Source: Manual of Ambulatory Pediatrics 2010
SOAP Note – Iron Deficiency Anemia
A hypochromic, microcytic anemia that is characterized by a lowered hemoglobin content of red blood cells and decreased numbers of red blood cells. It is the most common hematologic disease of infancy and childhood.
I. Etiology: Insufficient available iron for hemoglobin synthesis because of
A. Inadequate iron stores at birth due to prematurity, maternal or fetal bleeding, or maternal iron deficiency
B. Insufficient dietary iron to meet requirements of expanding blood volume during periods of rapid growth
C. Iron loss: Hemorrhage
D. Malabsorption: Occult gastrointestinal blood loss (e.g., in cow’s milk intolerance)
II. Incidence
A. Rarely seen in the full-term infant under 6 months of age, because the iron stores available at birth are adequate to meet the infant’s needs for the first 3 to 6 months
B. Iron deficiency anemia is the leading cause of anemia between 6 months and 2 years. It is common also during the adolescent years because of rapid growth and often inadequate dietary iron.
III. Subjective data
A. Mild
1. Pale appearance
2. Diminished energy level
3. May be asymptomatic and discovered in routine screening
B. Moderate to severe
1. Pallor
2. Listlessness, fatigue, irritability
3. Anorexia
4. Weight gain usually satisfactory in early deficiency: “milk baby,” poor growth rate in chronic, untreated cases
5. Delayed development
6. Slow growth of nails
7. Pica
8. Increased incidence of infections
C. Pertinent subjective data to obtain
1. History of prematurity
2. Detailed dietary history may reveal the following:
a. Excessive milk intake, more than 1 qt/d
b. Lack of iron-fortified formula or iron supplement in first year of life
c. Diet low in solid foods with high iron content
d. Poor appetite; “picky” eater
e. Increased intake of junk foods
3. History of iron deficiency anemia or other types of anemia in siblings or parents
4. History of blood loss
5. History of chronic infection (e.g., diarrhea)
IV. Objective data
A. Mild
1. Palpebral conjunctiva may be pale.
2. Physical findings normal
B. Moderate to severe
1. Pallor
2. Listlessness
3. Splenomegaly in 10% to 15% of children
4. Cardiomegaly
5. Tachypnea
6. May be obese or underweight
7. In marked iron deficiency anemia
a. Poor muscle tone
b. Heart murmur
c. Spoon-shaped nails
C. Laboratory tests
1. Order the following:
a. CBC with red cell indices
b. Reticulocyte count
c. Blood smear
d. Lead level
e. Iron level
f. Total iron binding capacity
g. Serum ferritin level
h. Stool for occult blood.
2. Findings in iron deficiency anemia
a. Hematocrit below normal value for age
b. Low hemoglobin: Less than one-third the hematocrit
c. Low serum iron: Below 30 g/100 mL (normal, 90–150 g/ 100 mL)
d. Elevated total iron binding capacity: 350 to 500 g/100 mL (normal, 250–350 g/100 mL)
e. Red cells on smear are microcytic and hypochromic.
f. Reticulocyte count is normal, or slightly elevated.
g. Decreased mean corpuscular hemoglobin: 12 to 25 g (Below normal value for age)
h. Decreased mean corpuscular volume: 50 to 80 µ3
i. Low mean corpuscular hemoglobin concentration: Below normal value for age.
j. Low serum ferritin levels: Less than 12 ng/mL
V. Assessment
A. Diagnosis is made by blood values consistent with findings identified as diagnostic for iron deficiency anemia and by the response to therapeutic doses of iron.
