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Abstract

Iron deficiency in infants and toddlers has been on the rise since the years after 1960s. Before then iron deficiency in infants had been declining from which study shows as tempering with achievement pointing out the results of the rising cases. This paper comes in to discuss the available ways in which iron can be supplemented in infants. The causes and the available means of diagnosis for the deficiency will be discussed including treatment.

Introduction

Prevalence of long-lasting mental, motor and behavioral functioning is associated with iron deficiency which seem to have been tempered thus bringing about an increase on the cases of iron deficiency in babies. This is pointed out by the fact that cases of this condition had declined immensely since the year 1960. The ratio, 1:3, at which iron deficiency cases are reported, happens to be rising for infants and toddlers. Deficiency of iron to an extended level results to anemia but the development effects of the condition are not well understood or even figured out until the deficiency becomes severe and chronic enough.

There are a number of iron supplementation methods of iron in infants, within which a number of supplementing measures are applied. The factor of consideration revolving around what each kind of measure is targeting. Some measurements are aimed at curing the iron deficiency while others are aimed at prevention of the condition.  The measures are classified into primary and secondary prevention methods. For the primary, no diagnosis is required to determine if there is iron deficiency on an infant. This is a case of exercising caution and providing iron supplementation incase a number of iron-deficiency causes have been in place, e.g. the consumption of cow milk and feeding on low iron cereals. For the secondary measures that are taken as means of prevention rely and utilize screening mostly because at the stages where these methods are employed are mostly or only when iron deficiency as gone past a certain stage. Thus after screening and a diagnosis have been established, these secondary measures are taken to resolve the condition whether it is just plain iron deficiency or whether anemia has resulted from severe iron deficiency.

Just like many other forms of health conditions, iron deficiency has stages within which it develops or within which supplementation is required to either prevent or treat iron deficiency. Although this papers main aim is to discuss iron supplementation in infants, establishment of what kind of issue concerning iron deficiency are to be addressing the stages within which they occur are discussed. Research has been conducted concerning iron deficiency, this research is included as a means of developing the history of iron deficiency and iron deficiency anemia and the resulting courses of actions that aimed at supplementing iron in cases where deficiency had been diagnosed or being prevented. (Katzman, 1972)

Special conditions like preterm and/or low-birth-weight of an infant are some of the main considerations before the employment of prevention or curative measures to infants. Low weight infants have a definitive dosage quantity within which a certain weight limit is defined for a specific dosage. This paper discusses what specific weights and their corresponding dosages are recommended and within what age group is this dosage supposed to be upped or done with.

At this point of prevailing condition that would be responsible for resulting to anemia if treatment is initialized, anemia can be reversed and restoration of iron can be achieved. This paper focuses on the primary intervention that is aimed to prevent anemia by discussing the means and ways in which iron can be supplemented in infants. Iron deficiency is associated with anemia only if the condition prevails for a long time resulting to severe and chronic almost irreversible level. The primary focus of this paper is to determine the appropriate time within which supplementation measures can be taken to do away with iron deficiency and what appropriate measures can be put in place before the condition gets out of hand.

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Logical Intervention

Completely avoiding the use of cow milk can be one way to prevent iron deficiency in the first year of living of an infant. Starting supplementation of iron within the age of four and six months by breastfeeding and/or using iron-fortified formula when as a substitute for breastfeeding are main methods of iron supplementation in infants. Formulas that consist of low iron are not supposed to be used. Diversified diet rich in iron, provision of iron fortified vitamin, vitamin C and a limiting use of cow's milk to not more than 24 oz a day are recommended in prevention of iron deficiency during the second year of life of an infant. For each and every infant that has not been provided with iron preventing or supplementing attention is legible to screening to determine whether deficiency of iron would be detected.

Screening performing is more appropriate at the age of 9 to 12 months, a half year later, and at two years of age. The adoption to hemoglobin/hematocrit screening selectively detects patients with enough iron deficiency to be anemic. Erythrocyte protoporphyrin screening identifies early stages of deficiency in iron levels. The definitive method in diagnosis of iron deficiency is established by a positive screening within which a therapeutic trial of iron is indicated. (Yip, 1987)

History of Supplementation Methods for Iron Deficiency in Infants

In 1930s the prevalence of iron deficiency in the US was a widely noted in infants. Almost 30 years later, this prevalence did not drop thus leading to the predicament being termed as a significant public health issue. Anemia was high in these cases and due to the fact that this was caused by nutritional factors the issue was referred to as nutritional anemia. It was standardized to screen all infants between the ages of nine and twelve months of anemia. Iron deficiency was marked by the employment of anemia with hematocrit being the main screening test. (Vazquez, 1985)

