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Has Routine Screening of Infants for Anemia Become Obsolete in the United States?

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PEDIATRICS (ISSN 0031 4005). Copyright © 1987 by the American Academy of Pediatrics.

PEDIATRICS Vol. 80 No. 3 September 1 987 439

COMMENTARIES

Opinions expressed inthese commentaries are those of the authors and not necessarily those of the American Academy of Pediatrics or its Committees.

Has Routine

Screening

of

Infants

for Anemia

Become

Obsolete

in the United

States?

Iron deficiency anemia was common and often

severe as recently as 15 years ago in the United

States.1 During that period, it had become a

well-established routine to evaluate all term infants for

anemia at about 1 year of age2; screening at the

preschool checkup and in adolescence also became widespread.

Declining

Prevalence

of Iron Deficiency

Anemia

During the past decade, iron deficiency anemia

has become less and less common.1’3 The first

strong evidence of a relatively low nationwide

prey-alence of anemia was provided by the second

Na-tional Health and Nutrition Examination Survey

(NHANES II) conducted between 1976 and 1980.

In that large, representative sampling of the US

population, only about 6% of infants between 1 and

2 years of age and 6% of adolescent girls between

15 and 17 years of age were anemic.4 Pockets of

greater prevalence still existed, because infants

liv-ing below the poverty level were three times more

likely to be iron deficient than those who were

economically better off.5 These percentages were

several times lower than in earlier reports from the

United States6’7 and estimates from developing

countries.8

A recent report from the Centers for Disease

Control makes it possible to follow the decline in

prevalence of anemia on a year to year basis during

the past decade. The analysis included hemoglobin

and hematocrit measurements from almost a half

million children primarily of low socioeconomic groups, performed between 1975 to 1985. In this nutritionally vulnerable population, the prevalence

of anemia between 1 and 5 years of age declined

steadily from 7.8% in 1975 to 2.9% in 1985.

Al-though the trend is unmistakable, the absolute

per-centages are misleadingly low because of the use of

somewhat lower than customary cutoff values. The

same trend using conventional cutoff values was

seen in a middle-class population at a private

pe-diatric clinic in Minneapolis.10 The overall rate of

anemia between the ages of 6 months and 6 years

decreased from 6.2% in the early 1970s to 2.7%

between 1982 and 1986 (and to 2.8% among 9- to

23-month-old infants).

The low rates of anemia in recent years are even more impressive when it is realized that the

labo-ratory definition of anemia (a value of less than the 95% range for healthy individuals of the same age

and sex) predicts that 2.5% of normal children will

be anemic (2.5% of values are expected to be less

than and 2.5% more than the 95% “normal” range).

Of those few remaining infants whose hemoglobin

values are found to be abnormal, a large proportion

has mild anemia as a spontaneously reversible

se-quel to common acute infections.’12 Those

increas-ingly infrequent cases of iron deficiency anemia

that are identified are usually mild, unless there

has been pathologic blood loss. The anemia is rarely

associated with clinical manifestations, and

diver-sification of the diet gradually reverses the

condi-tion in most instances, as is evident from the rarity

of anemia (less than 4%) between 3 years of age

and adolescence. These considerations make it

rea-sonable to question the need in the United States

for routine measurements of hemoglobin or

hema-tocrit in all infants.

Selective

Screening

for Anemia

Although many physicians continue to screen all

infants for anemia, it appears that an increasing

number are abandoning the procedure entirely.

More attractive than either of these extremes is the

use of selective screening on the basis of a history to identify the risk factors that warrant a blood test for anemia. These risk factors still crop up with surprising regularity if nutritional counseling is

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440

PEDIATRICS

Vol. 80 No. 3 September 1987

unavailable or is ignored. The inappropriately early

initiation of regular cow’s milk remains relatively

common.’3 The infants who should be tested are

those in one or more of the following categories: (1)

low socioeconomic background, (2) regular cow’s

milk started before 6 months of age, (3) use of

formula not fortified with iron, and (4) low birth

weight.

