12/1/2016

RecommendationstoPreventandControlIronDeficiencyintheUnitedStates

RecommendationsandReports
April03,1998/47(RR3)136

Personsusingassistivetechnologymightnotbeabletofullyaccessinformationinthisfile.For
assistance,pleasesendemailto:mmwrq@cdc.gov.Type508Accommodationandthetitleofthereport
inthesubjectlineofemail.

RecommendationstoPreventandControlIron
DeficiencyintheUnitedStates
Summary
Irondeficiencyisthemostcommonknownformofnutritionaldeficiency.Itsprevalenceishighestamong
youngchildrenandwomenofchildbearingage(particularlypregnantwomen).Inchildren,iron
deficiencycausesdevelopmentaldelaysandbehavioraldisturbances,andinpregnantwomen,itincreases
theriskforapretermdeliveryanddeliveringalowbirthweightbaby.Inthepastthreedecades,increased
ironintakeamonginfantshasresultedinadeclineinchildhoodirondeficiencyanemiaintheUnited
States.Asaconsequence,theuseofscreeningtestsforanemiahasbecomealessefficientmeansof
detectingirondeficiencyinsomepopulations.Forwomenofchildbearingage,irondeficiencyhas
remainedprevalent.
ToaddressthechangingepidemiologyofirondeficiencyintheUnitedStates,CDCstaffinconsultation
withexpertsdevelopednewrecommendationsforusebyprimaryhealthcareproviderstoprevent,detect,
andtreatirondeficiency.Theserecommendationsupdatethe1989"CDCCriteriaforAnemiainChildren
andChildbearingAgedWomen"(MMWR198938(22):4004)andarethefirstcomprehensiveCDC
recommendationstopreventandcontrolirondeficiency.CDCemphasizessoundironnutritionforinfants
andyoungchildren,screeningforanemiaamongwomenofchildbearingage,andtheimportanceoflow
doseironsupplementationforpregnantwomen.INTRODUCTION
Inthehumanbody,ironispresentinallcellsandhasseveralvitalfunctionsasacarrierofoxygento
thetissuesfromthelungsintheformofhemoglobin(Hb),asafacilitatorofoxygenuseandstorageinthe
musclesasmyoglobin,asatransportmediumforelectronswithinthecellsintheformofcytochromes,
andasanintegralpartofenzymereactionsinvarioustissues.Toolittleironcaninterferewiththesevital
functionsandleadtomorbidityandmortality.
IntheUnitedStates,theprevalenceofirondeficiencyanemiaamongchildrendeclinedduringthe1970s
inassociationwithincreasedironintakeduringinfancy(13).Becauseofthisdecline,thevalueofanemia
asapredictorofirondeficiencyhasalsodeclined,thusdecreasingtheeffectivenessofroutineanemia
screeningamongchildren.Incontrast,therateofanemiaamonglowincomewomenduringpregnancyis
high,andnoimprovementhasbeennotedsincethe1970s(4).Thesefindings,plusincreasedknowledge
aboutscreeningforironstatus,raisedquestionsaboutthenecessityandeffectivenessofexistingU.S.
programstopreventandcontrolirondeficiency.CDCrequestedtheInstituteofMedicinetoconvenean
expertcommitteetodeveloprecommendationsforpreventing,detecting,andtreatingirondeficiency
anemiaamongU.S.childrenandU.S.womenofchildbearingage.Thecommitteemetthroughout1992,
andin1993theInstituteofMedicinepublishedthecommittee'srecommendations(5).Theseguidelines
arenotpracticalforallprimaryhealthcareandpublichealthsettings,however,becausetheyrequire
https://www.cdc.gov/mmwr/preview/mmwrhtml/00051880.htm

1/26

12/1/2016

RecommendationstoPreventandControlIronDeficiencyintheUnitedStates

serumferritintestingduringpregnancy(6).Thistestingmaybeappropriateinpracticeswherewomen
consistentlyvisittheirphysicianthroughoutpregnancy,butitislessfeasiblewhenanalysisofserum
ferritinconcentrationisunavailableorwhenprenatalcarevisitsaresporadic.TheCDCrecommendations
inthisreportincludingthoseforpregnantwomenweredevelopedforpracticaluseinprimaryhealth
careandpublichealthsettings.
BesidetheInstituteofMedicine(5,7),theAmericanAcademyofPediatrics(8,9),theU.S.Preventive
ServicesTaskForce(10),theAmericanCollegeofObstetriciansandGynecologists(9,11),theFederation
ofAmericanSocietiesforExperimentalBiology(12),andtheU.S.PublicHealthService(13)haveall
publishedguidelineswithinthepast9yearsforhealthcareprovidersthataddressscreeningforand
treatmentofirondeficiencyintheUnitedStates.Preventingandcontrollingirondeficiencyarealso
addressedinNutritionandYourHealth:DietaryGuidelinesforAmericans(14).
TheCDCrecommendationsdifferfromtheguidelinespublishedbytheU.S.PreventiveServicesTask
Force(10)intwomajorareas.First,theTaskForcerecommendedscreeningforanemiaamonginfantsat
highriskforanemiaandpregnantwomenonly.TheCDCrecommendsperiodicscreeningforanemia
amonghighriskpopulationsofinfantsandpreschoolchildren,amongpregnantwomen,andamong
nonpregnantwomenofchildbearingage.Second,theTaskForcestatedthereisinsufficientevidenceto
recommendfororagainstironsupplementationduringpregnancy,buttheCDCrecommendsuniversal
ironsupplementationtomeettheironrequirementsofpregnancy.TheCDCrecommendationsforiron
supplementationduringpregnancyaresimilartotheguidelinesissuedbytheAmericanAcademyof
PediatricsandtheAmericanCollegeofObstetriciansandGynecologists(9).
Thisreportisintendedtoprovideguidancetoprimaryhealthcareprovidersandemphasizestheetiology
andepidemiologyofirondeficiency,thelaboratorytestsusedtoassessironstatus,andthescreeningfor
andtreatmentofirondeficiencyatallages.Therecommendationsinthisreportarebasedonthe1993
InstituteofMedicineguidelinestheconclusionsofanexpertpanelconvenedbyCDCinApril1994and
inputfrompublichealthnutritionprogrampersonnel,primaryhealthcareproviders,andexpertsin
hematology,biochemistry,andnutrition.
Nationalhealthobjective2.10fortheyear2000isto"reduceirondeficiencytolessthan3%among
childrenaged14andamongwomenofchildbearingage"(15).Therecommendationsinthisreportfor
preventingandcontrollingirondeficiencyaremeanttomovethenationtowardthisobjective.
BACKGROUNDIronMetabolism
Totalbodyironaveragesapproximately3.8ginmenand2.3ginwomen,whichisequivalentto50
mg/kgbodyweightfora75kgman(16,17)and42mg/kgbodyweightfora55kgwoman(18),
respectively.Whenthebodyhassufficientirontomeetitsneeds,mostiron(greaterthan70%)maybe
classifiedasfunctionalirontheremainderisstorageortransportiron.Morethan80%offunctionaliron
inthebodyisfoundintheredbloodcellmassasHb,andtherestisfoundinmyoglobinandintracellular
respiratoryenzymes(e.g.,cytochromes)(Table_1).Ironisstoredprimarilyasferritin,butsomeisstored
ashemosiderin.Ironistransportedinbloodbytheproteintransferrin.Thetotalamountofironinthe
bodyisdeterminedbyintake,loss,andstorageofthismineral(16).IronIntake
Regulationofironbalanceoccursmainlyinthegastrointestinaltractthroughabsorption.Whenthe
absorptivemechanismisoperatingnormally,apersonmaintainsfunctionalironandtendstoestablishiron
stores.Thecapacityofthebodytoabsorbironfromthedietdependsontheamountofironinthebody,
therateofredbloodcellproduction,theamountandkindofironinthediet,andthepresenceof
absorptionenhancersandinhibitorsinthediet.
Thepercentageofironabsorbed(i.e.,ironbioavailability)canvaryfromlessthan1%togreaterthan50%
(19).Themainfactorcontrollingironabsorptionistheamountofironstoredinthebody.The
gastrointestinaltractincreasesironabsorptionwhenthebody'sironstoresarelowanddecreases
absorptionwhenstoresaresufficient.Anincreasedrateofredbloodcellproductioncanalsostimulate
ironuptakeseveralfold(16,20).
https://www.cdc.gov/mmwr/preview/mmwrhtml/00051880.htm

2/26

12/1/2016

RecommendationstoPreventandControlIronDeficiencyintheUnitedStates

Amongadults,absorptionofdietaryironaveragesapproximately6%formenand13%fornonpregnant
womenintheirchildbearingyears(19).Thehigherabsorptionefficiencyofthesewomenreflects
primarilytheirlowerironstoresasaresultofmenstruationandpregnancy.Amongirondeficientpersons,
ironabsorptionisalsohigh(21).Absorptionofironincreasesduringpregnancy,buttheamountofthe
increaseisnotwelldefined(6)asironstoresincreasepostpartum,ironabsorptiondecreases.
Ironbioavailabilityalsodependsondietarycomposition.Hemeiron,whichisfoundonlyinmeat,poultry,
andfish,istwotothreetimesmoreabsorbablethannonhemeiron,whichisfoundinplantbasedfoods
andironfortifiedfoods(19,20).Thebioavailabilityofnonhemeironisstronglyaffectedbythekindof
otherfoodsingestedatthesamemeal.Enhancersofironabsorptionarehemeiron(inmeat,poultry,and
fish)andvitaminCinhibitorsofironabsorptionincludepolyphenols(incertainvegetables),tannins(in
tea),phytates(inbran),andcalcium(indairyproducts)(16,22).Vegetariandiets,bydefinition,arelowin
hemeiron.However,ironbioavailabilityinavegeteriandietcanbeincreasedbycarefulplanningof
mealstoincludeothersourcesofironandenhancersofironabsorption(14).Inthedietofaninfant,
beforetheintroductionofsolidfoods,theamountofironabsorbeddependsontheamountand
bioavailabilityofironinbreastmilkorformula(8)(Table_2).IronTurnoverandLoss
Redbloodcellformationanddestructionisresponsibleformostironturnoverinthebody.Forexample,
inadultmen,approximately95%oftheironrequiredfortheproductionofredbloodcellsisrecycled
fromthebreakdownofredbloodcellsandonly5%comesfromdietarysources.Incontrast,aninfantis
estimatedtoderiveapproximately70%ofredbloodcellironfromthebreakdownofredbloodcellsand
30%fromthediet(23).
Inadults,approximately1mgofironislostdailythroughfecesanddesquamatedmucosalandskincells
(24).Womenofchildbearingagerequireadditionalirontocompensateformenstrualbloodloss(an
averageof0.30.5mgdailyduringthechildbearingyears)(18)andfortissuegrowthduringpregnancy
andbloodlossatdeliveryandpostpartum(anaverageof3mgdailyover280days'gestation)(25).Inall
persons,aminuteamountofironislostdailyfromphysiologicalgastrointestinalbloodloss.Pathological
gastrointestinalironlossthroughgastrointestinalbleedingoccursininfantsandchildrensensitivetocow's
milkandinadultswhohavepepticulcerdisease,inflammatorybowelsyndrome,orbowelcancer.
Hookworminfections,althoughnotcommonintheUnitedStates(26),arealsoassociatedwith
gastrointestinalbloodlossandirondepletion(27).IronStores
Ironpresentinthebodybeyondwhatisimmediatelyneededforfunctionalpurposesisstoredasthe
solubleproteincomplexferritinortheinsolubleproteincomplexhemosiderin(16,17).Ferritinand
hemosiderinarepresentprimarilyintheliver,bonemarrow,spleen,andskeletalmuscles.Smallamounts
offerritinalsocirculateintheplasma.Inhealthypersons,mostironisstoredasferritin(anestimated70%
inmenand80%inwomen)andsmalleramountsarestoredashemosiderin(Table_1).Whenlongterm
negativeironbalanceoccurs,ironstoresaredepletedbeforeirondeficiencybegins.
Menstoreapproximately1.01.4gofbodyiron(17,28),womenapproximately0.20.4g(18,28),and
childrenevenless(23).Fullterminfantsofnormalorhighbirthweightarebornwithhighbodyiron(an
averageof75mg/kgbodyweight),towhichironstorescontributeapproximately25%(23).Pretermor
lowbirthweightinfantsarebornwiththesameratiooftotalbodyirontobodyweight,butbecausetheir
bodyweightislow,theamountofstoredironislowtoo.ManifestationsofIronDeficiency
Irondeficiencyisoneofthemostcommonnutritionaldeficienciesworldwide(29)andhasseveralcauses
(Exhibit1)(Table_1B).Irondeficiencyrepresentsaspectrum(Table_3)rangingfromirondepletion,
whichcausesnophysiologicalimpairments,toirondeficiencyanemia,whichaffectsthefunctioningof
severalorgansystems.Inirondepletion,theamountofstorediron(e.g.,asmeasuredbyserumferritin
concentration)isreducedbuttheamountoffunctionalironmaynotbeaffected(30,31).Personswho
haveirondepletionhavenoironstorestomobilizeifthebodyrequiresmoreiron.Inirondeficient
erythropoiesis,storedironisdepletedandtransportiron(e.g.,asmeasuredbytransferrinsaturation)is
reducedfurthertheamountofironabsorbedisnotsufficienttoreplacetheamountlostortoprovidethe
amountneededforgrowthandfunction.Inthisstage,theshortageofironlimitsredbloodcellproduction
https://www.cdc.gov/mmwr/preview/mmwrhtml/00051880.htm

