Anemia in Children

If your child has been tiring more quickly lately, looks pale, is eating less or has trouble concentrating at school, one of the reasons for this may be low blood, that is, anemia.

However, anemia in children is not a single disease.

Anemia means that the hemoglobin level in the blood is below the level accepted as normal for the child's age and characteristics. Iron deficiency is one of the most common causes of anemia in childhood; however, not every case of anemia is due to iron deficiency.

For this reason, when anemia is found in a child, instead of simply saying "let's give iron," the cause of the anemia needs to be identified first.

What Is Anemia in Children?

Hemoglobin is the protein found inside red blood cells that carries oxygen from the lungs to the tissues of the body.

When the hemoglobin level falls, the amount of oxygen carried to the tissues can be affected and different signs may appear in the child.

Because normal hemoglobin values in children change with age, it is not right to interpret a blood result using adult reference values.

Why Does Anemia Develop in Children?

Anemia in children can have many different causes.

In general, anemia can develop as a result of:

• Not enough red blood cells being produced
• Red blood cells breaking down faster than normal
• Blood loss

Among the causes commonly seen in childhood are the following:

• Iron deficiency
• Vitamin B12 or folate deficiency
• Inherited hemoglobin disorders such as thalassemia
• Chronic conditions and inflammation
• Blood loss from the digestive system or from other areas
• Hemolytic conditions in which red blood cells break down quickly
• More rarely, conditions affecting the bone marrow

For this reason "anemia" is the name of a result; the real question is why the anemia has developed.

Iron Deficiency Anemia in Children

One of the most commonly seen causes of anemia in childhood is iron deficiency.

Iron is a mineral needed to make hemoglobin.

When there is not enough iron in a child's body, the iron stores go down first. If the deficiency continues, hemoglobin production can be affected and iron deficiency anemia can develop.

Why Does Iron Deficiency Develop in Children?

The cause of iron deficiency can change with age.

The main causes may be:

• Not taking in enough iron through the diet
• The need for iron increasing during periods of rapid growth
• Excessive cow's milk consumption
• Certain digestive system conditions that affect iron absorption
• Blood loss
• Especially heavy menstrual bleeding during adolescence

Because infancy and early childhood are among the periods of rapid growth, the need for iron is high.

What Are the Signs of Anemia in Children?

In mild anemia the child may have no signs at all, and the anemia may only be noticed in blood tests.

As anemia becomes more pronounced, the following may be seen:

• Paleness of the skin and lips
• Weakness
• Tiring quickly
• Poor appetite
• Restlessness
• Headache
• Dizziness
• Palpitations
• Shortness of breath with exertion
• Difficulty focusing on lessons
• Changes in sleep or behavior

Long-lasting iron deficiency in particular matters for developmental and cognitive functions in young children.

Does a Child Looking Pale Show That There Is Anemia?

Not always.

Having fair skin, tiredness, illnesses the child has had and various other situations can make a child look pale.

On the other hand, a child with mild anemia may look quite normal from the outside.

For this reason, a diagnosis of anemia is made with blood tests, not just by looking at how the child appears.

Can Iron Deficiency in Children Have Different Signs?

Yes.

In some children, iron deficiency may come along with:

• A desire to eat non-food substances such as ice, soil or paper (pica)
• Restlessness
• Difficulty concentrating
• Sleep problems

These signs do not prove iron deficiency on their own, but they should be evaluated especially when they occur together with other findings.

How Is Anemia Diagnosed in Children?

The first step in the diagnosis is usually a complete blood count (CBC).

In the complete blood count, values such as the following are evaluated:

• Hemoglobin
• Hematocrit
• Red blood cell count
• MCV, which shows the size of the red blood cells

However, although the complete blood count can show that anemia is present, it does not always explain the cause on its own.

Depending on the clinical situation, the following may be used:

• Ferritin
• Reticulocytes
• Peripheral blood smear
• Other iron-related tests
• Vitamin B12 and folate
• Hemoglobin electrophoresis
• Markers of inflammation

along with other tests that are considered necessary.

What Is Ferritin?

Ferritin is one of the important tests that give information about the body's iron stores.

In evaluating iron deficiency, the ferritin level is important along with hemoglobin.

However, ferritin is also a value that can be affected by inflammation. For example, while the child has an infection or when there is inflammation in the body, ferritin may look higher than normal.

For this reason the ferritin result should also be interpreted together with the other laboratory findings and the child's clinical condition.

Can Ferritin Be Low While Hemoglobin Is Normal?

Yes.

Iron deficiency and iron deficiency anemia are not the same thing.

When the iron stores start to go down, ferritin may fall while hemoglobin is still within normal limits.

If the deficiency continues, hemoglobin may fall later as well and anemia may appear.

So saying "the hemoglobin is normal, there is no iron deficiency" is not always correct.

Is Iron Medication Used in Every Case of Anemia?

No.

Iron medication is used in children who have iron deficiency.

In anemias due to thalassemia, vitamin B12 deficiency, chronic disease or different causes, the treatment may be planned in another way.

For this reason it is not right to start an iron preparation at random before the cause of the anemia has been identified.

How Is Iron Deficiency Treated in Children?

