Recommendations from others
The United States Preventive Services Task Force,9 American Academy of Family Physicians,10 and American Academy of Pediatrics11 recommend screening infants for iron-deficiency anemia but do not address appropriate follow-up for positive screens.
The Centers for Disease Control and Prevention (CDC) guidelines recommend performing a confirmatory hemoglobin and hematocrit after a positive anemia screening. If anemia is confirmed and the child is not ill, then treat with iron replacement (3 mg elemental iron/kg/daily) for 4 weeks followed by a repeat test. An increase in hemoglobin concentration ≥1 g/dL or in hematocrit ≥3% confirms the diagnosis of iron-deficiency anemia. If iron-deficiency anemia is confirmed, they recommend continuing iron therapy for 2 more months (3 months total treatment), and rechecking hemoglobin or hematocrit 6 months after successful treatment is completed. Nonresponders, despite compliance with the iron supplementation regimen and the absence of acute illness, should undergo further evaluation including mean corpuscular volume, RDW, and serum ferritin concentration.12
Clinical commentary
Treating anemia without testing for the cause is the approach of most FPs
Quadri Yasmeen, MD
Baylor College of Medicine, Houston, Tex
For infants 9 months to 1 year of age, there is no consensus regarding appropriate follow-up of positive screens for anemia. It is known that most of them have iron deficiency anemia and empiric treatment with iron supplements have been studied in several prospective trials.
It is also unclear which red cell indices should be tested for diagnosing the different types of anemia. One study found RDW testing alone could predict the cause of anemia. Based on my clinical experience with innercity Hispanic babies, CDC guidelines seem to include appropriate follow-up. A Cochrane review suggests the need for further randomized controlled trials with long-term follow-up. There is evidence that treating anemia without initial testing for the cause is the approach of choice of most physicians, and there is some evidence that further testing may delay or result in nontreatment of infants who would have benefited from iron therapy.