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Iron Deficiency Anemia: Recommended Guidelines for the Prevention, Detection, and Management Among U.S. Children and Women of Childbearing Age (1993)
Institute of Medicine (IOM)

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Iron Deficiency Anemia:

Recommended Guidelines for the Prevention,
Detection, and Management Among U.S.
Children and Women of Childbearing Age

Committee on the Prevention, Detection, and
Management of Iron Deficiency Anemia Among
U.S. Children and Women of Childbearing Age

Food and Nutrition Board
Institute of Medicine

Robert Earl and Catherine E. Woteki, Editors

NATIONAL ACADEMY PRESS
Washington, D.C.
1993

 Page
I
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--> Iron Deficiency Anemia: Recommended Guidelines for the Prevention, Detection, and Management Among U.S. Children and Women of Childbearing Age Committee on the Prevention, Detection, and Management of Iron Deficiency Anemia Among U.S. Children and Women of Childbearing Age Food and Nutrition Board Institute of Medicine Robert Earl and Catherine E. Woteki, Editors NATIONAL ACADEMY PRESS Washington, D.C. 1993

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--> National Academy Press 2101 Constitution Avenue, N.W. Washington, D.C. 20418 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy's 1863 congressional charter responsibility to be an adviser to the federal government and its own initiative in identifying issues of medical care, research, and education. Dr. Kenneth I. Shine is president of the Institute of Medicine. This study was supported under contract no. 200-92-0574 from the Division of Nutrition, Centers for Disease Control and Prevention, Public Health Service, U.S. Department of Health and Human Services. Library of Congress Catalog Card No. 93-86771 International Standard Book Number 0-309-04987-3 Additional copies of this report are available from: National Academy Press 2101 Constitution Avenue, N.W. Box 285 Washington, DC 20055 Call 800-624-6242 or 202-334-3313 (in the Washington metropolitan area). B245 Copyright 1993 by the National Academy of Sciences. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The image adopted as a logotype by the Institute of Medicine is based on a relief carving from ancient Greece, now held by the Staatlichemuseen in Berlin.

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--> COMMITTEE ON THE PREVENTION, DETECTION, AND MANAGEMENT OF IRON DEFICIENCY ANEMIA AMONG U.S. CHILDREN AND WOMEN OF CHILDBEARING AGE DORIS H. CALLOWAY (Chair),* Department of Nutrition, University of California, Berkeley, California JOHN L. BEARD, Nutrition Department and Department of Biobehavioral Health, College of Health and Human Development, The Pennsylvania State University, University Park, Pennsylvania JAMES D. COOK, Division of Hematology, University of Kansas Medical Center, Kansas City, Kansas SAMUEL J. FOMON, Department of Pediatrics, University of Iowa Hospitals, Iowa City, Iowa JANET L. MITCHELL, Department of Obstetrics and Gynecology, Harlem Hospital Center, New York, New York DAVID RUSH, Epidemiology Program, USDA Human Nutrition Research Center on Aging at Tufts University, Boston, Massachusetts Consultants GEORGE H. BEATON, Department of Nutrition Science, University of Toronto, Toronto, Ontario, Canada PETER R. DALLMAN, Contract Writer, San Francisco, California *   Member, Institute of Medicine Staff CATHERINE E. WOTEKI, Project Director ROBERT EARL, Program Officer MARCIA S. LEWIS, Project Assistant MICHAEL K. HAYES, Editorial Consultant

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--> FOOD AND NUTRITION BOARD M.R.C. GREENWOOD (Chair),* Office of Graduate Studies, University of California, Davis, California EDWIN L. BIERMAN (Vice Chair),* Division of Metabolism, Endocrinology, and Nutrition, University of Washington, Seattle, Washington PERRY L. ADKISSON,† Department of Entomology, Texas A&M University, College Station, Texas LINDSAY ALLEN, Department of Nutrition, University of California, Davis, California DENNIS M. BIER, Pediatric Clinical Research Center, Washington University School of Medicine, St. Louis, Missouri HECTOR F. DeLUCA,† Department of Biochemistry, University of Wisconsin, Madison, Wisconsin MICHAEL P. DOYLE, Department of Food Science and Technology, Georgia Experiment Station, University of Georgia, Griffin, Georgia JOHANNA T. DWYER, Frances Stern Nutrition Center, New England Medical Center Hospital, Boston, Massachusetts JOHN W. ERDMAN, JR., Department of Food Science and Division of Nutritional Sciences, College of Agriculture, University of Illinois, Urbana, Illinois CUTBERTO GARZA, Division of Nutritional Sciences, Cornell University, Ithaca, New York K. MICHAEL HAMBIDGE, Department of Pediatrics, University of Colorado Medical Center, Denver, Colorado JANET C. KING, Department of Nutritional Sciences, University of California, Berkeley, California JOHN E. KINSELLA (deceased), School of Agriculture and Environmental Sciences, University of California, Davis, California LAURENCE N. KOLONEL, Cancer Center of Hawaii, University of Hawaii, Honolulu, Hawaii SANFORD A. MILLER, Graduate Studies and Biological Sciences, University of Texas Health Science Center, San Antonio, Texas ARTHUR H. RUBENSTEIN (IOM Council Liaison),* Department of Medicine, The University of Chicago, Chicago, Illinois ALFRED SOMMER,* School of Hygiene and Public Health, Johns Hopkins University, Baltimore, Maryland STEVE L. TAYLOR (ex officio), Department of Food Science and Technology, University of Nebraska, Lincoln, Nebraska VERNON R. YOUNG,† School of Science, Massachusetts Institute of Technology, Cambridge, Massachusetts *   Member, Institute of Medicine †   Member, National Academy of Sciences

