Iron-deficiency Anaemia in Children

Summary

Iron is a vital element for overall health of human beings as it helps the body make RBCs. Anaemia is a condition in which there is not enough RBCs in the body. One of the causes for the same is iron deficiency. Children who develop iron-deficiency anaemia may have delayed or impaired growth, which makes it a serious condition. In this article, we will learn more about this condition.

Introduction

Red-blood-cells found in the human blood help transport oxygen to all cells of the body and remove carbon-di-oxide out of the body. This is enabled by haemoglobin, an iron-containing protein found in RBCs. Iron, that comes from the diet consumed is used by the body to make new RBCs. The iron found in old RBCs (that eventually die out), is also harnessed by the body. When a child is in the womb, it gets its iron supply from the mother’s body and this is stored in the body. But once out of the body, a child needs adequate supply of iron in order to make RBCs. This requirement only increases with age till the child reaches adulthood (18 years plus).

Anaemia is a condition in which the blood does not contain enough RBCs. This can affect both adults and children alike. For the purpose of this article, we will stay focused on children only. Anaemia in children could be due to 3 common reasons:

1. The body is not making enough RBCs: This happens when the child is not getting enough iron from his/her diet. Also called iron-deficiency anaemia.
2. Auto-immune and inherited disorders: Auto-immune disorders are those in which the body mistakenly attacks the body’s cells mistaking them for pathogens. When they attack RBCs, it can result in death and hence shortage of RBCs in the blood. Sickle-cell anaemia is an inherited condition in which RBCs become abnormal and incapable of transporting oxygen. Here the anaemia is due to a shortage of healthy RBCs.
3. Bleeding: Trauma (injuries) and gastrointestinal bleeding can result in blood-loss and hence a nett reduction in the number of RBCs in the blood.

If none of the above is true and the child still has anaemia, then possible causes would be haemolytic diseases, hypersplenism, bone-marrow disorders, hypothyroidism, congenital aplasia, folate deficiency, thalassemia and vitamin B12 deficiency. For the purpose of this article, we will stay focused on iron-deficiency alone.

Causes and Risk Factors

• Premature birth: As mentioned above, the foetus gets its iron supply from the mother’s body and this happens in the last trimester of pregnancy. So, a prematurely born baby has not received its full quota of iron. So also, a baby born with low birth-weight has lesser quantity of blood and hence at risk for anaemia.
• Anaemic parents: Parents who themselves have a history of anaemia can result in the baby developing anaemia while still an infant. Iron-refractory iron deficiency anaemia (IRIDA), is a congenital condition caused by a gene mutation that causes iron deficiency.
• Obesity: Overweight infants have impaired metabolism which can affect iron absorption leading to iron-deficiency anaemia.
• Diets low in iron: A child gets its iron supply from the food consumed. However only a small portion of iron is absorbed by the body. In the first 4 to 6 months, the low iron content is still Ok, but as the child grows, it needs an increasing supply of iron. Deficiency can happen in all of these situations:
  • Infants are advised to be fed breast-milk for the first 6 months, and thereafter with formula food that is fortified with iron. This is because breast milk doesn’t have enough iron in it. So, for the first 6 months, there is a slight deficiency.
  • If the formula food is not fortified with iron (most of them are), it creates a risk.
  • Cow/goat milk: Babies who are introduced to cow’s milk or goat’s milk before the age of 1 year are also at risk. This is because such milk is low in iron and also, they impair absorption of whatever iron is there.
  • Excess of cow’s milk: After the age of 1 year, children who drink a lot of cow’s milk everyday (more than 750 ml) are also at risk for the reason explained previously.
  • Vegetarian diet: Meat is a rich source of iron which is absorbed easily (called heme iron), so vegetarian children can develop a deficiency if the shortfall is not made up by vegetarian sources of iron (called non-heme iron).
  • Poor appetite: Children who are picky eaters and poor eaters can develop a deficiency.
• Other conditions: Children who have chronic infections or fed restricted diets can develop a deficiency.
• Environmental: Children who have been exposed to lead at a young age (from nearby industries or chemical plants).
• Gastrointestinal (GI) tract problems: Children who have had surgery on the GI tract for some other problem can have impaired absorption of iron from food. So also, children suffering from celiac disease have impaired absorption of iron from food.
• Body changes: As the child grows it needs an increasing supply of iron. Children whose iron content in food has not increased over the years can develop a deficiency. For example, during puberty, the iron requirement is higher. In girls, its even higher due to blood-loss from menstruation. This is also due to the fact that girl’s bodies do not store iron as efficiently as boy’s bodies do.

