Blood loss, an important cause of iron-deficiency anemia, may be due to prenatal, intranatal, or postnatal causes (see Chapter 2, Table 2-1). Hemorrhage occurring later in infancy and childhood may be either occult or apparent (Table 3-1).
Iron deficiency by itself, irrespective of its cause, may result in occult blood loss from the gut. More than 50% of iron-deficient infants have guaiac-positive stools. This blood loss is due to the effects of iron deficiency on the mucosal lining (e.g., deficiency of iron-containing enzymes in the gut), leading to mucosal blood loss. This sets up a vicious cycle in which iron deficiency results in mucosal change, which leads to blood loss and further aggravates the anemia. The bleeding due to iron deficiency is corrected with iron treatment. In addition to iron deficiency per se causing blood loss, it may also induce an enteropathy, or leaky gut syndrome. In this condition, a number of blood constituents, in addition to red cells, are lost in the gut (Table 3-4).
Cow's milk can result in an exudative enteropathy associated with chronic gastrointestinal (GI) blood loss resulting in iron deficiency. Whole cow's milk should be considered the cause of iron-deficiency anemia under the following clinical circumstances:
1. One quart or more of whole cow's milk consumed per day
2. Iron deficiency accompanied by hypoproteinemia (with or without edema) and hypocupremia (Dietary iron-deficiency anemia unassociated with exudative enteropathy is usually associated with an elevated serum copper level). It is also associated with hypocalcemia, hypotransferrinemia, and low serum immunoglob-ulins due to the leakage of these substances from the gut.
3. Iron-deficiency anemia unexplained by low birth weight, poor iron intake, or excessively rapid growth
4. Iron-deficiency anemia that recurs after a satisfactory hematologic response following iron therapy
5. Rapidly developing or severe iron-deficiency anemia
6. Suboptimal response to oral iron in iron-deficiency anemia
7. Consistently guaiac-positive stool tests in the absence of gross bleeding and other evidence of organic lesions in the gut
8. Return of GI function and prompt correction of anemia on cessation of cow's milk and substitution by formula.
Blood loss can thus occur as a result of gut involvement due to primary iron-deficiency anemia (Table 3-4) or secondary iron-deficiency anemia as a result of gut abnormalities induced by hypersensitivity to cow's milk, or as a result of demonstrable anatomic lesions of the bowel, for example, Meckel's diverticulum.
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