What are the guidelines for pediatric anemia screening and treatment?

Pediatric Anemia Screening Guidelines

Universal screening for anemia is recommended for high-risk populations of infants and preschool children between ages 9-12 months, 6 months later, and annually from ages 2-5 years, while selective screening based on risk factors is appropriate for low-risk populations. 1, 2

Screening Recommendations

High-Risk Populations

• Screen all children for anemia:
  • Between 9-12 months of age
  • 6 months later (15-18 months)
  • Annually from ages 2-5 years

Low-Risk Populations

• Screen only children with the following risk factors:
  • Preterm or low-birthweight infants
  • Infants fed non-iron-fortified formula for >2 months
  • Infants introduced to cow's milk before 12 months
  • Breastfed infants with inadequate iron from complementary foods after 6 months
  • Children consuming >24 oz (720 mL) of cow's milk daily
  • Children with special healthcare needs (medications interfering with iron absorption, chronic infection, inflammatory disorders, restricted diets, or extensive blood loss)

Special Considerations

• Consider earlier screening (before 6 months) for preterm and low-birthweight infants not receiving iron-fortified formula 1
• For school-age children (5-12 years) and adolescent boys: screen only those with history of iron-deficiency anemia, special healthcare needs, or low iron intake 1

Diagnostic Approach

1. Initial screening with hemoglobin (Hb) concentration or hematocrit (Hct)
2. Confirm positive screening results with repeat Hb/Hct test
3. If tests agree and child is not ill, presumptive diagnosis of iron-deficiency anemia can be made 1

Treatment Protocol

1. Initial Treatment:

   • Prescribe 3 mg/kg/day of elemental iron (preferably ferrous sulfate) to be administered between meals 1, 2
   • Provide dietary counseling to address underlying low iron intake

2. Follow-up:

   • Repeat anemia screening after 4 weeks of treatment
   • An increase in Hb ≥1 g/dL or Hct ≥3% confirms iron-deficiency anemia
   • If confirmed, continue iron treatment for 2 additional months (total 3 months)
   • Recheck Hb/Hct at end of treatment and approximately 6 months after successful treatment 1, 2

3. Non-response to Treatment:

   • If anemia doesn't respond after 4 weeks despite compliance and absence of illness:
   • Further evaluate with additional tests: MCV, RDW, and serum ferritin
   • Serum ferritin ≤15 μg/L confirms iron deficiency
   • Serum ferritin >15 μg/L suggests another cause of anemia 1, 2
   • Consider hemoglobinopathies, thalassemias, or other causes 3

Dietary Recommendations for Prevention

• Breastfed infants: Introduce iron-rich complementary foods at 6 months
• Formula-fed infants: Use iron-fortified formula
• Introduce iron-fortified cereals at 4-6 months
• Include vitamin C-rich foods with meals to enhance iron absorption
• Limit cow's milk to no more than 24 oz (720 mL) daily after 12 months of age
• Avoid introducing cow's milk before 12 months 1, 2

Common Pitfalls and Caveats

• Despite screening recommendations, studies show many children are not adequately screened during periods of highest risk 4
• Iron deficiency without anemia may still have developmental consequences but is not detected by hemoglobin screening alone 5
• The red cell distribution width (RDW) may help identify causes of anemia when used in screening 12-month-old infants 6
• Untreated iron deficiency anemia in childhood can lead to persistent developmental delays and behavioral alterations 2
• There is ongoing debate about universal vs. selective screening approaches, with some organizations (USPSTF, UK National Screening Committee) not recommending universal screening while others (AAP) do 7

Special Dosing for Different Age Groups

• School-age children (5-12 years): One 60-mg iron tablet daily
• Adolescent boys: Two 60-mg iron tablets daily
• Preventive supplementation for non-anemic 12-month-olds: 1 mg/kg/day
• Preterm or low-birthweight infants: 2-4 mg/kg/day from 1 month until 12 months of age 1, 2