Iron deficiency anaemia remains one of the most common nutritional disorders worldwide, particularly affecting young children. In the UK, while public health efforts have improved general outcomes, certain groups remain disproportionately affected, notably, refugee and asylum-seeking children.
Conflict and instability across North Africa, the Middle East and beyond have led to a significant rise in displaced populations seeking refuge in Europe. Many refugee children arrive after prolonged periods in camps or unstable housing, often with limited access to nutrition, healthcare, or clean water.
Kay et al. (2019) found anaemia rates approaching 50% among displaced children, linked to chronic malnutrition, infections, and micronutrient deficiencies. Studies by Sheikh (2009) and Geltman (2001) have also shown high rates of anaemia and vitamin D deficiency in recently arrived refugee children, particularly those under two years old.
In clinical practice, this is reflected in an increasing number of paediatric referrals for severe anaemia. Globally, about 40% of children aged 6–59 months were anaemic in 2019, with 1% experiencing severe anaemia. These presentations are often complex, with contributing factors including parasitic infections, undiagnosed chronic conditions, and dietary insufficiencies. Language barriers, cultural differences, lack of medical records, and social instability further complicate diagnosis and management.
Ethnicity, Access, and Cultural Considerations
Ethnicity, cultural background, and life experiences are vital considerations when treating anaemia in children, particularly in refugee populations. Refugee families may face significant barriers in accessing healthcare, including difficulties obtaining prescriptions, language barriers, and logistical challenges such as transport.
These factors should influence our treatment decisions.
For instance, oral iron therapy may not be practical if adherence is likely to be poor or if access to follow-up is uncertain. Similarly, hospital-based intravenous iron infusions may pose emotional and logistical challenges, including fear of invasive procedures, transportation difficulties, and unfamiliarity with hospital environments.
For refugee families, these challenges can be compounded by the risk of family separation, such as when a parent must remain with one child in the hospital while others are cared for elsewhere. This is especially difficult for single parents or families without extended support networks, where there may be no one available to look after siblings.
Limited accommodation, hospital policies, and a lack of community ties can make accessing even essential care feel overwhelming or impossible. Clinicians should consider these broader factors when planning treatment and involve families in decision-making wherever possible.
Access to a varied and iron-rich diet is another common challenge among refugee families, particularly those residing in temporary accommodations with limited cooking facilities or on a restricted income. Many families may struggle to afford or access iron-rich foods, making dietary modification alone an insufficient primary intervention. Referral to a paediatric dietitian is essential in these cases, not only to provide tailored nutritional advice but also to help families navigate food insecurity and identify realistic dietary changes within their means.
Iron Deficiency Anaemia and Differential Diagnosis
Clinically, iron deficiency anaemia is defined as a reduction in red blood cell production due to inadequate iron stores. Treatment with iron should begin promptly to avoid complications, even while investigations for underlying causes, such as gastrointestinal blood loss or malabsorption, are underway. However, clinical decision-making must take into account each child’s social, psychological, and cultural context.
For many refugee families, oral iron supplementation can be challenging to sustain due to limited access to medications, transportation issues, or a lack of continuity in care. Additionally, the hospital setting itself — often associated with fear or past trauma — can affect how families engage with care plans, particularly when intravenous treatments or repeat visits are involved. Understanding and addressing these psychological factors is essential to delivering care that is not only clinically sound but also practical and patient-centred.
In refugee and ethnically diverse populations, think about inherited conditions like thalassaemia. These haemoglobinopathies, common among children of Mediterranean, Middle Eastern, South Asian, or North African descent, can mimic iron deficiency but require different management.
Misdiagnosis can lead to inappropriate treatment, delayed referral for specialist input, or missed opportunities for family counselling and genetic education, particularly important for communities with limited prior access to screening.
For families who have already experienced significant trauma and instability, and who may hold understandable mistrust toward systems and authority figures in host countries, such oversights can further undermine confidence in healthcare and contribute to disengagement from services.
The Considerable Role of MCV in Anaemia Classification
Mean corpuscular volume (MCV) is especially valuable in refugee populations where inherited haemoglobinopathies, such as thalassaemia, are more prevalent due to ethnic background.
It can help distinguish between microcytic, normocytic, and macrocytic types. In cases of microcytic anaemia, iron deficiency is the most common cause, particularly in young children with limited nutritional intake.
Misdiagnosing thalassaemia trait as iron deficiency can lead to inappropriate iron supplementation. This not only exposes children to unnecessary treatment and potential side effects but also delays correct diagnosis.
Inappropriate management can result in a cascade of further investigations, burdening already overstretched families and healthcare systems, and may prevent timely referral for genetic counselling and family planning.
For communities where consanguinity is more common, or where awareness of inherited conditions is limited due to disrupted access to healthcare, early identification of thalassaemia traits can have far-reaching implications — not just for the child, but for siblings and future generations.
For children of Mediterranean, Middle Eastern, South Asian, or North African descent — many of whom come from refugee backgrounds — recognising these patterns early is essential to providing appropriate care and supporting informed decision-making at both the clinical and family level.
The Psychological Impact of Hospital Settings on Refugee Children
Children from refugee and asylum-seeking backgrounds often experience trauma before, during, and after migration.
In 2017, an estimated 30 million children were forcibly displaced globally, with 17 million exposed to violence or conflict and 13 million eligible for refugee status. Many faced adversities during migration, including unsafe travel, separation, abuse in its many forms and even trafficking. What’s more, these communities often continue to face xenophobia, marginalisation, and social instability upon arrival — challenges that can further erode trust in systems, limit access to essential services, and compound the effects of prior trauma.
