Iron is a necessary mineral for body function and good health.

Every red blood cell in the

body contains iron in its hemoglobin, the pigment that carries oxygen to the tissues from
the lungs. But a lack of iron in the blood can lead to iron-deficiency anemia, which is a
very common nutritional deficiency in children.

About Iron-Deficiency Anemia

The body needs iron to make hemoglobin. If there isn't enough iron available,
hemoglobin production is limited, which in turns affects the production of red blood cells
(RBCs). A decreased amount of hemoglobin and RBCs in the bloodstream is known
asanemia. Because RBCs are needed to carry oxygen throughout the body, anemia
results in less oxygen reaching the cells and tissues, affecting their function.

Iron-deficiency anemia (IDA), often caused by insufficient iron intake, is the major cause
of anemia in childhood. It has become much less common in the United States over the
past 30 years, primarily due to iron-fortified infant formulas and cereals.

Iron-deficiency anemia doesn't develop immediately. Instead, a person progresses

through stages of iron deficiency, beginning with iron depletion, in which the amount of
iron in the body is reduced while the iron in RBCs remains constant. If iron depletion
isn't corrected, it progresses to iron deficiency, eventually leading to IDA.

Causes of IDA

Iron-deficiency anemia can be the consequence of several factors, including:

 insufficient iron in the diet

 poor absorption of iron by the body
 ongoing blood loss, most commonly from menstruation or from gradual blood loss
in the intestinal tract
 periods of rapid growth

A diet low in iron is most often behind IDA in infants, toddlers, and teens. Kids who don't
eat enough or who eat foods that are poor sources of iron are at risk for developing the
condition. Poverty is a contributing factor to IDA because families living at or below the
poverty level may not be getting enough iron-rich foods.

Iron deficiency can also cause the body to absorb more lead, which increases the risk of
lead poisoning in kids, especially those living in older homes. The combination of IDA
and lead poisoning can make kids very ill and can put them at risk for learning and
behavioral problems.
During infancy and adolescence, the body demands more iron. Kids are at higher risk for
IDA through these periods of rapid growth because they may not be getting enough iron
in their diet to make up for the increased needs.

In infants, discontinuing iron-fortified formula and introducing cow's milk before 12

months can lead to IDA. Cow's milk is low in the iron necessary for infant growth and
development and it often replaces the consumption of iron-rich foods. Milk decreases the
absorption of iron and can also irritate the lining of the intestine, causing small amounts
of bleeding. This slow, gradual loss of blood in the stool — combined with low iron intake
— may eventually result in iron deficiency and anemia.

More Risks By Age

Prematurity and low birth weight are other factors that put an infant at risk for IDA.
Before birth, full-term, normal-weight babies have developed iron stores that can last
them 4 to 6 months. Because preemies don't spend as much time in the uterus getting
nutrients from the mother's diet, their iron stores are not as great and are often
depleted in just 2 months.

Kids between 1 and 3 years old are at risk of iron deficiency and iron-deficiency anemia,
even though it isn't a period of exceptional growth. Most toddlers are no longer
consuming iron-fortified formula and infant cereal, and they aren't eating enough iron-
rich foods to make up the difference. Toddlers also tend to drink a lot of cow's milk,
often more than 24 ounces a day, an amount that injures the lining of the stomach
causing chronic blood loss leading to iron deficiency.

During the first stages of puberty, when a lot of growth occurs, boys are at risk of iron
deficiency anemia. But adolescent girls are at higher risk than boys for IDA because of
smaller iron stores and the iron lost in the blood in their monthly menstrual flow. Many
girls also tend to consume a diet low in iron.

Symptoms

Many kids with iron deficiency don't show any symptoms because the body's iron stores
are depleted slowly. As the anemia progresses, you may recognize some of the following
symptoms in your child:

 fatigue and weakness

 pale skin and mucous membranes
 rapid heartbeat or a new heart murmur (detected in an exam by your child's
doctor)
 irritability
 decreased appetite
 dizziness or a feeling of being lightheaded
Rarely, a person with IDA may experience pica, a craving to eat nonfood items such as
paint chips, chalk, or dirt. Pica may be caused by a lack of iron in the diet.

