Iron-Deficiency Anemia in Kids: When to Screen, How to Confirm, and What to Do

Iron-deficiency anemia (IDA) is common in early childhood and often silent. Universal screening catches kids before learning and behavior are impacted.

Universal vs. Selective Screening

Universal screening is recommended.

• All children: screen once at 9–12 months.

• If a child is on iron-fortified formula and otherwise low risk, you can consider screening at 15–18 months(often useful after the transition to cow’s milk).

High-risk groups (consider earlier/repeat screening):

• Excessive cow’s-milk intake

• Prematurity/low birth weight

• Special health needs: chronic infection/inflammation, chronic GI dysfunction, restricted diets, other dietary risk factors for IDA

Repeat screening (when appropriate):

• 15–18 months for high-risk children

• 15–18 months and again at 2–5 years for children with special health needs or ongoing dietary risks

Age-Based Anemia Thresholds (Hgb, g/dL)

• 6 months to <5 years: <11.0

• 5 to <12 years: <11.5

• 12 to <15 years: <12.0

How to Screen (and Confirm)

• CBC is preferred. If CBC isn’t available, Hgb alone is acceptable for screening.

• Add ferritin when you can—it detects iron deficiency before anemia develops.

  • Tip: Ferritin is an acute phase reactant; consider checking CRP if the child is ill to avoid false-normal ferritin.

If Hemoglobin Is Low: Next Steps

1. Focused history & exam

   • Diet (excess cow’s milk? prolonged exclusive breastfeeding without iron?)

   • Lead exposure, pica

   • GI symptoms or blood loss, chronic illness, family history of anemia/hemoglobinopathy

2. Confirm

   • Repeat CBC to rule out a one-off or lab error.

   • If atypical for IDA (microcytosis not present, normal RDW, etc.), start a broader workup (iron studies, lead level, hemoglobin electrophoresis, GI evaluation as indicated).

3. If typical for IDA (common pattern: child <3 years, dietary risk, no evidence of lead toxicity, otherwise healthy):

   • Trial of oral iron + dietary counseling

   • Dose: elemental iron 3 mg/kg/day (once daily or divided)

     • Usual range 3–6 mg/kg/day elemental iron; start low for tolerance.

   • Response goal: Hgb rises >1 g/dL in ~4 weeks

     • If yes → continue iron 1–2 months after Hgb normalizes to replete stores.

     • If no rise → reassess adherence, dosing, absorption (milk timing), ongoing blood loss; then broaden evaluation.

Practical Prescribing (copy/paste)

Example order (liquid):

Pearl: Calculate by elemental iron, not total ferrous sulfate. (220 mg ferrous sulfate per 5 mL ≈ 44 mg elemental per 5 mL.)

Parent Counseling Tips (that actually help)

• Limit cow’s milk to <16–24 oz/day; too much displaces iron-rich foods and reduces absorption.

• Give iron with vitamin C (fruit/juice) and avoid milk/calcium 1–2 hours around the dose.

• Expect dark stools and possible mild constipation; use fiber, fluids, prune/pear juice.

• Use a syringe for dosing (accuracy > kitchen spoons); rinse/brush teeth after liquid iron to prevent staining.

• Keep iron out of reach—overdose can be dangerous.

EMR SmartPhrase (drop in your note)

Quick FAQ

• Universal or selective? Universal at 9–12 months; repeat for high-risk kids.

• Ferritin worth it? Yes—catches deficiency before anemia (watch for inflammation).

• How fast should Hgb rise? About >1 g/dL in 4 weeks on adequate elemental iron.

References (for clinicians)

• American Academy of Pediatrics (AAP). Iron deficiency and iron-deficiency anemia in infants and young children—screening and prevention guidance.

• CDC. Iron deficiency/IDA resources for clinicians.

• UpToDate. Evaluation and treatment of iron deficiency in infants and children.

Education only; follow your local/state requirements and clinic protocols. Use clinical judgment for special populations.

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