Pediatric Nutrition Symposium February 12, 2015 Chan Centre, Vancouver and via Telehealth Milk Baby...

Pediatric Nutrition SymposiumFebruary 12, 2015Chan Centre, Vancouver and via Telehealth

Milk Baby and Anemia

Patient Presentation• Sally is a 23 month girl presenting with decreased

energy and concerns with growth. Parents notice she has been looking more pale recently

• Mom reports she eats little solids during the day compared to other children her age, and dislikes meats and vegetables.

• Mom has recently given birth to a baby boy and the family just moved into a new home.

• Whenever Sally cries, parents will give her a bottle of milk to calm her down.

• Medication and Vitamin Supplements: none

Today’s Anthropometrics:Weight 10.9 kg (15 – 50th percentile)Length: 87 cm (50 – 85th percentile)Weight for Length: 15th percentile

Usual IntakeBreakfast 1 cup homogenized milk in a

bottle¼ cup cheerios½ banana

Morning Snack 1 cup milk2 baby cookies¼ cup sliced grapes

Lunch ½ cup milk¼ pita bread with 1 tablespoon hummus½ hardboiled egg

Afternoon Snack 1 cup milk¼ cup fish crackers

Dinner ½ cup milk¼ cup mashed potatoes with gravy¼ cup strawberry slices½ cup apple juice

Bedtime 1 cup milk, 2 graham crackers

Middle of the Night 1 cup milk

Labs

Lab ResultNormal Range

Hemoglobin (Hgb)

106 g/L 105 - 135

Mean Corpuscular

Volume (MCV)

65.4 fl 75 - 87

Iron 3 µmol/L 3.7 – 5.3

Ferritin 3 µg/L 12 - 66

Nutrition Assessment

1. How does Sally’s current intake differ to one that is age appropriate?

• Low intake of iron, fibre• Excess intake of milk• Consuming milk from bottle instead of

cup

Nutrition Assessment

2. What do her lab values and clinical symptoms indicate?

• Iron deficiency anemia

3. What are some potential barriers to meeting nutrition goals?

• Family is stressed and busy, may feel it’s not the right time to implement recommendations

• Power struggle with a strong-willed and determined toddler

Nutrition Diagnosis

Inadequate iron intake related to high milk consumption as evidenced by labs (low MCV, iron and ferritin and low-normal Hgb) and high milk intake of 6 cups per day.

Nutrition Intervention

1. Limit milk intake to maximum 2 - 3 cups daily

2. Transition off bottle and encourage feeding milk from a cup

3. Start iron supplement• 3-6 mg elemental iron/kg/d divided into 1-3 times per

day• Sally was started on ferrous sulfate 1.5 mL (22.5mg

elemental iron) twice a day

Nutrition Intervention

4. Review food sources of iron to offer. Would expect Sally’s intake of food to increase with decreased milk intake.

Toddler friendly food sources of iron:• Meats – well cooked minced/pieces of

beef, poultry, pork, fish, meat sauce• Iron fortified cereal, enriched bread,

pasta• Legumes - hummus, peanut butter, tofu• Eggs• Green vegetables – spinach, broccoli

Age RDA (mg/d)

0 – 6 months 0.27 (AI)

7 – 12 months 11

1 – 3 years 7

4 – 8 years 10

9 – 13 years 8

14 – 18 years 11 (male)15 (female

Nutrition Monitoring and Evaluation

1. Growth

2. Intake – milk and solids

3. Age appropriate feeding

4. Labs - CBC, and iron studies in 2 months

.

References and Suggested Readings

1. Ziegler, E. Consumption of cow’s milk as a cause of iron deficiency in infants and toddlers. Nutrition Reviews. 2011;69(Suppl 1):S37-S42.

2. Bondi, S and Lieuw, K. Excessive cow’s milk consumption and iron deficiency in toddlers. ICAN: Infant, Child, and Adolescent Nutrition. 2009;1(3):133-139

3. Vancouver Coastal Health – Bye Bye Baby Bottle

http://vch.eduhealth.ca/PDFs/GK/GK.260.B995.pdf