Iron requirements and iron deficiency in adolescents
- Steven A Abrams, MD
Steven A Abrams, MD
- Section Editor — Neonatology
- Professor, Department of Pediatrics
- Dell Medical School at the University of Texas at Austin
- Section Editors
- Kathleen J Motil, MD, PhD
Kathleen J Motil, MD, PhD
- Section Editor — Pediatric Nutrition
- Professor of Pediatric Nutrition
- Baylor College of Medicine
- Donald H Mahoney, Jr, MD
Donald H Mahoney, Jr, MD
- Section Editor — Pediatric Hematology
- Professor of Pediatrics
- Baylor College of Medicine
- Diane Blake, MD
Diane Blake, MD
- Section Editor — Adolescent Medicine
- Professor of Pediatrics
- University of Massachusetts Medical School
Adolescence is a time of increased iron needs because of the expansion of blood volume and increases in muscle mass. The incidence of iron deficiency among adolescents appears to be rising ; at particular risk are adolescent athletes and adolescents who limit their intake of meat products.
Iron deficiency in adolescents is a complex disorder. The diagnosis often is controversial, and the effects on both physical endurance and cognitive performance in adolescents remain to be fully understood. These issues will be addressed here. Iron deficiency in infants and young children and in adults is discussed in separate topic reviews. (See "Iron deficiency in infants and young children: Screening, prevention, clinical manifestations, and diagnosis" and "Treatment of iron deficiency anemia in adults".)
The Third National Health and Nutrition Examination Survey (NHANES III) found a 9 percent incidence of iron deficiency and a 2 percent incidence of iron deficiency anemia among American females between the ages 12 and 15 years; the respective values were 11 and 3 percent in girls between the ages of 16 and 19 years . Less than 1 percent of adolescent males had iron deficiency. Studies in other countries have found higher rates of iron deficiency in male and female adolescents [3,4]. Some of the variation in incidence noted among different studies is related to the controversy regarding the appropriate laboratory cutoffs to make the diagnosis. (See 'Diagnosis' below.)
Risk groups — Adolescents with chronic illness, heavy menstrual blood loss (>80 mL/month), or who are underweight or malnourished are at increased risk for iron deficiency and should have laboratory screening for anemia during health supervision or specialty clinic visits [5-7]. (See 'Whom to screen' below.)
Overweight and obese children also appear to be at increased risk for iron deficiency and should undergo screening [8,9]. In one study, data from NHANES III were examined for an association between iron deficiency and weight . The prevalence of iron deficiency increased as body mass index increased from normal weight to >85th percentile for age and sex to >95th percentile for age and sex (2.1 percent, 5.3 percent, and 5.5 percent, respectively). Obesity was a risk factor for iron deficiency anemia in both boys and girls, but rates were approximately three times higher in girls. The etiology of anemia in obese individuals is uncertain but may be related to low-quality diets or increased needs relative to body weight [8,9].
- Maeda M, Yamamoto M, Yamauchi K. Prevalence of anemia in Japanese adolescents: 30 years' experience in screening for anemia. Int J Hematol 1999; 69:75.
- Looker AC, Dallman PR, Carroll MD, et al. Prevalence of iron deficiency in the United States. JAMA 1997; 277:973.
- Hallberg L, Hultén L, Lindstedt G, et al. Prevalence of iron deficiency in Swedish adolescents. Pediatr Res 1993; 34:680.
- Eskeland B, Hunskaar S. Anaemia and iron deficiency screening in adolescence: a pilot study of iron stores and haemoglobin response to iron treatment in a population of 14-15-year-olds in Norway. Acta Paediatr 1999; 88:815.
- Adolescence. In: Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescents, 3rd, Hagan JF, Shaw JS, Duncan PM. (Eds), American Academy of Pediatrics, Elk Grove Village, IL 2008. p.515.
- COMMITTEE ON PRACTICE AND AMBULATORY MEDICINE and, BRIGHT FUTURES PERIODICITY SCHEDULE WORKGROUP. 2016 Recommendations for Preventive Pediatric Health Care. Pediatrics 2016; 137:1.
- Johnson S, Lang A, Sturm M, O'Brien SH. Iron Deficiency without Anemia: A Common Yet Under-Recognized Diagnosis in Young Women with Heavy Menstrual Bleeding. J Pediatr Adolesc Gynecol 2016; 29:628.
- Pinhas-Hamiel O, Newfield RS, Koren I, et al. Greater prevalence of iron deficiency in overweight and obese children and adolescents. Int J Obes Relat Metab Disord 2003; 27:416.
- Nead KG, Halterman JS, Kaczorowski JM, et al. Overweight children and adolescents: a risk group for iron deficiency. Pediatrics 2004; 114:104.
- Beard JL. Iron requirements in adolescent females. J Nutr 2000; 130:440S.
- Hord JD. Anemia and coagulation disorders in adolescents. Adolesc Med 1999; 10:359.
- Merkel D, Huerta M, Grotto I, et al. Prevalence of iron deficiency and anemia among strenuously trained adolescents. J Adolesc Health 2005; 37:220.
