Pediatric Hfinatotog; and Otu.otogt. 21: .

521-534, 2004
Copyright Taylor X: Fninci.s Inc.
ISSN: 0888-0018 prim / I521-0C69 online
DOI: 10.1080/08880010490477310

^ TaylorStFrancis
TP healthsciences

CLINICOLABORATORY FINDINGS AND TREATMENT

OE IRON DEEICIENCY ANEMIA IN CHILDHOOD

John P. Panagiotou, MD D Department of Pediatric Hematology-Oncology,

"Aghia Sophia" Children's Hospital, Athens, Greece
Konstantinos Douros, MD D Department of Pediatrics, "Thriassion" General
Hospital, Athens, Greece
D One of the major cau.ses of anemia in childhood xuorldwide is iron deficiency. Its prevalence
depends mainly on age, being higher in infancy and adokscence. Its etiology vanes, but poor iron
diet is considered the commonesl causative factor. Belter ladies may be needed, like the targeted
screening of children who belong to high-risk groups, to eradicate childhood iron deficiency. The
amount of the body iron regulates its absorption from the gut through mechanisms that are still
poorly understood. Early identification of iron deficiency is essential for the prevention not only of
anemia but also the numerous and long-term consequences caused by the lack of iron. Many tests are
available for the diagno.sis of the disease. Some of them seem very promising for the early detection of
iron deficiency, but further research is needed before they become widely acceptable in clinical practice.
Treatment is based on oral iron salts, which do not have any serious side effects.

Keywords, childhood, etiology, iron-deficiency anemia, prevention, treatment

Iron is an essential nutrient well known to the ancient Greeks, and it was
recognized as a blood component more than 200 years ago [1]. Iron deficiency is the single most common nutritional disorder worldwide and the
leading cause of anemia during infancy and childhood [2]. Its appearance
in early childhood, especially if severe and prolonged, can adversely affect
behavior and psychomotor development, side effects that may not always be
fully reversible even with complete correction of iron deficiency [3].
This article reviews the epidemiology, etiology, clinical manifestations,
laboratory findings, diagnosis, treatment, and prevention strategies of irondeficiency anemia during the whole childhood.
DEFINITION OE IRON DEEICIENCY ANEMIA (IDA)
Anemia is a relatively common finding and correct diagnosis can usually
be established with relatively little discomfort for patient and little laboratory
cost. Finding the cause is always important.
Received 21 October 2003; accepted 27 April 2004.
Address correspondence to John P. Panagiototi, MD, Gennadioti 1, 184 52 Nikea, Athens, Greece.
E-mail: costasdouros@freemail.gr

521

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/. P. Panagiotou and K. Douros

TABLE 1 Values for Hemoglobin, Hematocrit, Retictilocytes, and MCV During
Infancy and Ghildhood
Hb (g/dL)

Gord blood
2wk
3 mo
6 mo-6 yr
7-12 yr

Ht 1(%)

MGV

Mean

Range

Mean

Range

lowest

RtG (%)

16.8
16.5
12.0
12.0
13.0

13.7-20.1
13.0-20.0
9.5-14.5
10.5-14.0
11.0-16.0

55
50
36
37
38

45-65
42-66
31-41
33-42
34-40

110

5.0
1.0
1.0
1.0
1.0

70-74
76-80

During infancy and childhood the normal ranges for hemoglobin and
hematocrit levels vary significantly and for this reason diagnosis of anemia
depends on normal values for each examined age (Table 1). A characteristic
example is that of normal neonates who show an increased hemoglobin level
after birth (15-22 g/dL), whereas, during infancy, under normal circumstances, have hemoglobin level as low as 10 g/dL, while premature infants
can reach a nadir hemoglobin level of 7-8 g/dL in the 8th-10th postnatal
week [4]. Thereafter, the normal values gradually increase until adult values
are reached after puberty.
Iron deficiency represents a total-body iron deficit, resulting from imbalance between iron requirements and iron supply. This deficit initially
is compensated by the mobilization of iron stores, which are represented
by ferritin levels. Three successive stages of iron deficiency may be distinguished [46]. Initially, storage iron deficiency is recognized by a decreased
serum ferritin (SF) concentration without any biochemical evidence of iron
deficiency. Later on, iron deficiency results in low serum ferritin (below
12 Mg/L) and iron concentration, progressive rise in the concentration of
serum-transferring receptor (TfR), increase in free erythrocyte protoporphyrin (FEP), and low serum transferrin saturation. During this period,
erythropoiesis becomes affected, although hemoglobin levels remain within
normal limits. Finally, anemia occurs when the supply of iron to the bone
marrow is sufficiently impaired presenting with a decrease in Hb concentration below of the 5th percentile of the reference range for age and sex. At
the same time, there is a decrease in the synthesis of iron metalloenzymes,
which are vital components of many metabolic pathways.
EPIDEMIOLOGY OE IDA AND IRON METABOLISM

