Overview
Definition:
Iron deficiency anemia (IDA) is a common hematologic disorder characterized by insufficient iron stores in the body, leading to a reduction in hemoglobin synthesis and red blood cell production
Oral formulations are the mainstay of treatment in most pediatric cases.
Epidemiology:
Affects approximately 40% of young children globally
Infants and toddlers (6-24 months), adolescent girls, and children with inadequate diets or malabsorption syndromes are at highest risk
In India, prevalence can be as high as 60-70% in certain vulnerable populations.
Clinical Significance:
Untreated IDA in children can lead to irreversible cognitive and developmental delays, impaired immune function, and poor academic performance
Optimal management requires not only appropriate iron supplementation but also sustained adherence to therapy, which is often challenging.
Adherence Challenges
Common Issues:
Gastrointestinal side effects (nausea, vomiting, constipation, diarrhea)
Unpleasant taste of formulations
Complex dosing schedules
Lack of parental understanding of disease severity and treatment duration
Cost of medications
Socioeconomic factors.
Pediatric Specific Factors:
Infants refusing oral medications
Toddlers spitting out or hiding medication
Older children or adolescents concerned about appearance or taste
Difficulty in administering to uncooperative children
Parental stress and competing priorities.
Impact Of Non Adherence:
Prolonged or recurrent anemia
Failure to achieve therapeutic hemoglobin levels
Need for parenteral iron, which is more invasive and costly
Missed developmental milestones
Increased healthcare utilization.
Oral Iron Formulations
Types:
Ferrous sulfate
Ferrous fumarate
Ferrous gluconate
Ferric compounds (e.g., ferric polymaltose, iron hydroxide-polysaccharide complexes)
Each has different absorption characteristics and side effect profiles.
Dosage Considerations:
Elemental iron dosage is crucial
typically 3-6 mg/kg/day divided into 1-3 doses for ferrous salts
For ferric compounds, dosages may vary
The duration of treatment is usually 3-6 months after normalization of hemoglobin, to replete iron stores.
Selection Criteria:
Choice depends on tolerability, cost, availability, and child's age and ability to swallow
Newer ferric formulations may offer better tolerability but can be more expensive
Liquid formulations are often preferred for infants and young children, while chewable tablets or capsules may be suitable for older children.
Adherence Strategies
Parent Education:
Explain the importance of iron for brain development and overall health
Clarify the duration and necessity of treatment
Discuss potential side effects and how to manage them
Emphasize that iron supplements can stain teeth and recommend wiping infant's teeth or using a straw for older children.
Formulation Selection And Administration:
Recommend formulations with better taste or fewer side effects if possible
For liquid ferrous sulfate, administer with a dropper or syringe directly into the mouth, avoiding contact with teeth
Giving with a small amount of juice (not milk or calcium-rich beverages) can mask taste and enhance absorption.
Scheduling And Monitoring:
Suggest administering iron between meals for optimal absorption, if tolerated
If GI upset occurs, give with a small meal or snack, but avoid milk or antacids
Encourage adherence through regular follow-up appointments, reinforcing the benefits of treatment, and addressing any emerging concerns.
Behavioral Approaches:
Use positive reinforcement and reward systems for children who take their medication
Make medication time a consistent part of the daily routine
Involve older children in understanding their condition and treatment plan to foster responsibility.
Monitoring And Follow Up
Laboratory Monitoring:
Regular hemoglobin and hematocrit levels to assess response
Ferritin levels can be checked to assess iron stores, usually after completion of initial therapy
Reticulocyte count can confirm bone marrow response.
Assessing Adherence:
Direct questioning of parents and child about medication intake
Asking about side effects
Observing for clinical improvement
Prescribing habits and refill rates can also be indirect indicators.
Long Term Follow Up:
For children with risk factors, consider periodic monitoring for recurrence
Educate families on dietary sources of iron and strategies for prevention, especially during periods of rapid growth or dietary transitions.
Key Points
Exam Focus:
DNB and NEET SS exams frequently test on diagnosis, management principles, and common challenges in pediatric IDA
Adherence strategies are crucial for successful outcomes and will likely be a question point.
Clinical Pearls:
Always assess adherence when a patient is not responding to treatment as expected
Newer, well-tolerated formulations may be more expensive but can significantly improve adherence
Ferrous salts are generally preferred due to cost and established efficacy.
Common Mistakes:
Stopping iron therapy too early once hemoglobin normalizes
Failure to adequately address gastrointestinal side effects
Incorrect dosing of elemental iron
Not considering malabsorption issues as a cause of persistent IDA despite supplementation.