The Centers for Disease Control and Prevention (CDC), in collaboration with experts on iron deficiency, has developed recommendations for the prevention, detection and treatment of iron deficiency. The recommendations, published in the April 3, 1998, issue of Morbidity and Mortality Weekly Report, include discussions on iron metabolism, manifestations of iron deficiency, the prevalence and risk of iron deficiency and tests for assessing iron status. The report also includes a discussion of the justifications for the recommendations.

According to the CDC, these recommendations differ in two major areas from the guidelines published by the U.S. Preventive Services Task Force. First, the Preventive Services Task Force recommends screening for anemia only among infants at high risk for anemia and among pregnant women. In contrast, the CDC recommends periodic screening for anemia among high-risk populations of infants and preschool children, among pregnant women and among women of childbearing age. Second, the Preventive Services Task Force recommendations state that evidence is insufficient to recommend for or against iron supplementation during pregnancy. The CDC, however, recommends universal iron supplementation to meet the iron requirements of pregnancy, similar to the guidelines issued by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists.

The following, excerpted from MMWR, summarizes the recommendations for prevention, detection and treatment of iron deficiency.

Prevention in Infants and Preschool Children

The recommendations for primary prevention in infants and preschool children are as follows:

• Encourage breast feeding of infants.

• Encourage exclusive breast feeding of infants (without supplementary liquid, formula or food) for four to six months after birth.

• When exclusive breast feeding is stopped, encourage use of an additional source of iron (approximately 1 mg per kg per day of iron), preferably from supplementary foods.

• For infants younger than 12 months of age who are not breast fed or who are partially breast fed, recommend only iron-fortified formula as a substitute for breast milk.

• For breast-fed infants who by age six months receive insufficient iron (i.e., less than 1 mg per kg per day) from supplementary foods, suggest 1 mg per kg per day of iron drops.

• Encourage use of only breast milk or iron-fortified infant formula for any milk-based part of the diet (e.g., in infant cereal) and discourage use of milk low in iron (e.g., cow's milk, goat's milk and soy milk) until age 12 months.

• Suggest that children aged one to five years consume no more than 24 oz of cow's milk, goat's milk and soy milk each day.

• At age four to six months or when the extrusion reflex disappears, recommend that infants be introduced to plain, iron-fortified infant cereal. Two or more servings per day of iron-fortified infant cereal can meet an infant's requirements for iron at this age.

• By approximately six months of age, encourage one feeding per day of foods rich in vitamin C (e.g., fruits, vegetables and juice) to improve iron absorption, preferably with meals.

• Suggest introducing plain, pureed meats after age six months or when the infant is developmentally ready to consume such food.

The recommendations for secondary prevention in infants and preschool children are as follows:

• In populations of infants and preschool children at high risk for iron deficiency anemia (e.g., children from low-income families, children eligible for the Special Supplemental Nutrition Program for Women, Infants and Children, migrant children and recently arrived refugees), screen all children for anemia between the ages of nine and 12 months, six months later, and then annually from ages two to five years.

• In populations of infants and preschool children not at high risk for iron deficiency anemia, screen only those children who have known risk factors.

• Consider anemia screening before age six months for preterm infants and low-birth-weight infants who are not fed iron-fortified formula.

• Annually evaluate children two to five years of age for risk factors of iron deficiency anemia (e.g., a low-iron diet, limited access to food because of poverty or neglect, and special health care needs). Screen these children if they have any of the risk factors.

• At ages nine to 12 months and then six months later, assess infants and young children for risk factors for anemia. Screen the following children: preterm and low-birth-weight infants; infants fed a diet of non–iron-fortified infant formula for more than two months; infants introduced to cow's milk before age 12 months; breast-fed infants who do not consume a diet adequate in iron after age six months; children who consume more than 24 oz of cow's milk daily; and children who have special health care needs.

Diagnosis and Treatment in Infants and Preschool Children

• Check a positive anemia screening result by obtaining a repeat hemoglobin concentration or hematocrit test. If the tests agree and the child is not ill, a presumptive diagnosis of iron deficiency anemia can be made and treatment begun.

• Treat presumptive iron deficiency anemia by prescribing 3 mg per kg per day of iron drops, to be administered between meals. Counsel parents or guardians about adequate diet to correct the underlying problem of low iron intake.

