Patient Population Under Consideration
This recommendation applies to children ages 6 to 24 months living in
the United States who are asymptomatic for iron deficiency anemia. It
does not apply to children younger than age 6 months or older than 24
months, children who are severely malnourished, children who were born
prematurely or with low birth weight, or children who have symptoms of
iron deficiency anemia. Recommendations regarding screening for iron
deficiency anemia in pregnant women and iron supplementation during
pregnancy are addressed in a separate recommendation statement
(available at www.uspreventiveservicestaskforce.org).
Suggestions for Practice Regarding the I Statement
Potential Preventable Burden
Estimates of the prevalence of iron deficiency in children ages 1 to 3
years in the United States range from 8% to 14%, and approximately one
third of these children also have anemia.3
Based on 1999 to 2002 National Health and Nutrition Examination Survey
(NHANES) data, the estimated prevalence of iron deficiency anemia in
children ages 12 to 35 months is 2.1%.1
Several factors have been identified that may increase a child’s risk
for iron deficiency anemia, including prematurity or low birth weight,
use of non–iron-fortified formula or introduction to cow's milk in the
first year of life, and exclusive breastfeeding without regular intake
of iron-fortified food after age 6 months. Demographic factors
associated with increased risk for iron deficiency anemia include low
socioeconomic status and having parents who are migrant workers or
recent immigrants. Additional factors that may be associated with
increased risk for iron deficiency in children include weight and height
in the 95th percentile or greater, bottle feeding beyond the first year
of life, having a mother who is currently pregnant, or living in an
urban area. Evidence on whether Hispanic ethnicity increases children's
risk for iron deficiency has been mixed, with some studies showing an
increased risk and others showing no increased risk. Older data from
NHANES (1988–1994) showed that Mexican American children were nearly 3
times more likely than white children to have iron deficiency, whereas
more recent NHANES data from 1999–2002 found no increased risk in
Hispanic children.3
The USPSTF found no studies that assessed the performance of risk
assessment tools to identify children who are at increased risk for iron
deficiency anemia.
Some observational studies suggest that iron deficiency anemia in
early childhood may be associated with neurodevelopmental and behavioral
delays and poorer performance on cognitive tests. However, concluding
that there is a direct causal link between iron deficiency anemia and
these outcomes is difficult because of the methodological flaws in these
studies and potential confounding due to underlying nutritional and
socioeconomic differences between groups.3
The aim of screening for iron deficiency anemia in young children is to
identify and treat anemia before it leads to poor child health
outcomes.
Potential Harms
The harms of screening for iron deficiency anemia have not been well
studied. Potential harms of screening include false-positive results,
anxiety, and cost. Reported adverse events of treatment with iron
include limited gastrointestinal symptoms, darkening color of stool,
staining of teeth and gums, and drug interactions with other
medications. The previous USPSTF recommendation also noted that
accidental iron overdose can occur in children receiving treatment or
supplementation with iron.
Current Practice
No recent nationally representative data on the current rate of screening are available.
Screening Tests
Although the evidence is insufficient to recommend specific tests for
screening, measurement of serum hemoglobin or hematocrit is often the
first step.
Treatment and Interventions
In the United States, iron deficiency anemia in children is usually
treated with oral iron. The usual dose in infants and young children is 3
to 6 mg/kg of elemental iron per day in 2 to 3 divided doses.3
Other Approaches to Prevention
According to the Institute of Medicine, the Recommended Dietary
Allowance for iron in infants ages 7 to 12 months is 11 mg per day. In
children ages 1 to 3 years, the Recommended Dietary Allowance is 7 mg
per day. Natural food sources of iron include certain fruits,
vegetables, meat, and poultry. The Institute of Medicine also notes that
nonheme iron, which is found in vegetarian diets, may be less well
absorbed than heme iron, which is found in diets containing meat;
therefore, the iron requirement may be almost twice as much in children
who eat a purely vegetarian diet.4 Fortified breads and grain products (such as cereal) are also good sources of iron for young children eating solid foods.5
Iron-fortified formula is another source of iron for infants. Federally
regulated iron fortification of food products in the United States
began in 1941, and the iron content in enriched grain products has
increased over the years.6 More than 50% of the iron in the U.S. food supply comes from iron-fortified cereal grain products.5
Useful Resources
The USPSTF has published a separate recommendation statement on
screening for iron deficiency anemia and iron supplementation in
pregnant women (available at www.uspreventiveservicestaskforce.org).