Anemia in Children With Inflammatory Bowel Disease

Abstract

Anemia is one of the most common extraintestinal manifestations of inflammatory bowel disease (IBD). It can be asymptomatic or associated with nonspecific symptoms, such as irritability, headaches, fatigue, dizziness, and anorexia. In IBD patients, the etiology of anemia is often multifactorial. Various causes include iron deficiency, anemia of inflammation and chronic disease, vitamin deficiencies, hemolysis, or myelosuppressive effect of drugs. Anemia and iron deficiency in these patients may be underestimated because of their insidious onset, lack of standardized screening practices, and possibly underappreciation that treatment of anemia is also required when treating IBD. Practitioners may hesitate to use oral preparations because of their intolerance whereas intravenous preparations are underutilized because of fear of adverse events, availability, and cost. Several publications in recent years have documented the safety and comparative efficacy of various intravenous preparations. This article reviews management of anemia in children with IBD, including diagnosis, etiopathogenesis, evaluation of a patient, protocol to screen and monitor patients for early detection and response to therapy, treatment including parenteral iron therapy, and newer approaches in management of anemia of chronic disease. This report has been compiled by a group of pediatric gastroenterologists serving on the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) IBD committee, in collaboration with a pediatric hematologist, pharmacist, and a registered dietician who specializes in pediatric IBD (IBD Anemia Working Group), after an extensive review of the current literature. The purpose of this review is to raise awareness of under-diagnosis of anemia in children with IBD and make recommendations for screening, testing, and treatment in this population.

Dietary Management in Pediatric Patients with Crohn’s Disease

“…Iron deficiency (ID) and Iron Deficiency Anemia (IDA) are frequently encountered clinical entities in pediatric IBD [ 69 , 70 ]. Using the World Health Organization definition of anemia, its prevalence at diagnosis reaches 78% in pediatric IBD populations [ 71 , 72 , 73 ].…”

“…Moreover, anemia affects up to 42% of children with IBD one year after diagnosis [ 69 , 74 ] and it has been reported to be more frequent in pediatric populations than in adult ones both at diagnosis and at follow-up [ 74 ]. Anemia of pediatric IBD has a complex and multifactorial pathogenesis, but the most common etiology arises from a combination of IDA and anemia of chronic diseases (ACD) [ 70 ]. More specifically, IDA has been reported as the leading cause of anemia in children with IBD and with CD [ 75 , 76 ].…”

“…When dealing with a child affected by IBD and anemia, the first therapeutic approach should include providing a balanced and diversified diet with iron-rich foods along with enhancement of alimentary iron absorption (i.e., pairing non-heme iron sources with food rich in ascorbic acid or avoiding coupling with foods that may impair iron absorption). Once having provided adequate control of disease activity and optimized dietary iron intake, the next step in case of persistence of IDA is represented by iron supplementation [ 70 ]. The choice of whether to administer oral or parenteral iron supplementation is not always straightforward [ 70 ].…”

“…Once having provided adequate control of disease activity and optimized dietary iron intake, the next step in case of persistence of IDA is represented by iron supplementation [ 70 ]. The choice of whether to administer oral or parenteral iron supplementation is not always straightforward [ 70 ]. Oral supplementation formulations have the relative advantage of not requiring infusions and thus scheduled access to the hospital, of being easily available and less expensive compared to parenteral products.…”

“…However, in a recent prospective, controlled, open-label trial, Rampton et al [ 84 ] demonstrated that oral iron supplementation did not increase disease activity in adolescents and adults with IBD over a period of 6 weeks. Therefore, oral iron supplementation may be used in children and adolescents with milder grades of anemia and inactive disease [ 70 ]. Besides oral iron compounds, different intravenous formulations are available as therapeutic options for IDA in patients with IBD.…”