Diagnosis

Iron-deficiency anemia is often first noticed during a routine exam. Because IDA
symptoms, such as fatigue and decreased appetite, are common to many conditions, the
doctor will need more information to make a diagnosis. If IDA is suspected, the doctor
will probably ask questions about your family's diet.

To diagnose iron deficiency, one of these blood tests will probably be done:

 A complete blood count (CBC) may reveal low hemoglobin levels and low
hematocrit (the percentage of the blood made up of RBCs). The CBC also gives
information about the size of the RBCs; those with low hemoglobin tend to be smaller
and each cell contains less hemoglobin.
 The reticulocyte count measures how fast these immature RBCs are produced. In
IDA, they're made too slowly in the bone marrow to reach a normal level.
 Serum iron directly measures the amount of iron in the blood, but may not
accurately reflect how much iron is concentrated in the body's cells.

 Serum ferritin reflects total body iron stores. It's one of the earliest indicators of
depleted iron levels, especially when used in conjunction with other tests, such as a
CBC.

The doctor may also do a stool test because IDA can be caused by gradual loss of small
amounts of blood through the gastrointestinal tract. Since the blood may not be visible,
a stool sample is placed on a special paper card and a drop of testing solution is applied.
A color change indicates the presence of blood.

Treating Iron Deficiency Anemia

Even though most cases of IDA are the result of poor dietary iron intake, diet changes
alone usually aren't enough to replenish depleted iron stores. Likewise, multivitamins
with iron aren't adequate for kids with IDA who have such low iron stores, so a separate
daily iron supplement may be required.

It's extremely important to remember that your child should not be given potent iron
supplements without first consulting a doctor. Taking too much iron is a major cause of
serious poisoning in children, according to the American Academy of Pediatrics (AAP).

Iron is best absorbed on an empty stomach, because it can occasionally cause stomach
upset. Kids who experience stomach problems when taking iron supplements may need
to take them with a small amount of food. Iron should not, however, be given with milk
or caffeinated beverages, which will interfere with absorption. Vitamin C enhances iron
absorption, so try to include plenty of sources of vitamin C in your child's diet.

After the first month on iron supplements, your doctor may want to repeat the blood
tests to check that hemoglobin and hematocrit levels are improving. If there's a good
response, the doctor will probably continue the iron supplement for several more
months. Once corrected, iron stores can be maintained with an iron-rich diet. About 6
months after discontinuing iron therapy, the doctor may want to recheck your child's
hemoglobin.

Rarely, IDA is so severe and possibly life-threatening that hospitalization and a blood
transfusion may be required.

Caring for Your Child

The effects of IDA will depend on the duration and severity of the anemia. If left
untreated, it may lead to behavioral or learning problems. These may not be reversible,
even with later iron supplementation.

But in most cases, IDA is preventable by following some basic recommendations:

 Infants younger than 1 year old should drink only breast milk or an infant formula
supplemented with iron. It is important for breastfed infants to receive iron-fortified
solid foods starting at about 6 months of age.

 Kids under 2 years old should have no more than 24 ounces of cow's milk a day.
As noted earlier, milk can inhibit absorption of iron, and drinking too much milk can
dampen a child's appetite for other iron-rich foods. In addition, too much cow's milk
has been shown to irritate the gastrointestinal tract, which may cause intestinal
bleeding — a cause of iron loss.

 Iron-fortified products such as cereal can be a great way to get kids — especially
those under 2 years old — to get more iron.

 A variety of foods can provide great sources of iron: lean meats; egg yolks;
broccoli, spinach, and other green leafy vegetables; dried peas and beans; blackstrap
molasses; raisins; and whole-grain bread.