Signs and Symptoms

The signs and symptoms vary from child to child and also depends on the condition being mild, moderate or severe. They include:

• Abnormal paleness or lack of colour of the skin, yellow skin
• Pale cheeks and lips
• Nail beds and lining of the eyelids also look pale in colour
• Irritability, being moody and grouchy most of the time
• Tiring easily, napping frequently, constant fatigue and lack of energy
• Tachycardia or an abnormally rapid heart-beat, and heart murmur
• Sore tongue, swollen tongue, mouth ulcers in some cases
• Enlarged spleen
• Pica – which is a strong and odd desire to eat non-food substances like dirt, ice, paint and starch
• Cough, runny nose and stuffy nose
• Vomiting and diarrhoea
• Pain in the abdomen
• Appearance of a mass in the neck
• Cellulitis which is a bacterial skin infection
• Bleeding from the nose, blood in the stools and vomiting blood
• Physical and mental developmental issues
• Jaundice (yellowing skin or eyes)
• Dark-coloured urine
• Dyspnoea or shortness of breath, rapid breathing
• Swollen hands and feet
• Frequent headache
• Dizziness and fainting (syncope)
• Restless leg syndrome
• Fast heartbeat or a heart murmur
• Cold hands and feet
• Poor appetite
• Behavioural problems
• Frequent infections

Diagnosis

• Blood tests are the first and most important diagnostic method.
  • Hemoglobin and hematocrit: These are the first parameters that will be checked. If the doctor is still not satisfied, he/she may order the next test
  • Complete blood count (CBC): Here, in addition to hemoglobin and hematocrit, the test will reveal concentrations of platelets, WBCs and young RBCs (reticulocytes).
• Peripheral smear: In this, a small sample of blood is examined under a microscope. This basically looks for any abnormalities in RBCs.
• Iron studies: This is a more thorough test to measure the levels of iron in the child’s body.
• Biopsy: In rare cases, a bone-marrow biopsy is done to check for irregularities there. The bone marrow is where RBCs are generated.

Treatment

For infants less than 1 year, the doctor will ensure he/she is being breast-fed and also fed formula food that is fortified with iron.

Iron-rich diet: Depending on the age of the child and dietary culture (vegetarian vs non-vegetarian), he/she may be advised to consume foods that are rich in iron, which includes:

• Cereals, breads, rice and pasta which are fortified with iron
• Meats, such as liver, beef, lamb, pork and other organ meats
• Poultry or lean meat such as chicken, turkey, duck and liver
• Seafood such as shellfish, anchovies, clams, sardines, mussels and oysters
• Leafy greens such as spinach, amaranth, kale, turnip greens and collard greens
• Cruciferous vegetables such as broccoli, cabbage, cauliflower and knol khol
• Legumes such as green peas, groundnuts, black-eyed peas, etc
• Whole-wheat bread and rolls that have yeast in them
• Citrus fruits such as orange, sweet-lime and lemon: these increase iron-absorption

Iron supplements: The child will have to take supplements in the form of pills, drops or IV injections for 7-8 months, or till iron levels have stabilized. There are minor side-effects to these supplements but the doctor will advise on how to overcome them.

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