IRON DEFICIENCY ANEMIA IN CHILDREN (Screening and Preventive Medication)
Updated 8/08/11

Evidence Statement

Clinical Preventive Service Recommendations

Special Note: This note is to inform employers of slight variations in the preventive service recommendations for iron deficiency anemia among children. The U.S. Preventive Services Task Force (USPSTF) found insufficient evidence for screening but recommends routine iron supplementation for children at increased risk of iron deficiency. The Centers for Disease Control and Prevention (CDC) recommends routine screening for iron deficiency among high-risk children. In order to ensure transparency, this evidence statement provides all relevant recommended guidance, both evidence-based and expert opinion, on iron deficiency anemia screening and supplementation.

Iron Deficiency Anemia (Screening)

U.S. Preventive Services Task Force Recommendation
The U.S. Preventive Services Task Force (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.1

Evidence Rating: I (Insufficient Evidence)
The USPSTF concludes that evidence for iron deficiency anemia screening among asymptomatic children aged 6 to 12 months is lacking, of poor quality, or conflicting and the balance of benefits and harms cannot be determined.1

CDC Recommendation
CDC recommends universal screening for infants in populations at high-risk for iron deficiency and selective screening for infants who are not in these populations, but have iron deficiency risk factors.2

Evidence Rating: None specified

Iron Deficiency Anemia (Preventive Medication)

U.S. Preventive Services Task Force Recommendation
The U.S. Preventive Services Task Force (USPSTF) recommends routine iron supplementation for asymptomatic children aged 6 to 12 months who are at increased risk (defined in subsequent sections) for iron deficiency anemia.1

Evidence Rating: B (Recommended/At Least Fair Evidence)
The USPSTF found fair evidence that iron supplementation (e.g. iron-fortified formula, iron-fortified cereal, or iron supplements) may improve neurodevelopmental outcomes in children at increased risk for iron deficiency anemia. The USPSTF concludes that the moderate benefits of iron supplementation in asymptomatic children aged 6 to 12 months at increased risk for iron deficiency anemia outweigh the potential harms.1



The Value of Prevention

Economic Burden of Condition/Disease
The economic burden of iron deficiency anemia in infancy has not been determined.

Workplace Burden of Condition/Disease
The workplace burden of iron deficiency anemia in infancy has not been determined. The negative effects of IDA, including poor mental, motor and behavioral development, may require additional visits with a child’s physician, school or child care facility resulting in decreased parental work performance.

Economic Benefit of Preventive Intervention
No economic evaluations of iron deficiency anemia screening or supplementation in early childhood have been published. The benefits result from reducing the societal impact IDA’s negative effects, including decreased mental, motor or behavioral development among children. For example, a Costa Rican study found that the average IQ scores of 19-year old individuals who were chronically iron-deficient as infants were at least 9 points lower than those who had normal iron stores.13 Individuals with lower IQ scores have been shown to earn an estimated 1.1% less in lifetime earnings per IQ point. A 9 point reduction in IQ could therefore result in an average loss in earnings of 10%, or several thousand dollars per year per person.14

Estimated Cost of Preventive Intervention: Screening
The cost of screening for iron deficiency anemia varies by location, provider and tests performed. In 2007, the median private-sector cost of venipuncture to collect blood for screening was $6.17 Approximately 95% of paid claims for venipuncture fell between $3 and $15.17 The median private-sector cost of screening for iron deficiency using hemoglobin or hematocrit was $4, with approximately 95% of paid claims falling between $2 and $17.17.

Table 1: Cost of Iron Deficiency Anemia Screening Among Children
Median Cost of Venipuncture Median Cost of Hemoglobin / Hematocrit Screening Total Cost of Iron Deficiency Anemia Screening among Children
$6
(range $3 - $15)*		 $4
(range $2 - $17)* 		$10
(range $5 - $32)*

* Approximately 95% of paid claims fell within the stated range.15

Estimated Cost of Preventive Intervention: Preventive Medication
Supplemental iron drops are available by prescription or over-the-counter (OTC). The cost varies depending on the brand of supplement and duration of use. The average wholesale price for the most common prescription iron drops’ is detailed in Table 1.18

Table 2: Prescription Iron Drops AWP, 200816
Chemical Name Units Available Average Wholesale Price
Iron dextran 50 mg/ml $18.85
Iron sucrose 20 mg/ml $13.20


The cost of over-the-counter iron drops are relatively inexpensive; OTC iron supplements is an out-of-pocket expense for which flexible spending accounts (FSA) may be used.

