Iron deficiency anemia is one of the most common hematologic disorders among

children.

A micrograph of red blood cells (erythrocytes) | National Institutes of Health

 Iron deficiency anemia develops when body stores of iron drop too low to
support normal red blood cell (RBC) production.
 Iron equilibrium in the body normally is regulated carefully to ensure that
sufficient iron is absorbed in order to compensate for body losses of iron.
 Iron deficiency is defined as a decreased total iron body content.
 Iron deficiency anemia occurs when iron deficiency is severe enough to
diminish erythropoiesis and cause the development of anemia.

Pathophysiology

Iron is vital for all living organisms because it is essential for multiple metabolic
processes, including oxygen transport, DNA synthesis, and electron transport.

Iron equilibrium in the body is regulated carefully to ensure that sufficient iron is
absorbed in order to compensate for body losses of iron.

 Whereas body loss of iron quantitatively is as important as absorption in terms

of maintaining iron equilibrium, it is a more passive process than absorption.
 In healthy people, the body concentration of iron (approximately 60 parts per
million [ppm]) is regulated carefully by absorptive cells in the proximal small
intestine, which alter iron absorption to match body losses of iron.
 Persistent errors in iron balance lead to either iron deficiency anemia or
hemosiderosis. Both are disorders with potentially adverse consequences.
 Iron uptake in the proximal small bowel occurs by 3 separate pathways; these
are the heme pathway and 2 distinct pathways for ferric and ferrous iron.
 Heme iron is not chelated and precipitated by numerous dietary constituent that
renders nonheme iron nonabsorbable, such as phytates, phosphates, tannates,
oxalates, and carbonates.
Statistics and Incidences

Iron deficiency is the most prevalent single deficiency state on a worldwide basis.

 In North America and Europe, iron deficiency is most common in women of

childbearing age and as a manifestation of hemorrhage.
 Depending upon the criteria used for the diagnosis of iron deficiency,
approximately 4-8% of premenopausal women are iron deficient.
 A study of the national primary care database for Italy, Belgium, Germany, and
Spain determined that annual incidence rates of iron deficiency anemia ranged
from 7.2 to 13.96 per 1,000 person-years.
 Higher rates were found in females, younger and older persons, patients with
gastrointestinal diseases, pregnant women and women with a history of
menometrorrhagia, and users of aspirin and/or antacids.
 Infants consuming cow milk have a greater incidence of iron deficiency
because bovine milk has a higher concentration of calcium, which competes
with iron for absorption.
 During childbearing years, an adult female loses an average of 2 mg of iron
daily and must absorb a similar quantity of iron in order to maintain
equilibrium; because the average woman eats less than the average man does,
she must be more than twice as efficient in absorbing dietary iron in order to
maintain equilibrium and avoid developing iron deficiency anemia.

Causes

Causes of iron deficiency anemia may include:

 Dietary factors. Meat provides a source of heme iron, which is less affected by
the dietary constituents that markedly diminish bioavailability than nonheme
iron is; the prevalence of iron deficiency anemia is low in geographic areas
where meat is an important constituent of the diet; in areas where meat is
sparse, iron deficiency is commonplace.
 Hemorrhage. Bleeding for any reason produces iron depletion; if sufficient
blood loss occurs, iron deficiency anemia ensues.
  Hemosiderinuria, hemoglobinuria, and pulmonary hemosiderosis. Iron
deficiency anemia can occur from loss of body iron in the urine; if a freshly
obtained urine specimen appears bloody but contains no red blood cells,
suspect hemoglobinuria.
 Malabsorption of iron. Prolonged achlorhydria may produce iron deficiency
because acidic conditions are required to release ferric iron from food; then, it
can be chelated with mucins and other substances (e.g., amino acids, sugars,
amino acids, or amides) to keep it soluble and available for absorption in the
more alkaline duodenum.
 Iron-refractory iron deficiency anemia (IRIDA). Iron-refractory iron
deficiency anemia (IRIDA) is a hereditary disorder marked by with iron
deficiency anemia that is typically unresponsive to oral iron supplementation
and may be only partially responsive to parenteral iron therapy.

Clinical Manifestations

The signs of iron deficiency anemia include:

Signs you have iron deficiency. (Click to enlarge)

 Below average body weight. The child with iron deficiency anemia consumes
more calcium than other nutrients, making them lighter than the average weight
for their age.
 Pale skin and mucous membranes. The hemoglobin in red blood cells gives
blood its red color, so low levels during iron deficiency make the blood less
red; that’s why the skin and mucous membranes can lose its healthy, rosy color
in people with iron deficiency.
 Anorexia. Loss of appetite is common, with milk as their only food source.
 Growth retardation. Due to a decrease in the consumption of other food
sources, the growth of the child becomes stunted.
 Listlessness. The child who has less hemoglobin in the blood becomes listless
and weak due to a decrease in oxygen circulating towards the brain.

