Abstract
Background:
Iron deficiency anemia (IDA) is the most common cause of anemia in children with the highest prevalence in early childhood and adolescence. While oral iron remains the mainstay of treatment, a subset of children may have an incomplete response due to various factors, including poor adherence, ongoing blood loss, and malabsorption. In addition, social and systemic factors can result in limited access to care or difficulty maintaining follow-up appointments. Variability in provider practice and comfort may contribute to inconsistent care and resource utilization. We conducted a needs assessment at our institution aimed at characterizing current practice patterns and self-reported comfort managing pediatric IDA to inform the development of a standardized clinical pathway. Here, we present the findings from our initial survey.
Methods: We distributed an online survey to residents, fellows, advanced practice providers (APPs), and attending physicians spanning the ED, Pediatric Hospital Medicine, Hematology/Oncology, and Pediatric Intensive Care Unit (PICU). The survey included general questions on transfusion and admission thresholds and three case-based clinical scenarios with brief vignettes adapted from real patient encounters to represent infants and children with moderate to severe anemia. Participants also completed Likert-scale items evaluating their comfort with aspects of anemia management, including workup of microcytic anemia, indications for IV iron, and management of IDA with hemoglobin (Hgb) less than 7g/dL. Responses were analyzed using descriptive statistics, and free-text responses were coded thematically.
Results:
A total of 81 individuals completed the survey, including 27 pediatric residents, 40 attendings, 10 fellows, and 4 APPs. Among those who answered “Yes” or “It depends” to threshold questions, 63% (48/76) identified a specific Hgb value as a transfusion trigger, while 48% (33/69) identified a specific admission threshold. For both admission and transfusion, the specific Hgb thresholds ranged from 3-8g/dL, with a Hgb<7g/dL being the most frequently reported. Clinical reasoning behind these varying thresholds included concerns about oxygen delivery for a given Hgb, reliable outpatient follow-up, degree of symptoms, underlying etiology, and comorbid conditions.
Case-based questions highlighted differences in disposition strategies, including whether to admit, which service to admit to, and whether to transfuse. For a patient with Hgb 3.9 g/dL with tachycardia and pallor, 13 providers opted not to admit the patient, yet 5 of them reported they would still transfuse—an intervention that typically entails admission for both patient safety and logistical feasibility. For a patient with Hgb of 1.8 g/dL and stable vitals, all participants chose to admit the patient, but opinions diverged on the appropriate level of service: 74% selected PICU, 15% preferred direct admission to Heme/Onc, and 11% favored admission to hospital medicine. Thematic analysis elucidated key factors behind these differences: varying perceptions of risk for acute decompensation, perceived need for subspecialist input, and varied emphasis on clinical cues, such as vital signs, degree of anemia, and symptom burden.
Likert responses demonstrated varying levels of comfort in evaluation and management of IDA, and most notably in comfort with indications for IV iron therapy. In addition, only 27% of participants reported familiarity with an existing order set designed to assist providers in the work-up of microcytic anemia. Further analysis identified key contributors to practice variation: limited ED infrastructure to accommodate transfusions, lack of centralized resources, variability in awareness of existing guidelines, and differences in provider training and clinical exposure.
Conclusion: This needs assessment reveals notable variability in both clinical practice and provider comfort when managing pediatric IDA in an acute care setting, underscoring the need for a standardized, evidence-informed clinical pathway. These findings led to the development of a cross-departmental standard operating procedure that incorporates guidance for transfusion and admission thresholds, while accounting for the patient's clinical presentation. Future steps include pathway implementation, targeted educational interventions, and prospective evaluation of adherence to the pathway, provider confidence, and patient outcomes.
