A two-and-a-half-year-old breastfed toddler presenting with anemia: a case report

BACKGROUND: Anemia is a common presentation in children but the differential diagnosis of iron deficiency and β-thalassemia remains a diagnostic challenge. Red blood cell indices have been shown to perform weakly in such scenarios. One potential cause is breastfeeding, but the evidence for unusually prolonged exclusive breastfeeding as a cause of iron deficiency anemia in older (>2 years) toddlers is sparse and the association of breastfeeding with iron deficiency in this age group of older toddlers is not unequivocally established. In this case we describe an unusual cause of nutritional iron deficiency anemia in the age group of 2–3 years. CASE PRESENTATION: We describe a two-and-a-half-year-old Turkish boy who presented to our outpatient clinic with recurrent diarrhea and anemia. The patient was febrile (99.1°F) with pale skin and signs of mild dehydration. A reduced nutritional status with a weight of 11.5 kg between the 3rd and 10th percentile was noted. Nutritional evaluation revealed that the boy was still exclusively breastfed with more than 6 times breastfeedings per day. Iron supplementation ameliorated the anemia and reduced hypochromic red blood cells. CONCLUSION: The case demonstrates that unusually prolonged (longer than two years) exclusive breastfeeding is a potential cause of iron deficiency anemia in older toddlers. We discuss a simple combination of laboratory tests with ferritin and red cell distribution width that together with a nutritional evaluation provide a quick diagnosis and show that even at such an advanced stage of nutritional iron deficiency oral iron supplementation is an effective treatment.