Treatment of iron deficiency anemia in children: a comparative study of ferrous ascorbate and colloidal iron

Treatment efficacy of vitamin C or ascorbate given as co-intervention with iron for anemia - A systematic review and meta-analysis of experimental studies

INTRODUCTION

Iron deficiency anemia (IDA) is one of the leading causes of anemia, globally. Oral vitamin C enhances iron absorption and is commonly prescribed with iron for anemia patients. Considering the lack of evidence to support this practice, we conducted this systematic review and meta-analysis to determine the treatment efficacy of experimental studies where oral vitamin C or ascorbate was given as co-intervention with iron compared to providing only iron among participants with anemia of all ages.

METHODOLOGY

A comprehensive strategy was used to search literature from PubMed, Cochrane and Google Scholar. Experimental studies conducted among participants with lab-confirmed anemia at baseline, with "oral ascorbic acid or vitamin C given as co-intervention with iron" as intervention and "only oral iron" as the comparator, and reported the outcomes hemoglobin or ferritin, were selected. Random-effects model was used to estimate standardized mean differences or odds ratio of outcomes, and sensitivity analyses were done. Sub-group and meta-regression analyses were conducted to evaluate the reasons for heterogeneity (PROSPERO number: CRD42022306612).

RESULTS

Of the total nine studies included in the review, seven studies with 905 participants were included for meta-analysis. The pooled estimate for standardized mean difference (SMD) of hemoglobin (g/dL) and Serum Ferritin (mcg/L) for intervention-type ferrous ascorbate were 0.44 (95% C.I.: -0.30, 1.26) and 0.03 (95% C.I.: -0.68, 0.73) respectively, and were not statistically significant. The pooled estimate for SMD of hemoglobin (g/dL) and Serum Ferritin (mcg/L) for intervention type 'oral iron and vitamin C' was 0.11 (95% C.I.: -0.05, 0.28) and -0.90 (95% C.I.: -1.09, -0.72) respectively, and were not statistically significant.

CONCLUSION

The SMD of hemoglobin or serum ferritin between the intervention group were not significantly favouring the intervention when the intervention group was ferrous ascorbate or oral iron and vitamin C, and the methodological quality of evidence of these effect measures was very low. This necessitates studying the treatment efficacy of oral vitamin C or ascorbate when given with oral iron for participants with anemia in future clinical trials.

Results of Randomized Comparative Efficacy Study of Iron Deficiency Anemia Management in Children with Iron III Hydroxide Polymaltose Complex and Iron Sulfate

Background. The guidelines on selection between iron preparations, iron sulfate (IS) and iron III hydroxide polymaltose complex (HPC), for iron deficiency anemia (IDA) management in pediatrics are contradictory. Objective. The aim of the study is to compare efficacy and safety of iron (III) HPC and IS for IDA treatment in children. Materials and methods. Randomization of children (aged from 1 month to 18 years) with IDA into 2 therapeutic groups was implemented in 2019-2020. on pediatric districts of children’s city outpatient's clinic: IS dosage of 3 mg/kg/day and iron (III) HPC dosage of 5 mg/kg/day. Hemogram monitoring was performed every 14 days. The efficacy was compared according to the rate of Hb level increase, erythrocytes indices, and serum ferritin (SF) level at the recorded moment of Hb normalization. For the safety — the rate of adverse effects. Results. 65 children with IDA were included in the study and randomized into 2 groups, the median age was 2.3 years (1st; 3rd quartile = 1.1; 4.3). Hb level increase was comparable in both groups (0.34 (0.23; 0.48) g/L/day and 0.24 (0.21; 0.30) g/L/day, р = 0.891). IS is more effective than iron (III) HPC in terms of average red blood cell volume by the time of Hb normalization (83.5 (80.0; 86.7) fl against 80.7 (79.0; 82.0) fl, р = 0.006), and mean cellular hemoglobin content (28.9 (SD = 2.0) pg against 27.4 (SD = 1.8) pg, р = 0.004). The timing of SF levels normalization did not differ. Adverse effects to iron III HPC treatment occurred 5.5 times more frequently than to IS (p = 0.0001). Conclusion. The efficacy of IS and iron III HPC at standard doses is comparable. The advantage in tolerability and recovery of erythrocytic indices justifies the feasibility of using IS preparations in the first line of treatment for children with IDA.

