Iron deficiency anaemia in children

Many children do not get enough iron from their diet to meet the demands of their growing bodies. This can result in iron deficiency (too little iron in the body), and eventually iron deficiency anaemia (an abnormally low level of haemoglobin in red blood cells).

In fact, iron deficiency is the most common cause of anaemia in children in Australia. However, children can have low iron levels without having anaemia - iron levels usually need to be low for some time before anaemia develops.

In addition to being needed to make haemoglobin, iron is also important for muscle function. It is essential for normal brain development in children and for keeping the immune system working well enough to fight disease.

The good news is that iron deficiency and iron deficiency anaemia are usually easy to treat with supplements and an iron-rich diet.

Symptoms

Symptoms and signs of iron deficiency anaemia in children include:

  • tiredness or weakness;
  • shortness of breath (especially when exercising);
  • feeling light-headed or dizzy;
  • headaches;
  • irritability; and
  • pale skin.

Other symptoms of iron deficiency in children include:

  • not growing at the expected rate;
  • getting more infections than usual;
  • tiredness and reduced energy to do exercise;
  • problems with concentration and memory; and
  • learning, developmental and behavioural problems.

Sometimes children with iron deficiency get cravings for unusual substances, such as soil or ice.

What causes iron deficiency anaemia in children?

Anaemia is when the number of red blood cells, or the oxygen-carrying protein contained in them - haemoglobin - falls below normal levels.

Iron is needed to make haemoglobin, so when the body’s iron stores are low, the amount of haemoglobin that can be made is reduced. Low iron levels can eventually result in the haemoglobin dropping below normal.

What causes iron deficiency?

Usually, iron deficiency develops because a child does not get enough iron from their diet.

The risk of iron deficiency is increased in:

  • babies of mothers who were iron-deficient during pregnancy or while breast feeding;
  • babies born more than 3 weeks premature or who were small at birth (low birth weight);
  • babies who start solid foods later than 6 months of age;
  • babies who drink cow’s milk as their main milk drink before 12 months of age;
  • children of any age who have a diet that is low in iron; and
  • children with increased iron requirements, such as during a growth spurt.

Less common causes include conditions that cause problems with absorption of iron from the bowel, such as undiagnosed or untreated coeliac disease. Inflammatory bowel disease can affect the absorption of iron from the intestine and cause bleeding that results in iron deficiency anaemia.

Girls who have heavy periods are also at risk of iron deficiency anaemia.

Tests and diagnosis

If you suspect that your child may be deficient in iron, it is very important that you take your child to the doctor. Your doctor will ask about symptoms of iron deficiency and examine your child.

They may recommend blood tests, including a full blood count (FBC) and iron studies, to make a diagnosis of iron deficiency and/or iron deficiency anaemia.

Treatment

Treatment for iron deficiency anaemia will depend on your child’s age and weight and the severity of their anaemia.

Increasing the amount of iron in your child’s diet is recommended, although dietary iron on its own is usually not sufficient to replenish your child’s iron stores. Iron supplements, which can be given as tablets, liquid or as injections, are usually needed to treat iron deficiency anaemia.

Iron supplements can usually be stopped soon after your child’s iron levels and haemoglobin are back to normal. But you should continue to give your child iron-rich foods to prevent iron deficiency developing again.

Dietary sources of iron

Your doctor may refer you and your child to a dietitian for advice on increasing the amount of iron in your family’s diet.

Haem iron is the type of iron in food that is most easily absorbed by the body. This type of iron is found in red meat, seafood, fish, poultry and organ meats such as liver (and foods such as pate made from these meats). The redder the meat, the more iron it contains.

Iron from sources other than meat is called non-haem iron. This type of iron is not absorbed as easily by the body. Non-haem iron is found in eggs, black beans, soy beans, dark green leafy vegetables (broccoli, spinach), dried fruit, raisins, apricots, iron-fortified bread and breakfast cereals, wholemeal pasta and bread, rice, maize, wheat, nuts and lentils. Absorption can be improved by consuming foods and drinks that are rich in vitamin C together with these foods.

Oral iron supplements

Oral iron supplements come in liquid or tablet form. Different supplements contain different amounts of iron - your doctor will recommend the most suitable supplement for your child. Do not give your child iron supplements unless recommended by your doctor.

Brand names of iron supplements that may be suitable for children include Ferro-liquid and Ferro-gradumet (for older children and teens). Don’t use over-the-counter multivitamins as they may not include the correct dose of iron.

Side effects of oral iron supplements include constipation, diarrhoea, nausea and taste disturbances. You can help reduce side effects by giving iron supplements in lower doses, or dividing the daily dose into 2-3 doses. Giving doses with food may also help.