Decreasing

the Quantity

but Improving

the

Quality of

Laboratory

Tests

As fewer infants in private practice settings

re-quire blood sampling, it becomes practical to put a

higher priority on the accuracy of the laboratory

test. The greater reproducibility of results from

venipuncture blood clearly outweighs the increased

convenience of skin puncture sampling14 when only

a small percentage of infants are tested. In addition,

it is worth considering the advantages of the

hemo-globin analysis over the hematocrit. Capillary

he-matocrit values tend to be misleadingly high and

sometimes yield false-negative results compared

with hemoglobin, possibly because the increasing

stiffness of the RBCs makes them less compressible when centrifuged.’5

Routine screening of infants for anemia is

prob-ably still justified in clinics serving low

socioeco-nomic groups. Widespread screening and greater

efforts at prevention also remain important in the

majority of countries because iron deficiency

ane-mia in infants is still common throughout most of

the world.8 Skin puncture blood sampling will be

justified in many such settings because of

limita-tions in time and personnel. In all health care

settings, laboratory testing for anemia is best done

when there has been no recent fever or infection,”

for practical purposes, when the infant has been

entirely well during the previous 2 or 3 weeks. In

the event that the infant is found to be anemic, it

is important to keep rarer conditions in mind,

es-pecially if the history and severity of anemia are

not typical of nutritional iron deficiency or inflam-matory illness.

Maintain

Nutrition

Counseling

Maintaining our enthusiasm for nutrition

coun-seling is particularly important under the present

circumstances of improved infant feeding.’6 It is

more difficult to remember anemia as a potential

problem if it is rarely seen and if it competes with

many other issues at a health maintenance visit.

The success with which iron deficiency anemia is

being prevented should not allow the problem to be

forgotten, because it will certainly recur if there is

a relaxation of effort. This success can be attributed

largely to improved infant-feeding practices, a trend

that was probably accelerated among the poor by

the availability of the WIC program3; an additional

factor is the improvement in the bioavailability of

iron used to fortify foods.’7 Fortunately, the

nutri-tional guidelines that are important in preventing

iron deficiency represent equally good advice for

the overall nutrition of the infant. The

recommen-dations that deserve greatest emphasis have

re-cently been summarized’8 and include (1)

prolon-gation of breast-feeding to 6 months of age or more

if possible, (2) use of iron-fortified infant formula

after weaning from breast milk and in infants who

are not breast-fed, (3) delay in starting regular

cow’s milk until 9 to 12 months of age, (4) use of

infant cereals fortified with iron or iron and

ascor-bic acid as one of the solid foods introduced after

about 4 to 6 months of age, (5) combination of

iron-rich and ascorbic acid-rich foods when meals of

solid foods are given, eg., iron-fortified infant

cer-eals and ascorbic acid-containing fruit juice, (6)

supplemental iron for preterm infants at a dosage

of 2 to 3 mg/kg/d starting at about 1 month of age.

The extent to which these and similar guidelines

continue to be incorporated into routine well-baby

care will largely determine how successfully we can maintain and further improve the present encour-aging results. Although iron deficiency anemia is not life threatening, the associated impairments in

muscle function, behavior, and the immune

response’9 justify continued efforts toward

preven-tion.

ACKNOWLEDGMENT

This work was supported by grant AM13897 from the

National Institutes of Health.

REFERENCES

PETER R. DALLMAN, MD

Department of Pediatrics University of California

San Francisco Medical Center

San Francisco

1. Vazquez-Seoane P, Windom R, Pearson HA: Disappearance of iron deficiency anemia in a high risk infant population given supplemental iron. N EnglJ Med 1985;313:1239-1240 2. American Academy of Pediatrics, Committee on Standards

of Child Health Care: Standards of Child Health Care, ed 2. Evanston, IL, American Academy of Pediatrics, 1972 3. Miller V, Swaney 5, Deinard AS: Impact of the WIC

pro-gram on the iron status of infants. Pediatrics 1985;75:100-105

4. Da!lman PR, Yip R, Johnson C: Prevalence and causes of anemia in the United States, 1976-1980. Am J Clin Nutr

1984;39:437-445

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PEDIATRICS (ISSN 0031 4005). Copyright © 1987 by the American Academy of Pediatrics.

COMMENTARIES

441

5. Expert Scientific Working Group: Assessment of the Iron

Nutrition Status of the U.S. Population Based on Data Collected in the Second National Health and Nutrition Ex-amination Survey, 1976-1980, Life Sciences Research Of-fice. Bethesda, MD, Federation of American Societies for Experimental Biology, 1984

6. Ten-State Nutrition Survey 1968-70: IV. Biochemical, US Department of Health, Education, and Welfare publication No. (HSM) 72-8132. Atlanta, Centers for Disease Control,

1972

7. Committee on Iron Deficiency: Iron deficiency in the United States. JAMA 1968;203:407-412

8. Florentino RF, Guirriec RM: Prevalence of nutritional ane-mia in infancy and childhood with emphasis on developing countries, in Stekel A (ed): Iron Nutrition in Infancy and Childhood. New York, Raven Press, 1984, pp 61-72 9. The Centers for Disease Control: Declining anemia

preva-lence among children enrolled in public nutrition and health programs, selected states, CDC Pediatric Nutrition Surveil-lance System, 1975-85. MMWR 1986;35:565-566

