Reducing Iron Deficiency in Teen-Aged Blood Donors

High school blood drives are one of the most cost-effective sites for blood collection.¹  Whole-blood donation by 16-year-olds rapidly increased after 2006, when many states lowered the minimum donation age to allow more high school students to donate.¹  An increase in collection from high school–aged children followed. Between 10% and 15% of the US blood supply now is collected from 16- to 17-year-olds, although they account for <3% of the population.¹  Blood donors commonly develop iron deficiency because each whole-blood donation removes ∼250 mg of iron, and testing for donor iron stores is not required.^2,3  The development of iron deficiency is of concern for all donors because of its side effects, such as fatigue⁴  and pica.⁵  However, it is of particular concern for teen-aged donors, who are more susceptible than adults to the development of iron⁶  deficiency and continue active iron-dependent neurocognitive development.⁷  In response to the vulnerability of teenagers to iron deficiency, AABB, the largest community of professionals practicing transfusion medicine, recommended in 2017 that blood collection agencies either limit 16- to 18-year-old donors to 1 whole-blood donation per year or do 1 of the following: (1) dispense iron supplements or (2) perform ferritin testing as a basis for advising donors about further actions.⁸ 

It is in this context that Dr Vassallo et al⁹  undertook a major initiative to promote safe teenager donation by performing ferritin testing on 16- to 18-year-old blood donors as presented in their study in this month’s issue of Pediatrics. A blood sample collected before donation was used for postdonation ferritin testing because a point-of-care ferritin test is not available. As such, the ferritin test result was not used to determine eligibility when a teenager presented to donate blood, but it was used to adjust the time interval between donations. Male donors with inadequate iron stores (ferritin level <30 ng/dL) waited at least 6 months between donations, whereas female donors with inadequate iron stores (ferritin level <20 ng/dL) waited at least 12 months. In addition, donors with ferritin levels below these cutoffs were sent a letter advising they take 18 to 28 mg of iron daily for 60 days. Those with ferritin levels above these cutoffs were not contacted and had to wait at least 56 days between donations, the same time period required for adult donors. Of the 125 384 teen-aged donors providing an index donation, 30 806 returned for a repeat donation during the 2-year study period. Interestingly, among those who did not return, 38.8% of the female and 12.3% of the male donors had low index ferritin levels, whereas among those who did return, 11.4% of female donors and 9.7% of male donors had low index ferritin levels. Thus, large numbers of teenagers with inadequate iron stores are donating blood, and many of those with low index ferritin levels in this study did not to return to donate. Furthermore, those receiving a letter advising them to take iron supplements were less likely to return to donate than those that did not receive this letter. Analyses comparing ferritin values from the index and the next donation confirmed that blood donation depletes iron stores. Among the teenagers who returned to donate, ∼40% of female and 20% of male donors had low ferritin levels 12 months after their index donation. This increased further to ∼50% of female donors and 30% of male donors who donated double units of red blood cells at their index donation. A key finding from statistical analyses of the data comparing index to subsequent donations was that index ferritin levels had to be ∼50 ng/mL in both male and female individuals for 90% of teen-aged donors to rebuild adequate iron stores within 3 to 9 months.

Vitalant is the second largest nonprofit blood collection organization in North America. They are to be congratulated for undertaking this major teen-aged donor safety initiative, collecting data, and reporting their findings, which are of considerable value to other organizations collecting blood from teenagers. The data presented confirm the high baseline level of iron deficiency in teenagers and its increase after blood donation. Pediatricians should be aware of the large number of teenagers donating blood in the United States, consider routinely asking about blood donation during routine physical examinations, and perform appropriate laboratory screening and treatment of iron deficiency. It is clearly indicated in the data that in the absence of other interventions, one year should be the minimum interdonation interval for teenagers. If ferritin testing is performed, teenagers with ferritin levels >50 ng/mL at index donation could perhaps donate twice per year. There is appropriate concern that stricter regulations on the collection of blood from teenagers will have a detrimental effect on the blood supply. However, the findings from this study emphasize that further efforts should be made to reverse the trend of increasing collections from teenagers with increased emphasis on collection from adults.