What are the recommendations for preschool screening and treatment of Iron Deficiency Anemia (IDA)?

Preschool Screening for Iron Deficiency Anemia

For preschool children (ages 2-5 years), screen annually only if they belong to high-risk populations (low-income families, WIC-eligible, migrants, refugees) or have specific risk factors including low-iron diet, excessive milk intake (>24 oz daily), poverty/food insecurity, or special healthcare needs. 1

Screening Strategy by Risk Level

High-Risk Populations (Universal Screening)

• Screen all children annually from ages 2 to 5 years if they are from low-income families, WIC-eligible, migrant populations, or recently arrived refugees 1
• Initial screening should have occurred at 9-12 months, with repeat at 15-18 months, before entering the annual preschool screening phase 1

Low-Risk Populations (Selective Screening)

• Screen only children with documented risk factors rather than universal screening 1
• Annual risk assessment at ages 2-5 years should identify children with:
  • Low-iron diet or limited food access due to poverty/neglect 1
  • Excessive cow's milk consumption (>24 oz daily) 1
  • Special healthcare needs (medications interfering with iron absorption, chronic infections, inflammatory disorders, restricted diets, or significant blood loss) 1

Specific Risk Factors Requiring Screening

Dietary red flags that mandate screening include:

• Milk consumption exceeding 24 oz daily, which remains a major contributor to severe IDA in toddlers 1, 2
• History of delayed introduction of iron-fortified foods 1
• Predominantly milk-based diet with inadequate iron-rich foods 1

Medical history concerns requiring screening:

• Previous diagnosis of iron deficiency or anemia 1
• Preterm birth or low birthweight 1
• Chronic conditions affecting iron absorption or utilization 1

Diagnostic Approach When Screening is Positive

Initial Confirmation

• Repeat hemoglobin (Hb) or hematocrit (Hct) to confirm positive screening before initiating treatment 1, 3
• If both tests agree and the child is not acutely ill, make a presumptive diagnosis of IDA and begin treatment 1

Treatment Protocol

• Prescribe 3 mg/kg per day of elemental iron administered between meals 1, 3, 4
• Provide dietary counseling addressing the underlying low iron intake 1, 3
• Limit milk to maximum 24 oz daily to prevent displacement of iron-rich foods 1, 4

Response Assessment at 4 Weeks

• Repeat Hb/Hct after 4 weeks of treatment 1, 3
• An increase of ≥1 g/dL in Hb or ≥3% in Hct confirms IDA diagnosis 1, 3, 4
• If confirmed, continue iron for 2 additional months, then recheck 1, 3
• Reassess approximately 6 months after successful treatment completion 1, 3

Non-Response Management

• If no response after 4 weeks despite compliance and absence of acute illness, obtain additional laboratory tests including MCV, RDW, and serum ferritin 1, 5
• Serum ferritin ≤15 μg/L confirms iron deficiency; >15 μg/L suggests alternative diagnosis 1, 3, 5
• Consider thalassemia carrier status in endemic populations, as this can confound IDA diagnosis 6

Critical Pitfalls to Avoid

Screening errors:

• Using hemoglobin alone misses all cases of iron deficiency without anemia, which may still cause developmental effects 7, 8
• In populations with high thalassemia prevalence, MCV and Mentzer index (MCV/RBC <13) should be incorporated to distinguish thalassemia carriers from IDA 6
• Macrocytosis (present in 32% of children with Down syndrome) can mask IDA; use RDW combined with ferritin for optimal detection in this population 7

Treatment failures:

• Inadequate treatment duration (must continue 2 months after Hb normalization to replenish stores) 3, 4
• Not addressing excessive milk consumption, which strongly correlates with severe IDA in toddlers 2
• Assuming compliance without verification—low follow-up rates (37-42% never return within 6 months) are common in high-risk populations 9
• Spontaneous resolution occurs in 68% of untreated cases, making therapeutic trials unreliable for diagnosis without proper follow-up 9

Dietary counseling must emphasize:

• Maximum 24 oz daily of cow's milk, goat's milk, or soy milk 1, 4
• Iron-fortified cereals (two or more servings daily) 1, 4
• Vitamin C-rich foods with meals to enhance iron absorption 1, 4
• Introduction of iron-rich meats and foods 1, 4