Anemia: When Is it Iron Deficiency?

Annette Carley, MS, RN, NNP, PNP


Pediatr Nurs. 2003;29(2) 

In This Article


Anemia, and specifically iron deficiency anemia, is an important health care concern. The World Health Organization calls iron deficiency the most common anemia (Centers for Disease Control [CDC], 2002), as it is estimated to affect approximately 2 billion people worldwide. In developing countries this high rate has been related to insufficient iron intake, exacerbated by chronic intestinal blood losses due to parasitic and malarial infections (Wu, Lesperance, & Bernstein, 2002). In developed countries it is more commonly due to insufficient iron intake. Although declining in prevalence in the United States since the l970s primarily as a result of food and formula supplementation, it remains a notable finding in toddlers, adolescents, and women of childbearing age. Iron deficiency (the lack of adequate iron stores in the body to meet physiological needs for growth) affects 9% of children under 2 years of age, 9%-11% of adolescent females, and less than l% of adolescent boys. Iron deficiency anemia (anemia resulting from lack of adequate iron to meet needs for red blood cell [RBC] formation) affects 3% children under 2 years of age, up to 3% of adolescent females, and less than 1% of adolescent males (Tender & Chang, 2002). Reduction of iron deficiency and anemia in these vulnerable populations remains a national health objective for 2010 (CDC, 2002).

Iron deficiency is responsible for lost productivity and premature death in adults (Wu et al., 2002) and has been implicated as a cause of perinatal complications such as low birth weight and premature delivery in affected mothers (CDC, 2002). In children, the initial manifestations may be subtle and amenable to treatment. Long-term findings attributable to iron deficiency include increased susceptibility to infection and poor growth. Children with iron deficiency anemia are at risk for developmental and behavioral delays, including lower mental and motor test scores (Lesperance, Wu & Bernstein, 2002; Wu et al., 2002). Some evidence suggests that severe iron deficiency anemia may cause behavior and learning problems that persist throughout childhood (Ioli, 2002).

Screening for anemia is common in clinical practice. Iron deficiency anemia is so prevalent in the pediatric population that the American Academy of Pediatrics (AAP) recommends universal screening by hematocrit or hemoglobin levels in areas with high prevalence rates, such as WIC eligible communities or areas with recently arrived immigrants, and selective screening in high risk populations (Lesperance et al., 2002; Kazal, 2002) (see Table 1 ). Of those screened by hematocrit or hemoglobin, 2.5% will have results indicating anemia (Korones & Cohen, 1997).

Controversy exists, however, regarding universal application of reference norms and screening recommendations. The utility of anemia as a marker of iron deficiency is determined by the prevalence of iron deficiency in that population. An increased prevalence will increase the positive predictive value of this marker (Wu et al., 2002). Children who are iron deficient but not anemic will not be identified by reference ranges based on hematocrit and hemoglobin alone. Hence, a substantial number of children at risk for adverse sequela of iron deficiency may be missed. Further, the timing of initial screening may falsely underestimate those at nutritional risk. Those screened while receiving routine iron supplementation in fortified infant formulas during the first year of life, for example, may not meet criteria for the diagnosis of anemia, though they may still be at nutritional risk (Kohli-Kumar, 2001).


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.