3/26

12/1/2016

RecommendationstoPreventandControlIronDeficiencyintheUnitedStates

andresultsinincreasederthryocyteprotoporphyrinconcentration.Inirondeficiencyanemia,themost
severeformofirondeficiency,theshortageofironleadstounderproductionofironcontainingfunctional
compounds,includingHb.Theredbloodcellsofpersonswhohaveirondeficiencyanemiaaremicrocytic
andhypochromic(30,31).
Ininfants(personsaged012months)andpreschoolchildren(personsaged15years),irondeficiency
anemiaresultsindevelopmentaldelaysandbehavioraldisturbances(e.g.,decreasedmotoractivity,social
interaction,andattentiontotasks)(32,33).Thesedevelopmentaldelaysmaypersistpastschoolage(i.e.,5
years)iftheirondeficiencyisnotfullyreversed(3234).Inthesestudiesofdevelopmentandbehavior,
irondeficiencyanemiawasdefinedasaHbconcentrationoflessthanorequalto10.0g/dLorlessthanor
equalto10.5g/dLfurtherstudyisneededtodeterminetheeffectsofmildirondeficiencyanemia(for
example,aHbconcentrationofgreaterthan10.0g/dLbutlessthan11.0g/dLinchildrenaged1lessthan
2years)oninfantandchilddevelopmentandbehavior.Irondeficiencyanemiaalsocontributestolead
poisoninginchildrenbyincreasingthegastrointestinaltract'sabilitytoabsorbheavymetals,including
lead(35).Irondeficiencyanemiaisassociatedwithconditionsthatmayindependentlyaffectinfantand
childdevelopment(e.g.,lowbirthweight,generalizedundernutrition,poverty,andhighbloodlevelof
lead)thatneedtobetakenintoaccountwheninterventionsaddressingirondeficiencyanemiaare
developedandevaluated(34).
Inadults(personsagedgreaterthanorequalto18years),irondeficiencyanemiaamonglaborers(e.g.,tea
pickers,latextappers,andcottonmillworkers)inthedevelopingworldimpairsworkcapacitythe
impairmentappearstobeatleastpartiallyreversiblewithirontreatment(36,37).Itisnotknownwhether
irondeficiencyanemiaaffectsthecapacitytoperformlessphysicallydemandinglaborthatisdependent
onsustainedcognitiveorcoordinatedmotorfunction(37).
Amongpregnantwomen,irondeficiencyanemiaduringthefirsttwotrimestersofpregnancyisassociated
withatwofoldincreasedriskforpretermdeliveryandathreefoldincreasedriskfordeliveringalow
birthweightbaby(38).Evidencefromrandomizedcontroltrialsindicatesthatironsupplementation
decreasestheincidenceofirondeficiencyanemiaduringpregnancy(10,3942),buttrialsoftheeffectof
universalironsupplementationduringpregnancyonadversematernalandinfantoutcomesare
inconclusive(10,43,44).RiskforandPrevalenceofIronDeficiencyintheUnitedStates
Arapidrateofgrowthcoincidentwithfrequentlyinadequateintakeofdietaryironplaceschildrenaged
lessthan24months,particularlythoseaged918months,atthehighestriskofanyagegroupforiron
deficiency(3).Theironstoresoffullterminfantscanmeetaninfant'sironrequirementsuntilages46
months,andirondeficiencyanemiagenerallydoesnotoccuruntilapproximatelyage9months.
Comparedwithfullterminfantsofnormalorhighbirthweight,pretermandlowbirthweightinfantsare
bornwithlowerironstoresandgrowfasterduringinfancyconsequently,theirironstoresareoften
depletedbyages23months(5,23)andtheyareatgreaterriskforirondeficiencythanarefullterm
infantsofnormalorhighbirthweight.DatafromthethirdNationalHealthandNutritionExamination
Survey(NHANESIII),whichwasconductedduring19881994,indicatedthat9%ofchildrenaged1236
monthsintheUnitedStateshadirondeficiency(onthebasisoftwoofthreeabnormalvaluesfor
erythrocyteprotoporphyrinconcentration,serumferritinconcentration,andtransferrinsaturation)andthat
3%alsohadirondeficiencyanemia(Table_4).Theprevalenceofirondeficiencyishigheramong
childrenlivingatorbelowthepovertylevelthanamongthoselivingabovethepovertylevelandhigher
amongblackorMexicanAmericanchildrenthanamongwhitechildren(45).
EvidencefromtheContinuingSurveyofFoodIntakesbyIndividuals(CSFII),whichwasconducted
during19941996,suggeststhatmostinfantsmeettherecommendeddietaryallowanceforironthrough
diet(Table_5thesedataexcludebreastfedinfants).However,theevidencealsosuggeststhatmorethan
halfofchildrenaged12yearsmaynotbemeetingtherecommendeddietaryallowanceforironthrough
theirdiet(Table_5thesedatadonotincludeironintakefromsupplementaliron).
Aninfant'sdietisareasonablepredictorofironstatusinlateinfancyandearlychildhood(23,48).For
example,approximately20%40%ofinfantsfedonlynonironfortifiedformulaorwholecow'smilkand
https://www.cdc.gov/mmwr/preview/mmwrhtml/00051880.htm

4/26

12/1/2016

RecommendationstoPreventandControlIronDeficiencyintheUnitedStates

15%25%ofbreastfedinfantsareatriskforirondeficiencybyages912months(23,48).Infantsfed
mainlyironfortifiedformula(greaterthanorequalto1.0mgiron/100kcalformula)(8)arenotlikelyto
haveirondeficiencyatage9months(48).Anotherstudyhasdocumentedthatintakeofironfortified
cerealprotectsagainstirondeficiency:amongexclusivelybreastfedinfantswhowerefedcerealstarting
atage4months,3%ofinfantswhowererandomizedtoreceiveironfortifiedcerealcomparedwith15%
ofinfantswhowererandomizedtoreceivenonironfortifiedcerealhadirondeficiencyanemiaatage8
months(49).Theeffectofprolongedexclusivebreastfeedingonironstatusisnotwellunderstood.One
nonrandomizedstudywithasmallcohortsuggestedthatexclusivebreastfeedingforgreaterthan7
monthsisprotectiveagainstirondeficiencycomparedwithbreastfeedingplustheintroductionofnon
ironfortifiedfoodsatagelessthanorequalto7months(50)infantsweanedtoironfortifiedfoodswere
notincludedinthisstudy.
Earlyintroduction(i.e.,beforeage1year)ofwholecow'smilkandconsumptionofgreaterthan24ozof
wholecow'smilkdailyafterthe1styearoflifeareriskfactorsforirondeficiencybecausethismilkhas
littleiron,mayreplacefoodswithhigherironcontent,andmaycauseoccultgastrointestinalbleeding
(8,48,51,52).Becausegoat'smilkandcow'smilkhavesimilarcompositions(53,54),infantsfedgoat's
milkarelikelytohavethesameriskfordevelopingirondeficiencyasdoinfantsfedcow'smilk.Ofall
milksandformulas,breastmilkhasthehighestpercentageofbioavailableiron,andbreastmilkandiron
fortifiedformulasprovidesufficientirontomeetaninfant'sneeds(55).Ironfortifiedformulasarereadily
available,donotcostmuchmorethannonironfortifiedformulas,andhavefewprovensideeffects
exceptfordarkerstools(56,57).Controlledtrialsandobservationalstudieshaveindicatedthatiron
fortifiedformulacausesnomoregastrointestinaldistressthandoesnonironfortifiedformula(5658),
andthereislittlemedicalindicationfornonironfortifiedformula(59).
Afterage24months,whenthegrowthrateofchildrenslowsandthedietbecomesmorediversified,the
riskforirondeficiencydrops(28,45,47).Inchildrenagedgreaterthan36months,dietaryironandiron
statusareusuallyadequate(45,47).Fortheseolderchildren,risksforirondeficiencyincludelimited
accesstofood(e.g.,becauseoflowfamilyincome(45)orbecauseofmigrantorrefugeestatus),alow
ironorotherspecializeddiet,andmedicalconditionsthataffectironstatus(e.g.,inflammatoryorbleeding
disorders)(3).
Duringadolescence(ages12lessthan18years),ironrequirements(46)andhencetheriskforiron
deficiencyincreasebecauseofrapidgrowth(60,61).Amongboys,therisksubsidesafterthepeak
pubertalgrowthperiod.Amonggirlsandwomen,however,menstruationincreasestheriskforiron
deficiencythroughoutthechildbearingyears.Animportantriskfactorforirondeficiencyanemiaamong
nonpregnantwomenofchildbearingageisheavymenstrualbloodloss(greaterthanorequalto80
mL/month)(18),whichaffectsanestimated10%ofthesewomenintheUnitedStates(17,18).Otherrisk
factorsincludeuseofanintrauterinedevice(whichisassociatedwithincreasedmenstrualbloodloss),
highparity,previousdiagnosisofirondeficiencyanemia,andlowironintake(45,60).Useoforal
contraceptivesisassociatedwithdecreasedriskforirondeficiency(18,62).
DatafromCSFIIsuggestthatonlyonefourthofadolescentgirlsandwomenofchildbearingage(1249
years)meettherecommendeddietaryallowanceforironthroughdiet(Table_5).Indeed,datafromthe
completeNHANESIIIindicatedthat11%ofnonpregnantwomenaged1649yearshadirondeficiency
andthat3%5%alsohadirondeficiencyanemia(Table_4).
Amongpregnantwomen,expansionofbloodvolumebyapproximately35%andgrowthofthefetus,
placenta,andothermaternaltissuesincreasethedemandforironthreefoldinthesecondandthird
trimesterstoapproximately5.0mgiron/day(18,46).Althoughmenstruationceasesandironabsorption
increasesduringpregnancy,mostpregnantwomenwhodonottakeironsupplementstomeetincreased
ironrequirementsduringpregnancycannotmaintainadequateironstores,particularlyduringthesecond
andthirdtrimesters(63).Afterdelivery,theironinthefetusandplacentaislosttothewoman,butsome
oftheironintheexpandedbloodvolumemaybereturnedtothewoman'sironstores(18).

https://www.cdc.gov/mmwr/preview/mmwrhtml/00051880.htm

5/26

12/1/2016

RecommendationstoPreventandControlIronDeficiencyintheUnitedStates

Theprevalenceofanemiainlowincome,pregnantwomenenrolledinpublichealthprogramsinthe
UnitedStateshasremainedfairlystablesince1979(4).In1993,theprevalenceofanemiaamongthese
womenwas9%,14%,and37%inthefirst,second,andthirdtrimesters,respectively(4).Comparable
datafortheU.S.populationofallpregnantwomenareunavailable.Thelowdietaryintakeofironamong
U.S.womenofchildbearingage(47),thehighprevalenceofirondeficiencyandirondeficiencyanemia
amongthesewomen(45),andtheincreaseddemandforironduringpregnancy(18,46)suggestthat
anemiaduringpregnancymayextendbeyondlowincomewomen.
PublisheddataonironsupplementusebyarepresentativesampleofpregnantU.S.womenarelimited.In
the1988NationalMaternalandInfantHealthSurveyofanationallyrepresentativesampleofU.S.women
whodeliveredachildinthatyear,83%ofrespondentsreportedthattheytooksupplementswithmultiple
vitaminsandmineralsgreaterthanorequalto3days/weekfor3monthsaftertheyfoundouttheywere
pregnant(64).SignificantlysmallerpercentagesofblackwomenEskimo,Aleut,orAmericanIndian
womenwomenagedlessthan20yearsandwomenhavinglessthanahighschooleducationreported
takingthesesupplements.Inthissurvey,selfreporteduseofsupplementationwaswithintherange
(55%95%)foundinareviewofstudiesusingobjectivemeasurestoestimateadherence(e.g.,pillcounts
andserumferritinconcentration)(65).Thesurveyresultssuggestthatthegroupsofwomenathighrisk
forirondeficiencyduringnonpregnancyarelesslikelytotakesupplementswithmultiplevitaminsand
mineralsduringpregnancy.Thissurveydidnotquestionrespondentsaboutchangesinsupplementuse
duringpregnancyorwhatdoseofironsupplementswasconsumed.
IntheUnitedStates,themainreasonsforlackofarecommendedironsupplementationregimenduring
pregnancymayincludelackofhealthcareproviderandpatientperceptionsthatironsupplementsimprove
maternalandinfantoutcomes(65),complicateddoseschedules(5,65),anduncomfortablesideeffects
(e.g.,constipation,nausea,andvomiting)(66,67).Lowdosesupplementationregimensthatmeet
pregnancyrequirements(i.e.,30mgiron/day)(46)andreduceunwantedsideeffectsareaseffectiveas
higherdoseregimens(i.e.,60or120mgiron/day)inpreventingirondeficiencyanemia(66).Simplified
doseschedules(e.g.,1dose/day)mayalsoimprovecompliance(65).Methodstoimprovecompliance
amongpregnantwomenathighriskforirondeficiencyrequirefurtherstudy.
Amongmen(malesagedgreaterthanorequalto18years)andpostmenopausalwomenintheUnited
States,irondeficiencyanemiaisuncommon.DatafromNHANESIIIindicatedthatlessthanorequalto
2%ofmenagedgreaterthanorequalto20yearsand2%ofwomenagedgreaterthanorequalto50years
hadirondeficiencyanemia(Table_4).DatafromCFSIIindicatethatmostmenandmostwomenaged
greaterthanorequalto50yearsmeettherecommendeddietaryallowanceforironthroughdiet(Table_5).
Inastudyofadultshavingirondeficiencyanemia,62%hadclinicalevidenceofgastrointestinalbleeding
asaresultoflesions(e.g.,ulcersandtumors)(68).InNHANESI,whichwasconductedduring1971
1975,abouttwothirdsofanemiacasesamongmenandpostmenopausalwomenwereattributableto
chronicdiseaseorinflammatoryconditions(69).Thefindingsofthesestudiessuggestthat,amongthese
populations,theprimarycausesofanemiaarechronicdiseaseandinflammatoryconditionsandthatlow
ironintakeshouldnotbeassumedtobethecauseoftheanemia.TESTSUSEDTOASSESSIRON
STATUS
Ironstatuscanbeassessedthroughseverallaboratorytests.Becauseeachtestassessesadifferentaspect
ofironmetabolism,resultsofonetestmaynotalwaysagreewithresultsofothertests.Hematological
testsbasedoncharacteristicsofredbloodcells(i.e.,Hbconcentration,hematocrit,meancellvolume,and
redbloodcelldistributionwidth)aregenerallymoreavailableandlessexpensivethanarebiochemical
tests.Biochemicaltests(i.e.,erythrocyteprotoporphyrinconcentration,serumferritinconcentration,and
transferrinsaturation),however,detectearlierchangesinironstatus.
Althoughallofthesetestscanbeusedtoassessironstatus,nosingletestisacceptedfordiagnosingiron
deficiency(70).Detectingirondeficiencyinaclinicalorfieldsettingismorecomplexthanisgenerally
believed.

