Management of Iron Deficiency in Neonates

SUMMARY

Watch Summary by Carey Mancuso, CRNP

• Iron deficiency (with or without anemia) affects 30–40% of women and is often underrecognized and undertreated (WHO, 2025; ACOG, 2021).
• It negatively impacts quality of life, increases morbidity and mortality, and is linked to adverse maternal/fetal outcomes (Govindappagari & Burwick, 2019; Wassef et al., 2019).
• Early recognition and treatment should be a high priority (Shander et al., 2023).

Sections

• Introduction
• Causes of Iron Deficiency Anemia (IDA)
• Symptoms
• Iron Deficiency without Anemia
• Consequences in Women and Children
• Heavy Menstrual Bleeding
• Pregnancy
• Postpartum
• Perimenopause

Introduction

• Global anemia prevalence: 24.8% (~1.62 billion people); 41.8% are pregnant women, and 30.2% are nonpregnant women (WHO, 2025)
• IDA affects women across all life stages: adolescents, reproductive-aged, pregnant, and perimenopausal.
• In pregnancy, anemia is an independent risk factor for maternal and fetal morbidity/mortality (ACOG, 2021).
• Racial disparities in anemia rates (women <50):
• 3.3% of Caucasians
• 8.7% of Latinas
• 24.5% of Black Americans (Krule et al., 2022)
• IDA affects 12% of premenopausal women; prevalence rises to 19% in Black women (Krule et al., 2022)

Causes of IDA

• Nutritional deficiency: Low dietary intake or poor iron bioavailability (ODS, 2025)
• Blood loss:
• Heavy menstrual bleeding (CDC, 2024)
• Gastrointestinal bleeding in postmenopausal women (Kaunitz, 2019)
• Impaired absorption:

• IBD, gastric bypass, celiac disease, proton pump inhibitors, autoimmune gastritis (Shander et al., 2023)

• Pregnancy: Increased iron demand and fetal iron transfer often outpace maternal intake, especially in women with marginal status before pregnancy (ACOG, 2021; WHO, 2025).

Symptoms of IDA

• Fatigue, low stamina, reduced exercise tolerance (Wassef et al., 2019)
• Palpitations, shortness of breath
• Headaches, cold intolerance
• Mood changes, depression, “brain fog” (Wassef et al., 2019)
• Alopecia, glossitis, koilonychia
• Restless legs syndrome
• Pica, especially pagophagia (ice-chewing) — often misrecognized, delaying diagnosis (Wassef et al., 2019)

Iron Deficiency Without Anemia

• Low ferritin may cause symptoms even in absence of anemia (Van Remoortel et al., 2021).
• Fatigue
• Reduced work performance 
• Reduced quality of life
• Early treatment improves symptoms and may prevent progression to anemia (Govindappagari & Burwick, 2019).

Consequences in Women and Children

Consequences Linked to Iron Deficiency Anemia in Pregnancy

• Preterm birth, IUGR, postpartum hemorrhage, increased infection (ACOG, 2021)
• Small-for-gestational-age newborns
• Postpartum depression and impaired maternal-neonatal bonding (Wassef et al., 2019)

Fetal-Neonatal Complications Linked to Maternal Iron Deficiency/Anemia

• Increased Risk of Schizophrenia:

• Maternal hemoglobin levels ≤10.0 g/dL during pregnancy are associated with a nearly fourfold increased risk of schizophrenia spectrum disorders in offspring. Each 1 g/dL increase in maternal hemoglobin reduced schizophrenia risk by 27% (Insel et al., 2008).

• Elevated Autism Spectrum Disorder (ASD) Risk:

• Mothers with low iron intake during pregnancy had a fivefold greater risk of having a child with ASD, especially among older mothers or those with metabolic conditions (Schmidt et al., 2014).

• Cognitive and Behavioral Delays:

• Early-life iron deficiency is associated with long-lasting neurocognitive impacts, including deficits in learning, memory, and behavioral regulation (Beard & Connor., 2003).

• Impaired Recognition Memory in Infants:

• Infants with fetal-neonatal iron deficiency exhibited altered recognition memory as early as 2 months of age Lukowski, et al., 2015).

• Association with Intellectual Disability and ADHD:

• Anemia diagnosed before 30 weeks’ gestation was linked with increased risks of autism, ADHD, and intellectual disability in offspring (Sundelin et al., 2019).

Heavy Menstrual Bleeding

• Menorrhagia: >80 mL or >7 days/cycle (CDC, 2024)
• Iron loss can be gradual and overlooked
• RDA: 18 mg iron/day (ODS, 2025)
• Fatigue is often misattributed or normalized (Kaunitz, 2019)
• Screening questions:
• How often do you saturate a pad or tampon?
• Does bleeding last more than 7 days?
• Do you bleed through clothes?
• Does it disrupt school or work?

