Fatigue NYD

Fatigue NYDFatigue NYDFatigue NYDFatigue NYDGinny BurnsGinny BurnsNP RoundsNP Rounds

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

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

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 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

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

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

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

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 –

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!

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

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

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

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

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?

?thalassemia• S/s: history – poor growth,

excessive fatigue, shortness of breath, pathologic fractures

• Physical exam: pallor, splenomegaly, jaundice

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

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

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

Comments?• What do you think?• Viral suppression? – no hx of

illness• Iron deficiency – iron is normal• Anything else I should do?

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

Prevalence of IDA• 3.5% to 10.5% in general

population• 14% to 50% in Canadian

aboriginal population

Clinical Signs and Symptoms

• Irritable• Apathetic• Poor appetite• Pallor of conjunctiva, tongue,

palms, nail beds• Severe – CHF – fatigue, tachypnea,

hepatomegaly, edema

Effects of ID• Infants and preschool –

developmental delays and behavioral disturbances such as decreased social interaction, decreased attention to tasks and decreased motor activity

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

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

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)

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

• Abdullah, K., Zlotkin, S., Parkin, P. & Grenier, D. (2011). Iron deficiency anemia in children. CPSP. Retrieved April 8th, 2011 from http://www.cps.ca/english/surveillance/cpsp/Resources/Iron-deficiency_anemia.pdf