Severe Anemia in 3 Toddlers with Gastric Lactobezoar

Abstract

Backround:

Anemia in toddlers may result from many disorders including excessive feeding with cow’s milk. Another sequel of age-inadequate cow’s milk nutrition may be gastric lactobezoar (GLB), a dense lump of coagulated milk and mucus in the stomach.

Patients:

3 toddlers presented with a history of excessive intake of full cream cow’s milk, abdominal distension, vomiting, dehydration, fatigue, marked pallor and tachycardia.

Diagnostic workup:

Diagnostic imaging revea­led large GLBs as the likely origin of the abdominal symptoms. Laboratory evaluation showed severe anemia with depleted iron stores and signs of protein catabolism. Non-cow’s milk-induced causes of anemia including defects of erythropoiesis, hemoglobin structure, RBC-enzymes and blood coagulation, hemolysis, immune disorders, infection, inflammation, extraintestinal hemorrhage, nephropathy were – according to the available data – unlikely to cause the anemia in our patients. Thus their anemia is thought to be due to age-inadequate cow’s milk nutrition leading to 1) low intake, decreased absorption/bioavailability and increased intestinal loss of iron, and 2) GLB which induced blood loss following mechanical irritation of the gastric mucosa and vomiting causing high gastric pH and decrease in duodenal iron absorption

Conclusion:

The anemia in our patients is due to both exaggerated feeding with cow’s milk and adverse effects of GLBs. This hypothesis is supported by the finding that, after erythrocyte transfusion, iron substitution, age-adapted nutrition and GLB-dissolution, the anemia did not recur. We propose to include GLB in the differential diagnosis of anemia in cow’s milk fed small children.

Zusammenfassung

Hintergrund:

Anämie bei Kleinkindern wird durch viele Erkrankungen und exzessive Kuhmilchernährung verursacht. Eine andere Folge altersinadäquater Kuhmilchgabe sind Magenlaktobezoare (MLBs), dichte Milch/Schleim-Koagulate im Magenlumen.

Patienten:

Wir beschreiben 3 exzessiv mit unverdünnter Kuhmilch ernährte Kleinkinder mit Bauchdeckenspannung, Erbrechen, Dehydrierung, Müdigkeit, Blässe und Tachykardie.

Diagnostik:

Die Bildgebung zeigte große MLBs als wahrscheinliche Ursache der abdominellen Symptomatik. Im Labor fanden sich schwere Anämien mit depletierten Eisenspeichern und Zeichen von Proteinkatabolismus. Nicht durch Kuhmilch verursachte Anämieformen wie Defekte von Erythropoese, Hämoglobinstruktur, Erythrozytenenzymen und Blutgerinnung, Hämolyse, Immunstörungen, Infektion, Entzündung, extraintestinale Blutungen und Nephropathien waren – entsprechend den vorhandenen Daten – bei unseren Patienten unwahrscheinlich. Ihre Anämien werden daher auf altersinadequate Kuhmilchernährung zurückgeführt, die 1) verminderte Zufuhr, Absorption/Bioverfügbarkeit und erhöhten intestinalen Verlust von Eisen nach sich zog, und 2) zur Entstehung von MLBs beitrug, welche durch Irritation der Magenschleimhaut Blutverluste und durch Erbrechen und erhöhten Magen-pH verminderte duodenale Eisenresorption verursachte.

Schlussfolgerung:

Die Anämie unserer Pati­enten wurde durch exzessive Kuhmilchgabe und MLB-Auswirkungen verursacht. Diese Hypothese wird dadurch unterstützt, dass nach Erythrozytentransfusion, Eisengabe, altersentsprechender Ernährung und MLB-Auflösung keine Anämie mehr auftrat. Wir schlagen vor MLBs in die Differenzialdiagnose von Anämien bei Kuhmilch-ernährten kleinen Kindern aufzunehmen.

Key words

anemia - gastric lactobezoar - cow’s milk - toddlers

Schlüsselwörter

Anämie - Magenlaktobezoar - Kuhmilch - Kleinkinder

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