Worldwide, anemia in children is a significant concern, impacting nearly half of all children younger than five years of age (Wang, 2016). The American Academy of Pediatrics (AAP) and the World Health Organization (WHO) recommend universal screening for anemia at one year of age, and certainly this makes sense globally. The U.S. Preventive Services Task Force hasn't found sufficient evidence to support this testing however, and shares that there are sufficient harms to doing so that put this practice into question.
Iron deficiency anemia is associated with cognitive delays in children, so important to identify and rectify, but interestingly, it is unclear if iron supplementation improves cognitive outcomes. The mother's pregnancy health and her birthing experience can also impact the incidence of anemia well into the future for the child as well, which is a discerning factor in how I proceed with testing, in discussion, with my own clients, as well as how the child's feeding experiences and health presented during their first year.
An infant for example, whose umbilical cord was cut immediately after being born, which is standard obstetrical practice in the United States, is much more likely to suffer anemia at 18 months of age, particularly if born premature, than a child whose cord remained intact for as little as 90 seconds after birth. We can see this as soon as two to six months (Wang, 2016).
In my own midwifery practice, the standard time of separation was 20 minutes. Cutting immediately prevents the blood within the placenta just prior to birth, yet part of the newborn's blood volume, to circulate back into the child. This is quite evident as well, in that a child born at home, who experienced a more physiologic separation of their cord is robust and ruddy. Midwives often refer to them as little lobsters. They nurse well and are quite alert.
The hospital born child however, more likely to have experienced early cord clamping, thereby leaving behind enough blood volume in their placenta to meet criteria for hemorrhage, are much more pale and sleepy. They respond and feed and engage like someone who has suffered hemorrhage, exhausted, but because this is the norm in our society, only those experiencing otherwise, and have comparison, recognize the vast difference. We think this behavior is simply, normal newborn behavior.
Ironically, conventional medicine has determined the child born in the hospital who endured early separation as the norm. Their blood samples create the bell curve, so when labs are drawn on the child who was offered their full blood volume, their blood cells report are high. They are diagnosed with polycythemia which is nothing more than their representing the high end of a bell curve otherwise comprised of babies who were hemorrhaged at birth. This is an issue of making pathology out of normal because pathology has become the norm. This scenario leads to another controversial and grossly misunderstood condition, physiologic jaundice, but that's a discussion for another post. Babies are resilient and most seemingly recover with little incident, but we can see the evidence of this as far out as their 18 month well-baby check when anemia is often identified.
What is Anemia?
Anemia is defined as having a hemoglobin level two standard deviations below the mean for a child's age (Wang, 2016). After a child turns 12 years old, normal hemoglobin levels are further determined by gender as women tend to have lower hemoglobin levels than men. As clinicians, when we look at anemia, we dig just a bit deeper and look at the cells themselves, their size and shape, and how the body has attempted to compensate. Their intent is to carry oxygen throughout the body, so they will adjust in effort to make this effort successful. We call this microcytic, normocytic, or macrocytic, depending on how the cell alters itself, which helps us understand the underlying cause. This post will talk primarily about microcytic, as this is the most common presentation.
The overall incidence of anemia in children in the United States is low, at about 6%; however, among low-income families, the incidence can be as high as 18% and more often in children 12 to 17 months of age (Wang, 2016). Selective screening dominates care practices today, with practitioners limiting investigations for anemia in those with feeding issues, poor growth, and inadequate dietary iron intake. When screening is positive for anemia, follow-up is essential, although as many as a quarter have no further follow-up after a positive finding.
What Does the Provider Evaluate When Assessing for Anemia?
Most infants and children with mild anemia have no overt clinical signs and symptoms (Wang, 2016). Management is dependent upon a few factors, which the clinician will discern when collecting the history. Was the child born premature? Did they have low birth weight? What is their diet like and do they have chronic disease? Is there family history of anemia and what is their family's ethnic background?
They will initially order a complete blood count to evaluate for anemia, and this allows the clinician differentiate for microcytic, normocytic, and macrocytic anemia based on the mean corpuscular volume. When the hemoglobin is low, the clinician will often confirm the level with a repeat test and add indices, evaluating for mean corpuscular volume. When the cells are found to be small, and the anemia mild, the clinician is likely to recommend treating with supplemental iron and dietary counseling, and then retesting in a month.
This is the most common type of anemia in children (Wang, 2016). If the hemoglobin has increased by 1.0g per dL, then diagnosis is confirmed. Treatment is likely to continue for another month or two. If the hemoglobin does not increase, then iron studies will be performed, including hemoglobin electrophoresis and a measurement of lead. If iron deficiency anemia is not responsive to oral therapy, then testing for gastrointestinal bleeding is wise and likely, referral to a pediatric gastroenterologist. If the anemia is related to Thalassemia (macrocytic) or is otherwise unknown, referral to a hematologist would be appropriate.
