Iron deficiency and iron deficiency anemia (pediatrics): Clinical sciences

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Introduction0:00–0:38

Iron deficiency is a condition that occurs when the body lacks sufficient iron for normal growth, development, and production of enough healthy red blood cells.
Iron plays a vital role in the production of hemoglobin, which is the protein responsible for carrying oxygen in red blood cells.
Consequently, when iron levels are low, the body is unable to produce an adequate amount of hemoglobin, leading to impaired red blood cell production.
You can differentiate between iron deficiency without anemia and iron-deficiency anemia by examining your patient’s laboratory results.Now, if a pediatric patient presents with a chief concern suggestive of iron deficiency or iron-deficiency anemia, first, you should obtain a focused history and physical examination.

Focused H&P0:38–2:34

The history typically reveals vague symptoms like fatigue, lightheadedness, low muscular endurance, and palpitations, which manifest as a compensatory response to inadequate tissue oxygen supply.
Caregivers may also report behavior changes, such as poor concentration or irritability, as well as pica, which is the compulsive consumption of non-nutritive substances like dirt or ice.
Finally, keep in mind iron deficiency risk factors, like heavy menstrual bleeding, exposure to lead, certain chronic conditions, low dietary iron intake, and active participation in athletics.
Additionally, the physical exam might reveal tachycardia and tachypnea. You may also notice pallor, which is most often visible in the conjunctivae, lips, and nail beds.
Other common findings include brittle nails and koilonychia, characterized by nails that are concave or spoon-shaped. Finally, you might notice glossitis, which is a smooth and glossy tongue, as well as angular stomatitis, which refers to inflammation and cracking at the corners of the mouth.
Now, here’s a clinical pearl to keep in mind! Certain medications can potentially result in iron deficiency, such as nonsteroidal anti-inflammatory drugs or NSAIDs, which can increase the risk of peptic ulcers and subsequent bleeding; and proton pump inhibitors or PPIs, which can reduce absorption of iron.
So, if your patient has been using these medications, this should increase your suspicion of iron deficiency. At this point, you should suspect iron deficiency, so your next step is to check labs.

Suspect iron deficiency2:34–3:50

First, to identify anemia, you’ll need to order a CBC, which includes a hemoglobin level, as well as red blood indices, such as the mean corpuscular volume, or MCV.
You should also order labs to check your patient’s iron status. These include the reticulocyte hemoglobin concentration; serum ferritin, which is a sensitive indicator of the body’s iron stores; transferrin saturation or TSAT, which is the percentage of occupied iron-binding sites on transferrin; and the total iron-binding capacity, or TIBC, which measures the blood’s ability to attach to iron and transport it throughout the body.
Here’s a high yield fact to keep in mind! Serum iron concentration is often not obtained in pediatrics, especially because it does not necessarily help with differentiating iron deficiency without anemia from iron deficiency anemia.
Even so, keep in mind that serum iron concentration is often normal in iron deficiency without anemia, and low in iron deficiency anemia.

Iron deficiency without anemia3:50–5:00

Now, let’s move on and discuss the lab results you’d expect to see in iron deficiency without anemia. In this case, the CBC will reveal normal hemoglobin values for your patient’s age and biological sex, and a normal MCV.
On the flip side, reticulocyte hemoglobin concentration, serum ferritin, and transferrin saturation will be low; while the total iron-binding capacity will be normal.
With these findings, you can diagnose iron deficiency without anemia. Now, here’s a clinical pearl to keep in mind!
Serum ferritin is a sensitive measure of the body’s iron stores, but because it’s also an acute phase reactant, it can be elevated in some chronic conditions, even in the setting of iron deficiency.
If your patient has a chronic illness, and their serum ferritin level is in the normal range, you should still consider iron deficiency.
Look at the TSAT, and if it’s below 20%, diagnose iron deficiency, in addition to anemia of chronic disease.Alright, now once you diagnose iron deficiency, let’s turn our attention to treatment.