In iron deficiency anemia the treatment has two basic aims:

To correct the hemoglobin level and to refill the emptied iron stores.

In treatment, iron preparations taken by mouth are mostly preferred.

The decision about the medication:

• In which form
• At which dose
• For how long

it will be used is made according to the child's age, weight and the degree of the anemia.

After the treatment starts, the blood values need to be checked at certain intervals.

Hemoglobin returning to normal may not mean that the treatment will be stopped right away. The treatment may need to continue for some time longer so that the iron stores can also be replaced.

How Should Iron Medication Be Given?

The absorption of iron can change according to the preparation used and to the diet.

It is generally preferred that iron preparations are not given at the same time as milk and dairy products, because calcium can reduce iron absorption.

Tea can also affect iron absorption unfavorably.

If the child has difficulty taking the medication or has stomach and bowel complaints, the pediatrician should be consulted rather than stopping the treatment completely.

Does Iron Medication Stain the Teeth?

Liquid iron preparations can cause a temporary color change on the teeth in some children.

Not keeping the medication in the mouth for a long time, giving it toward the back of the mouth when possible, and paying attention to mouth care afterward can help reduce this.

Does Iron Medication Make Stools Black?

Yes.

During iron treatment, stools taking on a dark green or almost black color is common and generally expected.

However, if the child has other signs that suggest bleeding, separate from the iron treatment, this needs to be evaluated separately.

What Are the Side Effects of Iron Medication?

With iron preparations taken by mouth, side effects such as the following may be seen:

• Nausea
• Abdominal pain
• Constipation
• Diarrhea
• A bad taste in the mouth
• Darkening of the stools

Rather than the family stopping the treatment on its own because of these complaints, it is more appropriate to have the preparation used or the way it is given evaluated again with the pediatrician.

What Should Nutrition Be Like in Childhood Anemia?

Nutrition is important in preventing and treating iron deficiency.

Among the foods that are valuable in terms of iron are:

• Red meat
• Chicken
• Fish
• Eggs
• Dried legumes
• Iron-fortified cereals
• Certain green leafy vegetables

Iron from animal sources is generally absorbed more easily in the body than iron from plant sources.

Consuming plant sources of iron together with vegetables and fruits containing vitamin C can help iron absorption.

Does Pekmez (Grape Molasses) Treat Anemia?

Pekmez (grape molasses) may be one of the foods that contain iron, but it is not a medication that will treat iron deficiency anemia on its own.

In a child who has been diagnosed with iron deficiency anemia, it is not right to expect hemoglobin and iron stores to recover adequately with pekmez, grapes or other foods alone.

Nutrition supports the treatment; it does not take the place of medical iron treatment when that is needed.

Does Too Much Cow's Milk Cause Anemia?

Excessive cow's milk consumption is an important risk factor for iron deficiency, especially in young children.

Cow's milk is not a food rich in iron. In addition, children who drink large amounts of milk may eat less of the other iron-rich foods.

For this reason it is not right for a large part of a child's diet to be built on milk.

The daily amount of milk and dairy products appropriate for the child's age should be evaluated together with the child's overall nutrition.

Does Anemia Affect a Child's Intelligence or Learning?

Long-lasting iron deficiency in particular is important in childhood in terms of:

• Attention
• Concentration
• Learning
• Memory
• Neurodevelopment

For this reason iron deficiency should not be evaluated simply as "the hemoglobin is a little low"; it should be noticed and treated in good time, especially during infancy and early childhood.

What Should Be Done If the Anemia Does Not Improve Despite Iron Treatment?

This situation is important.

First of all, the following should be evaluated:

• Whether the diagnosis really is iron deficiency
• Whether the medication is being used at a suitable dose
• Whether the child is taking the medication regularly
• Whether there is an absorption problem
• Whether there is ongoing blood loss

Thalassemia trait and other causes of anemia may also be considered in the differential diagnosis.

For this reason, in a child who does not give the expected response to iron treatment, the cause should be investigated again rather than continuing the same treatment for months without follow-up.

Can Thalassemia and Iron Deficiency Be Confused?

Yes.

In thalassemia trait the red blood cells can also be smaller than normal, and some of the values in the complete blood count can look similar to those in iron deficiency.

However, thalassemia trait and iron deficiency are not the same condition.

When it is considered necessary, they can be distinguished with additional investigations such as iron stores and hemoglobin electrophoresis.

It is not right to start iron in a child with thalassemia trait only because the red blood cells in the complete blood count are small; an accompanying iron deficiency needs to be shown.

Why Is Anemia Common in Adolescent Girls?

During adolescence, the need for iron increases along with rapid growth.

In girls who have started menstruating, blood loss may be added to this.

An evaluation for iron deficiency may be needed especially in adolescents who:

• Have very heavy periods
• Have bleeding that lasts a long time
• Experience weakness or dizziness
• Are vegetarian or have a restricted diet

When Is Anemia Serious in Children?

The seriousness of anemia depends not only on the hemoglobin value, but also on how quickly the anemia has developed and on the child's clinical condition.

Urgent evaluation may be needed especially if there are signs such as:

• Marked shortness of breath
• Palpitations at rest
• Fainting
• Chest pain
• Extreme weakness
• Marked paleness
• Bleeding
• A serious decline in the child's general condition