National Guide

Chapter 6 | Child health

Anaemia







National Guide to preventive healthcare for Aboriginal and <br/>Torres Strait Islander people
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      2. Anaemia

Child health | Childhood anaemia

Mr Luke Ruane 

Key messages

  • Anaemia is a common problem among infants and children globally and is most commonly due to iron deficiency.1,2
  • Iron deficiency anaemia (IDA) can impact childhood growth and development including brain, psychomotor and social development, as well as increasing susceptibility to infections.3
  • IDA is common in Aboriginal and Torres Strait Islander children, particularly in remote Australia, and requires preventive measures, early detection and effective treatment strategies.4–6
  • Low maternal iron stores, inadequate growth in utero, delayed commencement or progression of solids, low dietary iron intake, a high incidence of parasitic infection, environmental factors (eg food insecurity and poor environmental and living conditions) and social disadvantage are significant risk factors for IDA.7–9
  • Treating maternal anaemia in pregnancy is a major contributor to ensuring adequate iron stores and preventing anaemia in infants.7,10
  • Early preventive treatment to improve iron stores in babies born small for gestational age or preterm and in other high-risk children can substantially reduce the risk of anaemia in infancy and early childhood.6
  • IDA in infancy and childhood requires treatment but rarely extra investigation unless it does not respond to treatment.11
  • Multicomponent interventions, including supplementary iron for infants at increased risk, improving access to nutritious foods, food fortification and treating hookworm and other intestinal parasites, have proven effective and need to be tailored for specific community contexts.12
Type of preventive activity - Screening
Who/target population What When Strength of recommendation Key source(s) and reference(s) Rationale/key considerations informing recommendation
Pregnant and breastfeeding women Encourage iron-rich diet

Check full blood count (FBC) and iron studies/ferritin
Supplement with oral or intravenous iron if iron deficient		 Antenatally and postnatally

Test Hb at first antenatal visit and at 28 weeks gestation and consider iron studies at first antenatal visit and at 36 weeks gestation if in a high-risk area		 Strong National guideline13 Maternal nutritional status and iron stores in pregnancy and breastfeeding significantly affect infant iron levels
All children from birth Provide regular child health checks to monitor growth and development (see Chapter 6.1: Child health, Child growth and development) As per jurisdictional guidelines Strong Jurisdictional guideline12 Regular monitoring supports early detection and supports for children not on track in growth and/or development
Type of preventive activity -Increased screening
Who/target population What When Strength of recommendation Key source(s) and reference(s) Rationale/key considerations informing recommendation
Children with higher risk of IDAB:
  • maternal and birth factors, including maternal iron deficiency in pregnancy, prematurity (<32 weeks gestation), low birth weight (<2500 g), multiple birth
  • infant factors, including delayed introduction of iron-rich food; early introduction of cow’s milk; poor growth/growth that is not on track; poor environmental and living conditions (eg food insecurity, overcrowding, lack of functioning housing infrastructure ), other significant medical conditions
All children aged >6 months from communities with a high prevalence of IDA		 Measure haemoglobin (Hb), ideally via non-invasive point-of-care testing device, or capillary sampleA

Use age-appropriate Hb levels to diagnose anaemia		 At age 6 months

If normal, repeat six monthly to age 2 years and then yearly to age 5 years		 Strong Jurisdictional guidelines11,12 Aim for early detection and treatment of high-risk children
Type of preventive activity - Increased monitoring
Who/target population What When Strength of recommendation Key source(s) and reference(s) Rationale/key considerations informing recommendation
All children:
  • with Hb less than 90 g/L
  • with persistent anaemia after treatment with iron supplements
  • if unwell with signs/symptoms like bruising or bleeding
 Perform FBC If IDA is diagnosed and treatment is required, test after three months

Screen every six months to age 5 years once Hb is normal		 Good practice point Jurisdictional guideline12 High-risk populations require more targeted screening

Establishing regular recalls and a responsive screening approach with health education is crucial
Type of preventive activity - Behavioural 
Who/target population What When Strength of recommendation Key source(s) and reference(s) Rationale/key considerations informing recommendation
All children/carers of children Support mothers to breastfeed or use appropriate infant formula
Advise parents/carers to avoid giving the infant cow’s milk (fresh, powdered or long-life) before the age of 1 year

Advise that clean water can be given to infants after age 6 months, and support the avoidance of other drinks (tea, sweet drinks, fruit juice) in childhood