The prevalence of IDA varies widely depending on a variety of factors,

such as the age, ethnic composition, socioeconomic status, dietary habits,
and the criteria used to establish the diagnosis [5]. In general, IDA is most
common among children aged 6 months to 3 years, its prevalence drops
among school-age children, but increases again during adolescence [7].

Iron-Deficiency Anemia in Childhood

523

Normal-term infants are born with sufficient iron stores, having approximately 75 mg of elemental iron per kilogram of body weight [8], Totalbody iron changes vary little for the first 4 months of life so there are no
increased requirements during this period. In addition, the reduction of Hb
levels from 18 g/dL at birtb to 14 g/dL during the first 2 weeks of life releases iron, which is stored and gradually reused. Good absorption of human
milk and the increased use of iron-fortified formula, especially in developed
countries, fulfill the iron requirements in these ages, resulting in reduction
of cases with IDA during the first 4 months [9, 10], However, infants who
continue to receive only breast milk after the first 6 months of life are at increased risk. Also at risk are infants who, despite current policy, switch from
an infant formula to whole cow's milk before the age of 1 year [11], Between 4 and 12 months total-body iron increases by about 130 mg and an
external source of iron is necessary. If this is not met, iron deficiency and
subsequently IDA develop after the age of 1 year [12],
The highest prevalence of IDA occurs in toddlers and adolescents because the increment in hemoglobin iron per unit of body weight is greatest
at these ages [7, 12], The prevalence drops among school-age children but
increases again during adolescence [5], Factors that are implicated in this increase are mainly the dietary characteristics of adolescents. Many girls try to
control their weight and inadvertently limit iron intake, while many adolescents pass through a temporary period of vegetarianism because of concerns
with animal welfare. Moreover, athletic performance may lead to blood loss
from the gut and urinary tract, so athletic girls who have passed menarcbe
and are trying to slim may be at particular risk of iron deficiency [13],
IRON METABOLISM
Tbe human body contains about 3-4 g of iron [14], Iron is absorbed
mainly in tbe duodenum and upper jejunum, is transported in blood by
transferrin, and it is found either biologically active (70-90%) or stored
(10-30%), Tbe former is found mainly incorporated in hemoglobin, and
the latter in the reticuloendothelial cells (bone marrow, liver, spleen) as ferritin, a labile and readily accessible source of iron, or in an insoluble form
as bemosiderin [15],
The amount of iron absorption increases when iron deficiency exists,
while when stores are high, much of the iron absorbed by the mucosal cells
is returned into the intestinal lumen by desquamation [16], Although the
entire process of the regulation of iron absorption is still poorly understood, three ways are being considered [17], Tbe first is by dietary iron.
Following an oral iron load, the absorption rate diminishes even if there
is a systemic iron deficiency. It is believed that the intracellular accumulation of iron decreases further absorption. The second way depends on the