The total out-of-pocket cost of iron-fortified cereals and infant formulas varies by brand, store location, and duration of use. Iron-fortified cereals and infant formulas may qualify as an eligible expense for an FSA, but may be subject to a note of medical necessity from a physician.

Estimated Cost of Treatment
Not Applicable

Cost-Effectiveness and/or Cost-Benefit Analysis of Preventive Intervention
A complete cost-effectiveness or cost-benefit analysis for iron deficiency anemia screening or iron supplementation has not been conducted.



Condition / Disease Specific Information

Epidemiology of Condition/Disease
Iron deficiency is a condition in which a lack of iron limits the body’s ability to deliver and use oxygen for several vital functions.3,4 Iron deficiency exists along a continuum, with iron depletion being the least severe and iron deficiency anemia (IDA) the most severe.4

In early life, iron supports the body’s rapid growth and proper development of the brain.5 In the face of insufficient iron stores, the increased iron demand often results in iron deficiency or IDA.

Iron deficiency anemia among infants has been associated with poor mental, motor and behavioral development, as well as delayed growth.6-7 The effects of chronic or severe iron deficiency can be irreversible and long lasting.6 Long term effects include impaired learning, behavioral problems and decreased scholastic achievement.8,9 Iron deficiency may also contribute to lead poisoning due to an iron-deficient body’s propensity to absorb heavy metals.9

The rate of iron deficiency anemia among young children is unknown. The 2006 Pediatric Nutrition Surveillance Report indicates 16.9% of children 6-11 months were anemic. However, the population was largely low-income minorities and further testing was not completed to identify the proportion of anemic cases caused by iron deficiency.10

Condition/Disease Risk Factors
In the U.S., certain demographic and socioeconomic are associated with iron deficiency anemia in children.1 The following increase an infant’s risk of iron deficiency anemia:
  • Prematurity;4
  • Low birth weight;4
  • Maternal diabetes, preeclampsia or smoking;4, 13
  • Low Socioeconomic Status;14
  • Black, Native American or Alaskan Native;14
  • Recent immigrants from developing countries1
  • Lack of iron-fortified foods at six months for breastfed infants;4
  • Lack of iron-fortified formulas for formula-fed infants;4 and
  • Consumption of cow’s milk before 12 months.4


Preventive Intervention Information

Preventive Intervention: Purpose of Screening
Screening for iron deficiency anemia is a means of secondary prevention; screening allows health care providers to identify those children who have iron deficiency anemia or its early indicators to ensure treatment (i.e. iron supplementation) can be initiated.4

Purpose of Preventive Medication
Supplementation of young children at risk for iron deficiency anemia helps prevent iron depletion during critical developmental milestones thereby avoiding long-term consequences. In multiple studies, children who were iron deficient in infancy had lower intelligence test scores, decreased cognitive functioning, and behavioral problems later in childhood as compared to children who were not iron deficient.17-20

Benefits and Risks of Intervention: Screening
Screening for iron deficiency anemia decreases the risk of developmental delays by identifying those children who are unable to maintain adequate iron levels through diet alone and would benefit from iron supplementation.

The potential risks of screening for iron deficiency anemia include the cost and time to complete the screening tests, potential anxiety and false-positives. However, the USPSTF did not identify any information on these risks.

