Evaluation and Management of Iron Deficiency in Children Undergoing Intestinal Rehabilitation
Publication Date: April 30, 2023
Last Updated: May 1, 2023
Summary of Recommendations
In children with suspected altered GI motility (gastroparesis, PIPO) or a history of gastrojejunal bypass, persistently draining G tube, we recommend clamping the G tube for 30 minutes after enteral iron administration into the gastric port for improved absorption into the duodenum. (8 authors in favor)
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Screening for ID/IDA in children undergoing IR should not be based on a Hb and mean corpuscular volume (MCV) alone. We recommend screening for IDA based on a complete blood count (CBC), SF, TSAT, serum iron concentration, and TIBC. (8 authors in favor)
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A CRP should be obtained while screening for ID as SF is an acute phase reactant. (8 authors in favor)
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Children undergoing IR should be screened for ID/IDA. We recommend screening every 3–6 months. (7 authors in favor, 1 opposed)
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Vitamin B12, zinc, and copper deficiency should be evaluated based on anatomic risk and in children not responding to conventional treatment. (7 authors in favor, 1 opposed)
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While assessing iron status in children undergoing IR, we recommend categorizing children into 3 categories: 1. Children without ID; 2. Children with ID without anemia; and 3. Children with IDA. This will enable IR providers to make an informed decision regarding treatment. (8 authors in favor)
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Screening for thalassemia should be considered in children not responding to conventional treatment in certain patient populations. (6 authors in favor, 1 opposed and 1 abstained from commenting)
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In the assessment of ID in children undergoing IR, endoscopy is not routinely recommended. It can be considered if there is a poor response to enteral iron or if concerning signs and symptoms suggest GI bleeding, or intestinal inflammation. (6 authors in favor, 1 opposed and 1 abstained)
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Referral to a hematologist can be reserved for lack of recovery of Hb with iron supplementation, presence of pancytopenia, or difficulty distinguishing between multiple micronutrient deficiencies, portal hypertension, cancer, or other marrow insufficiency. (8 authors in favor)
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There is insufficient evidence to recommend a trial of dietary enrichment alone for the treatment of ID. Dietary enrichment may be used as an adjunct to supplementation. (8 authors in favor)
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In children undergoing IR without ID, we recommend enteral supplementation or IV supplementation in those who have minimal enteral intake, along with monitoring (every 3–6 months) for the development of ID or iron overload. (7 authors in favor, 1 opposed)
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In children undergoing IR with ID without anemia, we recommend enteral iron if tolerated and parenteral iron only in those without enteral tolerance or in children who are unresponsive to enteral supplementation. (7 authors in favor, 1 abstained)
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In children undergoing IR with IDA, we recommend parenteral iron to replace any iron deficit followed by enteral or parenteral iron maintenance (via intermittent infusions) as appropriate for the individual child. We recommend assessing treatment response every 1–3 months. (8 authors in favor)
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In children undergoing IR with ID without IDA, we recommend assessing response to treatment every 3–6 months. (8 authors in favor)
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In children undergoing IR with IDA, we recommend assessing response to treatment every 1–3 months. (8 authors in favor)
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- ID: Iron Deficiency
- IDA: Iron Deficiency Anemia
- IF: Intestinal Failure
- IR: Intestinal Rehabilitation
- SBS: Short Bowel Syndrome
- SF: Serum Ferritin
The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.
Title
Evaluation and Management of Iron Deficiency in Children Undergoing Intestinal Rehabilitation
Authoring Organization
North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition
Publication Month/Year
April 30, 2023
Last Updated Month/Year
February 14, 2024
Country of Publication
US
Document Objectives
Iron deficiency (ID) is the most common nutritional deficiency affecting children undergoing intestinal rehabilitation (IR). Patients may be asymptomatic or present with nonspecific symptoms including fatigue, irritability, and dizziness. The diagnosis of ID in this population can be complicated by the coexistence of systemic inflammation or other nutritional deficiencies which may mimic ID. Many routinely available laboratory tests lack specificity and no consensus on screening is available. Success in oral and enteral treatment is impeded by poor tolerance of iron formulations in a population already challenged with intolerance. Newer parenteral iron formulations exhibit excellent safety profiles, but their role in repletion in this population remains unclear. The following report, compiled by a multidisciplinary group of providers caring for children undergoing IR and representing the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Special Interest Group for Intestinal Rehabilitation, seeks to address these challenges. After discussing iron physiology and population-specific pathophysiology, we make recommendations on iron intake, iron status assessment, and evaluation for alternative causes of anemia. We then provide recommendations on iron supplementation and treatment of ID anemia specific to this nutritionally vulnerable population.
Inclusion Criteria
Male, Female, Adolescent, Child, Infant
Health Care Settings
Ambulatory, Outpatient
Intended Users
Dietician nutritionist, nurse, nurse practitioner, physician, physician assistant
Scope
Assessment and screening, Management, Rehabilitation
Diseases/Conditions (MeSH)
D007501 - Iron, D000090463 - Iron Deficiencies, D007410 - Intestinal Diseases
Keywords
iron deficiency, intestinal rehabilitation
Source Citation
Talathi S, Namjoshi S, Raghu V, Wendel D, Oliveira SB, Reed K, Yanchis D, Mezoff EA. Evaluation and Management of Iron Deficiency in Children Undergoing Intestinal Rehabilitation-A Position Paper From the NASPGHAN Intestinal Rehabilitation Special Interest Group. J Pediatr Gastroenterol Nutr. 2023 May 1;76(5):672-683. doi: 10.1097/MPG.0000000000003736. Epub 2023 Feb 16. PMID: 36800275.