Iron Deficiency Anemia in Kids

You’ve just heard the news from your child’s pediatrician — your child has anemia. Should you worry? 

Not usually, says Rachel Bercovitz, MD, MS, attending physician in hematology, oncology, neuro-oncology and stem cell transplantation at Lurie Children’s. Iron deficiency anemia is the most common anemia type in children and adolescents, and it’s treatable, she says. 

Here, Dr. Bercovitz shares what you need to know about anemia in kids and how healthcare providers treat this condition.

What is anemia? 

Red blood cells are like bags that contain a protein called hemoglobin. Children with anemia don’t make enough red blood cells or don’t have enough hemoglobin. Hemoglobin helps carry oxygen throughout the body. Healthcare providers take a blood sample to check the amount of red blood cells and hemoglobin in your child’s blood to determine if they have anemia. 

What is iron deficiency in kids? 

Iron is a mineral that helps red blood cells make hemoglobin. Think of iron as a building block for these cells. Without enough of this needed building block, your child’s body can’t make enough red blood cells. Some children have iron deficiency but don’t have anemia. Talk to your pediatrician if your child has iron deficiency.

About 1 in 5 children up to age 4 develop iron deficiency anemia. The condition is also common in adolescents who menstruate. However, “in most children, especially those who don’t have symptoms, it’s unlikely that a severe disease is the cause of anemia,” she says.

Types of Anemia

Nutrition problems, certain health conditions and genes you get from your parents can cause different types of anemia. Anemia types include:

Anemia Due to Nutritional Deficiencies

Your child needs different nutrients to make red blood cells, including iron, vitamin B12 and folate. 

Iron deficiency can cause a type of anemia where red blood cells are small and don’t have enough hemoglobin (microcytic anemia). Iron deficiency anemia is the most common microcytic anemia. 

Deficiencies in vitamin B12 and folate, while rare in children, cause a different type of anemia (macrocytic anemia). Children who have macrocytic anemia have small red blood cells because of changes in how their bodies build them.

Hemolytic Anemia

Hemolytic anemia happens when red blood cells die more quickly than your body can replace them. Some children are born with hemolytic anemias. Other hemolytic anemias develop on their own sometime after your baby is born. These anemias may arise if your child has conditions such as:

• Autoimmune disorders 
• Bone marrow failure
• Infections

How do healthcare providers diagnose anemia in children?

Healthcare providers typically diagnose iron deficiency anemia using a blood test. Most children have an anemia screening between 9 and 15 months old. Your child’s pediatrician typically pricks their finger and takes a small blood sample to check their hemoglobin levels. Older children and adolescents usually only have these blood tests when anemia symptoms are present.

A normal blood hemoglobin level is about 11 to 14 grams per deciliter (g/dL), depending on your child’s age. Hemoglobin levels that are lower than is typical for your child’s age may mean they have anemia. 

What causes iron deficiency in children?

The most common anemia in children, iron deficiency anemia, is always caused by a lack of iron in the blood. But what causes children to become iron deficient? Iron deficiency may occur for different reasons.

Iron Deficiency Anemia in Young Children

Iron deficiency may occur in young children who avoid iron-rich foods like meats and vegetables, especially if they drink a lot of cow’s milk. Milk doesn’t contain iron and can prevent the body from absorbing iron. According to Dr. Bercovitz, toddlers who drink more than 24 ounces of milk each day are at the highest risk for iron deficiency.

Anemia in Kids Who Menstruate

Blood loss from menstruation can cause iron deficiency anemia in some kids. Iron leaves the body faster than the body can replace it in kids who experience heavy periods. 

Health Conditions That Cause Iron Deficiency Anemia

Anemia can develop when your child has a health condition that causes bleeding or affects how they absorb iron from foods. Health conditions that can cause iron deficiency anemia include:

• Bloody stools (poop) 
• Celiac disease
• Crohn’s disease
• Gastric ulcer due to bacterial infection (H. pylori)
• Severe nosebleeds
• Ulcerative colitis

Thalassemia Trait

Some children have a genetic change (mutation) that affects how they make hemoglobin, which could cause anemia. One such mutation is thalassemia trait. Children with thalassemia trait inherit this mutation from one or both of their parents. Thalassemia trait can cause mild microcytic anemia that the child will have for their whole life. Thalassemia trait is rare and is diagnosed by examining hemoglobin inside red blood cells. Talk to your child’s hematologist about what to expect if they have thalassemia trait. 

