Putting Prevention into Practice

An Evidence-Based Approach

Screening for Iron Deficiency Anemia—Including Iron Supplementation for Children and Pregnant Women



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Am Fam Physician. 2009 May 15;79(10):897-898.

This clinical content conforms to AAFP criteria for evidence-based continuing medical education (EB CME). See CME Quiz on page 857.

Case Study

H.H., a 25-year-old woman, comes to your office with her six-month-old son during her first trimester of pregnancy. She is taking a prenatal vitamin and asks whether she should also take an iron supplement. There is a family history of anemia, and H.H. would like to be tested. She also wonders whether her son should be tested and whether he should take an iron supplement. Neither H.H. nor her son has a history of iron deficiency anemia, but her son was born prematurely.

Case Study Questions

1. Based on recommendations from the U.S. Preventive Services Task Force (USPSTF), which one of the following statements about iron deficiency anemia is correct?

  • A. Asymptomatic pregnant women should not be screened for iron deficiency anemia.

  • B. Iron deficiency anemia is more common than iron deficiency.

  • C. Hemoglobin measurement is a specific test for iron deficiency.

  • D. There is no evidence that universal screening for iron deficiency anemia in asymptomatic children results in improved health outcomes.

  • E. The prevalence of iron deficiency anemia in the general U.S. population continues to increase.

2. Which of the following statements about the harms of iron deficiency anemia is/are correct?

  • A. Children who have been diagnosed with iron deficiency anemia in infancy have developmental delays later in life.

  • B. Iron deficiency anemia may adversely affect mental and psychomotor skills in postpartum women.

  • C. Iron deficiency anemia in pregnancy is associated with an increased risk of preterm delivery and increased risk of low birth weight.

  • D. Maternal iron deficiency anemia may be associated with postpartum depression.

3. Which of the following statements about iron supplementation in children is/are appropriate to share with H.H.?

  • A. Healthy infants who are fed iron-fortified formula or iron-fortified cereal are less likely to develop iron deficiency compared with infants who are fed cow's milk or unfortified formula.

  • B. All children six to 12 months of age should receive iron supplementation.

  • C. Iron deficiency anemia rarely resolves spontaneously in children.

  • D. Almost all infant formula is iron fortified.

Answers

1. The correct answer is D. The USPSTF has found no evidence that screening for iron deficiency anemia in asymptomatic children improves health outcomes. It concludes that evidence is insufficient to recommend for or against routine screening in asymptomatic children six to 12 months of age.

The USPSTF concludes that the benefits of routine screening for iron deficiency anemia in asymptomatic pregnant women outweigh the harms. It recommends screening in these patients. Iron deficiency anemia during pregnancy has been associated with an increased risk of low birth weight, preterm delivery, and perinatal mortality. Evidence shows that treating asymptomatic pregnant women who have iron deficiency anemia results in moderately improved health outcomes.

Iron deficiency anemia is the extreme manifestation of iron deficiency and is less common than iron deficiency. Measurement of serum hemoglobin or hematocrit is the primary screening test for anemia. However, this test is not specific for iron deficiency anemia; many cases of anemia result from other causes. Hemoglobin measurement is sensitive for iron deficiency anemia but not for iron deficiency, because a mild deficiency may not affect hemoglobin levels.

The prevalence of iron deficiency anemia has remained stable in the United States during the previous decade. It continues to be more prevalent among minority and poor children.

2. The correct answers are A, C, and D. Studies have shown that children who have been diagnosed with anemia in infancy continue to have developmental delays after 10 years of follow-up. However, it is difficult to establish a causal relationship between anemia and developmental abnormalities because of environmental, socioeconomic, and nutritional confounding factors.

Maternal iron deficiency anemia may be associated with poor performance on mental and psychomotor tests in children, and with postpartum depression in mothers. Iron deficiency anemia in pregnancy has also been associated with decreased parental interaction and poor developmental outcomes in infants. Reduced work productivity, endurance, and exercise capacity have been associated with anemia in adults. Adults with severe anemia are also at risk of cardiopulmonary complications.

3. The correct answers are A and D. Substantial reductions in the incidence of iron deficiency and iron deficiency anemia have been demonstrated in healthy infants who are fed iron-fortified formula or iron-fortified cereal, compared with infants who are fed cow's milk or unfortified formula. Ninety-seven percent of all infant formula sold in the United States is iron fortified.

The USPSTF recommends routine iron supplementation for asymptomatic children six to 12 months of age who are at increased risk of iron deficiency anemia. Evidence is insufficient to recommend for or against routine iron supplementation for asymptomatic children six to 12 months of age who are at average risk of iron deficiency anemia. It is unclear whether screening for iron deficiency anemia in children will improve treatment outcomes because many families do not adhere to treatment and because the rate of spontaneous resolution is high.

SOURCES

Helfand M, Freeman M, Nygren P, Walker M. Screening for iron deficiency anemia in childhood and pregnancy: Update of 1996 U.S. Preventive Services Task Force Review. Evidence synthesis no. 40. Rockville, Md.: Agency for Healthcare Research and Quality. http://www.ahrq.gov/clinic/uspstf06/ironsc/ironscrev.pdf. Accessed March 4, 2009.

U.S. Preventive Services Task Force. Screening for iron deficiency anemia—including iron supplementation for children and pregnant women: recommendation statement. Rockville, Md.: Agency for Healthcare Research and Quality; 2006. AHRQ 06-0589. http://www.ahrq.gov/clinic/uspstf06/ironsc/ironrs.htm. Accessed March 4, 2009.

The case study and answers to the following questions on screening for iron deficiency anemia—including iron supplementation for children and pregnant women are based on the recommendations of the U.S. Preventive Services Task Force (USPSTF), an independent panel of experts in primary care and prevention that systematically reviews the evidence of effectiveness and develops recommendations for clinical preventive services. More detailed information on this subject is available in the USPSTF Recommendation Statement and the evidence synthesis on the USPSTF Web site (www.ahrq.gov/clinic/uspstfix.htm). The evidence synthesis and Recommendation Statement are available in print through the AHRQ Publications Clearinghouse (800-358-9295, e-mail, ahrqpubs@ahrq.hhs.gov). The practice recommendations in this activity are available at http://www.ahrq.gov/clinic/uspstf/uspsiron.htm.


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