Benefits and Risks of Intervention: Preventive Medication
Providing iron supplements to infants aged 6 to 12 months at increased risk is effective in preventing the depletion of iron stores and the onset of iron deficiency anemia. Thus, the irreversible delays in mental, motor or behavioral development associated with IDA may be avoided. Studies also suggest iron may also improve an infant’s height and weight.7

Excess iron is not easily excreted from the body and can cause a number of adverse health risks, ranging from gastrointestinal symptoms to unintentional overdose.7 Gastrointestinal symptoms are reversible and have no long-term effect. Unintentional overdose on iron supplements can be fatal,7 and is the leading cause of poisoning deaths among children. New evidence suggests that supplementation in iron-replete children may also impede growth and decrease intelligence (IQ).19,20

Initiation, Cessation, and Interval: Screening
Screening for iron deficiency anemia should be done at the discretion of the physician and based upon risk. High-risk children should be screened between ages 9 and 12 months and again six months later. High-risk children should also be screened annually between the ages of 2 to 5 years. For children not at high risk, assessment of risk factors should be done at similar ages. Subsequent screening should occur only for those children with identified risk factors (as identified above).2

Initiation, Cessation, and Interval: Preventive Medication
Supplemental iron drops, iron-fortified formula and iron-fortified cereals should be used as medically indicated. Iron supplementation is typically initiated between the ages of 4 to 6 months, when iron stores transferred from the mother can no longer support the infant’s needs.4

Clinicians should monitor hemoglobin concentrations four weeks after initiation of treatment and again in two months.4 Cessation of iron supplementation is based upon the results of follow-up testing and left to the discretion of the clinician.

Intervention Process: Screening
Screening for iron deficiency anemia is typically done by assessing venous hemoglobin or hematocrit concentrations. A low hemoglobin or hematocrit value indicates only anemia. Iron deficiency is then confirmed by utilizing more specific tests (e.g., serum ferritin) or assessing hemoglobin response to iron supplementation.7

Intervention Process: Preventive Medication
Infants at high-risk for iron deficiency anemia (infants with one or more risk factors)21 who are unable to reach recommended daily allowances with iron-fortified foods (cereal, formula) should be prescribed daily iron drops. Iron dosages vary depending on specific risk factors and infant age.
  • Premature and low birthweight infants should be prescribed 2-4 mg/kg body weight of iron drops daily beginning at one month.4
  • Term infants aged 6-12 months should consume 1mg/kg body weight of iron drops daily (approximately 11 mg iron/day25).4,21

Treatment Information
Not Applicable



Strength of Evidence for the Clinical Preventive Service

The level of evidence supporting the recommendations contained in this section is described below.

Evidence-Based Research:
U.S. Preventive Services Task Force (USPSTF)
Strength of Evidence: I (Insufficient Evidence)
  • The U.S. Preventive Services Task Force (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.1

Strength of Evidence: B (Recommended/At Least Fair Evidence)
  • The U.S. Preventive Services Task Force (USPSTF) recommends routine iron supplementation for asymptomatic children aged 6 to 12 months who are at increased risk for iron deficiency anemia.1
Recommended Guidance:
The Centers for Disease Control and Prevention (CDC)
Strength of Evidence: Not Specified
  • The Centers for Disease Control and Prevention (CDC) recommends screening for iron deficiency anemia in high-risk infants and high-risk preschool children.4
American Academy of Pediatrics
Strength of Evidence: Not Specified
  • The American Academy of Pediatricians (AAP) recommends screening for all infants between the ages of 9 to 12 months and then 6 months later; for children at high risk, screen once a year from ages 2 to 5 years. AAP recommends that preterm and low birth weight infants receive iron supplementation before 6 months of age.


Summary Plan Description

SPD Language

Covered Screening
All methods of screening for iron deficiency anemia in children are covered.
Initiation, Cessation and Interval
Infants and children between the ages of nine months and five years determined to be high-risk for iron deficiency anemia are eligible for iron deficiency screening.
Covered Preventive Medications**
  • Pediatric Vitamins with Iron
  • Prescription Strength Iron Supplements (Drops)
Initiation, Cessation and Interval
Prescription strength iron supplementation of any type is covered when used to prevent or treat iron deficiency anemia.