Pregnancy

• Up to 40% of women start pregnancy with depleted iron stores (Shander et al., 2023).
• Physiologic anemia expected (Hgb 10–11 g/dL)
• A comprehensive analysis of 272 studies found that maternal Hgb levels below 11 g/dL are associated with increased risks of low birth weight, preterm birth, small-for-gestational-age infants, stillbirth, and perinatal and neonatal mortality (Rahman et al., 2016).
• Contributing factors:

• ↑40–50% plasma volume, ↑20–30% RBC mass, fetal iron transfer

• WHO (2024): Recommends 30–60 mg elemental iron + 0.4 mg folic acid daily to reduce anemia, low birth weight, and sepsisg
• ACOG (2021) recommend: IV iron after 1st trimester if oral iron fails or is intolerable
• Blood loss at delivery increases need.

IV Iron in Pregnancy

• IV iron is more effective than oral iron for increasing hemoglobin and replenishing iron stores (Govindappagari & Burwick, 2019).
• A 2024 Cochrane review found that IV iron improves anemia and hemoglobin levels without increasing adverse maternal or neonatal outcomes (Cochrane Review, 2024).
• A meta-analysis of 34 studies showed fewer adverse events with IV iron compared to oral iron (Nature Scientific Reports, 2023).
• A large 2025 multicenter study found a single dose of IV iron in the second trimester was safe and effective (SMFM, 2025).
• IV iron isomaltoside was not associated with increased maternal or fetal complications; side effects were mild and infrequent (Qassim et al., 2020).
• ACOG (2021): Recommends IV iron after the first trimester if oral iron is not tolerated or is ineffective.

Postpartum

• Hgb <10 g/dL = clinically significant anemia (ACOG, 2021)
• Hemoglobin typically lowest ~48 hours after birth
• Ferritin unreliable postpartum due to inflammation; reassess after 6 weeks if needed (Wassef et al., 2019)
• Risk factors:

• Multiparity, obesity, adolescent mothers, low socioeconomic status

• WIC study (n=60,000):
• 27% postpartum anemia overall
• 40% Hispanic; 48% Black women (Wassef et al., 2019)
• Postpartum Depression:
• 8/10 studies found higher PPD risk with IDA
• 4/5 studies showed reduced risk with iron therapy (Wassef et al., 2019)

Perimenopause

• Perimenopause is the transitional stage before menopause when estrogen and progesterone levels begin to fluctuate.
• These hormonal changes lead to irregular ovulation, which can cause unpredictable or heavy menstrual bleeding.
• Heavy bleeding during this stage can result in significant iron loss and contribute to iron deficiency or anemia, especially if untreated.
• Signs of concern: Saturating pads/tampons every 2 hours, bleeding >8 days (CDC, 2024)
• Symptoms of iron deficiency in perimenopause:
• Fatigue, low energy, brain fog, poor concentration
• Decreased work productivity, reduced quality of life
• Mood changes, low self-esteem, difficulty coping with stress
• Mental health impact:
• Depression affects 4 in 10 perimenopausal women, often linked to both hormonal shifts and iron deficiency (Wassef et al., 2019)
• These challenges can persist for years and are often underrecognized
• Iron requirements:
• Recommended intake: 18 mg/day (Office of Dietary Supplements, 2025)
• Many women may be unaware of iron depletion unless screened
• Treatment and management options:
• Iron-rich diet (e.g., lean red meat, leafy greens, fortified grains)
• Oral iron supplementation (first-line)
• IV iron infusion if oral iron is not tolerated or ineffective
• Menstrual bleeding control strategies:
• Hormonal contraception (e.g., oral contraceptives)
• Intrauterine devices (IUDs)
• Tranexamic acid (TXA) to reduce blood loss
• Endometrial ablation in refractory cases
• Clinical considerations:
• Symptoms are often dismissed or minimized by providers
• Regular OB/GYN visits can help address both bleeding and mood symptoms
• Mental health referrals may be appropriate for persistent depression or anxiety