- Food and Nutrition Board of the Institute of Medicine. Iron in: Dietary reference intakes for vitamin A, vitamin K, arsenic, boron, chromium, copper, iodine, iron, manganese, molybdenum, nickel, silicon, vanadium, and Zinc. National Academy Press, Washington DC, 2000; p. 339.
- Dallman, PR. Changing iron needs from birth through adolescence. In: Nutritional Anemias, Fomon, SJ, Zlotkin, S (Ed), Nestle Nutrition Workship Series, vol 30, Nestec, Ltd. Vevey/Raven Press, Ltd, New York 1992. p. 29.
- Fomon SJ, Drulis JM, Nelson SE, et al. Inevitable iron loss by human adolescents, with calculations of the requirement for absorbed iron. J Nutr 2003; 133:167.
- Brittenham, GM. Disorders of iron metabolism: Iron deficiency and overload. In: Hematology Basic Principles and Practice, 2nd ed, Hoffman, R, Benz, EJ Jr, Shattil, SJ, et al (Eds), Churchill Livingstone, New York 1995.
- Cook JD, Skikne BS. Iron deficiency: definition and diagnosis. J Intern Med 1989; 226:349.
- Bridges, KR, Seligman, PA. Disorders of iron metabolism. In: Blood: Principles & Practice of Hematology, Handin, RI, Lux, SE, Stossel, TP (Eds), 1995.
- Crosby, WH. Physiology and pathophysiology of iron metabolism. Hosp Pract 1990; 26:7.
- Bruner AB, Joffe A, Duggan AK, et al. Randomised study of cognitive effects of iron supplementation in non-anaemic iron-deficient adolescent girls. Lancet 1996; 348:992.
- Murray-Kolb LE, Beard JL. Iron treatment normalizes cognitive functioning in young women. Am J Clin Nutr 2007; 85:778.
- Ballin A, Berar M, Rubinstein U, et al. Iron state in female adolescents. Am J Dis Child 1992; 146:803.
- Halterman JS, Kaczorowski JM, Aligne CA, et al. Iron deficiency and cognitive achievement among school-aged children and adolescents in the United States. Pediatrics 2001; 107:1381.
- Rowland TW, Deisroth MB, Green GM, Kelleher JF. The effect of iron therapy on the exercise capacity of nonanemic iron-deficient adolescent runners. Am J Dis Child 1988; 142:165.
- Rowland TW, Kelleher JF. Iron deficiency in athletes. Insights from high school swimmers. Am J Dis Child 1989; 143:197.
- Sharma R, Stanek JR, Koch TL, et al. Intravenous iron therapy in non-anemic iron-deficient menstruating adolescent females with fatigue. Am J Hematol 2016; 91:973.
- Brown WD, Dyment PG. Pagophagia and iron deficiency anemia in adolescent girls. Pediatrics 1972; 49:766.
- Rector WG Jr. Pica: its frequency and significance in patients with iron-deficiency anemia due to chronic gastrointestinal blood loss. J Gen Intern Med 1989; 4:512.
- Tunnessen WW, Smith C, Oski FA. Beeturia. A sign of iron deficiency. Am J Dis Child 1969; 117:424.
- Duncan PM, Duncan ED, Swanson J. Bright Futures: the screening table recommendations. Pediatr Ann 2008; 37:152.
- Recommendations to prevent and control iron deficiency in the United States. Centers for Disease Control and Prevention. MMWR Recomm Rep 1998; 47:1.
- White KC. Anemia is a poor predictor of iron deficiency among toddlers in the United States: for heme the bell tolls. Pediatrics 2005; 115:315.
- Sekhar DL, Murray-Kolb LE, Kunselman AR, Paul IM. Identifying factors predicting iron deficiency in United States adolescent females using the ferritin and the body iron models. Clin Nutr ESPEN 2015; 10:e118.
- Bergström E, Hernell O, Lönnerdal B, Persson LA. Sex differences in iron stores of adolescents: what is normal? J Pediatr Gastroenterol Nutr 1995; 20:215.
- Samuelson G, Bratteby LE, Berggren K, et al. Dietary iron intake and iron status in adolescents. Acta Paediatr 1996; 85:1033.
- Olsson KS, Marsell R, Ritter B, et al. Iron deficiency and iron overload in Swedish male adolescents. J Intern Med 1995; 237:187.
- Tran TN, Eubanks SK, Schaffer KJ, et al. Secretion of ferritin by rat hepatoma cells and its regulation by inflammatory cytokines and iron. Blood 1997; 90:4979.
- Committee on Nutrition, American Academy of Pediatrics. Screening for iron deficiency, in: Pediatric Nutrition Handbook, 6th ed, Kleinman, RE (Ed). American Academy of Pediatrics, Elk Grove Village, IL 2009. p. 419.
- Subar AF, Krebs-Smith SM, Cook A, Kahle LL. Dietary sources of nutrients among US children, 1989-1991. Pediatrics 1998; 102:913.
