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[2] In summary, [8] serum holoTC (transcobalamin) and serum B12 plasma methylmalonic acid (MMA) and urinary MMA excretion plasma homocysteine (tHcy) Hypersegmentation of nuclei in neutrophils Megaloblastic anemia (MCV, Hg, large RBC) Note folate and B12 share common metabolic pathways and should also be considered when assessing status.[8] Iron deficiency can mask macrocytosis due to B12 deficiency and also may need to be considered.[8,11] Measures of adequate status Older adults Persons with pernicious anemia Persons on a vegan diet without sufficient B12-fortified foods or supplements Infants of mothers with low B12 during pregnancy Prolonged use of proton pump inhibitors or conditions that reduce stomach acid Persons with gastrointestinal conditions - gastrectomy, ileal resection, pancreatic insufficiency, chronic diarrhea, and others (e.g., Crohns, gastric bypass, gastritis, sprue) Populations at risk for deficiency Deficiency signs and symptoms Nerve damage (demyelination), often presenting as tingling or numbness in hands or feet, which can be permanent, especially with deficiency beyond one year [1,2,4] Memory loss, confusion, poor cognitive performance, impaired motor function, dementia, depression [1,2,4] Sore tongue or mouth [2,4] Fatigue, weight loss, loss of appetite [2] Increased risk of birth defects (neural tube defects due to folates dependence on B12) [1] Increase risk of bone loss [1] Infant developmental delays [1,2] Macrocytic anemia [1,4] (also due to pernicious anemia that can cause B12 deficiency [4]) Neutrophil hypersegmentation, leukopenia (also from pernicious anemia) [4] For diets that are low in/lack animal-sourced foods, suggested prophylactic therapy with oral vitamin B12 supplements are provided below

While the exposure from bacteriostatic water is very low, there is a theoretical risk that an infant could ingest benzyl alcohol through breast milk

Even some meat eaters can have trouble absorbing vitamin B12

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A typical example of the latter is anorexia, a condition that frequently occurs in disease states associated with hypocobalaminemia