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Anemia means that your blood doesn’t have enough red blood cells. These red blood cells contain hemoglobin, a substance that carries and delivers needed oxygen to other cells in the body. The same goes for anemia in children. Most of the time, healthy babies and kids have enough red blood cells, but there are factors that can put your little one at higher risk, so it’s important to keep those levels on your radar.
There are three main causes of anemia. The first cause, which is most common in babies and kids, is when the body doesn’t produce enough red blood cells, which can result when there isn’t enough iron in a child’s diet. Other risk factors for iron deficiency, which can lead to anemia in children, before the age of two include preterm delivery or low birth weight, babies born to moms with anemia or poorly controlled diabetes, chronic infection and exposure to lead. If your baby’s umbilical cord was clamped (tied off or cut) within 30 seconds of birth, they may have an increased risk of anemia. The Society of Obstetricians and Gynaecologists of Canada recommends that the cord be clamped one to three minutes after birth to allow more blood to transfer from the placenta to the baby, which boosts the baby’s red blood cells and iron stores.
According to the Canadian Paediatric Society (CPS), the prevalence of iron-deficiency anemia in children in Canada today isn’t known, but it was about four percent in middle-class infants and toddlers in the 1990s. Today, in some Indigenous communities, iron-deficiency anemia can be as high as 36 percent, due to factors like poverty, food insecurity and a higher rate of infection from H. pylori (a type of bacteria that infects the stomach). For these reasons, families that are new to Canada, such as refugees, may also be at higher risk.
The second, much less common cause of anemia in children is an underlying illness or disorder, such as sickle cell anemia, which destroys red blood cells in the body.
The third cause is bleeding, such as heavy menstrual periods and gradual long-term blood loss from gastrointestinal bleeding, which can lead to anemia.
“The most common symptoms that families notice are pale skin, tiredness and decreased exercise tolerance,” says Jeff Critch, a paediatric gastroenterologist in St. John’s, Newfoundland. Other symptoms can include irritability, mild weakness, cold hands and feet, lack of appetite, frequent infections and cravings for non-food items, like ice or dirt (a condition known as pica). The lining of the eyelids and nail beds may look less pink than normal. If red blood cell destruction is causing anemia, the child may have yellowing of the skin or eyes (from jaundice) or dark urine that resembles the colour of cola.
“Anemia is not a diagnosis,” says Critch. “It’s a problem that can be caused by a variety of factors.” That means it’s key for your healthcare provider to figure out what is causing anemia. It’s especially crucial to prevent iron-deficiency anemia in kids under two, says Becky Blair, a registered dietitian in Barrie, Ontario, who advised the CPS on its most recent practice guidelines on iron deficiency in kids under two. “Iron is very important for forming the brain and helping neurons connect and synapse together,” she says. “We know that when infants and toddlers have iron-deficiency anemia, even if they end up being treated, it doesn’t necessarily make up for that deficit in their brain development.” Iron deficiency can also suppress growth and development and immune function.
The CPS recommends that healthcare providers assess the risk for iron deficiency at well-baby visits up to the age of two, through questions about food and activity levels, and watch for symptoms. Regardless of age, if a healthcare provider thinks that anemia or iron deficiency is a possibility, they will order a blood test that measures iron levels and blood cell levels. (In the United States, the American Academy of Pediatrics recommends a blood test between nine and 12 months and again at later ages if the child is in a higher risk group.)
Low birth weight and preterm babies are at higher risk of anemia because they may not have built up enough iron stores (passed along from their moms) while they were in the womb, so your healthcare provider may recommend a liquid iron supplement (for breastfed babies) or a formula that’s higher in iron. Babies who are exclusively breastfed for longer than six months are at increased risk because their existing stores of iron aren’t being replenished by iron-rich foods.
Whether your baby drinks breast milk or formula, it’s necessary to introduce iron-rich foods after six months. Mashed cooked egg yolks, iron-fortified baby cereals and meats are all good sources of iron in first foods, says Blair. She advises cooking meats in sauces or broths to make them tender and baby-friendly (think ground meat in pasta sauces, mild curries and pulled pork). If you’re serving plant-based alternatives to meat (such as lentils, beans and tofu), pair them with another food that’s higher in vitamin C (such as tomato sauce, broccoli and oranges) to boost iron absorption.
You can start to introduce cow’s milk between nine and 12 months of age. When transitioning from breast milk or formula, you should opt for whole milk (3.25 percent) or milk alternatives. However, be cautious about giving your baby too much milk. “Filling up on milk is a red flag for iron deficiency because they’re not hungry for solid food as much,” says Blair. Instead, offer your toddler a variety of nutritious foods and about two cups (500 to 720 mL) of milk products (such as milk, yogurt and cheese) every day.
Anemia usually isn’t much of an issue for school-age kids, says Blair. In general, stick to Canada’s Food Guide, which recommends that protein sources make up one-quarter of their plates.
Treating the source of anemia in children is crucial. In iron-deficiency anemia, that means making different food choices and may include offering an iron supplement if your healthcare provider thinks it’s needed. Iron supplements for kids come in liquid and tablet forms (or, in uncommon cases where a chronic condition is an issue, iron may be given intravenously, says Critch). “The side effects of iron supplements may include constipation and gastrointestinal upset,” says Critch, who adds that darker or even greenish poop is to be expected. “Taking a supplement with food can reduce the chances of an upset stomach.” It may interfere with iron absorption but typically not enough to matter much, he says. “A healthy diet with plenty of fibre and water will help prevent constipation,” adds Critch. An oral supplement may stain your child’s teeth, so it’s a good idea to wipe their teeth with a washcloth. Always keep iron supplements out of your child’s reach.
Once anemia is diagnosed and treatment begins, your healthcare provider will order another blood test to see how your child is responding, within a couple of weeks for severe anemia or after a month or two for milder cases. They may order more blood tests after that as well.