the Prevention and Management of Iron Deficiency and Iron Deficiency Anemia in Infants, Children and Adolescents
- Executive Summary
➡️Introduction
For most parts of the world, Iron Deficiency (ID) guideline recommendations are somewhat heterogeneous largely because different patient populations are addressed. The purpose of developing the Egyptian guidelines is to identify strategies and comprehensive actions needed across the life cycle to eliminate anemia as a major public health problem among infants, young children and adolescents based on the available evidence.
➡️Scope
This guideline focuses on prevention and management of Iron deficiency (ID) and Iron deficiency anemia (IDA) in infants, children and adolescents
➡️Guideline development process and methods
After reviewing all the inclusion and exclusion criteria and quality appraisal results, the GDG/ GAG recommended using the following source original clinical practice guidelines (CPGs):
1. WHO Guideline: Daily iron supplementation in adult women and adolescent girls. Geneva: World Health Organization; 2016.
2. Guideline: Daily iron supplementation in infants and children. Geneva: World Health Organization; 2016.
3. Patient Blood Management Guidelines: Module 6 – Neonatal and Paediatrics, National Blood Authority (NBA) (2016)
We conducted Adolopment for these guidelines: (Adoption, Adaptation, and Development)
- Adoption for most of the guideline recommendations.
- Development of Good Practice Statements
➡️Recommendations and Good Practice Statements (GPS)
This version of the CPG includes recommendations and good practice statements on the following four sub-sections:
A. Screening of Iron Deficiency and Iron Deficiency Anemia in Infants, Children and Adolescents
B. Diagnosis of Iron Deficiency and Iron Deficiency Anemia in Infants, Children and Adolescents
The guideline covers (Age group) Infants, children & adolescents less than 18 years
This guideline emphasis on
C. Treatment of Iron Deficiency and Iron Deficiency Anemia in Infants, Children and Adolescents
D. Prevention of Iron Deficiency and Iron Deficiency Anemia in Infants, Children and Adolescents
We can summarize the guidelines’ recommendations for the Prevention and Management of Iron Deficiency and Iron Deficiency Anemia in Infants, Children and Adolescents in the following:
▪️ Routine dietary history and clinical screening for symptoms and signs of iron deficiency anemia in infants, children and adolescents is recommended by the primary health care professional/ pediatricians in primary health care setting/ OPC, yearly school visits (GPS).
▪️ Laboratory screening of the general population for ID/IDA is not recommended. However, testing of infants, children and adolescents identified by clinical screening i.e. symptoms and signs is recommended (Very Low LOE, weak recommendation).
▪️ The presence of clinical manifestations of IDA in the presence of microcytic hypochromic anemia and low ferritin. Anemia is diagnosed if hemoglobin level is below the cut-off level for age and sex. Microcytosis is diagnosed if mean corpuscular volume is below -2SD for age related reference range. Iron deficiency is considered if serum ferritin level is below 12 ug/L in the absence of infection/ inflammation or below 30 ug/L in all age groups in the presence of infection/ inflammation. Oral iron therapy in a dose: 3-6 mg/kg / day for all ages. Forms: syrup; tablets (each preparation contains different elemental iron dose) (not exceed maximum dose). Time: 1hour before or 2 hours after meals with Vitamin C at daytime To be monitored after one month by CBC and reticulocytic count, then at 3, 6 months. If no response after one month: revise dose, compliance, tolerability, type of formula and consider change of formula for another month. Duration: for 3 months after recovery of hemoglobin (Very Low LOE, weak recommendation).
▪️ Daily iron supplementation of 10-12.5mg elemental iron for three consecutive months is recommended as a public health intervention in infants and young children aged 6-23 months, living in settings where anemia is highly prevalent (Moderate LOE, strong recommendation).
▪️ Daily iron supplementation of 30 mg elemental iron for three consecutive months is recommended as a public health intervention in preschool children aged 24 to 59 months, living in settings where anemia is highly prevalent (Very Low LOE, strong recommendation).
▪️ Daily iron supplementation of 30-60 mg elemental iron for three consecutive months is recommended as a public health intervention in school aged children aged 5-12 years, living in settings where anemia is highly prevalent (High Loe, strong recommendation).
▪️ Start complementary feeding with iron rich food. Avoid cow milk, goat milk, soy to infants under12 months of age. From 12 months, cow milk should not exceed 500 ml per day. For non- breast fed infants, iron fortified formula can play role in prevention and treatment of IDA (GPS).
▪️Tips for Oral iron intake (GPS)
- Lower and intermittent dose may be as effective and better tolerated
- To avoid gastric upset can be taken at night and increasing dose gradually
- Teeth staining can be avoided by brushing teeth and taking with water.
▪️ If oral iron is ineffective or is not tolerated consider other causes of anemia and refer to Hematologist (avoid parenteral iron therapy) (GPS).
▪️ Packed RBCs should be considered only after Hematologist opinion (GPS).
▪️Nutritional support with iron rich formulas, solid food and oral iron support 1-2mg/kg/day elemental iron should be used to treat asymptomatic iron deficiency anemia in infants (GPS).
▪️ Referral to hematologist should be considered in cases of severe anemia, history of recurrent bleeding or with failure of increase in the hemoglobin concentration after proper iron dose and proper way of administration (GPS).