Screening for Anemia in Children: AAP Recommendations—A Critique

Abstract

The American Academy of Pediatrics (AAP) recommends screening for anemia between the ages of 9 to 12 months with additional screening between the ages of 1 and 5 years for patients at risk. The screening may be universal or selective depending on the prevalence of iron deficiency anemia in the population. Improved infant rearing practices—including wider availability, acceptance, and use of iron-fortified formulas; iron fortification of foods; and increased awareness of the importance of dietary iron supplementation especially early in life—have lead to significant decline in the incidence of anemia in the first year of life. However, incidence of iron deficiency and ensuing anemia in children between 1 and 2 years continues to be significant and an important issue. Although iron deficiency may develop soon after cessation of or inadequate iron intake, anemia secondary to iron deficiency develops gradually over a period of several weeks to months. For children who have received/are receiving iron-fortified infant formulas and foods, hemoglobin screening at 9 to 12 months of age is inappropriate as there may not have been sufficient time to develop anemia, despite the rapid growth rate at this age. Widespread implementation of hemoglobin electrophoresis included in the neonatal metabolic screening programs in many states in the United States now has resulted in earlier diagnosis of hemoglobinopathies. Screening children at 9 to 12 months of age for hemoglobinopathies is somewhat redundant now. Screening for anemia before or around 1 year of age should continue to be important for communities and children at risk. Universal screening of toddlers at a later time allows sufficient time for nutritional anemia to become evident after the child has been weaned off iron-fortified formulas, for the influence of toddler dietary fads to manifest, and for evaluation of tolerance of cow's milk protein. This may be addressed via 2 approaches. The first involves postponing the currently recommended screening or an additional screening for anemia between 15 to 18 months of age. Determination of hemoglobin (or hematocrit) is not the optimal way to identify children at risk from effects of iron deficiency as it fails to identify patients who are iron-deficient but are not anemic. Long-term psychomotor, behavioral, and developmental effects secondary to iron deficiency anemia are known but sufficient data are lacking regarding the role of iron deficiency without anemia. Development and evaluation of sensitive, specific, and cost-effective screening tools to identify children at risk for iron deficiency is important. Until such methods are instituted, the AAP should emphasize and recommend universal screening for anemia during the second year of life.