What is the management of anemia (iron deficiency anemia) in babies and children?

Management of Anemia in Babies and Children

For iron deficiency anemia in children, treat with oral ferrous sulfate at 3 mg/kg per day of elemental iron administered between meals, continue for 2-3 months after hemoglobin normalizes, and provide dietary counseling to address underlying nutritional deficiencies. 1, 2

Diagnosis and Confirmation

Before initiating treatment, confirm the diagnosis with repeat hemoglobin or hematocrit testing if the initial screening is positive 1, 2. In a non-ill child with consistent laboratory findings, you can make a presumptive diagnosis of iron deficiency anemia and begin treatment 1, 2.

• Low serum ferritin ≤15 μg/L confirms iron deficiency, while levels >15 μg/L suggest another cause of anemia 1, 2
• Peripheral blood film typically shows hypochromia, microcytosis, and marked anisocytosis in iron deficiency 3
• If available, check mean corpuscular volume (MCV), red cell distribution width (RDW), and serum ferritin for definitive diagnosis 1

Treatment Protocol by Age Group

Infants Under 12 Months

• Standard dose: 3 mg/kg per day of elemental iron drops administered between meals 1, 2
• For exclusively breastfed infants after 6 months with insufficient iron from complementary foods: 1 mg/kg/day iron drops 2, 4
• For preterm or low birthweight breastfed infants: 2-4 mg/kg/day iron drops (maximum 15 mg/day) starting at 1 month of age until 12 months 2, 4

Children Ages 1-5 Years

• 3 mg/kg per day of elemental iron administered between meals 1, 2
• Limit cow's milk to no more than 24 ounces daily 1, 2, 4
• Include iron-rich foods and vitamin C sources with meals to enhance absorption 2, 4

School-Age Children (5-12 Years)

• One 60-mg iron tablet daily plus dietary counseling 1, 2
• Administer between meals for optimal absorption 2

Adolescent Boys (12-18 Years)

• Two 60-mg iron tablets daily plus dietary counseling 1, 2

Medication Selection and Administration

Ferrous sulfate is the preferred iron preparation because it is the most cost-effective and provides known amounts of elemental iron 2, 3. The optimal therapeutic response occurs with dosages of 3-6 mg/kg of elemental iron per day 3.

• Administer iron between meals to maximize absorption, as food can reduce iron absorption by up to 50% 2
• Avoid giving iron within 2 hours before or 1 hour after meals 2
• Do not use iron polysaccharide complex—despite being more expensive, it is no better tolerated and may be less effective than ferrous sulfate 2
• Do not add ascorbic acid supplements, as they do not improve ferrous iron absorption 2
• Aluminum-based phosphate binders reduce iron absorption and should be avoided 2

Monitoring Treatment Response

Recheck hemoglobin or hematocrit in 4 weeks 1, 2. An increase in hemoglobin ≥1 g/dL or hematocrit ≥3% confirms the diagnosis of iron deficiency anemia and indicates adequate treatment response 1, 2.

• If the response is adequate, continue iron treatment for 2 more months after hemoglobin normalizes to replenish iron stores 1, 2
• After completing the 2-month continuation phase, recheck hemoglobin or hematocrit 1
• Reassess hemoglobin approximately 6 months after successful treatment completion 1

If Treatment Fails After 4 Weeks

If anemia does not respond to iron treatment despite compliance and absence of acute illness, perform further evaluation with MCV, RDW, and serum ferritin 1. Consider:

• Non-compliance with medication regimen
• Ongoing blood loss (especially gastrointestinal from excessive cow's milk intake) 5
• Malabsorption issues
• Incorrect diagnosis (thalassemia trait, chronic disease, lead poisoning)

For patients having difficulty tolerating oral iron, start with smaller, more frequent doses and gradually increase to the target dose 2.

Dietary Management

Dietary counseling is essential to correct the underlying problem of low iron intake 1, 2.

For Infants

• Use only iron-fortified infant formula (≥1.0 mg iron/100 kcal) if not breastfeeding 2, 4
• Avoid cow's milk, goat's milk, and soy milk until age 12 months 2, 4
• Introduce iron-fortified infant cereal at 4-6 months with two or more servings daily—this reduces iron deficiency anemia from 15% to 3% compared to non-fortified cereal 2, 4
• Add pureed meats after 6 months or when developmentally ready to provide highly bioavailable heme iron 2, 4
• Include vitamin C-rich foods (fruits, vegetables, or juice) with at least one meal daily to enhance iron absorption 2, 4

For Children Ages 1-5 Years

• Limit cow's milk consumption to no more than 24 ounces daily—excessive milk intake is a common and preventable cause of iron deficiency because it has minimal iron content, displaces iron-rich foods, and may cause microscopic intestinal bleeding 2, 4
• Encourage iron-rich foods at meals 2, 4
• Include vitamin C sources with meals 2, 4

Critical Pitfalls to Avoid

• Excessive cow's milk consumption (>24 oz daily) is the most common preventable cause of iron deficiency in young children 2, 4
• Breast milk alone after 6 months is insufficient and must be supplemented with iron-rich complementary foods or iron drops 2, 4
• Introducing cow's milk before 12 months of age significantly increases iron deficiency risk 1, 2
• Failure to address underlying causes (dietary inadequacy, excessive milk intake, occult blood loss) leads to recurrence after treatment 2
• Parenteral iron therapy or red blood cell transfusion is usually not necessary for uncomplicated iron deficiency anemia 3

Screening Recommendations

Screen all infants at 9-12 months of age, with repeat screening 6 months later (at 15-18 months) 1, 6. For high-risk populations (low-income families, WIC-eligible children, migrant or refugee children), screen annually from ages 2-5 years 1, 6.

Risk Factors Requiring Earlier or More Frequent Screening

• Preterm or low birthweight infants 1, 6
• Infants fed non-iron-fortified formula for >2 months 1, 6
• Infants introduced to cow's milk before 12 months 1, 6
• Breastfed infants without adequate iron intake after 6 months 1, 6
• Children consuming >24 oz of cow's milk daily 1, 6
• Children with special health-care needs (medications interfering with iron absorption, chronic infection, inflammatory disorders, restricted diets, or extensive blood loss) 1, 6