Targeting Iron Deficiencies, AAP Advises Screening All Infants and Toddlers

Infants (breast- or formula-fed) and toddlers (1-3 years old) are the focus of the recommendations. Last revised in 1999, the guidelines are part of an AAP Clinical Report published in the November 2010 issue of Pediatrics. The screening guidelines from the pediatricians' group are more comprehensive than those from other organizations, which target only infants and toddlers with risk factors. (For more on this, see the screening article on iron deficiency in infants.)

Iron deficiency occurs in enough U.S. children and creates enough risk of harm that health care providers should strive to eliminate the problem, the AAP is urging. Citing data collected between 1999 and 2002 for the National Health and Nutrition Examination Survey, the AAP noted that between 6 and 15 percent of toddlers are iron-deficient and between 1 and 4 percent have iron-deficiency anemia, depending on race, ethnicity, and socioeconomic status. Preterm infants, infants who are exclusively breast-fed, and infants at risk of developmental disabilities are of even greater concern. The 2010 guidelines give weight to recent studies that link iron deficiency to damage to the brain and nervous system of the developing child. An affected child may suffer long-lasting and irreversible problems with behavior, IQ, and learning. Also, children with iron-deficiency anemia absorb more lead and risk lead poisoning, the report notes.

The AAP, via these guidelines, wants to identify and better treat children who can benefit from iron supplementation and more iron in their diet. The report discussed acceptable ways to screen infants and toddlers for iron deficiency and noted the importance of follow up.

• At about 1 year old, all infants should be checked for anemia with a simple blood test (from a finger or heel prick) that measures the concentration of hemoglobin. The health care provider also needs to learn if the child has any related risk factors, such as if the child was born prematurely or with a low birth weight, exposed to lead, exclusively breast-fed after 4 months of age without supplemental iron, or weaned to whole milk or eating foods but not iron-fortified cereals or iron-rich foods.
• At any age, a screening test is advised when a risk factor is found, such as a diet low in iron or history of a feeding problem, poor growth, or inadequate nutrition as seen in infants with special health care needs.
• Follow-up testing: There is no single screening test currently available that will accurately reflect the iron status of a child. The problems with using a hemoglobin level to detect iron deficiency or anemia are its lack of specificity and sensitivity. The AAP acknowledges that the hemoglobin test is only a first step—it doesn't actually tell if the child is iron-deficient or anemic from low iron. One problem is that most anemias in U.S. children today aren't related to iron deficiency. So, the guidelines explain, if a 12-month-old's hemoglobin result is below 11 g/dL, other tests should follow.
  • Testing for serum ferritin is the most widely available option. Measurement of ferritin level is widely used in clinical practice and readily available. A cutoff ferritin value of 12 mcg/L has been widely used for adults and denotes depletion of iron stores. In children, a cutoff value of 10 mcg/L has been suggested. However, ferritin is an acute-phase reactant, and levels can increase with conditions that cause inflammation. A simultaneous measurement of C-reactive protein (CRP) is required to rule out the presence of inflammation.
  • Testing for reticulocyte hemoglobin concentration (CHr) is also acceptable. This assay provides a measure of iron available to cells recently released from the bone marrow.
  • A new test, for serum soluble transferrin receptor 1 (TfR1), looks promising for the future, when it is more widely available and standard values for children are established for it. TfR1 is a measure of iron status, detecting ID at the cellular level.
  • When the anemia is mild (between 10 and 11 g/dL) and the child can be closely monitored, the hemoglobin test can be used for monitoring after a month of replacement therapy, especially if the diet history is the concern.

  The guidelines note some other weak links in screening all infants and toddlers for iron deficiency. Poor follow-up testing and poor recordkeeping are common flaws. Health care providers must take more care in tracking and following diagnosed children, the report notes. Two tools for this are technology-based reminders and electronic medical records. Parents can ask if these tools are available. Parents are encouraged to discuss their child's iron status and risks with the primary care provider.

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