** Note: Iron-fortified formula and cereal are also recommended for supplementation, but may not be part of the covered benefit



CPT Codes

85013 Blood count; spun microhematocrit
85014 Blood count; hematocrit (Hct)
85018 Blood count; hemoglobin (Hgb)



Other Information and Resources

Business Group Resource(s)

CDC Resource



Author(s)

Sherrets D, Grosse S, Cusick S. Iron deficiency anemia among children: screening and preventive medication. Available at: http://www.businessgrouphealth.org/preventive/topics/ida_children.cfm



References

1. U.S. Preventive Services Task Force. Screening for Iron Deficiency Anemia -Including Iron Supplementation for Children and Pregnant Women. Recommendation Statement. Rockville, MD: Agency for Healthcare Research and Quality; May 2006. Available at: http://www.ahrq.gov/clinic/uspstf06/ironsc/ironscr.pdf. Accessed May 23, 2008.
2. Centers for Disease Control and Prevention. Iron Deficiency --- United States, 1999-2000. MMWR. 2002;51(40):897-899.
3. National Institutes of Health. MedlinePlus Medical Encyclopedia: Iron deficiency anemia. at: http://www.nlm.nih.gov/medlineplus/ency/article/000584.htm. Accessed May 23, 2008.
4. Centers for Disease Control and Prevention. Recommendations to prevent and control iron deficiency in the United States. MMWR.1998;47(RR-3):1-29.
5. Kolb B, Whishaw IQ. An introduction to brain and behavior. 1st ed. New York (NY): Worth Publishers; 2001.
6. Carter, RC et al. Iron Deficiency Anemia and Cognitive Function in Infancy. Pediatrics. August 1, 2010; 126: e427-e434.
7. Helfand M, Freeman M, Nygren P, Walker M. Screening for iron deficiency anemia in childhood and pregnancy: Update of 1996 USPSTF Review. Evidence Synthesis No. 43. Rockville, MD: Agency for Healthcare Research and Quality; April 2006. Available at: http://www.ahrq.gov/clinic/uspstfix.htm.
8.. Lozoff B. Early Iron Deficiency Has Brain and Behavior Effects Consistent with Dopaminergic Dysfunction. The Journal of Nutrition. April 1, 2011; 141(4): 7405-7456.
9..Wright, R et al. Association between iron deficiency and blood lead level in a longitudinal analysis of children followed in an urban primary care clinic. The Journal of Pediatrics. January 2003; 142(1): 9-14.
10.. Polhamus B, Dalenius K, Borland E, Smith B, Grummer-Strawn L. Pediatric Nutrition Surveillance 2006 Report. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention; 2007.
11. Raoa R, Georgieffab MK. Iron in fetal and neonatal nutrition. Semin Fetal Neonatal Med. 2007;12(1):54-63.
12. Killip S, Bennett J, Chambers M. Iron deficiency anemia. Am Fam Physician. 2007;75(5):671-678.
13. Lozoff B, Jimenez E, Smith JB. Double burden of iron deficiency in infancy and low socioeconomic status: a longitudinal analysis of cognitive test scores to age 19 years. Arch Pediatr Adolesc Med. 2006;160(11):1108-13.
14.. Grosse SD. How much is an IQ point worth? Implications for regulatory impact analyses. Association of Environmental and Resource Economists (AERE) Newsletter. 2007;27(2):17-21.
15. Thomson Reuters. 2007 MarketScan® Commercial Claims and Encounters Database. 2009.
16.Physicians' Desk Reference, Micromedex, PDR. Red book 2009: pharmacy's fundamental reference. Montvale: Physicians' Desk Reference Inc; 2009.
17. Algarin C, Peirano P, Garrido M, Pizarro F, Lozoff B. Iron Deficiency Anemia in Infancy: Long-Lasting Effects on Auditory and Visual System Functioning. Pediatr Res. 2003;53(2):217-223.
18.. Lozoff B, Jimenez E, Hagen J, Mollen E, Wolf AW. Poorer Behavioral and Developmental Outcome More Than 10 Years After Treatment for Iron Deficiency in Infancy. Pediatrics. 2000;105(4):e51.
19. Kerr ML, D. Neurodevelopmental delays associated with iron-fortified formulas for health infants. Medscape medical news. 2008. Available at: www.medscape.com/viewarticle/574363. Accessed July 18, 2008.
20. Kazal L. Prevention of Iron Deficiency in Infants and Toddlers. Am Fam Physician. 2002;66:1217-1224.
21 Institute of Medicine. Dietary reference intakes for vitamin A, vitamin K, arsenic, boron, chromium, copper, iodine, iron, manganese, molybdenum, nickel, silicon, vanadium, and zinc. Washington DC: National Academy Press; 2001.