Group - 15

Case 6
MEMBERS:

SAURABH MADHESHIYA
SAVALIYA, JAYDEEP G.
SEBASTIAN, SHOUN
SHARMA, ROSHAN KUMAR
SICHOMPOO, KAOWTIP
SRIVASTAVA, AKSHAT
SUDTIVANNA, AKKHARADET

GENERAL DATA:

BT, a 22-month-old boy from Bacacay, Albay

CHIEF COMPLAINT:

Pallor

HISTORY OF PRESENT ILLNESS:

One day prior to consult, a visiting relative told his mother that he looks pale.
No other symptoms noted. Hence, consult.

REVIEW OF SYSTEM:

He is an active toddler, with no recent fatigue, increase in sleeping, or exercise intolerance.

He has had no blood in his diapers and no black or tarry stools.

FEEDING HISTORY:

He is a picky eater, taking only small amounts of chicken, pork, and some vegetables, but loves milk
and drinks six to eight bottles of whole milk daily; approximately 36 to 48 ounces (1.1 to 1.4 liters) per
day.
FAMILY HISTORY:

distant aunt who had anemia during her pregnancy.

There is no history of splenectomy, gallstones at an early age, or other anemia in the family.

PHYSICAL EXAMINATION:

Vital Signs:
Temperature 37.5 degrees C,
Blood Pressure 90/52 mmHg,
Pulse 145 beats/minute,
Respiration 16 breaths/minute
Height 85.5cm ,
Weight 13.2 kg.

PHYSICAL EXAMINATION:

General appearance: He is a pale appearing, active toddler, holding a bottle, tearing and eating
paper from your exam table.
Eyes: No scleral icterus. Pale conjunctiva.
Mouth: Dental caries.
Chest: clear breath sounds
Heart: Mild tachycardia, grade II/VI systolic ejection murmur heard best over the upper left
sternal border.
Abdomen: No hepatosplenomegaly.
Rectal: Dark brown, soft stool, negative for occult blood.

LABORATORY TEST:

Complete blood count (CBC):

White blood count (WBC) 6,100,
Hemoglobin (Hgb) 6.2 g/dL, [11.1-14.1]
Hematocrit (Hct) 19.8%, [38.0-52.0]
Platelet count 589,000, [200,000-550,000]
Mean corpuscular volume (MCV) 54 fL, [78-100]
RDW 21%.
Reticulocyte count is 1.8%.
The lab reports microcytosis, hypochromia, mild anisocytosis, and polychromasia.
There is no basophilic stippling.
 CASE DISCUSSION:
MISSING DATA IN PATIENT’S HISTORY:

GENERAL DATA:

• Child's ethnic background

• source of history with low reliability
HPI:

• Has there been a sudden change in colour, exercise intolerance, shortness of breath,
or fatigue?
• Is the infant irritable or has a weak appetite?
• Progress of disease; order and date of onset of symptoms
• Aggravating and alleviating factors

Past Medical History

• Birth history
• Past Hospitalizations
• Past Illness
• Immunizations and Tests

INITIAL DIAGNOSIS: iron deficiency anemia

REASON TO SUPPORT THE INITIAL DIAGNOSIS:

• Suggested because of patient’s presentation of pallor, low hemoglobin and hematocrit level,
microcytosis, hypochromia, and lack of other findings.
• Feeding history of excessive milk consumption and limited intake of iron-rich foods.

DIFFERENTIAL DIAGNOSIS:
FINAL DIAGNOSIS: IRON DEFICIENCY ANEMIA

INTRODUCTION:

• Anemia is one of the most common laboratory abnormalities defined in the pediatric
population.
• Anemia may be defined by a low normal number of circulating RBCs or low hemoglobin
concentration of hemoglobin (through both will typically be affected).
• As in most areas of pediatrics, what constitutes normal varies substantially with age, and there
is no uniform numerical cut-off.
• Instead, z-scores are used, with anemia being defined as a hemoglobin or hematocrit more
than two standard deviations below the mean for that age and sex

ETIOLOGY:

Infants and toddlers

• Low birth weight infants

• Prematurity
• Perinatal blood loss
• Early cord clamping
• Excessive consumption of cow’s milk (low in iron)
Older children and adolescents

• Increase requirements (e.g., growth spurt, pregnancy)

• occult/chronic blood loss (e.g., peptic ulcer, polyp, hemangioma)
• Menstrual blood loss
• infections.

MANIFESTATIONS:

General manifestations:

• Most patients with mild to moderate anemia are asymptomatic

• Hgb 6-10g/dL: mild irritability
• Hgb 7-8g/dL: pallor (most important clinical sign)
• Hgb <5 g/dL: lethargy, anorexia, easy fatigability, systolic flow murmurs, and high-output
cardiac failure
Other signs

• Koilonychia; spoon nails

• Pica: desire to eat non-nutritive substances
• Pagophagia: desire to ingest ice
• Irreversible neurocognitive effects
DIAGNOSIS:

CBC:

• Low RBC, MCV, reticulocyte count

• Increased red cell distribution width
• Peripheral blood smear
• Microcytic, hypochromic RBCs (due to decreased hemoglobin production or faulty function)
Other tests

• Low serum iron & ferritin

• High total iron binding capacity

TREATMENT:

• Look for cause of iron deficiency & address underlying problem

• Dietary counselling if anemia is due to a nutritional cause:
• Limit intake of cow’s milk to 24 ounces per day
• Iron salts at 4-6 mg/kg/day of elemental iron
• Iron polymaltose complex (cause less gastrointestinal upset)
• Continue treatment upto 2-3 months after Hgb has normalized.