at night · • acquired hemolytic anemia • sickle cell disease • bone marrow disorders...
TRANSCRIPT
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The McMaster
at night
Pediatric
Curriculum
Wang, M. (2016). Iron Deficiency and Other Types of
Anemia in Infants and Children. American Family Physician.
93 (4): 270-278.
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Objectives
• Recognize common signs and symptoms of anemia
• Develop an approach to the work-up of anemia based on
the differential diagnosis
• Understand the treatment of iron deficiency anemia
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Background
• Anemia is both a common presenting complaint (in the
Emergency Department and outpatient pediatric office)
• It is also a common incidental finding on bloodwork
ordered for other reasons
• Anemia in children: Two standard deviations below the
mean for age
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The Case
• You are working in a small community hospital as the
pediatrician. You are called to the emergency department
to assess a 2 year old girl who came in with upper
respiratory tract symptoms. The ER physician noted that
she looked pale and did some bloodwork. Her hemoglobin
came back at 55 and you are being consulted for anemia.
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History
What would you ask?
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History
• HPI:
• OPQRST about the reason they came in (URTI
symptoms)
• Any change in energy, ability to keep up with peers
when active
• Diet history – how much milk, how often and via bottle
or cup
• Any bruising, bleeding, limp, night sweats, fevers,
weight loss?
• Abdominal pain, diarrhea/blood diarrhea?
• Bleeding history - bums, gum, nose, hematemesis?
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History
• PMHx:
• Previous hospitalizations, recent surgeries, chronic
diseases
• Previous or known anemia? Previous bloodwork
done?
• Family history:
• Anyone in the family with anemia?
• Anyone with thalassemia/thalassemia trait?
• Anyone with hematologic malignancies?
• Ethnic background
• Birth history:
• Term, pre-term, any sequealae of prematurity?
• Medications:
• Previous treatment with iron? Calcium
supplementation?
• Allergies
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History
• Developmental history:
• Important to ascertain whether child is developmentally
appropriate, or delayed
• If delayed, find out what domains and when this
occurred
• Social history:
• Ability to afford food? Use of food banks?
• Access to nutritious food sources (proximity of grocery
stores)
• Parent’s employment
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Physical Exam
What would you look for?
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Physical Exam
• General appearance – pallor, lethargy
• HEENT: Conjunctival pallor, bleeding gums, nares,
lymphadenopathy
• Respiratory: Tachypnea, increased work of breathing,
crackles
• Cardiac: Tachycardia, flow murmur, delayed capillary refill
• Abdominal: Splenomegaly, hepatomegaly, masses
• Skin: Petechiae, purpura, edema, pallor of palms,
nailbeds
• MSK: Joint swelling
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Workup
What would you order?
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Workup
• CBC with differential and smear, reticulocyte count
• Ferritin if child is well, serum iron level if unwell
• Depending on history/physical, consider:
• Bilirubin, haptoglobin, LDH (Hemolytic process)
• Lytes, extended lytes, urate, LDH, CXR (Malignancy)
• Fecal occult blood (Ulcer, IBD, polyps)
• CRP, fecal calprotectin (Autoimmune/inflammatory)
• Hemoglobin electrophoresis, DNA alpha-thalassemia
(Hemoglobinopathies)
• Cross and match (If anticipating transfusion)
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Differential Diagnosis
Neonates
Microcytic • α-Thalassemia
Normocytic • Acute blood loss • Isoimmunization • Congenital hemolytic anemias
• Spherocytosis • Glucose-6-phosphate dehydrogenase deficiency
• Congenital infections
Macrocytic Congenital Aplasia
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Differential Diagnosis Infants and Toddlers
Microcytic • Iron deficiency anemia • Concurrent infection • Thalassemia • Lead poisoning
Normocytic • Concurrent infection • Acute blood loss • Sickle cell disease • Red blood cell enzyme defect
• G6PD • Pyruvate-kinase deficiency
• Red blood cell membrane defects • Spherocytosis • Elliptocytosis
• Hemolytic anemia (acquired, autoimmune) • Hypersplenism • Transient erythroblastopenia of childhood • Bone marrow disorders (leukemia, myelofibrosis)
Macrocytic • Vitamin B12 or folate deficiency • Hypothyroidism • Hypersplenism • Congenital aplasia
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Differential Diagnosis
Older Children and Adolescents
Microcytic • Iron deficiency anemia • Anemia of chronic disease • Thalassemia • Menorrhagia (menstruating females)
Normocytic • Acute blood loss • Anemia of chronic disease • Acquired hemolytic anemia • Sickle cell disease • Bone marrow disorders (leukemia,
myelofibrosis)
Macrocytic • Vitamin B12 or folate deficiency • Hypothyroidism
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Featured Diagnosis