Although most commonly anemia is microcytic, some may have normocytic red blood cells. Further testing may be necessary if suspected iron deficiency anemia does not respond to treatment. Ferritin measurement is the most sensitive test for diagnosing iron deficiency anemia, as it is a good reflection of total iron storage and is also the first laboratory index to decline with iron deficiency. It may be less accurate in children with infectious or inflammatory conditions because ferritin is also an acute phase reactant. An elevated red blood cell distribution width index can also be a sensitive test to differentiate iron deficiency anemia from other types of microcytic anemia if ferritin and iron studies are not available.
Normocytic and macrocytic are really beyond the discussion in this post, but normo is more related to blood loss, because this typically occurs so quickly, loss of volume, that the cells haven't had time to respond yet, but their overall quantity is low so what we have is normal remaining cells, just not enough of them. This can also occur because of iron deficiency, particularly when this is the result of infection or an autoimmune response, where the body attacks the red blood cells for whatever, misguided reason. Macrocytic anemia is often related to folate or vitamin B12 deficiency, bone marrow disorders, hypothyroidism, and liver disease.
Prevention of Iron Deficiency Anemia
Upwards of 42% of pregnant women worldwide have anemia, but there is a mere 6% in North America. Based on my bestie's #midwifery practice though, I think all these women are in the panhandle. Iron requirements increase with each trimester and momma's diet needs should adjust for that. The vast majority, as much as 80% of the iron storage in a newborn occurs during the third trimester, but it is unclear whether treatment of maternal anemia prevents anemia in newborns and infants. The USPSTF did not find sufficient evidence to recommend for screening for anemia in pregnant women in effort to improve maternal or neonatal outcomes (Wang, 2016). Two Cochrane reviews however, did find that maternal hemoglobin levels improve with antepartum iron supplementation, but this doesn't seem to be significant with regards to low birth weight, preterm birth, infection, or even postpartum hemorrhage.
Premature babies who are exclusively breastfed might be encouraged to supplement with 2mg per kg of elemental iron per day, throughout their first year, unless they had several blood transfusions. Iron is the most common single-nutrient deficiency. Generally though, in full-term babies, iron storage from in utero is adequate for the first four to six months of life. The American Academy of Pediatrics does recommend that full-term little ones who are exclusively breastfed start a single mg per kg of elemental iron supplementation at four months of age, until appropriate fortified foods are initiated, but in my own midwifery practice with over 1,000 births, almost all exclusively breastfed, I don't think we had a single anemic infant. This was something I recommended based on risk, rather than routine. Iron poses its own risk, as it is bacteriostatic, attracting bacteria into the gut. However, I also never had significantly anemic mommas in my practice, because they had to be sufficient for birthing at home. Formula-fed infants often receive adequate amounts of iron, and thus rarely require further supplementation.
Prevention really is key though. Start your pregnancy with a healthy iron level. Iron is so important for neurological development and it is required for proper myelininzation of neurons, neurogenesis and the differentiation of brain cells that can affect sensory systems, learning, memory and behavior (Wang, 2016). Iron is also a cofactor for enzymes that synthesize #neurotransmitters.
Elemental Iron Supplementation or Needs in Little Ones
For general maintenance for those with risk or concern for deficiency, the recommendation for supplementation if exclusively breastfed, for the preterm infant born prior to 37 weeks gestation would be recommended 2mg per kg of elemental supplementation per day, which would equate to 10mg/kg/day of ferrous sulfate. If they are receiving iron-fortified artificial breastmilk, 1mg per kg per day is recommended.
If born at term, at approximately 4 to 6 months through the first year, the recommendation would be 0.2 to 0.27mg per kg per day of elemental iron supplementation or 1 to 1.35 mg per day of iron ferrous sulfate for exclusively breastfed babies. If offered iron-fortified formula, supplementation is not typically necessary.
Toddlers from one to 3 years would require 7mg to 9m per day of elemental iron, and they would be encouraged to modify their diet. Their ferrous sulfate dose would range from 35 to 45mg/day. Children 4 to 8 years, would need 4 to 10mg per day, or 20 to 50mg/day of ferrous sulfate. Nine to 13-year-olds are recommended 6 to 8mg/day of elemental iron, and 14 to 18 year olds, 8 to 15mg/day of elemental iron. We typically divide these doses up one to three times daily.
If your child takes tablets, at 12 years or older, then one tablet a day of 325mg ferrous sulfate, or 65mg of elemental iron is recommended. There are no recommendations to adjust for liver or kidney disease. Doses change during pregnancy and lactation, with a maximum dose of 225mg ferrous sulfate and 45mg/day of elemental iron in either pregnancy or lactation, although if treating anemia, this may increase to as much as 300 to 600mg ferrous sulfate or 60 to 120mg/day elemental iron.
Keep in mind, supplements containing calcium, zinc, manganese, or copper decrease iron absorption. Antacids, H2 blockers, and proton pump inhibitors also decrease iron absorption, so do not take these within 1 to 2 hours of iron administration. Vitamin C and acidic foods increase iron absorption and delayed release and enteric coated formulations are better tolerated, but are not as well absorbed.
