What is the appropriate management for a 2-year-old patient with severe anemia, likely caused by a parasitic infection, presenting with diarrhea, vomiting, and a history of worm passage?

Management of Severe Anemia with Parasitic Infection in a 2-Year-Old

This child requires immediate blood transfusion followed by antiparasitic treatment and oral iron supplementation. The hemoglobin of 6.9 g/dL with microcytic anemia (decreased MCV/MCH), history of worm passage, and acute gastrointestinal symptoms indicates severe iron deficiency anemia likely from chronic parasitic blood loss, now complicated by acute illness.

Immediate Management: Blood Transfusion

Blood transfusion is indicated when hemoglobin is less than 6 g/dL, or less than 10 g/dL (100 g/L) in the presence of symptoms such as respiratory distress, tachycardia, or signs of heart failure. 1 This child's hemoglobin of 6.9 g/dL with pallor and acute illness warrants transfusion. 1

• Transfuse packed red blood cells to achieve hemoglobin >10 g/dL, as this threshold is recommended for symptomatic children with severe anemia 1
• Monitor for fluid overload during transfusion, though this is less common in parasitic anemia than in sepsis 1
• Transfuse only the minimum units needed for symptom resolution, as this is the safest approach 2

Antiparasitic Treatment

Empiric antiparasitic therapy should be initiated immediately based on the history of worm passage and endemic patterns.

• For presumed intestinal helminth infection (most likely Ascaris lumbricoides or Trichuris trichiura given the age and presentation), treat with albendazole or mebendazole 1
• Praziquantel 40 mg/kg as a single dose should be considered if schistosomiasis is endemic in the region, as this causes chronic intestinal bleeding and iron deficiency anemia 1
• Stool microscopy should be performed to identify specific parasites, though treatment should not be delayed pending results 1

Iron Supplementation

Oral iron therapy is the first-line treatment and should be started immediately after transfusion. 3

• Prescribe elemental iron 3-6 mg/kg/day using ferrous sulfate, ferrous fumarate, or ferrous gluconate 1, 3
• For a 2-year-old (approximately 12 kg), this translates to 36-72 mg elemental iron daily 3
• Continue iron supplementation for at least 3 months after hemoglobin normalizes to replenish iron stores 1, 4
• Iron is better absorbed on an empty stomach, but may be given with food if gastrointestinal side effects occur 1

Supportive Care for Acute Illness

Address the acute diarrhea and vomiting to prevent further deterioration.

• Provide intravenous hydration with 5% dextrose in 1/2 normal saline to prevent hypoglycemia and maintain perfusion 1
• Monitor blood glucose, as hypoglycemia can complicate severe anemia and acute illness 1
• Monitor electrolytes (potassium, phosphate, magnesium) and correct abnormalities 1
• Consider empiric broad-spectrum antibiotics (such as ceftriaxone 100 mg/kg/day) if secondary bacterial infection is suspected, particularly if there is leukocytosis or signs of sepsis 1, 5

Monitoring and Follow-up

Serial monitoring is essential to assess response to treatment and detect complications.

• Check hemoglobin weekly until stable, then monthly until iron stores are replenished 1
• Repeat stool examination after treatment to confirm parasite clearance 1
• Monitor for signs of heart failure during the acute phase, including dyspnea, enlarging liver, and gallop rhythm 1
• Assess for improvement in microcytic indices (MCV, MCH) over 2-3 months as iron stores replenish 1

Critical Pitfalls to Avoid

• Do not delay transfusion in a child with hemoglobin <7 g/dL who is symptomatic (pale, with acute illness), as this increases morbidity risk 1
• Do not rely on iron supplementation alone to correct severe anemia—transfusion is needed first for immediate correction 1
• Do not assume anemia will resolve with antiparasitic treatment alone—iron deficiency from chronic blood loss requires iron replacement even after parasite eradication 1, 6
• Do not use parenteral iron as first-line therapy in children; oral iron is effective and safer 3
• Do not stop iron supplementation when hemoglobin normalizes—continue for 3 months to replenish stores 1, 4

Long-term Prevention

• Provide nutritional counseling to increase dietary iron intake from bioavailable sources 6
• Implement regular deworming programs in endemic areas 7
• Improve hygiene, water, and sanitation to prevent reinfection 6
• Consider screening siblings and household contacts for parasitic infections 7