RISK SCORES

Cobalamin Deficiency Risk (CDR) Score

• Low Risk:                   0 to 1
• At Risk:                      2 to 4
• High Risk:                  5 or greater

I. Neurological Manifestations (+2)

• Paresthesias
• Weakness of arms, legs, or trunk
• Unsteady gait, balance problems
• Ataxia
• Dizziness or light-headedness
• Tremors
• Restless legs
• Lhermitte’s sign
• Romberg’s sign
• Abnormal Babinski reflex
• Visual disturbances
• Forgetfulness, short-term memory loss, or dementia
• Mental status changes
• Impotence, erectile dysfunction
• Urinary or fecal incontinence
• Impaired vibration, position sense
• Abnormal reflexes
• Seizures
• Paralysis

II. Neuropsychiatric Manifestations (+2)

• Depression, suicidal ideation
• Diagnosis of mental illness or on psychiatric medications
• Post-partum depression or psychosis
• Anxiety
• ADD/ADHD
• Personality changes
• Poor concentration or foggy thinking
• Paranoia
• Mania
• Hallucinations
• Psychosis
• Violent behavior
• Homicidal ideations

III. Hematologic Manifestations (+2)

• Anemia
• Macrocytosis
• Hypersegmented neutrophils
• Anisocytosis
• Leukopenia
• Thrombocytopenia
• Pancytopenia

IV. General Signs/Symptoms (+1)

• Generalized weakness or fatigue
• Shortness of breath
• Pallor or jaundice
• Frequent falls or near falls
• Loss of appetite/weight loss
• Frequent infections, poor wound healing
• Orthostatic hypotension
• Postural orthostatic tachycardia
• Occlusive vascular disorder or thrombotic events (e.g., PE, DVT, CVA, MI, portal vein thrombosis)
• Cervical dysplasia
• Intrauterine growth retardation
• Malnutrition
• Glossitis
• Tinnitus
• Skin hyperpigmentation or hypopigmentation
• Hepatomegaly or splenomegaly

V. Gastrointestinal Risks (+2)

• Decreased stomach acid or atrophic gastritis
• Gastroparesis
• Helicobacter pylori infection
• Giardiasis
• GERD or ulcer disease
• Gastrectomy (partial or complete), bariatric surgery
• Ileal resection (partial or complete)
• Malabsorption syndromes (e.g., Crohn’s disease, IBS, celiac disease)
• Pancreatitis, pancreatic exocrine insufficiency
• Small intestinal bacterial overgrowth
• Diphyllobothrium latum (fish tapeworm)
• Liver disease (e.g., cirrhosis, hepatitis C)

VI. (a) Population at Risk (+2)

• Vegans, vegetarians, macrobiotic diets
• MTHFR gene mutation
• Nitrous oxide administration or abuse
• Eating disorders

VI. (b) Population at Risk (+1)

• Age 50 and over
• Pregnancy
• Intrauterine growth retardation
• Autoimmune disorders (e.g., thyroid, IDDM, lupus)
• Family history of pernicious anemia
• Proton pump inhibitor or H2-blocker use
• Metformin use
• Alcoholism
• Dialysis patients
• AIDS
• Chemo- or radiation therapy
• Phenylketonuria (PKU)
• Down syndrome

Use the table below to add up your child’s score and determine his/her risk of B12 deficiency.

• Low Risk:                   0 to 1
• At Risk:                      2 to 4
• High Risk:                  5 or greater

I. Neurological Manifestations (+2)

• Developmental delay or regression (motor, speech, language, or social)
• Hypotonia
• Poor suckling/swallowing
• Abnormal movements
• Ataxia
• Tremors
• Seizures
• Paresthesias
• Lhermitte’s sign
• Romberg’s sign
• Weakness of extremities
• Clumsiness or falling
• Dizziness
• Visual disturbances
• Impaired vibration, position sense
• Mental status changes
• Abnormal reflexes
• Paralysis
• Coma

II. Neuropsychiatric Manifestations (+2)

• Depression or apathy
• Suicidal ideations
• Diagnosis of mental illness or on psychiatric medications
• Anxiety
• ADD/ADHD
• Personality changes
• Poor concentration or foggy thinking
• Poor verbal fluency or problem solving
• Low IQ
• Paranoia
• Mania
• Hallucinations
• Psychosis
• Violent behavior or homicidal ideations

III. Hematologic Manifestations (+2)

• Anemia
• Macrocytosis
• Hypersegmented neutrophils
• Anisocytosis
• Leukopenia
• Thrombocytopenia
• Pancytopenia

IV. General Signs/Symptoms (+1)

• Abnormal head circumference or growth
• Anorexia, poor feeding/appetite
• Drowsiness or lethargy
• Dyspnea
• Failure to thrive
• Frequent infections
• Glossitis or stomatitis
• Hepatomegaly or splenomegaly
• Irritability
• Orthostatic hypotension
• Pallor or jaundice
• Postural orthostatic tachycardia
• Skin hyperpigmentation or hypopigmentation
• Systolic flow murmur
• Tinnitus
• Chronic vomiting, diarrhea, or constipation
• Weakness or fatigue
• Weight loss, no weight gain, or weight <25th percentile

V. Gastrointestinal Risks (+2)

• Malabsorption syndromes (e.g., Crohn’s disease, IBS, celiac disease, gluten sensitivity)
• GERD
• Gastroparesis
• Helicobacter pylori infection
• Giardiasis
• Gastrectomy (partial or complete)
• Ileal resection (partial or complete)
• Small intestinal bacterial overgrowth
• Pancreatitis, pancreatic exocrine insufficiency
• Liver disease
• Diphyllobothrium latum (fish tapeworm)

VI. (a) Population at Risk (+2)

• Vegans, vegetarians, macrobiotic diets (mom or child)
• MTHFR gene mutation
• Nitrous oxide administration or abuse
• Eating disorders

VI. (b) Population at Risk (+1)

• Proton pump inhibitor or H2-blocker use
• Metformin use
• Breastfed children
• Pregnancy (teens)
• Family history of pernicious anemia
• Autoimmune disorders
• AIDS
• Chemo- or radiation therapy
• Low birth weight
• Neural tube defects, cleft lip/palate, or congenital heart defect
• Hydrocephalus
• Phenylketonuria (PKU)
• Down syndrome