A 13-month-old boy is brought to the clinic for a well-child visit. His father says that the child has not been eating as much solid food since he started walking. The parents think that he is "too busy exploring to eat" and have been supplementing his diet with whole milk in a cup that he carries with him. The patient's daily diet consists of 900 mL (30 oz) of whole cow's milk, rice, and occasional fruits and vegetables. He eats and drinks without gagging or choking; he can hold a spoon and feed himself finger foods. The child was born at term. Weight, height, and head circumference are at the 10th percentile for age. Examination shows a pale child who is playing in the examination room. The anterior fontanelle is open. Cardiac examination reveals a normal rhythm with no murmurs. The abdomen is soft, nontender, and without hepatomegaly. The skin has normal turgor and capillary refill is

Question

A 13-month-old boy is brought to the clinic for a well-child visit.  His father says that the child has not been eating as much solid food since he started walking.  The parents think that he is "too busy exploring to eat" and have been supplementing his diet with whole milk in a cup that he carries with him.  The patient's daily diet consists of 900 mL (30 oz) of whole cow's milk, rice, and occasional fruits and vegetables.  He eats and drinks without gagging or choking; he can hold a spoon and feed himself finger foods.  The child was born at term.  Weight, height, and head circumference are at the 10th percentile for age.  Examination shows a pale child who is playing in the examination room.  The anterior fontanelle is open.  Cardiac examination reveals a normal rhythm with no murmurs.  The abdomen is soft, nontender, and without hepatomegaly.  The skin has normal turgor and capillary refill is <2 seconds.  Complete blood count shows a hemoglobin of 9.2 g/dL.  The most likely diagnosis is discussed with the parents.  Without treatment, this patient is at risk for which of the following long-term complications?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c167_856b_8f63_bd76dbcf3bc4_MD0005_00 This child with excessive cow's milk intake (>20 oz/day), a diet lacking in iron-rich foods, pallor, and anemia likely has iron deficiency anemia (IDA). Because IDA is the most common nutritional deficiency in children, universal screening for IDA is recommended around age 1. A presumptive diagnosis is made in infants and children with a hemoglobin <11 g/L. Further testing (eg, peripheral smear, red blood cell indices, electrophoresis) is not necessary unless the patient has a history of chronic disease or a family history of anemia or hemoglobinopathy. Microcytic, hypochromic red blood cells (see black arrows) are seen on peripheral smear. hypochromic red blood cells Initial treatment is with oral ferrous sulfate. Iron is essential for neuronal myelination, migration, and differentiation; chronic deficiency can lead to psychomotor delay and neurocognitive impairment. With iron supplementation, gross motor skills usually improve; however, the remaining cognitive effects may be irreversible. (Choice A) An aplastic crisis may occur in a patient with parvovirus B19 infection and an underlying hemolytic anemia (eg, spherocytosis, sickle cell disease). This patient is asymptomatic and has no medical problems, making iron deficiency the most likely cause of anemia. (Choice B) Ataxia can result from deficiency in vitamin B₁₂, which is found in dairy and animal products (eg, meat, fish, eggs). Vitamin B₁₂ deficiency would be unlikely in an otherwise healthy child with adequate milk intake. ₁₂ ₁₂ (Choice C) Avascular osteonecrosis can occur in patients with sickle cell disease, which is typically identified on newborn screening and can present with anemia and vasoocclusive pain crises, not seen in this asymptomatic patient. (Choice D) Chronic kidney disease is a complication of chronic lead poisoning, a less common cause of anemia in young children. This child should have a routine lead screening test due to his age, but a presumed diagnosis of IDA is appropriate. Educational objective: Children with untreated iron deficiency anemia are at risk for psychomotor delay and long-term cognitive impairment. Therefore, universal screening should occur around age 1, and empiric iron supplementation is first-line treatment. References: Iron deficiency anemia in children. (http://www.ncbi.nlm.nih.gov/pubmed/25636824) Iron deficiency and other types of anemia in infants and children. (http://www.ncbi.nlm.nih.gov/pubmed/26926814)

A 13-Month-Old Boy Is Brought to the Clinic for a Well-Child