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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)

Chapter: RECOMMENDED GUIDELINES FOR PREVENTION, DETECTION, AND MANAGEMENT OF IRON DEFICIENCY ANEMIA

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Suggested Citation:"RECOMMENDED GUIDELINES FOR PREVENTION, DETECTION, AND MANAGEMENT OF IRON DEFICIENCY ANEMIA." Institute of Medicine. 1993. Iron Deficiency Anemia: Recommended Guidelines for the Prevention, Detection, and Management Among U.S. Children and Women of Childbearing Age. Washington, DC: The National Academies Press. doi: 10.17226/2251.
×

mens is poor and is often worse among those who were initially anemic (Bonnar et al., 1969). Additionally, suspected poor compliance attributed to the side effects of supplemental iron has been disputed in studies in which only small differences in side effects were found among subjects taking therapeutic doses of iron (high doses of > 180 mg of iron per day) and those taking placebos (Hallberg et al., 1967; Sölvell, 1970).

On the other hand, the proportion of the adult population that uses self-supplementation with over-the-counter mineral or vitamin-mineral products has increased from about 20 percent in the 1970s (Block et al., 1988) to about 40 percent of adults at present (Bender et al., 1992). In 1986, one in four women in the 18- to 44-year-old age group reported use of a supplement (most supplements taken were multivitamin-mineral supplements that contain iron), with a median dosage equal to 100 percent of the Recommended Dietary Allowance (RDA) (Stewart et al., 1985; Moss et al., 1989). Self-supplementation was higher among white women than among black and Hispanic women. It is not known whether users take the supplements regularly or intermittently.

Safety

Great caution should be exercised in storing iron-containing supplements. The composition of iron supplements intended for use by other household members (primarily women) is reported to be the most common cause of pediatric poisoning deaths in the United States. A toxic dose of elemental iron is 30 mg/kg of body weight for infants and children, and doses as low as 60 mg/kg have proved fatal (CDC, 1993).

Recommended Guidelines For Prevention, Detection, And Management Of Iron Deficiency Anemia

The committee's background papers and discussions provided the basis for developing its recommended guidelines for the prevention, detection, and management of iron deficiency anemia (previously published guidelines for the prevention, detection, and management of iron deficiency anemia are presented in Table 2; see also Appendixes B, C, and D). The sections below present the committee's guidelines for screening and treating iron deficiency anemia among infants, children, and nonpregnant and pregnant women of childbearing age. For all populations, the committee prefers and recommends dietary sources of iron over supplemental sources when possible, because food has physiological factors that improve iron absorption and other factors beneficial to overall health (NRC, 1989). In this report, dietary sources of iron include meat; iron-fortified infant formula; iron-fortified infant cereals; and iron-forti-

Suggested Citation:"RECOMMENDED GUIDELINES FOR PREVENTION, DETECTION, AND MANAGEMENT OF IRON DEFICIENCY ANEMIA." Institute of Medicine. 1993. Iron Deficiency Anemia: Recommended Guidelines for the Prevention, Detection, and Management Among U.S. Children and Women of Childbearing Age. Washington, DC: The National Academies Press. doi: 10.17226/2251.
×

TABLE 2 Summary of Previously Published Guidelines to Prevent or Treat Iron Deficiency Anemia Among Infants, Children, and Nonpregnant and Pregnant Women of Childbearing Age

 

Population

 

Infants

Women of Childbearing Age

Source

Preterm

Term

Children

Adolescents

Nonpregnant

Pregnant

American Academy of Pediatricsa

2-3 mg/kg/day from ferrous sulfate drops (breastfed) Iron-fortified infant formula (nonbreastfed)

2-3 mg/kg/day from ferrous sulfate drops (breastfed; at age 4 to 6 mo.)b Iron-fortified infant formula (nonbreastfed)

Iron-fortified infant cereal (at age 4 to 6 mo.)

