5
Biochemical and Other Medical Risk Criteria

Biochemical and other medical risk criteria are used during the certification process for the WIC program (Special Supplemental Nutrition Program for Women, Infants, and Children) to establish eligibility for participation in the program and as a basis for either preventive or curative nutrition or health interventions. WIC program regulations define this group of nutrition risks in two categories:

  • those determined by biochemical measures such as hemoglobin as a measure of anemia, and
  • other documented nutritionally related medical conditions, such as clinical signs of nutrition deficiencies, metabolic disorders, preeclampsia in pregnant women, failure to thrive in an infant, chronic infections in any person, alcohol or drug abuse or mental retardation in women, lead poisoning, history of high-risk pregnancies or factors associated with high-risk pregnancies (such as smoking; conception before 16 months postpartum; history of low birth weight, premature births, or neonatal loss; adolescent pregnancy; or current multiple pregnancy) in pregnant women, or congenital malformations in infants or children or infants born to women with alcohol or drug abuse histories or mental retardation (7 CFR Subpart C, Section 246.7(e)(2)(i and ii); Federal Register 60(75):19,487–19, 491).

Currently, biochemical risk or documented nutrition-based medical conditions fall under Priority I for pregnant women, breastfeeding women, and infants; Priority III for children; and Priority VI for nonbreastfeeding postpartum women. Biochemical and other medical risk criteria are used to certify applicants for participation in the WIC program within the same priority as anthropometric risk criteria. These criteria are assigned a higher priority for participation



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--> 5 Biochemical and Other Medical Risk Criteria Biochemical and other medical risk criteria are used during the certification process for the WIC program (Special Supplemental Nutrition Program for Women, Infants, and Children) to establish eligibility for participation in the program and as a basis for either preventive or curative nutrition or health interventions. WIC program regulations define this group of nutrition risks in two categories: those determined by biochemical measures such as hemoglobin as a measure of anemia, and other documented nutritionally related medical conditions, such as clinical signs of nutrition deficiencies, metabolic disorders, preeclampsia in pregnant women, failure to thrive in an infant, chronic infections in any person, alcohol or drug abuse or mental retardation in women, lead poisoning, history of high-risk pregnancies or factors associated with high-risk pregnancies (such as smoking; conception before 16 months postpartum; history of low birth weight, premature births, or neonatal loss; adolescent pregnancy; or current multiple pregnancy) in pregnant women, or congenital malformations in infants or children or infants born to women with alcohol or drug abuse histories or mental retardation (7 CFR Subpart C, Section 246.7(e)(2)(i and ii); Federal Register 60(75):19,487–19, 491). Currently, biochemical risk or documented nutrition-based medical conditions fall under Priority I for pregnant women, breastfeeding women, and infants; Priority III for children; and Priority VI for nonbreastfeeding postpartum women. Biochemical and other medical risk criteria are used to certify applicants for participation in the WIC program within the same priority as anthropometric risk criteria. These criteria are assigned a higher priority for participation

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--> than dietary or predisposing risk criteria (e.g., homelessness or migrancy) (see Chapter 3, Table 3-2). In the WIC program's certification process, medical risk is based on an assessment by a competent professional authority on the staff of the WIC agency or is based on referral data submitted by a competent professional authority not on the staff of the WIC agency (7 CFR Subpart C, Section 246.7(d)). This chapter covers the medical nutrition risk criteria related to nutrient deficiencies, medical conditions applicable to the entire WIC population, conditions related to intake of specific foods, conditions specific to pregnancy, conditions specific to infants, and potentially toxic substances. These groupings are somewhat different from those used by the WIC program to reduce overlap in content. A list of medical risk criteria that are used by state WIC programs appears in Table 5-1. A summary of the criteria as predictors of risk and benefit appears in Table 5-2. TABLE 5-1 Summary of Biochemical and Other Medical Risk Criteria in the WIC Program and Use by States   States Using Risk Criterion Women Infants Children Criteria Related to Nutrient Deficiencies Anemia 54 54 54 Nutrient deficiencies including failure to thrive       Malnutrition — 8 8 Nutrition related illness — 25 27 Failure to thrive — 30 27 Medical Conditions Applicable to the Entire WIC Population Gastrointestinal disorders 13 30 24 Nausea and vomiting of pregnancy 26 — — Chronic diarrhea — 16 15 Chronic vomiting — 15 7 Crohn's disease — 7 — Liver disease — 15 14 Hepatitis — 18 14 Intestinal diseases — 6 7 Cystic fibrosis — 30 32 Endocrine disorders — — 6 Diabetes mellitus (Types I and II) 54 35 41 Hypo- or hyperthyroidism 6 6 —

