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Management of Iron Deficiency in Neonates

SUMMARY

  • While iron deficiency (ID) is not common in healthy, full-term neonates, it is significantly more prevalent in preterm, low birth weight, and high-risk infants. Monitoring and early supplementation in those groups is essential for preventing neurodevelopmental consequences.
  • The timing of iron deficiency matters: Early-life deficiency, particularly in the first 6–12 months, is far more damaging than later-onset iron deficiency. This is why prevention and early detection in high-risk neonates are crucial.


How Common Is Iron Deficiency in Neonates?

  • Prevalence of ID in healthy, full-term neonates is estimated to be low (less than 5%) in high-income countries, assuming good maternal iron status.
  • Iron deficiency is more common in the following neonatal populations:
    • Preterm infants:
      • Most iron accumulation occurs in the missed third trimester.
      • Up to 30% may show signs of iron deficiency without supplementation.
    • Low birth weight infants:
      • Reduced iron stores due to overall lower body mass and blood volume.
    • Infants of diabetic mothers:
      • May have abnormal iron distribution, favoring other organs over the brain and liver.
    • Infants with intrauterine growth restriction (IUGR):
      • May have depleted iron stores due to placental insufficiency.
    • Infants of mothers with iron deficiency anemia:
      • Maternal iron deficiency can affect fetal iron stores, especially if severe.
    • Delayed cord clamping not practiced:
      • Immediate cord clamping reduces the infant’s blood and iron volume by up to 30%.

What Is the Impact of Iron Deficiency on Neonates?

  • Neurodevelopmental
    • Cognitive and behavioral delays
    • Impaired motor development
    • Diminished language and social-emotional skills
    • Deficits may persist even after iron levels are corrected if the deficiency occurs during critical windows of brain development
  • Hematological
    • Prolonged microcytic, hypochromic anemia
    • Decreased oxygen-binding capacity can affect tissue oxygenation and growth
  • Growth and Immunological
    • May impair physical growth and weight gain
    • Alteration in immune function may increase susceptibility to infections
  • Psychosocial
    • Behavioral problems
    • Increase risk of developing attention-deficit symptoms

Who Should Receive Screening?

  • All neonates should be screened early for iron deficiency 

What IV Iron Therapies Are Recommended for Neonates?

  • IV iron is rarely used in neonates and is generally reserved for specific, high-risk cases where oral iron is not effective, tolerated, or feasible.
  • Considered in only selected circumstances, including:
    • Severe Iron Deficiency
      • Failure of oral iron therapydue to poor absorption or gastrointestinal intolerance
      • Need for rapid iron repletion for symptomatic anemia, critical illness, or preoperative optimization
      • Concurrent erythropoietin therapy in preterm infants with anemia of prematurity, where iron demand is high
    • Gastrointestinal Issues or Malabsorption
      • Necrotizing enterocolitis (NEC)
      • Short bowel syndrome
      • Chronic diarrhea or enteropathy
      • Prolonged parenteral nutrition

What About Oral Iron?

  • Liquid oral iron solution is typically the first-line treatment in neonates and infants because it is effective, safe, and well-absorbed in most cases.

References

  1. Georgieff MK. The importance of iron deficiency in pregnancy on fetal, neonatal, and infant neurodevelopmental outcomes. Int J Gynaecol Obstet. 2023 Aug;162 Suppl 2(Suppl 2):83-88. doi: 10.1002/ijgo.14951. PMID: 37538010; PMCID: PMC10421617.
  2. Ataide R, Fielding K, Pasricha SR, Bennett C. Iron deficiency, pregnancy, and neonatal development. Int J Gynaecol Obstet. 2023 Aug;162 Suppl 2:14-22. doi: 10.1002/ijgo.14944. PMID: 37538017.
  3. Rusch JA, van der Westhuizen DJ, Gill RS, Louw VJ. Diagnosing iron deficiency: Controversies and novel metrics. Best Pract Res Clin Anaesthesiol. 2023 Dec;37(4):451-467. doi: 10.1016/j.bpa.2023.11.001. Epub 2023 Nov 17. PMID: 39764832.
  4. Gisslen T, Rao R, Georgieff MK. Anemia, Iron Supplementation, and the Brain. Clin Perinatol. 2023 Dec;50(4):853-868. doi: 10.1016/j.clp.2023.07.009. Epub 2023 Aug 31. PMID: 37866852; PMCID: PMC10590989.
  5. Georgieff MK. Maternal gestational iron status and infant haematological and neurodevelopmental outcomes. BJOG. 2023 Nov;130 Suppl 3:92-98. doi: 10.1111/1471-0528.17612. Epub 2023 Aug 2. PMID: 37530464.
  6. Mattiello V, Schmugge M, Hengartner H, von der Weid N, Renella R; SPOG Pediatric Hematology Working Group. Diagnosis and management of iron deficiency in children with or without anemia: consensus recommendations of the SPOG Pediatric Hematology Working Group. Eur J Pediatr. 2020 Apr;179(4):527-545. doi: 10.1007/s00431-020-03597-5. Epub 2020 Feb 4. PMID: 32020331.


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