In my office, there are times when residents, training to become pediatricians or medical students, “shadow” me. It means they follow my style of delivering care to babies, toddlers, younger children and teens. At times, some stories unfold that they will never forget.
Recently we saw a child who had pica — a term which refers to eating objects. My patient was eating lots of ice. Other forms of pica may include eating paper, tissues, wipes, dirt or rocks.
Nearing 40 years in the saddle as a pediatrician, I had an immediate inkling of what was happening to explain the ice story: I suspected low iron levels, which we refer to as ID (iron deficiency). Later lab studies revealed that indeed that was the case.
The iron was low, but the child was not pale or anemic. Spotting anemia is easy, but ID can be subtle. It can lead to long-term consequences of poor neurodevelopment, lack of concentration, low energy, a poorly functioning immune system, restless legs, poor sleep, and a delay in verbalization.
Prevention is what makes being a pediatrician so much fun, and preventing ID should be easy. But despite much education of both doctors and parents, 15 per cent of toddlers and 10 per cent of non-pregnant female adolescents experience ID.
Patients who are at risk are: babies whose cords were clamped early as opposed to delayed clamping, premature babies, babies who only receive breast milk until late into the first year, vegans and vegetarians, babies with excessive intake of a formula (more than 24 ounces in 24 hours), who have a late introduction to solids or girls with heavy menstruation.
A sad situation which has become more common after 2020, when inflation took off dramatically, is the fact that some families cannot afford formula after breastfeeding fails. They then use cow milk. The latter is not to be used prior to one year of age.
Cow milk only delivers one mg of iron per day, while iron-fortified formula delivers five to nine mg per every 24 hrs.
I have observed that the vast majority of vegan families I see are aware that ID must be avoided. They ensure a high intake of non-heme sources of iron. (Canada’s Food Guide has programmed Canadians to think that red meat is the only and best source of iron when that is not entirely true.)
For the longest time, experts suggested that solids be introduced at four months of age. Then various experts from all over the globe, led by WHO and in North America by the AAP, sold us on the benefits of starting solids at six months. Solids involve, for starters, iron-fortified cereals.
At the time of delivery, there are benefits to delaying the clamping of the umbilical cord of vigorous term babies. Pediatric organizations and Colleges of Obstetrics and Gynecology encourage this.
Premature babies are started on iron at two weeks of life. A quirk of nature is that toward the end of a pregnancy, iron gets transferred from a mom to her baby. Thus, earlier deliveries mean that whatever iron got transferred was not enough. I use the analogy of putting only a small amount of gasoline in a tank before a long trip — one will run out earlier.
For all the above reasons, and because ID can be subtle, not as obvious as a linen-white pale toddler, we are told to screen for low iron depending on the history, but routinely at one year of age and in pre-teen or teen girls after one year of menstruation.
When looking at serum iron levels, it is ideal to do that in a fasting state. That is not always possible, so we look at a useful marker of iron status — serum ferritin. This test can be both good and bad, and especially so these days when parents can look at their child’s lab results online.
Inflammation, both acute and chronic, can mess up the accuracy of ferritin and, if the latter is reported by a computer as abnormal, it may make some worry-prone parents more worried. We as MDs also look at other markers of iron metabolism, such as total iron binding capacity and transferrin saturation.
The point is that technology gives data to lay people, but they do not always have the skills to see the whole picture.
ID requires oral supplementation of iron. The most common format is ferrous sulphate. Usually the duration of treatment extends over three months.
Side effects to be aware of include abdominal pain, constipation, darker feces, a poor taste, nausea, and transient discoloration of the teeth. Between advice from pharmacists who tell folks about side effects, AI-derived information, and anticipatory advice by properly trained doctors, these side effects can be navigated in exchange for the solution of getting iron levels up to normal.
I was taught that Vitamin C taken in conjunction with iron enhances absorption. Apparently that is no longer true, according to an AAP statement released this July.
Dr. Nieman has worked as a community pediatrician since 1987. He is the founder of Centre 70 Pediatrics and has been a Herald columnist since 1999.
Source: Life Fitness – Calgary Herald