 Make sure kids or teens on a vegetarian diet get enough iron. Because iron from
meat sources is more easily absorbed than iron from plant sources, you may need to
add iron-fortified foods to their diet.
Proper nutrition, which includes a diet rich in iron, is important for all kids. Establishing
good eating habits early in life will help to prevent iron deficiency and iron-deficiency
anemia.

Reviewed by: Christopher N. Frantz, MD

Date reviewed: October 2010
Iron Deficiency Anemia: Risk, Symptoms and Treatment
Elizabeth M. Ross, M.D., L.D.N.
 
Dr. Ross is Assistant Professor of Medicine and Scientist, Human Nutrition Research Center on
Aging, Tufts University Schools of Medicine and Nutrition. 
This article is based on material first published in Nutrition in Clinical Care Vol. 5: Sept/Oct, 2002.

Iron deficiency is a common problem, especially for women, so common, in fact, that 5% of women
between the ages of 20 and 49 have iron deficiency with anemia and 11% have iron deficiency without
anemia.(1) 

Anemia has a complicated technical definition, but in simple terms it means that a person's blood contains a
lower than normal amount of red blood cells or other elements that help transport oxygen throughout the
body. Often caused by a lack of iron, anemia gradually starves the body of the oxygen it needs, leading to
symptoms such as extreme skin pallor, shortness of breath, heart palpitations and fatigue. 

Why We Need Iron

What many people don't know, however, is that iron plays a key role not only in the body's oxygen transport
and delivery system, but also in the regulation of metabolism. Iron is needed to synthesize vital substances
such as the brain chemical, dopamine, DNA and white blood cells. Thus iron deficiency can do much more
harm than merely causing anemia; it can have widespread effects — from damaging a person's ability to
think to weakening their resistance to infection. 

It is a common misconception that the amount of iron our bodies absorb is directly related to the amount of
iron we eat. While we do get most of our iron through food, getting enough iron is not quite as simple as
eating well. For one thing, the ability of our digestive systems to absorb iron from the food we eat varies; for
instance, those who are iron deficient do not absorb iron as well as those who are not. 

Because dietary iron comes in different forms, the percentage of dietary iron absorbed depends on the type
of food we eat and what other foods are being eaten at the same time. For example, iron from meat is easier
for the body to absorb than iron from vegetable and other sources. In addition, iron absorption can be greatly
increased or decreased by various factors. Certain salts, which store iron and other minerals in plant matter,
interfere with the ability of the human intestine to absorb them. Chemicals called polyphenols in tea, coffee,
cocoa, spinach and oregano inhibit iron absorption as well. Eating more ascorbic acid, which is common in
fruits, vegetables and fortified cereals, can improve iron absorption. Calcium inhibits the absorption of iron by
an unknown mechanism. This is probably why studies show a correlation between high milk intake and iron
deficiency. 
Who Is at Risk for Iron Deficiency?
Women in their childbearing years have greater iron needs than men as a result of menstrual blood loss, the
increased iron demands of pregnancy and blood loss during childbirth. In addition, anything that causes
heavier than normal menstrual periods, for example uterine fibroids, may lead to iron deficiency. Adolescent
girls are at particular risk because, out of concern for their weight, many follow diets that reduce the amount
of meat they eat at a time in their lives when their iron needs are increasing. Iron deficiency can also be
caused by other types of chronic blood loss including internal bleeding from gastritis and ulcers, inflammatory
bowel disease, parasitic infections (this is more common in Third World populations than developed
countries) and hemorrhoids. 

The best way to prevent iron deficiency is to educate yourself about your iron needs and the best iron
sources, and to use this knowledge to make sure dietary intake keeps pace with your body's demands.
Recommended dietary allowances (RDAs) for men over the age of 19 and women over the age of 51 are 8
mg per day; for women ages 19 to 50, the RDA is 18 mg per day.(2) In the typical American diet, major
sources of iron are meat, poultry, fish, nuts and seeds, legumes and bean products, green leafy vegetables,
raisins, whole grains and fortified cereals. The iron content of some popular high iron foods is shown in Table
1. 

Table 1.
Iron Content of Selected High-iron Foods.