American College of Obstetricians and Gynecologists

Vitamin-mineral supplement (meeting RDA for pregnancy)

Canadian Paediatric Society

Supplemental iron for low-birth-weight infants (at age 8 wk-12 mo)

Iron-fortified infant formula (nonbreastfed) Iron-fortified infant cereal (breastfed)

Institute of Medicine

Well-balanced diet

30 mg/day for nonanemic 60-120 mg/day for anemic

Suggested Citation:"RECOMMENDED GUIDELINES FOR PREVENTION, DETECTION, AND MANAGEMENT OF IRON DEFICIENCY ANEMIA." Institute of Medicine. 1993. Iron Deficiency Anemia: Recommended Guidelines for the Prevention, Detection, and Management Among U.S. Children and Women of Childbearing Age. Washington, DC: The National Academies Press. doi: 10.17226/2251.
×

 

Population

 

Infants

Women of Childbearing Age

Source

Preterm

Term

Children

Adolescents

Nonpregnant

Pregnant

Life Sciences Research Office

60-180 mg of iron per day for mild anemiac 30 mg/day for continued follow-up treatment

Routine iron supplementation for all pregnant women

Recommended Dietary Allowances, 10th ed.d

2 mg of supplemental iron per kg/day or iron-fortified infant formula

1 mg/kg/day (at age 0-3 mo) (nonbreastfed) 10 mg/day (at age 6 mo-3 yr)

10 mg/day (at age 3-10 yr)

12 mg/day, males; 15 mg/day, females

15 mg/day

30 mg/day from food sources and supplements

U.S. Preventive Services Task Force

 

Screen and, if necessary, treat No dosage recommended

Counsel on iron intake

Screen, and, if necessary, treat No dosage recommendede

a Recommended levels for all infants and children.

b Maintenance of breast-feeding beyond 6 months of age has been shown to protect against iron deficiency anemia in full-term infants.

c Nonanemic women do not require supplemental iron.

d Except for preterm infants and pregnant women, the source of iron is from the diet.

e A pending revision to the task force's statement on prevention of iron deficiency anemia during pregnancy recommends against routine iron supplementation during pregnancy (see Wolf and Washington, in press.).

SOURCES: AAP, CON (1969, 1976, 1985, 1989, 1992, 1993), ACOG (1989), Canadian Paediatric Society (1991), IOM (1990a,b, 1992b), LSRO (1991), NRC (1989), U.S. Preventive Services Task Force (1989).

Suggested Citation:"RECOMMENDED GUIDELINES FOR PREVENTION, DETECTION, AND MANAGEMENT OF IRON DEFICIENCY ANEMIA." Institute of Medicine. 1993. Iron Deficiency Anemia: Recommended Guidelines for the Prevention, Detection, and Management Among U.S. Children and Women of Childbearing Age. Washington, DC: The National Academies Press. doi: 10.17226/2251.
×

fied, ready-to-eat cereals. However, for some specific populations, supplemental iron in addition to dietary sources is necessary.

Infants and Children

Although iron deficiency anemia appears to be continuing to decrease in prevalence among infants and children, there remain significant portions of the population at risk for developing iron deficiency anemia. For infants and children less than 6 years of age, anemia is defined as a hemoglobin concentration of less than 11.0 g/all or a hematocrit level of less than 33 percent. Blacks may normally have lower hemoglobin levels; this justifies the use of cutoff values of less than 10.7 g/dl or less than 32 percent, respectively (Johnson-Spear and Yip, in press). Screening should be delayed if there is an indication of infection or if there has been an infection within the past 2 weeks.

For preterm infants who are no longer receiving hospital-based care, the committee recommends, after screening for anemia at no later than 3 months of age, the provision of supplemental iron (as ferrous sulfate drops) at 2 mg/kg/day or iron-fortified formula at no later than 1 month of age and continuing through 12 months of age to prevent further diminution of low fetal iron stores. Infants fed iron-fortified infant formula do not need an additional source of iron. Preterm infants should be screened for anemia by determining their hemoglobin or hematocrit level.

For most breastfed term infants, the committee recommends that they receive a source of iron (iron-fortified infant cereal, meat, or supplemental iron at 1 mg/kg/day) beginning at 4 months of age. After weaning from the breast, supplemental iron should stop being delivered and dietary sources of iron and iron-fortified formula should be used until the child is 12 months of age.

For formula-fed infants, the committee recommends the use of an iron-fortified infant formula until the infant consumes solid food or until age 12 months. When starting solid foods for all infants, iron-fortified infant cereal or meat should be used. Dietary counseling and nutrition education should include recommendations about the use of ascorbic acid-rich foods and meat to enhance iron absorption.

