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Understand Childhood Cancers and Blood Disorders

Iron Deficiency

Red blood cells contain hemoglobin, a complex molecule made up of proteins and iron. It gives blood its red color and carries oxygen from the lungs to the cells and tissues of the body. The oxygen-rich blood helps all organs function properly and gives our skin, lips, and eyelids their healthy pink color. Red blood cells are made in the bone marrow - a soft, spongy material located inside many of our bones. The bone marrow is the factory that makes red blood cells, white blood cells, and platelets. Iron, along with some other vitamins (like folic acid and vitamin B12) is needed in order to manufacture normal hemoglobin and normal red blood cells.

When iron is not available, the result is iron-deficiency anemia. Iron deficiency anemia is the most common anemia in the world. Anemia results in pale skin (as well as the lining of the eyelids, and lips). Many patients complain of extra fatigue, weakness, and sometimes, shortness of breath. Other patients may experience dizziness or light-headedness and complain of cold hands and feet. In children, the most common complaints are headaches, pale appearance, fatigue, poor sleep at night and decreased appetite. Some patients have cravings for items that are not normal foods such as ice, paper, etc (this abnormal eating pattern is called pica). Brittle nails can sometimes occur in adults with iron deficiency anemia. Symptoms usually take a long time to develop. Iron deficiency does not result in symptoms until it becomes significant. Over the last 30 years a significant connection was found between iron deficiency and impaired development in behavior, cognition (learning), and psychomotor skills (mental development) in children who are deficient in iron. Many studies have confirmed the relationship between iron deficiency anemia and slightly delayed child development. Researchers are not sure how reversible this delay may be, so it is best to avoid iron deficiency altogether.

Sources of iron include food (mostly red meat, eggs, whole-grain and iron-fortified foods) and recycled iron. Red blood cells typically die out after about 120 days. The hemoglobin with those dead red blood cells is broken apart, and the iron is used to make fresh hemoglobin for new red blood cells.

Iron deficiency anemia happens as a result of -
  • Loss of blood - if blood is lost, iron is lost along with the blood. That can happen in young women with heavy or prolonged menstrual cycles, children with frequent, prolonged nosebleeds, or patients with chronic and slow blood loss from their gastrointestinal tract (because of ulcers, colitis, or other chronic gastrointestinal illness).
  • No iron in the diet - over time, if an individual eats only foods that do not contain iron, an iron deficiency can develop. We see this very often in little children who drink too many bottles of formula or milk in a day. Milk prevents the body from properly absorbing iron; milk also makes the child full so he or she may not wish to eat any other foods, leading to iron deficiency.
  • Iron is not taken up properly by the body- we mentioned earlier that milk slows down the absorption of iron into the body. Therefore, patients who use certain medications (such as antacids, proton-pump inhibitors, etc) can suffer iron deficiency as well. Finally, some patients with other gastrointestinal disorders (celiac disease, colitis, etc) often have an iron deficiency as well.
  • Normal pregnancy - iron deficiency develops in the course of normal pregnancy because the mother has an expanded blood volume and must also supply blood to her fetus.

Anemia of Chronic Illness

Sometimes a child can have an anemia that looks like an anemia of iron deficiency, but in fact is caused by another condition. When a child has chronic illness (for example, celiac Disease, chronic urinary infections, and many others), the body is unable to use the iron in its storage properly. Some of these chronic conditions may be very mild and therefore may be first picked up because of the anemia. The result is an anemia that "looks like" iron deficiency anemia, but is not cured with iron treatment. If the doctor suspects that your child has an anemia as a result of a chronic illness, other tests will be done in order to diagnose that illness. The successful treatment of this type of anemia is to treat the chronic condition causing it.

Diagnosing Anemia

In many cases, doctors don't diagnose anemia until they run a blood test called a complete blood count (CBC). A CBC may show that there are fewer red blood cells than normal (anemia). Other tests we sometimes use include:
  • Blood smear examination: Blood is spread on a glass slide and the doctor looks at the blood cells under a microscope. Red blood cells of children with iron deficiency are smaller than normal red cells.
  • Iron profile: This test tells the doctors about the iron that is available to make red blood cells as well as the iron stored in the body.
  • Hemoglobin electrophoresis: This test is used to detect some abnormal types of hemoglobin (e.g., Sickle hemoglobin, Thalassemia, and others). Some children with anemia may only have an inherited trait of Thalassemia that can be easily diagnosed with this test and requires no treatment.
  • Reticulocyte count: This is a test that tells the doctor if your child's body is making new or young red blood cells (called reticulocytes).
Your child's doctor may also ask about a family history of anemia and your child's symptoms and medications. This information can help the doctor to either perform other tests or look for specific diseases that may cause the iron deficiency anemia.

Treatment of Iron Deficiency Anemia

  • If you feel your child may have iron deficiency anemia, please take him/her to the doctor. Avoid giving iron to your child on your own because too much iron can cause problems, such as damage to the liver.
  • Sometimes all that is needed is a change in your child's diet. Gradually replacing bottles of milk with other foods (such as iron-fortified cereals, red meat, etc) may well do the trick quite effectively. We highly recommend this treatment because it is the most natural way to improve a mild anemia and avoid any side effects of iron.
  • On occasion, it is necessary to give extra iron (iron supplementation). Iron is available as drops, syrups, tablets, and even as a medication that can be given through the vein (IV). We rarely give IV iron because it can cause significant allergic reactions. Therefore it is wise to make every effort to give the child oral iron. But if your child will absolutely not take any oral iron and refuses to eat any red meat, we may consider giving him or her IV iron, if the anemia is truly very severe.
  • Oral iron is best given on an empty stomach because it is best absorbed that way.
  • Often, we will prescribe vitamin C along with the oral iron treatment to enhance iron absorption.
Iron treatment, like any medication, may have side effects. The most common side effects include -
  1. Constipation - make sure your child drinks more water. A child can also be given a mild stool softener to avoid this unpleasant side effect (examples include over-the-counter medication like Senokot or Colace, but if the constipation is severe, we may prescribe Miralax, a more powerful laxative). Occasionally, some patients have diarrhea when they take iron orally, so it is best to wait and see before starting your child on a stool softener.
  2. Other less common side effects of oral iron include stomach pain, nausea, vomiting, and abdominal cramps. If those occur, one way to improve symptoms would be to give the iron with meals. This may decrease the uptake of iron by the gut, but would still be far better than not taking the iron at all.
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