“Our friend the screening
Hgb/Hct..” And “Lead paint
delicious but, deadly”
By
Matt Kassel, D.O.
Iron deficiency anemia in
children, an overview.
Iron is an essential micronutrient,
necessary for enzymes throughout the
body.
It is present in all cells. The most
familiar molecules include hemoglobin,
myoglobin and cytochromes.
Deficiency of Iron is the most common
known form of nutritional deficiency.
2
Iron deficiency
RBC destruction and formation is
responsible for most Iron turnover in
the body.
An adult is capable of recycling 95% of
Iron from RBC turnover and therefore
requires only 5% from the diet.
An infant is only capable of recycling
70%.
3
Iron deficiency
Iron beyond what is immediately
needed is stored as ferritin(soluble) or
as hemosiderin(insol.)
Iron deficiency develops only after iron
stores are depleted.
Anemia is a late sign of severe
depletion.
4
Iron deficiency
Infants are at increased risk of iron
deficiency because of their high growth
rate and low stores.
Average iron levels of an infant are
75mg per KG of weight
5
Iron deficiency
Pre-term and low birth weight infants
are at further risk of iron deficiency
because of their lower total iron. And
because of their even greater growth
rate compared to full-term and normal
birth weight infants.
6
Iron deficiency
A “normal” (no bleeding diathesis or
absorptive disorders) full term infant is
born with enough iron stores to carry
through 6-8 months of life.
In general this same full term infant will
display iron deficiency anemia at 9-12
mo. if not receiving adequate dietary
iron.
7
Iron deficiency
Breast milk alone does not have enough
iron to support a child past 6-9 months
of age. ( In fact breast milk is low in
iron, but the high bioavailability of this
iron can compensate in the first months
of life.)
Breast fed infants should start
supplemental food before 6 mo of life.
8
Iron deficiency
So infants who are supplemented with
cereal at 4 months should be ok right?
Not necessarily. In fact cereals have a
phytate (protein) that actually binds
iron and prevents its absorption.
This fact is easily overcome with iron
fortification of the cereal.
9
Iron deficiency
Iron fortified formulas do supply
enough iron to meet an infants needs
though the first year of life. Infants who
are given this formula are unlikely to
develop iron deficiency.
10
Iron deficiency
NHANESIII(national health and nutrition
examination survey 1988-1994) found
that 9% of children(age 12-36mo) were
iron deficient (not anemic).
Additionally found that 3% of these
children had iron deficiency anemia.
11
Iron deficiency
More specifically 700,000 children ages
12-24 mo. Have iron deficiency and
240,000 have iron deficiency anemia.
12
Why we care
In children, iron deficiency (not enough
to cause anemia) is most strongly
associated with behavioral disturbance
and poor school performance/learning
disabilities.
Additional symptoms include, irritability,
loss of memory, difficulties learning,
and deficiencies of the immune system.
13
Why we care
Developmental delays associated with
iron deficiency may persist past school
age if not completely reversed.
Obviously iron deficient children can
develop anemia with its associated
medical problems.
14
How to find it
Iron deficiency has declined in most
sub-populations such that screening
Hgb no longer efficiently predicts iron
deficiency
further, NHANES II(1976-80) indicates
that 2mos
breast-fed infants who do not consume
a diet adequate in iron after age 6 mos
22
Iron Deficiency
Children who consume >24 oz daily of
cows milk
children who have special healthcare
needs
23
AAFP universal high risk
factors
Living in poverty
black, native American, and Alaskan
native children
Children immigrating from developing
countries.
24
AAFP individual high risk
factors
Pre term
low birth-weight
infants whose principal dietary intake is
unfortified cow’s milk
25
Iron deficiency trivia
CDC recommends that we screen pre-
term and low birth-weight infants who
are not fed iron-fortified formula or who
are not supplemented before age 6 mos
CDC also recommends that all Breast-
fed lbw and pt infants be supplemented
with iron drops beginning at age 1 mos
and continuing through age 1 year (2-
4mg/kg per day) 26
Iron deficiency trivia
Relatively mild infections may cause
transient anemias. So screening should
not be done within 3-4 weeks of viral or
bacterial infection.
27
Iron deficiency trivia
Statistically, children of non-hispanic
black race have lower Hbg and HCT
levels at baseline. Therefore cutoffs for
normal should be lowered by 0.4g/dL
for Hgb and by 1% for HCT.
28
Iron trivia
Cow’s/goat’s milk is bad for kids on
three levels. 1. It has very low iron to
begin with 2. It fills them up and they
are less likely to consume other foods
rich in iron. 3. It may cause occult GI
bleeding.
29
Iron trivia
Once a child reaches 2 years they are
much less likely to become iron
deficient(unless they have risk factors)
because their growth rate decreases
dramatically and their diets become
more diversified.
