Ginny Burns
NP Rounds

• Cc: “my son is pale, more irritable than usual and I am wondering if he is anemic”
• HPI: mom reports noticing that CP is more pale than usual, and has been having episodes of “fatigue”. She notes that once a week or so, he will be “lazy” and will just want to stay on the couch. No other associated symptoms, no fevers, no N,V or diarrhea. Appetite normal. Sleeps well

• PMH: Anemia at age 2 – iron supplements x 2 yrs
• Childhood Illnesses: lots of colds and flu’s
• Immunizations: up to date
• Medications: Flintstones with Iron
• Allergies: none
• Birth History: Mom had significant nausea and vomiting with pregnancy – took gravol. Smoked 4 cigarettes per day in pregnancy. Born at 40 wks –
SVD – no complications – BW 5lb14oz length 51 cm
• No recent labwork

• FH: paternal grandfather – myelodysplastic disorder – no hx of leukemia or thyroid disorder
• Mom – 28 – healthy
• Dad – 53 – healthy
• Brother – 3 - healthy

• Social: mom – homemaker, father – logger – both smoke in the home
– No pets in home, wood heat, hardwood floors, 2 cats, 1 dog, outdoor pets
– Water – lake water – too dirty to drink so they get water from another “colder” lake, which they use for drinking and cooking

• General: no fevers, chills, night sweats
• Skin: no rashes
• GI: appetite good, has had “hard, pebbly stools” since infant, no change in bowel or bladder function

• Diet: appetite good, likes a wide variety of foods, eats lots of wild game, fruits, veggies, mom thinks his diet is well balanced
• Endocrine: no weight change, mom thinks he hasn’t gained much weight, no heat or cold intolerance
• Psychiatric: sociable child, gets on well with other children, mom notes when he is “fatigued” he tends to be a bit more irritable than usual

• Never did crawl – went from pulling self to walking
• Mom has no concerns – he runs, jumps, catches and throws a ball, knows his numbers and alphabet

• Alert, engaging child
• Pale in appearance
• Isolated post auricular, soft mobile node on left
• Chest clear, S1, S2, abd soft, normal bowel sounds
• Wt 17.3 kg, HC 53.5 cm, Ht 106 – all below
50% but within normal ranges –

• CBC and diff, ferritin, TSH and reticulocyte count
• Why a reticulocyte count?
– Because I was suspecting he would be anemic, and with our distance to town I thought it would be easier to just do it!

• Hgb – N, MCV – marginally low at
74.7, Ferritin 44 – N, TSH - N
• Reticulocyte count – 29 – n is 40-120
• Reticulocyte percentage – 0.6% - low

• Indicator of bone marrow activity
• Used in diagnosing anemias
• Immature RBC’s – mature to RBC’s in
1-2 days
• Should repeat test since results can be different according to time the blood is tested

• Anemias (pernicious, folic acid deficiency, hemolytic, sickle cell, iron deficiency, anemia of chronic disease)
• Adrenocortical hypofunction
• Anterior pituitary hypofunction
• Monitor when taking iron supplements, increased count suggests marrow is responding

• Consult my favorite md – Dr J
• He says – “let me call you back”
– (he really was consulting his wife)
– His plan – iron supplementation in one month – rpt levels with lead level, glucose in one month
– Do stool O+P now

• Sarah – his wife – doesn’t agree
• She says child is not iron deficient – refer to peds
• Distention in the ranks!!
• I decide to do more research….. And refer to peds and do the other tests
• Did I start iron – No – any idea why?

• S/s: history – poor growth, excessive fatigue, shortness of breath, pathologic fractures
• Physical exam: pallor, splenomegaly, jaundice

• Mentzer index (MCV/RBC count)
– <13 – thalassemia more likely
– >13 – iron deficiency more likely
CP Mentzer Index: 16.25 – could have perhaps given iron

• Await next labs and peds consult
• Next labs: normal hemoglobin and platelets – MCV
– now normal
• Wbc: slightly decreased at 4.7
• Retic count up to 37.8 from 29
• Percentage 0.8 up from 0.6%
• Lead level – normal
• Glucose – normal
• Stool O+P - negative

• Blood work not suggestive of anemia
• Unsure of the cause of reticulocyte count - ? Viral suppression
• Repeat his CBC, blood smear and reticulocyte count – (still not done- I have recalled them)
• No follow up planned

• What do you think?
• Viral suppression? – no hx of illness
• Iron deficiency – iron is normal
• Anything else I should do?

• Defn: hgb below 110 plus low iron
• Risks: term infants – not until 9 months of age
– Preterm and lbw – 2-3 months of age
– Limited access to food, low iron diet, high consumption of evaporated milk and cows milk after 6 mo of age, prolonged exclusive breast feeding

• 3.5% to 10.5% in general population
• 14% to 50% in Canadian aboriginal population

• Irritable
• Apathetic
• Poor appetite
• Pallor of conjunctiva, tongue, palms, nail beds
• Severe – CHF – fatigue, tachypnea, hepatomegaly, edema

• Infants and preschool – developmental delays and behavioral disturbances such as decreased social interaction, decreased attention to tasks and decreased motor activity

• Encourage breast feeding for 4-6 mo
• Less than 12 months – iron fortified formula if not exclusively breast fed
• Over 6 mo without adequate iron from foods (less than
1mg/kg day) give 1mg/kg day of iron drops
• Preterm or LBW – 2-4mg/kg/d drops (max 15 mg) until 12 mo
• 1-5 yrs – no more than 24 oz milk per day
• 4-6 mo – plain iron fortified cereal – 2 servings a day will meet needs for iron
• 6 mo – one feeding per day of vitamin C rich foods with meal
• Plain pureed meat after 6 months

• Screening: AAP committee on Nutrition recommends:
– Screen high risk children between 9-12 months, 6 months later and annually from age 2-5 – preterm or lbw, non fortified formula fed, on cows milk before age 1, breast fed and low iron intake after 6 mo, children taking more than 24 oz milk daily
– Screen before 6 mo if preterm/lbw and not on iron fortified formula
– Assess children age 2-5 annually for risk of IDA-low iron diet, poverty, etc

• Rpt hgb and hct to confirm diagnosis
• Repeat screen in 4 wks – if increase hgb by
1 gm or hct by 3% - confirms IDA – recheck in 2 months and 6 months
• If after 4 weeks, no response – do MCV,
RDW and ferritin (less than 15 is IDA)
• Treat with 3mg/kg/d of iron drops between meals, counsel re: diet (1mg/kg/d of iron by food)

• Five Minute Clinical Consult. Skyscape. Thalassemia.
• Centers for Disease Control and Prevention. Recommendations to
Prevent and control iron deficiency in the United States. MMWR
1998;47 (No.rr-3) retrieved on April 8, 2011 from http://www.cdc.gov/mmwr/preview/mmwrhtml/00051880.htm
• Abdullah, K., Zlotkin, S., Parkin, P. & Grenier, D. (2011). Iron deficiency anemia in children. CPSP. Retrieved April 8 th , 2011 from