Severe iron deficiency anemia in young children

Severe Unexplained Iron Deficiency Anemia in Children: High Yield of Upper Gastrointestinal Endoscopy Regardless of Gastrointestinal Symptoms

In this retrospective study spanning 2016 to 2022, we aimed to evaluate the diagnostic utility of upper gastrointestinal endoscopy (UGE) in children under 18 years presenting with severe unexplained iron deficiency anemia (IDA), defined as microcytic anemia of hemoglobin ≤7 g/dL with low ferritin levels. Of 106 children hospitalized for severe anemia, 29 had unexplained IDA (mean hemoglobin level of 6.2 [3.2 to 6.9] gr/dL), and 25 of them underwent UGE. The mean age was 10.7 ± 3.9 years, with 76% being female. Ten children (40%) had gastrointestinal (GI) symptoms at presentation. The cause of IDA was found in 18 (72%) of 25 children who underwent UGE, of whom 12 were without GI symptoms. Gastric nodularity, erosions, or polyps were observed in 68%, and gastritis was evident in 72% based on histopathology. Helicobacter pylori was found in 50% of those with gastritis. Follow-up showed normalized hemoglobin levels in 92% of cases, with only 2 children requiring repeat iron therapy. Our findings underscore the importance of incorporating UGE into the diagnostic investigation of severe unexplained IDA in children, irrespective of the presence of GI symptoms.

Hemoglobin Threshold for Blood Transfusion in Young Children Hospitalized with Iron Deficiency Anemia

Current recommendations advise against blood transfusion in hemodynamically stable children with iron deficiency anemia. In an observational study of 125 children aged 6 through 36 months, hospitalized with iron deficiency anemia, we found that hemoglobin level predicted red blood cell transfusion (area under the curve 0.8862). A hemoglobin of 39 g/L had sensitivity 92% and specificity 72% for transfusion.

Neurologic Complications in the Pediatric Intensive Care Unit

PURPOSE OF REVIEW

All critical care is directed at maintaining brain health, but recognizing neurologic complications of critical illness in children is difficult, and limited data exist to guide practice. This article discusses an approach to the recognition and management of seizures, stroke, and cardiac arrest as complications of other critical illnesses in the pediatric intensive care unit.

RECENT FINDINGS

Convulsive and nonconvulsive seizures occur frequently in children after cardiac arrest or traumatic brain injury and during extracorporeal membrane oxygenation. Seizures may add to neurologic morbidity, and continuous EEG monitoring is needed for up to 24 hours for detection. Hypothermia has not been shown to improve outcome after cardiac arrest in children, but targeted temperature management with controlled normothermia and prevention of fever is a mainstay of neuroprotection.

SUMMARY

Much of brain-directed pediatric critical care is empiric. Recognition of neurologic complications of critical illness requires multidisciplinary care, serial neurologic examinations, and an appreciation for the multiple risk factors for neurologic injury present in most patients in the pediatric intensive care unit. Through attention to the fundamentals of neuroprotection, including maintaining or restoring cerebral perfusion matched to the metabolic needs of the brain, combined with anticipatory planning, these complications can be prevented or the neurologic injury mitigated.

Iron Deficiency and Iron-deficiency Anemia in Toddlers Ages 18 to 36 Months: A Prospective Study

In young children, iron deficiency (ID)-the most common cause of anemia-may adversely affect long-term neurodevelopment and behavior. We prospectively evaluated the prevalence of ID and iron deficiency anemia (IDA) in 256 healthy 18- to 36-month-old children in Northern Israel. Complete blood count and ferritin evaluation were performed, and risk factors were assessed. Hemoglobin (Hgb) was compared with first-year routine screening. Complete data were obtained from 208 children: 56.2% were boys; the mean age was 26.1±5.27 months. A prevalence of 5.8% IDA, 16.3% ID without anemia, 9.6% anemia with normal ferritin, and 68.3% normal Hgb and ferritin was found. In nonanemic infants at 1 year of age (n=156), ID/IDA was found in 19.9%, and 12.8% became anemic at study evaluation. Despite iron supplementation in the first year, and normal Hgb at first-year screening, ID and IDA were still prevalent, and might develop during the second year of life. Recognition of this child subset and consideration of iron supplementation are mandatory.

