1. Fatigue NYD Ginny Burns NP Rounds

2. 5 yr old Male C.P. Cc: “my son is pale, more irritable than usual and I am wondering if he is anemic” HPI: mom reports noticing that CP is more pale than usual, and has been having episodes of “fatigue”. She notes that once a week or so, he will be “lazy” and will just want to stay on the couch. No other associated symptoms, no fevers, no N,V or diarrhea. Appetite normal. Sleeps well

3. 5 yr old Male - fatigue PMH: Anemia at age 2 – iron supplements x 2 yrs Childhood Illnesses: lots of colds and flu’s Immunizations: up to date Medications: Flintstones with Iron Allergies: none Birth History: Mom had significant nausea and vomiting with pregnancy – took gravol. Smoked 4 cigarettes per day in pregnancy. Born at 40 wks – SVD – no complications – BW 5lb14oz length 51 cm No recent labwork

4. 5 yr old male - Fatigue FH: paternal grandfather – myelodysplastic disorder – no hx of leukemia or thyroid disorder Mom – 28 – healthy Dad – 53 – healthy Brother – 3 - healthy

5. 5 yr old - Fatigue Social: mom – homemaker, father – logger – both smoke in the home –No pets in home, wood heat, hardwood floors, 2 cats, 1 dog, outdoor pets –Water – lake water – too dirty to drink so they get water from another “colder” lake, which they use for drinking and cooking

6. Review of Systems General: no fevers, chills, night sweats Skin: no rashes GI: appetite good, has had “hard, pebbly stools” since infant, no change in bowel or bladder function

7. Review of Systems Diet: appetite good, likes a wide variety of foods, eats lots of wild game, fruits, veggies, mom thinks his diet is well balanced Endocrine: no weight change, mom thinks he hasn’t gained much weight, no heat or cold intolerance Psychiatric: sociable child, gets on well with other children, mom notes when he is “fatigued” he tends to be a bit more irritable than usual

8. Developmental History Never did crawl – went from pulling self to walking Mom has no concerns – he runs, jumps, catches and throws a ball, knows his numbers and alphabet

9. Examination: Alert, engaging child Pale in appearance Isolated post auricular, soft mobile node on left Chest clear, S1, S2, abd soft, normal bowel sounds Wt 17.3 kg, HC 53.5 cm, Ht 106 – all below 50% but within normal ranges –

10. My initial workup CBC and diff, ferritin, TSH and reticulocyte count Why a reticulocyte count? –Because I was suspecting he would be anemic, and with our distance to town I thought it would be easier to just do it!

11. Results Hgb – N, MCV – marginally low at 74.7, Ferritin 44 – N, TSH - N Reticulocyte count – 29 – n is 40-120 Reticulocyte percentage – 0.6% - low

12. Why do a Reticulocyte count? What are they? Indicator of bone marrow activity Used in diagnosing anemias Immature RBC’s – mature to RBC’s in 1-2 days Should repeat test since results can be different according to time the blood is tested

13. Decreased Reticulocyte count Anemias (pernicious, folic acid deficiency, hemolytic, sickle cell, iron deficiency, anemia of chronic disease) Adrenocortical hypofunction Anterior pituitary hypofunction Monitor when taking iron supplements, increased count suggests marrow is responding

14. What to do now? Consult my favorite md – Dr J He says – “let me call you back” –(he really was consulting his wife) –His plan – iron supplementation in one month – rpt levels with lead level, glucose in one month –Do stool O+P now

15. What to do now? Sarah – his wife – doesn’t agree She says child is not iron deficient – refer to peds Distention in the ranks!! I decide to do more research….. And refer to peds and do the other tests Did I start iron – No – any idea why?

