Hemoglobin/Hematocrit Child and Teen Checkups (C&TC) FACT Sheet For Primary Care Providers C&TC Requirements: Hemoglobin/Hematocrit Use a micro hematocrit (Hct) determination or hemoglobin (Hgb) concentration test, for iron deficiency and iron deficiency anemia. Requirements for C&TC are: • One baseline Hgb or Hct is required between 9 months and 15 months of age. • One Hgb or Hct is required between 12 years and 20 years of age for all menstruating females. Qualified Personnel Physician, Nurse Practitioner, Physician Assistant, Registered Nurse, Certified Medical Assistant, or Lab Technician Documentation Document lab tests ordered. It is not necessary to have a complete record of lab test results on documentation form. Lab test results may be found elsewhere in the chart. Form could indicate where this information can be found. For documentation examples, refer to the C&TC Documentation Forms for Providers and Clinics: http://www.dhs.state.mn.us/id_028848 Important Facts about Iron Deficiency and Iron Deficiency Anemia: • Iron deficiency anemia is associated with psychomotor and cognitive abnormalities in • • • children. Iron deficiency anemia in pregnancy has been associated with increased risk for low birth weight, preterm delivery, and perinatal mortality. Recent studies suggest that maternal iron deficiency anemia may be associated with postpartum depression and poor performance on mental and psychomotor tests in offspring. The prevalence of iron-deficiency anemia has remained stable over the last decade in the general U.S. population and continues to be greatest among minority and poor children [2]. Iron deficiency (ID) without anemia is the most common single nutritional deficiency and Iron Deficiency Anemia (IDA) is the most common anemia in the United States [1, 2]. ID is defined as a condition in which there is depleted iron stores in the body and in its extreme form may progress to IDA, which is associated with functional or health impairment in several body systems. IDA can result from either an un-meet need for increased iron intake (such as the rapid growth in infancy) or a long standing iron deficiency due to inadequate iron intake or poor absorption [1, 2]. “The prevalence of IDA in the United States population has remained stable over the past decade with 7% of children in the first two years of life, 9% in adolescent females, and 2-5% in non-pregnant females [2].” MDH/DHS (Reviewed/Revised 10/2012) C&TC FACT Sheet – Hemoglobin/Hematocrit Page 1 of 4 • • • “IDA is greatest among minority and poor children/adolescents in the United States [2].” More recent research is indicating that that not only infants and young children with IDA, but also those children the same age with ID without anemia have poorer cognitive, motor, socialemotional, and neurophysiological test scores when compared with children the same age without iron deficiency or IDA. Some of these adverse neurodevelopmental outcomes of ID and IDA may be irreversible [3,4] • The AAP has recommended that an initial screening for IDA should be coupled with a comprehensive risk assessment for ID and IDA for those children 0-36 months. Risk factors for ID and IDA in infants and toddlers are as follows [3]: o Infants born to mother with IDA, diabetes, or pregnancy induced hypertension with intrauterine growth restriction during their pregnancy o Babies born premature, small, or low birth weight o Babies given cow’s milk before 12 months of age o Breastfed babies who are greater than 4-6 months of age without being given iron fortified cereal or foods naturally rich in iron o Formula-fed babies who are not fed iron fortified formula o Children ages 1-5 years who get more than 24 ounces of cow, goat, or soy milk per day. o Children with special health needs with feeding problems, poor growth and development, and inadequate nutrition The prevalence of IDA is 9% among adolescent females in the United States [2]. Contributing physiological, income, race, and socioeconomic factors associated with IDA in older girls, adolescent females, and young adult women include the following: o Menarche, especially heavy menstrual blood loss (> 80 ml/month) [5] o Increased iron need due to rapid growth [2] o Mexican-American females ages 12-39 were at higher risk of having IDA than nonHispanic women of the same age. This difference was markedly higher among poor women than women from higher income households [5]. o Eating disorders are more common adolescent females and young women and IDA is associated with eating disorders [5]. o An analysis of children, ages 2-16 years that were overweight and obese were at higher risk of IDA when controlling for confounding factors such as age, gender, ethnicity, poverty status, and parental education. In the same study, children/adolescents that were overweight were 2.3 times more likely to have ID than those children of the same age who were not overweight [5]. o Adolescent girls who diet to control weight are at risk for ID an IDA due to inadvertently limiting foods that are high in iron [5]. o Vegetarian diets which are low in heme iron [2]. o Some studies including adolescent females suggest that early detection or prevention of iron deficiency may improve social adjustment and cognitive function [5]. o Iron deficiency