• Iron deficiency anemia
• Most common type of childhood anemia
• Dietary history of poor iron intake, often exacerbated by
excess milk intake (>18-20 oz. per day)
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Featured Diagnosis
• Risk factors for iron deficiency and iron deficiency anemia:
• Race/ethnicity
• Low socioeconomic status
• Prematurity and low birth weight
• Excessive milk intake
• Early introduction of whole cow’s milk
• Prolonged bottle feeding
• Prolonged exclusive breastfeeding
• Overweight and obesity
• Non-attendance at daycare
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Featured Diagnosis
• Ferritin is the most sensitive test for iron deficiency
anemia
• Ferritin is less accurate in children who are ill or have
inflammatory conditions because it is an acute phase
reactant
• Order serum iron level in children who are ill or who have
inflammatory conditions
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Featured Diagnosis
• Treatment: Infants and toddlers
• Iron supplementation:
• 3-6 mg/kg elemental iron per day for 3-4 months
• Many of the iron supplements have metallic taste,
not well tolerated
• Consider using Feramax (powder, can be sprinkled
in food/drink, better tolerated)
• Side effects include black stools, constipation
• Consider prophylactically starting children on PEG
3350 to avoid constipation
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Featured Diagnosis
• Treatment: Adolescents
• Iron supplementation:
• Weight >40 kg
• 150-200 mg/day elemental iron, can dosed daily or
BID
• Non-pharmacologic treatments:
• Increase iron-rich food in diet (red meats, beans,
legumes, green leafy vegetables, cooking with cast
iron)
• Consume vitamin C containing foods with iron-
supplement or high iron foods to promote absorption
• For toddlers:
• Limit milk to 18 oz/day
• Get rid of bottles!
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Featured Diagnosis
• Follow-up
• Repeat bloodwork at 1 month
• Anemia should improve by 10 g/L after one month of
treatment with iron supplementation
• If not improving – need to determine, treatment
compliance and consider alternative diagnoses
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Featured Diagnosis
• Important to treat because iron is important for:
• Myelination
• Neurogenesis
• Differentiation of brain cells (sensory, learning,
memory, behaviour)
• Cofactor for neurotransmitters
• Iron deficiency anemia has long-term developmental
impacts
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Test Your Knowledge
• In addition to a CBC with a differential, what is one
additional test you would order to confirm your diagnosis
of iron deficiency anemia?
A. Serum iron
B. Ferritin
C. Transferrin saturation
D. Total iron binding
capacity
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The Answer
• Ferritin
• Unless the child is unwell or has an inflammatory
condition, in which case serum iron is indicated
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Test Your Knowledge
• Anemia is defined as…
A. Hb <120 g/L
B. Hb more than 1 standard deviation below the mean
for age
C. Hb more than 2 standard deviations below the mean
for age
D. Hb <100 g/L
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The Answer
• Anemia is defined as a hemoglobin more than 2 standard
deviations below the mean for age
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Test Your Knowledge
• List 4 risk factors for iron deficiency and iron deficiency
anemia
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Test Your Knowledge
• List 4 risk factors for iron deficiency and iron deficiency
anemia. Four of:
1. Race/ethnicity
2. Low socioeconomic status
3. Prematurity and low birth weight
4. Excessive milk intake
5. Early introduction of whole cow’s milk
6. Prolonged bottle feeding
7. Prolonged exclusive breastfeeding
8. Overweight and obesity
9. Non-attendance at daycare
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Summary
• Iron deficiency is the most common cause of anemia in
infants and young children
• Have a high index of suspicion if there is high milk
consumption, low dietary iron intake
• Important to treat because of long-term developmental
impact
• Low ferritin is the most sensitive test for iron deficiency
• Repeat CBC, ferritin 1 month into treatment and reassess
the diagnosis if patient is compliant with treatment and
there is no improvement
• In teenagers, particularly boys, iron deficiency is
uncommon, have a high index of suspicion for alternative
diagnoses such as inflammatory bowel disease
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References
• Abdullah K, Zlotkin S, Parkin P, Grenier D. (2011). Iron-
deficiency anemia in children. Canadian Paediatric
Surveillance Program.
http://www.cpsp.cps.ca/uploads/publications/RA-iron-
deficiency-anemia.pdf
• Abrams SA. (2017). Iron Requirements and iron
deficiency in adolescents. UpToDate. Feb. 21, 2017.
• Wang, M. (2016). Iron Deficiency and Other Types of
Anemia in Infants and Children. American Family
Physician. 93 (4): 270-278.
• Wu AC, Leperance L, Bernstein H. (2002). Screening for
Iron Deficiency. Pediatrics in Review. 23 (5): 171-177.
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