82 Management of Very Severe Iron Deficiency Anemia: Is Transfusion Always Necessary?

Abstract

Abstract Background Paediatric iron deficiency anemia (IDA) is a common condition in Canadian children; however, little is known about the natural history of extreme cases. This deficit makes it challenging to determine how to approach management when these patients present acutely to the emergency department (ED). Objectives To describe the clinical features and management of children presenting to the ED with very severe IDA with hemoglobin < 40 g/L. Design/Methods Retrospective chart reviews were performed for paediatric patients with IDA and hemoglobin < 40 g/L over a 5-year period (June 2017 – June 2022) at a Canadian tertiary care children’s hospital. Results Chart reviews were completed for 19 patients. The mean case rate was 3.1 patients annually (SD 2.14) with 11(58%) presenting in 2021–2022. Patients were young (median age 24 months; IQR 18–32) and predominantly female (79%). Nutritional deficiencies were the most common etiology (n=16, 84%). Median presenting hemoglobin was 25 g/L (IQR 22–36 g/L). The most common clinical features documented at presentation were pallor (n=19, 100%), tachycardia (n=17, 89%), and systolic ejection murmur (n=14, 74%). Thirteen (68%) patients had a ferritin measured in ED, 11(58%) had a chest x-ray, four (21%) had a lactate measured. One (5%) patient had an echocardiogram, and four (21%) had bedside cardiac ultrasounds documented. Eight (42%) patients with median hemoglobin 35 g/L (IQR 25–36 g/L) were managed without blood transfusion (PO iron only: n=3, 16%; IV iron only: n=5, 26%). Of the 11 (63%) patients who received blood, 2 (18%) had transfusion-related adverse events, with one patient undergoing intubation for transfusion-associated circulatory overload while admitted. All patients (100%) were initiated on oral iron supplementation. Ten patients (53%) received intravenous (IV) iron (dose 5–7 mg/kg) with one experiencing a mild reaction. Fifteen patients (79%) were hospitalized, with two (10%) admitted directly to the Paediatric Intensive Care Unit. Median duration of hospitalization was 5 days (IQR 2–9 days). Patients followed after transfusion-free management (n=5) demonstrated median hemoglobin increase of 21 g/L (IQR 20–32 g/L) within 12 days. No patient returned to the ED for anemia within 30 days. Conclusion Paediatric patients with very severe IDA do not always require transfusion. Some patients were effectively managed with IV iron alone. Investigation and management of these patients appears heterogenous. Given the risks of blood transfusion and the increased availability of IV iron, guidelines outlining evidence-based management of severe IDA are needed. These guidelines should promote optimization of iron therapy and guide judicious administration of blood transfusion.