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-->   States Using Risk Criterion Women Infants Children Medical Conditions Applicable to the Entire WIC Population Chronic hypertension 54 19 25 Renal disease 54 35 35 Cancer 20 26 30 Central nervous system disorders — 12 10 Epilepsy 5 6 6 Cerebral palsy — 36 37 Spina bifida — 12 13 Myelomeningocele — — 6 Genetic and congenital disorders 21 — 38 Cleft lip or palate — 41 39 Down syndrome — 16 10 Pyloric stenosis — 7 — Thalassemia 14 6 7 Sickle cell anemia 16 20 21 History of an infant with congenital disorder 32 — — History of a genetic disorder in infant 17 — — Nutritionally significant genetic disease 8 — — Congenital disorder — 37 — Genetic disorder — 8 — Inborn errors of metabolism       Phenylketonuria — 29 28 Maple syrup urine disease — 13 12 Galactosemia — 19 15 Metabolic disorder 32 24 26 Tyrosinemia and homocystinuria — 7 6 Other inborn errors of metabolism — 19 20 Chronic infections 52 21 10 Recurrent infections 25 — 11 Infectious disorder 28 — — Nutrition-related infectious disease 14 9 — Respiratory infections — 12 19 Tuberculosis — 25 25 Pneumonia — 19 18 Bronchitis — 7 12 Otitis media — 21 19 Meningitis — 14 15 HIV infection and AIDS 20 22 20 Recent surgery or trauma 18 28 27 Burns 10 24 24 Severe acute infections 28 — — Other medical conditions       Juvenile rheumatoid arthritis — — — Arthritis 2 — —

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-->   States Using Risk Criterion Women Infants Children Medical Conditions Applicable to the Entire WIC Population Lupus erythematosus 6 — — Cardiorespiratory disorders 17 37 38 Conditions Related to the Intake of Specific Foods Food allergies 27 29 34 Celiac disease or intolerance — 24 24 Food intolerances       Lactose intolerance — 20 16 Asthma — 6 8 Conditions Specific to Pregnancy Pregnancy at a young age 52 — — Pregnancy age older than 35 43 — — Closely spaced pregnancies 52 — — High parity 43 — — History of preterm delivery 42 — — History of postterm delivery 8 — — History of low birth weight 49 — — History of neonatal loss 43 — — History of previous birth of an infant with a congenital or birth defect 32 — — Lack of prenatal care 18 — — Multifetal gestation 51 — — Fetal growth restriction 17 — — Preeclampsia and eclampsia 54 — — Placental abnormalities 15 — — Conditions Specific to Infants and/or Children Prematurity — 39 6 Hypoglycemia 12 — — Fetal alcohol syndrome — 12 9 Potentially Toxic Substances Drug-nutrient interactions 9 — — Inappropriate use of medication — 23 23 Maternal smoking 51 — — Alcohol and illegal drug use       Alcohol use 51 36 23 Illegal drug use 50 36 23 Lead poisoning 19 24 24 NOTE: Dashes indicate risk is not applicable or not reported for that population.