Term infants who are breastfed or nonbreastfed infants who are not receiving iron-fortified infant formula should be screened for anemia at 9 months of age. For infants determined to be anemic, the infant should be placed on supplemental iron or iron-fortified formula. In the case of mild anemia in a formula-fed infant (hemoglobin level between 10 and 11 g/all, or hematocrit level between 30 and 33 percent), an iron-fortified infant formula without supplemental iron drops may be adequate. All anemic infants should be reevaluated after 4 weeks of treatment. If there is a response of greater than or equal to 1 g/dl in the hemoglobin level or greater than or equal to a rise of 3 units in the hematocrit level or a value within the normal range, iron should be continued for 2 more months and then the source of supplemental iron should be discon-

Suggested Citation:"RECOMMENDED GUIDELINES FOR PREVENTION, DETECTION, AND MANAGEMENT OF IRON DEFICIENCY ANEMIA." Institute of Medicine. 1993. Iron Deficiency Anemia: Recommended Guidelines for the Prevention, Detection, and Management Among U.S. Children and Women of Childbearing Age. Washington, DC: The National Academies Press. doi: 10.17226/2251.
×

tinued. If there is no response or a response of less than 1 g/dl in the hemoglobin level or less than 3 units in the hematocrit level, the clinician should check for compliance with supplemental iron or determine the serum ferritin concentration. A serum ferritin concentration of greater than 15 µg/liter suggests that the anemia is not due to iron deficiency.

Infants with moderate or severe anemia (hemoglobin of <10.0 g/dl or hematocrit of <30 percent [<9.7 g/dl or <29 percent, respectively, for blacks]) should be evaluated by a physician.

For young children 2 years of age and older, no routine screening is needed if the child was not found to be anemic during earlier screenings. Children at mid-youth (6-12 years) with other risk factors (e.g., poverty, abuse, or poor household conditions) may need to be rescreened. As with the committee's earlier discussion of the consequences of excess iron and in the absence of research that indicates that iron deficiency anemia is a problem in adolescent boys, the committee cannot recommend a routine screening during childhood and adolescence. For adolescent girls, clinicians should follow the committee's recommendations for nonpregnant women of childbearing age.

Nonpregnant Women of Childbearing Age

The committee believes that some subpopulations of nonpregnant women of childbearing age (those in poverty, recent immigrants, etc.) are at special risk of developing iron deficiency anemia. The committee recommends that all nonpregnant women of childbearing age be screened for anemia at least once between 15 and 25 years of age. If other biologic risk factors for anemia are present (i.e., high menstrual blood loss, frequent blood donation, high parity) or there is a previous diagnosis of iron deficiency anemia, more frequent screening is warranted (i.e., every 2-3 years).

The anemia screening should be done with blood obtained by venipuncture. If anemia was suspected on the basis of a skin puncture sample, anemia should be confirmed with a repeat screen with blood obtained by venipuncture. For nonsmoking women, the committee recommends the following cutoff values: hemoglobin, <12.0 g/dl; hematocrit, <36 percent; or serum ferritin concentration, <12 µg/liter. A serum ferritin concentration determination is recommended to confirm iron deficiency anemia. Note that cutoff hemoglobin values for blacks should be set at 0.8 g/all lower than the hemoglobin values given above. (See table of adjustments for smoking and altitude in the screening guidelines for nonpregnant women of childbearing age later in the report and in Appendix B.)

The recommended treatment approaches for iron deficiency anemia in nonpregnant women of childbearing age follow. If the concentration of hemoglobin is no more than 2 g/dl below the cutoff value for hemoglobin, the woman should be treated with a therapeutic dose of iron of about 60 mg twice a day (total daily dose of 120 mg of iron) and she should be provided with nutri-

Suggested Citation:"RECOMMENDED GUIDELINES FOR PREVENTION, DETECTION, AND MANAGEMENT OF IRON DEFICIENCY ANEMIA." Institute of Medicine. 1993. Iron Deficiency Anemia: Recommended Guidelines for the Prevention, Detection, and Management Among U.S. Children and Women of Childbearing Age. Washington, DC: The National Academies Press. doi: 10.17226/2251.
×

tion education (IOM, 1990b). The clinician should check for a response after 1 to 1.5 months. If there is no response (<l.0-g/dl increase in hemoglobin or <3-unit increase in hematocrit), despite what appears to be good compliance, the clinician should determine the serum ferritin concentration and consider other causes of anemia. A low hemoglobin or hematocrit level and a serum ferritin concentration of less than 20 µg/liter suggest iron deficiency anemia. In the presence of inflammation or infection, a low hemoglobin concentration or hematocrit level in conjunction with a serum ferritin concentration greater of than 15 µg/liter may also suggest iron deficiency anemia. If there has been a response resulting from supplemental iron, iron supplementation therapy should be continued until the hemoglobin concentration is 12.0 g/dl (see the table of adjustments for smoking and altitude in the screening guidelines for nonpregnant women of childbearing age later in the report), after which iron can be decreased to a maintenance level of about 30 mg of iron per day for 4 months and then discontinued.

Severe anemia is unusual in nonpregnant women of childbearing age and may not be due to iron deficiency. A complete medical history, including dietary history, a more thorough physical examination, and additional laboratory studies (i.e., complete blood count, reticulocyte count, and serum ferritin concentration), is indicated to determine the cause of anemia.

Alteration of diet may retard the development of iron deficiency anemia and avoid the need for supplemental iron in many nonpregnant women of childbearing age. Clinicians and other health care deliverers should emphasize dietary recommendations that encourage the consumption of ascorbic acid-rich foods or meats to enhance iron absorption from meals and discourage the consumption of tea or coffee with meals. In women at risk of multiple-nutrient deficiencies, clinicians may consider prescribing a multivitamin-mineral supplement of appropriate composition that contains approximately 30 mg of iron per tablet (see Appendix B, Table B-11, from IOM, 1992b).

Pregnant Women

The committee believes that pregnant women are the most at-risk population covered by this report. All pregnant women should be screened for iron deficiency anemia at the first prenatal visit and at least once during each subsequent trimester. Nutrition education about diet during pregnancy should be provided at every prenatal visit. This includes providing counseling on eating a diet rich in iron and foods that enhance iron absorption, avoiding foods that inhibit iron absorption (which should be consumed separately from iron-rich foods), and following guidelines in Nutrition and Your Health Dietary Guidelines for Americans (DHHS/USDA, 1991) and Nutrition During Pregnancy and Lactation: An Implementation Guide (IOM, 1992b).

The committee recommends that hemoglobin or hematocrit and, when feasible, serum ferritin concentration be determined early during the first tri-

Suggested Citation:"RECOMMENDED GUIDELINES FOR PREVENTION, DETECTION, AND MANAGEMENT OF IRON DEFICIENCY ANEMIA." Institute of Medicine. 1993. Iron Deficiency Anemia: Recommended Guidelines for the Prevention, Detection, and Management Among U.S. Children and Women of Childbearing Age. Washington, DC: The National Academies Press. doi: 10.17226/2251.
×

mester. Clinicians should refer the patient for further medical follow-up when the hemoglobin level is less than 9.0 g/dl or when the hemoglobin level is between 9.0 and 10.9 g/dl and the serum ferritin concentration is greater than 30 µg/liter. The committee does not recommend providing supplemental iron to pregnant women when the hemoglobin level is 11.0 g/all or greater in the presence of a serum ferritin concentration greater than 20 µg/liter. When the hemoglobin level is between 9.0 and 10.9 g/dl and the serum ferritin concentration is between 12 and 20 µg/liter or the hemoglobin level is 11.0 g/all or greater and the serum ferritin concentration is 20 µg/liter or less, 30 mg of supplemental iron should be provided on a daily basis.

The clinician should prescribe 60-120 mg of supplemental iron per day when the hemoglobin level is between 9.0 and 10.9 g/dl and the serum ferritin concentration is less than 12 µg/liter. Similar adjustments for hemoglobin and hematocrit levels in blacks should be made, as outlined above in the guidelines for nonpregnant women of childbearing age.

The hemoglobin level in anemic women should be evaluated at subsequent prenatal visits. If there has been no response to iron supplementation, the patient should be referred for additional follow-up. If the hemoglobin level is normal for that stage of pregnancy, the supplemental iron dose should be lowered to 30 mg/day.

If the first prenatal care visit does not occur until the second trimester, a blood specimen should be obtained by venipuncture and the hemoglobin level and serum ferritin concentration should be determined. Although the serum ferritin concentration declines during the second trimester of pregnancy, the measurement can be useful in assisting in the interpretation of the hemoglobin value. Clinicians should refer patients for further medical follow-up when the hemoglobin level is less than 9.0 g/dl. The clinician should prescribe 60-120 mg of supplemental iron per day when the hemoglobin level is between 9.0 and 10.4 g/dl and in the presence of a serum ferritin concentration of less than 12 mg/liter, and should prescribe 30 mg of supplemental iron per day when the hemoglobin level is 10.5 g/dl or greater in the presence of a serum ferritin concentration of 20 µg/liter or less. If the serum ferritin concentration is greater than 20 µg/liter, no intervention is recommended, regardless of the hemoglobin level.

At a visit during the third trimester, the clinician should obtain a blood specimen by venipuncture and determine the hemoglobin level. The patient should be referred for follow-up when the hemoglobin level is less than 9.0 g/dl. The clinician should prescribe 60-120 mg of supplemental iron per day when the hemoglobin level is between 9.0 and 10.9 g/dl and 30 mg of supplemental iron per day when the hemoglobin level is 11.0 g/dl or greater.

Supplemental iron can be stopped at the time of delivery unless anemia has continued throughout or after pregnancy or for those at high risk of iron deficiency anemia (i.e., excessive blood loss during pregnancy or multiple births). In that case, the clinician should continue supplementation until the 4- to 6-week postpartum visit. The committee's anemia criteria for nonpregnant

Suggested Citation:"RECOMMENDED GUIDELINES FOR PREVENTION, DETECTION, AND MANAGEMENT OF IRON DEFICIENCY ANEMIA." Institute of Medicine. 1993. Iron Deficiency Anemia: Recommended Guidelines for the Prevention, Detection, and Management Among U.S. Children and Women of Childbearing Age. Washington, DC: The National Academies Press. doi: 10.17226/2251.
×

women of childbearing age should be used for women at the 4- to 6-week postpartum visit.

Comments and Caution About Cutoff Values for Laboratory Tests

In this report, cutoffs for blood parameters are suggested in connection with recommended screening for iron deficiency. The committee emphasizes that it has selected cutoffs that should best be interpreted as follows: below this level, iron deficiency anemia may be present. For a significant proportion of people, the suggested cutoff levels do not mark any identified abnormality, and one should be careful to avoid generating unfounded concern in the patient or, in the case of infants, in the parents. Statistical evidence suggests that for a very substantial proportion of individuals selected for supplementation by the suggested cutoffs, a blood sample drawn a few days or weeks later (without any intervention) will show values in the normal range. However, for some individuals the values above the cutoffs will indicate a true anemia or iron deficiency. To protect those individuals, the committee made a conscious choice to set the cutoffs higher than might be used in clinical diagnostic practice, and certainly higher than the levels that are commonly recognized as driving clinical concern about detrimental consequences from iron deficiency anemia.

The recommendation to use lower cutoff values for hemoglobin in blacks in screening for iron deficiency anemia is consistent with the observation that hemoglobin values for this population are lower than those for other groups of comparable iron status (Johnson-Spear and Yip, in press; Perry et al., 1992). It is also consistent with the presently accepted definition of anemia as a hemoglobin concentration below the 95 percent confidence interval (i.e., below the 2.5th percentile) for a normal reference population. For all races, better information is urgently needed to provide functional, meaningful definitions of iron deficiency anemia and iron status.

Comments and Caution About Routine Use of Ferritin Values

Although the committee recommends the use of blood ferritin values as part of its screening protocol for the populations under study in this report, there are several explanatory comments and cautions about its use. It may be impractical or unfeasible to perform serum ferritin determinations in some settings. In settings where it is either impractical or too costly to obtain serum ferritin values, the committee continues to recommend the use of hemoglobin concentration or hematocrit value for the determination of iron deficiency anemia. When this is the case, clinicians and health care workers should be particularly aware that the anemia may not be the result of iron deficiency. However, the committee wishes to make it clear that it views serum ferritin values as being more precise in determining iron deficiency anemia. It also urges the development of more economical, uncomplicated serum ferritin concentration determination kits for use in many settings.