https://www.cdc.gov/mmwr/preview/mmwrhtml/00051880.htm

6/26

12/1/2016

RecommendationstoPreventandControlIronDeficiencyintheUnitedStates

Lackofstandardizationamongthetestsandapaucityoflaboratoryproficiencytestinglimitcomparison
ofresultsbetweenlaboratories(71).Laboratoryproficiencytestingiscurrentlyavailableformeasuring
Hbconcentration,hematocrit,redbloodcellcount,serumferritinconcentration,andserumiron
concentrationprovisionalproficiencytestingwasaddedin1997fortotalironbindingcapacityinthe
CollegeofAmericanPathologistssurveyandwasaddedtotheAmericanAssociationofBioanalysts
surveyin1998.AsofApril1998,threestates(NewYork,Pennsylvania,andWisconsin)hadproficiency
testingprogramsforerthrocyteprotoporphryinconcentration.Regardlessofwhetherteststandardization
andproficiencytestingbecomeroutine,betterunderstandingamonghealthcareprovidersaboutthe
strengthsandlimitationsofeachtestisnecessarytoimprovescreeningforanddiagnosisofiron
deficiencyanemia,especiallybecausetheresultsfromallofthesetestscanbeaffectedbyfactorsother
thanironstatus.
Onlythemostcommonindicatorsofirondeficiencyaredescribedinthissection.Otherindicatorsofiron
deficiency(e.g.,unboundironbindingcapacityandtheconcentrationsoftransferrinreceptor,serum
transferrin,andholoferritin)arelessoftenusedorareunderdevelopment.HbConcentrationand
Hematocrit
Becauseoftheirlowcostandtheeaseandrapidityinperformingthem,thetestsmostcommonlyusedto
screenforirondeficiencyareHbconcentrationandhematocrit(Hct).Thesemeasuresreflecttheamount
offunctionalironinthebody.TheconcentrationoftheironcontainingproteinHbincirculatingredblood
cellsisthemoredirectandsensitivemeasure.Hctindicatestheproportionofwholebloodoccupiedby
theredbloodcellsitfallsonlyaftertheHbconcentrationfalls.BecausechangesinHbconcentrationand
Hctoccuronlyatthelatestagesofirondeficiency,bothtestsarelateindicatorsofirondeficiency
nevertheless,thesetestsareessentialfordeterminingirondeficiencyanemia.
Becauseirondeficiencyissuchacommoncauseofchildhoodanemia,thetermsanemia,irondeficiency,
andirondeficiencyanemiaareoftenusedinterchangeably(3).Theonlycasesofanemiathatcanbe
classifiedasirondeficiencyanemia,however,arethosewithadditionalevidenceofirondeficiency.The
conceptofacloseassociationbetweenanemiaandirondeficiencyisclosesttocorrectwhenthe
prevalenceofirondeficiencyishigh.IntheUnitedStates,theprevalenceandseverityofanemiahave
declinedinrecentyearshence,theproportionofanemiaduetocausesotherthanirondeficiencyhas
increasedsubstantially.Asaconsequence,theeffectivenessofanemiascreeningforirondeficiencyhas
decreasedintheUnitedStates.
Irondeficiencymaybedefinedasabsentbonemarrowironstores(asdescribedonbonemarrowiron
smears),anincreaseinHbconcentrationofgreaterthan1.0g/dLafterirontreatment,orabnormalvalues
oncertainotherbiochemicaltests(17).Therecentrecognitionthatirondeficiencyseemstohavegeneral
andpotentiallyseriousnegativeeffects(3234)hasmadeidentifyingpersonshavingirondeficiencyas
importantasidentifyingpersonshavingirondeficiencyanemia.
Thecasedefinitionofanemiarecommendedinthisreportislessthan5thpercentileofthedistributionof
HbconcentrationorHctinahealthyreferencepopulationandisbasedonage,sex,and(amongpregnant
women)stageofpregnancy(45,72).Thiscasedefinitionforanemiawasshowntocorrectlyidentify37%
ofwomenofchildbearingageand25%ofchildrenaged15yearswhowereirondeficient(definedas
twoofthreepositivetestresults{i.e.,lowmeancellvolume,higherythrocyteprotoporphyrin,orlow
transferrinsaturation})(sensitivity)andtocorrectlyclassify93%ofwomenofchildbearingageand92%
ofchildrenaged15yearsasnothavingirondeficiency(specificity)(73).LoweringtheHbconcentration
orHctcutoffwouldresultinidentifyingfewerpeoplewhohaveanemiaduetocausesotherthaniron
deficiency(falsepositives)butalsoinoverlookingmorepeoplewithirondeficiency(truepositives)(74).
ThedistributionsofHbconcentrationandHctandthusthecutoffvaluesforanemiadifferbetween
children,men,nonpregnantwomen,andpregnantwomenandbyageorweeksofgestation(Table_6).The
distributionsalsodifferbyaltitude,smokingstatus,andrace.

https://www.cdc.gov/mmwr/preview/mmwrhtml/00051880.htm

7/26

12/1/2016

RecommendationstoPreventandControlIronDeficiencyintheUnitedStates

Amongpregnantwomen,HbconcentrationandHctdeclineduringthefirstandsecondtrimestersbecause
ofanexpandingbloodvolume(18,3942).Amongpregnantwomenwhodonottakeironsupplements,
HbconcentrationandHctremainlowinthethirdtrimester,andamongpregnantwomenwhohave
adequateironintake,HbconcentrationandHctgraduallyriseduringthethirdtrimestertowardthe
prepregnancylevels(39,40).BecauseadequatedataarelackingintheUnitedStates,thecutoffvaluesfor
anemiaarebasedonclinicalstudiesofEuropeanwomenwhohadtakenironsupplementationduring
pregnancy(3942,72).Forpregnantwomen,atestresultgreaterthan3standarddeviations(SD)higher
thanthemeanofthereferencepopulation(i.e.,aHbconcentrationofgreaterthan15.0g/dLoraHctof
greaterthan45.0%),particularlyinthesecondtrimester,likelyindicatespoorbloodvolumeexpansion
(72).HighHbconcentrationorHcthasbeenassociatedwithhypertensionandpoorpregnancyoutcomes
(e.g.,fetalgrowthretardation,fetaldeath,pretermdelivery,andlowbirthweight)(7578).Inonestudy,
womenwhohadaHctofgreaterthanorequalto43%at2630weeks'gestationhadmorethanatwofold
increasedriskforpretermdeliveryandafourfoldincreasedriskfordeliveringachildhavingfetalgrowth
retardationthandidwomenwhohadaHctof33%36%(76).Hence,ahighHbconcentrationorHctin
thesecondorthirdtrimesterofpregnancyshouldnotbeconsideredanindicatorofdesirableironstatus.
Longtermresidencyathighaltitude(greaterthanorequalto3,000ft)(79)andcigarettesmoking(80)
causeageneralizedupwardshiftinHbconcentrationandHct(Table_7).Theeffectivenessofscreening
foranemiaisloweredifthecutoffvaluesarenotadjustedforthesefactors(72,79,80).Adjustmentallows
thepositivepredictivevalueofanemiascreeningtobecomparablebetweenthosewhoresidenearsea
levelandthosewholiveathighaltitudeandbetweensmokersandnonsmokers(72).
IntheUnitedStates,thedistributionofHbconcentrationvaluesissimilaramongwhitesandAsian
Americans(81),andthedistributionofHctvaluesissimilaramongwhitesandAmericanIndians(82).
Thedistributionsareloweramongblacksthanwhites,however,evenafteradjustmentforincome(83,84).
Thesedifferentdistributionsarenotcausedbyadifferenceinironstatusindicators(e.g.,ironintake,
serumferritinconcentration,ortransferrinsaturation)thus,applyingthesamecriteriaforanemiatoall
racesresultsinahigherrateoffalsepositivecasesofirondeficiencyforblacks(84).Forexample,inthe
UnitedStatesduring19761980,28%ofnonpregnantblackwomenbutonly5%ofnonpregnantwhite
womenhadaHbconcentrationoflessthan12g/dLand,accordingtotheanemiacriteria,wouldbe
classifiedasirondeficient,eventhoughothertestsforironstatussuggestedthesewomenwerenotiron
deficient(84).Forthisreason,theInstituteofMedicinerecommendsloweringHbconcentrationandHct
cutoffvaluesforblackchildrenagedlessthan5yearsby0.4g/dLand1%,respectively,andforblack
adultsby0.8g/dLand2%,respectively(5).Becausethereasonforthisdisparityindistributionsbyrace
hasnotbeendetermined,therecommendationsinthisreportdonotprovideracespecificcutoffvaluesfor
anemia.Regardless,healthcareprovidersshouldbeawareofthepossibledifferenceinthepositive
predictivevalueofanemiascreeningforirondeficiencyamongblacksandwhitesandconsiderusing
otherironstatustests(e.g.,serumferritinconcentrationandtransferrinsaturation)fortheirblackpatients.
Accurate,lowcost,clinicbasedinstrumentshavebeendevelopedformeasuringHbconcentrationand
Hctbyusingcapillaryorvenousblood(85,86).SmalldiurnalvariationsareseeninHbconcentrationand
Hctmeasurements,butthesevariationsareneitherbiologicallynorstatisticallysignificant(87,88).A
potentialsourceoferrorofusingcapillarybloodtoestimateHbconcentrationandHctinscreeningis
impropersamplingtechnique.Forexample,excessivesqueezing(i.e.,"milking")ofthefinger
contaminatesthebloodwithtissuefluid,leadingtofalselowreadings(89).Confirmationofalowreading
isrecommendedbyobtainingasecondcapillarybloodsamplefromthefingerorbyvenipuncture.
AlthoughmeasuresofHbconcentrationandHctcannotbeusedtodeterminethecauseofanemia,a
diagnosisofirondeficiencyanemiacanbemadeifHbconcentrationorHctincreasesafteracourseof
therapeuticironsupplementation(23,51).Alternatively,otherlaboratorytests(e.g.,meancellvolume,red
bloodcelldistributionwidth,andserumferritinconcentration)canbeusedtodifferentiateirondeficiency
anemiafromanemiaduetoothercauses.