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--> TABLE 5-2 Summary of Broad Categories of Biochemical and Other Medical Risk Criteria as Predictive of Risk or Benefit Among Women, Infants, and Children   Women Infants Children Risk Criteriona Risk Benefit Risk Benefit Risk Benefit Women, Infants, and Children Anemia ✓ ✓ ✓ ✓ ✓ ✓ Nutrition deficiencies ✓ ✓ ✓ ✓ ✓ ✓ Gastrointestinal disorders ✓ ✓ ✓ ✓ ✓ ✓ Endocrine disorders ✓ ✓ ✓ ✓ ✓ ✓ Hypertension ✓ ✓ ✓ ✓ ✓ ✓ Renal disease ✓ ✓ ✓ ✓ ✓ ✓ Cancer ✓ ✓ ✓ ✓ ✓ ✓ Central nervous system disorders ✓ ✓ ✓ ✓ ✓ ✓ Genetic and congenital disorders ✓ ✓ ✓ ✓ ✓ ✓ Inborn errors of metabolism ✓ ✓ ✓ ✓ ✓   HIV infection and AIDS ✓ ✓ ✓ ✓ ✓ ✓ Recent major surgery or trauma, burns, and severe acute infections ✓ ✓ ✓ ✓ ✓ ✓ Food allergies ✓ ✓ ✓ ✓ ✓ ✓ Lead poisoning ✓ ✓ ✓ ✓ ✓ ✓ Women During Pregnancy Nausea and vomiting ✓ ✓         Diabetes mellitus ✓ ✓         Pregnancy at low age ✓ ✓         Pregnancy age older than 35 ✓ 0         Closely spaced pregnancies ✓ ✓         High parity ? 0         History of preterm delivery ✓ ✓         History of postterm delivery ? 0         Lack of prenatal care ✓ ✓         Multifetal gestation ✓ ✓         Fetal growth restriction ✓ ✓         Preeclampsia and eclampsia ✓ 0         Placental abnormalities ✓ 0         Maternal smoking ✓ ?         Alcohol and illegal drug use ✓ ✓        

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-->   Women Infants Children Risk Criteriona Risk Benefit Risk Benefit Risk Benefit Infants and Children Prematurity     ✓ ✓ ? ? NOTE: ✓ = predictive of risk or benefit; ? = evidence unclear; 0 = no evidence, or evidence but no effect; blank = not applicable to that group. a Within the broad category chronic or recurring infections, there is evidence for nutrition risk and benefit for some specific criteria, such as tuberculosis, but not for other specific criteria, such as upper respiratory infections, bronchitis, and otitis media. The same is true within the broad categories drug-nutrient interactions and food intolerances. Criteria Related To Nutrient Deficiencies Anemia Anemia is defined as a reduction of the red blood cell (erythrocyte) volume or hemoglobin concentration greater than two standard deviations below the mean (i.e., below the 2.5th percentile) occurring in healthy persons of the same age, gender, or, for women, stage of pregnancy (IOM, 1990, 1993). Anemias are generally classified into two groups—those resulting primarily from decreased production of red blood cells or hemoglobin, or those in which increased destruction or loss of red blood cells is the predominant mechanism. Megaloblastic anemia is associated with deficiencies of folate and vitamin B6 and/or vitamin B12. Microcytic anemia is associated with thalassemia trait, iron deficiency, and/or copper deficiency. The most common nutrition-related anemia is iron deficiency, which may be caused by diets low in iron, the insufficient assimilation of iron from the diet, the utilization of iron for rapid growth or pregnancy, or blood loss. Prevalence of and Factors Associated with Anemia Information on the prevalence of iron deficiency anemia in the United States comes from the National Health and Nutrition Examination Surveys (NHANES), conducted by the National Center for Health Statistics; the Pregnancy (PNSS) or Pediatric Nutrition Surveillance System (PedNSS), conducted by the Centers for Disease Control and Prevention (CDC); the U.S. Department of Agriculture's (USDA) WIC Eligibility Study; and the National WIC Evaluation. Between 1980 and 1991, the prevalence of anemia among United States infants and children through 5 years of age declined dramatically, from 7 to