Encourage solid food intake by the age of 6 months, including iron-rich food (meat, fortified cereals, leafy green vegetables) and vitamin C-containing foods with meals		 First year of life at all visits as required Good practice point National guidelines12,14,15 Aim to support dietary intake to minimise IDA
Type of preventive activity - Environmental 
Who/target population What When Strength of recommendation Key source(s) and reference(s) Rationale/key considerations informing recommendation
Children with IDA Include children on recall registers for regular review and Hb repeat testing after treatment and, once Hb is normal, continue to screen Hb every six months Six monthly until not considered at risk Strong National and jurisdictional guidelines12,15 Early intervention and continued monitoring of high-risk children reduces the prevalence and severity of IDA
Communities with a known high prevalence of IDA Advocate for and support nutritional programs

Support strategies that improve nutrition and food security, including improving the range and accessibility of healthy foods		 Immediately and ongoing Good practice point National and jurisdictional guidelines12,15 Population preventive health activities can reduce the overall impact of IDA in high-risk communities
Health services and practices in settings where environmental and living conditions have strong contribution (environmental attribution) to communicable disease transmission and other conditions, such as IDA and strongyloidiasis Know about diseases with a high environmental attribution

Develop a safe clinical relationship in order to ask sensitively about housing and living conditions (inadequate housing facilities, access to health hardware such as working plumbing for clean drinking water and washing facilities, access to hygiene and sanitation supplies)

Know about local arrangements for environmental health referral

Offer an environmental health referral according to local arrangements, ensuring consent is obtained when a home visit is involved

Advocate with Aboriginal and Torres Strait Islander leaders for adequate housing, facilities for washing and general living conditions

Provide community-based health promotion about environmentally attributable diseases

Check local guidelines		 Opportunistically, in response to any diagnosis or condition with an environmental attribution and as part of general healthcare Good practice point National and international narrative reviews16,17 Working collaboratively with communities to address community issues can make important contributions to health
Type of preventive activity - Medication
Who/target population What When Strength of recommendation Key source(s) and reference(s) Rationale/key considerations informing recommendation
Children aged 1–12 months with the following risk factors: maternal iron deficiency in pregnancy, prematurity (<35 weeks gestation), low birth weight (<2500 g), multiple birthB Prescribe preventive oral iron supplementation, especially in communities where the prevalence of anaemia is high Check local guidelines for starting age or start iron supplementation in consultation with paediatrician Strong Jurisdictional guidelines 11,12 Children with low iron stores can have their risk of IDA reduced by preventive therapy
Children aged 6 months – 16 years in areas with high rates of intestinal parasite infectionsB Consider treatment as part of a systematic child health surveillance program in consultation with local public health units

Refer to relevant local policy and guidelinesB		 Every six months Good practice point Jurisdictional guideline12 Hookworm and some other parasites can lead to high rates of IDA in a community. Population-level approaches may reduce rates of IDA
  • Make sure iron is safely stored to prevent accidental poisoning.
  • Advise parents how to optimise absorption:
    • Although iron is best absorbed on an empty stomach, taking it can cause an upset tummy, which may be reduced by taking it with a small amount of food.
    • Taking some vitamin C or drinking orange juice with the iron can help it be absorbed.
    • Avoid milk, tea, high-fibre foods (eg whole grains and raw vegetables) and foods containing caffeine (eg chocolate and some sugary drinks) at the time of taking iron because they can interfere with iron absorption.
  • Advise parents of the side effects and how to manage them, including:
    • iron preparations can make a child’s stool black in colour and may cause constipation, which can be managed by diet and/or laxatives
    • oral iron preparations may stain a child’s teeth; in older children, consider having the child drink the iron preparation through a straw and brush the child’s teeth after administration
    • twice weekly dosing has been shown to be as effective as daily dosing.6

Clinical guidelines

Other resources for health professionals

Background

IDA in early life can have significant negative implications for the child. IDA is the most common and significant nutritional problem among infants worldwide. The WHO considers childhood anaemia a public health concern when rates exceed 5%, and the reported prevalence of anaemia in children in 2019 was 39.8% worldwide.2 IDA is a major public health concern for Aboriginal and Torres Strait Islander communities, with reported rates around 30% in some northern Australia communities.4 Recent reporting of anaemia prevalence is limited outside remote settings; however, many risk factors for IDA are present in Aboriginal and Torres Strait Islander infants and children across Australia.

