Your browser has 'Cookies' disabled, alert boxes will continue to appear without this feature.

Clinical guidelines

National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people Second edition

Anaemia

Author Dr Jenny James
Expert reviewer Dr Hasantha Gunesekara

Background

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

Interventions

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

Recommendations: Anaemia
Preventive intervention typeWho is at risk?What should be done?How often?Level/strength of evidence
Screening 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
  • twin
  • 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 GPP28,42
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 GPP
More frequent testing if IDA is diagnosed IIC60,61
Behavioural Babies born without risk factors for IDA (see below) Recommend exclusive breastfeeding to 6 months Opportunistic IB26,31,52,58
Babies born with low birthweight (<2500 g), prematurity (<37 weeks) or to mothers who had maternal anaemia Recommend exclusive breastfeeding to 4 months GPP26,31,33
All babies 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
IB26,31,52,58
Chemoprophylaxis   Babies aged <6 months with IDA risk factors as above Consider oral iron supplementation in consultation with a paediatrician GPP35
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 GPP24,25,35,36
Environmental Children with IDA Include children on recall registers for regular review and Hb repeat testing as per above N/A GPP31
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  IA31,42,47,52,63
* 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

Resource

Iron deficiency anaemia assessment, prevention and control: a guide for programme managers (WHO)
www.who.int/ nutrition/publications/en/ ida_assessment_prevention_control.pdf.

