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Fatigue NYD. Ginny Burns NP Rounds. 5 yr old Male C.P. Cc: “my son is pale, more irritable than usual and I am wondering if he is anemic” - PowerPoint PPT Presentation
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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