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so let's focus in on iron deficiency
anemia and I want to do that because
this is so common in children this is
more common in periods of rapid growth
when kids need their iron the most also
it's more common and strict vegetarians
because iron is replete in meat most
commonly we see it in infants who drink
lots of milk so I've had many patients
come in and mom says oh well that's the
only thing he'll eat and I want him to
grow and so I give them four glasses of
eight ounces of milk a day those
children are gonna present with anemia
occasionally iron deficiency can also be
seen in blood loss because when you lose
blood you're essentially losing iron if
you don't replete the iron in your diet
so patients with inflammatory bowel
disease GI bleeds or parasites celiac
disease or even paid with patients with
excessive menses are all at risk for
iron deficiency well in Adeline girls
even girls with normal menstrual issues
can have blood loss and a resulting iron
deficiency if they're not having enough
iron in their diet so for iron
deficiency the CBC will show a
microcytic anemia and they will
typically have a low reticulocyte count
you might want to get iron studies
sometimes I get confused about the iron
studies so let's go through them
carefully so the ferritin affects your
total body stores this is the best
single test for iron deficiency and it
usually is low in iron deficiency
because it's reflecting your body stores
of iron
the challenge with ferritin is it also
an acute phase reactants so if I get an
ammonia I'm gonna have a high faring
I may have iron deficiency and have a
falsely high Feridun and miss the
diagnosis if ferritin is the only thing
I'm getting another iron study you might
get in your iron panel is the total iron
binding capacity this represents how
many free transferrin sites there are in
a patient so if there are a lot of free
spaces for iron to bind that means your
irons low they should be bound they're
not so you may have a tote
iron binding capacity this is high if I
have a patient who has inflammation and
a normal ferritin and a high iron
binding capacity I may have a patient
with iron deficiency Oh es and their
ferret is high because they have a
pneumonia
the serum iron is not really a
particularly useful test it comes along
with it often I don't use it very often
so how do we manage iron deficiency
anemia seems pretty obvious we have to
give them iron usually we provide iron
as a medication a dose of around four to
six millions per kilo per day we're
going to restrict milk consumption in
these children because that's such a
common cause sometimes kids don't want
to go along with that plan and you have
to spend some time encouraging the
families to teach them how to say no to
their child who wants more milk
additionally we will hopefully increase
iron containing foods you can look that
up on the Internet involves foods like
meat and legumes
we often supplement vitamin C because
this facilitates iron absorption in the
gut
also if a patient has become tachycardic
we're going to need to transfuse that
patient typically this is at a
hemoglobin of around seven we don't
usually use the hemoglobin number itself
for when we need to transfuse we usually
use when they're tachycardic however you
may use it in certain circumstances an
example would be if a patient has a
brisk GI bleed and was nine and then was
seven and stills in tachycardic I'm
probably going to transfuse that job
because next time I look the child will
be five okay vitamin b12 and folate
deficiency this is much more common in
adults than children because b12 and
folate are fairly ubiquitous in the diet
we typically think of this as a problem
in adult alcoholics it could happen in a
very severe teen alcoholic but whatever
the case may be divisions of VD of these
two nutritional elements caused a
macrocytic megaloblastic anemia b12 is
absorbed in the ill
so we also see this problem in patients
with ileal inflammation the classic
example would be a Crohn's patient
nutritional deficiency like I said is
rare we will treat these patients with
i.m vitamin b12 folate disease is very
very rare in children and generally
associated with a generalized
malnutrition we use oral supplementation
of folate and that will be fine so both
of these are erythrocyte a plages
transient at-risk oblast opini of
childhood is a disease that sometimes
pops up on exams and you should probably
be familiar with transient with robust
apini of childhood or TEC shows up
around six months to four years of age I
usually think of it about a year old or
a two-year old this is a transient
phenomenon but by transient I mean
several months not just for a few
minutes
it's a normocytic anemia because these
patients are transiently incapable of
making red blood cells and it's usually
preceded by a viral illness often that
virus is parvovirus b19 but it might be
another virus as well in fact parvo
virus is only implicated in the minority
of cases there is no known cure to this
but the good news is it always gets
better on its own so typically these
children will be fine
gradually become more pale begin getting
lethargy and that progression of signs
and symptoms that we discussed at the
beginning of this lecture and the parent
will bring them in for evaluation you
get a CBC and you notice they have a
pure erythrocyte aplasia will now watch
these patients for a period of time
sometimes they require transfusions and
then over a few months they get better
flipside is when a child never develops
those red cells in the first place they
start off with red blood cells because
they have fetal hemoglobin but then
they're incapable of making any further
this is a congenital erythrocyte aplasia
it presents soon after birth with a
rapid onset anemia and there is a pre
does
positioning can't to cancer in these
patients even after their anemic
one-third of cases will remit in the
first decade but many of these patients
after multiple transfusions simply go on
to a bone marrow transplant bone marrow
transplant is obviously not benign so we
want our purchased with care but that is
really the only cure for these patients
who have persistent disease
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you