References

  1. Central Australian Rural Practitioners Association. CARPA standard treatment manual, 5th edn. Alice Springs, NT: CARPA, 2009.
  2. Couzos S, Murray R. Aboriginal primary health care: an evidence-based approach, 3rd edn. Melbourne: Oxford University Press, 2008.
  3. Grant CC, Wall CR, Brewster D, Nicholson R, Whitehall J, Super L, et al. Policy statement on iron deficiency in pre-school-aged children. J Paediatr Child Health 2007;43(7–8):513–21.
  4. Siegel EH, Stoltzfus RJ, Kariger PK, Katz J, Khatry SK, LeClerq SC, et al. Anemia gives delay in walking in Nepal. J Nutr 2005;135(12):2840–4.
  5. US Preventive Services Task Force. Guide to clinical preventive services, 2010–2011: screening for iron deficiency anemia—including iron supplementation for children and pregnant women. Washington DC: US Department of Health and Human Services, 2010. Cited October 2011. Available at www.ahrq.gov/ clinic/pocketgd1011/gcp10s2d.htm.
  6. Centers for Disease Control and Prevention. Recommendations to prevent and control iron deficiency in the United States. MMWR Morb Mortal Wkly Rep (serial on the internet) 47(RR–3), 1998. Cited October 2011 October. Available at www.cdc.gov/ mmwr/pdf/rr/rr4703.pdf.
  7. Pasricha SS, Flecknoe-Brown SC, Allen KJ, Gibson PR, McMahon L, Olynyk JK, et al. Diagnosis and management of iron deficiency anaemia: a clinical update. Med J Aust 2010;193(9).
  8. Baker Robert D, Greer Frank R. Clinical report of American Academy of Pediatrics. Diagnosis and prevention of iron deficiency and iron-deficiency anemia in infants and young children (0–3 years of age). Pediatrics 2010;126(5):1040.
  9. World Health Organization. Iron deficiency anemia: assessment, prevention and control. A guide for programme managers. Geneva: WHO, 2001.
  10. Brewster DR. Iron deficiency in minority groups in Australia. J Paediatr Child Health 2004;40:422–23.
  11. Iannotti LL, Tielsch JM, Black MM, Black RE. Iron supplementation in early childhood: health benefits and risks. Am J Clin Nutr 2006;84(6):1261–76.
  12. Kimberley Aboriginal Medical Services Council medical staff Western Australia. KAMSC protocol for anaemia. Broome, WA: KAMSC, 2008, updated February 2011. Cited October 2011. Available at www.kamsc.org.au/ downloads/resources/cd_ anaemia_child_23_10_09.pdf.
  13. Smith JL, Brooker S. Impact of hookworm infection and deworming on anaemia in non-pregnant populations: a systematic review. Trop Med Int Health 2010;15(7):776–95.
  14. National Health and Medical Research Council. Genetics in family medicine: the Australian handbook for general practitioners, haemoglobinopathies. Canberra: Commonwealth of Australia, 2007. Cited October 2011. Available at www.nhmrc.gov.au/ _files_nhmrc/file/your_health/egenetics/practioners/ gems/sections/12_haemoglobanopathies.pdf.
  15. Mackerras D, Singh G. The Prevalence of anaemia depends on the definition: an example from the Aboriginal birth cohort study. Eur J Clin Nutr 2007;61(1):135–9.
  16. Australian Government. Northern Territory emergency response report. Canberra: Australian Government. Cited October 2011. Available at www.aihw.gov.au/ publications/ihw/ihw-28-10793/ihw-28–10793.pdf.
  17. World Health Organization. Worldwide prevalence of anaemia 1993–2005 Geneva: WHO, 2008. Cited October 2011. Available at http://whqlibdoc.who.int/ publications/2008/9789241596657_eng.pdf.
  18. Centre for Disease Control. PedNSS health indicators. Washington DC: United States Department of Health and Human Services, 2009. Cited October 2011. Available at www.cdc.gov/ pednss/what_is/pednss_health_indicators.htm.
  19. Institute for Clinical Systems Improvement. Health care guideline: preventive services for children and adolescents, 17th edn. Bloomington, MN: Institute for Clinical Systems Improvement, 2010. Cited January 2012. Available at www.icsi.org/ preventive_services_for_children__guideline_/ preventive_services_for_children_and_adolescents_2531.html.
  20. Sari M, dePee S, Martini E, Herman S, Bloem MW, Yip R. Estimating the prevalence of anaemia: a comparison of three methods. Bull World Health Organ 2001;79(6):506–11.
  21. Qu XH, Huang XL, Xiong P, Zhu CY, Huang YL, Lu LG, et al. Does Helicobacter pylori infection play a role in iron deficiency anemia? A meta-analysis. World J Gastroenterol 2010;16(16):886–96.
  22. Cardamone M, Alex G, Harari MD, Moss WP, Oliver MR. Severe iron-deficiency anaemia in adolescents: consider Helicobacter pylori infection. J Paediatr Child Health 2008;44(11):647–50.
  23. Christofides Anna, Schauer Claudia, Zlotkin Stanley H. Iron deficiency and anemia prevalence and associated etiologic risk factors in First Nations and Inuit Communities in Northern Ontario and Nunavut. Can J Public Health 2005;96(4):304–7.
