Iron deficiency is the most common nutritional deficiency affecting children, with up to 8% of children under 5 years of age in Australia suffering iron deficiency anaemia.¹ 

In both developing and developed countries, incidence of iron deficiency anaemia peaks between 1 and 3 years of age.² While the more common signs of anaemia are well known, it can present differently in very young children. This case study describes an unusual presentation of iron deficiency anaemia in a young child.

Initial Presentation

An 18 month old girl presented to my clinic with her parents, suffering from breath holding spells. When very upset or hurt, she would cry and exhale all her air, then hold her breath until she turned blue and lost consciousness. Once she had lost consciousness, she began breathing normally and quickly came back around. These episodes were occurring several times every day. They had seen their GP who ruled out cardiac and neurological causes.  They were advised that while the spells are involuntary, they are essentially benign and she will outgrow them by the time she is 4-6 years old, with no treatment required. However her parents understandably found the episodes terrifying and hoped some natural treatment may help.

The child was generally healthy, reaching development and growth milestones appropriately. Her birth was an uncomplicated vaginal delivery, and she was breastfed until 12 months of age. She was emotionally volatile, irritable and easily overtired. Her sleep patterns were poor, with frequent overnight waking. She was an extremely picky eater with a low appetite for food. Her diet was high in refined carbohydrates and low in fresh fruits, vegetables and protein. She was drinking up to 900mL of cow’s milk daily from a bottle, with several bottles overnight. She had pale conjunctiva, brittle nails with white spots, and a tongue quiver.

Treatment Plan

Breath holding spells are associated with iron deficiency in children.3 High cow’s milk consumption, particularly from a bottle, greatly increases the risk of iron deficiency.4 Cow’s milk is low in iron, and large intake may reduce the consumption of foods that do contain iron. Additionally, calcium and casein in milk bind to dietary non-haem iron, reducing iron absorption. Drinking milk from a bottle and feeding to sleep with a bottle increases the total consumption of milk by reducing the ability of the baby to self-regulate their consumption.4

Her physical examination found signs of iron and other mineral deficiencies, including magnesium and zinc. It is therefore important to refer for blood tests to assess iron status, while improving iron intake and general nutrition.

Prescription

• Blood test referral for Full Blood Count and Iron Studies
• Liquid Iron Supplement, 10mL daily; containing 9.58mg iron gluconate, thiamine hydrochloride 1.14mg, riboflavin sodium phosphate 1.13mg, pyridoxine hydrochloride 1.05mg and cyanocobalamin 860ng, in a base containing herbs, fruits and vegetable juices.
• Children’s Multivitamin Powder, 3g once daily; containing vitamins and minerals in highly absorbable forms, including iron bisglycinate 2.5mg, magnesium citrate 86mg and zinc citrate 4mg
• Reduce cow’s milk consumption to a maximum of 500mL per day. Switch to an open cup rather than a bottle for milk through the day. Reduce milk consumption overnight- try to settle back to sleep without milk, and offer water instead.
• Increase consumption of iron rich foods, including red meat, liver, spinach, legumes and ground nuts

2-Week Follow-Up

The blood tests confirm iron deficiency and mild microcytic anaemia, with her ferritin low at 10mcg/L and haemoglobin low at 92g/L. Compliance with the supplements has been good. Cow’s milk consumption has decreased to approximately 600mL per day, and they have switched to an open cup rather than a bottle during the day. They are still feeding to sleep with a bottle at night however they have reduced overnight feeds to one bottle per night. The breath holding spells have continued without major changes. Dietary changes have been difficult as the child has a poor appetite for food, preferring milk. 

Treatment Plan

Increase the dose of iron to address anaemia while improving diet. Provide support to assist parents in implementing dietary changes

Prescription

• Liquid Iron Supplement, 10mL twice daily
• Children’s Multivitamin Powder, 3g once daily
• Resources on improving diet for fussy eaters
• Resources on improving sleep in toddlers

6-Week Follow-Up

Compliance has been very good. Cow’s milk consumption is down to 400mL per day from a cup only. They have ceased all bottles and are no longer feeding to sleep or offering bottles overnight. While this was a slightly difficult transition, her sleep has markedly improved with no overnight waking on most nights. Her appetite has also improved with the reduction in cow’s milk, and she is happier to try new foods. The breath holding episodes have noticeably reduced, with only 3 episodes the previous week.

Treatment plan

Maintain current treatment while continuing to improve the diet

Prescription

• Liquid Iron Supplement, 10mL twice daily
• Children’s Multivitamin Powder, 3g once daily
• Blood test referral for Full Blood Count and Iron Studies to be taken at 12 weeks post initial consultation

14-Week Follow-Up

Compliance has been fantastic. The blood tests show great improvement, with both ferritin and haemoglobin back in the healthy range for her age group. The breath holding episodes have essentially ceased, with only one episode in the past three weeks. Her sleep has been good, and her mood is noticeably calmer. Her appetite has continued to improve, and while her vegetable consumption could be better, she is eating a much wider variety of foods, including iron rich foods.

Treatment plan

Continue iron and multivitamin supplementation at a low dose for three months to ensure stores are fully replenished.

Prescription

• Liquid Iron Supplement, 5mL once daily
• Children’s Multivitamin Powder, 3g once daily

Conclusion

Iron deficiency is extremely common in young children however it is often missed in routine practice. This can have long term health consequences for the child. Greater awareness of the more unusual symptoms of anaemia in this age group will improve diagnosis and treatment rates.

References

1. National Blood Authority (AU). Paediatric and Neonatal Iron Deficiency Anaemia Guide. Canberra; National Blood Authority Australia; 2017. Available from https://www.blood.gov.au/document/paediatric-and-neonatal-iron-deficiency-anaemia-guide-pdf
2. Parkin PC, Hamid J, Borkhoff CM, Abdullah K, Atenafu EG, Birken CS, Maguire JL, Azad A, Higgins V, Adeli K. Laboratory reference intervals in the assessment of iron status in young children. BMJ paediatrics open. 2017;1(1). DOI: 1136/bmjpo-2017-000074
3. Zehetner AA, Orr N, Buckmaster A, Williams K, Wheeler DM. Cochrane review: Iron supplementation for breath‐holding attacks in children. Evidence‐Based Child Health: A Cochrane Review Journal. 2010 Dec;5(4):1578-605. DOI: 1002/14651858.CD008132.pub2
4. Parkin PC, DeGroot J, Maguire JL, Birken CS, Zlotkin S. Severe iron-deficiency anaemia and feeding practices in young children. Public health nutrition. 2016 Mar;19(4):716-22. DOI: 1017/S1368980015001639