Food Portion Size Iron (mg)

Total® cereal 1 cup 18

Grape Nuts® cereal 1/2 cup 8.2

Instant plain
1 packet 6.7
oatmeal

Wheat germ 1 ounce (1/4 cup) 2.6

Broccoli 1 medium stalk 2.1

Baked potato 1 medium 2.7

Spinach 1 cup raw 0.8

Dried peach 5 halves 2.6

Raw tofu 1/2 cup 4

Lentils 1/2 cup 3.3

Kidney beans 1/2 cup 2.6

 Chickpeas 1/2 cup 2.4

Beef chuck 3 ounces 3.2

Dark meat turkey 3 ounces 2.0

Blackstrap molasses 1 tablespoon 5.0

Iron deficiency anemia (or iron deficiency anaemia) is a common type of anemia, and is known
as sideropenic anemia. It is the most common cause of microcytic anemia.

Iron deficiency anemia occurs when the dietary intake or absorption of iron is insufficient, and
hemoglobin, which contains iron, cannot be formed. [1] In the United States, 20% of all women of
childbearing age have iron deficiency anemia, compared with only 2% of adult men. [2]The principal
cause of iron deficiency anemia in premenopausal women is blood lost during menses. Iron
deficiency anemia can be caused by parasitic infections, such as hookworms. Intestinal bleeding
caused by hookworms can lead to fecal blood loss and heme/iron deficiency. [3] Chronic inflammation
caused by parasitic infections contributes to anemia during pregnancy in most developing countries. [4]

Iron deficiency anemia is an advanced stage of iron deficiency. When the body has sufficient iron to
meet its needs (functional iron), the remainder is stored for later use in the bone marrow, liver,
and spleen as part of a finely tuned system of human iron metabolism. Iron deficiency ranges from
iron depletion, which yields little physiological damage, to iron deficiency anemia, which can affect the
function of numerous organ systems. Iron depletion causes the amount of stored iron to be reduced,
but has no effect on the functional iron. However, a person with no stored iron has no reserves to use
if the body requires more iron. In essence, the amount of iron absorbed and stored by the body is not
adequate for growth and development or to replace the amount lost.

Symptoms and Signs

Iron deficiency anemia (BEETUS) is characterized by pallor (reduced amount of oxyhemoglobin in

skin or mucous membrane), fatigue and weakness. Because it tends to develop slowly, adaptation
occurs and the disease often goes unrecognized for some time. In severe cases, dyspnea (trouble
breathing) can occur. Unusual obsessive food cravings, known as pica, may develop. Pagophagia or
pica for ice is a very specific symptom and may disappear with correction of iron deficiency anemia.
Hair loss and lightheadedness can also be associated with iron deficiency anemia.

Other symptoms and signs of iron deficiency anemia include:

 Constipation
 Sleepiness
 Tinnitus
 Palpitations
 Hair loss
 Fainting or feeling faint
 Depression
 Breathlessness on exertion.
 Twitching muscles
 Tingling, numbness, or burning sensations
 Missed menstrual cycle
 Heavy menstrual period
 Slow social development
 Glossitis (inflammation or infection of the tongue)
 Angular cheilitis (inflammatory lesions at the mouth's corners)
 Koilonychia (spoon-shaped nails) or nails that are weak or brittle
 Poor appetite
 Pruritus (Itchiness)
 Dysphagia due to formation of esophageal webs (Plummer-vinson syndrome).
 Angular stomatitis
 RLS (Restless Leg Syndrome)
[edit]Infant development
Iron deficiency anemia for infants in their earlier stages of development may have significantly greater
consequences than it does for adults. An animal made severely iron deficient during its earlier life
cannot recover to normal iron levels even with iron therapy. In contrast, iron deficiency during later
stages of development can be compensated with sufficient iron supplements. Iron deficiency anemia
affects neurological development by decreasing learning ability, altering motor functions, and
permanently reducing the number of dopaminereceptors and serotonin levels. Iron deficiency during
development can lead to reduced myelination of the spinal cord, as well as a change in myelin
composition. Additionally, iron deficiency anemia has a negative effect on physical growth. Growth
hormone secretion is related to serum transferrin levels, suggesting a positive correlation between
iron-transferrin levels and an increase in height and weight.

