15mo with anemia

Daniel Tawfik Morning Report 6 February 2013

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 the ankles, hands, and eyelids, the day prior to admission Workup at local ED:
WBC 30, Hct 20, platelets 819 3+ atypical lymphocytes, 1+ schistocytes

Background
PAST MEDICAL HISTORY: Full term birth without complications, no major or chronic illnesses. No surgeries. IMMUNIZATIONS: Not immunized due to parental preference. (2 older siblings are also unimmunized.) MEDICATIONS: None ALLERGIES: None FAMILY HISTORY: No known family history of blood diseases or malignancies. No chronic or childhood illnesses. SOCIAL HISTORY: Lives in central Utah with parents and 4 of her 8 older siblings. Parents are married. Mother has recently had URI symptoms.

Physical Exam
Vital 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 conjunctival injection. 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.

Diet history
picky eater takes some fruits and vegetables. 40-48 oz of milk daily ( cows milk, goats milk)

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

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 <10, Ferritin 6 (low), transferrin 216 (nl), TIBC 293 (nl) Folate 4.9 (low), B12 234 (low) Rhinovirus positive

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

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

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)

Goats milk
Goats milk is less allergenic, naturally homogenized, easier to digest, lactose intolerant friendly, and biochemically/thermodynamically superior to cows milk. www.mtcapra.com The symptoms like gastrointestinal disturbances, vomiting, colic, diarrhoea, constipation and respiratory problems can be eliminated when goat milk is fed to the infants. - www.roseofsharonacres.com Allergy to cow's milk has been found in many people with conditions such as recurrent ear infections, asthma, eczema, and even rheumatoid arthritis. 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 babies with colic, habitual vomiting and those not gaining weight. www.healthnews-nz.com

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

Treatment
Dietary changes: <16oz milk daily Iron replacement: 6mg/kg/day x 3 months
Then 1-2mg/kg/day maintenance

Folate supplementation: 100 mcg/kg/day B12 supplementation: 1mg/day

References
Bamberg R. Occurrence and detection of iron deficiency anemia in infants and toddlers. Clin Lab Sci 21(4):225-31. 2008. Basnet S et al. Fresh goats milk for infants: myths and realitiesa review. Pediatrics. 125: e973-77. 2010. Capozzi L et al. Diet and iron deficiency in the first year of life: a retrospective study. Hematology 15(6):410-3. 2010. Ferrara M et al. Iron deficiency in childhood and adolescence: A retrospective review. Hematology 11(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 Rev 69 (S1): S37-42. 2011.