Symptoms of Anemia in Children

Anemia in kids can cause symptoms like: 

• Breathing problems (shortness of breath)
• Confusion and irritability
• Headaches and dizziness
• Pale skin 
• Tiredness (fatigue)

Most young children don’t have symptoms unless they’re severely anemic. Severe anemia is a hemoglobin level of less than 7 g/dL, according to Dr. Bercovitz. “Toddlers are typically very active,” she says. “Most parents aren’t going to identify their child as anemic until they’re very anemic.” Older children and adolescents are more likely to show symptoms than young children are.

Treatment for Iron Deficiency Anemia 

Healthcare providers treat anemia with iron supplements for kids. The amount of iron — and how it’s taken — depends on your child’s age. 

How much iron do kids need? 

Your child may have one or two doses of an iron supplement per day (totaling 3 to 6 milligrams [mg] of iron per kilogram [kg] of body weight). Pediatricians typically recommend liquid iron supplements for young children who can’t swallow pills.

“Once a child has iron deficiency anemia, it doesn’t matter if they eat a diet of iron-rich foods like kale and liver,” Dr. Bercovitz says. “They require iron supplementation. One of the hardest things is that liquid iron tastes terrible, and it's hard to mask in any sort of liquid.” 

Taking iron with orange juice can help increase iron absorption, she says. Give iron supplements with orange juice just before a meal. Dairy products and foods high in calcium can block iron absorption, so avoid giving them right after your child takes iron supplements. 

Treating Anemia in Kids Who Menstruate

Kids who menstruate and have iron deficiency anemia can take iron pills. A typical dose is one 325 mg tablet containing 65 mg of elemental iron each day.

Iron supplementation alone, though, may not be enough. It’s also important to reduce the amount of iron lost through menstrual periods, according to Dr. Bercovitz. Prescription birth control pills can help reduce menstrual bleeding, including the number of days a person menstruates. It may be best for some kids to prevent menstrual periods completely by using hormonal birth control methods, such as the:

• Birth control patch 
• Birth control shot 
• Hormonal intrauterine device (IUD)

“I tell families to imagine the body is a bathtub, and you're trying to fill it with iron,” says Dr. Bercovitz. “Having your period is like leaving the drain open. No matter how much supplemental iron you give, you’re not going to be able to fill the tub.”

Side Effects of Iron Supplements

Supplemental iron can cause certain side effects. Your child may experience:

• Constipation
• Nausea
• Stomach pain

How long will my child need iron supplements? 

Kids need about three months of supplemental iron to rebuild their iron stores and restore normal hemoglobin levels. Follow up with your child’s pediatrician after they’ve been on iron supplements for three months, Dr. Bercovitz says. 

When should a pediatric hematologist see kids with anemia?

Pediatricians may refer care to a pediatric hematologist. This will likely happen when your child’s hemoglobin levels are still low after taking supplemental iron for three months. A pediatric hematologist will:

• Order a blood test (complete blood count) to check your child’s hemoglobin, platelet and white blood cell levels 
• Perform a physical examination
• Talk with you about others in your family who may have anemia 
• Test your child’s kidney and liver function

Complications of Iron Deficiency Anemia

Iron deficiency anemia can cause certain complications. Young children may experience delays in development. Older kids may experience fatigue that affects their athletic and academic performance. 

“Iron and red blood cells are important for all these things. That’s why it’s important to fix iron deficiency,” Dr. Bercovitz says. 

When is anemia an emergency?

Symptoms of hemolytic anemia are more likely to develop rapidly and be concerning, according to Dr. Bercovitz. “It’s a fast process,” she says. “When hemoglobin levels drop quickly, your child is going to have symptoms.”

Call your child’s pediatrician right away if they experience new:

• Dizziness or confusion
• Pale or yellow skin
• Trouble breathing

Sudden anemia symptoms could be a sign of rapid destruction of red blood cells (hemolysis). Hemolytic anemia may cause your child’s hemoglobin to drop quickly. 

Children with iron deficiency anemia typically experience a much slower decline in hemoglobin. Any anemia symptoms they have tend to develop more slowly and may not be noticeable right away, says Dr. Bercovitz.

Can I prevent iron deficiency anemia in my child? 

Talk to your pediatrician to see if a multivitamin with iron is right for your child. Serve only the recommended amount of milk each day and encourage your child to eat a variety of foods. 

Dr. Bercovitz says there’s no need to worry about iron deficiency if you’re breastfeeding a young infant. Babies get enough iron during fetal development to last about nine months. Once your baby is 9 months old, talk to your pediatrician about starting a multivitamin with iron. 

Learn more about anemia in children and pediatric hematology at Lurie Children’s. 

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