A guide for health professionals working with
immigrant and refugee children and youth

Iron Deficiency and Iron Deficiency Anemia

Key points

  • All newly arrived refugee, internationally adopted and immigrant children from resource-poor countries should have complete blood count (CBC) testing for initial screening of iron deficiency anemia. 
  • Iron deficiency anemia incidence is high among refugee children, and it is the most common nutritional deficiency worldwide.
  • Dietary deficiency is the most common cause of low iron. Chronic infections and disease, notably recurrent malaria and parasitic infections, can compound anemia.
  • Iron deficiency can cause delayed cognitive and physical development, poor acquisition of language and learning skills, and increases risk of infection in children and adolescents.
  • All children who have iron deficiency anemia should be treated with therapeutic iron, but they must be screened for hemoglobinopathy before starting therapy.

Prevalence

Iron deficiency is the most common nutritional deficiency worldwide.1 It affects one-half of children living in low-resource countries and the reported prevalence of its consequence – anemia – is also high among refugee children.1 Iron deficiency among children who were long-term African refugees has been estimated to be from 23 to 75%.2

Definition

Table 1: Definitions of mild, moderate and severe anemia based on hemoglobin levels

 

Anemia, hemoglobin level g/L

 

Healthy range

Mild

Moderate

Severe

Children 6 to 59 months

≥ 110

100–109

70–99

< 70

Children 5 to 11 years

≥ 115

110–114

80–109

< 80

Children 12 to 14 years

≥ 120

110–119

80–109

< 80

Non-pregnant women (≥ 15 years)

≥ 120

110–119

80–109

< 80

Men (≥ 15 years)

≥ 130

110–129

80–109

< 80

Pregnant women

≥ 110

100–109

70–99

< 70

Source: Adapted from World Health Organization. Haemoglobin concentrations for the diagnosis of anaemia and assessment of severity. Vitamin and Mineral Nutrition Information System.Geneva, Switzerland: WHO, 2011 (WHO/NMH/NHD/MNM/11.1). 

Etiology

The most common cause of iron deficiency is dietary insufficiency, caused by poor bioavailablity of iron in food or factors relating to poor absorption. Non-dietary factors may play a contributing role for anemia, such as parasitic infections, recurrent malaria, and chronic infections.1 Other chronic conditions, notably hereditary anemias (e.g., sickle cell, thalassemias), are exacerbated by iron deficiency. 

Consequences

Iron deficiency can lead to delayed cognitive and physical development, poor acquisition of language or learning skills, and increases risk of infection in children and adolescents.1

Screening

All newly-arrived refugee, internationally adopted and immigrant children from resource-poor countries should have a complete blood count (CBC) test for initial screening of iron deficiency anemia. An infant found to be anemic should have a serum ferritin test, which reflects body iron stores. It is one of the earliest indicators of depleted iron levels,3 but results may be elevated by the presence of inflammatory disease and mask iron deficiency. Children coming from endemic areas or of ethnicities at risk should have hemoglobinopathy testing (high-performance liquid chromatography [HPLC], or hemoglobin analysis [e.g., Hb electrophoresis]) and be screened for G6PD levels if from endemic regions such as the Mediterranean, Africa and Asia. 

Treatment

Clinicians need to take a complete dietary history for children with iron deficiency anemia, and offer dietary education to newcomer families on culturally appropriate foods with a high iron content.

All children who have iron deficiency anemia should be treated with therapeutic iron but must be screened for hemoglobinopathy before starting therapeutic levels.

Children with hemoglobinophathies may also have iron deficiency and must be monitored closely to prevent iron loading.

Ferrous sulfate treatment

Children with anemia or low ferritin should receive iron at a treatment dose. Elemental iron is available in several forms such as ferrous sulfate or fumarate. To avoid confusion it should be ordered as elemental iron, specifying the quantity of drops, syrup, or tablets. Dose of elemental iron is 4 mg to 6 mg/kg/day divided q8–24h for 2 to 4 months. CBC and ferritin levels need to be closely monitored during this time.

Table 2: Treatment of iron deficiency in children and adolescents by weight

Weight, kg

Daily iron dose, mg elemental iron

Fer-in-Sol drops* (15 mg/mL)

Fer-in-Sol syrup*
(6 mg/mL)

Tablets*
(60 mg/tab)

PALAFER syrup†
(20 mg/mL)

FeraMAX
(15mg in ¼ tsp of powder or 150mg capsule)

2.5–4

15

0.5 mL bid

1 mL bid

 

0.5 mL bid

¼ tsp daily

5–9

30

1 mL bid

2.5 mL bid

 

0.5 mL tid

½ tsp daily

10–19

60

2 mL bid

5 mL bid

 

1.5 mL bid

1 tsp daily

20–29

120

 

10 mL bid

1 tab bid

3 mL bid

1 tsp BID

30–49

160–180

 

 

1 tab tid

4 mL bid

1 capsule daily

> 50

180–240

 

 

1 tab tid or qid

5 mL bid

2 capsules daily

*Elemental iron. Ferrous sulfate content: drops 75 mg/mL, syrup 30 mg/mL, tabs 300 mg/tab.

†Elemental iron. Ferrous fumarate content: 60 mg/mL.

Selected resources

References

  1. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic Infectious Diseases. Guidelines for evaluation of the nutritional status and growth in refugee children during the domestic medical screening process. Bethesda, MD: CDC, April 2012.
  2. Seal AJ, Creeke PI, Mirghani Z, et al. Iron and vitamin A deficiency in long-term African refugees. J Nutr 2005;135(4):808-13.
  3. Zlotkin S. Clinical nutrition: 8. The role of nutrition in the prevention of iron deficiency anemia in infants, children and adolescents. CMAJ 2003;168(1):59-63.

Editor(s)

  • Anna Banerji, MD
  • Andrea Hunter, MD

Last updated: September, 2016

Also available at: http://www.kidsnewtocanada.ca/conditions/iron
© 2017 Canadian Paediatric Society.
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Caring for Kids New to Canada is a resource for health professionals. The information here is not a substitute for medical advice, nor does it indicate an exclusive course of treatment or procedure to be followed. Variations, taking into account individual circumstances, may be appropriate.

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