Iron Deficiency - New Update on Screening and Treatment in Kids

Wooden letters spelling "IRON" are accompanied by a wooden spoon filled with iron supplement tablets on a bright blue background.

The American Academy of Pediatrics (AAP) recently updated its recommendations on screening for iron deficiency and iron deficiency anemia. Iron deficiency can occur without anemia, which is a later stage. I will summarize their recommendations, then outline which children are at greater risk and the modifications to their screening.

All babies should be screened between 9 and 18 months. When to screen depends on their feedings. Those exclusively breastfed beyond 6 months and not on an iron supplement should be screened at 9 months. Babies fed an iron-fortified formula, or those on an iron supplement, can be tested at 12 to 18 months. Most are tested at 12 month check-up and again at 18 months, after transitioning to milk.

A healthcare professional performs a finger-prick blood test on a patient's hand, preparing a small drop of blood for analysis.

The other group recommended to be universally screened is female adolescents, within one year after starting menstruation, or no later than 14 years. Female adolescents have the highest rate of both iron deficiency (ID) and iron deficiency anemia (IDA). ID and IDA are the most common nutrient deficiencies worldwide. These conditions are preventable but should be looked for. Once girls menstruate, they lose iron each month along with blood. Most girls should be on an iron supplement once entering puberty.

The following groups are at greater risk for iron deficiency and may need to be screened or supplemented earlier or more frequently.

Infant Risk Factors:

1. Preterm infants under 37 weeks gestation. 

These babies should begin iron supplementation by 2 weeks of age since their iron stores are depleted quickly.

2. Low birthweight infants

3. Babies with delayed cord clamping

4. Infants born to iron-deficient mothers

Dietary Risk Factors:

1. Infants exclusively bread-fed beyond 4-6 months without iron supplementation.

The AAP recommends these babies start an iron supplement by 4 months of age.

2. Babies who are given cow’s milk or plant-based milk early (before 12 months).

3. Children with excessive milk intake - more than 24 ounces or 3 cups a day. Calcium binds to iron in the gut and prevents its absorption.

4. Babies on a low-iron formula.

5. Children on a vegetarian or vegan diet.

A nutritious display of iron-rich foods, including nuts, seeds, liver, shrimp, eggs, beans, and grains alongside a small chalkboard with the chemical symbol "Fe" for iron.

Medical Risk Factors that Cause Iron Loss or Malabsorption:

1. Gastrointestinal diseases, such as celiac or inflammatory bowel disease, or a history of intestinal surgery in which bowel was removed or rerouted (as in bariatric surgery).

2. Any condition that causes chronic blood loss.

3. Heavy or frequent menstrual bleeding.

4. Endurance athletes and those with a high level of physical activity.

5. Those with chronic kidney disease.

6. Those with inflammatory diseases.

7. Those with lead exposure risk.

Most term infants are screened at the 12-month well-child visit. They are then screened again at 15-18 months, after transitioning off formula to milk and losing their main iron source. 

Initial screening is often done in the office with a finger-stick blood test, but the AAP reports that the optimal tests include a complete blood count and a ferritin level. If the office hemoglobin is low, then these tests are usually ordered and done through the lab.

If ID or IDA is detected, an oral supplement is started with repeat lab work done 1 and 3 months after starting therapy. In severe cases or those not responsive to oral therapy, intravenous (IV) iron may be used. 

Should you have concerns about iron deficiency in your child at any time, discuss with your doctor. The sooner it is diagnosed, the better, and earlier treatment may prevent anemia from developing.