the Prevention and Management of Iron Deficiency and Iron Deficiency Anemia in Infants, Children and Adolescents

- Introduction

Infants and young children are vulnerable to anemia especially iron deficiency anemia (IDA), which represents a public health problem with defined impacts on the health of communities.¹ Published evidence suggests that early infant feeding practices play a major role in the prevalence of iron deficiency (ID) and IDA.^2,3 Anemia early in life, with or without iron depletion, is known to seriously affect children’s general health and immunity, retarding their growth and development by causing multiple disorders and abnormalities in different body systems.^3–5

Anemia may be defined as haemoglobin (Hb) concentration 2 SD below the mean Hb concentration for a normal population of the same gender and age range. ID, the most common cause of anemia, is characterized by a depletion of iron in various body compartments and/or tissues. IDA evolves when ID is severe enough to significantly affect erythropoiesis.^{3- 6} IDA is a preventable and treatable condition; therefore, early diagnosis represents the cornerstone in protection from its adverse consequences and combating its contributing factors.

Globally, ID is the most common and widespread nutritional disorder affecting all age groups. Children in developing countries are particularly affected where prevalence as high as 50% has been reported among infants aged 12 months. IDA is a leading cause of mortality and morbidity among infants worldwide and some of its manifestations are possibly irreversible.^7–14 In a systematic review done in 2012 to evaluate micronutrient deficiencies and food fortification in the Middle East, ID represented one of the three most common micronutrient deficiencies in the region in addition to iodine and vitamin A.¹⁵ According to WHO, in 2013 63% of children under 5 years in the Eastern Mediterranean region (EMR) had IDA and in some studies, anemia among preschool children showed similarly high rates.¹⁶

According to a UNICEF report, more than two billion individuals have anemia worldwide and most of them have IDA, especially in underdeveloped and developing countries, where 40-50% of children are iron deficient compared with 6-20% in developed countries .¹⁷
In Egypt, High levels of anemia remain a critical issue of micronutrient deficiencies affecting children below five years, women of reproductive age and adolescents. Egypt Demographic and health survey (DHS) 2014 showed that 27.2 percent of children under-5 in Egypt have some degree of anemia, with 9.5 percent being moderately anemic and the remaining 17.8 percent mildly anemic. While, girls age 5-19 years were somewhat more likely than boys in the age group to be anemic (21 percent and 18 percent, respectively). Most anemic children age 5-19 years were only mildly anemic. Among girls, the proportion anemic was highest in the 12-14-year age group (25 %) and lowest among children in the 10-11 age group (14 %). Among boys, the anemia level was highest in the 15-19 age group (22 %) and, similar to the pattern for girls, lowest in the 10-11 age group (10 %).¹⁸

The prevalence of anemia among children less than 5 years (% of children under 5) in Egypt was 31.70 in 2016. Its highest value over the past 26 years was 42.50 % in 1990, while its lowest value was 31.70 % in 2016.¹⁹

Iron transfer from mother to fetus occurs mainly during the third trimester of pregnancy and is stored mainly in the liver and bone marrow. Thus, the amount of iron present at birth depends on the gestational age and weight of the baby.¹⁷ Full-term infants usually have sufficient iron stores until 4–6 months of age. During the infantile growth spurt, human milk (which contains 0.2–0.3 mg/L of iron) may not provide enough iron to meet high demands for rapid growth and erythropoiesis. Therefore, existing iron stores are mobilized to meet the iron requirements of the infant mostly around the age of 4–6 months. This may result in stores being generally depleted by the age of 6 months, yet from 4 months to 12 months after birth, the infant’s blood volume doubles, causing a ‘physiologically dilution effect’ for red blood cells and Hb. Thus, at this age, dietary sources of iron become critical to keep up with the rapid rate of growth and red blood cell synthesis.^20–22

Studies have shown that increased nutritional requirements during the growth spurt may often lead to a negative nutrient balance.² In general, prolonged exclusive breast feeding (more than 6 months) predisposes to decreased dietary iron intake and may lead to iron depletion.^{20-  26}

The diagnosis of iron deficiency is made primarily based on laboratory measurements; however, the tests used commonly have limitations because of their poor sensitivity or specificity, or because they are modified by conditions other than iron deficiency (such as inflammation). Therefore, combining several iron status indicators provides the best assessment of iron status. ² A complete blood count may indicate low Hb levels. Serum ferritin reflects total body iron stores. The most useful single laboratory value for the diagnosis of iron deficiency may be plasma ferritin.

Infant feeding counseling offered to mothers and other caregivers on how to gradually increase consistency and quantity of foods also assists in prevention of micronutrient deficiency^{.26, 27} Preterm babies, as well as, those born small for gestational age, are particularly vulnerable to ID in their first months of life.^{2 ,28 ,29} Infants delivered by caesarean section are more likely to get ID, as their delivery is associated with reduced placental transfusion and poor iron-related hematological indices in both cord and peripheral blood.³⁰

The treatment of IDA depends mainly on oral iron supplements, which are desirable as a first-line therapy. The most commonly used preparations are ferrous fumarate, ferrous sulfate, and ferrous gluconate and the main side effects are gastrointestinal disturbances. Treatment should be continued for at least 3 months at a dose of 3-6 mg/kg/day, best taken between meals on an empty stomach .^2,7,31

Prevention and control strategies against IDA are mainly dependent on the timing of diagnosis and start of treatment.⁷ The WHO ‘Global Strategy for Infant and Young Child Feeding’ was developed as guidance to the prevention of micronutrient deficiencies including ID and IDA.²⁶  Many studies indicate that incidence of IDA has significantly decreased over time due to promotion of breast feeding, improvement of overall nutritional status and use of iron-fortified baby foods.²

A recent systematic review of 29 guidelines was published in 2015.³² These guidelines were developed by professional associations throughout the world including the United States (n = 8), Europe (n = 6), Britain (n = 4), Canada (n = 3), other international organizations (n = 2), France (n = 2), Poland (n = 1), Australia (n = 1), Mexico (n = 1), and Japan (n = 1). Findings from this guideline summary reveal that, for the most part, Iron Deficiency (ID) guideline recommendations are somewhat heterogeneous largely because different patient populations were addressed. The purpose of developing the Egyptian guidelines was 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.

➡️Purpose and Scope

These guidelines have been developed to standardize the delivery of services and to implement the guidance on the prevention, diagnosis and management of Iron deficiency (ID) and Iron deficiency anemia (IDA) in infants, children and adolescents.

It provides guidance to primary health care providers, pediatricians and specially trained nurses.

The guidelines aimed to assist the practitioners (Primary and secondary Health care practitioners working in governmental, non-governmental and private sectors) to apply the best available research evidence to clinical decisions about the prevention and management of iron deficiency and iron deficiency anemia in infants, children and adolescents.

This version of the guideline includes recommendations and good practice statements for prevention, diagnosis and management of Iron deficiency (ID) and Iron deficiency anemia (IDA) in infants, children and adolescents.