Severe Iron Deficiency Anemia in Infants and Young Children, Requiring Hospital Admission

Objective. This study evaluated patient characteristics, milk intake, and associated lab findings of children 6 months to 5 years old, admitted to a children’s hospital with severe iron-deficiency anemia (IDA). Methods. A chart review was conducted on patients admitted with microcytic anemia (hemoglobin concentration less than 7 g/dL), accompanied by a low serum ferritin and/or low serum iron level between January 2000 and December 2006. Results. A total of 18 children with severe IDA were evaluated. Many had parents with private insurance and jobs. Almost all children drank >24 ounces of milk daily. Hemoglobin on admission was 3.8 g/dL, and the mean of the patients’ mean corpuscular volume was 52.8 fL. Median iron levels were 4 µg/dL. Conclusions. Severe IDA is still prevalent in children, yet physicians may not perform necessary testing. The devastating long-term effects of severe IDA should prompt clinicians to screen for severe IDA in children regardless of absent risk factors.

Severe iron-deficiency anaemia and feeding practices in young children

Objectives

Fe-deficiency anaemia (IDA) occurs in 1–2 % of infants in developed countries, peaks at 1–3 years of age and is associated with later cognitive deficits. The objectives of the present study were to describe the characteristics of young children with severe IDA and examine modifiable risk factors in a developed-country setting.

Design

Two prospective samples: a national surveillance programme sample and a regional longitudinal study sample.

Setting

Canada, 2009–2011.

Subjects

Two samples of young children recruited from community-based health-care practices: a national sample with severe anaemia (Hb<80 g/l) due to Fe deficiency and a regional sample with non-anaemic Fe sufficiency.

Results

Children with severe IDA (n201, mean Hb 55·1 g/l) experienced substantial morbidity (including developmental delay, heart failure, cerebral thrombosis) and health-care utilization (including a 42 % hospitalization rate). Compared with children with Fe sufficiency (n597, mean Hb 122·4 g/l), children with severe IDA consumed a larger volume of cow’s milk daily (median 1065 mlv. 500 ml,P<0·001) and were more likely to be using a bottle during the day (78 %v. 43 %, OR=6·0; 95 % CI 4·0, 8·9) and also in bed (60 %v. 21 %, OR=6·5; 95 % CI 4·4, 9·5).

Conclusions

Severe IDA is associated with substantial morbidity and may be preventable. Three potentially modifiable feeding practices are associated with IDA: (i) cow’s milk consumption greater than 500 ml/d; (ii) daytime bottle use beyond 12 months of age; and (iii) bottle use in bed. These feeding practices should be highlighted in future recommendations for public health and primary-care practitioners.

Venous stroke and status epilepticus due to milk-induced anemia in a child

The risk factors for cerebral sinus venous thrombosis include dehydration, infection, and anemia. The clinical presentation in children of venous strokes associated with cerebral venous thrombosis is variable and may include seizures. Acute management should focus on the treatment of the primary cause and anticoagulation or antiplatelet therapy if needed. Early recognition and targeted treatment is important because survivors are at increased risk for long-term neurologic complications. We report a case of a 4-year-old girl who presented with status epilepticus and was subsequently found to have a cerebral venous sinus thrombosis in the transverse and sigmoid sinus, with venous infarction in the temporal lobe. Laboratory results were significant for a microcytic anemia caused by excessive milk intake. Although iron deficiency anemia is a common pediatric disorder, this uncommon presentation demonstrates the potential for neurologic complications secondary to anemia, as well as the need for a high index of suspicion in order to identify venous stroke as a cause in children who present to the emergency department with seizures.

Severe iron-deficiency anemia still an issue in toddlers

BACKGROUND AND OBJECTIVES

Chronic, severe iron-deficiency anemia (IDA) in the first years of life increases the risk of irreversibly compromised cognitive, affective, and motor development. While IDA in infants has decreased because of dietary changes (iron-fortified formula and delaying cow's milk), toddlers (13-36 months) are equally vulnerable to the adverse effects of IDA. We aimed to show that despite public health efforts, severe IDA remains a problem in toddlers and is associated with excess milk consumption.

