Transcription:
Hematology Dilemmas: Cases for the General Pediatrician

Melanie Cole (Host): Welcome to Pediatrics In Practice with Children's Mercy, Kansas City. I'm Melanie Cole and I invite you to listen as we discuss hematology dilemmas: cases for the general pediatrician. Joining me is Dr. Lauren Amos. She's an Assistant Professor of Pediatrics, Fellowship Associate Program Director in the Division of Hematology, Oncology, Bone Marrow Transplant at Children's Mercy, Kansas City. Dr. Amos, it's a pleasure to have you join us today. This is a great topic. Before we get into it, how did you become interested in the field of hematology, oncology and BMT? Tell us a little bit about your background.

Lauren Amos, MD (Guest): Yeah, thanks for having me today. So, when I was in medical school, you know, as a third year medical student and I was just rotating on the inpatient pediatric ward, and I started taking care of kids who had blood and cancer disorders. And I realized that I found it so interesting. I connected to the families and wanted to follow them in the hospital and outside the hospital. I felt like the abnormal labs was a puzzle that I could figure out and help these families through times that could be challenging or scary and fell in love with it.

Host: Thank you so much for that. So, tell us a little bit about hematology dilemmas for the general pediatrician. What would you like pediatricians to know right off the bat, as we get started, about testing, monitoring their patients? Discuss for us the most common dilemmas that you see from pediatric primary care.

Dr. Amos: So, I think the first thing that happens is primary care providers obtain a complete blood count with differential and it comes back with a lot of different values and that can be overwhelming as you are not used to looking at all these values every day and interpreting them. So, I would say the first thing to do is make sure that you're using age adjusted values. So, blood count normal values in kids are different than adults. And so when you're using a lab that's not necessarily affiliated with a children's hospital, you may see things that are flagged as abnormal, but they are probably normal for the child's age range. So, my first tip is always used an age adjusted lab reference range.

And the next thing is, is to use some tricks. So, when you're looking at a low blood count, such as a low hemoglobin, the first thing to do is use your MCV or the measure of that red blood cell size. That's going to help you know which road you're going to go down. Are those cells big, are they small? And really look at common things being common. So iron deficiency anemia, viral induced neutropenia, you know, start with the basics. That's where we start and most of the time that gets you an answer pretty quickly.

Host: This advice that you would share with a pediatrician whose patients, as you just described, received an abnormal value on a CBC screening or other blood test. If it's only a little low or if it's only a little off, tell us what you'd like them to know if they're struggling with these abnormal values and where they turn next.

Dr. Amos: Absolutely. So, I always say, if it's just slightly below the lower limit of normal or slightly above the lower limit of normal, that's probably nothing. And so instead of making a referral at that time to hematology, although we're always happy to be here and talk through it. The best thing to do if the child is doing great, growing great, healthy, not having infections, is just give it a little bit of time, repeat it in three months, see what it is. If it's still pretty close to normal, it's probably nothing to worry about. If it's changed significantly, then that's a great time to refer to us.

Host: So, then tell us what's important to note during evaluation and management. Suppose we're discussing iron deficiency anemia; what strategies or therapies can be put in place to work towards not only improving iron levels, but other CBC values that the primary care might have encountered.

Dr. Amos: So, the first thing I say is iron deficiency anemia is very, very treatable and can be treated by the primary care physician. And I think the first thing to know is that, make sure you're dealing with iron deficiency. So, you do a screening CBC at 12 months and your hemoglobin comes back low. I think it's a great idea at that time to make sure it looks like iron deficiency. So, you're going to have a low MCV. Those cells are going to be small. You can have an elevated RDW or red cell distribution width. Your platelets may be elevated as an acute phase reactant, so don't get concerned about that. And then I like to test a ferritin. So, your ferritin is really your most accurate way of assessing iron deficiency.

It's the stores of the body's iron and a low ferritin, in the setting of a microcytic anemia, that's a slam dunk for iron deficiency. If that comes back low, then start iron replacement and make sure you're doing the right dose. So, a lot of times I get referrals for kids who are not getting better and it's because they're not getting enough iron. So, you really need to do three to six milligrams per kilogram, per day of elemental iron. And you don't need to divide the dosing. So, we used to advocate for three times daily iron, or twice daily iron. And that's so challenging for parents and evidence really shows that the iron is absorbed best if you take it daily or every other day. Now, I don't really advocate for every other day because it's hard as a parent to remember that.

So, just do it once a day and make sure you're doing the right dose of elemental iron. And then the last tip I have is ferrous sulfate or generic oral iron tastes terrible. So, if the family is really struggling, they can't get the kid to take it, they've mixed it with chocolate syrup, applesauce, putting all the tricks, then really there's some newer formulations that tastes better. So, NovaFerrum is available at CVS or Amazon or local pharmacies and it's raspberry grape, and kids do much better with it. So, make sure that their iron deficiency anemia is not getting better because they're not actually taking it versus they are taking it and something else is going on.

Host: That's great advice. I wish I had heard when I was a parent trying to get their child to take iron. So, thank you for that. Now, what if there are side effects, what would you like the primary care provider, the pediatrician to know about dealing with those such as constipation. You already discussed, if they're refusing to take it, but what about some of the others?

Dr. Amos: Yeah, I really try to set up families for success. So, when I'm prescribing iron, I make sure that they know don't take it with dairy products within an hour of the dose, cause it's going to bind that iron. It's not going to help. Try to use orange juice or vitamin C containing products to help with absorption. And then if kids are having upset stomachs, make sure you take it with food. If they are dealing with constipation, I always ask like does your child have a constipation problem because you know, if it's already there, it's going to get worse. And if they don't, it may happen and then making sure, so fiber gummies are a great thing for picky kids. Using things like MiraLax or just really making sure they're having daily soft stools to prevent a significant problem with that iron.

Host: So, how would you like physicians to counsel their patients that are experiencing hematology related health concerns? What advice can they offer parents and tell them as suppose they're referring? How would you like them to counsel their patients?

Dr. Amos: So, I think, it can be scary to refer a patient to hematology oncology clinic, for sure. And, so I think as a referring provider, most of the referrals that I see as the hematologist have nothing to do with scary things like leukemia and cancer. So, really just reassuring families that most problems with blood counts are not going to be due to that. That common things are common. Iron deficiency anemia, neutropenia, things like that are very treatable. And they're in the right place and we're going to take care of it. And just really try to set them up to feel comfortable and less anxious about coming to see us.

Host: That's very great advice. As we wrap up, what would you like to tell physicians to remember when they come across a hematology dilemma? And what do you want them to know about when you feel it's important they refer?

Dr. Amos: So, I just want physicians to remember to use those tricks that help you determine what's going on. So, a low hemoglobin, look for things like your MCV, you know, help that decide. Get a red count. Is a bone marrow making those cells? Go down the path that kind of helps you point in the direction of what's going on. But I also want to emphasize that we're here. We're one phone call away as pediatric hematologists oncologists, and we know you don't deal with these patients every day. So, we are here to help and always willing to see patients and even just be able to counsel you over the phone about what are the next steps and does the kid need to come see us?

Host: Thank you so much, Dr. Amos. Really great and informative episode today. This has been Pediatrics In Practice with Children's Mercy, Kansas City. To refer your patient or for more information, you can visit children'smercy.org to get connected with one of our providers. Please also remember to subscribe, rate and review this podcast and all the other Children's Mercy podcasts. I'm Melanie Cole.