Case 3: 3yo WCC, Iron Def Anemia Flashcards
1
Q
important topics for 3yo WCC visit
A
1) Social - family and friends
2) Nutrition (esp. for the “picky” eaters) - watch out for inadequate fruit, vegetable, iron, Ca, VitD ==> VitD supplementation
3) Exercise - unstructured outdoor play; prevention of obesity
4) Toilet training - started, but not always successful
5) Dental - should start dentist within 6mo of first tooth and by 1y of age (esp. if still using the bottle)
2
Q
when should the child start seeing the dentist?
A
within 6mo of first tooth / by 1y of age
3
Q
Until what height should older children stay in a booster seat
A
4’9” (142)
4
Q
what do you do for a child <3yo with suspected developmental problems?
A
1) early childhood intervention (ECI) - by state
2) developmental-behavioral pediatrician
3) child psychiatrist / psychologist
4) early childhood learning specialist
5
Q
what do you do for a child >3yo with suspected developmental problems?
A
Services by the school –> to catch up to peers
6
Q
define eczema
A
Atopic dermatitis = “the itch that rashes’ –> cycle of irritation leading to scratch –> to rash
7
Q
eczema: personal & family hx
A
if eczema + allergies ==> then likely triad of eczema + allergies + rhinitis
FHx = usually familial with clear environmental triggers
8
Q
diffdx eczema
A
psoriasis –> ADULTS; rare in kids; usually generalized rash (guttate) - usually precipitated by strep infection
seborrhea –> EARLY INFANCY (cradle cap).
9
Q
Treatment for eczema
A
1) extensive lubrication = protect skin
2) anti-inflammatories in short bursts
(a) Topical steroid - dose depends on severity (mild = 2.5% hydrocortisone)
(b) calcineurin inhibitors (SHORT-TERM)
(c) (ITCH) non-sedating antihitamines [CHILDREN] = loratidine, fexofenadine, cetrizine; sedating antihistamines @ night = diphenhydramine, hydroxyzine
10
Q
Common dietary issues in childhood
A
- inadequate nutrition
- milk & juice intake
- early childhood caries
- control problems with food
11
Q
Common dietary issues in childhood (aged 2-3): inadequate nutrition
A
- will eat 80% of recommended fruits, but 30% recommended vegetables
IRON (meat, legumes, fortified cereals) –> important as a CNS co-catalyst
12
Q
Common dietary issues in childhood (aged 2-3): milk & juice intake
A
concerns for intake of HFCS sweetened beverages
- risk of obesity
limit: <4-6oz of juice per day; <16oz of milk
13
Q
Common dietary issues in childhood (aged 2-3): caries
A
d/t bathing teeth throughout day with milk / juice from a bottle
usually hav ea lag time before visible decay (diet habits @ 1-3yo –> caries @ 3-5yo)
recommendation: discontinue bottles (esp. @ night) by 12-15mo.
14
Q
Common dietary issues in childhood (aged 2-3): control wrt food
A
food rewards & punishment –> can lead to obesity b/c kid’s can’t regulate own food intake
15
Q
common injuries in children
A
- car accidents
- swimming pools
- falls
- firearms
- poisonings
- fires
- guns (esp. boys 8-12 can handle & shot a gun)
- lead exposure (house paint <1960-1978, soil, plumbing/pipes, hobbies, occupational exposure, imported toys/ceramics/candy/cosmetics, folk remedies) –> esp. at 6-36mo
16
Q
Infectious disease concerns in children
A
- TB screening for kids who:
- spend time with TB+ ppl / where TB very common / around people who came from TB common country,
- infected with HIV
- sxs of TB
- use of injected illegal drugs
17
Q
what is the recommendation for blood lead testing
A
- All kids 2-3yo in areas where >25% of housing built before 1960; OR where prevalnce of blood levels >5ug/dl in children is >/= 5%
- individual children who live in / regularly visit places built < 1960 in poor repair or that have been renovated in the past 6mo.
18
Q
what is the connection between iron deficiency and lead?
A
occurrence of iron deficiency –> increased lead absorption
19
Q
what is the connection between iron deficiency and lead?