https://www.cdc.gov/mmwr/preview/mmwrhtml/00051880.htm

8/26

12/1/2016

RecommendationstoPreventandControlIronDeficiencyintheUnitedStates

IntheUnitedStatesinrecentyears,theusefulnessofanemiascreeningasanindicatorofirondeficiency
hasbecomemorelimited,particularlyforchildren.Studiesusingtransferrinsaturation(amoresensitive
testforirondeficiency)havedocumentedthatirondeficiencyinmostsubpopulationsofchildrenhas
declinedsuchthatscreeningbyHbconcentrationnolongerefficientlypredictsirondeficiency
(3,45,51,90).DatafromNHANESII,whichwasconductedduring19761980,indicatedthatlessthan
50%ofchildrenaged15yearsandwomenintheirchildbearingyearswhohadanemia(asdefinedbyHb
concentrationlessthan5thpercentile)wereirondeficient(i.e.,hadatleasttwoofthefollowing:low
meancellvolume,higherythrocyteprotoporphyrinconcentration,orlowtransferrinsaturation)
(70,73,83).Causesofanemiaotherthanirondeficiencyincludeothernutritionaldeficiencies(e.g.,folate
orvitaminB12deficiency),hereditarydefectsinredbloodcellproduction(e.g.,thalassemiamajorand
sicklecelldisease),recentorcurrentinfection,andchronicinflammation(91).Thecurrentpatternofiron
deficiencyanemiaintheUnitedStates(28,45)indicatesthatselectiveanemiascreeningofchildrenat
knownriskforirondeficiencyoradditionalmeasurementofindicatorsofirondeficiency(e.g.,
erythrocyteprotoporphyrinconcentrationandserumferritinconcentration)toincreasethepositive
predictivevalueofscreeningarenowsuitableapproachestoassessingirondeficiencyamongmostU.S.
children(3,73).Thecostsandfeasibilityofscreeningusingadditionalindicatorsofirondeficiencymay
precludetheroutineuseoftheseindicators.MeanCellVolume
Meancellvolume(MCV),theaveragevolumeofredbloodcells,ismeasuredinfemtoliters(1015liters).
ThisvaluecanbecalculatedastheratioofHcttoredbloodcellcountormeasureddirectlyusingan
electroniccounter.MCVishighestatbirth,decreasesduringthefirst6monthsoflife,thengradually
increasesduringchildhoodtoadultlevels(23,51).AlowMCVcorrespondswiththe5thpercentilefor
ageforthereferencepopulationinNHANESIII(28).
Someanemias,includingirondeficiencyanemia,resultinmicrocyticredbloodcellsalowMCVthus
indicatesmicrocyticanemia(Table_8).Ifcasesofleadpoisoningandtheanemiasofinfection,chronic
inflammatorydisease,andthalassemiaminorcanbeexcluded,alowMCVservesasaspecificindexfor
irondeficiencyanemia(28,87,94,95).RedBloodCellDistributionWidth
Redbloodcelldistributionwidth(RDW)iscalculatedbydividingtheSDofredbloodcellvolumeby
MCVandmultiplyingby100toexpresstheresultasapercentage:
RDW(%)={SDofredbloodcellvolume(fL)/MCV(fL)}x100
AhighRDWisgenerallysetatgreaterthan14.0%,whichcorrespondstothe95thpercentileofRDWfor
thereferencepopulationinNHANESIII(20).TheRDWvalueobtaineddependsontheinstrumentused
(51,95).
AnRDWmeasurementoftenfollowsanMCVtesttohelpdeterminethecauseofalowMCV.For
example,irondeficiencyanemiausuallycausesgreatervariationinredbloodcellsizethandoes
thalassemiaminor(96).Thus,alowMCVandanRDWofgreaterthan14.0%indicatesirondeficiency
anemia,whereasalowMCVandanRDWlessthanorequalto14.0%indicatesthalassemiaminor(51).
ErythrocyteProtoporphyrinConcentration
ErythrocyteprotoporphyrinistheimmediateprecursorofHb.Theconcentrationoferythrocyte
protoporphyrininbloodincreaseswheninsufficientironisavailableforHbproduction.Aconcentration
ofgreaterthan30ug/dLofwholebloodorgreaterthan70ug/dLofredbloodcellsamongadultsanda
concentrationofgreaterthan80ug/dLofredbloodcellsamongchildrenaged12yearsindicatesiron
deficiency(28,45,91).Thenormalrangeoferythrocyteprotoporphyrinconcentrationishigherfor
childrenaged12yearsthanforadults,butnoconsensusexistsonthenormalrangeforinfants(28,90).
Thesensitivityoffreeerythrocyteprotoporphyrintoirondeficiency(asdeterminedbyresponsetoiron
therapy)inchildrenandadolescentsaged6months17yearsis42%,andtheestimatedspecificityis61%
(74).

https://www.cdc.gov/mmwr/preview/mmwrhtml/00051880.htm

9/26

12/1/2016

RecommendationstoPreventandControlIronDeficiencyintheUnitedStates

Infection,inflammation,andleadpoisoningaswellasirondeficiencycanelevateerythrocyte
protoporphyrinconcentration(23,92).Thismeasureofironstatushasseveraladvantagesand
disadvantagesrelativetootherlaboratorymeasures.Forexample,thedaytodayvariationwithinpersons
forerythrocyteprotoporphyrinconcentrationislessthanthatforserumironconcentrationandtransferrin
saturation(87).Ahigherythrocyteprotoporphyrinconcentrationisanearlierindicatorofirondeficient
erythropoiesisthanisanemia,butitisnotasearlyanindicatoroflowironstoresasislowserumferritin
concentration(30).Inexpensive,clinicbasedmethodshavebeendevelopedformeasuringerythrocyte
protoporphyrinconcentration,butthesemethodscanbelessreliablethanlaboratorymethods(92).Serum
FerritinConcentration
Nearlyallferritininthebodyisintracellularasmallamountcirculatesintheplasma.Undernormal
conditions,adirectrelationshipexistsbetweenserumferritinconcentrationandtheamountofironstored
inthebody(97),suchthat1ug/Lofserumferritinconcentrationisequivalenttoapproximately10mgof
storediron(98).IntheUnitedStates,theaverageserumferritinconcentrationis135ug/Lformen(28),
43ug/Lforwomen(28),andapproximately30ug/Lforchildrenaged624months(23).
Serumferritinconcentrationisanearlyindicatorofthestatusofironstoresandisthemostspecific
indicatoravailableofdepletedironstores,especiallywhenusedinconjunctionwithotherteststoassess
ironstatus.Forexample,amongwomenwhotestpositiveforanemiaonthebasisofHbconcentrationor
Hct,aserumferritinconcentrationoflessthanorequalto15ug/Lconfirmsirondeficiencyandaserum
ferritinconcentrationofgreaterthan15ug/Lsuggeststhatirondeficiencyisnotthecauseoftheanemia
(93).Amongwomenofchildbearingage,thesensitivityoflowserumferritinconcentration(lessthanor
equalto15ug/L)forirondeficiencyasdefinedbynostainablebonemarrowironis75%,andthe
specificityis98%whenlowserumferritinconcentrationissetatlessthan12ug/L,thesensitivityfor
irondeficiencyis61%andthespecificityis100%(93).Althoughlowserumferritinconcentrationisan
earlyindicatoroflowironstores,ithasbeenquestionedwhetheranormalconcentrationmeasuredduring
thefirstorsecondtrimesterofpregnancycanpredictadequateironstatuslaterinpregnancy(6).
Thecostofassessingserumferritinconcentrationandtheunavailabilityofclinicbasedmeasurement
methodshampertheuseofthismeasurementinscreeningforirondeficiency.Inthepast,methodological
problemshavehinderedthecomparabilityofmeasurementstakenindifferentlaboratories(87),butthis
problemmaybereducedbyproficiencytestingandstandardizedmethods.Factorsotherthanthelevelof
storedironcanresultinlargewithinindividualvariationinserumferritinconcentration(99).For
example,becauseserumferritinisanacutephasereactant,chronicinfection,inflammation,ordiseases
thatcausetissueandorgandamage(e.g.,hepatitis,cirrhosis,neoplasia,orarthritis)canraiseits
concentrationindependentofironstatus(97).Thiselevationcanmaskdepletedironstores.Transferrin
Saturation
Transferrinsaturationindicatestheextenttowhichtransferrinhasvacantironbindingsites(e.g.,alow
transferrinsaturationindicatesahighproportionofvacantironbindingsites).Saturationishighestin
neonates,decreasesbyage4months,andincreasesthroughoutchildhoodandadolescenceuntiladulthood
(23,28).Transferrinsaturationisbasedontwolaboratorymeasures,serumironconcentrationandtotal
ironbindingcapacity(TIBC).Transferrinsaturationiscalculatedbydividingserumironconcentrationby
TIBCandmultiplyingby100toexpresstheresultasapercentage:
Transferrinsaturation(%)={serumironconcentration(ug/dL)/TIBC(ug/dL)}x100
Serumironconcentrationisameasureofthetotalamountofironintheserumandisoftenprovidedwith
resultsfromotherroutinetestsevaluatedbyautomated,laboratorychemistrypanels.Manyfactorscan
affecttheresultsofthistest.Forexample,theconcentrationofserumironincreasesaftereachmeal(71),
infectionsandinflammationscandecreasetheconcentration(69),anddiurnalvariationcausesthe
concentrationtoriseinthemorningandfallatnight(100).Thedaytodayvariationofserumiron
concentrationwithinindividualsisgreaterthanthatforHbconcentrationandHct(88,101).

https://www.cdc.gov/mmwr/preview/mmwrhtml/00051880.htm

10/26

12/1/2016

RecommendationstoPreventandControlIronDeficiencyintheUnitedStates

TIBCisameasureoftheironbindingcapacitywithintheserumandreflectstheavailabilityofiron
bindingsitesontransferrin(94).Thus,TIBCincreaseswhenserumironconcentration(andstorediron)is
lowanddecreaseswhenserumironconcentration(andstorediron)ishigh.Factorsotherthanironstatus
canaffectresultsfromthistest.Forexample,inflammation,chronicinfection,malignancies,liverdisease,
nephroticsyndrome,andmalnutritioncanlowerTIBCreadings,andoralcontraceptiveuseandpregnancy
canraisethereadings(87,102).Nevertheless,thedaytodayvariationislessthanthatforserumiron
concentration(87,101).TIBCislesssensitivetoirondeficiencythanisserumferritinconcentration,
becausechangesinTIBCoccurafterironstoresaredepleted(17,31,94).
Atransferrinsaturationoflessthan16%amongadultsisoftenusedtoconfirmirondeficiency(93).
Amongnonpregnantwomenofchildbearingage,thesensitivityoflowtransferrinsaturation(lessthan
16%)forirondeficiencyasdefinedbynostainablebonemarrowironis20%,andthespecificityis93%
(93).
ThefactorsthataffectserumironconcentrationandTIBC,suchasironstatus,diurnalvariation(87,103),
anddaytodayvariationwithinpersons(101),canaffectthemeasuredtransferrinsaturationaswell.The
diurnalvarationislargerfortransferrinsaturationthanitisforHbconcentrationorHct(87,103).
Transferrinsaturationisanindicatorofirondeficienterythropoiesisratherthanirondepletionhence,itis
lesssensitivetochangesinironstoresthanisserumferritinconcentration(30,31).Thecostofassessing
transferrinsaturationandtheunavailabilityofsimple,clinicbasedmethodsformeasuringtransferrin
saturationhindertheuseofthistestinscreeningforirondeficiency.JUSTIFICATIONFOR
RECOMMENDATIONS
Theserecommendationsareintendedtoguideprimaryhealthcareprovidersinpreventingandcontrolling
irondeficiencyininfants,preschoolchildren,andwomenofchildbearingage(especiallypregnant
women).Bothprimarypreventionthroughappropriatedietaryintakeandsecondarypreventionthrough
detectingandtreatingirondeficiencyanemiaarediscussed.PrimaryPrevention
Primarypreventionofirondeficiencymeansensuringanadequateintakeofiron.Areliablesourceof
dietaryironisessentialforeveryinfantandchild'sgrowthanddevelopment,becausearapidrateof
growthandlowdietaryironmaypredisposeaninfanttoexhaustionofironstoresbyages46months
(23).Primarypreventionofirondeficiencyismostimportantforchildrenagedlessthan2years,because
amongallagegroupstheyareatthegreatestriskforirondeficiencycausedbyinadequateintakeofiron
(28,45,47,48,91).Theadequacyoftheironcontentofaninfant'sdietisamajordeterminantoftheiron
statusoftheinfantasayoungchild,asindicatedbydeclinesintheprevalenceofirondeficiencyanemia
thatcorrespondwithimprovementsininfantfeedingpractices(13).Ininfantsandyoungchildren,iron
deficiencymayresultindevelopmentalandbehavioraldisturbances(33,34).
Theevidencefortheeffectivenessofprimarypreventionamongpregnantwomenislessclear.Although
irondeficiencyanemiaduringpregnancyisassociatedwithpretermdeliveryanddeliveringalow
birthweightbaby(38),welldesigned,randomizedcontroltrialsareneededtoevaluatetheeffectivenessof
universalironsupplementationonmitigatingadversebirthoutcomes.Somestudieshaveindicatedthat
adequateironsupplementationduringpregnancyreducestheprevalenceofirondeficiencyanemia
(6,10,3942,66,104),butoverthelastfewdecades,therecommendationbytheCouncilonFoodsand
Nutritionandothergroupstosupplementironintakeduringpregnancyhasnotresultedinareduced
prevalenceofanemiaamonglowincome,pregnantwomen(4,9,105).Evidenceonironsupplementuseis
limited,however,soitisnotknownhowwelltherecommendationhasbeenfollowed.Conclusive
evidenceofthebenefitsofuniversalironsupplementationforallwomenislacking,butCDCadvocates
universalironsupplementationforpregnantwomenbecausealargeproportionofwomenhavedifficulty
maintainingironstoresduringpregnancyandareatriskforanemia(6,18,63),irondeficiencyanemia
duringpregnancyisassociatedwithadverseoutcomes(38),andsupplementationduringpregnancyisnot
associatedwithimportanthealthrisks(10,65,66).PotentialAdverseEffectsofIncreasingDietaryIron
Intake

