089 - Iron Deficiency Screening: A Quality Improvement Initiative Introducing Reticulocyte Hemoglobin in a Neonatal Intensive Care Unit

Publication Number: 89.5815

Whitley N. Hulse, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States; Narmin Javadova, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States; Sally Norlin, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States; Pamela Kling, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States

Background: Iron deficiency (ID) is the most common nutritional deficiency worldwide, affecting 17% of infants. Preterm birth and being small for gestational age (SGA) increase the risk of both ID and its accompanying adverse neurodevelopmental outcomes. Reticulocyte hemoglobin (RET-He) is a newer validated erythrocyte iron biomarker with the advantage of being unaffected by inflammation. It is performed on the same blood sample as CBC and reflects the mean iron incorporated within reticulocytes over the previous week, compared to ferritin iron stores.

Objective: To implement ID screening as part of a neurodevelopmental strategy for neonates born < 33 weeks gestational age (wga) at 30 days ±7, and for SGA neonates born ≥33 wga before discharge using RET-He, targeting an 80% screening rate by June 2024.

Design/Methods: A multidisciplinary team led a quality improvement initiative in a level III neonatal intensive care unit (NICU) from March 2022 to August 2024. The primary outcome measure was 1-month RET-He screening at 30 ±7 days for < 33 wga or pre-discharge for SGA ≥33 wga. Exclusion criteria were death or transfer at < 1 month. Process measures included ID screening failure rate, defined as RET-He < 29 pg. Data was analyzed quarterly, guiding PDSA cycle adjustments, including recommending repeat screening at 2 months if still hospitalized.

Results: From March 2022 to August 2024, 339 neonates were eligible for screening. A prior QI project resulted in 80% 30-day ferritin screening compliance. P-chart analysis showed initial screening rates for 248 neonates < 33 wga declined from 74.4% (PDSA 1) to 67.7% (PDSA 2) to 82.7% (PDSA 3), Figure 1. For 91 SGA neonates ≥33 wga, screening rates rose from 12.4% to 34.1% after PDSA 2, later dropping to 20.0%, Figure 2. ID screening failure rate for neonates < 33 wga was 14.6%, comparable to 16% with ferritin < 70 µg/L. ID screening failure rate increased to 33.7% when neonates < 33 wga underwent repeat screening at 2 months.

Conclusion(s): ID screening using RET-He for < 33 wga was successfully implemented, reaching detection rates comparable to ferritin at 1 month. However, the rise in ID at 2 months in neonates < 33 wga supports higher iron demand near term-corrected age, indicating a need to determine the predictive threshold of 1-month values for 2-month failure that could dictate therapeutic iron strategies. Screening rates for SGA neonates >33 wga were lower despite multiple PSDA cycles, requiring further protocol adjustments in this high-risk population, including recommending outpatient screening.

Figure 1
Figure 1 PAS abstract.pdfFigure 1: P-chart showing the percentage of neonates < 33 weeks gestational age correctly screened for iron deficiency per month eligible for screening. A new centerline was established upon the introduction of each PDA cycle. No eligible infants in May 2024. CL: centerline, UCL: upper control limit, LCL: lower control limit

Figure 2
Figure 2 PAS abstract .pdfFigure 2: P-chart showing the percentage of neonates who are small for gestational age (SGA) and ≥ 33 weeks gestational age correctly screened for iron deficiency per month eligible for screening. A new centerline was established upon the introduction of each PDA cycle. CL: centerline, UCL: upper control limit, LCL: lower control limit