Too much milk?
Iron deficiency anemia can be seen in toddlers that have switched to cow’s milk (typically at age 1 yr) from formula. If the child’s diet is nearly exclusively cow’s milk, a severe anemia can slowly develop due to iron deficiency and chronic subclinical GI blood loss. Toddlers should not drink > 20 oz milk / day; their diet must contain a variety of foods. Only severe cow’s milk-associated anemia (Hgb < 5 g/dL) requires transfusion; otherwise diet modification and iron supplementation suffices. When transfusing hemodynamically stable patients who developed their anemia chronically, transfusion aliquots should be smaller and slower to avoid TACO (transfusion-associated circulatory overload). A good rule of thumb is: transfusion aliquot = Hemoglobin amount in mL/kg over 3-4 hours, so a child with a hemoglobin of 2.5 would receive 2.5 mL/kg PRBCs over 3-4 hours (instead of the typical pediatric transfusion aliquot of 10 mL/kg).