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--> Staff CATHERINE E. WOTEKI, Director MARCIA S. LEWIS, Administrative Assistant SUSAN M. WYATT, Financial Associate

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--> Preface Over the last decade, several expert groups have addressed the issue of iron deficiency anemia in young children and women of childbearing age. Dietary allowances have been revised, diagnostic criteria for defining anemia have been promulgated, and preventive and therapeutic measures have been developed and, for the most part, implemented. So, why another examination of the issue? There are several reasons why a responsible agency would undertake such a reexamination. There are seemingly straightforward questions about the continued necessity for and effectiveness of existing programs. These questions are, however, complex and difficult to answer because the information base is not entirely secure. The answers to such problematic questions depend on a reasoned judgment as to the significance of new epidemiologic evidence and other scientific findings and on an ability to forecast trends. In the present instance account needs to be taken of, inter alia, trends in the consumption and composition of foods and changes in the nutritional environment more generally. It is to be expected that committee members will not always be in perfect accord in the absence of sufficient, solid information. Members' judgments are influenced by their different experiences and disciplinary backgrounds. The present committee resolved this problem by accepting an argument that in order to set aside the recommendations of other expert groups, the contravening evidence must be as strong as the evidence that led to the others' decisions. The guidelines developed by the present committee are substantially in accord with existing recommendations. The committee did note areas of uncertainty and urges that high priority be given to developing the information needed to improve decision making. Some points are noted in the text, and an indicative list of research topics is included in the report. The committee's work was assisted very greatly by the background documentation prepared by Dr. Peter Dallman in a consultative capacity; we

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--> acknowledge his major contribution and appreciate the willingness with which he undertook revision as issues arose. Dr. Dallman participated in all deliberations of the committee as a member de facto. Professor George Beaton was available for consultation only at our last meeting; his ability to pose important clarifying questions was, as always, greatly appreciated. The committee owes a special debt to two of its members—to Professor John L. Beard for providing background on iron-dependent pathologies and to Dr. David Rush for a new analysis of data from the U.S. Department of Agriculture's Special Supplemental Food Program for Women, Infants, and Children and for solicitation of additional views and references relating to iron supplementation during pregnancy. We wish particularly to thank Dr. Anne Looker and Dr. Christopher Sempos and their colleagues at the National Center for Health Statistics who prepared preliminary analyses of data from the third National Health and Nutrition Examination Survey and shared other, as yet unpublished, work. I wish personally to thank the committee members for their diligence and patience, and for the care and concern they showed for those whom the guidelines are intended to benefit. None of the committee's tasks could have been accomplished without the leadership of Dr. Catherine Woteki and the support of her staff, especially Mr. Robert Earl and Ms. Marcia Lewis. We are grateful for their unfailing courtesy and generosity and commend the high standards reflected in their professional contributions. DORIS HOWES CALLOWAY, CHAIR COMMITTEE ON THE PREVENTION, DETECTION, AND MANAGEMENT OF IRON DEFICIENCY ANEMIA AMONG U.S. CHILDREN AND WOMEN OF CHILDBEARING AGE

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--> Contents     The Committee's Charge and Approach   1     Major Issues   2     Defining Anemia   3     Prevalence of Anemia as a Public Health Problem   5     Implications of Research on Excess Iron Intake   7     Developing Screening and Intervention Guidelines   8     Intervention Strategies: Efficacy and Safety   9     Supplementation for Infants and Children   10     Supplementation for Women   10     Safety   11     Recommended Guidelines for Prevention, Detection, and Management of Iron Deficiency Anemia   11     Infants and Children   14     Nonpregnant Women of Childbearing Age   15     Pregnant Women   16     Comments and Caution About Cutoff Values for Laboratory Tests   18     Comments and Caution About Routine Use of Ferritin Values   18     Recommended Guidelines for Preventing and Treating Iron Deficiency Anemia in Infants and Children   20     Recommended Guidelines for Preventing and Treating Iron Deficiency Anemia in Nonpregnant Women of Childbearing Age   22     Recommended Guidelines for Preventing and Treating Iron Deficiency Anemia in Pregnant Women   24

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-->     Recommendations for Research   26     Efficacy of Routine Iron Supplementation During Pregnancy   26     Research Base for Public Policy   29     References   32     Appendixes         A Acknowledgments   39     B Iron Deficiency Anemia: A Synthesis of Current Scientific Knowledge and U.S. Recommendations for Prevention and Treatment Peter R. Dallman   41     C Iron-Dependent Pathologies, John L. Beard   99     D Dietary Iron: Trends in the Iron Content of Foods, Use of Supplemental Iron, and the Framework for Regulation of Iron in the Diet   113     E Committee and Staff Biographies   123

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