What is the management for a 16-year-old girl with mild anemia?

Management of Anemia in a 16-Year-Old Girl with Hemoglobin 10 g/dL

Start oral iron supplementation immediately with ferrous sulfate 60-120 mg elemental iron daily and assess for menstrual blood loss as the most likely cause in this adolescent girl. 1

Initial Assessment and Diagnosis

A hemoglobin of 10 g/dL in a 16-year-old girl meets criteria for anemia (normal Hb for females is ≥12 g/dL). 1 At this age, the most common cause is menstrual blood loss, particularly menorrhagia, which accounts for iron deficiency anemia in 5-10% of menstruating women. 1

Key History Points to Obtain:

• Menstrual history: Duration, frequency, and heaviness of periods (though history is unreliable for quantifying loss; pictorial blood loss assessment charts have 80% sensitivity/specificity for menorrhagia) 1
• Dietary iron intake: Assess consumption of iron-rich foods and excessive milk intake (>24 oz daily can interfere with iron absorption) 1
• GI symptoms: Upper GI symptoms would warrant further investigation even in this age group 1

Confirm Iron Deficiency:

• Repeat hemoglobin to confirm the anemia 1
• Check MCV and ferritin: Ferritin <15 μg/dL is diagnostic of iron deficiency; MCV <76 fL suggests microcytic anemia 1
• If ferritin is <15 μg/dL, you can make a presumptive diagnosis of iron deficiency anemia and begin treatment 1

Treatment Protocol

Prescribe oral iron supplementation: 60-120 mg elemental iron daily (one to two 60-mg tablets of ferrous sulfate). 1 Ferrous sulfate 324 mg tablets contain 65 mg elemental iron. 2 Alternative formulations include ferrous gluconate or ferrous fumarate, which are equally effective. 1

Administration Guidelines:

• Take between meals for optimal absorption 1
• Consider adding ascorbic acid (vitamin C) if response is poor, as it enhances iron absorption 1
• Counsel on dietary iron intake: Emphasize iron-rich foods and foods that enhance absorption 1

Follow-Up Schedule

At 4 weeks:

• Recheck hemoglobin 1
• Expected response: Hemoglobin should increase by ≥1 g/dL (or hematocrit by ≥3%) 1
• If this confirms iron deficiency anemia, continue iron for 2 more months, then recheck 1

If no response at 4 weeks despite compliance:

• Evaluate with additional labs: MCV, RDW, and serum ferritin 1
• Consider alternative diagnoses (thalassemia, chronic disease, combined deficiencies) 1
• Ferritin >15 μg/dL suggests iron deficiency is not the cause 1

After successful treatment:

• Continue iron for 3 months after hemoglobin normalizes to replenish body stores 1
• Reassess hemoglobin approximately 6 months after completing treatment 1
• Monitor hemoglobin every 3 months for one year, then annually 1

Investigation Considerations

For adolescent girls <45 years old, extensive GI investigation is NOT routinely indicated unless specific symptoms are present. 1 However, consider:

• Screen for celiac disease with antiendomysial antibodies (and IgA level to exclude IgA deficiency) if no obvious cause is found 1
• Upper GI endoscopy with small bowel biopsy only if upper GI symptoms are present 1
• Gynecologic evaluation if menorrhagia is suspected but dietary and iron supplementation fail 1

Common Pitfalls to Avoid

• Don't skip iron repletion: Even if a cause is identified, all patients need iron supplementation to correct anemia AND replenish stores 1
• Don't stop iron too early: Continue for 3 months after hemoglobin normalizes 1
• Don't use parenteral iron first-line: Reserve for intolerance to at least two oral preparations or documented malabsorption 1
• Don't over-investigate young menstruating women: Extensive GI workup is not needed unless there are specific GI symptoms or failure to respond to treatment 1