The screening strategy discussed above together with campaigns to increase the rate of breastfeeding, iron-fortified infant formulas and food stuffs, start of WIC (Program for Supplementation Food for Women, Infants, and Children) in 1972, and educating physicians and the public tremendously succeeded. In the 1980s a big decline in the prevalence of iron deficiency and anemia was marked across the Social and Economic Diasporas in the United States. In 1971, 23% of 9-36 month old infants had hemoglobin of 98g per liter in a clinic in New Haven, Conn (Katzman, et al. 1972). Before the beginning of the year 1984 at the same clinic the percentage had dropped to 1% (Fleshood, et al. 1987). Windom (1985) conducted a study of middle class 9-23 month old infants that found 7.6% cases of iron deficiency in Minneapolis between the years of 1969 and 1973 had diminished to less than 3% between the period of 1982 and 1986.

Routine screening was suggested by leaders in the field within which their suggestion aimed at making routine screening a selective process. This was to done only to individual patient's high chances of iron deficiency (Walsh, et al. 1987). It was within this period that iron deficiency and anemia ws removed from the list of public health threats. It is unfortunate that after all the efforts, iron deficiency and anemia still is present in the society and the developmental effects seem to exist for long.

Effects of Iron Deficiency in Infants

When iron deficiency is severe and results to anemia, mental, motor and behavior effects develop. This is the only cause of these effects. Iron deficiency anemia results to the scoring of low score in motor and mental tests; it also results to fine and pathetic motor coordination thus resulting to differential effects like fearfulness, wariness, and sadness (Andraca, et al. 1989). Easily tired, less playful and preference to be held are associated differences that anemic infants depict. Routine physical examination does not detect the mental and motors effects.

Treatment with iron supplementation is not known to correct all the behavior changes associated with anemia even if it has been resolved completely (Nelson, et al. 1998). The low scores resulting from mental and motor effects have been noted to prevail after the successful resolution of iron deficiency anemia. At some instances, children rechecked at age 11-14 have shown signs of depicting impairment in terms of functioning. It is reported that among these children, several had repeated a grade have a diminished arithmetic and written expression ability, and they have indifference in motor function, partial memory and recalling that is selective in nature.

Iron Deficiency Anemia after the First Year of Life

Prevention of iron deficiency anemia was historically focusing on infants who were or less than 12 months of age. Toddlers deserve the same attention in terms of addressing the issue of iron deficiency; this is brought by the fact that the effects have been prevalent more than it was formerly thought to be. The prevalence of iron deficiency anemia in 1-2-year-old infants has been reported to be 3% and that of 1-3-year-old infants to be as high as 15%. Recent studies show that for middle and lower class social and economic groups, noted 1-3-year-olds had a 10% iron deficiency anemia.

Within this age bracket severe iron deficiency anemia has been reported. 12-month-old has been reported to be receiving 100% of daily recommended allowance for iron. However by 18 months intake of iron had declined to levels below the recommended average (Smiciklas, et al. 2000). Going by the studies, this kind of findings must have been anticipated in that 1-3-year-olds report the lowest iron intake among all age groups. Breastfeeding and use of fortified iron formulas are replaced with cow milk and non iron-fortified cereals respectively; these in presence of liquids reduce the infant's appetite for solid diets.

Primary Prevention and Iron Supplementation in Infants

Prevention of iron deficiency anemia in infants depends on healthy feeding observance. Introduction of cow's milk within the first year of the infant's life is the greatest cause of developing iron deficiency and iron deficiency anemia. Milk from cows contains low amounts of iron and the present bits are poorly absorbed. Avoiding milk from cows for the first four trimesters since birth is reliable in preventing iron deficiency and iron deficiency anemia (Stekel, et al. 1980). Reasons that make breastfeeding the ideal feeding practice include the ability to lower the chances of developing iron deficiency.

About 50% of the iron found in milk is bioavailable to the toddler or infant going by the fact that breast milk contains iron content. After four to six months, exclusive breastfeeding can result to iron deficiency; thus an iron-supplementing dietary measure responsible for providing 1mg/kg of elemental iron for infants ranging from the age of 4 to 6 months is highly recommended. Foods and cereals fortified with iron are termed as potential iron supplements in infants, however infants fed with cereals as the main food develop iron deficiency anemia (Dallman, 2008).