Acid-suppressive therapy among infants and risk of anemia at 12 months of age

Objectives:

Numerous studies have shown that links exist between exposure to acid suppression among adults and nutritional deficiencies, especially vitamin B12 and iron. While the use of acid suppression among children and infants is common, nutritional deficiency remains a concern but does not have numerous studies to support it. We conducted a cohort study to examine this concern; the hypothesis we proposed is that acid-suppressive therapy (AST) during infancy is linked to anemia in the first year of life.

Methods:

This retrospective cohort study included infants born between 2017 and 2018 who visited Legacy Community Health. The inclusion criteria were exposure to acid suppression for a minimum of 1 month and a hemoglobin reading at 12–15 months. Infants who had hemoglobinopathies, failure to thrive, or malabsorption syndromes were excluded. Mean hemoglobin was calculated, and student’s t-test was applied to find statistical differences between the two groups. Change in weight before and after treatment was recorded. Occurrence of respiratory and gastroenterological adverse events was recorded in the exposed group.

Results:

Overall, 135 exposed infants were identified 135 controls were selected. The majority of the sample included Hispanic girls. Ranitidine was the most commonly prescribed medicine. The duration of treatment was 3 months. Weight improved significantly at termination of the treatment. There was no significant difference between the hemoglobin level of cases and controls, and both were not considered anemic.

Conclusion:

AST was not linked to anemia, despite the slightly lower hemoglobin in some cases. There were few weaknesses in our study; therefore, further studies can examine this link by focusing further on medication type and close follow-up. We found that although proton pump inhibitors are considered the first line of treatment, histamine-2 receptor antagonists were more frequently prescribed. Strategies to familiarize general pediatricians with the NSAPGHAN guidelines might be needed.

Safety of Ferric Carboxymaltose in Children: Report of a Case Series from Greece and Review of the Literature

BACKGROUND

Parenteral iron is generally considered safe in adults, and severe adverse events are extremely rare. Ferric carboxymaltose (FCM), a third-generation parenteral iron product, is not licensed for pediatric use.

OBJECTIVE

The aim of this study was to present our data on the safety of FCM in children with iron deficiency (ID) and/or iron deficiency anemia (IDA) and to investigate through a systematic literature review articles reporting on the safety of FCM use in children with ID/IDA.

PATIENTS AND METHODS

Safety data regarding children treated with FCM for ID/IDA from four pediatric departments in Greece over a 26-month period are presented. Additionally, a literature search was performed in PubMed, Scopus, and Google Scholar on December 4, 2021 for articles reporting on the use of FCM in children with ID/IDA. Review articles, guidelines, case reports/case series, and reports on the use of FCM for conditions other than ID/IDA were excluded. Identified articles were screened for all reported adverse events (AE) that were graded according to the Common Terminology Criteria for Adverse Events, version 5.0.

RESULTS

In our cohort, 37 children with ID/IDA received 41 FCM infusions. All infusions were tolerated well. In addition, 11 articles reporting 1231 infusions of FCM in 866 children were identified in the literature. Among them, 52 (6%) children developed AE that were graded as mild or moderate (grades I-III).

CONCLUSIONS

Our patient cohort and this literature review provide further evidence for the good safety profile of FCM in children, although well-designed prospective clinical trials with appropriate safety endpoints are still required.