[edit]Cause

The diagnosis of iron deficiency anemia requires further investigation as to its cause. Iron deficiency
can be caused by increased iron demand or decreased iron intake [5], and can occur in both children
and adults. It can be a sign of other disease, such as colon cancer, which will cause the loss of blood
in the stool. In adults, 60% of patients with iron deficiency anemia may have underlying
gastrointestinal disorders leading to chronic blood loss. In addition to dietary insufficiency,
malabsorption, chronic blood loss, diversion of iron to fetal erythropoiesisduring pregnancy,
intravascular hemolysis and hemoglobinuria or other forms of chronic blood loss should all be
considered. Other common causes include gastrointestinal blood loss due to drug therapy (often in
the case of NSAIDs or aspirin), hypochlorhydria/achlorhydria (often due to long-term proton pump
inhibitor therapy) and even rapid growth in babies or adolescents. [5]

[edit]Diagnosis

Anemia may be diagnosed from symptoms and signs, but when anemia is mild it may not be
diagnosed from mild non-specific symptoms. Anemia is often first shown by routine blood tests, which
generally include a complete blood count (CBC). A sufficiently low hemoglobin (HGB)
or hematocrit (HCT) value is characteristic of anemia, and further studies will be undertaken to
determine its cause and the exact diagnosis. One of the first abnormal values to be noted on a CBC
will be a high red blood cell distribution width (RDW), reflecting a varied size distribution of red blood
cells (RBCs). A low MCV, MCH or MCHC, and the appearance of the RBCs on visual examination of
a peripheral blood smear will narrow the diagnosis to amicrocytic anemia. The blood smear of a
patient with iron deficiency shows many hypochromatic and rather small RBCs, and may also
show poikilocytosis (variation in shape) andanisocytosis (variation in size). With more severe iron
deficiency anemia the peripheral blood smear may show target cells, hypochromic pencil-shaped
cells, and occasionally small numbers of nucleated red blood cells. [6] Microcytic anemia can also be
the result of malabsorption phenomena associated with celiac disease.

The diagnosis of iron deficiency anemia will be suggested by appropriate history (e.g., anemia in a
menstruating woman), and by such diagnostic tests as a low serum ferritin, a lowserum iron level, an
elevated serum transferrin and a high total iron binding capacity (TIBC). Serum ferritin is the
most sensitive lab test for iron deficiency anemia.
Change in lab values in iron deficiency anemia
Change Parameter
Decrease ferritin, hemoglobin, MCV
Increase TIBC, transferrin, RDW

Iron deficient anemia and thalassemia minor present with many of the same lab results. It is very
important not to treat a patient with thalassemia with an iron supplement as this can lead
to hemochromatosis (accumulation of iron in various organs especially liver). A hemoglobin
electrophoresis would provide useful evidence in distinguishing these two conditions, along with iron
studies.

[edit]Gold standard
Traditionally, a definitive diagnosis requires a demonstration of depleted body iron stores by
performing a bone marrow aspiration, with the marrow stained for iron.[7][8] Because this is invasive
and painful, while a clinical trial of iron supplementation is inexpensive and non-traumatic, patients
are often treated based on clinical history and serum ferritin levels without a bone marrow biopsy.
Furthermore, a study published April 2009 [9] questions the value of stainable bone marrow iron
following parenteral iron therapy.

[edit]Treatment

If the cause is dietary iron deficiency, iron supplements, usually with iron(II) sulfate, ferrous gluconate,
or iron amino acid chelate ferrous bisglycinate, synthetic chelate NaFerredetate,EDTA will usually
correct the anemia.

