Hemoglobin/Hematocrit Child and Teen Checkups (C&TC) For Primary Care Providers

Child and Teen Checkups (C&TC)
FACT Sheet
For Primary Care Providers
C&TC Requirements:
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
Qualified Personnel
Physician, Nurse Practitioner, Physician Assistant, Registered Nurse, Certified Medical Assistant,
or Lab Technician
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:
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)
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“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)
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(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]
Age (years)
Hgb, g/dl
Hct, %
6 mo to <2 years
2 to <5 years
5 to <8 years
8 to <12 years
12 to <15 years
15 to <18 years
≥18 years
12 to <15 years
15to <18 years
≥18 years
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)
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(3rd Ed.) http://www.brightfutures.aap.org
Minnesota Department of Human Services (DHS)
o MHCP Enrolled Providers – Child and Teen Checkups
o Child and Teen Checkups (C&TC) Screening Components Standards and Guidelines
Minnesota Department of Health (MDH)
o Women, Infants, and Children (WIC) Program
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.
2. U.S. Preventative Task Force (USPSTF) (2006). Screening for Iron Deficiency Anemia Including Iron Supplementation for Children and Pregnant Women.
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.
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.
MDH/DHS (Reviewed/Revised 10/2012)
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