• Repeat anemia screening in four weeks. An increase in the hemoglobin concentration of 1 g per dL (10 g per L) or more, or an increase in the hematocrit of 3 percent (0.03) or more, confirms the diagnosis of iron deficiency anemia. If iron deficiency is confirmed, reinforce dietary counseling, continue iron treatment for two more months and then recheck hemoglobin concentration. Reassess hemoglobin or hematocrit approximately six months after successful treatment is completed.

• If after four weeks anemia does not respond to iron treatment despite compliance and the absence of acute illness, further evaluate the anemia by using other laboratory tests, including mean cell volume (MCV), red blood cell distribution width (RDW) and serum ferritin concentration.

Children Ages Five to 12 Years and Adolescent Boys

Only children and adolescent boys who have a history of iron deficiency anemia, special health care needs or low iron intake should be screened for anemia.

Treatment for iron deficiency anemia includes one 60-mg iron tablet each day for school-age children and two 60-mg iron tablets each day for adolescent boys. Counseling about dietary intake of iron should be carried out. Follow-up and laboratory evaluation are the same for this age group as they are for infants and preschool children.

Prevention in Adolescent Girls and Women of Childbearing Age

The recommendations for primary prevention in adolescent girls and women of childbearing age are as follows:

• Most adolescent girls and women do not require iron supplements, but encourage them to eat iron-rich foods and foods that enhance iron absorption.

• Women who have low-iron diets are at additional risk for iron deficiency anemia; guide these women in optimizing their dietary iron intake.

The recommendations for secondary prevention are as follows:

• Starting in adolescence, screen all nonpregnant women for anemia every five to 10 years throughout their child-bearing years during routine health examinations.

• Annually screen for anemia in women who have risk factors for iron deficiency (e.g., extensive menstrual or other blood loss, low iron intake, previous diagnosis of iron deficiency anemia).

Diagnosis and Treatment in Adolescent Girls and Women of Childbearing Age

• Confirm a positive anemia screening result by performing a repeat hemoglobin concentration or hematocrit test. If the adolescent girl or woman is not ill, a presumptive diagnosis of iron deficiency anemia can be made and treatment begun.

• Treat adolescent girls and women who have anemia by prescribing 60 to 120 mg per day of iron. Counsel these patients about correcting iron deficiency through diet.

• Follow-up of adolescent girls and women of childbearing age is the same as that for infants and preschool children. For a confirmed case of iron deficiency anemia, continue iron treatment for two to three more months.

• If after four weeks the anemia does not respond to iron treatment despite compliance with iron supplementation and the absence of acute illness, further evaluate the anemia by using other laboratory tests, including MCV, RDW and serum ferritin concentration. In women of African, Mediterranean or Southeast Asia ancestry, mild anemia unresponsive to iron therapy may be due to thalassemia minor or sickle cell trait.

Prevention in Pregnancy

The recommendations for primary prevention in pregnant women are as follows:

• Start oral low-dose (30 mg per day) supplements of iron at the first prenatal visit.

• Encourage pregnant women to eat iron-rich foods and foods that enhance iron absorption.

• Pregnant women whose diets are low in iron are at additional risk for iron deficiency anemia; guide these women in optimizing their dietary iron intake.

The recommendation for secondary prevention in pregnant women is as follows:

• Screen for anemia at the first prenatal visit.

Diagnosis and Treatment in Pregnancy

• Confirm a positive anemia screening result by performing a repeat hemoglobin concentration or hematocrit test. If the pregnant woman is not ill, a presumptive diagnosis of iron deficiency anemia can be made and treatment begun.

• If the hemoglobin concentration is less than 9.0 g per dL (90 g per L) or the hematocrit is less than 27 percent (0.27), refer the patient to a physician familiar with anemia during pregnancy for further medical evaluation.

• Treat anemia by prescribing an oral dose of 60 to 120 mg per day of iron. Counsel about correcting iron deficiency anemia through diet.

• If after four weeks the anemia does not respond to iron treatment despite compliance and absence of illness, further evaluate the anemia by using other tests, including MCV, RDW and serum ferritin concentration.

• When hemoglobin concentration or hematocrit becomes normal for the stage of gestation, decrease the iron dosage to 30 mg per day.

• During the second and third trimesters, if the hemoglobin concentration is more than 15.0 g per dL (150 g per L) or the hematocrit is more than 45 percent (0.45), evaluate the woman for potential pregnancy complications related to poor blood volume expansion.