Anemia in Children: Even your aunt can tell when you are anemic – Part I, Part 11, and 111

Anemia in Children: Even your aunt can tell when you are anemic – Part I

Within one week of private medical practice I encountered three children with anemia.

One was a seventeen-year-old girl who came to my office for a sports clearance medical examination. She enjoyed playing tennis a lot. When her blood test result came back, her hemoglobin level was 7.8. On speaking to mother, the teen did not have any signs of anemia. ‘Nothing,’ Mom said, ‘except that my daughter loves to sleep,’ which most teenage girls do.

The second child was a toddler of fifteen months, who came in for a regular visit to assess height and weight, and behavioral developmental progress. Her blood test showed a hemoglobin level of 7.7 gm/dl.

The third child was an energetic two-year-old girl. Her mother said she was diagnosed with anemia while in New York City, but now they had moved to Connecticut and the patient was attending my practice for the first time. She had a hemoglobin level of 9.5 gm/dl.

A normal hemoglobin level is anywhere between 11.3 gm/dl and 14.5 gm/dl. My three patients had anemia caused by lack of iron in their blood, most likely from eating food low in iron.

General introduction: childhood anemia due to lack of iron

If you are unlucky and have one of those intrusive aunties who stop unsuspecting children and use their index fingers to expose the inside of your lower eyelids, don’t panic – they are just checking you out for lack of blood, also known as anemia.

‘Does anybody feed this child?’ your auntie might ask the rest of the family. ‘His eyelids look pale, like egg white. Please make him eat more vegetables, eggs, cereals, beans and red meat.’

Your aunt probably got her way and made your mother promise she would take you to the doctor.

Your aunt might be right in noticing that you are anemic, but what she is not able to tell is the severity of the anemia and the specific reasons why you are anemic. Your anemia may or may not be due to your hatred for vegetables, beans, and red meat.

Having said that, since the lack of iron in the food we eat is a common reason why people become anemic, your aunt is not totally wrong in suggesting that your mother gives you more beans, and vegetables, eggs, and red meat, which are foods that contains plenty of iron.

Even though taking iron medication would not fix all types of anemia, trying it out for a few days may be a sensible option in a child suspected of lacking iron, as long as a hemoglobin recheck to determine improvement is possible.

Blood and hemoglobin

Varieties of cells swim in our blood. Each cell type has its individual function.  Inside one particular type of cell, called the red blood cells, resides a herculean molecule –hemoglobin – whose job it is to pick up oxygen [body fuel] from blood vessels near the lungs and transport it to all the living tissues of the body.  If red blood cells were hens’ eggs, hemoglobin would be the yolk inside the eggs.

Anemia and hemoglobin

A person’s degree of anemia is measured by the quantity of hemoglobin in their blood. The normal hemoglobin level is between 11.3 gm/dl and 14.5 gm/dl.

Iron and protein in hemoglobin

Irons [hemo] and proteins [globin] are the main raw materials needed for hemoglobin.  Production of the red blood cells and their hemoglobin content takes place primarily in the bone marrow. For our body and blood to have plentiful hemoglobin, it must have an abundant supply of iron, provided through the food we eat.

The protein portion of hemoglobin is as important as the iron part.  Anemia resulting from the protein part of hemoglobin has to do with the quality or the quantity of protein the body provides for hemoglobin production – issues which are mostly inherited and originate at the gene level.

Sickle cell disease is an example of a condition which frequently leads to anemia, not because of lack of iron but because of a problem with the protein [globin] part of hemoglobin. As a result the red blood cells are easily destroyed, and with that the degradation of hemoglobin and anemia.


  • Anemia in Children: Even your aunt can tell when you are anemic – Part II

Common causes of iron-deficiency anemia

Children often become anemic either because they do not eat food that contains iron, or because they lose iron for many days, or even months, from a source invisible to the naked eye. This tends to be at the gastrointestinal level, where blood loss occurs as undiagnosed gut pathology.

Iron-deficiency anemia due to poor nutrition and poor feeding habits

While in the womb, mothers transfer to their babies large quantities of iron with which to build hemoglobin. So babies are born with a high amount of hemoglobin, and as such are rarely anemic unless there are catastrophic medical circumstances.

After birth, with no more umbilical cord connection to the mother’s blood iron, the large quantity of iron and hemoglobin in the newborn begins to decrease.

Breast milk is still the best milk for newborn babies.  Baby formulas are used in situations where for some reason breast milk cannot be given.  Some babies go from breast milk to formula.

Breast milk alone has a good quantity of iron, but not enough for a baby after the age of four months. Therefore after four months, to prevent anemia, babies who feed on breast milk alone should get iron supplements.

Anemia can quickly develop in these newborns if solid foods containing iron are not introduced. Infant formulas, on the other hand, have enough iron to sustain a baby for a longer period of time.


Ages ten to nineteen is a time of tremendous increase in height and weight. From age fourteen through sixteen height velocity can reach up to four inches per year. Adolescents must match their iron consumption with their rapid growth. If their consumption of iron-rich food does not keep pace with the rapid gain in weight and height, iron deficiency and anemia can occur.

Teens who skip food, who routinely have an iron-poor diet, or who shun well-balanced meals of eggs, vegetables, beans, and red meat, are at an increased risk of anemia due to the reduction of body iron.

Girls are special

Girls who experience heavy or multiple monthly periods lose a lot of iron through bleeding. An above-average loss of blood during menstruation, and with it the loss of iron, is a frequent cause of anemia in females.

