Iron Deficiency Anemia and Screening

1. Iron Deficiency Anemia and Screening 2010 Guidelines from the American Academy of Pediatrics

2. Anemia • A hemoglobin value 2 SDs below the mean hemoglobin for age and gender based • Defined by the World Health organization, the UN Children’s Fund, and the UN University • Values • Hemoglobin <11.0 g/dL for males and females aged 12-35 months

3. Iron • Iron Sufficiency • A state in which there is sufficient iron to maintain normal physiologic function • Iron Deficiency • A state in which there is in sufficiency iron to maintain normal physiologic functions • Iron Deficiency Anemia • Anemia that results from ID

4. Iron Deficiency (ID) and Iron Deficiency Anemia (IDA) Iron is the most common single nutrient deficiency in the developing world IDA is still a common cause of anemia in industrialized nations ID without anemia may adversely affect long-term neurodevelopment and behavior implications

5. Iron Requirements • Term Infants • 80% of iron stores obtained during 3rd trimester • Can be affected by maternal conditions (anemia, HTN with IUGR, diabetes) • Pre Term Infants • Can miss out on final trimester iron storage • Can be at risk of iron overload in NICU if receiving multiple blood transfusions

6. Iron Requirements: Term Infants • 0-6 months • Average adequate iron intake 0.27 mg/day • Based on the average levels of iron in breast milk on a daily basis (calculated by the Institute of Medicine) • 7-12 months • 11 mg/day • Increase due to increased epithelial cell turnover (skin, GI, urinary tracts), increased blood volume, increased tissue mass, and increased storage of iron

7. Why such a big jump in requirements? • “It is noted that the iron needs of infants do not suddenly jump from 0.27 mg to 11 mg/day at 6 months; this disjuncture is the result of the use of very different methods of determining these values. However, it is very clear that healthy, term newborn infants require very little iron early in life compared with the significant amounts of iron required after 6 months of age”

8. Iron Requirements: 1-3 years • Based on Institute of Medicine • 7 mg/day

9. Prevalence of ID and IDA in Toddlers in the US

10. Prevalence of ID and IDA Overall prevalence has decreased since the 1970s due to iron-fortified formula and foods provided, especially by WIC ID still common; 6.6%-15.2 % of toddlers IDA 0.9-4.4% (but only represents 40% of all childhood anemia) Confounding factors: race/ethnicity and socioeconomic status

11. Neurodevelopment and ID Iron is an essential factor in normal neurodevelopment There has been some suggestive evidence of adverse affects on cognition and behavior in ID or IDA

12. Summary of Recommendations

13. Term infants • Breastfed • Formula • Preterm infants (<37 weeks) • Breastfed • Formula

14. Prevention • Preterm Infant (<37 weeks) • Breastfed: should receive 2mg/kg iron supplement starting by 1 month until 12 months • Preterm Formula has 14.6 mg/L iron • Term Formula has 12 mg/L iron • Formula fed groups: 1.8-2.2 mg/kg/day of iron supplement

15. Prevention • Term Infants (0-12 months) • Have normal iron stores until 4-6 months • Breastfed (if >50% is breast milk): start 1 mg/kg/day at 4 months and continue until adequate iron containing foods introduced • Formula fed: the 12 mg/L in formula is enough without additional supplementation • No cow’s milk introduction prior to 12 months

16. Screening Recommendations Universal screening at 12 months with hemoglobin

17. Prevention • Toddlers (1-3 years) • Parents can increase iron rich foods and/or give MVI with iron • (see article for listing of iron rich foods)

18. Summary Term infants have sufficient iron for at least the first 4 months Exclusively breastfed infants should be supplemented with 1 mg/kg/day of oral iron starting at 4 months of age to prevent ID or IDA Partially breastfed infants