Framing Childhood Anemia as an Adverse Childhood Experiences-Associated Health Condition: An Opportunity to Support Healthy Growth and Development.

INTRODUCTION: Both childhood adversity and childhood anemia have the potential to impact growth and development among young children. This study examined the relationship between Adverse Childhood Experience (ACE) scores and hemoglobin levels in young children receiving care in a safety net health system in California. METHODS: We conducted a retrospective review of electronic health records for pediatric patients ages zero to five years who received both ACE screening and hemoglobin testing between 2020 and 2025. Hemoglobin results were categorized as severe anemia (<7.0 mg/dl), mild-moderate anemia (7.0-10.9 mg/dl), and normal (>11.0 mg/dl). ACE scores were categorized into Low-Intermediate Risk (ACE score 0-3) and High Risk (ACE score ≥4). RESULTS: We found an association between higher ACEs and lower hemoglobin levels across all patients and within the subset of patients with mild-moderate anemia. Among a population of 8,979, 21.7% had any ACE, 18.3% reported ACE scores of 1-3, and 3.4% had ACE scores of ≥4. Mean hemoglobin was lower in the ACEs High Risk group compared to the ACEs Low-Intermediate Risk group (12.2 mg/dl vs. 12.6 mg/dl, p < 0.001). In the subgroup with mild-moderate anemia (N = 716), ACEs High Risk children also had lower mean hemoglobin levels (9.9 mg/dl vs. 10.3 mg/dl, p < 0.05). Moreover, linear regression models showed that each one-point increase in ACE score resulted in a 0.078 mg/dl decrease in mean hemoglobin (p < 0.0001). DISCUSSION: While statistically significant, the 0.4 mg/dl difference in hemoglobin levels alone does not often have clinical implications for treatment. However, in the context of high ACE scores, this difference may help guide preventative and treatment efforts. CONCLUSIONS: The association of higher ACE scores with lower hemoglobin levels in young children highlights an opportunity to better identify factors that may contribute to anemia in pediatric patients. Knowledge of such risk factors can inform efforts to provide comprehensive counseling and support for patients at risk for anemia. Further research will help determine whether integrating ACE screening into anemia prevention strategies could impact developmental and health outcomes in high-risk populations, and this inquiry may further establish childhood anemia as a meaningful ACE-associated health condition that can be identified and addressed before long-term health consequences emerge.