Pediatric Primary Care Case Studies (79 page)

   Discontinue baby bottle.

   Encourage iron-fortified foods and meats.

   Discontinue the use of Maltsupex and encourage juices to help ease constipation, especially nectars, prune juice, and apple juice.

   Increase caloric intake.

   Provide telephone follow-up in several days, not longer than 1 week, to determine how the family is doing with all the changes.

   Dental care: Iron may discolor teeth, but regular dental brushing and wiping teeth clean after administration of iron preparation will minimize this. This discoloration is temporary.

   Developmental assessment today, repeat in month, continue to monitor.

   Return to clinic in 2 weeks for repeat CBC and reticulocyte count.

   Provide telephone follow-up in several days, not longer than 1 week, to determine how the family is doing with all the changes.

With your written instructions, Oswaldo’s mother seems to understand what will happen and how to manage his care at this point. She is happy to know that help is coming for his condition.

What long-term follow-up should be planned for Oswaldo?

Long-Term Follow-up

Oswaldo should be followed closely for several months to ensure that his problems with anemia and lead poisoning are fully treated. Developmental assessments will be monitored regularly to determine if there has been a significant impact affecting Oswaldo’s development. The primary care provider needs to contact the agencies that investigate toxic environments (Department of Public Health, Environmental Protection Agency, local Visiting Nurse Association, or other agencies) in order to ensure the environment is once again conducive for the health of children such as Oswaldo.

The follow-up reports indicate that Oswaldo’s family now has been moved to one of the newer facilities at the orchard. There is no evidence of mice or lead. There is a functioning smoke detector. Mr. Garcia now showers at work and changes clothes before coming home, a change that the employer now encourages for all workers. The response from the employer has been very positive and several more safety measures have been instituted for these employees. The siblings have been screened but do not have toxic levels of organophosphates in their systems.

What information about the implications of IDA, even after treatment, could you give the concerned parents?

There can be cognitive developmental implications, especially regarding reading scores and behavioral manifestations. The brain is undergoing significant development during the first 2 years of life. Lack of proper nutrition (oxygenation) results in irreparable damage and lost developmental opportunities. Oswaldo will need to be followed to help him maximize his development with early intervention programs.

For a toddler with an uncomplicated CBC indicative of a microcytic, hypochromic anemia, what further appropriate diagnostic process should you consider?