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