Is a 6-year-old patient with a hemoglobin (Hb) level of 126 g/L, hematocrit (Hct) of 0.36, red blood cell (RBC) count of 4.56 million cells per microliter, and a white blood cell (WBC) count of 18,000 cells per microliter, indicating anemia, and would elemental iron supplementation be appropriate?

Assessment of a 6-Year-Old with Hemoglobin 126 g/L and Leukocytosis

This 6-year-old child does NOT have anemia and should NOT receive iron supplementation. The hemoglobin of 126 g/L (12.6 g/dL) is normal for this age, and the leukocytosis requires investigation for infection or inflammation rather than treatment with iron 1.

Is This Anemia?

No, the hemoglobin level is normal for a 6-year-old child.

• The CDC defines anemia as hemoglobin below the 5th percentile for age, which for children aged 5-11 years is approximately 11.5 g/dL (115 g/L) 1.
• This patient's hemoglobin of 126 g/L (12.6 g/dL) falls well above the anemia threshold 1.
• The hematocrit of 0.36 (36%) and RBC count of 4.56 million cells/μL are also within normal ranges for this age group 1.

Important caveat: Hemoglobin and hematocrit are not always equivalent in detecting abnormalities—hematocrit may miss 20-50% of cases identified by hemoglobin alone, but in this case both values are normal 2.

Relationship Between Hemoglobin and Leukocytosis

There is no direct causal relationship between normal hemoglobin and leukocytosis in this patient.

• The WBC count of 18,000 cells/μL represents leukocytosis that suggests acute infection or inflammatory process 1.
• Infection and chronic inflammation can cause anemia through different mechanisms than iron deficiency, but this patient does not have anemia 1.
• The leukocytosis should prompt investigation for the underlying cause (infection, inflammation, or other pathology) rather than focusing on iron status 1.

Should This Patient Receive Iron Supplementation?

No, iron supplementation is contraindicated in this patient.

Reasons to Avoid Iron:

• Normal hemoglobin excludes iron deficiency anemia as a diagnosis 1.
• Iron supplementation should only be given when iron deficiency has been determined by a physician, not in children with normal hemoglobin 3.
• The CDC emphasizes that less than 50% of children with anemia are actually iron deficient, and additional testing (MCV, serum ferritin, transferrin saturation) is needed to confirm iron deficiency before treatment 1.
• Giving iron to iron-replete children can cause harm: excess iron in children with normal or high hemoglobin (>125 g/L at 6 months) has been associated with reduced cognitive performance years later 4.

When Iron Would Be Appropriate:

Iron supplementation at 3 mg/kg/day between meals would only be indicated if 1:

• Hemoglobin was below age-specific cutoffs (not the case here)
• Additional testing confirmed iron deficiency (low MCV, elevated RDW >14%, low serum ferritin <15 μg/L, or elevated erythrocyte protoporphyrin) 1
• A therapeutic trial showed hemoglobin increase ≥1 g/dL after 4 weeks 1

Clinical Action Plan

The appropriate next steps are:

1. Investigate the leukocytosis: Evaluate for infection, inflammatory conditions, or other causes of elevated WBC 1.
2. Do not prescribe iron: This child has normal hemoglobin and no indication for iron therapy 1, 3.
3. If anemia screening is desired in the future: Screen only if risk factors develop (special dietary restrictions, chronic disease, medications interfering with iron absorption) 1.

Critical pitfall to avoid: Do not assume that anemia screening alone identifies iron deficiency—even when anemia is present, other causes (folate/B12 deficiency, thalassemia, sickle cell disease, infection, chronic inflammation) must be excluded before attributing it to iron deficiency 1.