AAP: Assess Hemoglobin Levels In All Infants at 12 Months

SAN FRANCISCO — All infants should be screened for anemia around 12 months of age by measuring hemoglobin concentrations and assessing risk factors associated with iron deficiency or iron-deficiency anemia, a new clinical report advises.

If the hemoglobin level is less than 11 g/dL, or if the infant has a high risk of dietary iron deficiency, physicians should test further by measuring serum ferritin and C-reactive protein (CRP) or by measuring reticulocyte hemoglobin concentration (CHr), according to the report.

These recommendations for screening are controversial, Dr. Frank Greer, a co-author of the report on iron deficiency and iron-deficiency anemia, said at the meeting.

"It's going to be very burdensome to screen for iron deficiency. It's burdensome until we get some kind of a spot test," said Dr. Greer, professor of pediatrics at the University of Wisconsin, Madison. "But until somebody makes a hue and cry that we need to screen kids for iron deficiency, the technology won't come around. Hopefully, this will stimulate the technology."

It's unclear who will pay the added cost involved in screening. About 55% of U.S. children would fit criteria for the need to screen with more than just a hemoglobin test simply because of their low socioeconomic status, which is a key risk factor for dietary iron deficiency, he noted. Other risk factors outlined in the report include a history of prematurity or low birth weight, exposure to lead, exclusive breast feeding beyond 4 months of age without supplemental iron, feeding problems, and poor growth.

The "Clinical Report – Diagnosis and Prevention of Iron Deficiency and Iron-Deficiency Anemia in Infants and Young Children (0–3 Years of Age)" will be published in the November issue of the journal Pediatrics. Dr. Greer was the lead co-author of the report with Dr. Robert D. Baker, professor of pediatrics at the State University of New York, Buffalo and Women's and Children's Hospital, Buffalo. The AAP's Committee on Nutrition also contributed to the report.

The new report revises and expands on a 1999 AAP policy statement that focused on iron fortification of formulas (Pediatrics 1999;104:119–23).

Serum ferritin concentration is the most widely available measure of total body iron stores, but concentrations of serum ferritin may be increased by infection (inflammation), malignancy, liver disease, or anemia of chronic disease. If used to diagnose iron deficiency, serum ferritin concentration must be combined with simultaneous measurement of CRP to rule out inflammation. If the CRP is elevated, one of the other recommended tests must be used to screen for iron deficiency, Dr. Greer explained.

The standard for diagnosing iron deficiency is low bone marrow iron concentration determined by iron staining – not a practical choice for clinicians. Three other parameters provide the most discriminatory information about iron status: serum ferritin, CHr, or transferrin receptor 1 concentration (TfR1), Dr. Greer said. CHr and TfR1 are not affected by inflammation, malignancy, or anemia of chronic disease. Serum TfR1 assays are not widely available and are not standardized for use in infants and children. The CHr assay is measured by flow cytometry, but only two of the four commonly used automated analyzers in the United States are able to measure CHr.

"Hopefully, within a generation they all will" measure CHr, he said.

The statement offers an alternative way to diagnose iron-deficiency anemia that was one of the compromises made among the authors, Dr. Greer said. A child with mild anemia (a hemoglobin level of 10–11 g/dL) and a history suggesting an iron-deficient diet could be given iron replacement therapy, and if the plasma hemoglobin concentration increases by 1 g/dL after 1 month, would be considered to have had iron deficiency.

Any child with iron deficiency or iron-deficiency anemia should be followed carefully, he added.

The statement also recommended steps to prevent iron deficiency and iron-deficiency anemia, including the option of iron supplements. Term healthy infants have sufficient iron for the first 4 months of life. Starting at 4 months, breast-fed infants should be given 1 mg/kg a day of oral iron supplementation until iron-rich complementary foods are introduced, the statement says. Exclusively formula-fed infants get adequate iron from formula. Whole milk should not be used before 12 months of age. At 6–12 months of age, infants need 11 mg/kg a day of iron. Red meat and vegetables with high iron content should be introduced early when complementary foods are given, and liquid iron supplements can be used if diet and formula do not provide enough iron.

Toddlers aged 1–3 years need 7 mg/day of iron, which is best obtained from foods but can be had from liquid iron supplements and chewable vitamins if needed.