week 5 response 2

Case Scenario 1

Type of Anemia: With his lab results of low hemoglobin, low serum iron, high TIBC, and low iron saturation, Tommy has iron deficiency anemia (IDA). IDA is the most common nutritional deficiency seen in toddlers within the United States (Camaschella, 2015). Low serum iron level along with high TIBC is diagnostic of IDA since his body is increasing transferrin levels in order to try and bind any iron that is available in circulation (Powers & Buchanan, 2019). Symptoms/Physical Findings: During Tommy’s well child visit, the provider can anticipate multiple symptoms/findings on physical exam and history. Behaviorally, Tommy may appear pale and irritable with decreased appetite. He may also demonstrate decreased energy or activity tolerance (Camaschella, 2015). On exam, findings can include pallor of the conjunctivae, palmar creases, and oral mucous membranes. Tachycardia may also be seen. On a developmental level, questioning may reveal delays related to cognition and behavior due to lack of iron impacting myelination and neurotransmitters early in life (Georgieff, 2020). In toddlers with IDA, pica is also common but rarely volunteered by parents; therefore, providers should ask about it directly (Powers & Buchanan, 2019). Other findings that may be seen on physical exam include glossitis, angular cheilitis, and spoon shaped nails although these findings are rare in children younger than 3 years old (Camaschella, 2015). Treatment: The preferred medication for nutritional iron deficiency anemia in toddlers is oral iron supplementation. An appropriate medication would be: Ferrous sulfate PO; available in liquid formulation Dose: 3–6 mg/kg/day of elemental iron given once daily or divided PO Administration: Administered on an empty stomach or with juice; avoid giving with milk or calcium-fortified dairy products as calcium inhibits iron absorption Education/Follow-up: Recheck a reticulocyte count in 1 week after starting supplementation to ensure there is evidence of reticulocytosis, confirming a therapeutic response. Recheck hemoglobin in 4 weeks and should be expected to rise at least 1 g/dL. Continue supplementation for another 2–3 months after hemoglobin normalizes to fully restore iron stores (ferritin). Continue to reinforce dietary counseling at every follow-up visit.

Common Causes: At 2 years old, the most common cause of iron deficiency is excessive cow’s milk intake (>24 oz/day), which displaces iron-rich foods and impairs iron absorption. Additional risk factors include low dietary intake of iron-rich foods such as red meat, legumes, and fortified cereals as well as prematurity or low birth weight at birth. Anticipatory Guidelines from American Academy of Pediatrics: 1. Decrease cow’s milk intake to less than 16–24 oz per day. 2. Offer iron-rich foods at every meal. 3. Include vitamin C–rich foods with iron-rich foods to promote absorption. 4. Avoid juice or milk with meals when starting iron supplementation. 5. Keep iron supplementation out of reach of children as iron toxicity is one of the most common causes of poisoning in toddlers. American Academy of Pediatrics. (2010). Diagnosis and prevention of iron deficiency and iron-deficiency anemia in infants and young children (0–3 years of age). Pediatrics , 126 (5), 1040-1050. https://doi.org/10.1542/peds.2010-2576 Addressing mom’s concerns about his history of ALL: Mom is completely justified in being concerned/worried about Tommy’s labs due to his past medical history of acute lymphoblastic leukemia, even though he has been in remission for the last year. It is important for the provider to validate these feelings by acknowledging to mom how scary it was to have a baby be diagnosed with cancer and that it is completely normal for her to continue to feel anxious about his health, even now that he is in remission. Next, it would be beneficial to educate mom that iron deficiency anemia is one of the most common nutrient deficiencies in toddlers worldwide and can affect any child regardless of medical history. Emphasize with her that iron deficiency anemia is not related to his leukemia or a sign that he is going to relapse. Offer to go over his labs with her again and explain that the findings that are concerning for iron deficiency (low hemoglobin, low serum iron, high TIBC) would not be seen with leukemia. Include the family in his plan of care by scheduling close follow-up to help ease her anxiety and continue communication with his oncologist. If mom’s anxiety begins to interfere with her daily life, may consider referring her for parental support groups/counseling. References

Camaschella, C. (2015). Iron-deficiency anemia. New England Journal of Medicine 372 , 1832-1843. doi:10.1056/NEJMra1401038 Georgieff, M. K. (2020). Iron deficiency in pregnancy. American Journal of Obstetrics and Gynecology 223 (4), 516-524. doi:10.1016/j.ajog.2020.03.006 Hunger, S. P., & Mullighan, C. G. (2015). Acute lymphoblastic leukemia in children. New England Journal of Medicine 373 (16), 1541-1552. doi:10.1056/NEJMra1400972 Powers, J. M., & Buchanan, G. R. (2019). Diagnosis and management of iron deficiency anemia. Hematology/Oncology Clinics of North America 33 (3), 393-408. doi:10.1016/j.hoc.2019.01.003