Daily iron supplement in form of oral drops is another method of supplementation of iron in infants that is effective in the prevention of iron deficiency and iron deficiency anemia. The drops can of ferrous sulfate or vitamin drops for infants. 10mg of elemental iron are contained in every Vitamin's drops dropper. This is the recommended daily allowance for infants of one year to children of 6 years. During the entire breastfeeding period, iron supplementation in either iron drops or iron-fortified cereals form should be adapted.

Breastfed preterm and underweight infants require a dosage of 2mg/kg of oral elemental iron as iron supplement, which should start between the second and the fourth week after birth. Infants born with a maximum weight of 1500g require iron supplementation dosage of 3mg/kg while those below that weight to the weight of 1000g need a dosage of 4mg/kg of supplementation iron. As a health precaution, supplemental iron especially one intended for adults should be kept out of the reach of children, otherwise carelessness may result to deadly poisoning.

Infants who have been introduced to formula at birth and those that have been introduced after sometime of breastfeeding should be introduced to iron-fortified formula. Infants fed with iron-fortified formulas have the capability of having sufficient iron without the need of extra iron supplements. This is the case for term and preterm infants; upon whose vitamin dosage shouldn't contain iron. (Driggers. 2011)

6.7mg/L of iron is considered low and it is advisable that formulas containing this or less amount of iron should be given to infants; this is because they have no advantage over iron-fortified formulas. Double-blinded and controlled trials have not shown any signs of differential effects between low and standard-iron formulas considering fussiness, colic, flatus, stool or regurgitation characteristics (Reeves, 2009)

24 to 16 oz of cow's milk is the recommended amount that should be fed to infants entering their second year of living; this is because cow's milk continues to cause issues in the maintenance of iron stores (). For mothers who intend to continue breastfeeding even after a year, are supposed to maintain the cow's milk feeding at the recommended levels and iron supplementation should be maintained at a certain form within the recommended daily allowance guidelines. If breastfeeding is to be stopped before 24 months, it is suggested that iron supplementation by iron-fortified formulas should be adapted over cow's milk. There is a great inapplicability of this suggestion to quite a number of parents. Encouraging diversified diet that is iron and vitamin C rich, continuance of iron-fortified cereals, juice intake avoidance, and the giving of iron rich vitamin are considered other preventive measure of iron deficiency and iron deficiency anemia. (Lozoff, 1996)

Secondary Prevention and Iron Supplementation in Infants

SCREENING

Screening for iron deficiency should be done for done for infants with a high risk. The introduction of cow or skimmed milk is the main factors of diet that lead to iron deficiency in infants. Significantly poverty is responsible for increased risks of iron deficiency among infants born in poverty stricken areas; this leads to the recommendation of a continued screening of infants to determine their iron levels. If primary prevvention has been conducted forgoing screening at this point can be appropriate.

Iron Deficiency in the First Year of Life and Associated Risk Factors

Special attention is given to preterm and low-birth-weight infants when screening which is done at the age of nine and 12 months after birth for term and normal weight infants. For their case, screening is done between the first three to six months after birth in settings where iron supplementation in terms of iron drops and use of fortified formulas hasn't been applied.

After one year in a case of an infant who was at a high risk of iron deficiency need to be tested within that period.  Between 15 to 18 months of age, other toddlers at the risk of iron deficiency are supposed to be screened at this time of their ages. The group classified as others include those infants who have had a history of iron deficiency anemia, low iron and vitamin diet, consumption of cow's milk in quantities larger than 24 oz per day, and/or recent immigration from a third world setting. Positive screenings require confirmation while negative provide a clear cut way for intervention with the necessary primary prevention (Smiciklas, 2000).

A reliable screening session should be able to take note of iron deficiency at the absence of anemia. This would provide a chance to treat iron deficiency in the pre-anemic level, and in return preventing behavioral changes resulting from mental and motor effects and iron deficiency. Standard test for iron deficiency anemia has always been hemoglobin level, which is only termed effective if the iron deficiency is a severe level to result to iron deficiency anemia. With this test iron deficiency cannot be detected unless it is enough to result to iron deficiency anemia and thus a diagnosis cannot be established. This test is questionable in that before anemia there is a preferably enormous iron deficiency which if identified would lead to primary prevention action and reaction. (Reeves, 2009)

For diagnosis of iron deficiency use of transferrin saturation, ferritin level, and erythrocyte protoporphyrin are used. Erythrocyte protoporphyrin measurement is the most reliable with the added advantages of low cost and office availability over the others. Its effectiveness has been researched on and endorsed by Dallman (2009). Probability of error in the use of elevated erythrocyte protoporphyrin level makes it not as specific as other markers. However, elevated erythrocyte protoporphyrin level is considered a likely positive screen for iron deficiency due to decline in the prevalence of lead toxicity and its severity.

