A 15-month-old boy is brought to the clinic due to fatigue. His father states that the patient used to nap for 2 hours in the afternoon but for the last 2 weeks has taken a 2-hour nap in the morning as well. The child is a picky eater and drinks 960 mL (32 oz) of cow's milk each day. He takes no daily medications, and his immunizations are up to date. Physical examination reveals a tired-appearing boy. Conjunctivae are pale and anicteric. Cardiac examination reveals normal heart tones. The abdomen is soft with no hepatomegaly. Capillary refill is

Question

A 15-month-old boy is brought to the clinic due to fatigue.  His father states that the patient used to nap for 2 hours in the afternoon but for the last 2 weeks has taken a 2-hour nap in the morning as well.  The child is a picky eater and drinks 960 mL (32 oz) of cow's milk each day.  He takes no daily medications, and his immunizations are up to date.  Physical examination reveals a tired-appearing boy.  Conjunctivae are pale and anicteric.  Cardiac examination reveals normal heart tones.  The abdomen is soft with no hepatomegaly.  Capillary refill is <2 seconds; nail beds have pallor.  Hemoglobin is 8.1 g/dL, and a capillary lead level is undetectable.  A presumptive diagnosis of iron deficiency anemia is made.  The boy is prescribed ferrous sulfate, which he takes with orange juice between meals.  His cow's milk intake is restricted to 480 mL (16 oz) per day.  Which of the following changes is expected to occur first in response to treatment?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c167_103a_8f63_178a8e0a86d8_MD0005_00 Iron deficiency is the most common nutritional deficiency in children and should be suspected in any child drinking >24 oz of cow's milk per day. Fatigue and pallor may occur, but patients are often asymptomatic and detected on universal screen around age 1. Given the high prevalence of iron deficiency anemia in infants and toddlers, a presumptive diagnosis of iron deficiency is made when hemoglobin <11 g/dL. Lead level should also be measured, but additional studies are usually not needed in the initial workup. An empiric trial of ferrous sulfate is considered the most cost-effective treatment, and the doses should be given with juice between meals as vitamin C facilitates iron absorption. Patients should also be advised to limit milk intake to <20 oz per day and to increase intake of iron-rich foods (eg, meats, fortified cereals). Patients with iron deficiency have hypochromic, microcytic red blood cells (RBCs) and decreased reticulocytes as the bone marrow is unable to produce the requisite number of RBCs without adequate iron substrate. Within 1-2 weeks of initiating supplementation, the reticulocyte count increases quickly. However, in patients with moderate to severe iron deficiency, it usually takes about a month for the hematocrit and hemoglobin to increase and a few months to return to regular levels (Choices B and C). Therefore, after a month of empiric iron supplementation, an increase in hemoglobin ≥1 g/dL supports the diagnosis of iron deficiency anemia. Ferrous sulfate should be maintained for 2-3 months after hemoglobin normalization to replenish iron stores. (Choice A) Ferritin reflects iron stores and does not begin to rise until after hemoglobin normalizes. (Choice D) The Mentzer index refers to the ratio of mean corpuscular volume (MCV) to total RBC count. Before treatment, patients with iron deficiency anemia generally have low MCV and total RBC counts with a high Mentzer index of >13. Educational objective: Children with presumed iron deficiency anemia due to poor diet are treated with an empiric trial of iron supplementation. Iron therapy increases reticulocyte production followed by an increase in hematocrit and hemoglobin in approximately 1 month. References: Diagnosis and prevention of iron deficiency and iron-deficiency anemia in infants and young children (0-3 years of age). (http://www.ncbi.nlm.nih.gov/pubmed/20923825) Evaluation of anemia in children. (http://www.ncbi.nlm.nih.gov/pubmed/20540485)

A 15-Month-Old Boy Is Brought to the Clinic Due to Fatigue