by Moza Obaid Rashed , SCHS Nursing unit

 

I. Introduction

Iron deficiency anemia is a major health challenge worldwide, especially among children. According to recent studies, the incidence of iron deficiency anemia among children is high in the Middle East. Owaidah et al.(2020), the prevalence of IDA is 9 to 11% of children in Saudi Arabia. The burden is higher in the United Arab Emirates where Faysal et al. (2020) found that the condition affects about 30 to 40% of children. Notably, it is crucial to detect and treat iron deficiency anemia early because untreated iron deficiency anemia may cause severe health complications. Long-lasting iron deficiency in children may result in poor growth, a weak immune system. Furthermore, alterations in hematology, metabolic disorders, and feeding obstacles have been found to increase the susceptibility of children with Down syndrome to iron deficiency anemia. Moreover, according to (Mittal et al. (2020), anemia affects between 22 and 23% of children with Down syndrome.

Why Children with Down Syndrome Are More Susceptible to Iron Deficiency Anemia

Biological Factors

Interestingly, children with Down syndrome are more susceptible to disruptions of their iron levels related to their unique physiological characteristics. This is mainly related to the presence of extra chromosome trisomy 21. Their metabolism is impaired due to this chromosomal aberration which makes them vulnerable to iron deficiency anemia. Their bodies fail to absorb recommended daily iron requirements and other vital nutrients from foods. It has been found that children with Down syndrome have shortages in iron and other important minerals, which is the result of their genetic and physiological composition. Therefore, they should have adequate intake of iron rich diet in addition to continuing serum iron monitoring to stay healthy and to detect any deficiency early.

Digestive complications

Children with Down syndrome experience feeding problems and digestive complications leading to the onset of iron deficiency anemia. In early childhood, children experience difficulties in learning how to chew and swallow foods, which makes eating habits a problem. One major study reported that 41.3 % of children with Down syndrome demonstrate food aversions or are selective eaters. Moreover, 26.5% of them have severe eating disorders that affect their intake of nutrients. Therefore, the nutritional status of the children with Down syndrome should be evaluated on a regular basis and appropriate assistance should be given to avoid iron deficiency.

Challenges in Diagnosing Iron Deficiency Anemia in Children with Down Syndrome

Symptom Overlap and Limitations of Hemoglobin-Based Diagnosis

Diagnosis of iron deficiency anemia in children with Down syndrome is a major health concern because of the similarity of symptoms between the two conditions. The most common symptoms of iron deficiency anemia are fatigue, poor appetite, and slow growth which are also typical features of Down syndrome regardless of iron deficiency anemia. However, it is hard to differentiate between the conditions. To diagnose iron deficiency anemia, physicians normally measure the hemoglobin and red blood cell size. Nevertheless, this method may be insufficient in children with Down syndrome because their hemoglobin levels can be normal despite their lack of iron. This presents a challenge in diagnosis, and relying only on of hemoglobin levels can result in unidentified iron deficiency among this population.

Iron Studies and the Impact of Inflammation

There are some challenges that are associated with evaluating iron levels in children having Down syndrome because of their inflammation and chronic illness. The level of ferritin that reflects the iron storage in the body and transferrin saturation which is an indicator of iron transport in the body may be either normal or high in the people with inflammation. Down syndrome children are more prone to infection, which results in inflammation. Therefore, such signs, like transferring saturation, may make the early diagnosis of iron deficiency among this group of people more difficult. Such a complication may lead to poor assessments of the levels of iron in children with Down syndrome. The complexities of iron research in this population can be highlighted by the possibility of misleading predictors such as transferrin saturation. This problem is especially relevant in the context of high morbidity of children with Down syndrome, which makes it difficult to measure their iron status, as Hart et al. (2020) mention. These diagnostic procedures explain why conventional screening techniques usually lack their ability to detect iron-deficiency anemia in Down syndrome children.

The best methods for identifying and diagnosing iron deficiency anemia in children with Down syndrome:

Primary Laboratory Tests

Recent studies focused on developing modern laboratory investigation for iron markers identification in order to early identify iron-deficiency anemia of children with Down syndrome. Red blood cell distribution width (RDW) is a major indicator among blood parameters that can be used as a good predictor of diagnosis of this condition. Notably, serum RDW is elevated when iron levels are low in the blood, moreover, it is not influenced by any other hematological problems of children with Down syndrome. Hart et al. (2020) suggest that RDW is the test of choice for detection of iron-deficiency anemia children with down syndrome since it shows early changes due to iron deficiency. A recent study conducted in 2020 revealed that the interaction of RDW with the saturation of transferring contributes significantly to the detection of iron deficiency and iron-deficiency anemia, thereby making it easier to diagnose almost all the cases.