There are significant and well-documented impacts related to a lack of adequate iron during early years of life. These include neurodevelopmental impacts that lead to diminished cognitive, motor and social development compared with infants with sufficient iron levels.18

The cause of IDA is usually multifactorial and includes maternal and childhood factors. Low maternal iron stores, higher rates of smaller babies at birth due to inadequate growth of a fetus in utero and/or preterm birth7 and early cord clamping at delivery19,20 all reduce the stores of iron a newborn has to sustain growth in the first six months of life. The risk of IDA is further increased by delayed commencement or progression of solids, a high incidence of parasitic infection, including hookworm, environmental factors (eg food insecurity and poor-quality housing and living conditions) and social disadvantage. These factors can all contribute to an increased risk of IDA among Aboriginal and Torres Strait Islander children.12

Detecting IDA

Regular health checks are vital for the early detection and treatment of anaemia.

In current Australian guidelines,21 anaemia is defined as:

  • Hb <105 g/L in children aged 6–12 months
  • Hb <110 g/L in children aged 1–4 years
  • Hb <115 g/L in children aged 5–7 years.

Laboratory testing of venous blood is the gold standard, but venous blood can be difficult to collect, may not always be acceptable to caregivers of young children and can be associated with delayed results, particularly in remote settings. The usual method of screening is point-of-care Hb testing, including non-invasive monitors (eg pulse oximeters) and minimally invasive haemoglobinometers (eg HemoCue®).22 Non-invasive Hb monitors allow checks for anaemia risks without blood samples and are now used in some areas of remote Australia. Haemoglobinometers require a small amount of capillary blood to test Hb. These are acceptable and practical. Although is not as accurate as laboratory testing, when conducted by well-trained personnel with good quality control, the results compare reasonably well with laboratory testing.22 The results can guide treatment and identify children with more severe anaemia, in whom formal venous sampling is required.

Anaemia is rare at birth and develops in infancy if iron stores are not adequate to cover the rapid growth and limited intake of iron in early life. Screening, where indicated, is recommended to commence from age six months, when anaemia is becoming more common and to align with regular health and developmental checks.12

Although the vast majority of anaemia in children is IDA, point-of-care screening does not identify the cause of the anaemia or provide information about iron stores. Further investigation with venous blood sampling to confirm the cause of anaemia is recommended if the Hb level is <90 g/L or anaemia is non-responsive to treatment.12

Preventing and managing IDA in children aged five years and under requires strategies to address the immediate causes, as well as the social and environmental determinants that contribute to overall health and wellbeing. These strategies need to be tailored to the unique circumstances of each community. This includes improving access to healthcare, addressing socioeconomic factors that contribute to IDA, promoting sanitation and hygiene and ensuring a diet that is well balanced and rich in essential nutrients, particularly iron.23

The effectiveness of comprehensive multicomponent interventions in preventing IDA has been demonstrated, including:

  • enhancing antenatal maternal nutrition and iron supplementation where indicated to optimise newborn iron stores during pregnancy7
  • delaying cord clamping at birth beyond three minutes to augment the infant’s postnatal iron stores20
  • early iron supplementation for high-risk children to prevent IDA6
  • addressing food security issues24 to improve nutrition intake, including fortified solids and micronutrients4,8
  • screening and management of intestinal parasite infections19
  • improving health literacy.25

Maternal interventions

Iron requirements during pregnancy are higher than at any other stage in life due to the need to support fetal development and build the infant's iron stores, which will be their primary source of iron for the first four to six months of life. Infants who were preterm (especially <32 weeks gestation), born small for gestational age and/or whose mothers were anaemic during the pregnancy are at higher risk for IDA in infancy even if their initial iron status at birth appears adequate.6,7,26

Normal Hb levels in pregnancy are slightly lower due to haemodilution, with the normal lower limit of normal defined as:

  • 110 g/L or more in women up to 20 weeks gestation
  • 105 g/L or more after 20 weeks gestation.12

Low (<30 mcg/L) ferritin is highly specific for iron deficiency; however, ferritin is also an acute phase reactant and can be raised with inflammation and chronic disease; therefore, ferritin >30 mcg/L does not exclude functional iron deficiency. Iron studies, not just ferritin, are recommended initially for Aboriginal and Torres Strait Islander women during pregnancy.