These experiences are associated with increased levels of PTSD, depression, anxiety, metabolic disorders, and poor long-term health outcomes. Even well-intentioned hospital settings may trigger distress, especially for children who have been separated from family or subjected to invasive procedures in the past.
Paediatric Medical Traumatic Stress (PMTS) refers to the psychological and physiological responses children and their families may have to pain, serious illness, medical procedures, or hospitalisation itself. These reactions can look like heightened anxiety, emotional withdrawal, or reluctance to engage with care, not out of defiance, but as a natural response to past experiences of fear or trauma. In many cases, these behaviours are protective and recognising them is a vital part of providing safe, compassionate care. Children and families may be less inclined to attend appointments or engage openly with medical professionals, not due to a lack of health concern, but due to fear, mistrust, or egregious negative experiences with authority systems in their countries of origin.
Trauma-informed care (TIC) offers a framework to address these needs.
It acknowledges the widespread impact of trauma on development and health, integrates this awareness into clinical practice, and actively works to avoid re-traumatisation. The American Academy of Pediatrics recommends TIC when working with refugee populations, yet many clinicians lack clear strategies for implementation.
Principles of TIC include promoting physical and emotional safety, building trusting relationships, fostering agency, supporting peer and family involvement, and recognising how cultural identity and systemic factors shape a child’s experience of care. Integrating these principles into routine paediatric care is essential to meeting the holistic needs of this vulnerable group.
A helpful resource for clinicians is the work by Miller et al., which outlines ten practical clinical strategies for applying trauma-informed care when working with refugee and immigrant youth. These ‘clinical pearls’ include tips on establishing trust, addressing fear and uncertainty, and adapting care to accommodate cultural and trauma-related needs. Incorporating these insights can help paediatric teams translate theory into action and provide more responsive, compassionate care to displaced children.
Iron deficiency anaemia in refugee children is rarely straightforward. It intersects with a host of medical, psychological, and social factors that require careful, contextualised decision-making. Clinicians must move beyond a one-size-fits-all approach to consider the impact of migration, trauma, disrupted access to care, and inherited conditions such as thalassaemia when formulating a diagnosis and management plan.
Applying trauma-informed care principles is not only appropriate but essential in this context. Recognising how previous experiences may influence a child’s or family’s response to medical intervention can improve engagement, reduce distress, and support more effective outcomes. Equally, understanding practical barriers — such as housing instability, family dynamics, or limited access to culturally appropriate nutrition — is vital in developing realistic, sustainable treatment plans.
Ultimately, effective management relies on multidisciplinary collaboration and a commitment to delivering care that is both clinically sound and responsive to the realities of displacement. Paediatric teams equipped with cultural competence and trauma-informed practice are better placed to identify anaemia early, tailor treatment appropriately, and support refugee families in navigating what can be a complex and intimidating healthcare system.
References
- World Health Organization. Anaemia [Internet]. Geneva: WHO; 2023. Available from: https://www.who.int/news-room/fact-sheets/detail/anaemia
- Kay A, Leidman E, Lopez V, Wilkinson C, Tondeur M, Bilukha O. The burden of anaemia among displaced women and children in refugee settings worldwide, 2013–2016. BMJ Glob Health. 2019;4(6):e001837.
- The Guardian. Hospital admissions due to lack of vitamins and iron up 10-fold since 1998. [Internet]. 2025 Jan 1 [cited 2025 Apr 30]. Available from: https://www.theguardian.com/society/2025/jan/01/hospital-admissions-lack-of-vitamins-iron-nhs-figures
- Sheikh M, Pal A, Wang Y, MacIntyre CR, Wood N, Kaldor JM, et al. The epidemiology of health conditions in newly arrived refugee children: a review of patients attending the Refugee Health Service, Sydney Children’s Hospital. J Paediatr Child Health. 2009;45(9):509–13.
- Geltman PL, Radin M, Zhang Z, Cochran J, Meyers AF. Growth status and related medical conditions among refugee children in Massachusetts, 1995–1998. Am J Public Health. 2001;91(11):1800–5.
- Gibson J, Evennett J. The health needs of asylum-seeking children. Br J Gen Pract. 2018;68(670):238. doi:10.3399/bjgp18X696041
- British National Formulary for Children. Anaemia, iron deficiency. London: NICE; 2023. Available from: https://bnfc.nice.org.uk/treatment-summaries/anaemia-iron-deficiency/
- McCarthy H, Skinner R, Ellis R. Iron deficiency anaemia: experiences and challenges. Proc Nutr Soc. 2019;78(OCE1):E4. doi:10.1017/S0029665119000076
- Royal Children’s Hospital Melbourne. Clinical Practice Guidelines: Anaemia. Melbourne: Royal Children’s Hospital; 2023. Available from: https://www.rch.org.au/clinicalguide/guideline_index/Anaemia_Guideline/
- UN High Commissioner for Refugees (UNHCR). Global Trends: Forced Displacement in 2017 [Internet]. Geneva: UNHCR; 2018 Jun 22 [cited 2025 May 10]. Available from: https://www.refworld.org/reference/annualreport/unhcr/2018/en/121035Shonkoff JP, Garner AS. The lifelong effects of early childhood adversity and toxic stress. Pediatrics. 2012 Jan;129(1):e232-46. doi:10.1542/peds.2011-2663
- Miller KK, Brown CR, Shramko M, Svetaz MV. Applying trauma-informed practices to the care of refugee and immigrant youth: 10 clinical pearls. Children (Basel). 2019;6(8):94. doi:10.3390/children6080094. PMID: 31434278; PMCID: PMC6721394.
- National Child Traumatic Stress Network. Medical Trauma [Internet]. 2023 [cited 2025 May 15]. Available from: https://www.nctsn.org/what-is-child-trauma/trauma-types/medical-trauma