B. Differential diagnosis
1. Thalassemia trait: Normal or increased serum iron; no response to iron therapy
2. Lead poisoning: Elevated lead level
3. Chronic infection: Evidence of infection on history or physical examination
4. Chronic disease
VI. Plan
A. Establish etiology: Deficient diet, blood loss, intestinal malabsorption
B. The aim of therapy is to achieve normal hemoglobin values and to replenish iron stores in the marrow.
C. Pharmacologic therapy
1. Elemental iron in doses of 3 to 4 mg/kg/d
a. Ferrous sulfate is the most effective and least expensive oral therapy
(1) Fer-in-Sol (15 mg elemental iron/0.6 mL) or
(2) Feosol Elixir (44 mg elemental iron/5 mL)
b. Continue treatment for at least 3 months after normal hemoglobin level is reached to replenish body stores.
2. Vitamin C: 35 mg/d for infants; 40 mg/d for children. Supplement if child is not on multivitamins and if dietary history is deficient in vitamin C (no citrus fruits, potatoes, or vegetables, such as cabbage, cauliflower, broccoli, spinach, tomatoes).
D. Dietary recommendations
1. Iron-fortified formula (supplemented with 12 mg/L) for infants
2. Foods high in iron
a. Best sources: Liver, dried pinto and kidney beans, Cream of Wheat, dry baby cereal
b. Good sources: Beef, veal; dried prunes, apricots, raisins; spinach and other leafy, dark green vegetables; egg yolks; nuts; fortified cereals
3. If milk intake is excessive, decrease to 24 oz/d.
VII. Education
A. Give iron in 2 divided doses between meals.
B. Absorption of iron is decreased if given with meals or with milk.
C. Iron may be given with juice.
D. Iron can stain teeth; give through a straw if possible. Follow medication with water, rinsing mouth, or tooth brushing.
E. Iron may cause gastrointestinal upset: Cramps, nausea, diarrhea, or constipation. It is best to give on an empty stomach, but if it is causing distress, consider giving with meals.
F. Stools may be black or green.
G. Keep iron out of reach of children. It is highly toxic in large doses.
H. Strive for a diet high in vitamin C to ensure optimal absorption of iron from foods.
I. Iron intake is a function of caloric intake. There are approximately 6 mg of iron per 1,000 calories.
J. Avoid whole cow’s milk in infants younger than one year. Blood loss induced by protein in cow’s milk is not related to lactose intolerance or milk allergy.
K. Iron losses increase in rapid pubertal growth and with heavy menses.
L. Athletes are particularly vulnerable. Twenty percent of runners have positive tests for fecal blood. Also, excess perspiration produces increased loss of iron in perspiration.
M. Iron therapy generally produces rapid recovery.
N. Continue iron therapy for 3 months after hemoglobin and hematocrit return to normal to replace marrow iron stores. A medication reminder chart may be helpful.
VIII. Follow-up
A. Marked or symptomatic anemia (hemoglobin 2 g or more below lower limits of normal)
1. Repeat reticulocyte count and hemoglobin in 1 to 2 weeks. (Reticulocyte count should rise in 3 to 5 days and reach a peak 7 to
10 days after therapy is initiated. Hemoglobin begins to increase during the first 7 to 10 days of therapy.)
2. Repeat hemoglobin and hematocrit after 1 month.
a. If normal, continue treatment for 3 months, and recheck at completion of therapy.
b. If no response to therapy, consult with physician. If below normal, but demonstrates a response, continue treatment (stress dosage and compliance), and recheck in 1 month. If no response, consult with physician. If normal, continue treatment for 3 months, and recheck at completion of therapy.
B. Mild anemia (hemoglobin 1–2 g below lower limits of normal): Repeat reticulocyte count and hemoglobin in 1 month.
1. If normal, continue treatment for 3 months, and recheck at completion of therapy.
2. If no response to treatment, consult with physician. If below normal but demonstrates a response, continue treatment (stress dosage and compliance), and recheck in 1 month. Consult with physician if below normal at this time. If normal, continue treatment for
3 months, and recheck at completion of therapy.
IX. Complications
A. Progressive anemia
B. Intercurrent infection
X. Consultation/referral
A. Marked, symptomatic anemia
B. Infants younger than 6 months
C. Noncompliance with oral pharmacologic therapy
D. Normal hemoglobin levels not achieved after 2 months of therapy