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An 18 month old toddler is brought in for decreased energy and “not acting right.” On exam, the child is noted to be pale, mildly tachypneic, and has a flow murmur. She is afebrile. Her point of care hemoglobin is 3.2 g/dL, and additional history reveals that she is a very picky eater and drinks five 8-oz bottles of milk per day and takes in little else. A full CBC and iron studies are sent to the lab.
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December 19, 2019 at 4:56 pm
B) The patient should be transfused 3-4 mL/kg of PRBCs and admitted for further monitoring and work-up
The patient presents with classic iron deficiency anemia due to excessive cow’s milk ingestion. Excessive cow’s milk ingestion results in low iron intake and a subclinical proctocolitis with GI blood loss. The degree of anemia is severe, but likely developed over a long period of time. Due to the severity of the anemia, the patient requires transfusion. However, transfusing the usual amount of 10 cc/kg PRBCs risks transfusion-associated circulatory overload with this degree of anemia in a child already showing some symptoms of heart failure. Transfusion should be in small aliquots and given slowly over 3-4 hours. A nice rule of thumb is for the number of cc/kg to transfuse to be equivalent to the patient’s hemoglobin, eg a patient with a hemoglobin of 3 gets only 3 cc/kg PRBCs at a time. Multiple small transfusions may be needed.