Ferrous fumarate tablets are available in 90mg, 324mg, 325mg, and 456mg. Ferrous gluconate tablets are available in 240mg, 256mg, and 325mg. Ferrous sulfate drops and oral solutions in 75mgs per mL. Elixir and liquid preparations come in 220mg per 5mL and syrup 300mg per 5mL. Tablets are available in 300mg, 324mg, and 325mg, with extended-release tablets 140mg, 160mg, and 325mg. Polysaccharide-iron complex and ferrous bisglycinate chelate is available in capsule form or elemental iron at 50mg, 150mg with or without 50mg of vitamin C, and elixir of elemental iron at 100mg per 5mL.
Food is a much better way to get iron into the anemic child, as the supplements can be hard for them to handle. Soybeans have a good amount of elemental iron, 4.4mgs in a half cup of cooked beans. Cooked lentils, half cup, is about 3.3mg and spinach cooked and boiled, drained and filling a half cup is about 3.2mg of elemental iron. Cooked beef, about 3 ounces, equates to about 2.5mg of elemental iron. Cooked lima beans, navy, kidney or pinto beans is about 1.8 to 2.2mg of elemental iron in about a half cup. Turkey and chicken, dark meat, again about 3 ounces, offer about 1.1 to 2mg of elemental iron.
If your child is in need of treatment though, because they have been diagnosed with iron deficiency anemia, younger than 5 years of age, we would recommend 3 to 6 mg/kg/day of elemental iron, which would be 15 to 30mg/kg/day of ferrous sulfate. Five to 12 years, 60mg/day elemental iron or 300mg ferrous sulfate. In boys 12 to 18 years, two 300mg ferrous sulfate is recommended, or 60mg elemental iron tablets daily. In girls the same age, the recommendation is 300 to 600mg day of ferrous sulfate or 60 to 120mg/day elemental iron. Dividing this up may be helpful, one to three times daily.
What if I want to Take an Herbal-Based Product?
In my years of experience though, I'll share that midwives have their own approach. We battle between clients not taking the supplements because they are so upsetting and really needing to elevate iron levels. Floradix is one of my best tricks of the trade, and while it is plant-based, and therefore not thought to be one of the quickest or most potent methods for elevating iron levels, I have had excellent success, even in mommas with significant postpartum hemorrhage who declined blood transfers. The challenge with utilizing all the many over-the-counter options, especially in children, is understanding what dose to use or even which form of iron because most over-the-counter supplements are not available as simply elemental iron. Rather, it is compounded, which we know to be helpful in the absorption of most other nutrients.
The most common form of iron that clinicians recommend is called Ferrous Sulfate, and the most common dose for adults is about 325mg. The confusing part is that providers will tell their clients to take 325mg of iron when in fact, 325mg of ferrous sulfate yields only 65mg of elemental iron. This is because iron is just a component of the entire iron sulfate compound, FeSO4. We could get into the math, but more simply, most all supplements will point out on their label the types of iron offered, whether ferrous sulfate or elemental iron. Assure you ask your provider how much elemental iron they want you to take because most likely it is 65mg of elemental iron from 325mg of ferrous sulfate.
Maybe you haven't even thought this through and just get it from your pharmacy and consume it without asking questions. If you're going the over-the-counter route or want to lean into a more natural approach, then you'll find there are multiple iron compounds available for supplementation and they each yield different amounts of elemental iron. Ferrous sulfate contains about 20% elemental iron and ferrous gluconate yields about 12%. Ferrous fumarate contains about 33% of elemental iron, Polysaccharide-iron complex offers about 46% of elemental iron, and Ferrous bisglycinate chelate varies on the formulation. Iron citrate, which is super common, also varies based on the formulation. Here you can see that 325mg of ferrous sulfate does in fact yield 65mg of elemental iron, so clinicians will sort of merge this in their mind or maybe not even recognize the complexity of it or even their muddied instructions.
With respect to Floradix, while there are many products in this line, the most common contains 10mg of elemental iron (from 83mg of ferrous gluconate). If your provider wants you to take 65mg of elemental iron (from 325mg of ferrous sulfate), you would need 6.5 servings of Floradix. This may not be a fabulous idea, as the product contains many additional vitamins and minerals that you don't want to get too much.
Even among the supplements with elemental iron, those aren't always interchangeable. Absorption may differ. Ferrous bisglycinate chelate is better absorbed than ferrous sulfate. Multiple studies have also identified that ferrous bisglycinate chelate, even when given in the same elemental amount as ferrous sulfate, increases blood iron levels more than ferrous sulfate products.
Most practitioners are pretty okay with their clients taking different forms of iron in different amounts, as long as they are supplementing with something and they will offer a follow-up test to see if your levels are rising so if not, they will adjust. In general, studies indicate that hemoglobin levels can rise to normal levels regardless if you take low doses of iron or high doses. Floradix also has the benefit of containing vitamin C which has been shown to improve absorption of iron and therefore, enhances the effect of the supplement.
Last though, ferrous gluconate tends to be fairly well tolerated and in my opinion, causes less belly upset compared to ferrous sulfate.
References
Short, M. W. & Domagalski, J. E. (2013). Iron deficiency anemia: evaluation and management. American Family Physician, 87(2), 98-104.
Wang, M. (2016). Iron deficiency and other types of anemia in infants and children. America Family Physicians, 93(4), 270-278.