Assessment and Diagnostic Findings

Although the history and physical examination can lead to the recognition of the
condition and help establish the etiology, iron deficiency anemia is primarily a laboratory
diagnosis.

Blood smear of a patient with Iron deficiency anemia at 40x enhancement

 Complete blood count. The CBC documents the severity of the anemia. In
chronic iron deficiency anemia, the cellular indices show a microcytic and
hypochromic erythropoiesis—that is, both the mean corpuscular volume
(MCV) and the mean corpuscular hemoglobin concentration (MCHC) have
values below the normal range for the laboratory performing the test.
 Peripheral smear. Examination of the erythrocytes shows microcytic and
hypochromic red blood cells in chronic iron deficiency anemia; the
microcytosis is apparent in the smear long before the MCV is decreased after
an event producing iron deficiency.
 Serum iron, total binding capacity, and serum ferritin. Low serum iron and
ferritin levels with an elevated TIBC are diagnostic of iron deficiency; while a
low serum ferritin is virtually diagnostic of iron deficiency, a normal serum
ferritin can be seen in patients who are deficient in iron and have coexistent
diseases (eg, hepatitis or anemia of chronic disorders); these test findings are
useful in distinguishing iron deficiency anemia from other microcytic anemias.
 Hemoglobin electrophoresis and measurement of hemoglobin
A2. Hemoglobin electrophoresis and measurement of hemoglobin A2 and fetal
hemoglobin are useful in establishing either beta-thalassemia or hemoglobin C
or D as the etiology of the microcytic anemia.
 Reticulocyte hemoglobin content. Mateos Gonzales et al assessed the
diagnostic efficiency of commonly used hematologic and biochemical markers,
as well as the reticulocyte hemoglobin content (CHr) in the diagnosis of iron
deficiency in children, with or without anemia.
 Stool testing. Testing stool for the presence of hemoglobin is useful in
establishing gastrointestinal (GI) bleeding as the etiology of iron deficiency
anemia.
 Incubated osmotic fragility. Microspherocytosis may produce a low-normal
or slightly abnormal MCV; however, the MCHC usually is elevated rather than
decreased, and the peripheral smear shows a lack of central pallor rather than
hypochromia.
  Tissue lead concentrations. Measure tissue lead concentrations; chronic lead
poisoning may produce a mild microcytosis; the anemia probably is related to
the anemia of chronic disorders.
 Bone marrow aspiration. A bone marrow aspirate can be diagnostic of iron
deficiency; the absence of stainable iron in a bone marrow aspirate that
contains spicules and a simultaneous control specimen containing stainable iron
permit establishment of a diagnosis of iron deficiency without other laboratory
tests.

Medical Management

Medical care starts with establishing the diagnosis and reason for the iron deficiency.

 Iron therapy. Oral ferrous iron salts are the most economical and
effective medication for the treatment of iron deficiency anemia; of the various
iron salts available, ferrous sulfate is the one most commonly used.
 Management of hemorrhage. Surgical treatment consists of stopping
hemorrhage and correcting the underlying defect so that it does not recur; this
may involve surgery for treatment of either neoplastic or nonneoplastic disease
of the gastrointestinal (GI) tract, the genitourinary (GU) tract, the uterus, and
the lungs.
 Diet. The addition of nonheme iron to national diets has been initiated in some
areas of the world.

Pharmacologic Management

Medications for iron deficiency anemia include:

 Iron products. These agents are used to provide adequate iron for hemoglobin
synthesis and to replenish body stores of iron.
 Parenteral iron. Reserve parenteral iron for patients who are either unable to
absorb oral iron or who have increasing anemia despite adequate doses of oral
iron; it is expensive and has greater morbidity than oral preparations of iron.

