Author Dr Jenny James
Expert reviewer Dr Hasantha Gunesekara
This chapter reviews the evidence for the prevention of iron deficiency anaemia (IDA).
IDA is very common in Aboriginal and Torres Strait Islander children although data are lacking from many settings, particularly in urban areas. A prevalence of greater than 5% is considered by the World Health Organization to be of public health significance; the data that are available indicate rates of IDA in Aboriginal and Torres Strait Islander children in remote Australia are significantly higher.24,25 IDA is associated with developmental delay of cognitive and psychomotor functions. It is not clear whether the relationship is causal or associative.24,26–31 Morbidity from infectious disease is increased in iron deficient populations because of the adverse effect of iron deficiency on the immune system. IDA also increases the risk of heavy metal poisoning in children as iron deficient individuals have an increased absorption capacity for other heavy metals, including toxic metals such as lead and cadmium.32
Contributors to IDA in Aboriginal and Torres Strait Islander children are multifactorial and may include: low birthweight, prematurity and maternal anaemia, twin birth, poor quality and late introduction of weaning foods, high rates of infection and tropical enteropathy syndrome associated with failure to thrive, and cow’s milk in the first year.26,31–35 Moderate to severe infestations with hookworm, via intestinal blood loss, can also contribute to IDA.24,33,35,36
There are different approaches to the diagnosis of IDA. Haemoglobin (Hb) levels combined with erythrocyte indices are commonly used. Iron indices can also be measured. Another diagnostic pathway is to measure the response in Hb to oral iron therapy, without any measurement of iron indices. In Aboriginal and Torres Strait Islander children, anaemia is almost always caused by iron deficiency, and intercurrent rates of infection are high, making iron indices an unreliable indication of current iron stores. In Aboriginal and Torres Strait Islander children, anaemia is most commonly diagnosed by Hb and red cell indices.24,26,31,35 The prevalence of haemoglobinopathies as a cause for microcytic anaemia is low, but should still be considered as a possible cause, particularly in those in whom treatment for IDA fails to show an improvement in Hb.37
There is widespread agreement that Hb limits to define anaemia should differ according to age, gender and physiological status (eg. pregnancy), and for babies, whether they are breast or bottle fed. However, there are differing recommendations on the cutoff levels of haemoglobin for definition of anaemia. The Kimberley Aboriginal Medical Services Council defines anaemia in children aged 6–24 months as being Hb <105 g/L, and in children aged 2–11 years as being Hb <115 g/L. The Central Australian Rural Practitioners’ Association define anaemia in children from 6 months of age as being Hb <110 g/L. This has implications for treatment decisions.24,26,35,38–41
International guidelines state there is insufficient evidence to recommend either for or against universal screening for IDA in children.28,42 However, these guidelines draw attention to groups of children at high risk of anaemia and the subsequent importance of clinical assessment as a means of informing decisions about whether to screen. Some Australian guidelines recommend screening all Aboriginal and Torres Strait Islander children.35 Screening can be done with venous blood, but if there is good training and quality control, point-of-care testing can correlate well with the lab testing.24,35,43 Though Helicobacter pylori infection is associated with IDA in children, benefits of mass screening are not clear.44–46
Evidence differs with regards to whether chemoprophylaxis using oral iron supplementation should be offered universally, without screening, to children who are at high risk of IDA and who are older than 6 months. This is a preventive use of iron supplementation, aimed at preventing IDA,28,31,32,34,47 as opposed to using it only for therapeutic effect.24,26,35,48 This preventive rationale is sometimes considered in areas where there are high prevalence rates of anaemia in the communities of children under question.
