Screening for Iron Deficiency in Early Childhood Using Serum Ferritin in the Primary Care Setting

Abstract

on behalf of the TARGet Kids! Collaboration OBJECTIVES: The American Academy of Pediatrics recommends universal screening for anemia using hemoglobin at 12 months. However, hemoglobin lacks diagnostic accuracy for iron deficiency, and the optimal age for screening has not been determined. Our objective was to assess a screening strategy for iron deficiency using serum ferritin. METHODS: We conducted a cross-sectional study of children 1 to 3 years old attending a health supervision visit. We examined the relationship between child age and serum ferritin, age and hemoglobin, hemoglobin and serum ferritin, and the prevalence of elevated C-reactive protein (CRP). RESULTS: Restricted cubic spline analysis (n = 1735) revealed a nonlinear relationship between age and serum ferritin (P < .0001). A linear spline model revealed that from 12 to 15 months, for each 1-month increase in age, serum ferritin levels decreased by 9% (95% confidence interval [CI]: 5 to 13). From 15 to 24 months, the rate of change was nonsignificant. From 24 to 38 months, for each month increase in age, serum ferritin increased by 2% (95% CI: 1 to 2). For hemoglobin, from 12 to 24 months, the rate of change was nonsignificant. From 24 to 38 months, for each 1-month increase in age, hemoglobin increased by 20% (95% CI: 9 to 32). Compared with the serum ferritin cutoff of <12 μg/L, the hemoglobin cutoff of <110 g/L had a sensitivity of 25% (95% CI: 19 to 32) and a specificity of 89% (95% CI: 87 to 91). Elevated CRP ≥10 mg/L occurred in 3.3% (95% CI: 2.5 to 4.2). CONCLUSIONS: Screening for iron deficiency using serum ferritin at 15 or 18 months may be a promising strategy. For children at low risk for acute inflammation, concurrent measurement of CRP may not be necessary.

Sleeping without Prescription: Management of Sleep Disorders in Children with Autism with Non-Pharmacological Interventions and Over-the-Counter Treatments

“…During the first stages of iron deficiency, ferritin levels—reflecting the iron stores—drop faster, while hemoglobin remains normal. As a consequence, measuring serum ferritin is suggested to detect non-anemic iron deficiency, especially in children with ASD and sleep disorders [ 18 , 167 , 168 ], even if false increases in ferritin levels are possible because ferritin is an acute-phase reactant [ 169 ].…”

Maternal ethnicity and iron status in early childhood in Toronto, Canada: a cross-sectional study

“…All models were adjusted for all prespecified covariates regardless of statistical significance 27. Restricted cubic spline analysis was used to test for a non-linear relationship between age and serum ferritin and then confirmed by loess curves, selecting three knot points to correspond to the age at scheduled visits (15, 18 and 24 months) 28. Multiple imputation using the fully conditional specification method was used to handle missing data.…”

Iron deficiency screening for children at 18 months: a cost-utility analysis

“…We selected the 18-month visit, as our previous analysis showed that the serum ferritin level is lowest between 15 and 24 months and that the hemoglobin level does not change substantially between 12 and 24 months. 15 Finally, Shaker and colleagues 47 included the cost of use of additional health care services for children with untreated iron deficiency, whereas we did not.…”

“…The estimates used for our base case came from 2 published randomized controlled trials and a long-term observational study (Table 1). 6,12,15 Untreated iron deficiency in infancy is associated with poor neurodevelopmental and functional outcomes. 5,11,12,36 Lozoff and colleagues 6 reported that, at 10 years of age, compared to children with good iron status in infancy, children with chronic, severe iron deficiency in infancy had higher rates of grade repetition (26% v. 12%) and referral for special services (21% v. 7%).…”

“…The American Academy of Pediatrics recommends universal screening for anemia through mea-surement of hemoglobin at 12 months of age, but this approach has limitations, as the rapidly developing brain may be exposed to chronic iron deficiency by the time anemia is detected. 2,14 We recently assessed a strategy to screen for iron deficiency through measurement of serum ferritin at 18 months; 15 however, the cost of this strategy has not been assessed. 16 The purpose of the present study was to model the long-term cost-utility of a proposed iron deficiency screening program using measurement of serum ferritin in 18-monthold children during a scheduled health supervision visit in the general population and in a targeted high-risk population in Ontario.…”