- Hallberg L, Brune M, Rossander L. Effect of ascorbic acid on iron absorption from different types of meals. Studies with ascorbic-acid-rich foods and synthetic ascorbic acid given in different amounts with different meals. Hum Nutr Appl Nutr 1986; 40:97.
- Disler PB, Lynch SR, Charlton RW, et al. The effect of tea on iron absorption. Gut 1975; 16:193.
- Hallberg L, Rossander L, Skånberg AB. Phytates and the inhibitory effect of bran on iron absorption in man. Am J Clin Nutr 1987; 45:988.
- Hallberg L, Hulthén L. Prediction of dietary iron absorption: an algorithm for calculating absorption and bioavailability of dietary iron. Am J Clin Nutr 2000; 71:1147.
- Cook JD. Adaptation in iron metabolism. Am J Clin Nutr 1990; 51:301.
- Ames SK, Gorham BM, Abrams SA. Effects of high compared with low calcium intake on calcium absorption and incorporation of iron by red blood cells in small children. Am J Clin Nutr 1999; 70:44.
- Mølgaard C, Kaestel P, Michaelsen KF. Long-term calcium supplementation does not affect the iron status of 12-14-y-old girls. Am J Clin Nutr 2005; 82:98.
- Bendich A. Calcium supplementation and iron status of females. Nutrition 2001; 17:46.
- Adish AA, Esrey SA, Gyorkos TW, et al. Effect of consumption of food cooked in iron pots on iron status and growth of young children: a randomised trial. Lancet 1999; 353:712.
- Angeles-Agdeppa I, Schultink W, Sastroamidjojo S, et al. Weekly micronutrient supplementation to build iron stores in female Indonesian adolescents. Am J Clin Nutr 1997; 66:177.
- Shah BK, Gupta P. Weekly vs daily iron and folic acid supplementation in adolescent Nepalese girls. Arch Pediatr Adolesc Med 2002; 156:131.
- Baynes RD, Cook JD. Current issues in iron deficiency. Curr Opin Hematol 1996; 3:145.
- Viteri FE. Iron supplementation for the control of iron deficiency in populations at risk. Nutr Rev 1997; 55:195.
- Crosby WH. The rationale for treating iron deficiency anemia. Arch Intern Med 1984; 144:471.
- Food and Nutrition Board of the Institute of Medicine. Iron in: Dietary reference intakes for vitamin A, vitamin K, arsenic, boron, chromium, copper, iodine, iron, manganese, molybdenum, nickel, silicon, vanadium, and Zinc. National Academy Press, Washington DC, 2000; p. 292-294.
- Food and Nutrition Board of the Institute of Medicine. Iron in: Dietary reference intakes for vitamin A, vitamin K, arsenic, boron, chromium, copper, iodine, iron, manganese, molybdenum, nickel, silicon, vanadium, and Zinc. National Academy Press, Washington DC, 2000; p. 311.
- Siegenberg D, Baynes RD, Bothwell TH, et al. Ascorbic acid prevents the dose-dependent inhibitory effects of polyphenols and phytates on nonheme-iron absorption. Am J Clin Nutr 1991; 53:537.
- Boggs DR. Fate of a ferrous sulfate prescription. Am J Med 1987; 82:124.
- Kelly AL, Rhodes DA, Roland JM, et al. Hereditary juvenile haemochromatosis: a genetically heterogeneous life-threatening iron-storage disease. QJM 1998; 91:607.
- Adams PC, Kertesz AE, Valberg LS. Screening for hemochromatosis in children of homozygotes: prevalence and cost-effectiveness. Hepatology 1995; 22:1720.
- Powers JM, Shamoun M, McCavit TL, et al. Intravenous Ferric Carboxymaltose in Children with Iron Deficiency Anemia Who Respond Poorly to Oral Iron. J Pediatr 2016.
- Laass MW, Straub S, Chainey S, et al. Effectiveness and safety of ferric carboxymaltose treatment in children and adolescents with inflammatory bowel disease and other gastrointestinal diseases. BMC Gastroenterol 2014; 14:184.
- Plummer ES, Crary SE, McCavit TL, Buchanan GR. Intravenous low molecular weight iron dextran in children with iron deficiency anemia unresponsive to oral iron. Pediatr Blood Cancer 2013; 60:1747.
- Auerbach M, Adamson JW. How we diagnose and treat iron deficiency anemia. Am J Hematol 2016; 91:31.
- Rodgers GM, Auerbach M, Cella D, et al. High-molecular weight iron dextran: a wolf in sheep's clothing? J Am Soc Nephrol 2008; 19:833.
- Risk groups
- IRON REQUIREMENTS
- STAGES OF IRON DEFICIENCY
- CLINICAL FEATURES
- Cognitive function
- Physical performance and fatigue
- Pica and pagophagia
- Restless legs syndrome
- Whom to screen
- How to screen
- Dietary iron
- Iron supplements
- - Absorption
- - Intolerance
- - Toxicity
- Parenteral therapy
- Blood transfusion
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS