What is the most likely diagnosis for a 2-year-old girl with pallor, microcytic anemia, low hemoglobin (Hb) and ferritin levels, who consumes 3 glasses of cow's milk daily and has a limited diet, with a family history of similar presentations in her brothers?

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Iron Deficiency Anemia

The most likely diagnosis is iron deficiency anemia (Option C). This 2-year-old presents with the classic triad of severe microcytic anemia (MCV 62 fL, Hb 4 g/dL), low ferritin (9 μg/L), and clear dietary risk factors—excessive cow's milk intake (3 glasses daily) with meat avoidance—which directly causes iron deficiency through both reduced iron intake and gastrointestinal microbleeding from cow's milk protein. 1, 2, 3

Why Iron Deficiency Anemia is the Clear Diagnosis

Laboratory findings are pathognomonic for iron deficiency:

  • Ferritin 9 μg/L is definitively diagnostic, as serum ferritin <12 μg/dL confirms iron deficiency, and even in the presence of inflammation, ferritin <30 μg/L establishes the diagnosis. 1, 4
  • Severe microcytosis (MCV 62 fL) with hypochromia (MCH 18 pg/cell) indicates impaired hemoglobin synthesis from iron depletion. 2, 5
  • Elevated reticulocyte count (3%) reflects appropriate bone marrow response attempting to compensate for anemia, distinguishing this from bone marrow failure or chronic disease. 2
  • Reactive thrombocytosis (480 × 10⁹/L) commonly accompanies severe iron deficiency in children. 3

Dietary history confirms the mechanism:

  • Excessive cow's milk consumption (>24 ounces daily) is the most common cause of severe iron deficiency in toddlers, causing both reduced dietary iron intake and occult gastrointestinal blood loss from cow's milk protein-induced enteropathy. 3, 6
  • Meat refusal eliminates the primary source of bioavailable heme iron. 3
  • This dietary pattern is documented in nearly all children hospitalized with severe IDA. 6

Why Other Diagnoses Are Excluded

Sickle cell disease (Option A) is ruled out by:

  • Normal reticulocyte response rather than the marked reticulocytosis (>10%) expected in chronic hemolysis. 2
  • Absence of hemolytic features (no mention of jaundice, splenomegaly, or elevated indirect bilirubin). 2
  • Low ferritin excludes hemolytic anemia, which typically shows normal or elevated ferritin from chronic transfusions or hemolysis. 1

Alpha thalassemia trait (Option B) is excluded by:

  • Low ferritin definitively rules out thalassemia trait, as thalassemia presents with normal or elevated iron stores (ferritin typically >30 μg/L). 1, 7
  • While thalassemia trait causes microcytosis, it produces mild anemia (Hb typically 10-12 g/dL) with elevated RBC count, not the severe anemia (Hb 4 g/dL) and low RBC count (3 × 10¹²/L) seen here. 7
  • The family history of "similar presentation" likely reflects shared dietary patterns rather than genetic inheritance. 3, 6

Anemia of chronic disease (Option D) is excluded by:

  • **Low ferritin (<30 μg/L) excludes ACD**, which requires ferritin >100 μg/L or 30-100 μg/L with transferrin saturation <20% in the presence of inflammation. 4, 1
  • No clinical evidence of chronic inflammatory disease, infection, or malignancy. 4
  • ACD causes functional iron sequestration with elevated ferritin, not true iron depletion. 1, 8

Critical Clinical Pitfalls to Avoid

Do not assume family history indicates genetic disease:

  • Shared dietary patterns in siblings commonly cause similar presentations of nutritional iron deficiency, particularly in families with cultural preferences for high milk intake. 3, 6
  • Many children with severe IDA have parents with private insurance and stable employment, indicating this is not solely a socioeconomic issue but a knowledge gap about appropriate toddler nutrition. 6

Do not overlook the severity requiring urgent intervention:

  • Hemoglobin of 4 g/dL represents life-threatening anemia requiring immediate evaluation for transfusion and cardiac decompensation. 6
  • This degree of anemia can cause irreversible neurodevelopmental and cognitive deficits in toddlers if not promptly corrected. 3

Do not perform unnecessary genetic testing:

  • The low ferritin makes this diagnosis straightforward without requiring hemoglobin electrophoresis or genetic studies for thalassemia. 1, 7
  • Parallel screening for thalassemia is only indicated when ferritin is normal or elevated despite microcytic anemia. 7

References

Guideline

Microcytic Anemia Causes and Diagnosis

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

Research

Anemia in children.

American family physician, 2001

Research

Iron deficiency anemia in children.

Indian journal of pediatrics, 2015

Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

Research

[Microcytic and hypochromic anemias].

Vnitrni lekarstvi, 2001

Guideline

Causes et Évaluation de l'Anémie Normocytaire

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

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This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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