Nursing Management
Nursing care of a child with iron deficiency anemia include the following:

Nursing Assessment

Assessment of the child include:

 Dietary history. A dietary history is important; vegetarians are more likely to

develop iron deficiency unless their diet is supplemented with iron; national
programs of dietary iron supplementation are initiated in many portions of the
world where meat is sparse in the diet and iron deficiency anemia is prevalent.
 History of hemorrhage. Bleeding is the most common cause of iron
deficiency, either from parasitic infection (hookworm) or other causes of blood
loss; with bleeding from most orifices (hematuria, hematemesis, hemoptysis),
patients will present before they develop chronic iron deficiency anemia;
however, gastrointestinal bleeding may go unrecognized.
 Physical exam. Anemia produces nonspecific pallor of the mucous
membranes; a number of abnormalities of epithelial tissues are described in
association with iron deficiency anemia; these include esophageal webbing,
koilonychia, glossitis, angular stomatitis, and gastric atrophy.

Nursing Diagnosis

Based on the assessment data, the major nursing diagnoses are:

 Fatigue related to decreased hemoglobin and diminished oxygen-carrying

capacity of the blood.
 Deficient knowledge related to the complexity of treatment, lack of resources,
or unfamiliarity with the disease condition.
 Risk for infection
 Risk for bleeding

Nursing Care Planning and Goals

Main Article: 4 Anemia Nursing Care Plans

The major nursing care planning goals for patients with iron deficiency anemia are:
  Client/caregivers will verbalize the use of energy conservation principles.
Client/caregivers will verbalize reduction of fatigue, as evidenced by reports of
increased energy and ability to perform desired activities.
 Client/caregivers will verbalize understanding of own disease and treatment
plan.
 Client will have a reduced risk of infection as evidenced by an absence of fever,
normal white blood cell count, and implementation of preventive measures
such as proper hand washing.
 Client will have vital signs within the normal limit.
 Client will have a reduced risk for bleeding, as evidenced by normal or
adequate platelet levels and absence of bruises and petechiae.

Nursing Interventions

The nursing interventions for a child with iron deficiency anemia are:

Administer prescribed medications, as ordered:

 Administer IM or IV iron when oral iron is poorly absorbed.

 Perform sensitivity testing of IM iron injection to avoid risk of anaphylaxis.
 Advise patient to take iron supplements an hour before meals for maximum
absorption; if gastric distress occurs, suggest taking the supplement with meals
— resume to between-meals schedule if symptoms subside.
 Inform patient that iron salts change stool to dark green or black.
 Advise patient to take liquid forms of iron via a straw and rinse mouth with
water.
Reduce fatigue

 Assist the client/caregivers in developing a schedule for daily activity and rest.
 Stress the importance of frequent rest periods.
 Monitor hemoglobin, hematocrit, RBC count, and reticulocyte counts.
 Educate energy-conservation techniques.
 Encourage patient to continue iron therapy for a total therapy time (6 months to
a year), even when fatigue is no longer present.
Educate the client and caregivers about iron deficiency anemia:

 Explain the importance of the diagnostic procedures (such as complete blood

count), bone marrow aspiration and a possible referral to a hematologist.
 Explain the importance of iron replacement/supplementation.
 Educate the client and the family regarding foods rich in iron (organ and other
meats, leafy green vegetables, molasses, beans).
Prevent infection

 Assess for local or systemic signs of infection, such as fever, chills,

swelling, pain, and body malaise.
 Monitor WBC count; anticipate the need for antibiotic, antiviral,
and antifungal therapy.
 vInstruct the client to avoid contact with people with existing infections.
 Stress the importance of daily hygiene, mouth care, and perineal care.
Prevent bleeding

 Monitor platelet count; instruct the client/caregivers about bleeding

precautions.
 Anticipate the need for a platelet transfusion once the platelet count drops to a
very low value.
 Assess the skin for bruises and petechiae.

Evaluation

Goals are met as evidenced by:

 Client/caregivers will verbalize the use of energy conservation principles.

 Client/caregivers will verbalize reduction of fatigue, as evidenced by reports of
increased energy and ability to perform desired activities.
 Client/caregivers will verbalize understanding of own disease and treatment
plan.
 Client will have a reduced risk of infection as evidenced by an absence of fever,
normal white blood cell count, and implementation of preventive measures
such as proper hand washing.
  Client will have vital signs within the normal limit.
 Client will have a reduced risk for bleeding, as evidenced by normal or
adequate platelet levels and absence of bruises and petechiae.

Documentation Guidelines

Documentation for a child with iron deficiency anemia include:

 Baseline and subsequent assessment findings to include signs and symptoms.

 Individual cultural or religious restrictions and personal preferences.
 Plan of care and persons involved.
 Teaching plan.
 Client’s responses to teachings, interventions, and actions performed.
 Attainment or progress toward the desired outcome.
 Long-term needs, and who is responsible for actions to be taken.