Background

Please see clinical practice guideline - anaemia.

Anaemia and iron deficiency are common in children of refugee background.  Australian data suggest the prevalence of anaemia is 10–30% in refugee background children,^1-4 with similar prevalence in children from Africa, Middle East or Asia. Iron deficiency affects a similar proportion,^1,3,4 and is associated with tiredness, irritability and adverse effects on cognitive development.⁵

Definitions 

Anaemia is defined as haemoglobin (Hb) below the lower limit of reference range for age.

Table 1 - Haemoglobin - lower limit of reference range for age

Anaemia is usually multifactorial in the paediatric refugee population. Contributors include iron deficiency, thalassaemia carrier status and parasite infection/infestation, including malaria. Iron deficiency is usually nutritional, but may be due to gastrointestinal loss or associated with Helicobacter pylori infection.

Other causes of anaemia to consider include: 

• Haemoglobinopathies - which are more common in African, Asian and Middle Eastern populations. This means many children will be carriers, with microcytosis, and sometimes, mild anaemia (actual disease is uncommon). See fact sheet: Beta Thalassaemia. 
• B12 deficiency has been reported in refugees from Bhutan, Iran, Afghanistan, Iraq and the Horn of Africa in Australia,⁶ and should be considered in any refugee with restricted food access pre-arrival (lack of animal products associated with B12 deficiency) – see low B12 guideline. 
• Folate deficiency - associated with lack of fresh food, especially vegetables/greens, consider in situations of restricted food access, and restrictive eating (e.g. autism spectrum disorder).
• Lead toxicity – elevated blood lead levels have been reported in up to 7–13% of African^7,8 South Asian^9,10 and Burmese^11-13 refugee children, especially in those aged < 6 years; although rarely to a level requiring chelation therapy. Testing for blood lead levels is recommended in recently arrived refugee children (aged 6 months – 16 years) in the United States¹⁴  but is not currently part of initial refugee screening protocols in Australia – see lead guideline.
• G6PD deficiency - glucose-6-phosphate dehydrogenase deficiency may be associated with haemolysis - see fact sheet (with medications and food to avoid).

African background children and adolescents commonly have a neutrophil count below Australian reference ranges. In clinically well children and adolescents (including no fevers, gingivitis, or skin infections) this is usually a normal variant.^15-17

Assessment

• Pregnancy – maternal anaemia/iron deficiency/pica, maternal malaria
• Delivery – birthweight, complications
• Dietary history – duration breastfeeding, cow milk intake, age started solids, meat/animal product intake, food access overseas and in Australia
• Infections – malaria, worm infestations, GIT symptoms, including PR bleeding, features of H. pylori
• Growth history, including previous malnutrition
• Family history (haemoglobinopathies)

Clinical symptoms and signs may be subtle, despite significant anaemia. Look for: 

• Symptoms – lethargy, irritability, shortness of breath, pica
• Signs - pallor - conjunctival pallor is probably more useful than palmar crease pallor, poor growth, flow murmur, signs of cardiac failure, any features of haemolysis. 

Admission should be considered if: Hb < 6 g/dL, haemolysis, signs of cardiac failure, severe B12 or folate deficiency, or where multiple cell lines are affected

Screening

• Routine refugee health screening tests are FBE, film, and ferritin
  • The serum ferritin level, an iron storage protein, provides a reasonably accurate estimate of iron stores in the absence of inflammatory disease. In practice, we have not seen raised ferritin in paediatric refugee screening.
  • Normal ranges of ferritin are age dependent; levels decrease early in iron deficiency.
  • Microcytic anaemia with decrease in mean corpuscular volume (MCV) and haemoglobin (Hb) occur later, as iron deficiency progresses.
  • Macrocytic anaemia may be seen in B12 or folate deficiency, although macrocytosis with low B12 is uncommon in refugee background populations.⁶ 
• Consider blood lead levels in initial screening in children with pica, developmental issues or a history of exposure, including through traditional medicines, and as second line screening in children with microcytic anaemia
• Consider serum active B12 and red cell folate screening in people from Bhutan, Iran, Afghanistan and Iraq and countries in the Horn of Africa (especially where there has been poor food access). Complete screening in exclusively breastfed babies where there has been poor maternal food access, or where deficiency is suspected clinically or based on initial blood test results.
• Haemoglobin electrophoresis (and testing for alpha thalassaemia status) is not part of refugee health screening and screening for carrier status is not routine for children. Sickle cell disease/thalassaemia major/significant other haemoglobinopathy should be apparent based on clinical examination and FBE. Note: Low iron stores may result in false negative results (lack of elevated HbA2) in haemoglobin electrophoresis in beta-thalassaemia carrier state.

Management

• Consider causes of anaemia and/or iron deficiency; screen and treat for parasites and malaria if present
• Support breastfeeding and limit cow milk intake to 500 mL/day after 12 months of age; milk consumption may be high in some groups
• Dietary advice (regular meat intake, pulses, green vegetables)
• Correct iron deficiency with oral iron therapy (in the form of ferrous salts)
  
  • Elemental iron 2 - 6 mg/kg/day is given in divided doses - see table 2
  • Absorption is better if given with orange juice; don't take with milk
  • Discuss side effects (dark stool, constipation, gastrointestinal upset) safety and storage with families. See easidose to provide picture based dosing if needed
  • Treatment should be for 3 months after Hb normalises to replenish stores; levels seem to improve quickly once treatment is started and there is access to adequate nutrition in Australia.
• Consider adding folate if treating severe anaemia, particularly if access to food has been limited.

Table 2: Iron content of common commercial preparations

Resources

• Better Health Channel - Iron deficiency children (English only)
• Health translations - Iron
  

References

• References

^{Immigrant health clinic protocols. Author: Georgie Paxton January 2014, updated April 2020. Contact georgia.paxton@rch.org.au}