Hidden blood loss

Long-standing blood loss that is hard to see with the naked eye, especially in the gut through feces, can add up quickly to a major loss of iron and then to anemia.  Hidden but substantial blood loss can result from undiagnosed allergies to cow’s milk, ulcers, polyps, or blood vessel tumors in the gut.

Even chronic diarrhea in infants and children can occur with hidden blood loss, which over time adds up to a significant iron loss and anemia.


A battalion of hookworms can suck so much blood from the gut that a child becomes anemic. In areas where worms are common, hookworm infestation must be suspected and treated.

Goat’s milk and anemia due to lack of folic acid

Lack of folic acid delays maturation of red blood cells at their DNA level. The result is the production of frail, large cells that may easily die, a disorder whose consequence is known as megaloblastic anemia.

Unlike cow’s milk, goat’s milk and powdered milk have low amounts of folic acid, and babies and infants who solely drink goat’s milk are at a great risk of developing anemia due to folic acid deficiency.

Pregnant women require more folic acid than normal, so that they can pass some to their unborn babies where folic acid is essential for brain development.  Taking adequate amounts of folic acid during pregnancy prevents babies from developing brain abnormalities.

Green vegetables, fruits, and meat are good natural sources of folic acid.

Anemia due to lack of Vitamin B12

Similar to folic acid, lack of Vitamin B12 at nuclear level can delay red blood cell DNA maturation, leading to the same type of megaloblastic anemia, with frail, large red blood cells that die easily.

Since Vitamin B12 is only found in animal meat and animal meat products, people who do not eat meat, particularly strict vegetarians, run a risk of developing Vitamin B12 deficiency.  This is the type of anemia that is likely to develop in the breast-fed infant of a vegan or a strict vegetarian.

Some people who eat food rich in vitamin B12 may still lack this vitamin because they do not have a stomach protein called the intrinsic factor, which aids Vitamin B12 absorption from the stomach into the bloodstream.



  • Anemia in Children: Even your aunt can tell when you are anemic – Part III

At the doctor’s

At the doctor’s, nobody told you why you had come but you suspected your visit had to do with your nosy aunt. Your dislike for her rose to your throat even though in your heart you knew she loves you.

The doctor comes in in his white coat, checks you out for anemia just like your aunt did, and asks your mother to take you to the laboratory for a blood test. Ouch! The laboratory generates a number to indicate the level of anemia.

Signs and symptoms of anemia

Lots of people have anemia without knowing it. Clinicians stumble across people with anemia when they are doing routine or unrelated blood tests. The mothers of the three children I diagnosed with anemia did not suspect their kids had the condition. They felt fine, yet they were anemic.

How someone feels when they are anemic depends on how long they have been anemic and how low their hemoglobin is. People with long-standing anemia tend not have any complaints, or perhaps they have learned to manage or ignore their symptoms effectively.  At a certain low hemoglobin level, 7-8 gm/dl, signs and symptoms may eventually occur.

Signs and symptoms

Weakness, fast breathing, restlessness, difficulty in breathing, and rapid heartbeat are some of the common signs of anemia. If you catch your child eating soil or dirt, or he is inattentive or forgetful, or failing in school, he might well have anemia. It wouldn’t hurt to screen him or her with a blood test. Heart failure and death can occur in severe anemia.


For all the good things about breast milk, it still does not have enough iron to sustain infants as they grow, especially those infants who have to breastfeed as the only source of food.

Iron supplements are needed beginning at age four months for infants who take only breast milk. When introduced, baby cereals are good sources of iron.

Most baby formulas have an adequate supply of iron in them to prevent anemia due to lack of iron.

Balanced food at every age is the best way to prevent diet-related anemia.  People with suspected blood loss through the gut, or feces, or excessive menstrual bleeding in females, should receive further investigation and the cause of the ailment treated.


A minimum of hemoglobin level determination should be obtained before commencing any medication treatment. In most countries doctors have a laboratory that can test the hemoglobin level by pricking the finger – ouch!

This baseline hemoglobin level is important to access future progress when a clinician puts a patient on iron, folic acid or vitamin B12.

A person whose hemoglobin does not respond swiftly, in a matter of three days or so, merits further investigation. A look at their blood film under the microscope to see the shapes and sizes of red blood cells can reveal the presence of well-established causes of anemia, such as sickle cell disease and other inherited causes.

A test of their stool will find out if ‘hard to see’ blood loss is occurring in their gut, or to check for the presence of bloodsucking hookworms.

Iron medication and other treatments

People who are anemic due to lack of iron respond quickly when iron is given.  Oral iron supplements may not taste good and may cause constipation, but they work. You can mask the unpleasant taste with flavored syrup.

Females who are iron deficient due to prolonged menstrual loss may need iron in addition to hormone therapy to better control their periods.

Combat constipation with a high-fiber diet and lots of water. Continue iron medication up to two months after your hemoglobin has returned to normal.

Folic acid is given either by injection or by mouth at a dose of 0.5 mg-1mg daily for about one month in cases of anemia due to folic acid deficiency.

Vitamin B12 deficiency anemia is treated with monthly muscle injections of vitamin B12; in some cases treatments are given for life. Vitamin B12 is not as effective if given by mouth.

Once in a blue moon a blood transfusion is necessary in iron-deficiency anemia. Blood transfusion is more frequent in other types of anemia where the destruction of red blood cell is rapid and ongoing.



This article is not intended to treat or diagnose any illnesses or ailments. Some of the information may be outdated by the time of reading. Readers should consult with their clinicians before implementing any suggestion made in this article.


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