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--> 3 percent, according to most recent data from the PedNSS, a low-income sample that includes many WIC program participants (Yip et al., 1992). However, there has been negligible decrease in anemia among black and Hispanic infants and children less than 2 years of age (Figure 17, p. 20, Yip et al., 1992). In 1990, the PNSS reported prevalences of iron deficiency anemia of 10, 14, and 33 percent in the first, second, and third trimesters of pregnancy, respectively, for low-income pregnant women of all races (Kim et al., 1992). Black women exhibited a significantly higher prevalence of iron deficiency anemia than did women of other races. PNSS data show that the prevalence of iron deficiency anemia among low-income pregnant women has remained stable since 1979. Estimates of the prevalence of iron deficiency anemia among the population potentially eligible for participation in the WIC program were reported in the 1985 WIC Eligibility Study (USDA, 1987) and were based on data from the NHANES II survey. These prevalence estimates were 2.3 percent for women 12 through 49 years of age, 14.3 percent for infants 6 to 11 months of age, 13.5 percent for children 12 to 23 months of age, 14.8 percent for children 2 to 3 years of age, 8.6 percent for children 3 to 4 years of age, and 8.4 percent for children 4 to 5 years of age. Factors associated with anemia in women include poverty, low education, high parity, and black and Hispanic ethnicity (IOM, 1990; LSRO, 1991), with pregnancy imposing increased iron needs for the growth of the fetus and for expansion of the maternal blood volume (IOM, 1993). Factors associated with anemia in infants and children include poverty, inadequate dietary intake, malabsorption, and moderate to severe malnutrition (Behrman, 1992; IOM, 1993). Low-birth-weight (LBW) infants are at increased risk of developing anemia because of low neonatal iron stores (IOM, 1993). Anemia as an Indicator of Nutrition and Health Risk Anemia can impair energy metabolism, temperature regulation, immune function, and work performance (IOM, 1993). Anemia during pregnancy may increase the risk of prematurity, poor maternal weight gain, LBW, and infant mortality (IOM, 1990). CDC recently confirmed earlier associations between anemia during pregnancy, hemoglobin concentrations of less than 10 g/dl in the first trimester, and delivery of LBW infants (Kim et al., 1992). Other studies (Ulmer and Goepel; 1988; Scholl et al., 1992) report that maternal iron deficiency is associated with both LBW and poor gestational weight gain. Data from the National WIC Evaluation (Rush et al., 1988b) showed a significant negative relationship between the woman's initial hemoglobin concentration and birth weight. There was no evidence of a relationship between a hemoglobin concentration of less than 10 g/dl or greater than 14 g/dl and adverse

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--> perinatal outcomes among white women. Among a small group of black WIC participants, however, a high hemoglobin concentration (> 14 g/dl) at entry in either the first or second trimester was associated with LBW, and low hemoglobin concentration (< 10 g/dl) in the first trimester was associated with LBW. There was no association of low hemoglobin concentration at entry in the second trimester with LBW. In infants and children, the greatest risk from iron deficiency anemia (even if mild) is a delay in mental and motor development. Consistently, the mental and motor development scores of iron deficient anemic infants and toddlers fall behind those of children of the same age with replete iron stores (Idjradinata and Pollitt, 1993; Lozoff et al., 1982; Walter et al., 1989). Among preschool and school age children, iron deficiency anemia is associated with comparatively poor scores in tests of intelligence, school achievement, and specific cognitive processes (Pollitt et al., 1989; Seshadri and Gopaldas, 1989; Soewondo et al., 1989). Anemia as an Indicator of Nutrition and Health Benefit Because low-income women (and to a lesser extent infants and children) are at increased risk for iron deficiency anemia, their potential to benefit through participation in the WIC program is clear. Iron is one of the nutrients targeted in the WIC program food package through the provision of iron-fortified cereals and infant formula. The WIC program food package also supplies sources of folate and vitamin B12, which can assist in the prevention of other nutritional anemias. Additionally, the WIC program encourages mothers to breastfeed their infants, which normally ensures adequate iron status for the first 4 to 6 months in infants born at term. Studies have shown that the provision of supplemental iron (through food or supplements, or both) can reduce the prevalence of iron deficiency anemia in women, infants, and children (IOM, 1990, 1993; Rush et al., 1988a, b; Yip et al., 1992). The large decline in the prevalence of anemia since 1980 is principally attributed to participation in the WIC program. Studies show that prevention or treatment of anemia during pregnancy improves pregnancy outcomes (primarily LBW) (Kim et al., 1992; Rush et al., 1988b). Studies in infants and children have revealed mixed results in the reversal of cognitive delays and behavioral changes through the delivery of supplemental iron (Lozoff et al., 1991; Pollitt, 1993). Some studies have shown that impaired cognitive function is still present at the time when formerly anemic children enter school, whereas others have shown strong evidence of complete recovery in response to iron treatment. Among infants, the administration of iron-fortified infant formula contributed to the prevention of anemia and of the motor delays

