9m and screening for anemia CC case of the week #3 A new 9 month old Hispanic female presents to clinic for

a well visit. She has relocated from California with her family; both of her parents were born in Mexico, and she has an older brother who was also born in California. She was exclusively breastfed until 4 months when her mother introduced rice cereal, vegetables and soup. Her current diet includes nursing 4 times per day and 4 meals of table foods or Gerber including fruits, vegetables and meats. Her family lives in an apartment building that was built in 1995. Her favorite toy is one of her mothers toys from childhood. She is growing well and her developmental surveillance in normal. She naps twice daily for 60-90 minutes per nap. Her mother has a concern about recent awakening in the middle of the night and has begun to nurse her again between 1 and 3 am.

R1: What are priorities to discuss at the 9 month well-child check? Should more formal developmental testing occur? Which of the following are her risk factors for iron deficiency? a. b. c. d. Breastfeeding exclusively for 4 months Living in a home built in 1995 Playing with toys that could contain lead Being of Mexican-American decent

R2/R3: You decide to perform a hemoglobin and it is 10.1. What is your next course of action? a. Perform a CBC only b. Start an iron supplement and perform further lab testing c. Start a multivitamin with iron and plan for lab testing at the next visit d. Discuss adding more iron rich foods in the diet and plan for follow-up at 12 months How would you counsel the mother on the sleep changes and nighttime feeds? a. When babies eat more solid foods sometimes they need an extra feed in the middle of the night because solids for babies dont have as much fat as breast milk b. Most 9 month olds are teething and a nightly dose of acetaminophen will help with sleeping through the night c. 9 month olds need parental reassurance so wakening in the middle of the night can be developmentally appropriate; feeding is not necessary d. The infant is napping too much during the day and one nap should be eliminated.

R1: What are priorities to discuss at the 9 month well-child check?

Should more formal developmental testing occur? The AAP recommends a structured developmental screen at the 9m, 18m and 24m(or30m) visit. Examples of these are the PEDS (parents evaluation of development), the ASQ (ages and stages questionnaire) or the Denver II. Which of the following are her risk factors for iron deficiency? a. b. c. d. Breastfeeding exclusively for 4 months Living in a home built in 1995 Playing with toys that could contain lead Being of Mexican-American decent

R2/R3: You decide to perform a hemoglobin and it is 10.1. What is your next course of action? a. Perform a CBC only b. Start an iron supplement and perform further lab testing c. Start a multivitamin with iron and plan for lab testing at the next visit d. Discuss adding more iron rich foods in the diet and plan for follow-up at 12 months

Some might argue to only start a supplement and closely monitor the patient to demonstrate an increase in hgb on the supplement. However, since this is a new patient with risk factors, it is more appropriate to start a supplement and look for further evidence of iron deficiency.

How would you counsel the mother on the sleep changes and nighttime feeds? a. b. c. d. When babies eat more solid foods sometimes they need an extra feed in the middle of the night because solids for babies dont have as much fat as breast milk Most 9 month olds are teething and a nightly dose of acetaminophen will help with sleeping through the night 9 month olds need parental reassurance so wakening in the middle of the night can be developmentally appropriate; feeding is not necessary The infant is napping too much during the day and one nap should be eliminated.