Iron deficiency anaemia — viva

Branching structured oral on iron deficiency anaemia in children, covering the WHO age-banded thresholds, the ferritin-gated classification of the microcytic anaemias, the hepcidin-ferroportin axis and functional iron deficiency, the cow's milk history, oral elemental iron at 3 to 6 mg per kg per day once daily or alternate day for at least three months, the reticulocyte and haemoglobin response, the refractory workup with coeliac serology and occult blood loss, intravenous iron, restrictive transfusion, and the neurodevelopmental stakes of infant deficiency.

branching clinical structured oral5 min readVerification in progress

Prompt

A 20-month-old boy presents with pallor, irritability and pagophagia. He drinks 900 mL of cow's milk a day and eats little else. His haemoglobin is 74 g per litre with a mean cell volume of 65 fL, a raised red cell distribution width, and a ferritin of 4 micrograms per litre with a normal C-reactive protein. You are the paediatric registrar. Take me through your assessment and management.

Opening (must-hit)

"This is a microcytic hypochromic anaemia with a low ferritin and a normal CRP — iron deficiency anaemia, uncomplicated by inflammation. For his age the WHO threshold is below 110 g per litre, so 74 is markedly low. The cause is written into the history: excessive cow's milk at 900 mL per day, early introduction, and the pagophagia is a specific clue to iron deficiency. He is haemodynamically stable, so my plan is oral elemental iron at 3 to 6 mg per kg per day once daily or on alternate days for at least three months, combined with cutting the cow's milk below 500 mL per day and introducing iron-rich solids. I would expect reticulocytes to rise by day 7 to 10 and the haemoglobin by about 10 g per litre per week, and I would recheck at four weeks." [3][5]

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References9Show ledger

[1]Lopez A; Cacoub P; Macdougall IC; Peyrin-Biroulet L Iron deficiency anaemia. Lancet, 2016.PMID 26314490
[3]Mattiello V; Schmugge M; Hengartner H; von der Weid N; Renella R; SPOG Pediatric Hematology Working Group Diagnosis and management of iron deficiency in children with or without anemia: consensus recommendations of the SPOG Pediatric Hematology Working Group. Eur J Pediatr, 2020.PMID 32020331
[4]Leung AKC; Lam JM; Wong AHC; Hon KL; Li X Iron Deficiency Anemia: An Updated Review. Curr Pediatr Rev, 2024.PMID 37497686
[5]Wang M Iron Deficiency and Other Types of Anemia in Infants and Children. Am Fam Physician, 2016.PMID 26926814
[7]Cappellini MD; Comin-Colet J; de Francisco A; Dignass A; Doehner W; Lam CS; Macdougall IC; Rogler G; Camaschella C; Kadir R; Kassebaum NJ; Spahn DR; Taher AT; Musallam KM; IRON CORE Group Iron deficiency across chronic inflammatory conditions: International expert opinion on definition, diagnosis, and management. Am J Hematol, 2017.PMID 28612425
[8]Stoffel NU; Cercamondi CI; Brittenham G; Zeder C; Geurts-Moespot AJ; Swinkels DW; Moretti D; Zimmermann MB Iron absorption from oral iron supplements given on consecutive versus alternate days and as single morning doses versus twice-daily split dosing in iron-depleted women: two open-label, randomised controlled trials. Lancet Haematol, 2017.PMID 29032957
[6]Cappellini MD; Musallam KM; Taher AT Iron deficiency anaemia revisited. J Intern Med, 2020.PMID 31665543
[10]Pasricha SR; Hasan MI; Braat S; Larson LM; Tipu SMM; Hossain SJ; Shiraji S; Baldi A; Bhuiyan MSA; Tofail F; Fisher J; Grantham-McGregor S; Simpson JA; Hamadani JD; Biggs BA Benefits and Risks of Iron Interventions in Infants in Rural Bangladesh. N Engl J Med, 2021.PMID 34496174
[11]Larson LM; Phiri KS; Pasricha SR Iron and Cognitive Development: What Is the Evidence? Ann Nutr Metab, 2017.PMID 29268256