Stages of Iron Deficiency

A large number of toddlers and infants can be served with the use of hematofluorimeter in the measurement of erythrocyte protoporphyrin if it invested in. Even in the presence of anemia hematofluorimeter will tend to miss some cases of iron deficiency, thus making the employment of erythrocyte protoporphyrin and hemoglobin testing rather a more effective method. A case where the erythrocyte protoporphyrin measurement isn't an option, the obtaining of a RDW (red-cell distribution width) can be a reliable consideration with the hemoglobin measurement blended together (Smiciklas, 2000)

Elevated RDW is a reliable indicator of iron deficiency that requires a therapeutic trial of iron as means of diagnosis confirmation. The reliability of this kind of testing is associated with the CBC nature of the test in which screening for iron deficiency and iron deficiency anemia using the indexes of red blood cells alone. The use of this method is not a standard method; hence cut-off values are instrument specific for RDW which prompt any ordering clinician to have prior knowledge about.

Therapeutic Trial of Iron to Diagnose Iron Deficiency

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There are cases where the obtaining of CBC and erythrocyte protoporphyrin level may prove to be impractical; in this case screening entirely with hemoglobin can be resulted to. In doing so is as result last option for it is worthy the try to test for iron deficiency anemia and give a diagnosis than not to as the severity of the condition may worsen the resulting outcomes.

Iron deficiency is verifiable by the presence of the baseline hemoglobin level which is the reason why the hemoglobin test should be carried either alone or alongside another form of screening. Iron deficiency diagnosis is achieved if the hemoglobin is less than 110g/L or if the erythrocyte protoporphyrin level is elevated. A population that comprises of Blacks will result to infants with low hemoglobin and a definitive cut-off of 107g/L which signifies anemia within this population. (Nelson, et al. 2007)

Therapeutic trial of iron is a reliable and less expensive than obtaining iron panels thus making it a preferred approach in the diagnosis of iron deficiency and iron deficiency anemia. It is recommended that a delay in therapeutic trial of iron should be sought when an infection had attacked an infant in not more than a fortnight ago; for in cases like these result to a brief dressing of hemoglobin. Negative therapeutic trial of iron results to a work-up indication of the anemia etiology.

Iron supplementation after therapeutic trial of iron

An infant is supposed to complete an iron therapy if a positive screening test and diagnosis has been established and confirmed by a therapeutic trial of iron test. Supplemental iron of 3g/Kg is recommended as a method of iron supplementation which is to be ingested orally (Nelson, 2007). Absorption of the supplemental iron is improved if it is taken with some source of C vitamin such as mango juice. The treatment takes duration of 3 months with an inclusion of the four-week of therapeutic trial of iron.

Summary

History of the developments that had been put in place and why there still cases of iron deficiency are as a result of tempering of the effort measures, mainly being the abolishment of a mandatory iron deficiency screen for infants and prioritizing of high risk cases only. Causes of anemia are associated with advanced iron deficiency that becomes too severe and chronic enough to result to iron deficiency anemia. Measures taken in iron supplementation are both preventive and curative with primary measures employed being iron drops, vitamin C and iron-fortified cereals to infants who have been withdrawn from breastfeeding. Addressing of iron deficiency and in devising a method to supplement is carried with stages of the iron deficiency; screening is done for the determination of whether an infant lacks sufficient iron or whether it is anemic. Underweight and preterm infants are enrolled for a mandatory iron supplementation course of not less than six months.

Conclusions

Oral iron drops, vitamin-rich iron drops, and iron-fortified cereals are some of the main iron supplementation methods. Iron deficiency is prevented by the incorporation of iron supplementing foods with breastfeeding in which avoiding of cow' milk and low iron foods are preventive measures to curb the issue of iron deficiency.  Iron supplementation in infants is not carried out in the quantities but rather in a systematic manner where issues as preterm and low-birth-weight infants are considered and given the right dosage of the iron supplements.

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