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--> observed among iron deficient anemic infants who received non-iron-fortified formula (Moffat et al., 1994). Similarly, in a randomized trial, the administration of ferrous sulfate led to the saturation of iron stores among previously anemic infants and toddlers and was accompanied by a full reversal of the developmental delays in these children (Idjradinata and Pollitt, 1993). Such developmental improvement was not observed among those anemic children who received a placebo. In other studies, iron treatment failed to improve performance on the Bayley Mental Development Scale (Pollitt, 1994). Various experimental and quasi-experimental studies have shown that iron repletion therapy among anemic preschool and school children improves cognitive test performance and school achievement (Watkins and Pollitt, in press). Use of Anemia as a Nutrition Risk Criterion in the WIC Setting Measurement of either hemoglobin or hematocrit concentration is used to detect the presence of anemia or putative iron deficiency because both are easy to use and inexpensive. These measurements are the methods most frequently used to identify the presence of anemia among participants in the WIC program. Among women and children, hemoglobin and hematocrit values vary by age, stage of pregnancy, smoking status, and altitude (see Table 5-3). During pregnancy, hemoglobin values gradually fall to a low point near the end of the second trimester, largely because of expanded blood volume. From this point until term, the concentration of hemoglobin rises again. Serum ferritin concentration, erythrocyte protoporphyrin, mean corpuscular volume, serum iron concentration and iron-binding capacity, and serum transferrin receptor concentration are other biochemical tests used to define anemia. However, they are more expensive and less practical for use in the WIC program. In the WIC program, anemia is the most frequently cited nutrition risk among participants in all categories. (The WIC program's priority system gives individuals with hematologic- and anthropometric-based nutrition risks priority for participation in the WIC program.) According to 1992 state WIC agency plans, all states use hematocrit or hemoglobin concentration measurements to evaluate the risk of anemia (see Table 5-1) (USDA, 1994). The recommended cutoff values for anemia from the CDC (1989) and the Institute of Medicine (IOM, 1993) are found in Table 5-3. The cutoff points for anemia currently in use vary substantially among states and by participant category.

