Algorithm for evaluation of iron deficiency anemia in children 6 months to 12 years old

Hgb: hemoglobin; IDA: iron deficiency anemia; GI; gastrointestinal; CBC: complete blood count; MCV: mean corpuscular volume; IV: intravenous; RDW: red cell distribution width; TIBC: total iron-binding capacity.
* Routine screening for IDA in children typically consists of measurement of a CBC or Hgb^[1]. This approach to screening does not detect nonanemic iron deficiency. For children with risk factors for iron deficiency, we suggest measuring serum ferritin at the time of the initial screen.
¶ CBC findings typical for IDA are low hemoglobin (Hgb <11 g/dL), low MCV (microcytic anemia), elevated RDW, and, occasionally, thrombocytosis. These findings do not exclude some other causes of anemia, including anemia of chronic disease/inflammation, or thalassemia. A low serum ferritin level is always consistent with iron deficiency, but normal or elevated ferritin does not exclude iron deficiency.
Δ Evaluation may include an iron panel (serum iron, ferritin, TIBC), peripheral blood smear, Hgb electrophoresis, evaluation for gastrointestinal blood loss, assessment for inflammatory disease (eg, C-reactive protein), and review of newborn screening results to assess for alpha thalassemia trait (which cannot be diagnosed by Hgb electrophoresis). Anemia is severe if Hgb <7 g/dL. For details, refer to UpToDate content on approach to anemia in children. Depending on the type of concern, referral to a pediatric hematologist or gastroenterologist and/or IV iron supplementation may be appropriate.
◊ Dietary counseling includes measures to improve iron intake and avoid excessive cow's milk. Infants should not consume unmodified (nonformula) cow's milk. For children 12 months of age and older, cow's milk consumption should be limited to less than 20 oz (600 mL) daily. If occult blood is present in the stool, all milk products should be stopped and the patient should be evaluated to determine the cause of the GI blood loss.
§ In children with IDA, the Hgb rise (>1 g/dL) is expected within 4 weeks for those with mild or moderate anemia (baseline Hgb 7 to 11 g/dL) and within 2 weeks for those with severe anemia (baseline Hgb <7 g/dL).