Suggested Citation:"RECOMMENDED GUIDELINES FOR PREVENTION, DETECTION, AND MANAGEMENT OF IRON DEFICIENCY ANEMIA." Institute of Medicine. 1993. Iron Deficiency Anemia: Recommended Guidelines for the Prevention, Detection, and Management Among U.S. Children and Women of Childbearing Age. Washington, DC: The National Academies Press. doi: 10.17226/2251.
×
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Suggested Citation:"RECOMMENDED GUIDELINES FOR PREVENTION, DETECTION, AND MANAGEMENT OF IRON DEFICIENCY ANEMIA." Institute of Medicine. 1993. Iron Deficiency Anemia: Recommended Guidelines for the Prevention, Detection, and Management Among U.S. Children and Women of Childbearing Age. Washington, DC: The National Academies Press. doi: 10.17226/2251.
×
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Suggested Citation:"RECOMMENDED GUIDELINES FOR PREVENTION, DETECTION, AND MANAGEMENT OF IRON DEFICIENCY ANEMIA." Institute of Medicine. 1993. Iron Deficiency Anemia: Recommended Guidelines for the Prevention, Detection, and Management Among U.S. Children and Women of Childbearing Age. Washington, DC: The National Academies Press. doi: 10.17226/2251.
×
Page 12
Suggested Citation:"RECOMMENDED GUIDELINES FOR PREVENTION, DETECTION, AND MANAGEMENT OF IRON DEFICIENCY ANEMIA." Institute of Medicine. 1993. Iron Deficiency Anemia: Recommended Guidelines for the Prevention, Detection, and Management Among U.S. Children and Women of Childbearing Age. Washington, DC: The National Academies Press. doi: 10.17226/2251.
×
Page 13
Suggested Citation:"RECOMMENDED GUIDELINES FOR PREVENTION, DETECTION, AND MANAGEMENT OF IRON DEFICIENCY ANEMIA." Institute of Medicine. 1993. Iron Deficiency Anemia: Recommended Guidelines for the Prevention, Detection, and Management Among U.S. Children and Women of Childbearing Age. Washington, DC: The National Academies Press. doi: 10.17226/2251.
×
Page 14
Suggested Citation:"RECOMMENDED GUIDELINES FOR PREVENTION, DETECTION, AND MANAGEMENT OF IRON DEFICIENCY ANEMIA." Institute of Medicine. 1993. Iron Deficiency Anemia: Recommended Guidelines for the Prevention, Detection, and Management Among U.S. Children and Women of Childbearing Age. Washington, DC: The National Academies Press. doi: 10.17226/2251.
×
Page 15
Suggested Citation:"RECOMMENDED GUIDELINES FOR PREVENTION, DETECTION, AND MANAGEMENT OF IRON DEFICIENCY ANEMIA." Institute of Medicine. 1993. Iron Deficiency Anemia: Recommended Guidelines for the Prevention, Detection, and Management Among U.S. Children and Women of Childbearing Age. Washington, DC: The National Academies Press. doi: 10.17226/2251.
×
Page 16
Suggested Citation:"RECOMMENDED GUIDELINES FOR PREVENTION, DETECTION, AND MANAGEMENT OF IRON DEFICIENCY ANEMIA." Institute of Medicine. 1993. Iron Deficiency Anemia: Recommended Guidelines for the Prevention, Detection, and Management Among U.S. Children and Women of Childbearing Age. Washington, DC: The National Academies Press. doi: 10.17226/2251.
×
Page 17
Suggested Citation:"RECOMMENDED GUIDELINES FOR PREVENTION, DETECTION, AND MANAGEMENT OF IRON DEFICIENCY ANEMIA." Institute of Medicine. 1993. Iron Deficiency Anemia: Recommended Guidelines for the Prevention, Detection, and Management Among U.S. Children and Women of Childbearing Age. Washington, DC: The National Academies Press. doi: 10.17226/2251.
×
Page 18
Suggested Citation:"RECOMMENDED GUIDELINES FOR PREVENTION, DETECTION, AND MANAGEMENT OF IRON DEFICIENCY ANEMIA." Institute of Medicine. 1993. Iron Deficiency Anemia: Recommended Guidelines for the Prevention, Detection, and Management Among U.S. Children and Women of Childbearing Age. Washington, DC: The National Academies Press. doi: 10.17226/2251.
×
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This book summarizes information related to public health measures on the prevention, detection, and management of iron deficiency anemia. It presents draft guidelines and recommendations related to this area, as applicable in primary health care and public health clinic settings, and it formulates recommendations for research. This volume is intended both to provide a common frame of reference for health professionals in preventing and treating iron deficiency anemia and to enable the U.S. Centers for Disease Control and Prevention to prepare national guidelines and recommendations for the prevention and control of iron deficiency anemia.

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