Routine antenatal care should include an FBC and iron studies at the first antenatal visit, then, if normal at the first visit, a repeat FBC and ferritin at 28 and 36 weeks gestation. In the first trimester, if iron deficiency with or without anaemia is diagnosed, oral iron supplementation should be trialled, with repeat testing in eight weeks. After the first trimester, if the response to oral therapy is insufficient or oral therapy is not well tolerated/poorly adhered to, or if IDA is more severe, then intravenous iron should be considered. Intravenous iron produces a more rapid response, and hence may be a better option later in pregnancy.12

Interventions in infancy

It is important for infants to have either breast milk or appropriate infant formula during the first 12 months of life. It is essential to avoid using low-iron formula or cow’s milk (fresh and long-life) because these do not provide the necessary iron for infants.27 Water can be introduced from age six months, whereas other liquids, such as tea (which reduces the absorption of iron), cordials and juices, should be avoided.14

Breast milk contains only small amounts of iron, although this iron is highly bio-available. There is conflicting evidence regarding the additional iron needs of infants who are exclusively breastfed;28 however, neither breast milk nor infant formula have sufficient iron to replace depleted iron stores.

The Australian Infant feeding guidelines emphasise the importance of introducing iron-rich foods and cooked fish when an infant is around six months of age and exhibiting signs of readiness, like sitting with minimal support and showing an interest in food.14 As the infant develops, appropriate textured iron-rich first foods should be introduced, including fortified rice cereal, pureed or finely mashed meats and egg, pieces of hardboiled egg or cooked fish. Coarser textured and finger foods should be gradually introduced to promote the development of oral motor skills.14

Providing iron supplements to children at high risk of IDA in the first year of life before they become anaemic is an important intervention These iron supplements can be introduced from the age of one month where the risk of IDA is high, or from age four months depending on local and organisational guidelines, and continued until 12 months of age.6,8

Treatment of parasites

Infection with a number of intestinal parasites is associated with increased rates of IDA in children worldwide. Where parasites associated with IDA are endemic, routine treatment is useful to prevent/reduce IDA.19 Current Northern Territory programs recommend universal biannual anthelmintic (worm) treatment for children with albendazole, primarily to minimise hookworm infection.12 Universal deworming in low-risk environments, without prior screening, is not widely supported. Local information on the prevalence of infections and regional or jurisdiction guidelines should be followed.

Iron supplementation

Iron supplementation, whether preventive or for the treatment of IDA, is usually prescribed as daily oral therapy. Oral supplementation has the advantage of being non-invasive, economical and easily administered. However, its effectiveness depends on adherence, and it can cause gastrointestinal side effects.

The evidence supports the need to give oral iron supplements for at least three months when treating anaemia.6 If giving oral iron, the recommended dosage is as follows:11,12

  • for a child 30 kg or under with mild–moderate anaemia (Hb >80 g/L), 3 mg/kg/day daily for three months
  • for a child 30 kg or under with severe anaemia (Hb <80 g/L), 6 mg/kg/day daily for three months
  • for a child over 30 kg, one iron tablet (80–105 mg elemental iron) once a day for three months.

Where families need extra support or there are concerns about adherence to dosing, then increased support and/or supervision may be appropriate. Intermittent supplementation regimes, such as twice-weekly supervised oral iron at double the daily dose, are useful where adherence to daily dosing is low.6,12

Intramuscular iron injections, although not ideal, may be used for IDA when oral supplements have not worked or cannot be used due to issues such as malabsorption, non-adherence or severe difficulty administering oral iron. Intramuscular iron is painful, risks skin staining at the injection site and needs medical supervision.21 The preferred injection site is the upper outer quadrant of the buttock or the anterolateral thigh, using the Z-track method to minimise medication leakage leading to skin staining.12 Intravenous therapy is an alternative; however, because it requires more medical intervention and takes longer to administer than intramuscular iron, this may further distress the child. It is important to refer to local guidelines before administering parenteral iron. Close monitoring for potential side effects and regular follow up for treatment response are essential.

Parenteral iron therapy should be considered in persistent anaemia, underlying gastrointestinal disease and other chronic conditions like heart failure.8,11

Children with a history of IDA may experience recurrence, highlighting the importance of ongoing IDA prevention programs managed not just by individual clinicians, but also by health services and at the community level.4

