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 1987unavailable 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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Pediatrics
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Has Routine Screening of Infants for Anemia Become Obsolete in the United States?
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