The McMaster at night Pediatric Curriculum

Transcription

1 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):

2 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

3 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

4 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.

5 History What would you ask?

6 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?

7 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

8 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

9 Physical Exam What would you look for?

10 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

11 Workup What would you order?

12 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)

13 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

14 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

15 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

16 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)

17 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

18 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

19 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

20 Featured Diagnosis Treatment: Adolescents Iron supplementation: Weight >40 kg 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 ironsupplement or high iron foods to promote absorption For toddlers: Limit milk to 18 oz/day

21 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

22 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

23 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

24 The Answer Ferritin Unless the child is unwell or has an inflammatory condition, in which case serum iron is indicated

25 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

26 The Answer Anemia is defined as a hemoglobin more than 2 standard deviations below the mean for age

27 Test Your Knowledge List 4 risk factors for iron deficiency and iron deficiency anemia

28 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

29 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

30 References Abdullah K, Zlotkin S, Parkin P, Grenier D. (2011). Irondeficiency anemia in children. Canadian Paediatric Surveillance Program. Abrams SA. (2017). Iron Requirements and iron deficiency in adolescents. UpToDate. Feb. 21, Wang, M. (2016). Iron Deficiency and Other Types of Anemia in Infants and Children. American Family Physician. 93 (4): Wu AC, Leperance L, Bernstein H. (2002). Screening for Iron Deficiency. Pediatrics in Review. 23 (5):

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