Anaemia (weak blood) in children and youth ⚠️

                               

  • Low iron in infancy and childhood delays development and learning — prevention is vital
  • Treatment should include home visits when possible for family support, help with feeding and nutrition and giving oral iron

Most common cause of anaemia is iron deficiency (low iron)

  • Reasons for low iron include
    • Low iron in mother before and during pregnancy
    • Low birth weight and/or preterm birth
    • Starting food later than 6 months, not enough food or iron-rich foods
    • Drinking cow’s milk before 1 year, drinking tea before 5 years
    • Recurrent infections
    • Hookworm — less common with regular de-worming

Prevention of iron deficiency in young children
  • Babies born with low iron stores are likely to become anaemic in their first 6 months
  • Babies at high risk of low iron stores  
    • Birth weight less than 2,500g and/or preterm babies (born less than 35 weeks)
    • Born to mothers who had anaemia and/or diabetes in pregnancy
    • Twin or multiple birth
    • Umbilical cord clamped immediately (within 30 seconds) after birth
    • Early introduction of complementary (solid) foods — before 4 months of age OR cow’s milk before 12 months of age
    • Delayed (after 7 months) introduction of iron rich complementary (solid) foods

Do not

  • Do not give cow’s milk (fresh, powdered or UHT) as a drink before 1 year — give breastmilk or appropriate infant formula only. Clean water can be given after 6 months
  • Do not give tea, sweet drinks, fruit juice to babies or young children

Do

  • Medical or child health nurse follow-up for all low birth weight or preterm babies on return to community

Oral iron supplementation

Iron doses throughout protocol are expressed as elemental iron 
  • Give supplementary oral iron from 1 month to 1 year of age to all infants* in communities where prevalence of anaemia is high
    • 2mg/kg per dose, twice per week supported in clinic
    • OR 1mg/kg per dose, once daily
    • Provide 2 weeks supply at a time — review uptake after 2 weeks
  • Check Hb level at 6 months (do not check before 6 months of age) — Table 3.8
    • If normal — continue preventative oral iron supplementation
    • If low — start treatment regimen — Table 3.9

*There are significant long term health benefits for preventive oral iron supplementation for all infants where prevalence of anaemia is high however organisations may limit supplementation to high risk infants based on local capacity — follow organisational policy

Dietary strategies

  • Encourage breastmilk only until around 6 months of age if unable to breastfeed provide infant formula
  • Continue breastfeeding on demand after 6 months and provide age appropriate iron rich foods several times day 
    • Encourage foods high in iron like red meats, chicken, fish, eggs, baked beans, smooth peanut butter
    • Encourage foods high in vitamin C like fruits and vegetables including bush foods  to help body absorb iron

Other strategies

  • Regular de-worming — where hookworm is or has been common
  • Prevent and treat anaemia in both pregnant and non-pregnant women 
  • Advise mothers that their smoking can contribute to iron deficiency anaemia in children. Provide information and encouragement to quit

Screening and treatment of anaemia 

  • Check Hb every 6 months from 6 months to 5 years — use non-invasive testing where available
    • Hb testing not needed before 6 months
    • Make sure POC Test machine well maintained and calibrated, collection done correctly — see Testing haemoglobin
  • Treat and follow-up all children with anaemia
  • Most anaemia in children is due to low iron — FBC usually not needed
  • Do FBC if
    • Hb less than 90g/L
    • Still has anaemia after treatment with iron medicine
    • Child unwell — signs like bruising or bleeding

Diagnosis

Table 3.8   Diagnosis of anaemia — using POC Test Hb by age
  • FBC suggests iron deficiency if
    • Hb on FBC low for age
    • Mean cell volume (MCV) less than 72fL, red cell volume distribution width (RDW) more than 16%
    • Blood film shows a hypochromic-microcytic picture
  • Iron studies usually not needed

Ask

  • About diarrhoea and other sickness
  • About diet — usual food and drinks (including breastmilk) each day
  • When foods were started — in particular high iron foods and cow’s milk 
  • About family supports — money, social situation
  • Who is responsible for feeding child and who else could help

Check

  • Calculate age-appropriate REWS — AVPU, respiratory distress, RR, O2 sats, pulse, central capillary refill time, Temp
  • Weight, BGL
  • Measure height and weight and plot on growth chart
  • Head-to-toe exam
  • Immunisation status

Treatment of anaemia

Do not

Treat anaemia when child is acutely unwell

Do

  • Treat anaemia if present — Table 3.9 AND look for and manage other problems (eg growth faltering)
  • Give albendazole oral, single dose
    • 6–11 months — 200mg
    • 1 year and over — 400mg
    • Do not give in first trimester of pregnancy (pregnancy test if not sure) without medical consult
  • Encourage healthy eating including high-iron foods 

Table 3.9   Hb level and what to do

Medicines
  • Iron medicine is dangerous in overdose — need to keep in childproof container, in a safe place

Oral Iron

  • Oral iron medicine must be given for full 3 months when treating anaemia
  • Give iron, oral
    • If mild-moderate anaemia (Hb more than 80g/L) for child 29kg or under — 3mg/kg/d, once a day for 3 months  — Table 3.10 for quick dose reference
    • If severe anaemia (Hb less than 80g/L) for child 20kg or under — 6mg/kg/d, once a day for 3 months — Table 3.11 for quick dose reference
    • If child over 30kg (mild-moderate or severe anaemia) —  1 iron tablet (80–105mg elemental iron) once a day for 3 months 
    • Give iron once a day if possible — provide 2 weeks supply at a time — review after 2 weeks
    • OR give daily dose twice a week under supervision in clinic or community

Table 3.10 Ferro-Liquid treatment doses (6mg/mL) for children up to 30kg, with Hb more than 80g/L

Table 3.11 Ferro-Liquid treatment doses (6mg/mL) for children up to 30kg, with Hb less than 80g/L 

Children and youth with Hb less than 80g/L need — medical consult

Iron by IM injection

  • IM iron can very rarely cause anaphylaxis
  • Do not give if fever (Temp more than 38°C) or very unwell
  • Give every second day (alternate days) until total dose given 
    • Do not give more than maximum dose per day
  • Use iron polymaltose (eg Ferrum H, Ferrosig) only
  • Use z-track technique — ventrogluteal or anterolateral thigh
  • Carefully review child's file notes and check with carer to find out if anaemia has been treated in past 3 months — 
    • Hb may still be rising from previous iron doses

Table 3.12 Iron polymaltose (eg Ferrum H, Ferrosig) IM Injection by weight and Hb level (50mg/mL strength)  

Iron by IV infusion

  • If 3 or more IM injections needed —  medical consult to consider giving iron in hospital by IV infusion

Follow-up

  • Recheck Hb — Flowchart 3.3
  • Always encourage healthy diet with foods high in iron every day

Flowchart 3.3 Checking Hb after iron treatment

  • If total dose not given but Hb in normal range after 6 weeks — recheck in another 4 weeks
  • If treatment course is not completed and Hb remains low
    • Check caregivers have iron supplements and if any barriers to use
    • Attempt oral iron twice within a one week timeframe then medical consult to consider FBC, iron studies and IV iron