1. Pediatric Nutrition Symposium February 12, 2015 Chan Centre, Vancouver and via Telehealth Milk Baby and Anemia

2. 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 – 50 th percentile) Length: 87 cm (50 – 85 th percentile) Weight for Length: 15 th percentile

4. Usual Intake Breakfast1 cup homogenized milk in a bottle ¼ cup cheerios ½ banana Morning Snack1 cup milk 2 baby cookies ¼ cup sliced grapes Lunch½ cup milk ¼ pita bread with 1 tablespoon hummus ½ hardboiled egg Afternoon Snack1 cup milk ¼ cup fish crackers Dinner½ cup milk ¼ cup mashed potatoes with gravy ¼ cup strawberry slices ½ cup apple juice Bedtime1 cup milk, 2 graham crackers Middle of the Night1 cup milk

5. Labs LabResult Normal Range Hemoglobin (Hgb) 106 g/L105 - 135 Mean Corpuscular Volume (MCV) 65.4 fl75 - 87 Iron3 µmol/L3.7 – 5.3 Ferritin3 µg/L12 - 66

6. 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

7. 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

8. 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.

9. 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

10. 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 AgeRDA (mg/d) 0 – 6 months0.27 (AI) 7 – 12 months11 1 – 3 years7 4 – 8 years10 9 – 13 years8 14 – 18 years11 (male) 15 (female

12. Nutrition Monitoring and Evaluation 1.Growth 2.Intake – milk and solids 3.Age appropriate feeding 4.Labs - CBC, and iron studies in 2 months.

13. 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