https://www.cdc.gov/mmwr/preview/mmwrhtml/00051880.htm

11/26

12/1/2016

RecommendationstoPreventandControlIronDeficiencyintheUnitedStates

Approximately3.3millionwomenofchildbearingageand240,000childrenaged12yearshaveiron
deficiencyanemia(45)conversely,uptoonemillionpersonsintheUnitedStatesmaybeaffectedbyiron
overloadduetohemochromatosis(106,107).Hemochromatosisisageneticconditioncharacterizedby
excessiveironabsorption,excesstissueironstores,andpotentialtissueinjury.Ifundetectedand
untreated,ironoverloadmayeventuallyresultintheonsetofmorbidity(e.g.,cirrhosis,hepatomas,
diabetes,cardiomyopathy,arthritisorathropathy,orhypopituitarismwithhypogonadism),usually
betweenages40and60years.Clinicalexpressionofironoverloaddependsontheseverityofthe
metabolicdefect,thepresenceofsufficientquantitiesofabsorbableironinthediet,andphysiological
bloodlossfromthebody(e.g.,menstruation)(16).Transferrinsaturationistherecommendedscreening
testforhemochromatosisarepeatedhighvalueindicateshemochromatosis(108).Preventingortreating
theclinicalsignsofhemochromatosisinvolvesrepeatedphlebotomytoremoveexcessironfromthebody
(108).
Althoughincreasesinironintakewouldseemcontraindicatedinpersonswithhemochromatosis,thereis
noevidencethatironfortificationoffoodsortheuseofarecommendedironsupplementationregimen
duringpregnancyisassociatedwithincreasedriskforclinicaldiseaseduetohemochromatosis(16).Even
whentheirdietaryintakeofironisapproximatelyaverage,personswithironoverloaddueto
hemochromatosiswillrequirephlebotomytoreducetheirbody'sironstores(108).SecondaryPrevention
Secondarypreventioninvolvesscreeningfor,diagnosing,andtreatingirondeficiency.Screeningtestscan
beforanemiaorforearlierindicatorsofirondeficiency(e.g.,erythrocyteprotoporphyrinconcentrationor
serumferritinconcentration).Thecost,feasibility,andvariabilityofmeasurementsotherthanHb
concentrationandHctcurrentlyprecludetheiruseforscreening.Thedecisiontoscreenanentire
populationortoscreenonlypersonsatknownriskforirondeficiencyshouldbebasedontheprevalence
ofirondeficiencyinthatpopulation(73).
Thepercentageofanemicpersonswhoaretrulyirondeficient(i.e.,thepositivepredictivevalueof
anemiascreeningforirondeficiency)increaseswithincreasingprevalenceofirondeficiencyinthe
population(73).IntheUnitedStates,childrenfromlowincomefamilies,childrenlivingatorbelowthe
povertylevel,andblackorMexicanAmericanchildrenareathigherriskforirondeficiencythanare
childrenfrommiddleorhighincomefamilies,childrenlivingabovethepovertylevel,andwhite
children,respectively(2,3,45).Routinescreeningforanemiaamongpopulationsofchildrenathigherrisk
forirondeficiencyiseffective,becauseanemiaispredictiveofirondeficiency.Inpopulationshavinga
lowprevalenceofanemiaoraprevalenceofirondeficiencylessthan10%(e.g.,childrenfrommiddleor
highincomefamiliesandwhitechildren)(2,3,45),anemiaislesspredictiveofirondeficiency(73),and
selectivelyscreeningonlythepersonshavingknownriskfactorsforirondeficiencyincreasesthepositive
predictivevalueofanemiascreening(3,70).Becausetheironstoresofafullterminfantofnormalorhigh
birthweightcanmeetthebody'sironrequirementsuptoage6months(23),anemiascreeningisoflittle
valuebeforeage6monthsfortheseinfants.Anemiaamongpregnantwomenandanemiaamongall
nonpregnantwomenofchildbearingageshouldbeconsideredtogether,becausechildbearingincreases
theriskforirondeficiency(bothduringandafterpregnancy)(41,42),andirondeficiencybefore
pregnancylikelyincreasestheriskforirondeficiencyduringpregnancy(109).Periodicscreeningfor
anemiaamongadolescentgirlsandwomenofchildbearingageisindicatedforseveralreasons.First,most
womenhavedietaryintakeofironbelowtherecommendeddietaryallowance(46,47).Second,heavy
menstrualbloodloss,whichincreasesironrequirementstoabovetherecommendeddietaryallowance,
affectsanestimated10%ofwomenofchildbearingage(17,18).Finally,therelativelyhighprevalenceof
irondeficiencyandirondeficiencyanemiaamongnonpregnantwomenofchildbearingage(45)andof
anemiaamonglowincome,pregnantwomen(4)suggeststhatperiodicscreeningforanemiaisindicated
amongadolescentgirlsandnonpregnantwomenofchildbearingageduringroutinemedicalexaminations
(73)andamongpregnantwomenatthefirstprenatalvisit.Amongmenandpostmenopausalwomen,in
whomirondeficiencyandirondeficiencyanemiaareuncommon(45),anemiascreeningisnothighly
predictiveofirondeficiency.RECOMMENDATIONSInfants(PersonsAged012Months)andPreschool
Children(PersonsAged15Years)
https://www.cdc.gov/mmwr/preview/mmwrhtml/00051880.htm

12/26

12/1/2016

RecommendationstoPreventandControlIronDeficiencyintheUnitedStates

Primarypreventionofirondeficiencyininfantsandpreschoolchildrenshouldbeachievedthroughdiet.
InformationondietandfeedingisavailableinthePediatricNutritionHandbook(8),GuidetoClinical
PreventiveServices(10),NutritionandYourHealth:DietaryGuidelinesforAmericans(14),
BreastfeedingandtheUseofHumanMilk(110),andClinician'sHandbookofPreventiveServices:Put
PreventionintoPractice(111).Forsecondarypreventionofirondeficiencyinthisagegroup,screening
for,diagnosing,andtreatingirondeficiencyanemiaarerecommended.PrimaryPreventionMilkand
InfantFormulas
Encouragebreastfeedingofinfants.
Encourageexclusivebreastfeedingofinfants(withoutsupplementaryliquid,formula,orfood)for
46monthsafterbirth.
Whenexclusivebreastfeedingisstopped,encourageuseofanadditionalsourceofiron
(approximately1mg/kgperdayofiron),preferablyfromsupplementaryfoods.
Forinfantsagedlessthan12monthswhoarenotbreastfedorwhoarepartiallybreastfed,
recommendonlyironfortifiedinfantformulaasasubstituteforbreastmilk.
Forbreastfedinfantswhoreceiveinsufficientironfromsupplementaryfoodsbyage6months(i.e.,
lessthan1mg/kgperday),suggest1mg/kgperdayofirondrops.
Forbreastfedinfantswhowerepretermorhadalowbirthweight,recommend24mg/kgperdayof
irondrops(toamaximumof15mg/day)startingat1monthafterbirthandcontinuinguntil12
monthsafterbirth.
Encourageuseofonlybreastmilkorironfortifiedinfantformulaforanymilkbasedpartofthe
diet(e.g.,ininfantcereal)anddiscourageuseoflowironmilks(e.g.,cow'smilk,goat'smilk,and
soymilk)untilage12months.
Suggestthatchildrenaged15yearsconsumenomorethan24ozofcow'smilk,goat'smilk,orsoy
milkeachday.SolidFoods
Atage46monthsorwhentheextrusionreflexdisappears,recommendthatinfantsbeintroducedto
plain,ironfortifiedinfantcereal.Twoormoreservingsperdayofironfortifiedinfantcerealcan
meetaninfant'srequirementforironatthisage.
Byapproximatelyage6months,encourageonefeedingperdayoffoodsrichinvitaminC(e.g.,
fruits,vegetables,orjuice)toimproveironabsorption,preferablywithmeals.
Suggestintroducingplain,pureedmeatsafterage6monthsorwhentheinfantisdevelopmentally
readytoconsumesuchfood.SecondaryPreventionUniversalScreening
Inpopulationsofinfantsandpreschoolchildrenathighriskforirondeficiencyanemia(e.g.,
childrenfromlowincomefamilies,childreneligiblefortheSpecialSupplementalNutrition
ProgramforWomen,Infants,andChildren{WIC},migrantchildren,orrecentlyarrivedrefugee
children),screenallchildrenforanemiabetweenages9and12months,6monthslater,and
annuallyfromages2to5years.SelectiveScreening
Inpopulationsofinfantsandpreschoolchildrennotathighriskforirondeficiencyanemia,screen
onlythosechildrenwhohaveknownriskfactorsforthecondition.Thesechildrenaredescribedin
thenextthreebulleteditems.
Consideranemiascreeningbeforeage6monthsforpreterminfantsandlowbirthweightinfants
whoarenotfedironfortifiedinfantformula.
https://www.cdc.gov/mmwr/preview/mmwrhtml/00051880.htm

13/26

12/1/2016

RecommendationstoPreventandControlIronDeficiencyintheUnitedStates

Annuallyassesschildrenaged25yearsforriskfactorsforirondeficiencyanemia(e.g.,alowiron
diet,limitedaccesstofoodbecauseofpovertyorneglect,orspecialhealthcareneeds).Screen
thesechildreniftheyhaveanyoftheseriskfactors.
Atages912monthsand6monthslater(atages1518months),assessinfantsandyoungchildren
forriskfactorsforanemia.Screenthefollowingchildren:
1.Pretermorlowbirthweightinfants
2.Infantsfedadietofnonironfortifiedinfantformulaforgreaterthan2months
3.Infantsintroducedtocow'smilkbeforeage12months
4.Breastfedinfantswhodonotconsumeadietadequateinironafterage6months(i.e.,who
receiveinsufficientironfromsupplementaryfoods)
5.Childrenwhoconsumegreaterthan24ozdailyofcow'smilk
6.Childrenwhohavespecialhealthcareneeds(e.g.,childrenwhousemedicationsthat
interferewithironabsorptionandchildrenwhohavechronicinfection,inflammatory
disorders,restricteddiets,orextensivebloodlossfromawound,anaccident,orsurgery).
DiagnosisandTreatment
CheckapositiveanemiascreeningresultbyperformingarepeatHbconcentrationorHcttest.Ifthe
testsagreeandthechildisnotill,apresumptivediagnosisofirondeficiencyanemiacanbemade
andtreatmentbegun.
Treatpresumptiveirondeficiencyanemiabyprescribing3mg/kgperdayofirondropstobe
administeredbetweenmeals.Counseltheparentsorguardiansaboutadequatediettocorrectthe
underlyingproblemoflowironintake.
Repeattheanemiascreeningin4weeks.AnincreaseinHbconcentrationofgreaterthanorequalto
1g/dLorinHctofgreaterthanorequalto3%confirmsthediagnosisofirondeficiencyanemia.If
irondeficiencyanemiaisconfirmed,reinforcedietarycounseling,continueirontreatmentfor2
moremonths,thenrecheckHbconcentrationorHct.ReassessHbconcentrationorHct
approximately6monthsaftersuccessfultreatmentiscompleted.
Ifafter4weekstheanemiadoesnotrespondtoirontreatmentdespitecompliancewiththeiron
supplementationregimenandtheabsenceofacuteillness,furtherevaluatetheanemiabyusing
otherlaboratorytests,includingMCV,RDW,andserumferritinconcentration.Forexample,a
serumferritinconcentrationoflessthanorequalto15ug/Lconfirmsirondeficiency,anda
concentrationofgreaterthan15ug/Lsuggeststhatirondeficiencyisnotthecauseoftheanemia.
SchoolAgeChildren(PersonsAged5lessthan12Years)andAdolescentBoys(MalesAged12
lessthan18Years)
Amongschoolagechildrenandadolescentboys,onlythosewhohaveahistoryofirondeficiency
anemia,specialhealthcareneeds,orlowironintakeshouldbescreenedforanemia.Agespecificanemia
criteriashouldbeused(Table_6).Treatmentforirondeficiencyanemiaincludesone60mgirontablet
eachdayforschoolagechildrenandtwo60mgirontabletseachdayforadolescentboysandcounseling
aboutdietaryintakeofiron.Followupandlaboratoryevaluationarethesameforschoolagechildrenand
adolescentboysastheyareforinfantsandpreschoolchildren.AdolescentGirls(Females12lessthan18
Years)andNonpregnantWomenofChildbearingAge

