys - 130

     

    Anaemia is usually multifactorial in the paediatric refugee population. Contributors include malaria infection, iron deficiency and parasite infection/infestation. Iron deficiency is usually nutritional, but may be due to gastrointestinal loss or associated with Helicobacter pylori infection.

    Other causes of anaemia to consider include: 

    • Haemaglobinopathies - which are more common in African, Asian and Middle Eastern populations. This means many children will be carriers, with microcytosis, and sometimes, mild anaemia (actual disease is uncommon). 
    • B12 deficiency has been reported in refugees from Bhutan, Iran, Afghanistan, Iraq and the Horn of Africa in Australia,6 and should be considered in any refugee with restricted food access pre-arrival (lack of animal products associated with B12 deficiency; lack of fresh food associated with folate deficiency) – see low B12 guideline
    • Lead toxicity – elevated blood lead levels have been reported in up to 7–13% of African7,8 South Asian9,10 and Burmese11-13 refugee children, especially in those aged < 6 years; although rarely to a level requiring chelation therapy. Testing for blood lead levels is recommended in recently arrived refugee children (aged 6 months – 16 years) in the US14  but is not currently part of initial refugee screening protocols in Australia – see lead guideline.

    Children and adolescents from Africa commonly have a neutrophil count below Australian reference ranges. In clinically well children and adolescents (including no fevers, gingivitis, or skin infections) this is usually a normal variant.

    Assessment

    • Pregnancy – maternal anaemia/iron deficiency/pica, maternal malaria
    • Delivery – birthweight, complications
    • Dietary history – duration breastfeeding, cow milk intake, age started solids, meat/animal product intake, food access overseas and in Australia
    • Infections – malaria, worm infestations, GIT symptoms, including PR bleeding, features of H Pylori
    • Growth history, including previous malnutrition
    • Family history (haemoglobinopathies)

    Clinical symptoms and signs may be subtle, despite significant anaemia. Look for: 

    • Symptoms – lethargy, irritability, shortness of breath, pica
    • Signs - pallor - conjunctival pallor is probably more useful than palmar crease pallor, poor growth, flow murmur, signs of cardiac failure. 

     Some children may have severe anaemia, admission should be considered if Hb < 6 g/dL

    Screening

    • Routine screening tests are FBE, film and ferritin
      • The serum ferritin level, an iron storage protein, provides a reasonably accurate estimate of iron stores in the absence of inflammatory disease. In practice, we have not seen raised ferritin in paediatric refugee screening.
      • Normal ranges are age dependent; levels decrease early in iron deficiency.
      • Microcytic anaemia with decrease in mean corpuscular volume (MCV) and haemoglobin (Hb) occur later, as iron deficiency progresses.
    • Consider blood lead levels in initial screening in children with pica, developmental issues or a history of exposure, including through traditional medicines, and as second line screening in children with microcytic anaemia
    • Consider serum active B12 and red cell folate screening in people from Bhutan, Iran, Afghanistan and Iraq and countries in the Horn of Africa (especially where there has been poor food access), and complete screening in exclusively breastfed babies where there has been poor maternal food access, or where deficiency is suspected clinically or based on initial blood test results
    • Haemoglobin electrophoresis (and testing for alpha thalassaemia status) is not part of refugee health screening and screening for carrier status is not routine for children. Sickle cell disease/thalassaemia major/significant other haemoglobinopathy should be apparent based on clinical examination and FBE. Note: Low iron stores may result in false negative results (lack of elevated HbA2) in haemoglobin electrophoresis in beta-thalassaemia carrier state.

    Management

    • Consider causes of anaemia and/or iron deficiency; screen and treat for parasites and malaria if present
    • Support breastfeeding and limit cow milk intake to 500 ml/day after 12 months of age; milk consumption may be high in some groups
    • Dietary advice (regular meat intake, pulses, green vegetables)
    • Correct iron deficiency with oral iron therapy (in the form of ferrous salts)
      • Elemental iron 2 - 6 mg/kg/day is given in divided doses - see table 2
      • Absorption is better if given with orange juice; don't take with milk.
      • Discuss side effects (dark stool, constipation, Git upset) safety and storage with families. See easidose to provide picture based dosing if needed
      • Treatment should be for 3 months after Hb normalises to replenish stores; levels seem to improve quickly once treatment is started and there is access to food in Australia.
    • Consider adding folate if treating severe anaemia, particularly if access to food has been limited.

    Table 2: Iron content of common commercial preparations

    PRODUCT DOSE

    Ferro-liquid
    (6 mg elemental iron/ml; 30 mg FeSO4/ml))

    0.3–1 ml/kg/d given in divided doses
    It may be sensible to give children within a family the same dose (i.e. that for the smallest child) to avoid confusion.

    Ferrogradumet
    (105 mg elemental iron/tablet; 325 mg FeSO4/tablet)

    =6 mg/kg elemental iron at weight = 17.5kg
    Adult dosing - 1 tablet daily

    Ferro-tab
    (65.7 mg elemental iron/tablet; 200 mg ferrous fumarate/tablet)

    =6 mg/kg elemental iron at weight = 11kg
    Adult dosing - 1 tablet 2–3 times daily

    Fefol delayed release
    (87.4 mg elemental iron/tablet; 270 mg FeSO4/tablet; also contains folic acid 300 mcg/tablet)

    =6 mg/kg elemental iron at weight = 14.5kg
    Adult dosing - 1 tablet daily

    References

    Immigrant health clinic protocols. Author: Georgie Paxton January 2014, updated April 2016. Contact georgia.paxton@rch.org.au