User login
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.
All preterm infants should get at least 2 mg/kg a day of iron (the amount in iron-fortified formulas) through 12 months of age. Preterm infants feeding on human milk should get an iron supplement of 2 mg/kg a day by 1 month of age, which should be continued until the infant is weaned to iron-fortified formula or begins eating complementary foods that provide 2 mg/kg a day of iron.
Try mixing iron supplements with food or formula to make it more palatable, Dr. Greer suggested. "It tastes nasty" and can stain clothing if the baby spits it up, he said. Tri-Vi-Sol, which contains vitamins A, C, and D with iron, can be used. Giving iron starting at birth is not recommended. Alternatively, give the child some red meat in baby food or other forms. In Germany, often the first food introduced to children is a mash of vegetables, potatoes, and red meat.
The screening recommendations are the most controversial, but the prevention recommendations also are not without controversy. Iron is "both a good guy and a bad guy – either too much or too little are bad for you," and the difference between the lower and upper limits of intake are very narrow, compared with most other nutrients, Dr. Greer explained. Many physicians are unwilling to give iron supplements or iron-rich foods to children younger than 6 months or even to older children, he noted.
About 4% of 6-month-old infants and 12% of 12-month-olds in the United States are iron deficient. In toddlers aged 1–3 years, iron deficiency occurs in 7%-15%, depending on ethnicity and socioeconomic status.
Data from the 1999–2002 National Health and Nutrition Examination Survey (NHANES) suggest that 9% of children aged 12–35 months are iron deficient and 2% have iron-deficiency anemia. These data drove the AAP to create the new report, Dr. Greer said.
"I've worked on a lot of statements. This was by far the most difficult and controversial," he added.
The report declared that the authors had no pertinent conflicts of interest.
I think this is a very important, challenging issue. Hemoglobin alone identifies only anemia, and it doesn't tell you if it's specific to iron deficiency. And if it is due to inadequate iron, it means you have severe iron deficiency. There are severe consequences to iron deficiency without anemia.
There's no easy way to get around more comprehensive testing, so I support these efforts.
This is complicated but important. If people look, they're going to find iron deficiency if they're looking at the right populations, especially older infants and toddlers who have been primarily breast fed and are on a regular mixed diet.
Unless a baby has been exclusively formula fed, there's no way that a practitioner can assess whether the baby's diet meets iron needs. In premature or partially breast-fed infants, estimating actual amounts of iron from complementary foods is very difficult. There's really no way to tell if the child is iron deficient unless you check.
I'm not in primary care, but I see lots of infants and toddlers who are referred to me for growth alterations of some degree. In the right circumstances, I screen for iron deficiency and anemia. I screen with ferritin, I get a CBC if that has not already been done, and I order a sedimentation rate, a CRP, and an iron panel. I'm using what's clinically readily available, assessing total iron binding capacity and transferrin saturation.
The serum transferrin receptor 1 (SfTR1) concentration test is not readily available. I'm not familiar with the reticulocyte hemoglobin content (CHr) test.
I'm amazed that the AAP is recommending this, because it's not ready for prime time as far as I'm aware.
NANCY KREBS, M.D., is head of the Section of Nutrition and professor of pediatrics at the University of Colorado, Denver. She provided early input to the authors but was not involved in producing the final report. In an interview, she said she has no pertinent conflicts of interest.
I think this is a very important, challenging issue. Hemoglobin alone identifies only anemia, and it doesn't tell you if it's specific to iron deficiency. And if it is due to inadequate iron, it means you have severe iron deficiency. There are severe consequences to iron deficiency without anemia.
There's no easy way to get around more comprehensive testing, so I support these efforts.
This is complicated but important. If people look, they're going to find iron deficiency if they're looking at the right populations, especially older infants and toddlers who have been primarily breast fed and are on a regular mixed diet.
Unless a baby has been exclusively formula fed, there's no way that a practitioner can assess whether the baby's diet meets iron needs. In premature or partially breast-fed infants, estimating actual amounts of iron from complementary foods is very difficult. There's really no way to tell if the child is iron deficient unless you check.
I'm not in primary care, but I see lots of infants and toddlers who are referred to me for growth alterations of some degree. In the right circumstances, I screen for iron deficiency and anemia. I screen with ferritin, I get a CBC if that has not already been done, and I order a sedimentation rate, a CRP, and an iron panel. I'm using what's clinically readily available, assessing total iron binding capacity and transferrin saturation.
The serum transferrin receptor 1 (SfTR1) concentration test is not readily available. I'm not familiar with the reticulocyte hemoglobin content (CHr) test.
I'm amazed that the AAP is recommending this, because it's not ready for prime time as far as I'm aware.
NANCY KREBS, M.D., is head of the Section of Nutrition and professor of pediatrics at the University of Colorado, Denver. She provided early input to the authors but was not involved in producing the final report. In an interview, she said she has no pertinent conflicts of interest.