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/. P. Panagiotou and K. Douros

total-body iron stores and is termed the stores regulator. It works with a mechanism still unknown and is capable of increasing iron absorption by only 2-3
times. It has been postulated that the saturation of circulating transferrin
affects the iron "set point" of developing duodenal enterocytes. The third
way is the erylhropoielic regulator. Through this mechanism the iron absorption can be increased greatly in cases of ineffective erythropoiesis, even in
cases where an iron overload exists, Tbalassemia, sideroblastic anemia, and
other congenital disorders of red cell maturation are some examples. It is
worth mentioning that such an increase in iron absorption does not happen
in cases of anemias that are characterized by peripberal destruction, sucb as
sickle cell and autoimmune hemolytic anemias. The mediator of this procedure remains unknown.
Additional factors that influence tbe absorption rate are the composition
of the diet and the efficacy and integrity of the mucosa of the upper small
bowel [18], Tbere are two kinds of iron in the diet with respect to the mechanism of absorption, heme and nonheme, utilizing two different receptors
on the mucosal cells, Heme iron, found in meat, poultry, and fish, constitutes about 5-10% of the daily iron intake in most industrialized countries,
and is highly bioavailable, being 2-3 times more absorbable than nonheme
iron. Its absorption is less influenced by body iron stores, and the only dietary factor that negatively acts on the absorption procedure is calcium [19,
20], Within the mucosal cells, an enzyme splits heme, releasing iron into the
circulation.
The main sources of nonbeme iron are plant-based foods, eggs, and ironfortified foods, primarily in the form of ferric complexes [21], In the process
of digestion, the iron is reduced from tbe ferric to the ferrous form, which is
more readily absorbed. Its absorption is enhanced by ascorbic acid and hydrochloric acid, and inhibited by phytates (in bran), polyphenols (in certain
vegetables and legumes), tannins (in tea), calcium, and pbosphate (in high
concentration in unmodified cow's milk) [16, 22],
After having been absorbed by the enterocytes, the iron must cross the
serosal membrane to enter the circulation. Studies in animals have shown
that a protein similar to ceruloplasmin is probably responsible for this transport [14, 23], Once iron has traversed the serosal membrane it is bound to
transferrin, wbicb is its main vebicle in tbe serum and extracellular fluid.
The transferrin-iron complex beads for the marrow and liver through the
circulation, Transferrin's high affinity for iron protects the body from free
iron, but has the drawback of competing witb iron cbelators. This is the reason why the development of efficient and easy to use chelators is a difficult
task.
The transferrin-iron complexes attach to transferrin receptors, which
are found on every nucleated cell's surface. Liver, placenta, and developing red cells are equipped with large numbers of sucb receptors. After tbe

Iron-Deficiency Anemia in Chitdhood

525

new complexes of transferrin-iron-transrerrin receptor have been formed

on cell surface, tbey are internalized into endosomes, Tbese endosomes undergo acidification, and when the pH is <6 transferrin both loses its iron and
becomes more tightly bound to transferrin receptor. Finally, the transferrin's
molecules return to the circulation, whereas iron exits the endosome and either incorporates into enzymes or is stored in the ferritin molecules [24],
Ferritin is the major device cells use to store iron. It consists of 24 similar
subunits, which form a kind of cage. Up to 4500 iron molecules can congregate in the cavity of this cage [25], The regulation of iron mobilization from
ferritin still remains obscure, altbough a lot of research has been focused
on tbis matter recently [26], Opening tbe ferritin pore for iron release by
mutation of conversed amino acids at interhelix and loop sites [27],
About 80% of tbe circulating iron, through a similar pathway, is utilized
by the developing red cells for the hemoglobin formation [17], Tbe circulating red cells at tbe end of their life span either are lysed, releasing their
hemoglobin in tbe plasma, or are taken up by macropbages in tbe spleen,
liver, and bone marrow, Hemopexin and haptoglobin are the plasma proteins responsible for binding free heme and hemoglobin, respectively. The
complexes that are formed are finally taken up by hepatocytes through endocytosis [17], As for the red cells that were removed by macrophages, they
undergo intracellular processing. The procedure ends with the release of
iron in the circulation and its conveyance to the liver with transferring [24],
ETIOLOGY

