Iron Deficiency and Other Types of Anemia in Infants and Children

 


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Anemia, defined as a hemoglobin level two standard deviations below the mean for age, is prevalent in infants and children worldwide. The evaluation of a child with anemia should begin with a thorough history and risk assessment. Characterizing the anemia as microcytic, normocytic, or macrocytic based on the mean corpuscular volume will aid in the workup and management. Microcytic anemia due to iron deficiency is the most common type of anemia in children. The American Academy of Pediatrics and the World Health Organization recommend routine screening for anemia at 12 months of age; the U.S. Preventive Services Task Force found insufficient evidence to assess the benefits vs. harms of screening. Iron deficiency anemia, which can be associated with cognitive issues, is prevented and treated with iron supplements or increased intake of dietary iron. The U.S. Preventive Services Task Force found insufficient evidence to recommend screening or treating pregnant women for iron deficiency anemia to improve maternal or neonatal outcomes. Delayed cord clamping can improve iron status in infancy, especially for at-risk populations, such as those who are preterm or small for gestational age. Normocytic anemia may be caused by congenital membranopathies, hemoglobinopathies, enzymopathies, metabolic defects, and immune-mediated destruction. An initial reticulocyte count is needed to determine bone marrow function. Macrocytic anemia, which is uncommon in children, warrants subsequent evaluation for vitamin B12 and folate deficiencies, hypothyroidism, hepatic disease, and bone marrow disorders.

Worldwide, anemia affects up to one-half of children younger than five years.1 Anemia is defined as a hemoglobin level that is two standard deviations below the mean for age.2,3 After children reach 12 years of age, the hemoglobin norm can be further divided into gender-specific ranges.3  Table 1 lists age-based hemoglobin levels.3,4  Anemia can be categorized as microcytic, normocytic, or macrocytic. Microcytic iron deficiency anemia is a common cause of childhood anemia, whereas macrocytic anemia is rare in children. Table 2 summarizes the causes of anemia.3,5

View/Print Table

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

The American Academy of Pediatrics and the World Health Organization recommend universal screening for anemia at one year of age. However, the U.S. Preventive Services Task Force found insufficient evidence to assess the benefits vs. harms of screening.

C

1, 2, 8

Although iron deficiency anemia is associated with cognitive delays in children, it is unclear if iron supplementation improves cognitive outcomes.

C

2, 2629

Screening for iron deficiency in nonanemic infants and children is not recommended.

A

1, 2


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

The American Academy of Pediatrics and the World Health Organization recommend universal screening for anemia at one year of age. However, the U.S. Preventive Services Task Force found insufficient evidence to assess the benefits vs. harms of screening.

C

1, 2, 8

Although iron deficiency anemia is associated with cognitive delays in children, it is unclear if iron supplementation improves cognitive outcomes.

C

2, 2629

Screening for iron deficiency in nonanemic infants and children is not recommended.

A

1, 2


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

View/Print Table

Table 1.

Age-Based Hemoglobin Levels in Children and Adolescents

AgeMean hemoglobin level−2 standard deviations

Birth (term infant)

16.5 g per dL (165 g per L)

13.5 g per dL (135 g per L)

1 month

13.9 g per dL (139 g per L)

10.7 g per dL (107 g per L)

2 months

11.2 g per dL (112 g per L)

9.4 g per dL (94 g per L)

3 to 6 months

11.5 g per dL (115 g per L)

9.5 g per dL (95 g per L)

6 months to 2 years

12 g per dL (120 g per L)

10.5 g per dL (105 g per L)

2 to 6 years

12.5 g per dL (125 g per L)

11.5 g per dL

6 to 12 years

13.5 g per dL

11.5 g per dL

12 to 18 years

Males

14.5 g per dL (145 g per L)

13 g per dL (130 g per L)

Females

14 g per dL (140 g per L)

12 g per dL


Information from references 3 and 4.

Table 1.

Age-Based Hemoglobin Levels in Children and Adolescents

AgeMean hemoglobin level−2 standard deviations

Birth (term infant)

16.5 g per dL (165 g per L)

13.5 g per dL (135 g per L)

1 month

13.9 g per dL (139 g per L)

10.7 g per dL (107 g per L)

2 months

11.2 g per dL (112 g per L)

9.4 g per dL (94 g per L)

3 to 6 months

11.5 g per dL

The Author

MARY WANG, MD, is an associate professor of family medicine and public health at the University of California–San Diego.

Address correspondence to Mary Wang, MD, University of California–San Diego, 9333 Genesee Ave., #200, San Diego, CA 92121 (e-mail: mjw011@ucsd.edu). Reprints are not available from the author.

Author disclosure: No relevant financial affiliations.

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