Paeds Vivas · gastroenterology-hepatology-and-nutrition
Micronutrient deficiencies — branching viva
Branching viva from the definition and mechanisms of micronutrient deficiency through the iron-deficient toddler, the rachitic infant, the breastfed infant of a vegan mother with B12 deficiency, and the malnourished child with vitamin A and zinc deficiency, testing the laboratory workup, the replacement regimens and the region-aware prevention.
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RACP General PaediatricsRACP DCEMRCPCH ClinicalRCPSC Pediatrics
Prompt
You are the paediatric registrar in a general clinic. The consultant asks you to talk through four children referred with possible micronutrient deficiency: a two-year-old with pallor and pica, a ten-month-old with bowed legs and a waddling gait, an eight-month-old exclusively breastfed infant of a vegan mother with developmental regression, and a three-year-old recently arrived refugee with night blindness and a chronic rash.
Branch 1 — The two-year-old with pallor and pica
The consultant presents a two-year-old boy with pallor, tiredness and pica whose diet is heavy in cow's milk. [1]
Examiner probes:
- What is the most likely diagnosis and what in the history points to it? Lead the candidate to iron-deficiency anaemia with the microcytic film, the excessive cow's milk displacing iron-rich solids and the pica. [1]
- How do you confirm it and what is the role of the C-reactive protein? The candidate should describe a low ferritin, low transferrin saturation and raised transferrin, and explain that ferritin rises in inflammation so the C-reactive protein must be read alongside it. [1]
- What is the treatment and the expected timeline? Oral elemental iron at around three milligrams per kilogram per day, continued for about three months after the haemoglobin normalises, with a reticulocyte rise within one to two weeks and haemoglobin normalisation within two to three months. [1]
References6ShowHide
- [1]Baker RD; Greer FR Diagnosis and prevention of iron deficiency and iron-deficiency anemia in infants and young children (0-3 years of age). Pediatrics, 2010.PMID 20923825
- [5]Wagner CL; Greer FR Prevention of rickets and vitamin D deficiency in infants, children, and adolescents. Pediatrics, 2008.PMID 18977996
- [6]Elder CJ; Bishop NJ Rickets. Lancet, 2014.PMID 24412049
- [7]Green R; Allen LH; Bjørke-Monsen AL; Brito A; Guéant JL; Miller JW Vitamin B(12) deficiency. Nat Rev Dis Primers, 2017.PMID 28660890
- [9]Song A; Mousa HM; Soifer M; Perez VL Recognizing vitamin A deficiency: special considerations in low-prevalence areas. Curr Opin Pediatr, 2022.PMID 35125379
- [11]Black RE; Victora CG; Walker SP; Bhutta ZA; Christian P; de Onis M Maternal and child undernutrition and overweight in low-income and middle-income countries. Lancet, 2013.PMID 23746772