Prevalence of Anemia and Iron Deficiency in Pediatric Patients on Ventricular Assist Devices

The prevalence and characteristics of anemia and iron deficiency in children supported by a ventricular assist device (VAD) are unknown. Patients <21 years of age on durable VAD support for ≥7 days at Texas Children's Hospital from 2006 to 2015 were retrospectively reviewed. Red blood cell (RBC) and iron deficiency indices in pulsatile VAD (P-VAD) and continuous-flow VAD (CF-VAD) were evaluated. Anemia, iron deficiency, and iron therapy regimens were identified. Seventy-six VAD implants in 74 patients were included: 45 P-VAD and 31 CF-VAD. Overall, 48% (36/75) of patients were anemic at VAD implant, with 67% of CF-VAD and 34% of P-VAD affected. Iron deficiency was seen in 52% (39/75) of patients at implant (similar in both groups). At explant, 71% (53/75) had anemia (similar in both groups). No patients had microcytosis. Iron supplementation was given to 20 patients, with four receiving target replacement therapy (2-6 mg/kg/d × 90 days). Red blood cell transfusion volumes were higher for P-VAD versus CF-VAD. We concluded that anemia and iron deficiency are common in pediatric VAD patients. Pulsatile VAD patients tend to develop anemia over the course of VAD support. Lack of microcytosis, likely masked by high RBC transfusions, suggests that specific iron studies are necessary to identify iron deficiency.

Deficiencies in the Management of Iron Deficiency Anemia During Childhood

Limited high-quality evidence supports the management of iron deficiency anemia (IDA). To assess our institutional performance in this area, we retrospectively reviewed IDA treatment practices in 195 consecutive children referred to our center from 2006 to mid-2010. The majority of children were ≤4 years old (64%) and had nutritional IDA (74%). In 11- to 18-year-old patients (31%), the primary etiology was menorrhagia (42%). Many were referred directly to the emergency department and/or prescribed iron doses outside the recommended range. Poor medication adherence and being lost-to-follow-up were common. Substantial improvements are required in the management of IDA.

Advances in Pediatric Intravenous Iron Therapy

Iron deficiency anemia (IDA) continues to be very common worldwide. Intravenous (IV) iron is an infrequently used therapeutic option in children with IDA despite numerous studies in adults and several small but notable pediatric studies showing efficacy and safety. Presently, the availability of newer IV iron products allows for replacement of the total iron deficit at a single setting. These products appear safer compared to the high molecular weight iron dextrans of the past. Herein, we review the medical literature and suggest that front line use of IV iron should be strongly considered in diseases associated with IDA in children.

Management of iron deficiency anemia: a survey of pediatric hematology/oncology specialists

BACKGROUND

Iron deficiency anemia (IDA) is the most common hematologic condition in children and adolescents in the United States (US). No prior reports have described the management of IDA by a large cohort of pediatric hematology/oncology specialists.

PROCEDURE

A 20-question electronic survey that solicited responses to two hypothetical cases of IDA was sent to active members of the American Society of Pediatric Hematology/Oncology (ASPHO) in the US.

RESULTS

Of 1,217 recipients, 398 (32.7%) reported regularly treating IDA and completed the survey. In a toddler with nutritional IDA, 15% (N = 61) of respondents reported ordering no diagnostic test beyond a complete blood count. Otherwise, wide variability in laboratory testing was reported. For treatment, most respondents would prescribe ferrous sulfate (N = 335, 84%) dosed at 6 mg/kg/day (N = 248, 62%) divided twice daily (N = 272, 68%). The recommended duration of iron treatment after resolution of anemia and normalized serum ferritin varied widely from 0 to 3 months. For an adolescent with heavy menstrual bleeding and IDA, most respondents recommended ferrous sulfate (N = 327, 83%), with dosing based on the number of tablets daily. For IDA refractory to oral treatment, intravenous iron therapy was recommended most frequently, 48% (N = 188) using iron sucrose, 17% (N = 68) ferric gluconate, and 15% (N = 60) low molecular weight iron dextran.

CONCLUSION

The approach to diagnosis and treatment of IDA in childhood was widely variable among responding ASPHO members. Given the lack of an evidence base to guide clinical decision making, further research investigating IDA management is needed.