KARL ABIAAD

Department of Pediatrics
Medicine IV
EBM series
Searching for systematic reviews: exercise

Exercise and search for the evidence for this clinical scenario:
You have a 7 month old girl presenting to well-child visit. Upon checking her
nutrition you find that she was formula-fed and has never been supplemented with
iron for anemia prevention. The baby does not sit without support yet but
otherwise has a normal physical examination. You decide to look for the best
available evidence on the routine iron supplementation in children to prevent
anemia and improve neuro-developmental outcomes.
i) Phrase the question using the PICO strategy.
ii) What type of question is it? (Therapy, diagnosis, prognosis, etc?)
iii) Search the literature for the answer of this question, using the PICO strategy:
iv) From the retrieved search results, please read the recent systematic review
on the topic published in Pediatrics, and submit your critical appraisal &
the answers to the searching questions as SOFT copies by 9:00 am
Thursday June 18, 2015.
Thank you
Mona Nabulsi, MD, MSc
i) P: 7 month old girl
I: Iron supplementation
C: Lack of supplementation
O: Prevention of anemia and/or neuro-developmental delays
ii) It is a therapy question

iii)
iv)
Did the review explicitly address a sensible clinical question?
Yes. It is mentioned in the introduction in the introduction that there is insufficient
evidence to recommend for or against routine screening for IDA or routine iron
supplementation for asymptomatik children aged between 6 to 12 months who are at
average risk for IDA on screening or iron supplementation for iron deficiency anemia
according to USPSTF and that the present review was commissioned by the USPSTF to
update the previous.
Was the search for relevant studies detailed and exhaustive?
Yes it was. It was mentioned in METHOD that A research librarian searched the
Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic
Reviews (through the second quarter, 2014), and Medline (1996August 2014) for
relevant studies to update the previous USPSTF reviews They also searched the
reference lists of systematic reviews for studies dating before 1996. Also at least 2
independent reviewers evaluated each study to determine its eligibility. Limitations of
the report include restricting inclusion of studies
published in English and studies conducted in developed countries or
studies in developing countries where the population enrolled was
similar to the population of the United States, particularly in terms of
rates of malnutrition, hemoparasite burden, and general
socioeconomic status.
Were the primary studies of high methodological quality?

Yes, the primary studies were of high methodological quality. The clinical outcomes they
were looking for were listed as well as the methods used in the selected articles like
Randomized controlled trials, nonrandomized controlled clinical trials, and controlled
cohort studies were included for all Key Questions. Also Two investigators independently
applied criteria developed by the USPSTF15 to rate the internal validity of each study as
good, fair, or poor.
Were assessments of studies reproducible?
Yes, assessments of studies were reproducible.
Discrepancies were resolved through a consensus process (between the 2 investigators)
When otherwise not reported and where possible, relative risks (RRs) and 95%
confidence intervals (CIs) or P values were calculated.
Were the results similar from study to study?
Results did vary from study to study, and there were no data like chi
square on similarities between the studies.
Some of the variation in findings may have been due to inadequate
sample sizes for specific outcomes. For example, there was important
variability in the definitions of IDA, anemia, and iron deficiency (mostly
unknown baseline risk of children enrolled) and wide variation in
control group rates across these studies
What are the overall results of the review?
They mention in the article that they did not pool the results because
of the heterogeneity of the studies in terms of supplementation
method, dose, duration, timing of initiation and follow-up, and
methodologic limitations. In addition, risk factors were largely not
reported, and no studies stratified results according to risk groups.
How precise are the results?
There was no overall result of all the studies with its confidence
interval. Furthermore, some individual studies had non-significant
results.

How can I best interpret the results to apply them to the care of
patients in my practice?

The age of the patient (7 months) does apply to the age range found in
the studies (6 to 24 months). However, the studies were inconclusive
on whether iron affects growth and neurodevelopment, and the results
for preventing IDA were variable (and no pooling of studies was
calculated to asses). However, regarding harm, studies did not show
evidence of harm for giving iron for such infants. Therefore, it would be
an option to give iron supplements to the patients and monitor the
progress.
Were all clinically important outcomes considered?
Yes. Referring to tables 1,2 and 3, all outcomes were considered.
However regarding benefits and harms of screening, no studies were
found to address the issue.
Are the benefits worth the costs and potential risks?
The benefits and harms of treatment are largely unclear. However
because no significant harm was found in the studies, it could be
inferred that the benefits are probably more worthy than the costs and
potential risks.