METHODS

Retrospective chart review of children 6 to 36 months admitted to or evaluated by hematology at a children's hospital from January 1, 2005 to December 31, 2010 with a severe microcytic anemia (hemoglobin [Hb] <9 g/dL and mean corpuscular volume (MCV) <75 fL).

RESULTS

We identified 68 infants and toddlers with severe IDA; most (84%) were 13 to 36 months old. The mean Hb and MCV were 6.0 g/dL (range = 2.2-8.9 g/dL) and 54.0 fL (range = 45.5-69.8 fL), respectively. Fatigue, poor appetite, and pica were the most common symptoms, found in 43%, 29%, and 22% of patients, respectively. Only 41% of parents reported pale skin while 77% of physicians recorded it on physical exam. Daily cow's milk consumption surpassed 24 ounces for 47 of 48 children with reported intake; 11 consumed more than 64 ounces per day.

CONCLUSIONS

Despite current screening recommendations, severe IDA continues to be a problem in toddlers and strongly correlates with excess cow's milk consumption. This reiterates the importance of screening for IDA into routine toddler care.

Consumption of cow's milk as a cause of iron deficiency in infants and toddlers

Consumption of cow's milk (CM) by infants and toddlers has adverse effects on their iron stores, a finding that has been well documented in many localities. Several mechanisms have been identified that may contribute to iron deficiency in this young population group. The most important of these is probably the low iron content of CM, which makes it difficult for infants to obtain the amounts of iron needed for growth. A second mechanism is the occult intestinal blood loss associated with CM consumption during infancy, a condition that affects about 40% of otherwise healthy infants. Loss of iron in the form of blood diminishes with age and ceases after the age of 1 year. A third mechanism is the inhibition of non-heme iron absorption by calcium and casein, both of which are present in high amounts in CM. Fortification of CM with iron, as practiced in some countries, can protect infants and toddlers against CM's negative effects on iron status. Consumption of CM produces a high renal solute load, which leads to a higher urine solute concentration than consumption of breast milk or formula, thereby narrowing the margin of safety during dehydrating events, such as diarrhea. The high protein intake from CM may also place infants at increased risk of obesity in later childhood. It is thus recommended that unmodified, unfortified CM not be fed to infants and that it be fed to toddlers in modest amounts only.

Iron supplementation of breastfed infants

Reported here are three studies performed with the objective of finding ways to improve the iron status of breastfed infants and to prevent iron deficiency (ID). Participating infants were exclusively breastfed until 4 months of age; thereafter, they could receive complementary foods and, in some studies, supplemental formula. In the first study, infants were given medicinal iron between the ages of 1 and 5.5 months. During this period, iron status improved and ID was prevented; however, these benefits did not continue after the intervention ceased. In the second study, infants received medicinal iron or an equivalent amount of iron from an iron-fortified cereal between the ages of 4 and 9 months. Again, iron supplementation largely prevented ID from occurring, while non-anemic ID and ID anemia occurred in the control group as well as in the intervention groups before the intervention began. In the third study, infants received dry cereals fortified with electrolytic iron or with ferrous fumarate between the ages of 4 and 9 months. The cereals were equally effective in providing relative protection from ID. The results of these three studies indicate it is possible to protect breastfed infants from ID and IDA.

Excessive Cow's Milk Consumption and Iron Deficiency in Toddlers

Elimination of iron deficiency and iron deficiency anemia in children is a crucial public health concern because these conditions have been linked to cognitive and behavioral deficits. In the infant age group, great strides have been made to reduce iron deficiency and iron deficiency anemia significantly. However, similar progress has not yet been made with toddlers. Cow's milk consumption has long been associated with iron deficiency and iron deficiency anemia in children. Because cow's milk is a staple in the diet of most toddlers, they are at particular risk for these conditions. Two unusual presentations of anemia in toddlers caused by excessive cow's milk consumption are described: one in a child with congestive heart failure, the other in a child with profound eosinophilia. The role of cow's milk in iron deficiency and iron deficiency anemia is also examined.

