Dietary deficiency of iron--an extreme example.

Iron deficiency anaemia is still a problem in childhood, and even mild anaemia may interfere with psychomotor development. Occasionally, very severe anaemia is seen in paediatric wards. We present an extreme example of anaemia secondary to dietary deficiency of iron. CASE REPORT: A three and a half year old girl was admitted with lethargy and extreme pallor. The history was of increasing lethargy for three weeks with nothing to suggest acute or chronic blood loss. She was not troubled with recurrent infections but her mother described her as a "picky" eater who had sustained herself almost exclusively on cow's milk for one year. On examination she was severely anaemic with signs of marked congestive heart failure. Temperature was normal. There was no bruising, koilonychia or glossitis. Weight which was on the tenth centile at birth had dropped to the third centile and height was on the tenth centile. Chest radiography showed marked congestive heart failure, and an electrocardiograph demonstrated right ventricular strain. Prior to transfusion haemoglobin was 1.3 g/dl, MCV 56 fl, white cells 7.9 x 109/1, platelets 62 x 109/1. The blood film was consistent with iron deficiency anaemia with normal white cell morphology. Serum ferritin was 4.2 jig/litre, serum iron 1.3 jmol/litre, total iron-binding capacity 102.3 jimol/litre and the transferrin was 1.3% saturated. Other investigations were performed post transfusion. Serum B,2 folate, copper, zinc, urea, electrolytes, calcium, thyroid and liver function were normal. Anti-gliadin and anti-endomysial antibody screening was negative. Faecal occult bloods were negative and there was no haematuria. She was slowly transfused with semi-packed cells with diuretic cover for 48 hours. Her heart failure resolved and she was commenced on oral folate and iron. Three days after commencing her oral therapy haemoglobin had risen to 9.0 g/dl, MCV to 77 fl and platelets to 630 x 109/1 with a reticulocytosis of 5%. One week after transfusion, echocardiography revealed a small pericardial effusion but good ventricular function. Two months later haemoglobin was 12.6 g/dl and oral iron was stopped with no recurrence of anaemia. Repeat echocardiography showed only a rim of pericardial fluid anteriorly and good left ventricular function. Over the following six months her weight gradually increased from the third to the fiftieth centile and her height from the tenth to the twenty-fifth centile. DISCUSSION This child had been breast fed for six months. Her mother did not require extra iron during the pregnancy but had …