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I actually concur with you that routine CBC's to screen for anemia in the
acute care setting is worthless. However, you have missed the original point
of discussion, initiated by our colleague down under. If and I repeat iff,
one obtains a CBC as part of the work up of an unrelated acute illness (NOT
as a screen for anemia) in the ED and one detects microcytic anemia what
should be the course of action? I believe this was the original question.

It is indeed true that acute infection can lower hemoglobin levels and this
does not reflect baseline hemoglobinopathy. However, I still maintain my
position, that in an effort to sort this out the MCV is helpful. If their
MCV is normal and they have a mild anemia in the setting of an acute
infection I would ignore it. Most acute changes in hemoglobin due to
infection do not affect the MCV. In the face of microcytosis the possibility
of REAL chronic iron deficiency exists.

The prevalence of IDA in the developed world is a meaningless statistic when
I have a CBC obtained on a febrile infant with, for argument sake, the
following numbers: MCV of 68 & a Hgb of 9.5 and a Menstzer index of 17. This
patient is more likely to have chronic IDA as an underlying co-morbidity as
opposed to a heterozygous variant of thalassemia, which is a common benign
cause of low MCV in our African-American population.

As Dr. Forbes has mentioned, the consequences for these children with
IDA are not be taken lightly. Cognitive impairment is one of them.
There is also the association of behavioral disturbances like temper
tantrums with IDA. Also, in our inner city population lead poisoning is
still
a problem. IDA causes increased lead absorption. Lead poisoning can also
lead to microcytic anemia by impairing iron bioavailability.

I strongly believe, that these children with incidental detection of
microcytic anemia, deserve a follow up and another screening hemogram, when
the acute illness has resolved, to assess their iron and lead status managed
appropriately.

It appears to me that, based on your line of thinking, the aforementioned
infant be discharged without the anemia being addressed. If so, I beg to
differ.

Jay Pershad
Pediatric Emergency Specialists, PC

---- Original Message -----
Where is the evidence that isolated microcytosis or a Menstzer index
greater than 13 in the face of an acute infection needs follow-up? A CBC
should
never be done in the ER for precisely this reason.You are advocating using a
screening test with poor sensitivity and specificity (in the acute care
setting), to attempt to capture illnesses with very low prevalence (in the
developed world). This a recipe for
chasing one's tale.
See:
Dallman PR et al. Changing characteristics of childhood anemia. J Pediatr
1989;114:161-164.

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