Iron deficiency is the most common nutritional disturbance in pediatrics and the number one cause of anemia in the pediatric age range. Iron is absorbed in the proximal small intestine and about 10% of dietary iron is absorbed. 

Iron in foods comes in two forms; heme-Fe as meat hemoglobin and myoglobin and non-heme iron, as iron salts Heme iron is better absorbed and non-heme iron is dependent on other factors for absorption such as ascorbic acid, meat, fish, and poultry. Inhibitors of iron absorption include bran, vegetable fiber, tannic acid found in tea, and phosphates. Most infants diets are deficient in heme-iron and are therefore dependent on supplementation to guarantee adequate dietary iron. 

The incidence of anemia secondary to iron deficiency has decreased with the increase incidence of breast feeding, the addition of iron to formula (12 mg/L), and the development of WIC programs. 

Etiology

1. Most of the newborns iron is contained in their red blood cells with little stores. Low birthweight babies and neonates who lose blood at birth, will have an increased risk of iron deficiency later. Low birthweight infants need increased amounts for their rapid growth. Without supplementation, they may demonstrate iron deficiency at 2 months of age. 
2. The normal newborn has enough iron stores to last 4 months without supplementation.
3. Early introduction of whole cow's milk
4. Blood loss- more common in older children
1. Meckel's diverticulum
2. malabsorption and inflammatory bowel disease
3. milk protein intolerance with blood loss
4. polyps and hemangiomas of the GI tract . 
5. Heavy menses with poor diet in adolescents associated with increase growth rate
5. Increase demands associated with chronic hypoxia
6. Urine loss with intravascular hemolysis
7. Lung losses with pulmonary hemosiderosis and Gooodpasture's syndrome.

1. Irritability
2. Pica- may have concurent lead poisoning
3. or malnourished
4. Exercise intolerance
5. Inattentive, cognitive delays
6. Beeturia
7. sclera

1. Serum ferritin, an iron storage protein, is low
2. Decreased serum iron, increased iron binding capacity, < 16% saturation
3. Microcytosis, hypochromia, anisocytosis, poikilocytosis
4. Increased red cell distribution width(RDW)
5. Decreased absolute reticulocyte count with inadequate response to anemia.
6. Normal WBCs 
7. thrombocytosis
8. Decreased iron stains in the bone marrow

1. Lead levels above 100ug may be associated with microcytosis.
2. Alpha thal trait and Beta thal trait may be associated with low MCV, but RDW is WNL
3. Chronic disease often have normochromic and normocytic anemia, but may be microcytic. The ferritin is usually normal.

1. 6 mg./kg/day of elemental iron. Ferrous sulfate contains 20% elemental iron. Fer-in-sol, contains 25 mg of elemental iron/cc. 
2. Diet adjustments- increase amount of Fe in the diet and eliminate whole cow's milk
3. In 3-4 days will see a reticulocyte response and after 2 months of therapy, bone marrow stores replenished.
4. Blood transfusions rarely necessary
5. Reasons for treatment failure
1. Wrong diagnosis
2. Failure to take the medicine or wrong dosage
3. Associated folate deficiency(B6)
4. Malabsorption of Fe.
Prevention of Iron Deficiency
1. Encourage breast feeding for 6 months. If solely breastfed, after 4 months need Fe supplementation. 
2. Use iron fortified formulas for 12 months
3. Use iron fortified cereals
4. Avoid whole cow's milk
5. parents to supply diet high in Fe- cereals, greeen vegetables, meat, and chicken.
Reference
1. Oski, Frank A. Iron Deficiency in Infancy and Childhood. New England Journal of Medicine. July 15, 1993.
2. Pappas DE and Cheng TL. Iron Deficiency Anemia. Pediatrics in Review. 1998; 19:321-322.
3. Zlotkin S. Single Vervus Three-Times-Daily Iron Drops to Treat Anemia Pediatrics September 2001