30
Iron trivia
One last thing on Fe deficiency, an
infant is physiologically capable of
increasing the absorption of iron by five
times in the small intestine. In the
absence of Iron, this increased
absorption is then available for any
metal mineral.
31
Lead
The majority of lead is found in
commercial paint. (Formally removed in
1978, though use decreased after 1950)
Also commonly found in soil near high
traffic areas, dust, contaminated water,
newsprint, occupations and recreational
(hobbies) contacts.
32
Lead
Also it is very commonly found in Folk
Remedies. (Especially common in
Mexican, Asian, and Middle Eastern
cultures.)
33
A little more background
Prior to the industrial revolution the
average total body burden of lead was
2mg.
Currently in industrialized societies the
average lead burden is 200mg.
Adults with non-occupational exposure
ingest approx. 150-200mcg of lead per
day.
34
Lead background
In adults only about 5-10% is absorbed.
Children have a markedly lower intake,
however their rate of absorption is
~50%. (the uptake can be up to 5
times higher when there are
concaminant deficiencies of Iron, Ca,
Zn.)
35
Lead Background
If children are exposed to lead their
levels tend to increase during ages 0-2
years and peak at ages 18-24 months.
36
Lead Physiology
Lead is absorbed by both the GI tract
and by the Lungs.
Once lead is absorbed ~85% is taken
up by bones and teeth, ~10% in the
blood, and the remaining percent into
soft tissues.
Lead is then excreted by the kidneys.
37
Lead Physiology
The half life of lead in blood and soft
tissues is measured in hours to days.
The half life of lead in skeletal and
dental deposits is months to years, and
is related to bone salt recycling.
Among other effects, Lead poisons
enzymes by binding to sulfhydryl
groups and denaturing proteins.
38
Lead effects on blood
Changes in the blood are seen early.
Lead blocks the incorporation of iron
into the heme. Molecule, and instead,
zinc is incorporated into the heme
molecule. (non-functional) This leads to
a microcytic, microchromic, mild
hemolytic anemia, with basophilic
stippling of erythrocytes.
39
Lead effects on GI
GI effects are late signs of very high
levels.
Symptoms include colicky abdominal
pain and constipation.
40
Lead effects on Kidney
Lead deposits in the proximal tubule of
the Kidney and leads to dysfunction of
the proximal convoluted tubule/tubulo-
interstitial disease/Fanconi’s syndrome.
Glycosuria, protienuria, hematuria,
amino-aciduria are the early signs.
Late signs are; decrease secretion of
uric acid->hyperuricemia->Saturine
gout 41
Lead effects on the Kidney
(cont.)
Another late sign is that the distal
tubule becomes resistant to aldosterone
which leads to RTA.
42
CNS effects of lead
Full spectrum of effects from mild
functional changes to cerebral edema
and death.
This is where the majority of Lead
poisoning Morbidity is seen.
It is believed that of all of the toxic
effects of lead, CNS effects are the least
likely to be reversible.
43
CNS effects cont.
Low level poisoning Serious overload is
is associated with: associated with:
Irritability, memory ataxia, severe
lapses, sleep mental impairment,
disturbance focal neuro deficits
HA, lethargy, Vomiting, seizures,
dizziness and blindness and coma
incoordination
44
CNS effects cont.
The common concern in children is that
even low levels (10mg/dl) are strongly
associated with deficits in intelligence
and memory.
Also at low levels children may have
subclinical impaired psychomotor, and
visual motor function, lowered auditory
threshold, abnormal postural balance,
and poor hand-eye coordination. 45
CNS effects of lead cont.
In one quoted population study; a
population of young children with BLLs
(blood lead level) of >30mcg/dL, there
was an increase in the number of
children with severe impairment (
IQ125
decreased from the expected 5% to 46
0%.
What has been done?
Primary treatment of lead poisoning is
removal of environmental contacts.
Lead has been removed from paint,
gasoline, food cans, and water pipes.
The vast majority of lead poisoning and
lead exposure today is from paint
applied before 1978.
47
What we still face
It has been estimated that 74% of
privately owned and occupied housing
units are likely to contain lead paint.
The best predictors of lead based
hazards are the age and condition of
housing.
48
The Good News
Based on data from NHANES II-III
(1976-1994) the incidence of U.S.
children with elevated BLLs decreased
from 88.2% to 4.4%.
Because of this dramatic decrease in
the incidence of elevated lead levels,
universal screening is no longer efficient
or recommended.
49
Not so good news
Data from NHANES III suggests that
there are still ~890,000 children ages 1-
5 who have BLLs >10mcg/dL.
50
Selective Screening
Extensive studies have been performed
to delineate who should now be
screened for lead. The results point to
the group already disadvantaged (and
at risk for Iron deficiency). These at risk
groups are; children from low-income
families, children of non-Hispanic black
race, Mexican-American children, and
children living in or frequenting housing51
built before 1946.