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--> TABLE 5-3 Cutoff Points for Anemia Used in the WIC Program and Recommended Cutoff Points from the Centers for Disease Control and Prevention and the Institute of Medicine for Women, Infants, and Children   Cutoff Point Population WIC Programs CDCa IOMa, b Pregnant Women First trimester 10.0-12.6 g/dl Hgb 30-38% Hct 11.0 g/dl Hgb 33% Hct 11.0 g/dl Hgb, with ferritin <20 µg/l Second trimester 10.0-12.0 g/dl Hgb 30-37% Hct 10.5 g/dl Hgb 32% Hct 10.5 g/dl Hgb, and 20 µg/l ferritin Third trimester 10.0-12.6 g/dl Hgb 30-37% Hct 11.5 g/dl Hgb 34% Hct 11.0 g/dl Hgb, and no ferritin collected Lactating Women 12.0 g/dl Hgb 36% Hct 12.0 g/dl Hgb 36% Hct 12.0 g/dl Hgb 36% Hct Postpartum, Nonlactating Women 12.0 g/dl Hgb 36% Hct 12.0 g/dl Hgb 36% Hct 12.0 g/dl Hgb 36% Hct Infants (birth to 6 mo) 9.9-15 g/dl Hgb 30.9-44% Hct N/A N/A 11.0 g/dl Hgb 33% Hct Children (> 6 mo to 23 mo) 9.9-13 g/dl Hgb 30.9-39% Hct 11.0 g/dl Hgb 33% Hct 11.0 g/dl Hgb 33% Hct (2 to 5 yr) 10.0-12.7 g/dl Hgb 31-38% Hct 11.0 g/dl Hgb 33% Hct 11.0 g/dl Hgb 33% Hct NOTE: Hgb = hemoglobin; Hct = hematocrit. a Adjustments for altitude (> 5,000 feet, add 0.5 g/dl hemoglobin or 1.5 percent hematocrit) or smoking (add 0.3 to 0.5 g/dl hemoglobin or 1 to 1.5 percent hematocrit, depending on the number of cigarettes smoked per day) should be added to the cutoff points for pregnant, breastfeeding, and nonlactating postpartum women. b The IOM recommendations listed here for lactating and nonlactating postpartum women correspond to the IOM recommendations for women of childbearing age. SOURCE: WIC program cutoff values reported in 1992 state plans (USDA, 1994); CDC guidelines for pregnant women (CDC, 1989); Report of the Committee on the Prevention, Management, and Treatment of Iron Deficiency Anemia Among U.S. Infants, Children, and Women of Childbearing Age (IOM, 1993). Recommendation for Anemia The risk of anemia is well documented for women, infants, and children; anemia can be identified by measures of hemoglobin or hematocrit concentration.

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--> There is empirical evidence and a theoretical basis for benefit from participation in the WIC program. Therefore, the committee recommends use of anemia as a nutrition risk criterion for women, infants, and children in the WIC program, using cutoff values from the CDC (1989) or the IOM (1993) (see Table 5-3). Use of higher cutoff values is not recommended because the yield of risk will be very low for both anemia and iron deficiency. The committee's recommendations for biochemical and other medical risk criteria are summarized in Table 5-4. Failure to Thrive and Other Nutrient Deficiency Diseases Failure to thrive (FTT) is ordinarily a mild form of protein-energy malnutrition (PEM) that is manifested by a reduction in the rate of somatic growth. Severe PEM presents as marasmus or kwashiorkor. Marasmus (less than 60 percent median weight for age) is characterized by severe loss of muscle and fat. Kwashiorkor is characterized by edema and hypoproteinemia, but loss of lean body mass and fat is less severe than in marasmus. Examples of micronutrient deficiencies include scurvy (vitamin C deficiency) and vitamin D deficiency rickets. Prevalence of and Factors Associated with Failure to Thrive and Other Nutrient Deficiency Diseases Although clinically obvious undernutrition is relatively uncommon in the United States, it does occur; FTT is the form most commonly encountered among infants and young children. On occasion, severe forms of protein-energy malnutrition (PEM) or micronutrient deficiency diseases are encountered. PEM results from a combination of social, economic, biologic, and environmental factors (Torun and Chew, 1994). Impaired family dynamics, lack of knowledge on the part of the caregiver for the infant or child, and, in some instances, organic diseases are all major factors contributing to failure to thrive in infants and young children in this country. Whatever the primary factor, however, malnutrition is the final common pathway. Inappropriately low weight for the stature of the infant or child provides a clear indication of recent malnutrition. Impaired linear growth, with weight appropriate for stature, is also a frequent end result of malnutrition, although other causes, e.g., endocrinopathies, need to be excluded. Approximately 1 to 5 percent of all pediatric hospital admissions are for FTT (Bithoney et al., 1991; Phelps, 1991). A large number of infants and children with FTT are managed as outpatients by physicians throughout the United States (Mitchell et al., 1980). FTT without an apparent medical cause accounts for a majority of cases of FTT

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