A
occurrence of iron deficiency –> increased lead absorption
20
Q
Iron deficiency anemia
- epidemiology
- complications
- causes
- tx
A
- epidemiology: deficiency iron stores in 35% of low income children (v. 7% of other children), and 10% with iron deficiency anemia
- complications: later cognitive deficits (d/t iron def, anemia itself, concurrent environmental factors)
- causes: lack of iron intake; chronic GI blood loss (food allergies, gluten enteropathy)
- tx: MILD = trial of iron; (dx by tx - if anemia improves)
21
Q
causes of anemia in children
A
“minor” = Hgb <12
1) iron deficiency anemia
2) in Mediterranean / Asian / African –> hemoglobinopathy (alpha thalassemia, G6PD def, sickle cell) == ABNORMAL newborn screening Hgb electrophoresis
----------------- "major" = Hgb <9 1) decreased bone marrow production (aplastic anemia) 2) hemolytic anemia 3) vit deficiencies (folate, B6)
“chronic / severe illness”
- collagen vascular disease
- malignancy (leukemia, with pancytopenia)
22
Q
Physical exam: what to prioritize if child is fussy (3-5yo)
A
- do heart & lungs first
- monitor previously recognized findings
- neurodevelopment
- new findings identified by parents
- physical problems common in preschoolers where intervention can be helpful
23
Q
in 3-5yo, what are some physical problems common where intervention can be helpful
A
- Ear: middle ear effusions persisting after earlier URI, affecting hearing
- Eyes: strabismus
- Neck - ?enalrged thyroid; “shoddy” nodes (pea-sized, movable) in anteiror & posterior cervical chain
- throat/mouth - caries
- CV - nml functional systolic murmur / ASD (fixed systolic split)
- Lungs - wheezes if have allergies
- Abdomen - for oganomegaly, masses
- MSK - gait variants (most common = in-toeing)
- GU - hernia; nonspecific vulval erythema due to poor hygiene; teaching on who is appropriate to examine them “down there”
- Neurologic - Assessment of overall muscle tone, strength, and coordination & overall neurodevelopmental state
24
Q
you have a 4yo in your office, and dad is worried about a pea-sized, nontender,
easily mobile lymph nodes that are not fixed to surrounding structures - 2 in the anterior and 1 in the posterior chain. what do you tell him?
A
it’s small, movable, doesn’t hurt —> normal in cervical & inguinal chains in children
can persistent for years.
25
what is the most common cause of an abdominal mass in children aged 3-5?
- stool
- --------
- enlarged kidney
- abdominal tumor (Wilms', neuroblastoma)
26
what is the most common gait variant in children, and what is it caused by?
in-toeing
TODDLERS = tibial torsion (with tibia internally rotated wrt patella)
--> resolves naturally with weight bearing by 4yo
OLDER SCHOOL-AGED CHILDREN - femoral anteversion (with both tibia & femur internally rotated)
--> resolves naturally by 8-12yo
27
Strabismus
- define
- complications
- assessment
= misalignment of the eyes
complications:
- amblyopia (where nothing is organically wrong with the eye, but now since one is not getting used, it stays in the misaligned position
- poor visual development
assessment
- Hirschberg light reflex
- cover / uncover test
28
Describe the neurodevelopmental exam of a 3yo
A. Developmental milestones
- Language (speaks in short sentences; 75% of language is intelligible to a stranger)
- Fine motor (holds a pencil or crayon; copies a circle)
- Gross motor (hops; can ride a tricycle)
Cognitive (draws a person with three body parts)
other ("adult" exam)
- CN function
- DTRs
- muscle tone
- gait
29
At what point is anemia SCREENING done?
12 mo, preschool, kindergarten --> period of development where diet (esp. iron sources) is variable
- use H&H (or CBC)
- false positive anemia -- d/t hydration
30
How to improve a toddler's eating habits?
- Stop the bottle now (let the kid do it) ==> usually kids will stop their request for it after a few days
- Limit child's eating to 3 meals and 2 snacks; stop food & drink grazing ==> drink water (not juice / milk)
- No bargaining or cajoling ==> structured time-limited meals; hunger to drive food choices (which should be healthy); do NOT use dessert as an incentive for 'good' eating
- gradually change diet content and add new foods.
31
Aside from the newborn screen, when does vision and hearing screening start?
Vision screening --> 3yo (chart)
Hearing screening --> 4yo (audiometry)
- if "can't be tested" --> be concerned about developmental delays.
32
by what age should children stop using a bottle and why?
discontinue bottles (esp. @ night) by 12-15mo.
risk of developing dental caries
33
what is the one of the best ways that doctor's offices can help parents improve development and learning in their kids
providing books and encouraging parents to read to their kids.
