• U.S. Preventive Services Task Force (USPSTF). Screening for iron deficiency anemia - including iron supplementation for children and pregnant women. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2006. 12 p. [12 references]

This is the current release of the guideline.

It updates a previously published guideline summary: U.S. Preventive Services Task Force. Guide to clinical preventive services. 2nd ed. Baltimore (MD): Williams & Wilkins; 1996. Chapter 22, Screening for iron deficiency anemia--including iron prophylaxis. p. 231-46.

Note from the U.S. Preventive Services Task Force (USPSTF): The USPSTF is redesigning its recommendation statement in response to feedback from primary care clinicians. The USPSTF plans to release, later in 2006, a new, updated recommendation statement that is easier to read and incorporates advances in USPSTF methodology. The recommendation statement below is an interim version that combines existing language and elements with a new format. Although the definitions of grades remain the same, other elements have been revised.

The USPSTF grades its recommendations (A, B, C, D, or I) and the quality of the overall evidence for a service (good, fair, poor). The definitions of these grades can be found at the end of the "Major Recommendations" field.

Summary of Screening Recommendations

Screening Children and Pregnant Women for Iron Deficiency Anemia

1. The USPSTF concludes that evidence is insufficient to recommend for or against routine screening for iron deficiency anemia in asymptomatic children aged 6 to 12 months. I recommendation
2. The USPSTF recommends routine screening for iron deficiency anemia in asymptomatic pregnant women. B recommendation

The USPSTF was unable to determine the balance between the benefits and harms of routine screening for iron deficiency anemia in asymptomatic children aged 6 to 12 months. The USPSTF concludes that the benefits of routine screening for iron deficiency anemia in asymptomatic pregnant women outweigh the potential harms.

Summary of Supplementation Recommendations

Iron Supplementation for Children and Pregnant Women

1. The USPSTF recommends routine iron supplementation for asymptomatic children aged 6 to 12 months who are at increased risk for iron deficiency anemia (see Clinical Considerations below for a discussion of increased risk). B recommendation
2. The USPSTF concludes that evidence is insufficient to recommend for or against routine iron supplementation for asymptomatic children aged 6 to 12 months who are at average risk for iron deficiency anemia. I recommendation
3. The USPSTF concludes that evidence is insufficient to recommend for or against routine iron supplementation for non-anemic pregnant women. I recommendation

The USPSTF concludes that the moderate benefits of iron supplementation in asymptomatic children aged 6 to 12 months who are at increased risk for iron deficiency anemia outweigh the potential harms. The USPSTF was unable to determine the balance between the benefits and harms of iron supplementation in children aged 6 to 12 months who are at average risk for iron deficiency anemia, and of iron supplementation in non-anemic pregnant women.

Clinical Considerations

• These USPSTF recommendations address screening for iron deficiency anemia and iron supplementation in children aged 6 to 12 months who are at increased risk and average risk, in asymptomatic pregnant women, and in non-anemic pregnant women. Infants younger than 6 months of age, older children, non-pregnant women, and men are not addressed.
• Iron deficiency anemia can be defined as iron deficiency (abnormal values for serum ferritin, transferrin saturation, and free erythrocyte protoporphyrin) with a low hemoglobin or hematocrit value. Iron deficiency is much more common than iron deficiency anemia and is part of a continuum that ranges from iron depletion to iron deficiency anemia. Many of the negative health outcomes of iron deficiency are associated with its extreme manifestation, iron deficiency anemia. Iron deficiency has also been associated with negative neurodevelopmental outcomes in children.
• Other causes of anemia vary by population and include other nutritional deficiencies, abnormal hemoglobin (e.g., thalassemia), enzyme defects, and anemia associated with acute and chronic infections.
• In the U.S., race, income, education, and other socioeconomic factors are associated with iron deficiency and iron deficiency anemia. Individuals considered to be at high risk for iron deficiency include adult females, recent immigrants and, among adolescent females, fad dieters, and those who are obese. Premature and low birth weight infants are also at increased risk for iron deficiency.
• Venous hemoglobin is more accurate than capillary hemoglobin for identifying anemia. Ferritin has the highest sensitivity and specificity for diagnosing iron deficiency in anemic patients.
• Iron deficiency anemia is usually treated with oral iron preparations. The likelihood that iron deficiency anemia identified by screening will respond to treatment is unclear because many families do not adhere to treatment and because the rate of spontaneous resolution is high. Ninety-seven percent (97%) of the infant formula sold in the U.S. is iron-fortified. Substantial reductions in the incidence of iron deficiency and iron deficiency anemia have been demonstrated in healthy infants fed iron-fortified formula or iron-fortified cereal, compared with infants fed cow's milk or unfortified formula.
• Iron supplements accounted for 30% of fatal pediatric pharmaceutical overdoses occurring between 1983 and 1990, and iron poisoning has been observed even in the context of controlled trials in which parents were instructed in the safe storage and use of iron products. A reduction in deaths of children due to iron overdose was observed when unit-dose packaging was required between 1998 and 2002; this requirement was overturned by the courts in 2003.

