Anemia in Toddlers

7/29/2019 Anemia in Toddlers

1/14

15mo with anemia

Daniel Tawfik

Morning Report

6 February 2013


2/14

Christmas Day

Admit to Lahey Team

HPI: 15mo previously healthy girl

2 weeks of fatigue.

Initially had cough as well, which has since resolved up to 16 hours of sleep per day.

3-4 days of pallor

developed generalized edema, primarily noticed over theankles, hands, and eyelids, the day prior to admission

Workup at local ED:

WBC 30, Hct 20, platelets 819

3+ atypical lymphocytes, 1+ schistocytes


3/14

Background

PAST MEDICAL HISTORY: Full term birth without complications, no majoror chronic illnesses. No surgeries.

IMMUNIZATIONS: Not immunized due to parental preference. (2 oldersiblings are also unimmunized.)

MEDICATIONS: None

ALLERGIES: None

FAMILY HISTORY: No known family history of blood diseases ormalignancies. No chronic or childhood illnesses.

SOCIAL HISTORY: Lives in central Utah with parents and 4 of her 8 oldersiblings. Parents are married. Mother has recently had URI symptoms.


4/14

Physical ExamVital signs: T36.8, P124, R18, BP92/68, SpO2 98% RA

Weight: 14.2 kg

GENERAL: Well-developed, well-nourished, pale infant lying in crib in no apparent distress.

Fussy with exam but consolable by father.

HEAD: Normocephalic, atraumatic.

EYES: Normal pupillary reflexes bilaterally, extraocular movements intact, no conjunctivalinjection. Moderate conjunctival pallor.

NOSE: No discharge or obstruction.

OROPHARYNX: Moist mucous membranes, no cleft palate, no pharyngeal erythema or lesions.

NECK: Supple without lymphadenopathy or tenderness to palpation.

CARDIOVASCULAR: Normal rate, rhythm, and S1/S2 with I/VI soft systolic ejection murmur

heard only at LLSB, no gallop. Femoral pulses appropriate. Capillary refill time 2 seconds.

LUNGS: Clear to auscultation bilaterally, good air flow, no retractions.ABDOMEN: Soft, non-tender, non-distended with active bowel sounds and no masses or

hepatosplenomegaly.

EXTREMITIES: All extremities warm and well perfused. No cyanosis or clubbing. 1+ edema of

hands and feet bilaterally.

NEUROLOGIC: Awake and alert, grossly normal strength and tone.

SKIN: No rashes, mottling, jaundice, or unusual birthmarks.


5/14

Diet history

picky eater takes some fruits and

vegetables. 40-48 oz of milk daily ( cows

milk, goats milk)


6/14

Differential Diagnosis

Acute viral illness

Leukemia

Anemia of chronic disease

Iron deficiency anemia

Folic acid deficiency anemia Anemia of malnutrition

Occult GI bleed

Spherocytosis

Lead poisoning

Diamond-Blackfan anemia

Fanconi anemia

HUS


7/14

Workup

WBC 23.4, Hgb 5.9, Hct 21.3, Plts 683

MCV 61.9, MCH 17.2, MCHC 27.7, RDW 20.9

Protein 4.1, Albumin 1.8

Iron


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Diagnoses

Severe iron deficiency anemia secondary to

excessive milk intake

Severe hypochromic microcytic anemia with wide

red cell distribution width

Mild folate deficiency

Mild Vitamin B12 deficiency

Hypoalbuminemia


9/14

Infants/toddlers and anemia

Normal diet is low in iron

Iron stores from birth last 4-6 months

At 12 months 7.2% iron deficient

2.3% with iron deficiency anemia


10/14

Cows milk and anemia

Low iron content

0.5 mg/L (similar to human milk)

Infants daily iron need = 7mg = 14L milk

Occult intestinal blood loss

Infants with cows milk: 1.7 mL/day

Decreases with age

Inhibition of iron absorption

Calcium/casein (higher than in human milk)


11/14

Goats milk

Goats milk is less allergenic, naturally homogenized, easier to digest,lactose intolerant friendly, and biochemically/thermodynamically superiorto cows milk. www.mtcapra.com

The symptoms like gastrointestinal disturbances, vomiting, colic,diarrhoea, constipation and respiratory problems can be eliminated whengoat milk is fed to the infants. - www.roseofsharonacres.com

Allergy to cow's milk has been found in many people with conditions suchas recurrent ear infections, asthma, eczema, and even rheumatoidarthritis. Replacing cow's milk with goat's milk may help to reduce some of

the symptoms of these conditions. www.whfoods.com Beneficial for the treatment of asthma, eczema, migraines, stomach

ulcers, liver complaints and chronic catarrh, goat's milk also helps babieswith colic, habitual vomiting and those not gaining weight. www.healthnews-nz.com
http://www.mtcapra.com/http://www.mtcapra.com/http://www.roseofsharonacres.com/http://www.roseofsharonacres.com/http://www.whfoods.com/http://www.healthnews-nz.com/http://www.healthnews-nz.com/http://www.healthnews-nz.com/http://www.healthnews-nz.com/http://www.healthnews-nz.com/http://www.whfoods.com/http://www.roseofsharonacres.com/http://www.mtcapra.com/


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Goats milk and anemia

Goats milk anemia Macrocytic hyperchromic megaloblastic anemia

First described 1920s in Europe Folate 6 ug/L (versus 50 ug/L in human milk)

Other dangers Hypernatremia (Na 500 mg/L versus 170)

Azotemia (Prot 36 g/L versus 10)

Metabolic acidosis (2/2 increased protein)

Anaphylaxis (cross-reactivity with cows milk protein)

If unpasteurized: Q fever, toxoplasmosis, brucellosis, HUS


13/14

Treatment

Dietary changes:


14/14

References

Bamberg R. Occurrence and detection of iron deficiency anemia ininfants and toddlers. Clin Lab Sci21(4):225-31. 2008.

Basnet S et al. Fresh goats milk for infants: myths and realitiesareview. Pediatrics. 125: e973-77. 2010.

Capozzi L et al. Diet and iron deficiency in the first year of life: a

retrospective study. Hematology15(6):410-3. 2010. Ferrara M et al. Iron deficiency in childhood and adolescence: A

retrospective review. Hematology11(3):183-6. 2006.

Kett JC. Anemia in infancy. Peds in Rev. 33:186-87. 2012.

Ziegler EE. Consumption of cows milk as a cause of iron deficiency

in infants and toddlers. Nut Rev69 (S1): S37-42. 2011.

Anemia in Toddlers

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