34
kid has rash in the flexors of the arms. what is it?
antecubital fossa
==> eczema
35
older kid has rash in the flexors of the arms. what is it?
elbow
==> psoriasis
36
how to achieve success in toiler training
- consistency between caregivers
- need toddler "buy in"
- avoid punishment & shaming for accidents / unwillingness to sit on toilt
- positive reinforcement and modeling
- remove physical obstacles --> dress children in easily removed pants / utilize "naked" time
- provide relaxed "potty time"
37
single parenting is a risk factor for what problems in early childhood?
- non/accidental injury or poisoning
- failure to thrive
- behavioral difficulties
38
maternal depression is a risk factor for what problems in early childhood?
- mood/behavior problems in children (increased frontal & parietal brain activation)
- more social stressors --> less consistent and effective parenting
39
Do you have to worry about SIDs at age 3yo
By definition, SIDs affects kids <1yo.
40
When you ask about safety you learn that Benjamin's mother has a gun in the home, and that she and Benjamin live near a busy road. You note that because they live alone, Mrs. Jones purchased a handgun "for protection."
When you ask about safety you learn that Benjamin's mother has a gun in the home, and that she and Benjamin live near a busy road. You note that because they live alone, Mrs. Jones purchased a handgun "for protection."
the only foolproof way to prevent accidental injury due to the gun is to remove the gun from the house as recommended by the American Academy of Pediatrics.
Parents who possess guns for protection from crime are likely unwilling to place the gun in one locked cabinet and ammunition in another.
41
you have a picky 3yo eater. How do you best evaluate him?
Risk of anemia
--> fingerstick H&H (if that's available; if not --> CBC)
a diagnostic, rather than a screening test at this point.
only do a lead level if
1) concerns for anemia (b/c would lead to increased lead absorption)
2) risk factors for lead poisoning
42
A 3-year-old boy presents for a follow-up visit after being diagnosed with iron deficiency anemia. He is currently receiving oral iron supplements, 2 mg/kg of elemental iron daily. He has a dietary history of eating mostly sweet, bland, low-texture foods. What strategies may be used to improve his diet?
A Continue bottle-feeding
B Encourage eating small amounts of food throughout the day (grazing)
C Gradually introduce new foods and slowly decrease his old favorites
D Bargain and cajole with the child
E No change is needed; bland, low-texture foods are optimal for a child this age
C
the rest of it are highly not recommended
child should be encouraged to restrict eating to 3 meals and 2 snacks per day (BEHAVIORAL). He should be eating a varied diet with the recommended servings of fruits and vegetables per day.
43
A 2-year-old girl is examined as an outpatient. While waiting for the pediatrician, her mother reads her a short book. When they are done, her mother asks her to take the book and return it to a bookshelf in the room. The child is not able to hold a pencil and cannot write her name. She can kick and throw a ball, but cannot jump in place. Which of the following best describes this child’s development?
```
A Delayed language
B Delayed social skills
C Advanced fine motor skills
D Advanced gross motor skills
E Age-appropriate development
```
E.
language - A 24-month-old child is expected to use pronouns inappropriately, but should be able to follow two-step commands such as taking a book and returning it to a location in the room.
Social skills - At 24 months of age, children are able not only to listen to short stories, they also engage in parallel play.
Fine motor skills - While a child can hold a pencil at 24 months, the grip is immature and the child imitates pencil strokes. Children can remove their pants and socks at this age, but need help to undress completely.
gross motor -
Being able to jump in place is a 30-month-old milestone. Being able to throw a ball overhand is expected at 24 months of age.
44
At a routine well-child visit, the frantic mother of your 4-year-old male patient states that she thinks her son has some developmental delays based on what she hears from other parents. Although he knows how to do such things as throw a ball and copy a circle, he cannot brush his teeth on his own, tie his shoes, or hop on one foot. According to the AAP’s Bright Futures, which of the following are development milestones for typical 4-year-olds?