I think this is a very important, challenging issue. Hemoglobin alone identifies only anemia, and it doesn't tell you if it's specific to iron deficiency. And if it is due to inadequate iron, it means you have severe iron deficiency. There are severe consequences to iron deficiency without anemia.
There's no easy way to get around more comprehensive testing, so I support these efforts.
This is complicated but important. If people look, they're going to find iron deficiency if they're looking at the right populations, especially older infants and toddlers who have been primarily breast fed and are on a regular mixed diet.
Unless a baby has been exclusively formula fed, there's no way that a practitioner can assess whether the baby's diet meets iron needs. In premature or partially breast-fed infants, estimating actual amounts of iron from complementary foods is very difficult. There's really no way to tell if the child is iron deficient unless you check.
I'm not in primary care, but I see lots of infants and toddlers who are referred to me for growth alterations of some degree. In the right circumstances, I screen for iron deficiency and anemia. I screen with ferritin, I get a CBC if that has not already been done, and I order a sedimentation rate, a CRP, and an iron panel. I'm using what's clinically readily available, assessing total iron binding capacity and transferrin saturation.
The serum transferrin receptor 1 (SfTR1) concentration test is not readily available. I'm not familiar with the reticulocyte hemoglobin content (CHr) test.
I'm amazed that the AAP is recommending this, because it's not ready for prime time as far as I'm aware.
NANCY KREBS, M.D., is head of the Section of Nutrition and professor of pediatrics at the University of Colorado, Denver. She provided early input to the authors but was not involved in producing the final report. In an interview, she said she has no pertinent conflicts of interest.
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.
All preterm infants should get at least 2 mg/kg a day of iron (the amount in iron-fortified formulas) through 12 months of age. Preterm infants feeding on human milk should get an iron supplement of 2 mg/kg a day by 1 month of age, which should be continued until the infant is weaned to iron-fortified formula or begins eating complementary foods that provide 2 mg/kg a day of iron.
Try mixing iron supplements with food or formula to make it more palatable, Dr. Greer suggested. "It tastes nasty" and can stain clothing if the baby spits it up, he said. Tri-Vi-Sol, which contains vitamins A, C, and D with iron, can be used. Giving iron starting at birth is not recommended. Alternatively, give the child some red meat in baby food or other forms. In Germany, often the first food introduced to children is a mash of vegetables, potatoes, and red meat.
The screening recommendations are the most controversial, but the prevention recommendations also are not without controversy. Iron is "both a good guy and a bad guy – either too much or too little are bad for you," and the difference between the lower and upper limits of intake are very narrow, compared with most other nutrients, Dr. Greer explained. Many physicians are unwilling to give iron supplements or iron-rich foods to children younger than 6 months or even to older children, he noted.
About 4% of 6-month-old infants and 12% of 12-month-olds in the United States are iron deficient. In toddlers aged 1–3 years, iron deficiency occurs in 7%-15%, depending on ethnicity and socioeconomic status.
Data from the 1999–2002 National Health and Nutrition Examination Survey (NHANES) suggest that 9% of children aged 12–35 months are iron deficient and 2% have iron-deficiency anemia. These data drove the AAP to create the new report, Dr. Greer said.
"I've worked on a lot of statements. This was by far the most difficult and controversial," he added.
The report declared that the authors had no pertinent conflicts of interest.
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.
All preterm infants should get at least 2 mg/kg a day of iron (the amount in iron-fortified formulas) through 12 months of age. Preterm infants feeding on human milk should get an iron supplement of 2 mg/kg a day by 1 month of age, which should be continued until the infant is weaned to iron-fortified formula or begins eating complementary foods that provide 2 mg/kg a day of iron.
Try mixing iron supplements with food or formula to make it more palatable, Dr. Greer suggested. "It tastes nasty" and can stain clothing if the baby spits it up, he said. Tri-Vi-Sol, which contains vitamins A, C, and D with iron, can be used. Giving iron starting at birth is not recommended. Alternatively, give the child some red meat in baby food or other forms. In Germany, often the first food introduced to children is a mash of vegetables, potatoes, and red meat.
The screening recommendations are the most controversial, but the prevention recommendations also are not without controversy. Iron is "both a good guy and a bad guy – either too much or too little are bad for you," and the difference between the lower and upper limits of intake are very narrow, compared with most other nutrients, Dr. Greer explained. Many physicians are unwilling to give iron supplements or iron-rich foods to children younger than 6 months or even to older children, he noted.
About 4% of 6-month-old infants and 12% of 12-month-olds in the United States are iron deficient. In toddlers aged 1–3 years, iron deficiency occurs in 7%-15%, depending on ethnicity and socioeconomic status.
Data from the 1999–2002 National Health and Nutrition Examination Survey (NHANES) suggest that 9% of children aged 12–35 months are iron deficient and 2% have iron-deficiency anemia. These data drove the AAP to create the new report, Dr. Greer said.
"I've worked on a lot of statements. This was by far the most difficult and controversial," he added.
The report declared that the authors had no pertinent conflicts of interest.