Though various factors may cause IDA, nutritional factors are the most
frequent causes in infancy and childhood (Table 2), Rapid growth during
the first 2 years of life and again during adolescence under conditions of
either decreased or deficient iron uptake may result in IDA, More vulnerable
are preterm infants and twins, baving botb lower iron stores at birth and a
more rapid growth. Their blood volume expansion may be so rapid that their
iron stores may be depleted by 2-3 months of age. Proportional growth spurt
occurs during adolescence and increased iron requirements are needed to
maintain positive balance [5], Especially for adolescent girls, there is more
need for iron because of menstrual blood loss, which is about 40 mL (20 mg
iron) per period [28],
Poor iron diet is a major etiologic factor to the development of IDA,
Both breast and cow's milk bave low levels of iron, containing less than 0,31 mg/L, The iron content of human is highest in early transitional milk
(0,97 mg/L) [29] but decreases steadily during lactation, reaching a level
of approximately 0,3 mg/L by tbe age of 5 months [30], It is important to
stress the high bioavailability of breast milk, possibly because of tbe lower calcium content and the presence of lactoferrin [22], Nevertheless, prolonged

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/ P. Panagiotou and K. Douros

TABLE 2 Causes of Iron-Deficiency Anemia in Children
Increased physiologic demands
Rapid growth
Blood loss (hemorrhage)
Menstrual
Castrointestinal
Pulmonary
Perinatal
Urinary
Inadequate iron intake
Prolonged exclusive breast feeding
Decreased availability and/or bioavailability of dietary iron
Malabsorption
Extended gastrointestinal surgery
Tropical and nontropical sprue
Defective plasma iron transport
Congenital atransferrinemia
Defective transferrins

breast-feeding without iron supplementation may lead to IDA in 30% of

these infants at 12 months of age [31].
Malabsorption of iron is an uncommon cause of IDA in children. Extended gastrointestinal surgery or nosologic syndromes such as tropical and
nontropical sprue may result in impaired iron absorption and IDA [32].
Blood loss is another important factor, with miscellaneous etiology, which
may cause iron deficiency and subsequently IDA. In infants and older children the commonest causes of chronic IDA from occult bleeding are lesions
of the gastrointestinal tract (e.g., peptic ulcer and Meckel's diverticulum),
consumption of whole cow's milk in infants younger than 12 months, pulmonary hemosiderosis, and hookworm infestation [5, 12].
Very rarely, IDA may result from congenital atransferrinemia or defective transferrins. Congenital atransferrinemia is inherited as an autosomal
recessive disorder in which absorbed iron is either free or loosely bound
to plasma proteins other than transferrin. Moreover, the uptake of iron by
normoblasts is insufficient and much of the iron is taken by the liver [4].
Defective transferrin molecules is an extremely rare condition that disrupts
the delivery of iron to the bone marrow with resultant IDA [4].
CLINICAL AND LABORATORY FINDINGS

Symptoms and signs of IDA vary with the severity of the deficiency and
are often nonspecific. Mild IDA is usually asymptomatic. In infants with more
severe IDA pallor, irritability, fatigue, and delayed motor development are
common, while in the case of feeding with unfortified cow's milk they may
be fat and flabby with poor muscle tone. In older children pallor is the

Iron-Deficiency Anemia in Childhood

527

most frequent presenting feature and is accompanied by weakness, dizziness,

easy fatigability, irritability, and anorexia, while a history of pica is common.
In severe IDA, diaphoresis, dyspnea, tachycardia, soft ejection systolic flow
murmurs, and cardiomegaly may occur [33]. IDA may also produce general
clinical manifestations that do not have any association with iron deficiency,
such as headache, paresthesia, angular stomatitis, and gastric atrophy. Also,
blue sclerae might be an extra sign due to impairment of collagen synthesis with resulting thinning of the sclerae [34]. Very rare complications of severe pediatric IDA are Plummer-Vinson syndrome (postcricoid eosophageal
web, glossitis, dysphagia), atrophy of skin, and koilonychias [8, 35].
A matter of great interest is the proven associations of numerous conditions with IDA, especially during the first 2 years of life. First, numerous
studies have shown the existing association of delayed psychomotor development with IDA due to either low brain iron and reduced neurotransmitter
level or systemic effects of hypoxia [36]. One recent study showed that adolescents who were iron deficient as infants had diminished performance on
a number of tests of cognition, attention, and motor function, compared
with those who had not been iron deficient as infants [37]. Second, chronic
severe iron deficiency is often associated with reduced growth rate, especially among preschool children, and several studies have shown that iron
supplementation improves physical growth [38]. Third, geophagia or compulsive eating of dirt (pica) is more common in iron-deficient children [39],
and considerable evidence suggests that iron deficiency is usually the cause
and pica the consequence [40]. It is notable that iron therapy is followed
by an abrupt loss of pica. Fourth, iron deficiency is known to adversely affect immune functions by causing decreased myeloperoxidase activity, reduced bactericidal capacity, a quantitative decrease in the number of circulating T cells, impaired mitogenic response, and poor natural killer activity
[30].
The severity of anemia depends on the degree of iron deficiency, and
the Hb level may be as low as 3-4 g/dL. Typically in IDA, Hb and MCV are
reduced, red cell distribution width (RDW) is increased (i.e., microcytosis
and anisocytosis), and the shape of the cell cytogram scatter is moved down
and to the left with a large proportion of cells in the hypochromic microcytic zone [12]. The relative number of reticulocytes is usually normal or
slightly elevated, but the absolute reticulocyte count is often low, indicating
an insufficient response to anemia [41]. The white blood cell count is usually normal, while platelet count varies from thrombocytopenia to thrombocytosis. In general, thrombocytosis is associated with blood losses, whereas
thrombocytopenia often is associated with more severe anemia [5].
Regarding the iron status in IDA, low serum iron, elevated total ironbinding capacity (TIBC), and decreased transferrin saturation are found.
TIBC reflects the total amount of transferrin available in the blood, and

