Boston University School of Medicine, Boston, MA.
Division of Pediatric Hematology, Department of Pediatrics, Boston University School of Medicine, Boston, MA.
J Dev Behav Pediatr. 2020 Sep;41(7):583-585. doi: 10.1097/DBP.0000000000000831.
Late on a Friday afternoon, a new family presents to your practice for urgent care. They come with their youngest child Mai, a 2-year-old girl, who, although born in the United States at 36 weeks gestation, has resided in Laos with her grandparents for the past 16 months. Your triage nurse tells you that she has a fever and was found to have profound anemia while at the WIC (Special Supplemental Nutrition Program for Women, Infants, and Children) office earlier today.On walking into the room, you describe Mai as "listless" and "sickly." Her vitals were notable for fever (102°F), tachycardia (140 beats per minute), and tachypnea (35 breaths per minute). On physical examination, she was grunting with a systolic ejection murmur and without hepatosplenomegaly. Laboratory test results revealed hemoglobin of 2.2 g/dL, hematocrit of 12%, mean corpuscular volume of 50 fL, red cell distribution width of 27%, reticulocyte count of 3%, ferritin of <2 ng/mL, iron of 15 μg/dL, total iron binding count of 420 μg/dL, white blood cell count of 13.5 K/μL, and platelets of 605 K/μL. Her evaluation was consistent with severe iron deficiency anemia (IDA), which was further supported by reported restrictive diet and excessive cow milk intake of 35 ounces daily. She was admitted to the Pediatric Intensive Care Unit in high-output cardiac failure and was slowly transfused with 15 mL/kg of packed red blood cells over 2 days with careful monitoring. Once stabilized, she was transferred to the inpatient floor for further nutritional evaluation and supplementation. Additional workup, including hemoglobin electrophoresis, fecal occult blood test, celiac studies, and stool parasite testing were normal. The clinical picture was consistent with a viral infection in the setting of profound IDA and malnutrition.Although her clinical status had improved, she remained inpatient for nutritional optimization. Her height was at the 54th percentile (z-score: 0.11), weight was at the first percentile (z-score: -2.25), and body mass index was below the first percentile (z-score: -3.18), diagnostic of severe protein-calorie malnutrition. She was evaluated by an interdisciplinary growth and nutrition team, received multivitamin and mineral supplements, and was monitored for refeeding syndrome. She was noted to be "difficult to engage," "resistant to new faces," and made little progress on expanding her dietary choices. Concerns about a possible diagnosis of autism spectrum disorder were raised by her treating team. What would you do next?
一个周五的下午晚些时候，一个新家庭来到你的诊所寻求紧急护理。他们带着他们的小女儿 Mai 来，Mai 是一个 2 岁的女孩，尽管她在美国 36 周时出生，但过去 16 个月一直和她的爷爷奶奶住在老挝。你的分诊护士告诉你，她发烧了，今天早些时候在 WIC（妇女、婴儿和儿童特别补充营养计划）办公室发现她患有严重贫血。当你走进房间时，你形容 Mai 是“无精打采”和“病态”的。她的生命体征明显发热（102°F）、心动过速（140 次/分钟）和呼吸急促（35 次/分钟）。体格检查时，她有咕噜声和收缩期喷射性杂音，无肝脾肿大。实验室检查结果显示血红蛋白 2.2 g/dL，血细胞比容 12%，平均红细胞体积 50 fL，红细胞分布宽度 27%，网织红细胞计数 3%，铁蛋白<2ng/mL，铁 15μg/dL，总铁结合计数 420μg/dL，白细胞计数 13.5 K/μL，血小板 605 K/μL。她的评估结果与严重缺铁性贫血（IDA）一致，这进一步得到了她报告的限制饮食和每天过量饮用 35 盎司牛奶的支持。她因高心输出量心力衰竭被收入儿科重症监护病房，并在 2 天内缓慢输注 15 mL/kg 的浓缩红细胞，同时进行仔细监测。一旦稳定下来，她就被转到住院病房进行进一步的营养评估和补充。进一步的检查，包括血红蛋白电泳、粪便潜血试验、乳糜泻研究和粪便寄生虫检查均正常。临床表现与严重 IDA 和营养不良相关的病毒感染一致。尽管她的临床状况有所改善，但她仍因营养优化而住院。她的身高处于第 54 百分位（z 分数：0.11），体重处于第 1 百分位（z 分数：-2.25），体重指数低于第 1 百分位（z 分数：-3.18），诊断为严重蛋白质-热量营养不良。她由一个跨学科的生长和营养团队进行了评估，接受了多种维生素和矿物质补充剂，并监测了再喂养综合征。她被描述为“难以参与”、“对新面孔有抵触”，并且在扩大饮食选择方面没有取得什么进展。她的治疗团队提出了可能患有自闭症谱系障碍的担忧。你下一步会怎么做？