Definitions:

Strength of Recommendations

The USPSTF grades its recommendations according to one of five classifications (A, B, C, D, I) reflecting the strength of evidence and magnitude of net benefit (benefits minus harms):

A

The USPSTF strongly recommends that clinicians provide [the service] to eligible patients. The USPSTF found good evidence that [the service] improves important health outcomes and concludes that benefits substantially outweigh harms.

B

The USPSTF recommends that clinicians provide [this service] to eligible patients. The USPSTF found at least fair evidence that [the service] improves important health outcomes and concludes that benefits outweigh harms.

C

The USPSTF makes no recommendation for or against routine provision of [the service]. The USPSTF found at least fair evidence that [the service] can improve health outcomes but concludes that the balance of benefits and harms is too close to justify a general recommendation.

D

The USPSTF recommends against routinely providing [the service] to asymptomatic patients. The USPSTF found at least fair evidence that [the service] is ineffective or that harms outweigh benefits.

I

The USPSTF concludes that the evidence is insufficient to recommend for or against routinely providing [the service]. Evidence that the [service] is effective is lacking, of poor quality, or conflicting and the balance of benefits and harms cannot be determined.

Strength of Evidence

The USPSTF grades the quality of the overall evidence for a service on a 3-point scale (good, fair, poor):

Good

Evidence includes consistent results from well-designed, well-conducted studies in representative populations that directly assess effects on health outcomes.

Fair

Evidence is sufficient to determine effects on health outcomes, but the strength of the evidence is limited by the number, quality, or consistency of the individual studies, generalizability to routine practice, or indirect nature of the evidence on health outcomes.

Poor

Evidence is insufficient to assess the effects on health outcomes because of limited number or power of studies, important flaws in their design or conduct, gaps in the chain of evidence, or lack of information on important health outcomes.

None provided

The type of evidence supporting the recommendations is identified in the "Major Recommendations" field.

• U.S. Preventive Services Task Force (USPSTF). Screening for iron deficiency anemia - including iron supplementation for children and pregnant women. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2006. 12 p. [12 references]

Not applicable: The guideline was not adapted from another source.

1996 (revised 2006)

United States Preventive Services Task Force - Independent Expert Panel

The U.S. Preventive Services Task Force (USPSTF) is a federally-appointed panel of independent experts. Conclusions of the U.S. Preventive Services Task Force do not necessarily reflect policy of the U.S. Department of Health and Human Services (DHHS) or its agencies.

United States Government

U.S. Preventive Services Task Force (USPSTF)

The U.S. Preventive Services Task Force has an explicit policy concerning conflict of interest. All members and evidence-based practice center (EPC) staff disclose at each meeting if they have an important financial conflict for each topic being discussed. Task Force members and EPC staff with conflicts can participate in discussions about evidence, but members abstain from voting on recommendations about the topic in question.

From: Harris RP, Helfand M, Woolf SH, Lohr KN, Mulrow, CD, Teutsch SM, Atkins D. Current methods of the U.S. Preventive Services Task Force: a review of the process. Methods Work Group, Third U.S. Preventive Services Task Force. Am J Prev Med 2001 Apr;20(3S):21-35.

This is the current release of the guideline.

It updates a previously published guideline summary: U.S. Preventive Services Task Force. Guide to clinical preventive services. 2nd ed. Baltimore (MD): Williams & Wilkins; 1996. Chapter 22, Screening for iron deficiency anemia--including iron prophylaxis. p. 231-46.

This summary was completed by ECRI on June 30, 1998. The information was verified by the guideline developer on December 1, 1998. This summary was updated by ECRI on May 8, 2006. The updated information was verified by the guideline developer on May 17, 2006.