A Throw a ball overhand, ride tricycle, build tower of 6-8 cubes
B Hop on 1 foot, copy a cross, brush teeth
C Tie a knot, copy squares
D Mature pencil grasp, print some letters and numbers
E Skip, draw a person with 6 or more body parts
B
Throw a ball overhand, ride tricycle, build tower of 6-8 cubes --> 3yo
Hop on 1 foot, copy a cross, brush teeth --> 5yo
Tie a knot, copy squares --> 5yo
Mature pencil grasp, print some letters and numbers --> 5yo
Skip, draw a person with 6 or more body parts --> 5yo
45
A 3-year-old boy described by his mother as a picky eater comes in for a regularly scheduled well-child visit. His mother complains that he has had less energy than usual for the past few months. There is a high clinical suspicion he is anemic. Which of the following is most correct?
A The most cost-effective test to diagnose anemia is a CBC.
B Lead screening is never warranted since a 3-year-old is usually not mouthing objects.
C The most likely cause of anemia in the question is picky eating resulting in low iron intake, which would cause microcytic anemia.
D The most common cause of anemia in this situation is folate deficiency.
E If anemia is due to poor nutrition, restarting the bottle will help the child recover the most.
C
Low iron intake causes a microcytic anemia. A girl with menometrorrhagia would present with iron deficiency, and her MCV also would be indicative of microcytic anemia.
Most effective method = screening Hgb
Although most 3-year-olds stop mouthing objects, they may have been exposed to lead in the past but were not symptomatic at the time.
folate deficiency may be associated with a goat’s milk diet.
It is best to stop the bottle by age one year. Solid foods provide more complete nutrition, including iron. An additional concern of prolonged bottle usage is the development of dental caries.
46
A 5-year-old girl comes into your office for a well-child visit. The mother says that child is overall very healthy, but she highlights “occasional colds” and recently more frequent temper tantrums. She does well in preschool, is toilet trained, and enjoys eating mostly pasta, bread, and milk. She lives with her mother and father in a home built in 1985. Lab studies were significant for a mild anemia with a hemoglobin of 10.0 g/dL. You note that her hemoglobin was in the normal range at her 3-year-old visit. Which of the following is the most likely cause of her anemia?
```
A Chronic blood loss
B Lead poisoning
C Chronic illness
D Iron deficiency
E Hemoglobinopathy
```
D
Iron deficiency --> irritability, prefernece for pasta & milk
if lead --> weight loss, lethargy, vomiting, learning difficulties
47
effects of iron deficiency (+/-
| anemia) on development
- worsened school performance
48
causes of iron deficiency
inadequate iron absorption to accomodate an increase in requirements attributable to growth
long-term negative iron balance
49
Iron requirements by age
- how they may be deficient
- t
preterm ==> 2-4mg/kg/d (PO)
- deficit in total body iron assoc. with how premature
- frequent phlebotomies
==> tx: suppl. iron + recombinant humna erythropoietin
0-6mo ==> 0.27mg/d; 7-12mo ==> 11mg/d
- maternal anemia, HTN, IUGR, GDM
- rapidly increasing growth in this time period (2x by 6mo, 3x by 9-12 mo)
1-3yo ==> 7mg/day
>3yo ==> 2mg/day
50
Iron requirements by age
- how they may be deficient
- t
preterm ==> 2-4mg/kg/d (PO)
- deficit in total body iron assoc. with how premature
- frequent phlebotomies
==> tx: suppl. iron + recombinant humna erythropoietin
0-6mo ==> 0.27mg/d; 7-12mo ==> 11mg/d
- maternal anemia, HTN, IUGR, GDM
- rapidly increasing growth in this time period (2x by 6mo, 3x by 9-12 mo)
1-3yo ==> 7mg/day
3-11yo ==> 10-15mg/day
12-19yo ==> 16mg/d
>19yo ==> 20mg/d
51
causes of iron overload
1) genetic predisposition to absorb & store iron in excess amts (hereditary hemochromatosis)
2) complication of other hematologic d/o --> resulting in chronic transfusion therapy, repeated injections of parenteral iron, excessive iron ingestion.
52
what is the risk in giving recombinant human erythropoietin to a child that is anemia?
how do you fix it?
==> further deplete iron stores
tx = additional supplemental iron + Epo
53
how long does a RBC live?
100-120 days
54
what is a reticulocyte
Reticulocyte: New RBC with stainable RNA
55
define: anemia
Anemia:
Hgb/Hct < 2 SD below mean
age / race / sex dependent
56
causes of anemia
and which is the most common in peds?
1) Decreased production
Increased destruction
Abnormal Loss, ie, bleeding
57
What is the most common cause of decreased production of blood in pediatric patients?
iron deficiency anemia
58
How can you suspect iron deficiency anemia without getting iron studies?