Management5:00–6:30

Managing iron deficiency without anemia involves treating any underlying cause that’s contributing to the iron deficiency, such as malabsorptive conditions like celiac disease or inflammatory bowel disease.
And, owing to the fact that iron deficiency in children is commonly caused by low iron intake, treatment should always include incorporating iron-rich foods into the diet, as well as limiting foods that are low in iron.
Next, replenish iron stores by giving oral supplementation, like ferrous sulfate. The duration of the treatment depends on the severity of the deficiency and typically lasts several months.
For optimal iron absorption, you should advise your patients to take oral iron with acidic foods, such as citrus fruits.
Also, encourage patients to avoid taking iron with anything that interferes with its absorption, like milk, eggs, soy protein, or calcium supplements.Here’s another clinical pearl to keep in mind!
Full term infants who are exclusively breastfed should receive oral iron supplementation beginning at four months of age, until iron-containing solid foods such as cereal are introduced into their diet.
In addition, all preterm infants who are fed human milk require iron supplementation from birth until 12 months of age.Now let’s switch gears and discuss lab results in iron-deficiency anemia.

Iron deficiency anemia6:30–7:52

In this case, the CBC will reveal a hemoglobin that is more than 2 standard deviations below the mean for your patient’s age and biological sex, with a low MCV.
These findings confirm the presence of anemia. In addition, the reticulocyte hemoglobin concentration, serum ferritin, and transferrin saturation will all be low, while the total iron-binding capacity will be elevated.
At this point you can diagnose iron-deficiency anemia.Now, here’s a high-yield fact to keep in mind! A peripheral blood smear from an individual with iron-deficiency anemia will reveal microcytic, hypochromic red blood cells, indicating reduced hemoglobin synthesis.
Other findings associated with this type of anemia include anisocytosis, or red blood cells with varying sizes, and poikilocytosis, or red blood cells with various shapes.
However, these findings are not specific to iron-deficiency anemia, and they can also be seen in other conditions, such as thalassemia and sideroblastic anemia.
So, don’t rely on blood smear alone to diagnose iron deficiency, and remember to check iron studies too!Now let’s discuss the management of iron-deficiency anemia!

Management7:52–9:30

First, you should treat any underlying condition contributing to the deficiency. Next, you should always incorporate iron-rich foods into the diet and limit foods that interfere with iron absorption.
Next, replenish iron stores by giving oral iron supplementation. However, if your patient can’t tolerate oral supplementation, has hemoglobin below 7 to 8 grams per deciliter, or has ongoing blood loss, consider parenteral iron therapy, which involves administering an iron formulation, such as iron dextran, either intravenously or intramuscularly.
Finally, for patients with severely symptomatic anemia, consider giving a packed red blood cell transfusion.Now, here’s one final clinical pearl!
All children should receive routine hemoglobin screening between 9 and 12 months of age, but if you identify risk factors for iron deficiency, you should screen your patient regardless of age.
If your patient’s hemoglobin is low, consider ordering additional tests of iron status. Alternatively, you could provide oral iron supplementation for a month and then reassess the hemoglobin.
If the hemoglobin has improved, you can confirm that the anemia was from iron deficiency. On the other hand, if the hemoglobin hasn’t improved after a month of oral iron supplementation, consider other causes of anemia, such as gastrointestinal blood loss from conditions like inflammatory bowel disease, peptic ulcer disease, or even hookworm infection!Alright, as a quick recap… Iron deficiency is a condition in which the body lacks sufficient iron required for normal growth, development, and hemoglobin production.

Review9:30–10:38

If you suspect iron deficiency, order labs to differentiate iron deficiency from iron-deficiency anemia. In iron deficiency without anemia, labs reveal normal hemoglobin, MCV, and total iron-binding capacity.
However, the reticulocyte hemoglobin concentration, serum ferritin, and transferrin saturation are low. On the flip side, in iron-deficiency anemia, labs reveal low hemoglobin, MCV, reticulocyte hemoglobin concentration, serum ferritin, and transferrin saturation.
Additionally, the total iron-binding capacity is elevated! Treatment of iron deficiency and iron-deficiency anemia involves addressing the underlying cause, dietary modifications, and oral iron supplementation.
In some cases of iron-deficiency anemia, you should also consider parenteral iron and packed red blood