AAP Publishes New Recommendations for Iron Intake Among Infants, Toddlers

Report Also Offers Guidance on Screening, Supplementation

October 20, 2010 05:00 pm News Staff

Nine percent of U.S. toddlers (i.e., children ages 12 months to 35 months) are iron-deficient, putting them at risk for adverse neurodevelopmental effects, according to a report(pediatrics.aappublications.org) from the American Academy of Pediatrics, or AAP. The report includes new guidelines for the diagnosis and prevention of iron deficiency and iron-deficiency anemia.

One of the report's co-authors, Robert Baker, M.D., Ph.D., said in a news release(www.aap.org) that feeding older infants and toddlers foods such as meat, shellfish, beans, iron-rich fruits and vegetables and iron-fortified cereals can help prevent iron deficiency and iron-deficiency anemia. Fruits high in vitamin C, which helps iron absorption, also are beneficial.

However, some children still will need liquid supplements or chewable vitamins to achieve adequate iron intake, Baker said.

The guidelines -- which were published online Oct. 5 and will appear in the November issue of the journal Pediatrics -- include the following age-specific recommendations for iron intake.

  • Healthy infants born at term have sufficient iron for their first four months. However, breastfed infants should receive 1 mg/kg of an oral iron supplement per day beginning at age 4 months and continuing until iron-rich complementary foods are introduced.
  • Formula-fed infants will receive adequate iron from formula and complementary foods. Whole milk should not be given before age 12 months.
  • Infants ages 6 months to 12 months need 11 mg of iron per day. When infants are given complementary foods, red meat and vegetables with high iron content should be introduced. If iron needs are not met by formula and complementary foods, liquid supplements can be used.
  • Children ages 1 year to 3 years need 7 mg of iron per day, preferably from foods. Liquid supplements and chewable multivitamins also can be used.
  • In their first 12 months, preterm infants should have at least 2 mg/kg of iron per day, which is the amount of iron in fortified formulas. Breastfed preterm infants should receive an iron supplement of 2 mg/kg per day by 1 month of age, and this should be continued until the infant is weaned to iron-fortified formula or begins eating complementary foods.

According to the report, between 6.6 percent and 15.1 percent of U.S. toddlers are iron-deficient, depending on ethnicity and socioeconomic status. Iron-deficiency anemia affects 1 percent to 4.4 percent of children in the same age group.

Roughly 20 percent of children will have some form of anemia during their childhood. The AAP recommends universal screening for anemia at 12 months, including an assessment of risk factors associated with iron deficiency and iron-deficiency anemia, which accounts for 40 percent of anemia in toddlers. Risk factors include premature birth, low birth weight, lead exposure and exclusive breastfeeding after age 4 months.

This recommendation contrasts with AAFP and U.S. Preventive Services Task Force, or USPSTF, recommendations that say evidence is insufficient to recommend for or against routine screening for iron-deficiency anemia in asymptomatic children ages 6 months to 12 months.

The task force, however, recommends routine iron supplementation for asymptomatic children ages 6 months to 12 months who are at increased risk for iron-deficiency anemia, and both groups recommend routine screening of asymptomatic pregnant women for iron-deficiency anemia.

The new AAP recommendations say that if an infant's hemoglobin level is less than 11 mg/dL, additional evaluation for iron-deficiency anemia is necessary because hemoglobin concentration lacks specificity and sensitivity. Additional screening for iron deficiency or iron-deficiency anemia should include measurements of serum ferritin and C-reactive protein or reticulocyte hemoglobin.

The report says that the transferring receptor 1 assay is a promising screening tool for iron-deficiency screening, and the AAP supports development of standards for its use in infants and children.

Children with a diagnosis of iron deficiency or iron-deficiency anemia should be carefully tracked, according to the report, which points out that electronic health records can be used to remind physicians to screen for iron deficiency and iron-deficiency anemia at age 12 months and to document that the conditions have been treated if diagnosed.

Finally, the report points out that iron-deficiency anemia increases intestinal lead absorption, so preventing such anemia also can help prevent lead poisoning.