Iron supplements can also cause dark or black stools, so don’t be alarmed if this happens.

Liquid preparations may temporarily discolour teeth, but brushing teeth with baking soda can reduce staining. Encouraging your child to drink the liquid supplement through a straw may help reduce its effect on teeth.

Too much iron can be highly poisonous in children. Iron supplements should be kept out of reach of small children to prevent an accidental overdose.

Iron injections

Injections of iron into a vein (intravenous iron) may be recommended if:

  • oral iron supplements have not been effective or are not well tolerated due to side effects;
  • there are problems with the absorption of iron taken by mouth; or
  • iron needs to be replaced quickly.

Side effects of intravenous iron supplements can include nausea and vomiting, taste disturbance, headache, mild fever and joint and muscle pains. Pain at the site of the injection and discolouration of the skin can also occur. There is also a risk of severe allergic reactions associated with this treatment, so children are closely monitored during and after treatment.

Iron injections given into a muscle are generally not recommended. They are painful and may cause permanent skin discolouration.

Treating heavy periods in teenage girls

If iron-deficiency anaemia in a teenage girl is thought to be due to heavy periods, hormonal treatments to make periods lighter (such as the oral contraceptive pill) may be recommended. The reduced blood loss each month can help correct iron deficiency.

Making sure your child gets enough iron

Babies and children have changing requirements when it comes to dietary iron. Steps to take to ensure your child gets enough iron will change depending on their age and stage of development.

Babies who were born very prematurely or who had a very low birth weight are at higher risk of developing iron deficiency. They will usually be prescribed an iron supplement to be taken in addition to dietary iron as appropriate for their age.

Babies younger than 6 months

Most babies younger than 6 months of age have enough iron in their body stores at birth to meet their needs.

Babies who are exclusively breast fed should get enough iron from breast milk during their first 6 months, as long as their mother has sufficient iron in her diet. Babies who are bottle fed should be given iron-fortified formula.

Babies older than 6 months of age

Iron stores start to run low at about 6 months of age, so it is generally recommended to introduce iron-rich solids, such as iron-fortified rice cereal, from about 6 months. Breast feeding or bottle feeding with iron-fortified formula should continue until at least 12 months.

Cow’s milk, goat’s milk and soy milk are low in iron and should not be introduced as the main milk drink until your baby is at least 12 months old and getting sufficient iron from solid foods.

Toddlers and young children

Toddlers and older children should be encouraged to eat iron-containing foods such as red meat, poultry, fish, fortified cereals and bread, and vegetables such as spinach and broccoli. Foods containing vitamin C, such as tomatoes and citrus fruits, will improve iron absorption when eaten at the same time as iron-rich foods.

Cow’s milk is low in iron. So is goat’s milk and soy milk. Children who fill up on milk instead of food are at risk of iron deficiency. So, from the age of 12 months, children should not drink more than 500 mL of milk per day.

Older children

Children who are having a growth spurt will need more iron-rich foods than usual. Teenagers who are very sporty and regularly train or compete are also at risk of iron deficiency and need additional dietary iron.

Children and teenagers who eat a vegetarian or vegan diet are at increased risk of iron deficiency and should see a dietitian about the best non-animal sources of dietary iron.

Talk to your doctor or dietitian if you are concerned that your child is not getting enough iron from their diet.

Last Reviewed: 5 June 2018
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References

1. Mayo Clinic. Iron deficiency in children: prevention tips for parents (updated 29 Nov 2018). https://www.mayoclinic.org/healthy-lifestyle/childrens-health/in-depth/iron-deficiency/art-20045634 (accessed May 2018).
2. National Blood Authority Australia. Paediatric and neonatal iron deficiency anaemia guide. Guidance for Australian Health Providers, December 2017. https://www.blood.gov.au/paediatric-and-neonatal-iron-deficiency-anaemia-guide (accessed May 2018).
3. Gastroenterological Society of Australia (GESA); Digestive Health Foundation (DHF). Information about iron deficiency, Third Edition, August 2013. http://www.gesa.org.au/resources/patients/iron-deficiency/ (accessed May 2018).
4. Baird-Gunning J, Bromley J. Correcting iron deficiency. Aust Prescr 2016;39:193-9. https://www.nps.org.au/australian-prescriber/articles/correcting-iron-deficiency (accessed May 2018).
5. Iron deficiency (published March 2016). In: eTG complete. Melbourne: Therapeutic Guidelines Limited; 2018 Mar. https://tgldcdp.tg.org.au (accessed May 2018).
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