https://www.cdc.gov/mmwr/preview/mmwrhtml/00051880.htm

14/26

12/1/2016

RecommendationstoPreventandControlIronDeficiencyintheUnitedStates

Primarypreventionofirondeficiencyforadolescentgirlsandnonpregnantwomenofchildbearingageis
throughdiet.Informationabouthealthydiets,includinggoodsourcesofiron,isavailableinNutritionand
YourHealth:DietaryGuidelinesforAmericans(14).Screeningfor,diagnosing,andtreatingiron
deficiencyanemiaaresecondarypreventionapproaches.Agespecificanemiacriteriashouldbeused
duringscreening(Table_6).PrimaryPrevention
Mostadolescentgirlsandwomendonotrequireironsupplements,butencouragethemtoeatiron
richfoodsandfoodsthatenhanceironabsorption.
Womenwhohavelowirondietsareatadditionalriskforirondeficiencyanemiaguidethese
womeninoptimizingtheirdietaryironintake.SecondaryPreventionScreening
Startinginadolescence,screenallnonpregnantwomenforanemiaevery510yearsthroughout
theirchildbearingyearsduringroutinehealthexaminations.
Annuallyscreenforanemiawomenhavingriskfactorsforirondeficiency(e.g.,extensive
menstrualorotherbloodloss,lowironintake,orapreviousdiagnosisofirondeficiencyanemia).
DiagnosisandTreatment
ConfirmapositiveanemiascreeningresultbyperformingarepeatHbconcentrationorHcttest.If
theadolescentgirlorwomanisnotill,apresumptivediagnosisofirondeficiencyanemiacanbe
madeandtreatmentbegun.
Treatadolescentgirlsandwomenwhohaveanemiabyprescribinganoraldoseof60120mg/day
ofiron.Counselthesepatientsaboutcorrectingirondeficiencythroughdiet.
Followupadolescentgirlsandnonpregnantwomenofchildbearingageasisdoneforinfantsand
preschoolchildren,exceptthatforaconfirmedcaseofirondeficiencyanemia,continueiron
treatmentfor23moremonths.
Ifafter4weekstheanemiadoesnotrespondtoirontreatmentdespitecompliancewiththeiron
supplementationregimenandtheabsenceofacuteillness,furtherevaluatetheanemiabyusing
otherlaboratorytests,includingMCV,RDW,andserumferritinconcentration.Inwomenof
African,Mediterranean,orSoutheastAsianancestry,mildanemiaunresponsivetoirontherapymay
beduetothalassemiaminororsicklecelltrait.PregnantWomen
Primarypreventionofirondeficiencyduringpregnancyincludesadequatedietaryironintakeandiron
supplementation.Informationabouthealthydiets,includinggoodsourcesofiron,isfoundinNutrition
andYourHealth:DietaryGuidelinesforAmericans(14).Moredetailedinformationforpregnantwomen
isfoundinNutritionDuringPregnancyandLactation:AnImplementationGuide(112).Secondary
preventioninvolvesscreeningfor,diagnosing,andtreatingirondeficiencyanemia.PrimaryPrevention
Startoral,lowdose(30mg/day)supplementsofironatthefirstprenatalvisit.
Encouragepregnantwomentoeatironrichfoodsandfoodsthatenhanceironabsorption.
Pregnantwomenwhosedietsarelowinironareatadditionalriskforirondeficiencyanemiaguide
thesewomeninoptimizingtheirdietaryironintake.SecondaryPreventionScreening
Screenforanemiaatthefirstprenatalcarevisit.Usetheanemiacriteriaforthespecificstageof
pregnancy(Table_6).DiagnosisandTreatment
ConfirmapositiveanemiascreeningresultbyperformingarepeatHbconcentrationorHcttest.If
thepregnantwomanisnotill,apresumptivediagnosisofirondeficiencyanemiacanbemadeand
treatmentbegun.
https://www.cdc.gov/mmwr/preview/mmwrhtml/00051880.htm

15/26

12/1/2016

RecommendationstoPreventandControlIronDeficiencyintheUnitedStates

IfHbconcentrationislessthan9.0g/dLorHctislessthan27.0%,referthepatienttoaphysician
familiarwithanemiaduringpregnancyforfurthermedicalevaluation.
Treatanemiabyprescribinganoraldoseof60120mg/dayofiron.Counselpregnantwomenabout
correctingirondeficiencyanemiathroughdiet.
Ifafter4weekstheanemiadoesnotrespondtoirontreatment(thewomanremainsanemicforher
stageofpregnancyandHbconcentrationdoesnotincreaseby1g/dLorHctby3%)despite
compliancewithanironsupplementationregimenandtheabsenceofacuteillness,furtherevaluate
theanemiabyusingothertests,includingMCV,RDW,andserumferritinconcentration.Inwomen
ofAfrican,Mediterranean,orSoutheastAsianancestry,mildanemiaunresponsivetoirontherapy
maybeduetothalassemiaminororsicklecelltrait.
WhenHbconcentrationorHctbecomesnormalforthestageofgestation,decreasethedoseofiron
to30mg/day.
Duringthesecondorthirdtrimester,ifHbconcentrationisgreaterthan15.0g/dLorHctisgreater
than45.0%,evaluatethewomanforpotentialpregnancycomplicationsrelatedtopoorblood
volumeexpansion.PostpartumWomen
Womenatriskforanemiaat46weekspostpartumshouldbescreenedforanemiabyusingaHb
concentrationorHcttest.Theanemiacriteriafornonpregnantwomenshouldbeused(Table_6).Risk
factorsincludeanemiacontinuedthroughthethirdtrimester,excessivebloodlossduringdelivery,anda
multiplebirth.Treatmentandfollowupforirondeficiencyanemiainpostpartumwomenarethesameas
fornonpregnantwomen.Ifnoriskfactorsforanemiaarepresent,supplementalironshouldbestoppedat
delivery.Men(MalesAgedgreaterthanorequalto18Years)andPostmenopausalWomen
Noroutinescreeningforirondeficiencyisrecommendedformenorpostmenopausalwomen.Iron
deficiencyoranemiadetectedduringroutinemedicalexaminationsshouldbefullyevaluatedforitscause.
Menandpostmenopausalwomenusuallydonotneedironsupplements.CONCLUSION
IntheUnitedStates,irondeficiencyaffects7.8millionadolescentgirlsandwomenofchildbearingage
and700,000childrenaged12years(45).Primaryhealthcareproviderscanhelppreventandcontroliron
deficiencybycounselingindividualsandfamiliesaboutsoundironnutritionduringinfancyandbeyond
andaboutironsupplementationduringpregnancy,byscreeningpersonsonthebasisoftheirriskforiron
deficiency,andbytreatingandfollowinguppersonswithpresumptiveirondeficiency.Implementing
theserecommendationswillhelpreducemanifestationsofirondeficiency(e.g.,pretermbirths,low
birthweight,anddelaysininfantandchilddevelopment)andthusimprovepublichealth.

References
1.YipR,WalshKM,GoldfarbMG,BinkinNJ.Decliningprevalenceofanemiainchildhoodina
middleclasssetting:apediatricsuccessstory?Pediatrics198780(3):3304.
2.YipR,BinkinNJ,FleshoodL,TrowbridgeFL.Decliningprevalenceofanemiaamonglowincome
childrenintheUnitedStates.JAMA1987258(12):161923.
3.YipR.ThechangingcharacteristicsofchildhoodironnutritionalstatusintheUnitedStates.In:
FilerLJJr,ed.Dietaryiron:birthtotwoyears.NewYork,NY:RavenPress,1989:3761.
4.PerryGS,YipR,ZyrkowskiC.NutritionalriskfactorsamonglowincomepregnantUSwomen:
theCentersforDiseaseControlandPrevention(CDC)PregnancyNutritionSurveillanceSystem,
1979through1993.SeminPerinatol199519(3):21121.

https://www.cdc.gov/mmwr/preview/mmwrhtml/00051880.htm

16/26

12/1/2016

RecommendationstoPreventandControlIronDeficiencyintheUnitedStates

5.EarlR,WotekiCE,eds.Irondeficiencyanemia:recommendedguidelinesfortheprevention,
detection,andmanagementamongU.S.childrenandwomenofchildbearingage.Washington,DC:
NationalAcademyPress,1993.
6.AllenLH.Pregnancyandirondeficiency:unresolvedissues.NutrRev199755(44):91101.
7.InstituteofMedicine.Nutritionduringpregnancy.Washington,DC:NationalAcademyPress,1990.
8.BarnessLA,ed.Pediatricnutritionhandbook.3rded.ElkGroveVillage,IL:AmericanAcademyof
Pediatrics,1993.
9.HauthJohnC,MerensteinBB,eds.Guidelinesforperinatalcare.4thed.ElkGroveVillage,IL:
AmericanAcademyofPediatricsandAmericanCollegeofObstetriciansandGynecologists,1997.
10.U.S.PreventiveServicesTaskForce.Screeningforirondeficiencyanemiaincludingiron
prophylaxis.In:Guidetoclinicalpreventiveservices.2nded.Alexandria,VA:International
MedicalPublishing,1996:23146.
11.InternationalFederationofGynecologyandObstetrics.Nutritionduringpregnancy.IntJGynecol
Obstet199343:6774.(ACOGTechnicalBulletinno.179.)
12.AndersonSA,ed.Guidelinesfortheassessmentandmanagementofirondeficiencyinwomenof
childbearingage.Bethesda,MD:U.S.DepartmentofHealthandHumanServices,FoodandDrug
Administration,CenterforFoodSafetyandAppliedNutrition,1991.
13.PublicHealthService.Caringforourfuture:thecontentofprenatalcare.AreportofthePublic
HealthServiceExpertPanelontheContentofPrenatalCare.Washington,DC:U.S.Departmentof
HealthandHumanServices,PublicHealthService,1989.
14.U.S.DepartmentofAgricultureandU.S.DepartmentofHealthandHumanServices.Nutritionand
yourhealth:dietaryguidelinesforAmericans.4thed.Washington,DC:U.S.Departmentof
AgricultureandU.S.DepartmentofHealthandHumanServices,1995.(HomeandGardenBulletin
no.232.)
15.PublicHealthService.Healthypeople2000:nationalhealthpromotionanddiseaseprevention
objectives.Washington,DC:U.S.DepartmentofHealthandHumanServices,PublicHealth
Service,1991.DHHSpublicationno.(PHS)9150212.
16.BothwellTH.Overviewandmechanismsofironregulation.NutrRev199553(9):23745.
17.BothwellTH,CharltonRW,CookJD,FinchCA.Ironmetabolisminman.Oxford,UK:Blackwell
ScientificPublications,1979.
18.BothwellTH,CharltonRW.Irondeficiencyinwomen.Washington,DC:TheNutritionFoundation,
1981.
19.HallbergL.Bioavailabilityofdietaryironinman.AnnuRevNutr19811:12347.
20.SkikneB,BaynesRD.Ironabsorption.In:BrockJH,HallidayJW,PippardMJ,PowellLW,eds.
Ironmetabolisminhealthanddisease.London,UK:W.B.Saunders,1994:15187.
21.FinchCA,CookJD.Irondeficiency.AmJClinNutr198439:4717.
22.SiegenbergD,BaynesRD,BothwellTH,etal.Ascorbicacidpreventsthedosedependent
inhibitoryeffectsofpolyphenolsandphytatesonnonhemeironabsorption.AmJClinNutr
199453:53741.
https://www.cdc.gov/mmwr/preview/mmwrhtml/00051880.htm

17/26

12/1/2016

RecommendationstoPreventandControlIronDeficiencyintheUnitedStates

23.DallmanPR,SiimesMA,StekelA.Irondeficiencyininfancyandchildhood.AmJClinNutr
198033:86118.
24.GreenR,CharltonR,SeftelH,etal.Bodyironexcretioninman:acollaborativestudy.AmJMed
196845:33653.
25.HallbergL.Ironbalanceinpregnancy.In:BergerH,ed.Vitaminsandmineralsinpregnancyand
lactation.NewYork,NY:RavenPress,1988:11527.
26.KappusKD,LundgrenRGJr,JuranekDD,RobertsJM,SpencerHC.Intestinalparasitisminthe
UnitedStates:updateonacontinuingproblem.AmJTropMedHyg199450(6):70513.
27.StoltzfusRJ,ChwayaHM,TielschJM,SchulzeKJ,AlbonicoM,SavioliL.Epidemiologyofiron
deficiencyanemiainZanzibarischoolchildren:theimportanceofhookworms.AmJClinNutr
199765:1539.
28.DallmanPR,LookerAC,JohnsonCL,CarrollM.Influenceofageonlaboratorycriteriaforthe
diagnosisofirondeficiencyanemiaandirondeficiencyininfantsandchildren.In:HallbergL,Asp
NG,eds.Ironnutritioninhealthanddisease.London,UK:JohnLibby&Co.,1996:6574.
29.DeMaeyerEM.Preventingandcontrollingirondeficiencyanaemiathroughprimaryhealthcare:a
guideforhealthadministratorsandprogrammemanagers.Geneva,Switzerland:WorldHealth
Organization,1989.
30.HerbertV.Everyoneshouldbetestedforirondisorders.JAmDietAssoc199292(12):15029.
31.BaynesRD.Irondeficiency.In:BrockJH,HallidayJW,PippardMJ,PowellLW,eds.Iron
metabolisminhealthanddisease.London,UK:W.B.Saunders,1994:189225.
32.PollittE.Irondeficiencyandcognitivefunction.AnnuRevNutr199313:52137.
33.IdjradinataP,PollittE.Reversalofdevelopmentaldelaysinirondeficientanaemicinfantstreated
withiron.Lancet1993341(8836):14.
34.LozoffB,JimenezE,WolfAW.Longtermdevelopmentaloutcomeofinfantswithirondeficiency.
NEnglJMed1991325(10):68794.
35.GoyerRA.Nutritionandmetaltoxicity.AmJClinNutr199561(suppl):646S650S.
36.LiR,ChenX,YanH,DeurenbergP,GarbyL,HautvastJG.Functionalconsequencesofiron
supplementationinirondeficientfemalecottonmillworkersinBeijing,China.AmJClinNutr
199459(4):90813.
37.CookJD,SkikneBS,BaynesRD.Irondeficiency:theglobalperspective.In:HershkoC,Konijn
AN,AisenP,eds.Progressinironresearch.NewYork,NY:PlenumPress,1994:21928.
38.SchollTO,HedigerML,FischerRL,ShearerJW.Anemiavsirondeficiency:increasedriskof
pretermdeliveryinaprospectivestudy.AmJClinNutr199255:9858.
39.SvanbergB,ArvidssonB,NorrbyA,RyboG,SlvellL.Absorptionofsupplementalironduring
pregnancy:alongitudinalstudywithrepeatedbonemarrowstudiesandabsorptionmeasurements.
ActaObstetGynecolScandSuppl197548:87108.
40.SjostedtJE,MannerP,NummiS,EkenvedG.Oralironprophylaxisduringpregnancy:a
comparativestudyondifferentdosageregimens.ActaObstetGynecolScandSuppl197760:39.
https://www.cdc.gov/mmwr/preview/mmwrhtml/00051880.htm