  1. World Health Organization (WHO). Global nutrition targets 2025: Anaemia policy brief. WHO, 2014 [Accessed 25 April 2024].
  2. World Health Organization (WHO). WHO global anaemia estimates, 2021 Edition. WHO, 2021 [Accessed 25 April 2024].
  3. Saloojee H, Pettifor JM. Iron deficiency and impaired child development. BMJ 2001;323(7326):1377–78. doi: 10.1136/bmj.323.7326.1377.
  4. Leonard D, Buttner P, Thompson F, Makrides M, McDermott R. Anaemia in early childhood among Aboriginal and Torres Strait Islander children of Far North Queensland: A retrospective cohort study. Aust N Z J Public Health 2019;43(4):319–27. doi: 10.1111/1753-6405.12911.
  5. Udovicich C, Perera K, Leahy C. Anaemia in school-aged children in an Australian Indigenous community. Aust J Rural Health 2017;25(5):285–89. doi: 10.1111/ajr.12338.
  6. Wetten A, Brand A. Anaemia Expert Advisory Group. Evidence summary: Preventative oral iron supplementation (OIS) of infants at risk of iron deficiency. Remote Primary Health Care Manuals, 2021 [Accessed 6 May 2024]
  7. Hansen M, Singh G, Barzi F, et al. Maternal anaemia in pregnancy: A significantly greater risk factor for anaemia in Australian Aboriginal Children than low birth weight or prematurity. Matern Child Health J 2020;24(8):979–85. doi: 10.1007/s10995-020-02913-7.
  8. Mithra P, Khatib MN, Sinha AP, et al. Interventions for addressing anemia among children and adolescents: An overview of systematic reviews. Front Pediatr 2021;8:549549. doi: 10.3389/fped.2020.549549.
  9. Cappellini MD, Musallam KM, Taher AT. Iron deficiency anaemia revisited. J Intern Med 2020;287(2):153–70. doi: 10.1111/joim.13004.
  10. Onyeneho NG, Corsi DJ, Kurpad A, Subramanian SV. Intergenerational influences on childhood anaemia. Matern Child Nutr 2019;15(2):e12673. doi: 10.1111/mcn.12673.
  11. The Royal Children’s Hospital Melbourne. Iron deficiency. In: Clinical practice guidelines. RCH, 2019 [Accessed 25 April 2024].
  12. Central Australian Rural Practitioners Association. CARPA standard treatment manual. 8th edn. Flinders University, 2022 [Accessed 25 April 2024].
  13. Department of Health and Aged Care. Australian pregnancy care guidelines. Australian Government, 2020 [Accessed 30 May 2024].
  14. National Health and Medical Research Council (NHMRC), New Zealand Ministry of Health. Infant feeding guidelines. NHMRC, 2013 [Accessed 25 April 2024].
  15. The Royal Australian College of General Practitioners (RACGP). Guidelines for preventive activities in general practice. RACGP, 2018 [Accessed 25 April 2024].
  16. McMullen C, Eastwood A, Ward J. Environmental attributable fractions in remote Australia: The potential of a new approach for local public health action. Aust N Z J Public Health 2016;40(2):174–80. doi: 10.1111/1753-6405.12425.
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  18. Pivina L, Semenova Y, Doşa MD, Dauletyarova M, Bjørklund G. Iron deficiency, cognitive functions, and neurobehavioral disorders in children. J Mol Neurosci 2019;68(1):1–10. doi: 10.1007/s12031-019-01276-1.
  19. World Health Organization (WHO). Guideline: Preventive chemotherapy to control soil-transmitted helminth infections in at-risk population groups. WHO, 2017 [Accessed 25 April 2024].
  20. Mercer JS, Erickson-Owens DA, Deoni SC, et al. The effects of delayed cord clamping on 12-month brain myelin content and neurodevelopment: A randomized controlled trial. Am J Perinatol 2022;39(1):37–44. doi: 10.1055/s-0040-1714258.
  21. The Royal Children’s Hospital Melbourne (RCH). Anaemia. In: Clinical practice guidelines. RCH, 2019 [Accessed 25 April 2024].
  22. Muñoz M, Romero A, Gómez JF, Manteca A, Naveira E, Ramírez G. Utility of point-of-care haemoglobin measurement in the HemoCue-B haemoglobin for the initial diagnosis of anaemia. Clin Lab Haematol 2005;27(2):99–104. doi: 10.1111/j.1365-2257.2005.00678.x.
  23. World Health Organization (WHO). Accelerating anaemia reduction: A comprehensive framework for action. WHO, 2023 [Accessed 25 April 2024].
  24. Brand A. Working at the cultural interface to meet the needs of remote Australian Aboriginal caregivers with children progressing through the nutritional period of weaning [PhD thesis]. Flinders University, 2020 [Accessed 25 April 2024].
  25. Kearns T, Ward F, Puszka S, Gundjirryirr R, Moss B, Bailie R. Anaemia health literacy of community members and health practitioners knowledge of best practice guidelines in a remote Australian Aboriginal Community. Univers J Public Health 2017;5(1):32–39. doi: 10.13189/ujph.2017.050105.
  26. Frayne J, Pinchon D. Anaemia in pregnancy. Aust J Gen Pract 2019;48(3):125–29. doi: 10.31128/AJGP-08-18-4664.
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