Background

Please see clinical practice guideline - 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 and asylum seeker children,^1-6 with similar prevalence in children from Africa, Middle East and Asia. Iron deficiency affects a similar proportion^1,3-5,7 and is associated with tiredness, irritability and adverse effects on cognitive development.⁸

Definitions 

Anaemia is defined as haemoglobin (Hb) below the lower limit of reference range for age.

Anaemia is usually multifactorial in the paediatric refugee and asylum seeker populations. Contributors include iron deficiency, vitamin B12 deficiency, folate deficiency, thalassaemia carrier status and (less commonly in recent years) parasite infection/infestations, including malaria. Iron deficiency is usually nutritional, but may be due to gastrointestinal loss or associated with Helicobacter pylori infection. Vitamin B12 is increasingly common, and appears to be highly prevalent in Afghan cohorts. Causes of anaemia to consider include: 

• Iron deficiency - common across all groups, related to any combination of low stores, prolonged breast feeding, high cow milk intake, low dietary intake (food access issues, late introduction solids, vegetarian/vegan diets, restrictive eating), Helicobacter pylori infection, parasite infections (including malaria), can also relate to increased losses (menstrual losses in adolescent females, gut inflammation/malabsorption).
• Haemoglobinopathies - more common in African, Asian and Middle Eastern populations. This means many children will be thalassaemia carriers, with microcytosis and sometimes mild anaemia (actual disease is uncommon). See fact sheets: Beta Thalassaemia (RCH), and thalassaemia: Better Health Channel, Health Direct and NSW Health Centre for Genetic Education.
• B12 deficiency is reported in refugees from Bhutan, Iran, Afghanistan, Iraq and the Horn of Africa in Australia,⁹ and seems to be highly prevalent in recent Afghan cohorts (46% - data submitted for publication 2025). We have also seen low B12 in Gazan and Rohingyan children. Despite high prevalence of B12 deficiency in recent cohorts, we have not seen associated macrocytosis. Low B12 should be considered in any refugee with restricted food access pre-arrival (lack of animal products associated with B12 deficiency) – see low B12 guideline. 
• Folate deficiency - associated with lack of fresh food, especially vegetables/greens, consider in situations of restricted food access, lack of freshvegetables, and restrictive eating (e.g. autism spectrum disorder).
• Lead toxicity – elevated blood lead levels have been reported in 7–13% of African^10,11 South Asian^12,13 and Burmese^14-17 refugee children, especially in those aged <6 years; although rarely to a level requiring chelation therapy. Risk factors include environmental exposure before and after arrival, and use of car batteries for electricity supply in camp settings. Testing for blood lead levels is recommended in recently arrived refugee children (6 months – 16 years) in the US¹⁷  but is not currently part of initial refugee screening protocols in Australia. Recent arrival families from Gaza have suggested lead screening due to concerns around soil contamination. See lead guideline.
• G6PD deficiency - glucose-6-phosphate dehydrogenase deficiency may be associated with haemolysis - see fact sheet (with medications and food to avoid).

African background children and adolescents 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.^18-20

Assessment

Clinical

• Pregnancy – maternal anaemia/iron deficiency/pica, maternal malaria (and consider pregnancy in adolescents)
• Delivery – birthweight, complications
• Dietary history – duration breastfeeding, cow milk intake, age started solids, meat/animal product intake, food access overseas and in Australia
• Infections –  GIT symptoms, including PR bleeding, features of H. pylori, malaria, worm infestations
• Growth history, including previous malnutrition
• Family history (haemoglobinopathies, G6PD, jaundice, gallstones, splenomegaly, fava bean intolerance)
• Heavy menstrual bleeding in adolescent females (common, often not disclosed, ask specifically in an appropriate clinical setting) - see RCH guideline.

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, any features of haemolysis. 

Admission should be considered if: Hb <6 g/dL, haemolysis, signs of cardiac failure, severe B12 or folate deficiency, or where multiple cell lines are affected

Screening

• Routine refugee health 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 rarely seen raised ferritin in paediatric refugee screening.
  • Normal ranges of ferritin are age dependent, ferritin levels decrease early in iron deficiency.
  • Microcytic anaemia with decrease in mean corpuscular volume (MCV) and haemoglobin (Hb) occur later as iron deficiency progresses.
  • Macrocytic anaemia may be seen in B12 or folate deficiency, although macrocytosis with low B12 is uncommon in refugee background populations,⁶ and we have not seen this in Afghan cohorts. Consider hypothyroidism as a cause of macrocytosis. 
• Include serum active B12 and red cell folate screening in all Afghan, Rohingyan, and Gazan children, consider people from Bhutan, Iran and Iraq and countries in the Horn of Africa (especially where there has been poor food access). 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.
  
• Consider blood lead levels in initial screening in children with developmental issues or a history of exposure, including through traditional medicines, or pica; consider in Gazan and Rohingyan children, and include as second line screening in children with unexplained microcytic anaemia, especially if not improving.
  
• Haemoglobin electrophoresis (and testing for alpha thalassaemia status) is not part of initial 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, and more recently has been flagged in offshore (pre-arrival) health alerts. 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, or in children with developmental delays.
• Dietary advice (regular meat intake, grains/pulses, green vegetables, traditional foods; avoid processed packaged foods).
• 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, gastrointestinal upset, dental staining (rinse mouth, use a straw to take medications), 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 adequate nutrition in Australia.
• Consider adding folate if treating severe anaemia, particularly if access to food has been limited, but only after normal B12 levels are confirmed.

Resources

• Better Health Channel - Iron deficiency children (English only)
• Health translations - Iron
  

References

• References

^{Immigrant health clinic protocols. Author: Georgie Paxton January 2014, most recent update July 2025. Contact georgia.paxton@rch.org.au}