  24. Lutter CK. Iron deficiency in young children in low-income countries and new approaches for its prevention. J Nutr 2008;138(12):2523–8.
  25. Sachdev H, Gera T, Nestel P. Effect of iron supplementation on mental and motor development in children: systematic review of randomised controlled trials. Public Health Nutr 2005;8(2):117–32.
  26. Hutton EK, Hassan ES. Late vs early clamping of the umbilical cord in full-term neonates: systematic review and meta-analysis of controlled trials. JAMA 2007;297(11):1241–52.
  27. van Rheenen P, Brabin BJ. Late umbilical cord-clamping as an intervention for reducing iron deficiency anaemia in term infants in developing and industrialised countries: a systematic review. Ann Trop Paediatr 2004;24(1):3–16.
  28. Weckerta R, Hancock H. The importance of delayed cord clamping for Aboriginal babies: a life-enhancing advantage. Women Birth 2008;21(4):165–70.
  29. National Institute for Health and Clinical Excellence. Improving the nutrition of pregnant and breastfeeding mothers and children in low income households. PH11. London: National Institute for Health and Clinical Excellence, 2008. Cited October 2011. Available at www.nice.org.uk/ nicemedia/live/11943/40097/40097.pdf.
  30. Giovannini M, Sala D, Usuelli Livio L, et al. Double-blind, placebo-controlled trial comparing effects of supplementation with two different combinations of micronutrients delivered as sprinkles on growth, anemia, and iron deficiency in cambodian infants. J Pediatr Gastroenterol Nutr 2006;42.
  31. Hirve S BS, Bavdekar A, Naik S, et al. Low dose ‘Sprinkles’ – an innovative approach to treat iron deficiency anemia in infants and young children. Indian Pediatr 2007;44(2).
  32. Christofides A, Asante KP, Schauer C, Sharieff W, Owusu-Agyei S, Zlotkin S. Multi-micronutrient sprinkles including a low dose of iron provided as microencapsulated ferrous fumarate improves haematologic indices in anaemic children: a randomized clinical trial. Matern Child Nutr 2006;2(3).
  33. Geltman PL, Hironaka LK, Mehta SD, et al. Iron supplementation of low-income infants: a randomized clinical trial of adherence with ferrous fumarate sprinkles versus ferrous sulfate drops. J Pediatr 2009;154(5):738–43.
  34. Falkingham M, Abdelhamid A, Curtis P, Fairweather-Tait S, Dye L, Hooper L. The effects of oral iron supplementation on cognition in older children and adults: a systematic review and meta-analysis. Nutr J 2010;9(4).
  35. National Health and Medical Research Council. Dietary guidelines for children and adolescents in Australia incorporating the infant feeding guidelines for health workers. Canberra: Commonwealth of Australia, 2003. Cited October 2011. Available at www.nhmrc.gov.au/_files_nhmrc/file/publications/ synopses/n34.pdf.
  36. Untoro J, Karyadi E, Wibowo L, Erhardt MW, Gross R. Multiple micronutrient supplements improve micronutrient status and anemia but not growth and morbidity of Indonesian infants: a randomized, double-blind, placebo-controlled trial. J Nutr 2005;135.
  37. Lima AC, Lima MC, Guerra MQ, Romani SA, Eickmann SH, Lira PI. Impact of weekly treatment with ferrous sulfate on hemoglobin level, morbidity and nutritional status of anemic infants. J Pediatr (Rio J) 2006;82(6):452.
  38. Biondich PG, Downs SM, Carroll AE, et al. Shortcomings in infant iron deficiency screening methods. Pediatrics 2006;117(2).
  39. Bailie RS, Si D, Dowden M, et al. Delivery of child health services in Indigenous communities: implications for the federal government’s emergency intervention in the Northern Territory. Med J Aust 2008;188(10):615–8.
  40. Dewey KG, Adu-Afarwuah S. Systematic review of the efficacy and effectiveness of complementary feeding interventions in developing countries. Matern Child Nutr 2008;4(Suppl 1):S24–85.
  41. Antibiotic Expert Group. Therapeutic guidelines: antibiotic. Version 14. Melbourne: Therapeutic Guidelines Limited, 2010. Cited October 2011. Available at www.tg.org.au/?sectionid=41.
Advertisement loading...

Advertisement

The Royal Australian College of General Practitioners

Contact Us

General Inquiries

General Enquiries

Opening hours 8:00 am-8:00 pm AEST

1800 4RACGP

1800 472 247 | +61 (3) 8699 0300 (international)

Payments

Payments

Pay invoices online

RACGP automated payment service: 1800 198 586

Follow us on

Follow RACGP on Twitter Follow RACGP on Facebook Follow RACGP on LinkedIn


Healthy Profession. Healthy Australia Logo

The Royal Australian College of General Practitioners (RACGP) ABN 34 000 223 807
RACGP House, 100 Wellington Parade, East Melbourne, Victoria 3002 Australia

Terms and conditions | Privacy statement
Sponsor conditions | Delegate conditions