Recent research suggests the replacement dose of iron, at least in the elderly with iron deficiency,
may be as little as 15 mg per day of elemental iron. An experiment done in a group of 130 anemia
patients showed a 98% increase in iron count when using an iron supplement with an average of
100 mg of iron. Women who develop iron deficiency anemia in mid-pregnancy can be effectively
treated with low doses of iron (20–40 mg per day). The lower dose is effective and produces fewer
gastrointestinal complaints.
Many tests have shown that iron supplementation can lead to an increase in infectious
disease morbidity in areas where bacterial infections are common. For example, children receiving
iron-enriched foods have demonstrated an increased rate in diarrhea overall and enteropathogen
shedding. Iron deficiency protects against infection by creating an unfavorable environment for
bacterial growth. Nevertheless, while iron deficiency might lessen infections by certain pathogenic
diseases, it also leads to a reduction in resistance to other strains of viral or bacterial infections, such
as Salmonella typhimurium or Entamoeba histolytica. Overall, it may be concluded that iron
supplementation can be both beneficial and harmful to an individual in an environment that is prone to
many infectious diseases.

There can be a great difference between iron intake and iron absorption, also known
as bioavailability. Scientific studies indicate iron absorption problems when iron is taken in
conjunction with milk, tea, coffee and other substances. There are already a number of proven
solutions for this problem, including:

 Fortification with ascorbic acid, which increases bioavailability in both presence and absence
of inhibiting substances, but which is subject to deterioration from moisture or heat. Ascorbic acid
fortification is usually limited to sealed dried foods, but individuals can easily take ascorbic acid
with basic iron supplement for the same benefits.
 Microencapsulation with lecithin, which binds and protects the iron particles from the action of
inhibiting substances. The primary benefit over ascorbic acid is durability and shelf life, particularly
for products like milk which undergo heat treatment.
 Using an iron amino acid chelate, such as NaFeEDTA, which similarly binds and protects the
iron particles. A study performed by the Hematology Unit of the University of Chile indicates that
chelated iron (ferrous bis-glycine chelate) can work with ascorbic acid to achieve even higher
absorption levels
 Separating intake of iron and inhibiting substances by a couple of hours.
 Using goats' milk instead of cows' milk.
 Gluten-free diet resolves some instances of iron-deficiency anemia, especially if the anemia is
a result of celiac disease.
 It is believed[10][11] that "heme iron”, found only in animal foods such as meat, fish and poultry, is
more easily absorbed than "non-heme" iron, found in plant foods and supplements.
Iron bioavailability comparisons require stringent controls, because the largest factor affecting
bioavailability is the subject's existing iron levels. Informal studies on bioavailability usually do not
take this factor into account, so exaggerated claims from health supplement companies based on this
sort of evidence should be ignored. Scientific studies are still in progress to determine which
approaches yield the best results and the lowest costs.

If anemia does not respond to oral treatments, it may be necessary to administer

iron parenterally (e.g., as iron dextran) using a drip or hemodialysis. Parenteral iron involves risks of
fever, chills, backache, myalgia, dizziness, syncope, rash and anaphylactic shock. A follow up blood
test is essential to demonstrate whether the treatment has been effective.

Iron supplements should be kept out of the reach of children, as iron-containing supplements are a
frequent cause of poisoning in children.

[edit]Effect of vitamin and mineral supplements

There is an observed correlation between serum retinol and hemoglobin levels. Women with a low
serum retinol concentration are more likely to be iron-deficient and anemic, compared to those with
normal to high levels of retinol. While vitamin A deficiency has an adverse effect on hemoglobin
synthesis, even a slight increase in vitamin A intake can lead to a significant rise in hemoglobin
levels. However, vitamin A is less effective in alleviating severe iron-deficiency anemia. Low levels of
iron in the body cannot be relieved by vitamin A supplementation alone. Additionally, a low ascorbic
acid stores in the body causes an impairment in the release of stored iron in
the reticuloendothelial cells. Copper is necessary for iron uptake, and acopper deficiency can result in
iron deficiency. Copper deficiency can sometimes be caused by excessive zinc or vitamin
C supplementation.

[edit]