18/26

12/1/2016

RecommendationstoPreventandControlIronDeficiencyintheUnitedStates

41.PuolakkaJ,JanneO,PakarinenA,JarvinenA,VihkoR.Serumferritinasameasureofironstores
duringandafternormalpregnancywithandwithoutironsupplements.ActaObstetGynecolScand
Suppl198095:4351.
42.TaylorDJ,MallenC,McDougallN,LindT.Effectofironsupplementationonserumferritinlevels
duringandafterpregnancy.BrJObstetGynaecol198289:10117.
43.HemminkiE,RimpelaU.Arandomizedcomparisonofroutineversusselectiveiron
supplementationduringpregnancy.JAmCollNutr199110(1):310.
44.HemminkiE,MerilainenJ.Longtermfollowupofmothersandtheirinfantsinarandomizedtrial
onironprophylaxisduringpregnancy.AmJObstetGynecol1995173(1):2059.
45.LookerAC,DallmanPR,CarrollMD,GunterEW,JohnsonCL.Prevalenceofirondeficiencyin
theUnitedStates.JAMA1997277(12):9736.
46.NationalResearchCouncil.Recommendeddietaryallowances.10thed.Washington,DC:National
AcademyPress,1989.
47.U.S.DepartmentofAgriculture,AgriculturalResearchService.Datatables:resultsfromUSDA's
199496ContinuingSurveyofFoodIntakesbyIndividualsand199496DietandHealth
KnowledgeSurvey{online}.Riverdale,MD:U.S.DepartmentofAgriculture,Agricultural
ResearchService,BeltsvilleHumanNutritionResearchCenter,December1997.Availableat:
http://www.barc.usda.gov/bhnrc/foodsurvey/home.htm.AccessedJanuary14,1998.
48.PizarroF,YipR,DallmanPR,OlivaresM,HertrampfE,WalterT.Ironstatuswithdifferentinfant
feedingregimens:relevancetoscreeningandpreventionofirondeficiency.JPediatr1991118:687
92.
49.WalterT,DallmanPR,PizarroF,etal.Effectivenessofironfortifiedinfantcerealinpreventionof
irondeficiencyanemia.Pediatrics199391(5):97682.
50.PisacaneA,DeViziaB,ValienteA,etal.Ironstatusinbreastfedinfants.JPediatr1995
127(3):42931.
51.OskiFA.Irondeficiencyininfancyandchildhood.NEnglJMed1993329(3):1903.
52.BoutryM,NeedlmanR.Useofdiethistoryinthescreeningofirondeficiency.Pediatrics
199698(6):113842.
53.SawayaWN,KhalilJK,AlShalhatAF.Mineralandvitamincontentofgoat'smilk.JAmDiet
Assoc198484(4):4335.
54.USDANutrientDatabaseforStandardReference{databaseonline}.Riverdale,MD:UnitedStates
DepartmentofAgriculture,AgriculturalResearchService,BeltsvilleHumanResearchCenter,
September1996.Availableat:http://www.nal.usda.gov/fnic/cgibin/nut_search.pl.Accessed
January16,1998.
55.YipR.Irondeficiency:contemporaryscientificissuesandinternationalprogrammaticapproaches.J
Nutr1994124:1479S1490S.
56.OskiFA.Ironfortifiedformulasandgastrointestinalsymptomsininfants:acontrolledstudy.
Pediatrics198066(2):16870.
57.NelsonSE,ZieglerEE,CopelandAM,EdwardsBB,FomonSJ.Lackofadversereactionstoiron
fortifiedformula.Pediatrics198881(3):3604.
https://www.cdc.gov/mmwr/preview/mmwrhtml/00051880.htm

19/26

12/1/2016

RecommendationstoPreventandControlIronDeficiencyintheUnitedStates

58.ScariatiPD,GrummerStrawnLM,FeinSB,YipR.Riskofdiarrhearelatedtoironcontentof
infantformula:lackofevidencetosupporttheuseoflowironformulaasasupplementfor
breastfedinfants.Pediatrics{serialonline}.March199799(3).Availableat:
http://www.pediatrics.org/cgi/content/full/99/3/e2.
59.AmericanAcademyofPediatricsCommitteeonNutrition.Ironfortifiedinfantformulas.Pediatrics
198984(6):11145.
60.YipR,DallmanPR.Iron.In:ZieglerEE,FilerLJJr,eds.Presentknowledgeinnutrition.7thed.
Washington,DC:InternationalLifeSciencesInstitutePress,1996:27792.
61.HallbergL.Ironrequirements:commentsonmethodsandsomecrucialconceptsinironnutrition.
BiolTraceElemRes1992:35:2545.
62.MooijPNM,ThomasCMG,DoesburgWH,EskesTKAB.Theeffectsoforalcontraceptivesand
multivitaminsupplementationonserumferritinandhematologicalparameters.IntJClinPharmacol
TherToxicol199230(2):5762.
63.ThomsenJK,PrienLarsenJC,DevantierA,FoghAndersenN.Lowdoseironsupplementation
doesnotcovertheneedforironduringpregnancy.ActaObstetGynecolScand199372:938.
64.YuSM,KeppelKG,SinghGK,KesselW.Preconceptionalandprenatalmultivitaminmineral
supplementuseinthe1988NationalMaternalandInfantHealthSurvey.AmJPublicHealth
199686(2):2402.
65.GallowayR,McGuireJ.Determinantsofcompliancewithironsupplementation:supplies,side
effects,orpsychology?SocSciMed199439(3):38190.
66.ChanarinI,RothmanD.Furtherobservationsontherelationbetweenironandfolatestatusin
pregnancy.BrMedJ19712:814.
67.HemminkiE,UskiA,KoponenP,RimpelaU.Ironsupplementationduringpregnancy
experiencesofarandomizedtrialrelyingonhealthservicepersonnel.ControlledClinTrials
198910:2908.
68.RockeyDC,CelloJP.Evaluationofthegastrointestinaltractinpatientswithirondeficiency
anemia.NEnglJMed1993329(23):16915.
69.YipR,DallmanPR.Therolesofinflammationandirondeficiencyascausesofanemia.AmJClin
Nutr198848:1295300.
70.YipR.Ironnutritionalstatusdefined.In:FilerLJJr,ed.Dietaryiron:birthtotwoyears.NewYork,
NY:RavenPress,1989:1936.
71.TietzNW,ed.Clinicalguidetolaboratorytests.3rded.Philadelphia,PA:W.B.Saunders,1995.
72.CDC.CDCcriteriaforanemiainchildrenandchildbearingagedwomen.MMWR1989
38(22):4004.
73.BinkinNJ,YipR.Whenisanemiascreeningofvalueindetectingirondeficiency?In:HercbergS,
GalanP,DupinH,eds.Recentknowledgeonironandfolatedeficienciesintheworld.Vol.197.
Paris,France:L'InstitutNationaldelaSanteetdelaRechercheMedicale,1990:13745.
74.MargolisHS,HardisonHH,BenderTR,DallmanPR.Irondeficiencyinchildren:therelationship
betweenpretreatmentlaboratorytestsandsubsequenthemoglobinresponsetoirontherapy.AmJ
ClinNutr198134(10):215868.
https://www.cdc.gov/mmwr/preview/mmwrhtml/00051880.htm

20/26

12/1/2016

RecommendationstoPreventandControlIronDeficiencyintheUnitedStates

75.SteerP,AlamMA,WadsworthJ,WelchA.Relationbetweenmaternalhaemoglobinconcentration
andbirthweightindifferentethnicgroups.BrMedJ1995310:48991.
76.LuZM,GoldenbergRL,CliverSP,CutterG,BlanksonM.Therelationshipbetweenmaternal
hematocritandpregnancyoutcome.ObstetGynecol199177:1904.
77.GarnSM,RidellaSA,PetzoldAS,FalknerF.Maternalhematologiclevelsandpregnancy
outcomes.SeminPerinatol19815(2):15562.
78.MurphyJF,O'RiordanJ,NewcombRG,ColesEC,PearsonJF.Relationofhaemoglobinlevelsin
firstandsecondtrimesterstooutcomeofpregnancy.Lancet19861(8488):9925.
79.DirrenH,LogmanMHGM,BarclayDV,FreireWB.Altitudecorrectionforhemoglobin.EurJClin
Nutr199448:62532.
80.NordenbergD,YipR,BinkinNJ.Theeffectofcigarettesmokingonhemoglobinlevelsandanemia
screening.JAMA1990264(12):15569.
81.DallmanPR,BarrGD,AllenCM,ShinefieldHR.Hemoglobinconcentrationinwhite,black,and
Orientalchildren:isthereaneedforseparatecriteriainscreeningforanemia?AmJClinNutr
197831:37780.
82.YipR,SchwartzS,DeinardAS.Hematocritvaluesinwhite,black,andAmericanIndianchildren
withcomparableironstatus:evidencetosupportuniformdiagnosticcriteriaforanemiaamongall
races.AmJDisChild1984138:8247.
83.JohnsonSpearMA,YipR.Hemoglobindifferencebetweenblackandwhitewomenwith
comparableironstatus:justificationforracespecificanemiacriteria.AmJClinNutr199460:117
21.
84.PerryGS,ByersT,YipR,MargenS.Ironnutritiondoesnotaccountforthehemoglobindifferences
betweenblacksandwhites.JNutr1992122:141724.
85.BridgesN,ParvinRM,vanAssendelftOW.Evaluationofanewsystemforhemoglobin
measurement.AmClinProductsRev19876(4):2225.
86.BartfieldJM.RobinsonD,LekasJ.Accuracyofmicrocentrifugedhematocritsintheemergency
department.JEmergMed199311:6736.
87.BeatonGH,CoreyPN,SteeleC.Conceptualandmethodologicalissuesregardingtheepidemiology
ofirondeficiencyandtheirimplicationsforstudiesofthefunctionalconsequencesofiron
deficiency.AmJClinNutr198950:57588.
88.BorelMJ,SmithSM,DerrJ,BeardJL.Daytodayvariationsinironstatusindicesinhealthymen
andwomen.AmJClinNutr199154:72935.
89.ThomasWJ,CollinsTM.Comparisonofvenipuncturebloodcountswithmicrocapillary
measurementsinscreeningforanemiainoneyearoldinfants.JPediatr1982101(1):325.
90.PilchSM,SentiFR,eds.AssessmentoftheironnutritionalstatusoftheU.S.populationbasedon
datacollectedinthesecondNationalHealthandNutritionExaminationSurvey,19761980.
Bethesda,MD:FederationofAmericanSocietiesforExperimentalBiology,LifeSciencesResearch
Office,1984.
91.DallmanPR,YipR,JohnsonC.PrevalenceandcausesofanemiaintheUnitedStates,1976to
1980.AmJClinNutr198439:43745.
https://www.cdc.gov/mmwr/preview/mmwrhtml/00051880.htm

