AAP Issues New Guidelines for Management of Iron Deficiency

From Medscape Medical News

Jim Kling

October 14, 2010 — Correction: The original text of this article described the daily iron dose for infants 6 to 12 months as 11 mg/kg. This is incorrect. The dose should be 11 mg/day.

October 5, 2010 (San Francisco, California) — Iron deficiency is one of the most common, yet undetected, problems among children. Here at the American Academy of Pediatrics (AAP) 2010 National Conference and Exhibition, the American Association of Pediatrics released a clinical report, with guidelines for iron intake in infants and children and to improve screening methods.
The clinical report, entitled Diagnosis and Prevention of Iron Deficiency and Iron Deficiency Anemia in Infants and Young Children (0–3 Years of Age), was published online October 5 in Pediatrics. It is a revision of a 1999 policy statement.

Iron deficiency can have long-term irreversible effects on a child’s cognitive and behavioral development. By the time a child develops iron-deficiency anemia, it might be too late to prevent future problems. “The body has a preferential tracking of iron. Red blood cells take precedence over the iron requirements of the brain. By the time you get iron-deficiency anemia, you’ve been iron-deficient for a long time,” said Frank Greer, MD, professor of pediatrics at the University of Wisconsin School of Medicine and Public Health in Madison, and a coauthor of the report.

The 1999 guidelines call for children to have their hemoglobin checked sometime between 9 and 12 months of age, and again between 15 and 18 months of age. However, the existing test misses many children with iron deficiency and iron-deficiency anemia. Even those found to be iron deficient frequently receive no follow-up testing or treatment, according to Dr. Greer.

Although supplementing all children with iron would reduce iron deficiency, such a program does not have widespread support in the medical community at this point. That’s partly because toddlers, who are the most widely affected group, have a wide range of diets and it is unclear what foods to fortify.

Liquid iron supplements or vitamins could be used, but there is a risk for iron overload in some populations, according to Michael K. Georgieff, MD, professor of pediatrics and child psychology and director of the Center for Neurobehavioral Development at the University of Minnesota in Minneapolis. Dr. Georgieff was on the AAP’s committee on nutrition from 1993 to 1999 and played a key role in the 1999 guidelines.

“Iron supplementation and awareness of iron nutrition has probably been one of the most successful public health programs in the United States. In the 1960s, iron deficiency was probably 30% to 40%. Today, it may be under 10%. But in trying to eliminate that last 10%, you have to consider it in terms of exposing kids to [too much] iron,” said Dr. Georgieff.

No single screening test is available that will accurately characterize the iron status of a child, he noted. In the report, the AAP recommends 4 protocols for screening for iron deficiency and iron-deficiency anemia, including combinations of several tests and follow-up protocols. “It’s burdensome,” Dr. Greer admitted.
“Since we’re not going to do universal supplementation, we need to identify kids who are at risk for iron deficiency and start targeting them,” said Dr. Georgieff, who studies the neurodevelopmental effects of iron deficiency in children.

The AAP report identified several factors associated with iron deficiency and iron-deficiency anemia, including prematurity or low birth-weight, lead exposure, exclusive breastfeeding past 4 months of age without iron supplements, and weaning to foods that don’t include iron-fortified cereals or iron-rich foods. Infants with special healthcare needs might also be at risk. Children of low economic status, particularly those of Mexican American descent, are also of concern, according to the report, which recommends selective screening for these individuals.

The guidelines also address means to prevent iron deficiency through a diet of foods naturally rich in iron, such as meat, shellfish, legumes, iron-rich fruits and vegetables, and iron-fortified cereals. Fruits rich in vitamin C help iron absorption. Some children might require liquid iron supplements or chewable vitamins to get sufficient iron.
The AAP recommends varying amounts of iron based on a child’s age:

• Term, healthy infants have sufficient iron for the first 4 months of life. Because human breast milk contains very little iron, breastfed infants should be supplemented with 1 mg/kg per day of oral iron from 4 months of age until iron-rich foods (such as iron-fortified cereals) are introduced.


• Formula-fed infants will receive adequate iron from formula and complementary foods. Whole milk should not be used before 12 months.


• Infants 6 to 12 months of age need 11 mg/day of iron a day. When infants are given complementary foods, red meat and vegetables with high iron content should be introduced early. Liquid iron supplements can be used if iron needs are not met by formula and complementary foods.


• Toddlers 1 to 3 years of age need 7 mg per day of iron. It is best if this comes from foods such as red meats, iron-rich vegetables, and fruits with vitamin C, which enhance iron absorption. Liquid supplements and chewable multivitamins can also be used.


• All preterm infants should have at least 2 mg/kg of iron per day until 12 months of age, which is the amount of iron in iron-fortified formulas. Preterm infants fed human milk should receive an iron supplement of 2 mg/kg per day by 1 month of age; this should be continued until the infant is weaned to iron-fortified formula or begins eating foods that supply the required 2 mg/kg of iron.

American Academy of Pediatrics (AAP) 2010 National Conference and Exhibition. Presented October 5, 2010.