The effect of dietary habits and socioeconomic status on the prevalence of iron deficiency in children of northern Greece

BACKGROUND

Despite encouraging reports concerning the declining prevalence of iron deficiency, this easily preventable disorder is still an existing problem in presumably developed regions.

OBJECTIVE

To evaluate the prevalence of iron deficiency and relevant anemia in children residing in Northern Greece and to study possible associations.

DESIGN

3,100 children aged 8 months to 15 years were evaluated. Socioeconomic status was determined based on the parents' profession and place of residence. Nutrition habits were also evaluated.

RESULTS

The incidence of iron deficiency was found to be 14% and that of iron deficiency anemia was 2.9%, with a higher prevalence in children younger than 2 years of age. The place of residence was the most significant factor in relation to the development of iron depletion in the children studied. Additional independent factors were revealed to be breast-feeding, meat-containing meal consumption and the consumption of non-home-cooked meals.

CONCLUSION

Iron deficiency remains prevalent in Northern Greece, mainly affecting the vulnerable toddler group. Nutritional iron deficiency is still a severe public health problem even in what are considered to be developed regions. An improvement of dietary habits and an upgrading of semiurban areas should contribute substantially to decreasing the prevalence of iron depletion in Greek children.

Differing perspectives of inner-city parents and pediatric clinicians impact management of iron-deficiency anemia

OBJECTIVE

To ascertain the beliefs and experiences of inner-city pediatric clinicians and parents regarding anemia in young children.

DESIGN

Focus groups and in-depth interviews.

SETTING

Pediatric clinics and community agencies in Hartford, Connecticut.

PARTICIPANTS

Convenience sample of 41 pediatric clinicians (93% white, 73% female) and 85 parents (100% minority, 88% female, 47% < 12 years education).

PHENOMENON OF INTEREST

Identification, understanding, and management of anemia.

ANALYSIS

Researcher pairs coded complete transcriptions. Recurrent themes were identified, which were then contrasted and compared between clinicians and parents.

RESULTS

Both clinicians and parents were familiar with, but frustrated by the persistence of anemia. They noted time constraints and poor communication during office visits as contributing to the problem. Parents felt alarmed upon initial diagnosis; linked anemia with heredity, food patterns, and activity; reported culturally linked management strategies; but were uncertain of the seriousness. Health clinicians saw physiological processes as outside the parents' understanding and emphasized prevention through feeding recommendations.

CONCLUSIONS AND IMPLICATIONS

In order to address childhood anemia effectively, differing socio-cultural perspectives of clinicians and parents need to be incorporated into a unified health care plan. Nutritionists are well suited to collaborate on the health care team to effectively address this issue.

Severe iron-deficiency anemia among hospitalized young children in an urban hospital

The aim of this study was to investigate the prevalence and some characteristics of young children with severe iron-deficiency anemia hospitalized in an urban hospital. All of the young children (aged 7-24 months) hospitalized in a city hospital during the last 3 years were searched for iron-deficiency anemia and those with severe anemia were retrospectively evaluated. During this period, 3117 young children were hospitalized and 61.6% of them had a hemoglobin value of less than 11 g/dL and 52 children (2.7%) had severe iron-deficiency anemia (hemoglobin < 6 g/dL). It was concluded that iron-deficiency anemia is still an important health problem among young children in our society.

Trends in diagnosis and management of iron deficiency during infancy and early childhood

Iron deficiency remains a public health challenge. The neurocognitive deficits that are associated with iron deficiency are most worrisome. Moreover, iron deficiency-associated elevated blood lead levels magnify the problem. Pediatricians must strive to prevent iron deficiency.

Hereditary Hemochromatosis Genetic Testing of At-Risk Children: What Is the Appropriate Age?

The objective of this study was to consider the objective evidence and ethical arguments for the appropriate age to test children at risk of developing hereditary hemochromatosis. A literature search for information on iron overload in children, onset of disease expression for hemochromatosis, and recommendations for age of cascade screening was undertaken. We examined the objective evidence and arguments for testing in early childhood and those for delaying testing until later teenage years. Cascade testing of offspring of people with hemochromatosis is widely advocated because it is an easily preventable disease. The ideal age to test those offspring is a matter of debate. Some authorities advocate testing at a very young age whereas others recommend delaying testing until late teenage years. To date there has been no published overview of the objective evidence and arguments central to this debate. In children who are C282Y homozygous, iron overload is rare in the first two decades of life and associated morbidity has only been documented in 1 patient. In the cascade setting, genetic testing for hemochromatosis need not be offered until late teenage years.