References

1. ACOG Practice Bulletin No. 233. (2021). Anemia in Pregnancy. Obstetrics & Gynecology, 138(2), e55–e64. https://doi.org/10.1097/AOG.0000000000004477
2. Beard, J. L., & Connor, J. R. (2003). Iron status and neural functioning. Annual Review of Nutrition, 23, 41–58. https://doi.org/10.1146/annurev.nutr.23.011702.073139
3. Centers for Disease Control and Prevention (CDC). (2024). Bleeding Disorders in Women. https://www.cdc.gov/female-blood-disorders/about/heavy-menstrual-bleeding.html
4. Cochrane Review. (2024). Interventions for treating iron-deficiency anemia in pregnancy. Cochrane Database of Systematic Reviews, Issue 3. https://pubmed.ncbi.nlm.nih.gov/39651609
5. Congdon, E. L., et al. (2019). [Title and journal were truncated in the original source. If you have the full citation, I can complete this entry.]
6. Govindappagari, S., & Burwick, R. M. (2019). Treatment of iron deficiency anemia in pregnancy with intravenous versus oral iron: A systematic review and meta-analysis. American Journal of Perinatology, 36, 366–376. https://doi.org/10.1055/s-0038-1676096
7. Kaunitz, A. M. (2019). Abnormal uterine bleeding in reproductive-age women. JAMA, 321(21), 2126–2127. https://doi.org/10.1001/jama.2019.4444
8. Krule, A., Abraham, K., Dulce, D., Cuellar-Puri, S., Salahudeen, A. A., & Chaudhry, A. (2022). Evaluating anemia-related morbidity in premenopausal female minority and disadvantaged populations. Blood, 140(Supplement 1), 5114–5115. https://doi.org/10.1182/blood-2022-157807
9. Lukowski, A. F., Koss, M., Burden, M. J., Jonides, J., Nelson, C. A., & Georgieff, M. K. (2015). Iron deficiency in infancy and neurocognitive functioning at 19 years: Evidence of long-term deficits in executive function and recognition memory. The Journal of Pediatrics, 167(3), 524–530.e1. https://doi.org/10.1016/j.jpeds.2015.05.015
10. Nature Scientific Reports. (2023). Maternal intravenous iron therapy in pregnancy: A systematic review and meta-analysis. Scientific Reports, 13, Article 50234. https://www.nature.com/articles/s41598-023-50234-w
11. Office of Dietary Supplements (ODS). (2025). Iron: Fact Sheet for Health Professionals. https://ods.od.nih.gov/factsheets/Iron-HealthProfessional/
12. Qassim, A., Thorne, M., Grzeskowiak, L. E., & Grieger, J. A. (2020). Safety and effectiveness of intravenous iron isomaltoside during pregnancy: A retrospective cohort study. European Journal of Obstetrics & Gynecology and Reproductive Biology, 246, 1–6. https://doi.org/10.1016/j.ejogrb.2020.01.016
13. Rahman, M. M., Abe, S. K., Kanda, M., Narita, S., Rahman, M. S., Bilano, V., … & Shibuya, K. (2016). Maternal anemia and risk of adverse birth and health outcomes in low- and middle-income countries: systematic review and meta-analysis. The American Journal of Clinical Nutrition, 103(2), 495–504. https://doi.org/10.3945/ajcn.115.107896
14. Schmidt, R. J., Tancredi, D. J., Ozonoff, S., Hansen, R. L., Hartiala, J., Allayee, H., … & Hertz-Picciotto, I. (2014). Maternal intake of supplemental iron and risk of autism spectrum disorder. American Journal of Epidemiology, 180(9), 890–900. https://doi.org/10.1093/aje/kwu195
15. Shander, A., Corwin, H. L., Meier, J., Auerbach, M., Bisbe, E., Blitz, J., … & Muñoz, M. (2023). Recommendations from the International Consensus Conference on Anemia Management in Surgical Patients (ICCAMS). Annals of Surgery, 277(4), 581–590. https://doi.org/10.1097/SLA.0000000000005721
16. Society for Maternal-Fetal Medicine (SMFM). (2025). Large study finds IV iron treatment during pregnancy safe and effective for anemia. https://www.smfm.org/news/large-study-finds-iv-iron-treatment-during-pregnancy-safe-and-effective-for-anemia
17. Sundelin, H. E. K., Sjöqvist, H., Stephansson, O., Hultman, C. M., & Dalman, C. (2019). Association of maternal anemia in early pregnancy with neurodevelopmental disorders in offspring. JAMA Psychiatry, 76(4), 339–347. https://doi.org/10.1001/jamapsychiatry.2018.4172
18. Van Remoortel, H., Laermans, J., Avau, B., Bekkering, G., Georgsen, J., Manzini, P. M., … & Vandekerckhove, P. (2021). Effectiveness of iron supplementation with or without erythropoiesis-stimulating agents on red blood cell utilization in patients with preoperative anemia undergoing elective surgery: A systematic review and meta-analysis. Transfusion Medicine Reviews, 35(2), 103–124. https://doi.org/10.1016/j.tmrv.2021.03.004
19. Wassef, A., Nguyen, Q. D., St-André, M., & Richebé, P. (2019). Anemia and depletion of iron stores as risk factors for postpartum depression: A literature review. Journal of Psychosomatic Obstetrics & Gynecology, 40(1), 19–28. https://doi.org/10.1080/0167482X.2018.1449257
20. World Health Organization (WHO). (2024). Daily iron and folic acid supplementation during pregnancy.