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% = low||Not specific test.|
|MCV||<80 fL = low||Not specific test.|
|MCHC||<29.5 g/dL = low||Medium sensitivity and specificity.|
|Peripheral blood smear||Was normal||Subjective test|
|Reticulocytes count||Low||High 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:
Oral iron + Diet educationIf it failed (see success criteria ), not tolerated/CI, or Hb< 5g/dL
IV ironFailed (see criteria ), not tolerated/CI, or Hb< 5g/dL+ Cardiac decompensation+ symptomatic
Blood transfusion, as needed.If it failed (see success criteria ), not tolerated/CI, or Hb< 5g/dL
- Physical Activity, Growth, Cognitive, and/or Neurodevelopment should have a noticeable improvement.
- Hemoglobin should rise at least 1g/dL every 2-4 weeks to reach the normal range.
- Reticulocyte count should reach a normal range within 1 to 2 weeks.
- Serum iron/TIBC/Transferrin/Ferritin should reach a normal range within 6 months.
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.
Increasing iron-rich foods + vitamin C-rich foods. Iron Deficiency Anemia From Diagnosis to Treatment in Children
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