Selective Screening
Accordingly the AAFP recommends;
screening all infants at 12 months of
age if;
1) live near geographic area with
elevated levels
2)live in or frequent a building
constructed before 1950
3)have a close contact with elevated
lead levels. 52
Selective screening
4)live near lead industry or heavy
traffic.
5)receive any traditional remedies
6)use of lead based pottery.
53
Wonderful!
Now we have to somehow get our
DDS filled out, review IMMs,
review height and weight, perform
a thorough history and physical
exam, provide education and deal
with whatever 3 complaints our
pts have. Then we must asses
every patient for risks of lead and
iron deficiency?
54
Well, yes and no
55
Did you know?
Of the 890,000 children in the U.S with
elevated BLLs, Medicaid enrollees
accounted for 60% (535,000) of them?
This equates to a risk of elevated BLL 3
times greater than children not enrolled
in Medicaid?
Of the children in the U.S. with BLLs
greater than 20mcg/dL 83% of them
are enrolled in Medicaid? 56
Did you Know?
Since 1989 the Federal Government has
required that states screen children
enrolled in Medicaid for elevated BLLs?
Federal Medicaid requirements were
updated in 1998 to require that all
children must receive a blood lead
screening test at ages 12 and 24
months?
57
Did you Know?
Federal Medicaid requirements were
further updated in 1998 so that all
children aged 36 to 72 months of age
who have not previously been screened
must also receive a blood lead test?
There is NO waiver to this Medicaid
requirement for blood lead screening?
58
Did you Know?
That a risk assessment screening
questionnaire instead of a blood lead
test does NOT meet Medicaid
requirements?
59
Did you Know?
NHANES III(1991-1994) also revealed
that ~81% of children ages 1-5,
enrolled in Medicaid had not been
screened according to 1989
requirements?
This then prompted the CDC and
Medicaid to issue their rec/requirements
in 1998?
60
Wow, 81% of pts were not
appropriately screened.
How embarrassing for them.
The losers
61
What I did
Reviewed 244 charts of Pts seen for
WCC with birth dates from 1/2001-
1/2004 in our clinic.
sought charts where a WCC was
performed at 1yr or greater age.
If they had a WCC which pts had a
screening hgb/hct.. And which had a
screening lead test.
62
What I did
And what percentage of these children
were Medicaid enrollees.
63
Of the 244 charts only 96 met my
criteria for inclusion.
31% (30/96)had a screening HCT
24% (23/96)had lead screens
23% (22/96)had both a lead and HCT
2 of the patients who were screened
had non-Medicaid insurance (Cigna,
First Health, and both were screened
for lead and HCT)
64
1 of the patients not screened had
pacificare
and 4 of the patients not screened had
no insurance (charity, contract, self
pay).
If you take out the insured pts the
screening percents drop to 30,22,21
65
These results also apply to the
screening HCT
According to CDC and AAFP guidelines
we should be screening all 12 mos
infants who are impoverished. If we
use the CDC definition of requiring
government assistance as impoverished
then we had 93 pts who qualified for
high risk screening. We screened 28 or
30%.
66
To look at the numbers a different way;
(removing the insured pts.) we failed to
screen ~ 75% of the pts at risk for lead
toxicity.
And didn’t screen 70% of high risk
children for iron deficiency.
67
Super, Wonderful!
Now we have to somehow get our DDS
filled out, review IMMs, review height
and weight, perform a thorough history
and physical exam, provide education
and deal with whatever 3 complaints
our pts have. Then we must asses
every patient for risks of lead and iron
deficiency?
Not to worry! 68
Lead screening made simple
Actually, it is simple, if the pt is enrolled
in Medicaid they are required to have a
Lead test at 12 and 24 months. No
questionnaires they just have to have it.
69
Lead screening made simple
If you see a Medicaid enrolled child for
WCC less than 6 years of age. And if
they have no Objective Proof of normal
lead levels. They too are required to be
screened.
70
Iron Deficiency screen
More “complicated” as not required by
Medicaid
AAFP and CDC guidelines
a clinic wide policy would be helpful for
universal screening of a population(i.e.
low income).
Always use risk factors to guide specific
case screening.
71
Iron deficiency screen
Likely all pts screened for lead at 12
months qualify to be screened for iron
deficiency as well.
72
“A Physician treats those who are ill.”
“A Good Physician treats those who are
well.”
Mike Allen, D.O. circa 2004
73
“First do no harm.”
– Chad Fowler, M.D. circa 2003
74
“Those who forget the past……I can’t
remember the rest.”
– Tiffany Stewart, M.D. 2004 (B.C.)
75
“I’m Gonna kick your ---”
– Deb Hass, M.D. whenever you say hello
76
If a tree falls in the woods, and it kills a
mime, does anyone care?
– Amy Chudik, D.O. 2001
77