may also affect memory and other cognitive functions in adolescents [2]. Screening Tools: • Three basic methods are used to determine Hgb concentration and Hct level: o Venipuncture with analysis by automated cell counter, o Capillary sampling with analysis by hemoglobin meter, or o Capillary sampling with micro hematocrit analysis by centrifuge. MDH/DHS (Reviewed/Revised 10/2012) C&TC FACT Sheet – Hemoglobin/Hematocrit Page 2 of 4 • • (NOTE: The micro hematocrit method yields slightly higher values and is somewhat less sensitive than the automated cell counter method. The capillary methods may provide less reliable results because of greater variation in sampling technique than venipuncture.) If the capillary method is used, observe the following principles of collection: o In infants, the best site is the lateral aspect of the plantar surface of the heel. In older children, the best sites are the medial and lateral aspects of the pulp of a finger; make the puncture perpendicular to the skin and across the dermal ridges. o To increase blood flow and accuracy of the test, make sure the heel or finger is warm. o Before puncture, clean the site with an antiseptic and allow it to dry. o Use sterile, disposable lancets with tips less than 2.5 mm long for infants aged 6 months or younger. Lancets with longer tips (up to 5 mm) may be used for older children. Wipe away the first two to three drops of blood, which contain tissue fluids, with dry gauze. Do not milk or squeeze the puncture site, because this may cause hemolysis and admixture of tissue fluids with the specimen. The table of Hgb Concentration and Hct Values Used to Define Anemia below can be used as a reference to screen children for ID and IDA. Hgb and Hct values provided by individual laboratories may vary from this chart and from one laboratory to another. Hgb Concentration and Hct Values Used to Define Anemia [6] Gender Age (years) Hgb, g/dl Hct, % Both 6 mo to <2 years 11.0 32.9 Both 2 to <5 years 11.1 33.0 Both 5 to <8 years 11.5 34.5 Both 8 to <12 years 11.9 35.4 Males 12 to <15 years 12.5 37.3 15 to <18 years 13.3 39.7 ≥18 years 13.5 39.9 Females 12 to <15 years 11.8 35.7 (non-pregnant) 15to <18 years 12.0 35.9 ≥18 years 12.0 35.7 Professional Recommendations American Academy of Pediatrics (AAP) and Bright Futures: • Initial measurement of Hgb or Hct for all full term infants should be completed between 9 months and 12 months of age, with additional risk assessment screening annually beginning at age 2 years through age 21 years [3]. • If Hgb is < 11.0 mg/dl for children 0-36 months than further evaluation and additional screening tests are required to establish ID or IDA as the cause of anemia [3]. NOTE that, due to a higher risk of IDA in low-income children, a screening Hgb or Hct is still required for C&TC-eligible menstruating females at least once during adolescence, even though this is no longer standard per AAP recommendations, which are for average-risk children. Resources: (Accessed 10/2012) • • AAP (2010) Clinical Report--Diagnosis and prevention of iron deficiency and iron-deficiency anemia in infants and young children (0-3 years of age). Pediatrics, 126(5), 1040-1050. AAP Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents MDH/DHS (Reviewed/Revised 10/2012) C&TC FACT Sheet – Hemoglobin/Hematocrit Page 3 of 4 • • (3rd Ed.) http://www.brightfutures.aap.org Minnesota Department of Human Services (DHS) o MHCP Enrolled Providers – Child and Teen Checkups http://www.dhs.stsate.mn.us/provider/ctc o Child and Teen Checkups (C&TC) Screening Components Standards and Guidelines http://www.health.state.mn.us/divs/fh/mch/ctc/ctcscreencomp.pdf Minnesota Department of Health (MDH) o Women, Infants, and Children (WIC) Program http://www.health.state.mn.us/divs/fh/wic/index.html o Child and Teen Checkups (C&TC) http://www.health.state.mn.us/divs/fh/mch/ctc/ o For questions, training, or additional information, contact the C&TC Support Staff at (651) 201-3760. References: (Accessed 10/2012) 1. Center for Disease Control and Prevention (CDC) (2011). Iron and Iron Deficiency. http://www.cdc.gov/nutrition/everyone/basics/vitamins/iron.html 2. U.S. Preventative Task Force (USPSTF) (2006). Screening for Iron Deficiency Anemia Including Iron Supplementation for Children and Pregnant Women. http://www.uspreventiveservicestaskforce.org/uspstf/uspsiron.htm 3. AAP (2010). Clinical Report--Diagnosis and prevention of iron deficiency and irondeficiency anemia in infants and young children (0-3 years of age). Pediatrics, 126(5), 10401050. 4. Lozoff, B. (2007). Iron deficiency and child development. Food and Nutrition Bulletin, 28(supplement 4), S560-S571. 5. Agency for Healthcare Research and Quality (2006). Section 2: Background, in Screening for Iron Deficiency Anemia in Childhood and Pregnancy: Update of the 1996 USPTF Review. http://www.ncbi.nlm.nih.gov/books/NBK33398/#A33256 6. CDC (1998). Recommendations to prevent and control iron deficiency in the United States, MMWR, 47(RR-3), 1-36. 7. Hagan, J.F., Shaw, J.S., Duncan, P.M., (Eds.) (2008). Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents (3rd ed.). Elk Grove Village, IL: AAP. http://www.brightfutures.aap.org MDH/DHS (Reviewed/Revised 10/2012) C&TC FACT Sheet – Hemoglobin/Hematocrit Page 4 of 4