Supplementary Laboratory Tests and Clinical   Assessment

Ferritin is a good measure of iron stores in the body. However, it may give false positive results in cases of infection or inflammation. Therefore, ferritin and inflammatory markers should be evaluated simultaneously to have more accurate and clear results of iron status. Notably, in cases where ferritin results are ambiguous, measuring transferrin receptor levels can provide additional insights into iron status.

The responsibilities of teachers and school nurses

Role of the School Nurse

 Available literature shows that school nurses can be very critical towards the early identification and treatment of iron deficiency anemia at school. School nurses perform health screening and observe the possible symptoms of iron deficiency anemia such as weakness, chronic fatigue, and pallor. Moreover, School nurses should participate in the process of identifying and treating iron deficiency anemia among children with Down syndrome. Kataria et al. (2024) and Murthy et al. (2021) revealed that school nurses play a significant role in making sure that iron supplementation programs in schools are effective in decreasing the prevalence of iron deficiency anemia and the increment in hemoglobin levels can be achieved. Accordingly, iron supplementation programs are critical to be successful among school children, through school nurses.

Role of Teachers and School-Based Collaboration

Teachers have a major role in early detection of students with iron deficiency anemia because of their daily contact with students. Furthermore, they help prevent students avoid iron deficiency anemia by educating them about iron rich diet.  Therefore, the role of teacher is to observe the possible symptoms of iron deficiency anemia such as weakness, chronic fatigue, and pallor (Ibrahim & El-Moniem, 2022; Parwati et al., 2020).

Strategies to Improve Iron Levels and Family roles

Bialek-Dratwa et al. (2025), recommend that children with Down syndrome should take adequate amounts of iron and vitamin C daily. Although these are the crucial nutrients in their health conditions, children with Down syndrome are supposed to eat foods that contain these nutrients. Sufficient intake of iron is encouraged through proper iron meal planning and nutritional education at home and in school settings. In case the iron deficiency has been diagnosed, iron supplements need to be provided under the supervision of doctors to replace iron levels and avoid certain complications. Notably, Effective management requires cooperation among nurses, families, and teachers (Kataria et al., 2024). Families play a crucial role in managing iron deficiency anemia by ensuring adherence to iron-rich diets, monitoring symptoms, following medical advice, and maintaining regular follow-up with healthcare providers .

Conclusion

Children with Down syndrome are more likely to have iron deficiency anemia related of their high susceptibility to health problems, feeding disorders, and gastrointestinal complications. These issues make diagnosis of iron deficiency anemia more difficult and complicated, because the standard tests might fail to detect it in such children. The application of RDW with ferritin or transferring saturation can offer an ultimate diagnosis (Ibrahim & El-Moniem, 2022; Bialek-Dratwa et al., 2025). It is strongly recommended that early screening programs for iron deficiency anemia be implemented and strengthened in schools, especially for children with Down syndrome.

References

• Aggarwal, A., Aggarwal, A., Goyal, S., & Aggarwal, S. (2020). Iron-deficiency anemia among adolescents: A global public health concern. International Journal of Advanced Community Medicine, 3(2), 35–40. https://doi.org/10.33545/comed.2020.v3.i2a.148
• Białek-Dratwa, A., Szczepańska, E., Grajek, M., & Charzewska, J. (2025). Nutritional deficiencies and feeding difficulties in children with Down syndrome. Nutrients, 17(3), 412. https://doi.org/10.3390/nu17030412
• Białek-Dratwa, A., Zur, S., Sokal, A., Staśkiewicz-Bartecka, W., & Kowalski, O. (2025). Feeding challenges in trisomy 21: Prevalence and characteristics of feeding disorders and food neophobia—A cross-sectional study of Polish children and adolescents with Down syndrome. Nutrients, 17, 2030. https://doi.org/10.3390/nu17122030
• Faysal, W., Zaidi, A. R. Z., Al-Abdi, S., Alhumaid, S., AlShehery, M. Z., & Al Mutair, A. (2020). Hospital-based prevalence of iron deficiency anemia among pre-school children in Dubai. Cureus, 12(10), e10894. https://doi.org/10.7759/cureus.10894
• Hart, S. J., Smith, C. M., & Jones, K. L. (2020). Screening for iron deficiency and iron deficiency anemia in children with Down syndrome. The Journal of Pediatrics, 222, 162–168. https://doi.org/10.1016/j.jpeds.2020.03.034
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موزة عبيد راشد سالم علي
ممرضة – مدينة الشارقة للخدمات الإنسانية (فرع كلباء)
بكالوريوس في التمريض – كليات التقنية العليا

أبرز الخبرات العلمية والعملية: تدريب عملي في مستشفى كلباء في أقسام متعددة (الطوارئ، الجراحة، الأمومة، الأطفال)، بالإضافة إلى التدريب في مستشفى الفجيرة، ومستشفى حتا، ومستشفى الأمل للصحة النفسية
المهارات: مهارات التواصل الفعال، العمل ضمن فريق، إدارة الوقت، تقديم التثقيف الصحي