Diet history
| Red blood cell indices—specifically the mean corpuscular volume (MCV)
59
What is iron deficiency anemia?
How is it diagnosed?
microcytic anemia == more common hematologic disease of infancy & childhood
60
diagnosis of Fe deficiency anemia
1) MCV, MCH = low
2) TIBC = high
3) Transferrin sat = low
4) serum iron, ferritin = low
5) thrombocytosis / thrombocytopenia
6) reticulocyte - low, normal (b/c low iron = no heme = no reticulocyte)
61
what do you have to be wary about a "normal" iron, ferritin in kids where you are concerned about iron deficiency anemia
Serum iron = can be raised rapidly w/out correcting the problem
serum ferritin = acute phase reactant ==> can be abnormally high b/c kid is sick
62
Why is the reticulocyte count low or normal in iron-deficiency anemia?
No iron, no heme, no reticulocyte
63
What is treatment for iron deficiency anemia?
How soon should you see a response?
2-6mg elemental iron/kg/d (need more than maintenance to replenish)
milk and food decrease absorption!
Reticulocytosis in 3-5 days, peaking at 7-10 days
1-2gm/dL rise in Hgb in 4 weeks
64
what are the side effects to iron supplementation in children
Stained teeth, dark stools
NO constipation ==> adults
65
Anemia of Chronic illness/inflammation/disease - mechanism?
decreased efficiency of absorption
66
Thalassemia - alpha chain
| - 1-2 defective chains
thalassemia trait
normal Hgb
may have abnormal newborn screen
67
Thalassemia - alpha chain
| - 3` defective chains
Hgb H
68
Thalassemia - alpha chain
| - 4 defective chains
hydrops
69
who gets thalassemia
SE asian
mediterranean
african
anywhere there is a monsoon
70
Thalassemia - beta chain
| - 1 defective chains
thalassemia trait
71
Thalassemia - beta chain
| - 2 defective chains
Cooley's
| thalassemia major
72
7month old Baby Girl Sunshine Lake, lives with hippie vegan parents.
+ hypersegmented neutrophils
megaloblastic anemia
==> goat's milk: folate deficiency
3y to deplete VitB12 (usually intrinsic factor deficiency; fish taepworm; short gut)
73
what are the usual causes of VitB12 deficiency
3y to deplete VitB12 (usually intrinsic factor deficiency; fish taepworm; short gut without supplementation)
alcoholics
74
Fanconi's anemia
no thumbs!
problems with blood, and with bone marrow
75
who gets fanconi's anemia
Jewish ashkanazi
76
what is the danger of fanconi's anemia?
leukemias, brain tumors
77
What virus is associated with red cell aplasia leading to anemia?
parvo B19
any virus can cause mild pancytopenia
normal reticulocyte = 1%
78
ITP in peds patient
Usual viral cause
79
what is the danger of a sickle cell kid who becomes sick with Parvo virus?
most kids with sickle cells @ reticulocyte count = 27% (totally normal for them)
hit with virus ==> decreased Hgb => becomes dangerously anemic
80
Using the “3” soundbyte, what are causes of excess destruction in a red cell?
and what does it look like on peripheral smears
1) Membrane defect = inside (stomatocytes, elliptocytosis); sickle cell ==> usually fine until dehydrated
2) Enzyme defect = outside (G6PD deficiency --> schistiocytes, acanthocytes, burr cells, bite cells)
3) Hemolysis (mechanical heart valve)
81
why would a sickle cell pt also have hypersegmented neutrophils?
can have HIGH reticulocyte count of 27% ==> require folate
can deplete folate
82
who gets spherocytes
- hemolytic anemia
| - hereditary spherocytosis
83
who gets howell jolly bodies?
splenectomy ==> not plucking out bad RBCs
84
What are the steps to determining the cause of a pediatric patient’s anemia?
```
Look at MCV!
Look at diet
Look at red cell morphology
Look at ethnic background
Use algorithm of MCV
```
85
prognosis for those with hereditary spherocytosis
- can be slightly anemic
- if needed, steroids, platelet infusion
- when sick ==> hemolytic anemia
IF get splenomegaly d/t sequestration ==> splenectomy
86
If you diagnose iron-deficiency anemia, how will you treat?
give the high side dose for age / weight
okay to give a kid higher than adult dose ==> b/c kid could need it for growth
