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Guideline Summary
Guideline Title
Diagnosis and prevention of iron deficiency and iron-deficiency anemia in infants and young children (0–3 years of age).
Bibliographic Source(s)
Baker RD, Greer FR, Committee on Nutrition American Academy of Pediatrics. Diagnosis and prevention of iron deficiency and iron-deficiency anemia in infants and young children (0-3 years of age). Pediatrics. 2010 Nov;126(5):1040-50. [77 references] PubMed External Web Site Policy
Guideline Status

This is the current release of the guideline.

All clinical reports from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.

Scope

Disease/Condition(s)
  • Iron deficiency (ID)
  • Iron-deficiency anemia (IDA)

Note: Anemia is defined as a hemoglobin (Hb) concentration 2 standard deviations (SDs) below the mean Hb concentration for a normal population of the same gender and age range.

Guideline Category
Diagnosis
Prevention
Risk Assessment
Screening
Clinical Specialty
Family Practice
Hematology
Nutrition
Pediatrics
Preventive Medicine
Intended Users
Advanced Practice Nurses
Dietitians
Hospitals
Nurses
Physician Assistants
Physicians
Guideline Objective(s)

To provide recommendations for diagnosis and prevention of iron deficiency (ID) and iron-deficiency anemia (IDA) in infants (both breastfed and formula fed) and toddlers aged 1 through 3 years

Target Population
  • Infants (both term and preterm, breastfed and formula-fed)
  • Toddlers aged 1 through 3 years
Interventions and Practices Considered

Prevention

Iron supplementation:

  • Oral iron
  • Iron-fortified formula
  • Iron-containing complementary foods

Diagnosis/Risk Assessment/Screening

  1. Universal screening tests for anemia at 12 months of age with determination of hemoglobin (Hb) concentration and assessment of risk factors
  2. Further evaluation for iron-deficiency anemia (IDA) with additional screening tests:
    • Serum ferritin (SF) and C-reactive protein (CRP) levels
    • Reticulocyte Hb content (CHr) concentration
  3. Use of the transferrin receptor 1 (TfR1) assay as screening for iron deficiency (ID)
  4. Careful monitoring of children with ID or IDA
Major Outcomes Considered
  • Prevalence of iron deficiency (ID) and iron-deficiency anemia (IDA)
  • Adverse effects of ID and IDA on cognitive and behavioral development
  • Sensitivity and specificity of diagnostic and screening tests

Methodology

Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

This report was written by the primary authors after extensive review of the literature using PubMed, previous American Academy of Pediatrics (AAP) reports, Cochrane reviews, and reports from other groups.

Multiple searches were done starting in 2003 and going through January of 2010. The searches were performed at least every six months. The search engines used for each of these searches were PubMed, Medline, and Cochrane Database of Systemic reviews. The terms used for each of the searches were: iron, iron deficiency anemia, iron deficiency, dietary iron, iron metabolism. Limiting the search by age was frequently applied to decrease the number of citations found.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Expert Consensus
Rating Scheme for the Strength of the Evidence

Not applicable

Methods Used to Analyze the Evidence
Systematic Review
Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

This report was written by the primary authors after extensive review of the literature. The Centers for Disease Control and Prevention (CDC), the Department of Agriculture (WIC), the National Institutes of Health (NIH), and the Food and Drug Administration (FDA) governmental agencies were involved in the development of the statement. As it was developed it was extensively reviewed and revised by members of the American Academy of Pediatrics (AAP) Committee on Nutrition, who unanimously approved this clinical report. It is openly acknowledged that where the highest levels of evidence are absent, the opinions and suggestions of members of the Committee on Nutrition as well as other groups consulted for this statement were taken into consideration in developing this clinical report.

