PEDIATRIC IRON DEFICIENCY:
  OFTEN MISSED

 NOTE and DISCLAIMER:

These articles are for general interest of qualified family physicians only. They are NOT for diagnostic or therapeutic use.

The articles are definitely NOT for any public use whatever, nor intended in any way to be taken as advice for any medical or health condition.

There is no use waiting for a blood count or clinical suggestion
of pallor to alert you to the diagnosis of iron deficiency.

Iron deficiency is a common problem - in fact it is the most common nutritional deficiency in Australia, as it is in the entire world. One of the aspects of this condition that is perhaps least recognised by Australian family physicians is the way it manifests in children.

A common problem

Iron deficiency is by no means rare in children, although if the results of a small survey conducted by the author are to believed many Australian family physicians think it is. When these family physicians were questioned about how often they made the diagnosis they reported an average of only 1.2 cases of paediatric iron deficiency in the preceding twelve months. In fact the condition has a prevalence of 2-20% in various Australian paediatric age and population groups. Highest levels (between 8-20%) are seen in toddlers, teenage girls and socioeconomically disadvantaged groups.

One of the reasons that family physicians may miss the diagnosis so often is because they do not realise the vital differences between the clinical picture of iron deficiency in children as compared to adults. One of these differences relates to cause. Iron deficiency in adults usually stems from blood loss in one form or another (whether from menstruation, GIT pathology or whatever).
In Western children, by contrast, it is almost always the result of dietary factors.

The most common of these dietary factors are:

Another significant problem with diagnosis stems from the traditional thinking that iron deficiency and iron deficiency anaemia are virtually the same thing. They are not. Iron deficiency only causes anaemia in a quarter or less of cases. There is no use waiting for a blood count or clinical suggestion of pallor to alert you to the diagnosis.

How it presents

A further difference between children and adults is in the presentation of iron deficiency. What both age groups have in common is that most often the condition will be entirely asymptomatic. However, apart from this children may well present with failure to thrive, recurrent infections or minor behavioural disturbances that are all too easy to dismiss as minor problems of toddlerhood.

The most sinister potential problem with iron deficiency is retarded psychomotor and cognitive development. In many ways this is the real sting in the tail of paediatric iron deficiency. Although this may be subtle in an individual child and therefore not really a presenting symptom as such, there is increasing evidence that marked iron deficiency can cause significant CNS damage even in the absence of anaemia. There seems to be a vulnerable period for this damage particularly between 9 and 18 months. An even more important issue is that some research has suggested that this damage may not always be reversible when iron stores are corrected.

What does this mean for the family physician?

  • Be suspicious and check the diet: Remember that you are dealing with a condition that will be present in up to a fifth of certain age groups of children in your practice. So find out what your toddler and adolescent patients are eating, and couple this with a socioeconomic history. Look out for the child exclusively breast fed into their second 6 months, or who otherwise does not have much in the way of iron-rich foods, particularly the highly absorbable haem sources (meat, chicken, fish) Also be alert for the child who has been given cow's milk in the first year (as a significant source of food, not just in custards etc.). Thereafter look out for the milkaholic, consuming large quantities of milk as a mainstay of their caloric intake .
  • Treat on suspicion: In the US, some experts have suggested taking a fairly routine approach to blood testing in infants to screen for iron deficiency. Howver, Australian paediatric practice tends more to avoidance of blood tests in children unless strictly indicated. For this reason, the recommendation is to treat possible iron deficiency on clinical suspicion, rather than rush into ordering serum ferritin assay. Laboratory work-up would be reserved for cases where anaemia had already been demonstrated through some other investigation or in more seriously ill clinical presentations.
  • Dietary treatment is always the mainstay, based on increased consumption of iron-rich foods, particularly highly absorbable haem iron sources, (meat, chicken and fish). In the first six months, ensure that any milk formula consumed is iron-fortified. Where the parents prefer their child to be vegetarian, emphasise the most absorbable sources of non-haem iron (such as grains) and enhancing non-haem iron absorption by vitamin C-rich foods taken at the same meal.
  • Iron supplementation and follow-up over many months is mandatory if the patient has iron deficiency anaemia, as by this stage iron stores are exhausted and will take a long time to replete. (And never forget to caution the family about the risk of accidental iron poisoning!)

    Practice tips

    • Be suspicious and check on diet.
    • Act on suspicion, but not necessarily with blood tests
    • Diet is always the mainstay of treatment
    • Iron supplements are required in all cases of anaemia

    For comprehensive information on iron deficiency in children, see the
     Clinical Management Guide   produced by the Australian Iron Status Advisory Panel

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