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J. P. Panagiotou and K. Douros

levels greater than 400 /xg/dL suggest iron deficiency, whereas values less
than 200 /ig/dL characterize inflammatory diseases [5]. The role of these
tests in the diagnosis of IDA should be reevaluated because of their unpredictable variability and relative insensitivity [42-44].
Ferritin and serum-transferrin receptor (sTfR) are more sensitive indicators of early iron deficiency. Both undergo a gradual change as iron stores
decrease from normal levels to those found in IDA. The continuous process
of iron depletion passes through 3 stages. The first stage, where a progressive
decrease in serum ferritin takes place, represents the depletion of storage
iron compartments. The sTfR, which reflects the functional iron compartments (i.e., hemoglobin, myoglobin, cytochromes, etc.), remains stable. The
second stage is characterized by the depletion of functional iron compounds
and the beginning of iron-deficient erythropoiesis (IDE). The indicator of
this phase is the elevated concentration of sTfR. Finally, the third stage begins with the fall of Hb below the lower normal limits due to the continuing
IDE, and, as a consequence, IDA ensues.
Ferritin measurements have been used to distinguish normality from
IDA, so the reference limits have been designed for this purpose. Disagreement still remains on the value of ferritin that indicates clinically relevant
storage iron depletion. This is chiefly attributed to the large physiologic
variability occurring between individual patients [46, 47]. Another confusing factor is that ferritin is a well-known acute phase reactant that rises in
inflammatory diseases [46, 48]. In any case, levels ranging between 10 and
20 fA-g/h are considered indicative of depletion of iron stores, while levels
less than 10 fJ.g/h are diagnostic of iron deficiency. In reverse, levels greater
than 50 Mg/L argue against the diagnosis of iron deficiency, even in the
presence of other conditions that may cause an elevation of the ferritin level
[5].
The functional iron status can be estimated better with the measurement of sTfR instead of ferritin. Apart from that, sTfR is not an acute phase
reactant, so its concentrations remain unchanged in inflammatory diseases
[45, 49]. Its day-to-day fluctuation is limited, so it is much more acceptable
than other conventionally used indices, as, for example, transferrin saturation [50]. sTfR concentrations exceeding 2.75 mg/L, but not 3.6 mg/L,
are deemed to define those having depletion of the functional iron compartment leading to IDE, whereas sTfR levels above 3.6 mg/L indicate IDA
[45,49].
As mentioned above, serum ferritin reflects the storage iron compartment, whereas sTfR reflects the functional iron compartment. These two
indices can be combined in the sTfR/log ferritin ratio (TfR-E index), which
is very useful for the estimation of the entire range of body iron stores
[51]. A ratio of 1.8 or greater indicates storage iron depletion, whereas 2.2
or greater indicates IDE. Some evidence suggests that this index might be

