Iron deficiency anemia (IDA) in pediatric patients.

By Abdulrahman M Al Jahhaaf, MD, Published on June 01, 2020 - 3 min read

In your clinic, a calm toddler with his mother visited you for the first time.

You started your clinical routine, “he is cranky, all the time, and easily exhausted.”, the mother. While asking a thorough medical history, you discovered the family’s diet was mainly plant-based, and the starch is the main source of calories.

On physical examination, the kid’s weight and height are falling behind the chart and his conjunctivae are pale.

No other physical signs.


Iron deficiency anemia (IDA) is the usual suspect.

For a quick confirmation:

hemoglobin 7 g/dL, reference [10.9–15.0]Not specific test.
hematocrit< 40% = lowNot specific test.
MCV<80 fL = lowNot specific test.
MCHC<29.5 g/dL = lowMedium sensitivity and specificity.
Peripheral blood smearWas normalSubjective test
Reticulocytes countLowHigh sensitivity, low specificity
serum ferritin low (<12 nanograms/mL is generally diagnostic of IDA, but thresholds vary between guidelines)High sensitivity, high specificity
Exclude other causes of IDA.

After confirming the chief complaint, let’s treat.

Main treatment tree:
  1. Oral iron + Diet education
    If it failed (see success criteria ), not tolerated/CI, or Hb< 5g/dL
  2. IV iron
    Failed (see criteria ), not tolerated/CI, or Hb< 5g/dL+ Cardiac decompensation+ symptomatic
  3. Blood transfusion, as needed.
    If it failed (see success criteria ), not tolerated/CI, or Hb< 5g/dL
Success criteria:
  1. Physical Activity, Growth, Cognitive, and/or Neurodevelopment should have a noticeable improvement.
  2. Hemoglobin should rise at least 1g/dL every 2-4 weeks to reach the normal range.
  3. Reticulocyte count should reach a normal range within 1 to 2 weeks.
  4. Serum iron/TIBC/Transferrin/Ferritin should reach a normal range within 6 months.
Oral Iron:

Ferrous Sulfate or ferrous gluconate: 3-6 mg/Kg/day of (elemental iron), PO, TID X 12 weeks

Special instruction: Ascorbate, aka Vit C (found in orange juice or as a supplement) helps in the absorption of iron. While calcium, fiber, tea, and coffee, inhibit the absorption.

Iron Deficiency Anemia From Diagnosis to Treatment in Children

Diet Education

Increasing iron-rich foods + vitamin C-rich foods. Iron Deficiency Anemia From Diagnosis to Treatment in Children

IV Iron:

Iron sucrose

Calculate Iron Deficit= Total replacement dose (mg of iron) = 0.6 x weight (kg) x [100 - (actual Hgb /Target Hgb x 100)]

Maximum single-dose/administration = 100mg

Maximum total daily dose = 300mg/day

Special instruction: Side effect includes Anaphylaxis, however, the risk is uncommon when given in low doses.

Crary SE, Hall K, Buchanan GR. Intravenous iron sucrose for children with iron deficiency failing to respond to oral iron therapy [published correction appears in Pediatr Blood Cancer. 2012 Apr;58(4):655]. Pediatr Blood Cancer. 2011;56(4):615-619. doi:10.1002/pbc.22930

Red blood transfusion

Note: 1 bag of 250ml of PRBC contains 250 mg of elemental iron; which will increase Hb by 1 g/dL.

Replacement rate: The volume of PRBC: 4 ml/kg/hour until reaching the target Hb.

Caution: To reduce the risk of volume overload; especially in patients with a cardiac deficit, consider using diuretics as needed. Özdemir N. Iron deficiency anemia from diagnosis to treatment in children. Turk Pediatri Ars. 2015;50(1):11-19. Published 2015 Mar 1. doi:10.5152/tpa.2015.2337