NHD PAEDIATRIC HUB FACT FILE

Iron deficiency anaemia

Overview

Iron deficiency anaemia (IDA) is a condition characterised by reduced red blood cell production due to insufficient iron in the body. It is the most common nutritional deficiency worldwide, with significant implications for cognitive and physical development, particularly in children and adolescents.(1)

Prevalence and concerns

According to the National Diet and Nutrition Survey (Years 9-11), 4% of children aged 4-10 years and 17% of children aged 11-18 years in the UK have red blood cell folate concentrations below the threshold, putting them at risk for anaemia.(2) This issue is more prevalent among females, which may be exacerbated by the rising popularity of vegan and vegetarian diets, as well as reduced red meat consumption.

Risk factors

Infants:

  • Maternal iron deficiency
  • Prematurity or/and low birth weight
  • Late or insufficient introduction of iron-rich solids
  • Excessive cow’s milk

Children and Adolescents:

  • Vegan or Vegetarian Diet
  • Gastrointestinal disorders like coeliac disease, intestinal surgery, IBD
  • Other chronic blood loss
  • Athletic populations
  • Females with heavy menstrual bleeding

Symptoms of Iron Deficiency

Cognitive Impairments:

Decreased memory, concentration and learning abilities.

Physical Symptoms:

Fatigue, pale skin, loss of appetite, pica and growth delays.

Behavioural Issues:

Increased irritability and decreased attention span.

Other Symptoms:

Decreased immunity, sleep disturbances, brittle hair/nails and fast heartbeat.

Assessment

Causes of iron deficiency range, but it’s important to detect the cause in the assessment. Possible causes include the following:

 

  • Depletion of Iron Stores in the second half of infancy occurs when the iron content of the weaning diet is poor, even though deficiency may not be evident until 12 months of age.
  • The early introduction of cow’s milk as a main drink before 12 months of age can also be a contributing factor, hence there is reason to consider whether the WHO's recent update on complementary feeding should be applied to the UK.
  • Availability and choice of baby foods may also contribute to iron deficiency, especially for Muslim families where there is a limited range of halal meat-based products.
  • An overdependence on milk (consuming more than 400mls/day) in toddlers and preschool children, where it replaces iron rich foods.
  • In older children, deficiency occurs most commonly in teenage girls who have commenced menustrationg and have higher iron requirements and in children who are vegetarian or vegan and are struggling to follow a balanced diet.

Screening and diagnosis

  1.  Full blood count (FBC): Key for diagnosing anaemia by evaluating haemoglobin levels. Anaemia is defined as Hb level two standard deviations below the normal for age and sex.(3) In children aged 12-14 years, this is below 120g/L. For women over 15 years it's 120g/L and men over 15 it's Hb below 130g/L.

 

 2. Serum ferritin: Most reliable for assessing iron stores, with <30 μg/L indicating low iron. This can confirm the diagnosis of iron deficency. However, there are some caveats to this, for example, if infection or inflammation is present, levels can be high even with iron deficiency.(3)

Treatment

It’s important that the medical team investigate any other underlying causes of anaemia, but these investigations should not delay the starting of treatment.(4)

Medical treatment

Iron supplementation: Ferrous fumarate, gluconate, sulfate, or sodium feredetate are commonly prescribed. Dosage and duration depend on the severity of deficiency and the patient’s response to treatment.

Please note that iron supplementation may also be required to produce an optimum response to erythropoietin in iron-deficient children with chronic renal failure,or in preterm neonates.(4)

Monitoring: Iron levels are reassessed two to four weeks after starting supplementation, and treatment continues for three months after correction.

Iron levels usually return to normal within one to two months. However, if there is no response to supplementation, then a referral to a specialist medical team will be made.

If responding well, this treatment is usually continued for three months after the iron deficiency is corrected to make sure blood levels remain stable and build up the store of iron in the body.(3)

Some of the common side effects of these medications include black stool, constipation, gastrointestinal discomfort and nausea.(4)

Iron can be administered parenterally but is reserved for use when oral therapy is unsuccessful because the child cannot tolerate oral iron or does not take it reliably, or if there is continuing blood loss, or in malabsorption.(4)

 

Dietetic treatment

Dietitians should promote the following:

  • Iron-rich foods: Include red meats, dark poultry, fish, eggs, legumes and fortified cereals.
  • Enhancing absorption: Vitamin C-rich foods (like citrus fruits) should be consumed with iron-rich meals.
  • Avoid inhibitors: Tea, coffee and excessive dairy during meals can hinder iron absorption.

Iron-rich meals to suggest:

  • Spaghetti Bolognese
  • Shepard’s pie
  • Baked beans on toast
  • Kidney bean chilli with rice
  • Iron-fortified cereals or porridge with fruit or a glass of fresh orange juice

Iron-rich snacks to suggest:

  • Hummus with breadsticks and vegetable crudites
  • Trail mix of dried figs or apricots with mixed nuts (please note that this should only be suggested to children over 5the age of five)
  • Peanut butter on rice cakes or crackers
  • Hard boiled eggs
  • Roasted chickpeas

Fortified foods and gluten-free fortified foods Database Table

Want to know more about fortified products in iron and calcium (including gluten-free products)? We have released a brand-new database for this!
Some foods may surprise you...

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Recent Research in This Area

  1. Berger MM, Shenkin A. Micronutrient deficiency and supplements in schoolchildren and teenagers. Curr Opin Clin Nutr Metab Care. 2024 May 1;27(3):266-274. doi: 10.1097/MCO.0000000000001027. Epub 2024 Mar 8. PMID: 38462972.

  2. Gruda Sussman R, Baker JM. An urgent appeal to paediatric primary caregivers to help prevent severe iron deficiency anemia in toddlers. Paediatr Child Health. 2023 Mar 22;29(4):209-210. doi: 10.1093/pch/pxac089. PMID: 39045470; PMCID: PMC11261818.

  3. Svensson L, Chmielewski G, Czyzewska E, Domellöf M, Konarska Z, Piescik-Lech M, Späth C, Szajewska H, Chmielewska A. Effect of Low-Dose Iron Supplementation on Early Development in Breastfed Infants: A Randomized Clinical Trial. JAMA Pediatr. 2024 Jul 1;178(7):649-656. doi: 10.1001/jamapediatrics.2024.1095. PMID: 38739382; PMCID: PMC11091819.

  4. Perera DN, Palliyaguruge CL, Eapasinghe DD, Liyanage DM, Seneviratne RACH, Demini SMD, Jayasinghe JASM, Faizan M, Rajagopalan U, Galhena BP, Hays H, Senathilake K, Tennekoon KH, Samarakoon SR. Factors affecting iron absorption and the role of fortification in enhancing iron levels. Nutr Bull. 2023 Dec;48(4):442-457. doi: 10.1111/nbu.12643. Epub 2023 Nov 15. PMID: 37965925.

  5. da Silva Lopes K, Yamaji N, Rahman MO, Suto M, Takemoto Y, Garcia-Casal MN, Ota E. Nutrition-specific interventions for preventing and controlling anaemia throughout the life cycle: an overview of systematic reviews. Cochrane Database Syst Rev. 2021 Sep 26;9(9):CD013092. doi: 10.1002/14651858.CD013092.pub2. PMID: 34564844; PMCID: PMC8464655.

Fact file references

  1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4462328/
  2. National Diet and Nutrition Survey (publishing.service.gov.uk)
  3. https://cks.nice.org.uk/topics/anaemia-iron-deficiency/
  4. https://bnfc.nice.org.uk/treatment-summaries/anaemia-iron-deficiency/

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