American Society for Clinical Laboratory Science

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Released June 10, 2020

Avoid using hemoglobin to evaluate patients for iron deficiency in susceptible populations. Instead, use ferritin.

Iron depletion is a progressive process with anemia as the final phase. Thus, screening for iron deficiency using hemoglobin (Hgb) will only identify the most severe cases. Moreover, Hgb is not specific for iron deficiency or iron deficiency anemia. Iron deficiency is one of the most common nutritional deficiencies worldwide. Prevalence of iron deficiency in USA women ages 12–49 years rose from 11% in 2003 to 14.8% in 2010. Pregnant women and young children are also high-risk groups and must be evaluated. Iron deficiency in U.S. toddlers, without anemia, is estimated at 6.6%–15.2%.

Serum ferritin is a measure of iron stores and is the most sensitive biomarker to test for early stages of iron deficiency as well as iron deficiency anemia. Sensitivity of ferritin test is 89% for diagnosis of iron depletion compared to hemoglobin, which is only 26%. Moreover, a ferritin cut off of ≤30 ng/mL provides 92% sensitivity and 98% specificity for iron deficiency anemia and is the best screening test for this disorder.

Evaluating patients for iron deficiency with ferritin will identify early stage iron deficiency and will potentially result in iron therapy, preventing iron deficiency anemia. Iron deficiency anemia has been long associated with psychomotor and cognitive abnormalities but even iron deficiency without anemia has been related to negative  eurodevelopmental outcomes in children.

Ferritin is an acute phase reactant, and occasionally in inflammatory conditions, ferritin levels may be normal or elevated even in the presence of iron deficiency. Additional laboratory tests such as reticulocyte hemoglobin content (CHR or Ret-He), mean corpuscular volume (MCV), red cell distribution width (RDW), and additional iron studies such as percent transferrin saturation and total iron binding capacity, accompanying clinical correlation are also helpful to determine iron deficiency.

These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.

How The List Was Created

George Fritsma, MS, MLS (ASCP), and the late Cindy Johns, MS, MLS (ASCP) hosted a plenary presentation “Enhancing Laboratory Communication to Reduce Extra-analytical Errors” at the ASCLS Clinical Laboratory Educators’ Conference in Boston in February 2017. Their talk referenced the ABIMF Choosing Wisely initiative. Subsequent discussions resulted in the ASCLS Board of Directors appointing a Choosing Wisely task force that evolved to a standing committee. The committee is composed of ASCLS members representing all medical laboratory science disciplines.

The committee collaborated with respective ASCLS Scientific Assemblies in developing and reviewing recommendations, which the Board of Directors reviewed and accepted for publication. The recommendations were subsequently reviewed in collaboration with the ASCP Test Utilization Steering Committee prior to submission.



American Society for Clinical Laboratory Science (ASCLS) recommendations were developed under the leadership of ASCLS’s Choosing Wisely Committee and the ASCLS president and executive vice president. The Committee examined numerous options based on evidence available through an extensive review of  the literature and member proposals. Subject matter experts from the ASCLS Scientific Assemblies reviewed and recommended approval of their respective recommendations, which are subsequently approved by the ASCLS Board of Directors. The recommendations were subsequently reviewed in collaboration with the ASCP Test Utilization Steering Committee prior to submission.


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