There is good evidence to support the widespread use of multicomponent interventions that don’t involve medicinal iron supplementation in prevention of IDA. This includes delaying cord clamping beyond 3 minutes, which increases iron stores from birth.49–51 Multicomponent interventions need to be both early and often, and may also involve food based approaches, food and formula fortification, iron supplementation, treatment for hookworm, and integration of IDA prevention with other primary health prevention programs such as immunisation and micronutrient supplementation for children with failure to thrive. Interventions can be delivered through local healthcare providers including GPs and Aboriginal and Torres Strait Islander health workers, and through government funded nutritional supplementation programs.24,26,31,32,34,35,47,52
There is good evidence that oral iron supplementation has a beneficial effect on some cognitive domains in iron deficiency and IDA in children older than 6 years of age. Iron supplementation provided as ‘sprinkles’ shows promise,53-55 as it may have fewer side effects and improve adherence to daily iron supplementation. However, this has not been borne out in all studies.56 It is not clear whether oral iron supplementation in children with IDA younger than 6 years confers benefits on cognitive or motor development. There is considerable variation in the populations studied, and there are no studies assessing this outcome in Aboriginal and Torres Strait Islander communities.34,48,57
Exclusive breastfeeding until 6 months has many benefits and is currently recommended Australia wide,52,58 however, there are concerns that this may not provide enough iron to babies at increased risk of IDA.26,31,33 In such instances, introduction of iron fortified weaning foods at 4 months or supplementation with oral iron have been suggested. While IDA is often associated with failure to thrive in Aboriginal and Torres Strait Islander children, treatment of iron deficiency does not appear to improve growth.48,59
In children with a history of IDA, recurrence of IDA may occur. This has major implications for long term follow up of children, highlighting the importance of IDA prevention programs being managed not just by individual clinicians, but at the health service level.60–62
Guidelines make strong reference to the link between poverty and poor nutrition. In low income households nutrition counselling on its own is not recommended. However, it may be effective if combined with government funded nutritional support programs that remove financial barriers to improved nutrition.31,42,47,52,63
|Preventive intervention type||Who is at risk?||What should be done?||How often?||Level/strength of evidence|
||All children aged >6 months from communities with a high prevalence of iron deficiency anaemia (IDA)
Children in other areas with risk factors:
- history of low birthweight or pre-term birth
- maternal anaemia
- failure to thrive30,35
- chronic infections25
|Take a nutritional history asking about intake of iron rich foods such as meat and fortified cereals, leafy green vegetables and vitamin C intake with meals
||At age 6–9 months and repeat at 18 months
|Perform haemoglobin (Hb) via point-of-care capillary sample or venous blood (including blood film)*†
||Test at age 6–9 months and repeat at 18 months
|More frequent testing if IDA is diagnosed
||Babies born without risk factors for IDA (see below)
||Recommend exclusive breastfeeding to 6 months
|Babies born with low birthweight (<2500 g), prematurity (<37 weeks) or to mothers who had maternal anaemia
||Recommend exclusive breastfeeding to 4 months
||Introduce iron rich foods at weaning. Examples include meat (three serves per week), fortified cereals, leafy green vegetable, eaten with vitamin C rich food (eg. fresh citrus fruit)
Also discuss withholding cow’s milk until 12 months of age and avoiding tea
||Babies aged <6 months with IDA risk factors as above
||Consider oral iron supplementation in consultation with a paediatrician
|Children aged 6 months to 16 years in areas with high rates of hookworm infections
||Consider use of single dose albendazole as part of a systematic child health surveillance program in consultation with local public health units
Refer to Australian Therapeutic Guidelines for dosing regimen64
|Every 6 months
||Children with IDA
||Include children on recall registers for regular review and Hb repeat testing as per above
|Communities with a known high prevalence of IDA
||Advocate for and support nutritional programs that remove financial barriers to improved nutrition and improve the range and accessibility of healthy foods alongside the food strategies recommended above (see Chapter 1: Lifestyle, section on overweight/obesity)
||Immediately and ongoing
|* Diagnose IDA using erythrocyte indices (eg. blood film, mean cell volume) and Hb levels of less than 110 g/L in children over 6 months of age. Consult local laboratories for reference limits of Hb levels in children >2 years
† There are jurisdictional differences in the screening for anaemia (eg. Queensland and the Northern Territory) and local guidelines should be consulted
Iron deficiency anaemia assessment, prevention and control: a guide for programme managers (WHO)
www.who.int/ nutrition/publications/en/ ida_assessment_prevention_control.pdf.
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