10. Yip R, Walsh KM, Goldfarb MG, et al: Declining childhood anemia prevalence in a middle-class setting: A pediatric success story? Pediatrics 1987;80:330-334

1 1. Reeves JD, Yip R, Kiley V, et al: Iron deficiency in infants: The influence of antecedent infection. J Pediatr

1984;105:874-879

12. Jansson LT, Kling 5, Dallman PR: Anemia in children with acute infections seen in a primary care pediatric outpatient clinic. Pediatr Infec Dis 1986;5:424-427

13. Sadowitz DP, Oski FA: Iron status and infant feeding prac-tices in an urban ambulatory center. Pediatrics 1983;72:33-36

14. Thomas WJ, Collins TM: Comparison ofvenipuncture blood counts with microcapillary measurements in screening for anemia in one-year-old infants. J Pediatr 1982;101:32-35

15. Yip R, Mohandas N, Clark MR, et a!: Red cell membrane stiffness in iron deficiency. BloOd 1983;62:99-106

16. Martinez GA, Krieger FW: 1984 Milk-feeding patterns in the United States. Pediatrics 1985;76:1004-1008

17. Rees J, Monsen E, Merrill J: Iron fortification of infant foods. Clin Pediatr 1985;24:707-710

18. American Academy of Pediatrics, Committee on Nutrition: Pediatric Nutrition Handbook. Elk Grove Village, IL, Amer-ican Academy of Pediatrics, 1985, pp 212-220

19. Dailman PR: Biochemical basis for manifestations of iron deficiency. Annu Rev Nutr 1986;6:13-40

Child

Abuse:

The Conflict

of

Underdetection

and

Overreporting

In 1946, Caffey’ reported the association of

mul-tiple bone fractures and subdural hematomas in

children and set the stage for the identification of

what subsequently became known as the battered

child syndrome. For the next 15 years, radiologists

involved in the care of children added support to

his observations and demonstrated that the lesions

he described had a specificity that indicated

physi-cal trauma when a history of injury was lacking or

even denied. These reports met with little response

until Kempe and associates2 indicated, in a

sym-posium at a meeting of the American Academy of

Pediatrics in October 1961, the serious nature of

the observations in relation to pediatric morbidity

and mortality. The title for the symposium was

“The Battered Child”, a term coined by Kempe for

its shock value, and the substance of the

presenta-tion appeared in June 1962 under the same title.

Kempe’s assessment of the effect of the term he

chose was immediately confirmed by numerous

ar-tides in newspapers and magazines including a

rapidly increasing number of professional

publica-tions. Equally responsive was the action of the

Children’s Bureau in January 1962 when it

sup-ported a meeting of medical, paramedical, and legal

consultants to address the problem of child abuse

and how to contain it. Impressed by results reported

by participants from California where mandatory

reporting by physicians and hospitals was already

in place, the group suggested that similar action in

other states could indicate the magnitude of the

problem as well as play a role in its control. To

accomplish this, it was further suggested that the

Children’s Bureau might support the development

of a “model law” that other states could use as a

basis for their individual approach to the issue. A

second meeting was undertaken to which additional

members of the legal profession were invited, and

using this group’s conclusions as a basis, the

Chil-then’s Bureau provided principles and suggested

language for the states to use in the generation of

their own legislation.3 Physicians and hospitals or

similar institutions were to be required to report to

an appropriate police authority the occurrence of

physical injuries to a child when there was

reason-able cause to suspect that they had been inflicted

by other than accidental means. Anyone

participat-ing in good faith in making a report was to have

immunity from legal liability as a consequence of

reporting, and knowing and willful failure to report

was subject to legal penalty. The principles stated

that the proposed legislation was not intended to

prevent or discourage voluntary reporting by others

than those mandated to report.

Within a few years, all of the states had a child

abuse law enacted that conformed more or less

closely to the “model law.” Further legislation in

the form of the federal Child Abuse Prevention and

Treatment Act of 1974 required states to expand

laws on reporting child abuse to all forms of

ma!-treatment, including neglect and sexual abuse, and

provided federal grants to states meeting the

ex-panded standards. Child protection services were

strengthened and child abuse discovery became a

more important function of social service agencies.

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1987;80;439

Pediatrics

PETER R. DALLMAN

Has Routine Screening of Infants for Anemia Become Obsolete in the United States?

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1987;80;439

Pediatrics

PETER R. DALLMAN

Has Routine Screening of Infants for Anemia Become Obsolete in the United States?

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American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 1987 by the

been published continuously since 1948. Pediatrics is owned, published, and trademarked by the

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