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Take a closer look at iron recommendations.

I read with a great deal of interest the recent American Academy of Pediatrics Committee on Nutrition's Clinical Report "Diagnosis and Prevention of Iron Deficiency and Iron-Deficiency Anemia in Infants and Young Children (0-3 Years of Age)" in the November issue of Pediatrics (2010;126:1040-50).

The authors of this report should be congratulated for calling attention to the underestimated and undertreated problem of iron deficiency (ID) and for recommending iron supplementation for toddlers whose diets are inadequate.

However, after careful analysis, it appears to me that the report not only is confusing, but also places the physician in a difficult and perhaps untenable position, both in terms of screening for and preventing toddler ID. Allow me to explain.

The association of ID and iron deficiency anemia (IDA) in infants and toddlers with long-lasting and perhaps irreversible impaired psychomotor and mental development has been well known and clearly established.

The good news is that the prevalence of ID and IDA during the first year of life has been dramatically reduced. This success has been largely due to increased breastfeeding rates and the use of iron-fortified formulas and iron-fortified infant cereals.

Unfortunately, this success story does not hold during the toddler years, ages 1-3 years.

Large numbers of toddlers, especially those in the low socioeconomic group, continue to suffer from ID and IDA.

This comes as no great surprise to me. Many toddlers are picky and finicky eaters, often consuming large quantities of milk and apple juice and very little iron-rich food. Large-scale studies have demonstrated that the daily dietary iron intake of 1- to 3-year-olds is lower than in any other age group throughout life (Arch. Pediatr. Adolesc. Med. 1997;151:986-8).

The reported prevalence rates of toddler ID vary from 9% to more than 30% (JAMA 1997;277:973-6). Although not proven, I believe that it would be fair to say that the actual prevalence would be even higher if multiple tests for ID were obtained between 1 and 3 years of age.

There is another compelling reason to prevent toddler ID. A number of studies in recent years showed that ID increases lead absorption and that lead-associated cognitive deficits occur at blood lead levels below 10 mcg/dL, a level previously thought to be harmless.

The bottom line is that the large number of toddlers who are ID are doubly at risk for neurodevelopmental damage, from ID and from increased lead absorption.

I take serious issue with both the screening and prevention recommendations for the 1- to 3-year-olds in the report.

* Screening: The report recommends screening for ID at 12 months of age for the "high-risk group." This includes low socioeconomic status, prematurity, low birth weight, exclusive breastfeeding beyond 4 months of age without supplemental iron, feeding problems, exposure to lead, and poor growth. These "high-risk" groups represent over one-half of the total.

The problem with this recommendation is the chaos and frustration it will create. The current available laboratory tests for ID all require venipuncture. They also are expensive. Even if ordered, the compliance rate would probably be low. It places the physician in the real predicament of whether or not to order a screening test for ID.

* Prevention: As pointed out in the report, toddlers require 7 mg/day of iron-rich foods. The authors state that if the diet is inadequate, iron supplements or iron-fortified vitamins are recommended.

Once again, the physician is put in the difficult situation of determining which toddlers require iron supplementation.

Toddler ID remains a major public health issue. The new screening and prevention recommendations report is important in that it has brought the important subject of ID to the attention of the medical community. However, in my opinion, it has confused rather than helped solve the problem.

For the past 15 years, I have been actively advocating dally iron supplementation for all toddlers. Our office routine has been to order a dally iron-fortified vitamin containing 10 mg of iron at the time the baby is switched from breast milk or iron-fortified formula to regular milk. This approach eliminates the need to screen for ID (we do test for anemia with a simple hemoglobin).

This approach to the prevention of ID is easy, effective, and safe. We have never had a problem with iron overdose. If a toddler drank an entire bottle of liquid Poly-Vi-Sol with iron, the iron level would not reach the toxic level.

In 2007, our local AAP Committee on Nutrition, New York Chapter 2 officially recommended the routine use of an iron-fortified vitamin for all children when placed on regular milk. Of interest is that a survey sent out to the membership shortly after the initial mailing showed that 86% of the pediatricians who responded agreed with the recommendation.

It is my sincere hope that groups such as the AAP Committee on Nutrition will revise their recommendations to include routine iron supplementation for at least the high-risk toddlers, and better yet for all toddlers when placed on regular milk.


DR. EDEN is chairperson of the Committee on Nutrition for AAP New York Chapter 2 and clinical professor of pediatrics at Weill Medical College of Cornell University in New York. He said he had no conflicts of interest regarding this issue.
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Title Annotation:COMMENTARY
Author:Eden, Alvin
Publication:Family Practice News
Geographic Code:1USA
Date:Dec 1, 2010
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