Rating Scheme for the Strength of the Recommendations

Not applicable

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation
External Peer Review
Internal Peer Review
Description of Method of Guideline Validation

The report was submitted to the following sections and committees of the American Academy of Pediatrics (AAP) that were asked to comment on the manuscript: Committee on Fetus and Newborn (COFN); Committee on Practice and Ambulatory Medicine (COPAM); Committee on Psychosocial Aspects of Child and Family Health (COPACFH); Section on Administration and Practice Management (SOAPM); Section on Developmental and Behavioral Pediatrics (SODBP); Section on Gastroenterology, Hepatology, and Nutrition (SOGHN); Section on Hematology and Oncology (SOHO); and Section on Breast Feeding (SOBr).

Additional comments were sought from the Centers for Disease Control and Prevention (CDC), the Department of Agriculture (WIC), the National Institutes of Health (NIH), and the Food and Drug Administration (FDA), because these governmental agencies were involved in the development of the statement and will necessarily deal with its impact.

Recommendations

Major Recommendations

Given that iron is the world's most common single-nutrient deficiency and there is some evidence of adverse effects of both iron deficiency (ID) and iron-deficiency anemia (IDA) on cognitive and behavioral development, it is important to minimize ID and IDA in infants and toddlers without waiting for unequivocal evidence. Controversies remain regarding the timing and methods used for screening for ID/IDA as well as regarding the use of iron supplements to prevent ID/IDA. Although further study is required to generate higher levels of evidence to settle these controversies, the currently available evidence supports the following recommendations.

  1. Term, healthy infants have sufficient iron for at least the first 4 months of life. Human milk contains very little iron. Exclusively breastfed infants are at increasing risk of ID after 4 completed months of age. Therefore, at 4 months of age, breastfed infants should be supplemented with 1 mg/kg per day of oral iron beginning at 4 months of age until appropriate iron-containing complementary foods (including iron-fortified cereals) are introduced in the diet (see Table 3 in the original guideline document). For partially breastfed infants, the proportion of human milk versus formula is uncertain; therefore, beginning at 4 months of age, partially breastfed infants (more than half of their daily feedings as human milk) who are not receiving iron containing complementary foods should also receive 1 mg/kg per day of supplemental iron.
  2. For formula-fed infants, the iron needs for the first 12 months of life can be met by a standard infant formula (iron content: 12 mg/dL) and the introduction of iron-containing complementary foods after 4 to 6 months of age, including iron-fortified cereals (see Table 3 in the original guideline document). Whole milk should not be used before 12 completed months of age.
  3. The iron intake between 6 and 12 months of age should be 11 mg/day. When infants are given complementary foods, red meat and vegetables with higher iron content should be introduced early (see Table 3 in the original guideline document). To augment the iron supply, liquid iron supplements are appropriate if iron needs are not being met by the intake of formula and complementary foods.
  4. Toddlers 1 through 3 years of age should have an iron intake of 7 mg/day. This would be best delivered by eating red meats, cereals fortified with iron, vegetables that contain iron, and fruits with vitamin C, which augments the absorption of iron (see Tables 3 and 4 in the original guideline document). For toddlers not receiving this iron intake, liquid supplements are suitable for children 12 through 36 months of age, and chewable multivitamins can be used for children 3 years and older.
  5. All preterm infants should have an iron intake of at least 2 mg/kg per day through 12 months of age, which is the amount of iron supplied by iron-fortified formulas. Preterm infants fed human milk should receive an iron supplement of 2 mg/kg per day by 1 month of age, and this should be continued until the infant is weaned to iron-fortified formula or begins eating complementary foods that supply the 2 mg/kg of iron. An exception to this practice would include infants who have received an iron load from multiple transfusions of packed red blood cells.
  6. Universal screening for anemia should be performed at approximately 12 months of age with determination of hemoglobin (Hb) concentration and an assessment of risk factors associated with ID/IDA. These risk factors would include low socioeconomic status (especially children of Mexican American descent [see Table 1 in the original guideline document]), a history of prematurity or low birth weight, exposure to lead, exclusive breastfeeding beyond 4 months of age without supplemental iron, and weaning to whole milk or complementary foods that do not include iron-fortified cereals or foods naturally rich in iron (see Table 3 in the original guideline document). Additional risk factors are the feeding problems, poor growth, and inadequate nutrition typically seen in infants with special health care needs. For infants and toddlers (1–3 years of age), additional screening can be performed at any time if there is a risk of ID/IDA, including inadequate dietary iron intake.
  7. If the Hb level is less than 11.0 mg/dL at 12 months of age, then further evaluation for IDA is required to establish it as a cause of anemia. If there is a high risk of dietary ID as described in point 6 above, then further testing for ID should be performed, given the potential adverse effects on neurodevelopmental outcomes. Additional screening tests for ID or IDA should include measurement of:
    • Serum ferritin (SF) and C-reactive protein (CRP) levels
    • Reticulocyte hemoglobin content (CHr) concentration
  8. If a child has mild anemia (Hb level of 10-11 mg/dL) and can be closely monitored, an alternative method of diagnosis would be to document a 1 g/dL increase in plasma Hb concentration after 1 month of appropriate iron-replacement therapy, especially if the history indicates that the diet is likely to be iron deficient.
  9. Use of the serum transferrin receptor 1 (TfR1) assay as screening for ID is promising, and the American Academy of Pediatrics (AAP) supports the development of TfR1 standards for use of this assay in infants and children.
  10. If IDA (or any anemia) or ID has been confirmed by history and laboratory evidence, a means of carefully tracking and following infants and toddlers with a diagnosis of ID/IDA should be implemented. Electronic health records could be used not only to generate reminder messages to screen for IDA and ID at 12 months of age but also to document that IDA and ID have been adequately treated once diagnosed.
Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of evidence supporting the recommendations is not specifically stated.