Iron deficiency is unacceptably high in refugee children from Burma

Iron-deficiency anemia (IDA) in refugees is reported to be among the major medical problems worldwide. Because food rations are typically inadequate in iron, long-term reliance is a key predictor of anemia among displaced people. Comprehensive nutritional assessments of refugee children from Burma have not previously been completed. Refugee children aged 6-59 mo were studied to determine 1) the prevalences of anemia, iron deficiency (ID) and IDA and 2) the factors associated with anemia and ID. Cluster sampling in three camps and convenience sampling in two additional camps were used. Hemoglobin (Hb) levels were measured and micro mol zinc protoporphyrin/mol heme were determined in 975 children. Logistic regression analyses (95% CI) determined predictors of anemia and ID. The prevalences of IDA, anemia and ID in these refugee children were 64.9, 72.0 and 85.4%, respectively. Predictors of anemia included young age (P < 0.001), food ration lasting <1 mo (P = 0.001), daily consumption of dietary iron inhibitors (P < 0.05), weight-for-height Z-score of <-2 (P < 0.05), male gender (P < 0.05) and uneducated father (P < 0.001). Predictors of ID were young age (P < 0.001) and recently reported illness (P < 0.05). Laboratory tests confirmed that anemia and ID are major health problems among these refugee children and that ID is the leading cause of anemia. A comprehensive nutrition and public health-focused approach to combating anemia and ID is essential. Following the presentation of results to policy makers, the improvement of the micronutrient content of rations has been initiated.

Prolonged bottle feeding in a cohort of children: does it affect caloric intake and dietary composition?

Little is known about the consequences to children of bottle feeding prolonged beyond age 1 year on caloric intake and overall dietary composition. To obtain these data, 165 children, followed up from infancy, were assessed in these respects for a 24-hour period at age 3 1/2 years. Bottle-fed children (n = 14) consumed more milk than their weaned counterparts (p < 0.001), had a higher mean daily calcium intake (p < 0.05), received fewer calories from carbohydrates (p = 0.034), and received a greater percentage of calories from protein (p = 0.033). There were no significant differences between the groups in total caloric intake, total iron intake, total volume ofjuice, or calories from fat. Pediatricians questioned about the effects of continuing to offer children nutritive liquids from bottles as well as cups (versus offering cups alone) may inform parents that this feeding practice is associated with significantly greater milk consumption and daily calcium intake. However, this study could not find evidence that prolonged bottle feeding at age 3 1/2 years is associated with a significantly decreased total daily iron intake or an increased risk for factors associated with adiposity such as a greater daily calorie intake, a higher body mass index, or greater percentage of total calories derived from fat.

Updates in pediatric nutrition

There have been many remarkable advances in pediatric nutrition. Solid scientific evidence now supports certain fundamental assumptions long held in the pediatric community. For example, obesity in children has for some time been believed to have adverse health effects; recent large scale studies now confirm relationships between childhood obesity and specific morbidities. Likewise, the beneficial effects of human breast milk on growth and development have been the focus of recent prospective studies of full term and preterm infants. There has been active research in the area of formula intolerance and allergy, allowing practicing physicians to better counsel parents about dietary choices. Although many health problems are caused by the abundance of high fat and high calorie foods in the average US child's diet, a large number of children remain at risk for hunger in the United States. Other research provides important breakthroughs in our understanding of the impact of pediatric nutrition on lifelong health. Retrospective epidemiological studies have uncovered relationships between prenatal factors and health later in life. These studies have lead to ongoing prospective observational trials that should provide further information about the extent to which certain health factors are determined before birth. In addition, basic science research has revealed previously unknown mechanisms by which essential minerals, such as iron, are transported into the body. In sum, this section reviews exciting new information in the areas of childhood diet quality, obesity, breast milk, formula intolerance, and iron metabolism.