Week 5 response 1

Case Scenario 1: Tommy is a 2-year-old brought into the clinic for his well-child examination. His hemoglobin in the clinic is 9g/dL, his serum iron is below normal, TIBC is elevated, and his iron saturation is low. Although in remission, Tommy's mother mentions she always worries about Tommy since he was diagnosed with infant ALL.

Type of anemia Tommy has

Tommy most likely has iron deficiency anemia (IDA), which is the most common anemia in toddlers and is often related to inadequate dietary intake. His laboratory findings; low hemoglobin, low serum iron, low transferrin saturation, and elevated total iron-binding capacity (TIBC); are characteristic of IDA (Almutairi et al., 2024; Short & Domagalski, 2013). TIBC reflects transferrin availability, and its elevation represents a compensatory response to low iron stores. In IDA, insufficient iron impairs hemoglobin synthesis, resulting in microcytic, hypochromic anemia (Short & Domagalski, 2013). A low mean corpuscular volume (MCV <80 fL) is also typically observed.

Symptoms and Physical Exam Findings

Common symptoms include:

• Fatigue, irritability, and pallor due to decreased oxygen delivery (Gruda Sussman & Baker, 2024).

• Pica: Low iron can make kids crave and eat things that are not food, like dirt or paper. • Brittle nails: Iron deficiency slows nail growth, making nails weak and thin(Maaks et

al., 2019)

Physical exam findings:

• Pallor: Low iron reduces hemoglobin, causing pale skin and mucous membranes. • Glossitis (smooth, shiny tongue): Iron deficiency slows tongue cell growth, leading to

a red, sore, or smooth tongue (Maaks et al., 2019) • Tachycardia due to compensatory increased cardiac output • Poor appetite and possible developmental delay in prolonged cases (Chatterjee et al.,

2022)

Treatment

Nonpharmacologic treatment

• Iron rich diet: Lean meats, fortified cereals, beans, leafy greens (Almutairi et al., 2024) • Limit cow’s milk: 16–24 oz/day to prevent decreased iron absorption (Gruda

Sussman & Baker, 2024)

• Vitamin C intake: Enhances iron absorption (Short & Domagalski, 2013) • Avoid inhibitors: Tea, coffee, and calcium-rich foods during iron intake reduce

absorption (Short & Domagalski, 2013)

Pharmacological treatment:

• Ferrous sulfate (liquid) orally 3–6 mg/kg/day of elemental iron, divided into 2–3 doses for 30 days for iron deficiency anemia on an empty stomach if tolerated. Quantity:150 mL bottle x1 Refills: 1 (Woo & Robinson, 2019)

Follow-up:

• Re-evaluate in 4–6 weeks with repeat CBC and ferritin (Gruda Sussman & Baker, 2024)

• Expected response: o Hemoglobin increase of about 1 g/dL within 1 month (Short & Domagalski, 2013) • Continue iron therapy for 2–3 months after normalization to replenish iron stores • Monitor for side effects (constipation, GI upset)

The common causes and anticipatory guidance

Common cause:

• Inadequate dietary iron intake (Almutairi et al., 2024) • Excessive cow’s milk consumption, which reduces iron absorption (Chatterjee et al.,

2022) • Cow's milk contains calcium and casein, which can significantly reduce iron

absorption, making it difficult for toddlers to meet their iron needs (Chatterjee, More, & Joshi, 2022).

Anticipatory Guidance:

• Limit cow’s milk to 16–24 oz per day to avoid interference with iron absorption (Gruda Sussman & Baker, 2024).

• Encourage iron-rich foods: Lean meats, beans, fortified cereals, and dark leafy greens (Almutairi et al., 2024).

• Include vitamin C rich foods: Vitamin C enhances the absorption of iron, so recommend fruits like oranges and strawberries (Woo & Robinson, 2019).

• Avoid iron absorption by inhibitors: Limit the intake of tannin rich foods like tea and coffee during meals.

• Common side effects of ferrous sulfate: Dark stools, mild constipation, stomach upset, temporary teeth staining

• Precautions: Keep out of reach of children; do not give extra doses; complete full course; avoid giving with dairy or antacids due to calcium binds to iron.

The way to address his mother’s anxiety about Tommy’s past medical history of ALL

It is important to acknowledge and validate the mother’s concerns while providing reassurance. Iron deficiency anemia is a common nutritional condition and is not associated with recurrence of acute lymphoblastic leukemia (ALL). Leukemia would typically present with abnormal white blood cells, low platelets, and symptoms like bruising or bone pain, which are not seen here (Maaks et al., 2019). Providing clear education that IDA is treatable and unrelated to malignancy can help reduce anxiety. Additionally, reinforcing that Tommy remains in remission and continues appropriate follow up care can further reassure the parent. Offering emotional support and encouraging open communication are essential in addressing ongoing concerns.

References

Almutairi, A. M., Alwehaibi, S. A., Almousa, A. Y., Alanazi, S., Bin Muaibed, R. R., Althobaiti, R., Alkheraiji, A. M., & Alamrani, H. A. (2024). A Multicenter Retrospective Chart Review Study Estimating the Prevalence of Iron Deficiency Anemia Among Infants, Toddlers, and Children in Riyadh, Saudi Arabia. Cureus, 16(9), e70031. https://doi.org/10.7759/cureus.70031Links to an external site.

Chatterjee, D., More, S., & Joshi, S. (2022). Evaluation of pediatric anemia in rural population of Maharashtra, India. Journal of Applied Hematology, 13(1), 9–12. https://doi.org/10.4103/joah.joah_50_21Links to an external site.

Gruda Sussman, R., & Baker, J. M. (2024). An urgent appeal to paediatric primary caregivers to help prevent severe iron deficiency anemia in toddlers. Paediatrics & Child Health, 29(4), 209–210. https://doi.org/10.1093/pch/pxac089Links to an external site.

Maaks, D.L. G., Starr, N., & Gaylord, N. (2019). Burns' Pediatric Primary Care (7th ed.). Elsevier - Evolve. https://online.vitalsource.com/books/9780323581967Links to an external site.

Woo, T. M., & Robinson, M. V. (2019). Pharmacotherapeutics for Advanced Practice Nurse Prescribers with Davis Edge (5th ed.). F. A. Davis Company. https://online.vitalsource.com/books/9781719641531