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Appropriate diagnosis and prevention of iron deficiency (ID) and iron-deficiency anemia (IDA) in infants and young children (0-3 years of age)

Potential Harms

Not stated

Qualifying Statements

Qualifying Statements

The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools
Patient Resources
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Staying Healthy
IOM Domain
Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)
Baker RD, Greer FR, Committee on Nutrition American Academy of Pediatrics. Diagnosis and prevention of iron deficiency and iron-deficiency anemia in infants and young children (0-3 years of age). Pediatrics. 2010 Nov;126(5):1040-50. [77 references] PubMed External Web Site Policy
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2010 Oct
Guideline Developer(s)
American Academy of Pediatrics - Medical Specialty Society
Source(s) of Funding

American Academy of Pediatrics

Guideline Committee

Committee on Nutrition

Composition of Group That Authored the Guideline

Lead Authors: Robert D. Baker, MD, PhD, Former Committee Member; Frank R. Greer, MD, Immediate Past Chairperson

Committee on Nutrition, 2009–2010: Jatinder J. S. Bhatia, MD, Chairperson; Steven A. Abrams, MD; Stephen R. Daniels, MD, PhD; Marcie Beth Schneider, MD; Janet Silverstein, MD; Nicolas Stettler, MD, MSCE; Dan W. Thomas, MD

Liaisons: Laurence Grummer-Strawn, PhD, Centers for Disease Control and Prevention; Rear Admiral Van S. Hubbard, MD, PhD, National Institutes of Health; Valérie Marchand, MD, Canadian Paediatric Society; Benson M. Silverman, MD, Food and Drug Administration; Valery Soto, MS, RD, LD, US Department of Agriculture

Staff: Debra L. Burrowes, MHA

Financial Disclosures/Conflicts of Interest

All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.

Guideline Status

This is the current release of the guideline.

All clinical reports from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.

Guideline Availability

Electronic copies: Available from the American Academy of Pediatrics (AAP) Policy Web site External Web Site Policy.

Print copies: Available from American Academy of Pediatrics, 141 Northwest Point Blvd., P.O. Box 927, Elk Grove Village, IL 60009-0927.

Availability of Companion Documents

None available

Patient Resources

The following is available:

Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.

NGC Status

This NGC summary was completed by ECRI Institute on April 5, 2011.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions. Please contact the Permissions Editor, American Academy of Pediatrics (AAP), 141 Northwest Point Blvd, Elk Grove Village, IL 60007.

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