Recommendations of Major Authorities

• American Academy of Family Physicians (AAFP) and US Preventive Services Task Force (USPSTF) --
• Hemoglobin concentration screening should be performed between 6 and 12 months of age for infants in high-risk groups. The AAFP and USPSTF define high-risk groups as infants living in poverty; African Americans; American Indians; Alaska Natives; immigrants from developing countries; preterm and low-birth-weight infants; and infants whose principal intake is unfortified cow's milk.

• American Academy of Pediatrics and Bright Futures --
• Hemoglobin or hematocrit should be measured once during infancy (between 1 and 9 months) for all children and once during adolescence for all menstruating teenagers. Bright Futures recommends hemoglobin and hematocrit screening at age 6 months if certification for Women, Infants, and Children (WIC) is needed. Bright Futures also recommends annual hemoglobin and hematocrit screening for adolescent females (ages 11 to 21 years) if any of the following risk factors are present: moderate to heavy menses, chronic weight loss, nutritional deficit, or athletic activity.

• Canadian Task Force on the Periodic Health Examination --
• There is conflicting and insufficient evidence to recommend for or against inclusion or exclusion of routine hemoglobin measurements at 6 to 12 months of age in normal infants. However, there is fair evidence to recommend a routine measurement for high-risk infants (infants of families of low socioeconomic status, Chinese or aboriginal ethnic origin, low birth weight [<2500 grams], or fed only whole cow's milk during the first year of life).

Basics of Anemia Screening

1.

Three basic methods are used to determine hemoglobin levels and hematocrits: venipuncture with analysis by automated cell counter, capillary sampling with analysis by hemoglobinometer, or capillary sampling with microhematocrit analysis by centrifuge. ( NOTE: The microhematocrit 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.)

2.

In general, do not screen for anemia in a child who has had fever or infection during the preceding 2 to 3 weeks.

3.

If the capillary method is used, observe the following principles of collection:

• In infants, the best sites are the medial and lateral aspects 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.
• To increase blood flow and accuracy of the test, make sure the heel or finger is warm.
• Before puncture, clean the site with an antiseptic and allow it to dry.
• 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 a dry gauze.
• Do not milk or squeeze the puncture site, because this may cause hemolysis and admixture of tissue fluids with the specimen.

4.

Table 1.1 shows hemoglobin and hematocrit cut points for the diagnosis of anemia in children, which are derived from the Second National Health and Nutrition Examination Survey (NHANES II) conducted from 1976 through 1980. Although NHANES II did not provide data for children younger than 1 year of age, the cut points for 6-month-old children determined by extrapolation are only a fraction of a unit less than those for 1-year-old children.

Table

Table 1.1. Hemoglobin and Hematocrit Cut Points for Anemia in Children 1 Year of Age or Older.

• Cut points for anemia should be adjusted upward for children and adolescents who live at high altitudes or smoke (See Tables 27.1 and 27.2).

Table

Table 27.1. Adjustments for Hemoglobin and Hematocrit Cut Points for Anemia in Smokers.

Table

Table 27.2. Altitude Adjustments for Hemoglobin and Hematocrit Cut Points for Anemia.

Patient Resources

• Sickle Cell Anemia (New Hope for People With). FDA Office of Consumer Affairs. HFE 88 Rm 1675, 5600 Fishers Ln, Rockville, MD 20857; (800)532-4440.

Provider Resources

• Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents; Bright Futures Pocket Guide; Bright Futures Anticipatory Guidance Cards. Available from the National Center for Education in Maternal and Child Health, 2000 15th Street North, Suite 701, Arlington, VA 22201-2617; (703)524-7802. Internet address: http://www.brightfutures.org

Selected References

1. American Academy of Family Physicians. Summary of Policy Recommendations for Periodic Health Examination. Kansas City, Mo: American Academy of Family Physicians; 1997.
2. American Academy of Pediatrics, Committee on Nutrition. Pediatric Nutrition Handbook. .3rd ed. Elk Grove Village, Il: American Academy of Pediatrics; 1993.
3. American Academy of Pediatrics, Committee on Practice and Ambulatory Medicine. Recommendations for pediatric preventive health care. Pediatrics. . 1995; 96:373–374. [PubMed: 7630705]
4. Canadian Task Force on the Periodic Health Examination. Prevention of iron deficiency anemia in infants. In: The Canadian Guide to Clinical Preventive Health Care. Ottawa, Canada: Minister of Supply and Services; 1994: chap 23.
5. Centers for Disease Control. CDC criteria for anemia in children and childbearing-aged women. MMWR. . 1989; 38:400–404. [PubMed: 2542755]
6. Dallman PR. Has routine screening of infants for anemia become obsolete in the United States? Pediatrics. . 1987; 80:439–441. [PubMed: 3627895]
7. Dallman PR. New approaches to screening for iron deficiency. J Pediatr. . 1977; 90:678–681. [PubMed: 320303]
8. Dallman PR, Yip R, Johnson C. Prevalence and causes of anemia in the United States, 1976 to 1980 Am J Clin Nutr. 1984 39437–445.View this and related citations using . [PubMed: 6695843]
9. Green M, ed. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. Arlington, Va: National Center for Education in Maternal and Child Health, 1994.
10. Lozoff B, Brittenham GM, Wolf AW, et al. Iron deficiency anemia and iron therapy effects on infant developmental test performance. Pediatrics. . 1987; 79:981–995. [PubMed: 2438638]
11. Meites S, Levitt MJ. Skin-puncture and blood-collecting techniques for infants. Clin Chem. . 1979; 25:183–189. [PubMed: 761363]
12. Randolph VS. Considerations for the clinical laboratory serving the pediatric patient. Am J Med Technol. . 1982; 48:–. [PubMed: 7041649]
13. Reeves JD, Yip R, Kiley VA, Dallman PR. Iron deficiency in infants: the influence of mild antecedent infection. J Pediatr. . 1984; 105:874–879. [PubMed: 6502335]
14. Thomas WJ, Collins TM. Comparison of venipuncture blood counts with microcapillary measurements in screening for anemia in one-year-old infants. J Pediatr. . 1982; 101:32–35. [PubMed: 7086621]
15. US Preventive Services Task Force. Screening for iron deficiency anemia.In: Guide to Clinical Preventive Services. 2nd ed. Washington, DC: US Department of Health and Human Services; 1996: chap 22.
16. Yip R, Binkin NJ, Fleshood L, Trowbridge FL. Declining prevalence of anemia among low-income children in the United States. JAMA. . 1987; 258:1619–1623. [PubMed: 3625969]
17. Young PC, Hamill BH, Wasserman RC, Dickerman JD. Evaluation of the capillary microhematocrit as a screening test for anemia in pediatric office practice. Pediatrics. . 1986; 78:206–209. [PubMed: 3737297]