| Anemia is usually diagnosed when your Pediatrician does a routine blood test at a well child visit, usually at or before the nine month old checkup and again in adolescence. If this blood test is low, you may be told that your child has a 'low iron level' or that 'his iron is low,' but that usually isn't totally accurate. What is usually being checked is your child's hematocrit, which is low in children with anemia.
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| A low iron level is the most common cause of anemia in children |
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So why did your Pediatrician say that your child's iron was low? It is because having a low iron level is the most common cause of anemia in children. It is standard practice to empirically treat most children with uncomplicated anemia (especially if the MCV is low (microcytic anemia)) with a one month course of a daily iron vitamin (a therapeutic iron trial). The blood counts are then rechecked in a month and if they have gone up, then the diagnosis of iron deficiency is confirmed. If the blood counts did not go up after being on supplemental iron for a month, then further testing is done, which may include a complete blood count, iron level, total iron binding capacity (TIBC), ferritin level and a reticulocyte count. Other testing can include a lead level, a blood smear (in which the labs looks at the blood cells under a microscope to look for abnormalities), a hemoglobin electrophoresis, and/or a stool guiac test to see if blood is being lost in your child's bowel movements.
If a CBC (complete blood count) was done, then there are other clues that would favor a diagnosis of having a low iron level, including having a low MCV (microcytic anemia), which measures the size of the red blood cells, a high RDW (which measures the variability in the size and shape of red blood cells) and a low red blood cell (RBC) count. These measurements are not available in all Pediatrician's offices, it depends on the type of testing that they do. If they just perform a 'spun hematocrit' then the MCV and RDW may not be available.
A newer test should be more widely available soon, and should make it easier to diagnose iron deficiency anemia. By checking the reticulocyte hemoglobin content, iron deficiency may also be diagnosed earlier. The reticulocyte hemoglobin count drops very early in iron deficiency, often before the child is even anemic.
Another common cause of mild anemia in children, especially with a normal MCV and no other symptoms, is a recent infection, such as an ear or sinus infection, which can cause decreased production of red blood cells for a short period of time (usually about a month).
If your child doesn't have any risk factors for having iron deficiency (see below), and has a mild anemia without symptoms and has a normal MCV (normocytic anemia), then his blood counts may just be rechecked in a month or so without beginning empiric treatment with iron, especially if he has had a recent infection.
It is usually a much more urgent problem if a child has severe anemia that is causing symptoms, such as a fast heart rate or respiratory rate, heart murmur, decreased energy level, fainting, having an enlarged liver (hepatomegaly), or jaundice. Children with anemia who are symptomatic should be quickly evaluated for the cause and to begin treatment.
Iron Deficiency Anemia
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| Iron deficiency can lead to many problems, including learning disabilities and behavior problems. |
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Anemia in children is usually caused by having an iron deficiency. The low iron in the body causes blood counts to be low and can cause your child to feel tired, have pale skin, and be irritable and weak. It can lead to many problems, including learning disabilities and behavior problems.
The most common cause of iron deficiency is having a diet that doesn't have enough iron in it. This can be caused by using a low iron formula, not supplementing breast milk or formula with an iron fortified cereal, not eating foods that are rich in iron and most commonly, by drinking too much milk. Regular cow's milk does not contain very much iron in it and it can actually prevent your child from absorbing other sources of iron in his intestines. Too much milk can also cause your child too loose small amounts of blood in his stool.
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| Foods rich in iron include meat, beans, spinach and other foods that say they are iron fortified. |
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Treatments for iron deficiency anemia includes taking an iron vitamin and improving the dietary intake of iron. Foods rich in iron include meat, beans, spinach and other foods that say they are iron fortified. It is best to give iron vitamins with orange juice, because Vitamin C can help the iron be absorbed. Do not give iron vitamins with cow's milk.
It is important that your doctor rechecks your child's blood counts about one month after he has started treatment to make sure it is working and the anemia is resolving.
Other causes of anemia in children
Although iron deficiency is a common cause of anemia in children, there are many other conditions that can also cause anemia, including those that cause a decreased production of red blood cells, an increased destruction of red blood cells or from blood loss (bleeding).
Conditions that cause anemia from a decreased production of red blood cells (and which will have a low reticulocyte count), in addition to iron deficiency, include:
- lead poisoning. Should be considered in children at risk of lead poisoning (take our Lead Screening Quiz to see if your child has any risk factors).
- thalassemias, which are inherited disorders that can be mistaken for iron deficiency, because they can also cause a microcytic (low MCV) anemia. If your child has a microcytic anemia that does not improve with iron therapy, then a thalassemia should be considered. Although certain thalassemias can cause severe anemia, in most cases it just causes a mild anemia that does not cause any symptoms and does not require treatment. Testing for thalassemia includes a hemoglobin electrophoresis. Beta thalassemias are most common in people of Mediterranean and African descent. Alpha thalassemias are most common in African-Americans and people of Asian descent.
- chronic disease. Many chronic illnesses can lead to anemia.
- Vitamin B12 deficiency (sometimes associated with being on a strict vegetarian or vegan diet) and/or folate deficiency (most common in children that goat's milk). These conditions are associated with a raised MCV (macrocytic anemia).
- red cell aplasia, including transient erythroblastopenia of childhood (TEC).
- aplastic anemia
- malignant disease, including leukemia (usually also associated with a low platelet count and an abnormal white blood count) and other symptoms.
Conditions that cause anemia from an increased destruction of red blood cells (and which will have a normal reticulocyte count), include:
- sickle cell anemia and other conditions that cause a defect in hemoglobin, including Hemoglobin E, which is prevalent in populations from south east Asia
- other defects of the red blood cells, such as membrane defects (hereditary spherocytosis or elliptocytosis), or enzyme defects (glucose-6-phosphate dehydrogenase deficiency or G-6-PD and pyruvate kinase deficiency)
- hemolytic anemia
Anemia from blood loss can be secondary to trauma and active bleeding or from prolonged or excessive menstrual bleeding (which can also cause an iron deficiency anemia).
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