Addressing Anemia in Pediatrics and Geriatrics

Anemia occurs in up to 25% of people in the United States1

The most common blood disorder, according to the National Heart, Lung, and Blood Institute, the condition affects more than three million Americans of all ages, but will most likely trend to more alarming rates as the country’s aging population takes its toll. However, according to Douglas L. Smith, MD, anemia should not be considered an inevitable acceptable consequence of aging,2 This article will review recent literature as it pertains to the diagnosis and treatment of anemia among both older and younger patients.

Types of Anemia & Causes

Anemia occurs when the blood doesn’t have enough healthy red cells to transport oxygen to body organs and can range from mild to severe. Diagnosis is confirmed when a blood test shows a hemoglobin value of less than 13.5 gm/dl among men or less than 12.0 gm/dl in a woman. Normal values for children will reportedly vary with age. The most common causes of anemia among elderly patients are chronic disease and iron deficiency.2 According to the National Institutes of Health’s National Heart, Lung, and Blood Institute, there are more than 400 types of anemia, but the causes can be divided into three main groups: anemia caused by blood loss, anemia caused by decreased or faulty red blood cell production and anemia caused by destruction of red blood cells.

Nurses and other healthcare providers should consider the possible presence of anemia when certain symptoms present, including physical weakness, shortness of breath, dizziness, fast or irregular heartbeat, pounding or “whooshing” in the ears, headache, cold hands and/or feet, pale or yellow skin, and chest pain. Some chronic comorbid conditions expose individuals to greater risk of developing anemia, including rheumatoid arthritis (or other autoimmune disease), kidney disease, cancer, liver disease, thyroid disease and inflammatory bowel diseases such as Crohn’s disease or ulcerative colitis. Then there are dietary causes of anemia, chief among them are iron deficiency and vitamin B12 and folate deficiencies. A family history of an inherited anemia, such as sickle cell anemia, can also predispose someone to the condition.


FDA Approves Drug for Pediatric Dialysis Patients With Associated Anemia

The U.S. Food & Drug Administration (FDA) has approved methoxy polyethylene glycol-epoetin beta (brand name Mircera) for the treatment of pediatric patients ages 5-17 who are on hemodialysis and who are converting from another erythropoiesis-stimulating agent (ESA) after their hemoglobin level was stabilized with an ESA.

Approval was reportedly based on data from an open-label, multiple dose, multicenter, dose-finding trial in 64 pediatric patients living with chronic kidney disease who are on hemodialysis and had stable hemoglobin levels while previously receiving another ESA. Patients were administered Mircera intravenously once every four weeks for 20 weeks. After the first administration of Mircera, dosage adjustments were permitted to maintain target hemoglobin levels. Efficacy was based on maintaining hemoglobin levels within target levels in the clinical trial and from extrapolation from trials of Mircera in adult CKD patients. The safety findings observed in pediatric patients were consistent with those previously reported in adults, according to FDA officials.

For conversion from another ESA, Mircera is dosed intravenously once every four weeks based on total weekly epoetin alfa or darbepoetin alfa dose at the time of conversion.

Treatment for Children & Adults
There is no specific therapy for anemia that is a result of chronic disease except to manage or treat the underlying disorder.2 Most children with anemia are said to be asymptomatic and have an abnormal hemoglobin or hematocrit level on routine screening. Treatment suggestions for anemia resulting from an iron, vitamin and/or folic acid deficiency includes encouraging patients to consume a balanced diet.3

Typically, the recommended dose of elemental iron is 50-100 mg three times per day; however, a smaller amount of elemental iron, such as a single 325-mg tablet of iron sulfate, may minimize side effects and improve compliance.4 According to the American Society of Hematology, foods that can be included in one’s diet to help reverse the effects of anemia are those with high levels of iron (beef, dark green leafy vegetables, dried fruits, nuts), vitamin B-12 (meat and dairy) and folic acid (citrus juices, dark green leafy vegetables, legumes, fortified cereals). According to Joseph J. Irwin, MD, and Jeffrey T. Kirchner, MD, most children who are living with anemia are asymptomatic and are found to have an abnormal hemoglobin or hematocrit level on routine screening.5 Symptoms among children who are living with the condition can include pallor, fatigue and jaundice, possibly absent of critical illness. Among full-term infants, iron deficiency is rarely the cause of anemia until after six months of age.5 In premature infants, iron deficiency can occur only after the birth weight has been doubled. The most common cause of anemia worldwide is iron deficiency, and this holds true for pediatrics.6 Symptoms of iron-deficiency anemia among children include abnormal paleness or lack of skin color, irritability, lack of energy or tiring easily (fatigue), increased heart rate (tachycardia), sore or swollen tongue, enlarged spleen, and/or a desire to eat peculiar substances such as dirt or ice (also called pica).6 For pregnant women, mild anemia is considered normal due to an increase in blood volume.7 More severe anemia, however, can place an unborn baby at higher risk for anemia later in infancy. Those women who are significantly anemic during the first two trimesters are at greater risk for having a pre-term delivery or low-birth-weight baby.7 Being anemic also burdens the mother by increasing the risk of blood loss during labor and making it more difficult to fight infections.7


  1. Baltierra D, Harper T, Jones MP, Nau KC. Hematologic disorders: anemia. FP Essent. 2015;433:11-5.
  2. Smith DL. Anemia in the elderly. Am Fam Physician. 2000;62(7):1565-72.
  3. ChooseMyPlate. United States Department of Agriculture. 2018. Accessed online:
  4. Balducci L, Saba HI. Hematologic diseases and disorders. In: Reuben DB, Yoshikawa TT, Besdine RW, eds. Geriatrics review syllabus: a core curriculum in geriatric medicine. 3d ed. New York, NY: American Geriatrics Society, 1996:314–8.
  5. Irwin JJ, Kirchner JT. Anemia in children. Am Fam Physician. 2001;64(8):1379-87.
  6. Pediatric anemia (iron-deficiency). Children’s National Health System. Accessed online:
  7. Anemia and pregnancy. American Society of Hematology. 2018. Accessed online:

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