16. ?thalassemia S/s: history – poor growth, excessive fatigue, shortness of breath, pathologic fractures Physical exam: pallor, splenomegaly, jaundice

17. Diagnostic tests Mentzer index (MCV/RBC count) –<13 – thalassemia more likely –>13 – iron deficiency more likely CP Mentzer Index: 16.25 – could have perhaps given iron

18. Plan: Await next labs and peds consult Next labs: normal hemoglobin and platelets – MCV – now normal Wbc: slightly decreased at 4.7 Retic count up to 37.8 from 29 Percentage 0.8 up from 0.6% Lead level – normal Glucose – normal Stool O+P - negative

19. Peds consult Blood work not suggestive of anemia Unsure of the cause of reticulocyte count - ? Viral suppression Repeat his CBC, blood smear and reticulocyte count – (still not done- I have recalled them) No follow up planned

20. Comments? What do you think? Viral suppression? – no hx of illness Iron deficiency – iron is normal Anything else I should do?

21. Review of IDA Defn: hgb below 110 plus low iron Risks: term infants – not until 9 months of age –Preterm and lbw – 2-3 months of age –Limited access to food, low iron diet, high consumption of evaporated milk and cows milk after 6 mo of age, prolonged exclusive breast feeding

22. Prevalence of IDA 3.5% to 10.5% in general population 14% to 50% in Canadian aboriginal population

23. Clinical Signs and Symptoms Irritable Apathetic Poor appetite Pallor of conjunctiva, tongue, palms, nail beds Severe – CHF – fatigue, tachypnea, hepatomegaly, edema

24. Effects of ID Infants and preschool – developmental delays and behavioral disturbances such as decreased social interaction, decreased attention to tasks and decreased motor activity

25. Primary Prevention – ensure adequate intake of Iron Encourage breast feeding for 4-6 mo Less than 12 months – iron fortified formula if not exclusively breast fed Over 6 mo without adequate iron from foods (less than 1mg/kg day) give 1mg/kg day of iron drops Preterm or LBW – 2-4mg/kg/d drops (max 15 mg) until 12 mo 1-5 yrs – no more than 24 oz milk per day 4-6 mo – plain iron fortified cereal – 2 servings a day will meet needs for iron 6 mo – one feeding per day of vitamin C rich foods with meal Plain pureed meat after 6 months

26. Secondary Prevention Screening: AAP committee on Nutrition recommends: –Screen high risk children between 9-12 months, 6 months later and annually from age 2-5 – preterm or lbw, non fortified formula fed, on cows milk before age 1, breast fed and low iron intake after 6 mo, children taking more than 24 oz milk daily –Screen before 6 mo if preterm/lbw and not on iron fortified formula –Assess children age 2-5 annually for risk of IDA-low iron diet, poverty, etc

27. Diagnosis and Treatment Rpt hgb and hct to confirm diagnosis Repeat screen in 4 wks – if increase hgb by 1 gm or hct by 3% - confirms IDA – recheck in 2 months and 6 months If after 4 weeks, no response – do MCV, RDW and ferritin (less than 15 is IDA) Treat with 3mg/kg/d of iron drops between meals, counsel re: diet (1mg/kg/d of iron by food)

28. References Kee, L. (2005). Handbook of Laboratory and Diagnostic Tests. Upper Saddle River, NJ:Prentice Hall. Five Minute Clinical Consult. Skyscape. Thalassemia. Centers for Disease Control and Prevention. Recommendations to Prevent and control iron deficiency in the United States. MMWR 1998;47 (No.rr-3) retrieved on April 8, 2011 from http://www.cdc.gov/mmwr/preview/mmwrhtml/00051880.htm http://www.cdc.gov/mmwr/preview/mmwrhtml/00051880.htm Abdullah, K., Zlotkin, S., Parkin, P. & Grenier, D. (2011). Iron deficiency anemia in children. CPSP. Retrieved April 8 th, 2011 from http://www.cps.ca/english/surveillance/cpsp/Resources/Iron- deficiency_anemia.pdf http://www.cps.ca/english/surveillance/cpsp/Resources/Iron- deficiency_anemia.pdf