Iron-Deficiency Anemia in Childhood

529

sensitive enough for the detection of iron-deficient states in cases where ferritin and sTfR are borderline [45].
A hematologic index currently in use for the assessment of functional
iron status is the measurement of hypochromic red cells (HYPO). Since
erythrocytes have a relatively long life span of about 120 days, the HYPO
index provides information over a several-month period, so it is a late indicator of iron-restricted erythropoiesis [52]. Another noteworthy index is the
reticulocyte Hb content (CHr), which can be used as an early marker of functional iron deficiency (ID), since reticulocytes circulate in the bloodstream
for only 1-2 days [53, 54]. Unfortunately, the aforementioned hematologic
indices have two major drawbacks. First, they are available only on analyzers
from a single manufacturer and, second, various cutoff values for functional
ID have been reported in literature, ranging from 2 to 10% for HYPO and
23 ng to 29 ng for CHr [52, 53, 55, 56].
Another investigation, as diagnostic or screening method, is the level of
free erythrocyte (EPP) or zinc (ZPP) protoporphyrin. EPP reflects the adequacy of iron delivery to the erythroid precursors in the bone marrow. Its
level is increased in IDA, and values greater than 3 A'-g/g of Hb are considered abnormal [57].

DIFFERENTIAL DIAGNOSIS

Although no single test can reliably document iron-deficiency, in many

cases, low values of Hb-MCV-MCH and high values of RDW-EPP provide
strong supportive findings. So the differential diagnosis includes other
hematologic diseases that are characterized by hypochromia and microcytosis (Table 3).
Thalassemic syndromes, which belong in hypochromic microcytic anemias, should be considered in infants, especially in endemic regions.
Infants with thalassemia have an elevated number of erythrocytes, normal
or increased levels of serum iron and ferritin, while TIBC is normal. The
RDW is usually lower in terms of IDA levels, and using cytometry plots,
the proportion (%) of hypochromic cells is lower than the proportion of
microcytic cells. On electrophoretic studies the HbA2 level is elevated in
TABLE 3 DiiTerendal Diagnosis of Iron-Deficiency Anemia from Other
Hypochromic-Microcytic Anemia
Thalassemic syndromes
Chronic disease
Infection
Cancer
Inflammation
Renal disease

Lead poisoning
Vitamin Bg responsive
Copper deficiency
Sideroblastic anemia (some)

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/. P. Panagiotou and K. Douros

j8-thalassemia minor, but the value is falsely low if iron deficiency coexists.
Therefore, in cases of clinical suspicion repeated testing is necessary after
iron-replacement therapy [5, 12, 58].
The anemia of chronic inflammation or infection is classically normochromic and normocytic, but in about 20-30% of infected children may
be bypochromic. It is the result of a decreased red blood cell survival, diminished reutilization of iron, impaired iron mobilization from macrophages by
transferrin, and decreased intestinal absorption of iron. Characteristic laboratory findings of this disorder should be considered a decreased TIBC, a
normal RDW, an increased serum ferritin level, and a normal serum transferrin receptor level [5, 12, 59]. An elevated serum transferrin receptor level
is characteristic of iron deficiency irrespective of whether the patient has coexisting anemia of chronic disease [60].
SCREENING AND PREVENTION

Strategies for prevention can be achieved by screening tests, avoidance

of blood loss, and by giving supplementary iron or fortification of foods. The
best way to prevent iron deficiency is by dietary interventions. Promotion of a
diet containing more bioavailable iron like red meat, poultry, and fish would
be very efficient for infants and children above 6 months of age. However,
more promising seems to be the fortification of foods with iron. These can be
either staple foods like flour or more specific foods, such as infant formula,
infant cereals, and breakfast cereals. The former would probably help more
adults and adolescents, but the latter would be a continous source of iron
for tbose who are most in need, namely infants and small children [11, 61].
The proper age for screening tests is not apparent and depends on
whether children belong to high-risk groups for IDA. Prematurity, low birth
weight, early consumption of cow's milk, fast growth rate, low-iron diet, and
limited access to food are considered the major risk factors [20]. All these
children must be screened between the ages of 9 and 12 months, and later
between the ages of 1 and 5 years [12]. On the other hand, in populations
not at high risk, only those children with known risk factors need to be
screened [20].
Supplementation is generally not favored for prevention because a toxic
medicine is put into the household and compliance is poor [12]. Additionally, there are a few publications describing slower growth in iron-replete
infants receiving liquid iron supplementation. However, no such adverse effect has been described for iron-fortified foods [62-64]. But there are conditions in which iron administration is necessary and if not given then IDA will
occur. Eull-term or preterm infants who are exclusively breast-fed must start
iron supplementation at 4-6 and 2 months of age, respectively. The dosage
of iron for full-term infants should be 1 mg/kg per day, while for preterm