21/26

12/1/2016

RecommendationstoPreventandControlIronDeficiencyintheUnitedStates

92.PiomelliS.Thediagnosticutilityofmeasurementsoferythrocyteporphyrins.HematolOncolClin
NorthAm19871(3):41930.
93.HallbergL,BengtssonC,LapidusL,LindstedtG,LundbergPA,HultenL.Screeningforiron
deficiency:ananalysisbasedonbonemarrowexaminationsandserumferritindeterminationsina
populationsampleofwomen.BrJHaematol199385:78798.
94.GibsonRS.Principlesofnutritionalassessment.NewYork,NY:OxfordUniversityPress,1990.
95.OskiFA,BrugnaraC,NathanDG.Adiagnosticapproachtotheanemicpatient.In:NathanDG,
OrkinSH,eds.NathanandOski'shematologyofinfancyandchildhood.5thed.Philadelphia,PA:
W.B.SaundersCo.,1998:37584.
96.NovakRW.Redbloodcelldistributionwidthinpediatricmicrocyticanemias.Pediatrics
198780(2):2514.
97.LipschitzDA,CookJD,FinchCA.Aclinicalevaluationofserumferritinasanindexofironstores.
NEnglJMed1974290(22):12136.
98.CookJD,FinchCA.Assessingironstatusofapopulation.AmJClinNutr197932:21159.
99.CooperMJ,ZlotkinSH.Daytodayvariationoftransferrinreceptorandferritininhealthymenand
women.AmJClinNutr199664:73842.
100.HamiltonLD,GublerCJ,CartwrightGE,WintrobeMM.Diurnalvariationintheplasmaironlevel
ofman.ProcSocExpBiolMed195075(1):658.
101.LookerAC,SemposCT,LiuK,JohnsonCL,GunterEW.Withinpersonvarianceinbiochemical
indicatorsofironstatus:effectsonprevalenceestimates.AmJClinNutr199052:5417.
102.BrittenhamGM.Disordersofironmetabolism:irondeficiencyandoverload.In:HoffmanR,Benz
EJJr,ShattilSJ,FurieB,CohenHJ,eds.Hematology:basicprinciplesandpractice.2nded.New
York,NY:ChurchillLivingstone,1995:492523.
103.LookerAC,GunterEW,JohnsonCL.MethodstoassessironstatusinvariousNHANESsurveys.
NutrRev199553(9):24654.
104.SimmonsWK,CookJD,BinghamKC,etal.Evaluationofagastricdeliverysystemforiron
supplementationinpregnancy.AmJClinNutr199358:6226.
105.CouncilonFoodsandNutritionCommitteeonIronDeficiency.IrondeficiencyintheUnitedStates.
JAMA1968203(6):11924.
106.EdwardsCQ,KushnerJP.Screeningforhemochromatosis.NEnglJMed1993328(22):161620.
107.BradleyLA,HaddowJE,PalomakiGE.Populationscreeningforhaemochromatosis:aunifying
analysisofpublishedinterventiontrials.JMedScreening19963:17884.
108.WitteDL,CrosbyWH,EdwardsCQ,FairbanksVF,MitrosFA.Hereditaryhemochromatosis.Clin
ChimActa1996245:139200.
109.ViteriFE.Effectiveironsupplementationdoesnothappeninisolation.AmJClinNutr
199765:88990.
110.AmericanAcademyofPediatricsWorkGrouponBreastfeeding.Breastfeedingandtheuseof
humanmilk.Pediatrics1997100(6):10359.
https://www.cdc.gov/mmwr/preview/mmwrhtml/00051880.htm

22/26

12/1/2016

RecommendationstoPreventandControlIronDeficiencyintheUnitedStates

111.PublicHealthService.Clinician'shandbookofpreventiveservices:putpreventionintopractice.
Washington,DC:U.S.DepartmentofHealthandHumanServices,PublicHealthService,Officeof
DiseasePreventionandHealthPromotion,1994.
112.InstituteofMedicine.Nutritionduringpregnancyandlactation:animplementationguide.
Washington,DC:NationalAcademyPress,1992.

Table_1
Note:Toprintlargetablesandgraphsusersmayhavetochangetheirprintersettingstolandscapeanduseasmallfontsize.
TABLE1.Normaldistributionofironcontaining
compoundsinmen(17)andwomen(18)(milligrams
ofironperkilogramofbodyweight)
====================================================
CompoundMenWomen

Storagecomplexes
Ferritin94
Hemosiderin41
Transportprotein
Transferrin<1<1
Functionalcompounds
Hemoglobin3131
Myoglobin44
Respiratoryenzymes22
Total5042
====================================================

Returntotop.
Table_2
Note:Toprintlargetablesandgraphsusersmayhavetochangetheirprintersettingstolandscapeanduseasmallfontsize.
TABLE2.Ironabsorptionbyinfantsfedformulaormilk(8)
===============================================================================================
SubstanceIroncontent(mg/L)Bioavailableiron(%)Absorbediron(mg/L)

Nonfortifiedformula1.54.8*~100.150.48
Ironfortifiedformula+10.012.8*~40.400.51
Wholecow'smilk0.5~100.05
Breastmilk0.5~500.25

*Valuesaregivenforcommonlymarketedinfantformulas.
+Ironfortifiedformulacontains>=1.0mgiron/100kcalformula(8).Mostironfortified
formulascontainapproximately680kcal/L,whichisequivalentto>=6.8mgiron/L.
===============================================================================================

Returntotop.
Table_3
Note:Toprintlargetablesandgraphsusersmayhavetochangetheirprintersettingstolandscapeanduseasmallfontsize.
TABLE3.Spectrumofbodyironcontent(17,30,31)
=================================================================================
IronstatusStoredironTransportironFunctionaliron

IrondeficiencyanemiaLowLowLow
IrondeficienterythropoiesisLowLowNormal
IrondepletionLowNormalNormal
NormalNormalNormalNormal
IronoverloadHighHighNormal
=================================================================================

Returntotop.
https://www.cdc.gov/mmwr/preview/mmwrhtml/00051880.htm

23/26

12/1/2016

RecommendationstoPreventandControlIronDeficiencyintheUnitedStates

Table_4
Note:Toprintlargetablesandgraphsusersmayhavetochangetheirprintersettingstolandscapeanduseasmallfontsize.
TABLE4.Prevalence(%)ofirondeficiencyandirondeficiencyanemia,
UnitedStates,thirdNationalHealthandNutritionExaminationSurvey,
19881994(45)
=======================================================================
Sexandage(years)IrondeficiencyIrondeficiencyanemia

Bothsexes
1293*
353<1
6112<1
Nonpregnantfemales
121592*
161911*3*
2049115*
506952
>=707*2*
Males
12151<1
1619<1<1
2049<1<1
506921
>=7042

*Prevalenceinnonblacksis1percentagepointlowerthanprevalance
inallraces.
=======================================================================

Returntotop.
Table_5
Note:Toprintlargetablesandgraphsusersmayhavetochangetheirprintersettingstolandscapeanduseasmallfontsize.
TABLE5.1989Recommendeddietaryallowance(RDA)forironandtheproportion
ofAmericanshavingdietsmeeting100%oftheRDAforiron,19941996
==============================================================================
Sexandage(years)RDA(mg/day)*ProportionofAmericans
meeting100%ofthe1989
RDAforiron+(%)

Bothsexes
<161087.9&
121043.9
351061.7
Females
6111060.9
12191527.7
20291525.9
30391526.6
40491522.1
50591055.2
60691059.3
>=701059.2
Males
6111079.8
12191283.1
20291086.9
30391088.9
40491085.9
50591083.8
60691085.5
>=701078.5

*NationalResearchCouncil(46).Theagegroupsdesignatedbythecouncil
areslightlydifferentfromthosepresentedinthistable.
+Twodayaveragedietaryintakes,fromtheU.S.DepartmentofAgriculture
ContinuingSurveyofFoodIntakesbyIndividuals,19941996(47).
&Excludesbreastfedinfants.
==============================================================================

Returntotop.
Table_6
Note:Toprintlargetablesandgraphsusersmayhavetochangetheirprintersettingstolandscapeanduseasmallfontsize.
TABLE6.Maximumhemoglobinconcentrationandhematocritvaluesforanemia*(45,72)
======================================================================================

https://www.cdc.gov/mmwr/preview/mmwrhtml/00051880.htm

24/26

12/1/2016

RecommendationstoPreventandControlIronDeficiencyintheUnitedStates

HemoglobinconcentrationHematocrit(<%)
(<g/dL)

Children(age,inyears)
1<2+11.032.9
2<511.133.0
5<811.534.5
8<1211.935.4
Men(ageinyears)
12<1512.537.3
15<1813.339.7
>=1813.539.9
Nonpregnantwomenand
lactatingwomen(agein
years)
12<1511.835.7
15<1812.035.9
>=1812.035.7
Pregnantwomen
Weeks'gestation
1211.033.0
1610.632.0
2010.532.0
2410.532.0
2810.732.0
3211.033.0
3611.434.0
4011.936.0
Trimester
First11.033.0
Second10.532.0
Third11.033.0
*Ageandsexspecificcutoffvaluesforanemiaarebasedonthe5thpercentilefrom
thethirdNationalHealthandNutritionExaminationSurvey(NHANESIII),which
excludedpersonswhohadahighlikelihoodofirondeficiencybyusingthesame
methodsdescribedbyLookeretal.(45).Maximumvaluesforanemiaduringpregnancy
arebasedonvaluesfrompregnantwomenwhohadadequatesupplementation(3942,72).
+AlthoughnodataareavailablefromNHANESIIItodeterminethemaximumhemoglobin
concentrationandhematocritvaluesforanemiaamonginfants,thevalueslistedfor
childrenaged1<2yearscanbeusedforinfantsaged612months.
======================================================================================

Returntotop.
Table_7
Note:Toprintlargetablesandgraphsusersmayhavetochangetheirprintersettingstolandscapeanduseasmallfontsize.
TABLE7.Adjustmentofmaximumhemoglobinconcentrationandhematocrit
valuesforanemia(72,79,80)
=======================================================================
HemoglobinHematocrit(%)
concentration
(=2.0packsperday0.72.0
Allsmokers0.31.0
=======================================================================

Returntotop.
Table_8
Note:Toprintlargetablesandgraphsusersmayhavetochangetheirprintersettingstolandscapeanduseasmallfontsize.
TABLE8.Cutoffvaluesforlaboratorytestsforirondeficiency
==================================================================================================
TestCutoffvalueReference

HemoglobinconcentrationSeeTable6forcutoffsforanemiaLookeretal.(45),
CDC(72)
HematocritSeeTable6forcutoffsforanemiaLookeretal.(45),
CDC(72)
MeancellvolumeCutoffsformicrocyticanemiaatDallmanetal.(28)
age:
12years:<77fL
35years:<79fL
611years:<80fL
1215years:<82fL
>15years:<85fL
RedbloodcelldistributionCutoffforirondeficiencyanemia*:Dallmanetal.(28),
width14.0%Oski(51)
ErythrocyteprotoporphyrinCutoffsforirondeficiency:Dallmanetal.(28),

https://www.cdc.gov/mmwr/preview/mmwrhtml/00051880.htm

25/26

12/1/2016

RecommendationstoPreventandControlIronDeficiencyintheUnitedStates

concentrationAdults:30u/dLofwholebloodorPiomelli(92)
70ug/dLofredbloodcellsChildren
aged12years:
80ug/dLofredbloodcells
SerumferritinconcentrationCutoffforirondeficiencyinHallbergetal.(93)
personsaged>6months:<=15ug/L
TransferrinsaturationCutoffforirondeficiency:<16%Dallmanetal.(23),
PilchandSenti(90)

*Thecutoffisinstrumentspecificandmaynotapplyinalllaboratories.
==================================================================================================

Returntotop.
Table_1B
Note:Toprintlargetablesandgraphsusersmayhavetochangetheirprintersettingstolandscapeanduseasmallfontsize.
EXHIBIT1.Causesofirondeficiency
===================================================================
IncreasedironrequirementsInadequateironabsorption

BloodlossDietlowinbioavailableiron
MenstruationImpairedabsorption
GastrointestinaltractIntestinalmalabsorption
FoodsensitivityGastricsurgery
HookwormsHypochlorhydria
Genitourinarytract
Respiratorytract
Blooddonation
Growth
Pregnancy
===================================================================

Returntotop.

DisclaimerAllMMWRHTMLversionsofarticlesareelectronicconversionsfromASCIItextintoHTML.This
conversionmayhaveresultedincharactertranslationorformaterrorsintheHTMLversion.Usersshouldnotrelyonthis
HTMLdocument,butarereferredtotheelectronicPDFversionand/ortheoriginalMMWRpapercopyfortheofficialtext,
figures,andtables.AnoriginalpapercopyofthisissuecanbeobtainedfromtheSuperintendentofDocuments,U.S.
GovernmentPrintingOffice(GPO),Washington,DC204029371telephone:(202)5121800.ContactGPOforcurrent
prices.

**Questionsormessagesregardingerrorsinformattingshouldbeaddressedtommwrq@cdc.gov.
Pageconverted:10/05/98
HOME|ABOUTMMWR|MMWRSEARCH|DOWNLOADS|RSS|CONTACT
POLICY|DISCLAIMER|ACCESSIBILITY

MorbidityandMortalityWeeklyReport
CentersforDiseaseControlandPrevention
1600CliftonRd,MailStopE90,Atlanta,GA30333,
U.S.A

DepartmentofHealth
andHumanServices

Thispagelastreviewed5/2/01

https://www.cdc.gov/mmwr/preview/mmwrhtml/00051880.htm

26/26