Iron-Deficiency Anemia in Childhood

531

infants the dosage depends on birth weight and varies between 2 and 4
mg/kg per day. Infants who are not breast-fed should receive iron-fortified
formula up to 12 months of age [57].
Proportional situations may be found among adolescents in whom iron
deficiency is the most common cause of anemia. Surveys reflect an irondeficiency prevalence up to 24% and overt anemia in 10% of high school
students [65]. Also, IDA is a common disorder in the athletes, especially
in girls [66]. Because females, besides having lower Hb levels, tend to have
higher iron losses and, as a consequence, higher prevalence of IDA [67].

TREATMENT PLAN

The goals of treatment of iron deficiency should be twofold: replenishment of body iron stores and correction of underlying diseases. Treatment
is based on oral administration of one of the ferrous salts, among which ferrous sulfate is preferred because of high bioavailability and low cost. It must
be pointed out that ferrous sulfate is 20% elemental iron by weight, and that
optimal response is achieved with a dosage of elemental iron of 6 mg/kg
per day in 2 or 3 divided doses. The medicine must be given between meals
and not with milk. Side effects are uncommon and dose related. The most
frequent are transient staining of teeth, nausea, constipation, diarrhea, and
abdominal pain [67, 68]. Reducing the dosage of the medication or giving
it with food minimizes these side effects.
Apart from oral administration there are parenteral iron preparations
that are alternative solutions in cases of patients noncompliant with oral
therapy or genuine intolerance of oral iron, and in malabsorption situations
compromising gastrointestinal iron absorption. The dosage of iron (mg)
may be calculated by using the following formula: deficient Hb (g/dL) x
body weight (kg) x 0.22. The most severe side effect is anaphylaxis and a
tolerance test must be performed. Other side effects of parenteral administration are nausea, vomiting, abdominal pain, flushing, fever, headache,
malaise, shivering, myalgia, arthralgia, urticaria, lymphadenopathy, pleural
effusion, hypotension, and shock [68]. Intramuscular injection of iron is
painful and may be associated with permanent staining of the skin, muscle necrosis, and sterile abscesses [68]. Iron dextran preparations for intramuscular or intravenous administration have been in use for many years.
Recently, however, there has been concern about their safety since they
have been assosiated with life-threatening reactions [69]. Two new nondextran preparations for intravenous administration are now being tested: iron
sucrose and sodium ferric gluconate complex. Both seem to be associated
with a markedly lower incidence of life-threatening anaphylactoid reactions.
Nonanaphylactoid reactions also seem to be extremely uncommon [70, 71].

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J. P. Panagiotou and K. Douros

The regular response of IDA is an important diagnostic and therapeutic feature. Within 72-96 h after administration of iron peripheral reticulocytosis is noted, which is followed by an increase of Hb levels as much as
0.5 g/dL/day [41]. Failure to respond to iron therapy may be caused by
poor compliance, an inadequate iron dose, an ineffective iron preparation,
ongoing blood loss, coexistent disease resulting in nonabsorption or nonutilization of iron, or a misdiagnosis [41]. Iron replacement should continue
for 3 months more after the Hb level is within the normal range for age and
gender [72].
In conclusion, IDA is the most common anemia in infancy and childhood, which must be differentiated from other microcytic anemias. Strategies for prevention are screening, health education, fiscal measures, food
fortification, and supplementation. Iron fortification of formulas and cereals
is the most effective method of prevention and has reduced the prevalence
of this disease. However, pediatricians should be cognizant of its presence,
especially in high-risk children (preterm infants, children of immigrants or
minorities, etc.).
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