A 21-month-old girl was brought by ambulance to the emergency department in a collapsed state. She was very pale. Her pulse was 120 bpm and she was apyrexial. It was noted that she was unkempt. She had an infestation of head lice with matted hair (Image 12) and an excoriated scalp and an eczematous rash around her hairline at the nape of her neck and down her back between her shoulder blades. Investigations revealed haemoglobin of 2.9 g/dL with an iron deficiency picture. There were no other significant abnormalities on examination or investigation. She and her 4-year-old sister were primarily looked after by their father as their mother worked full time. https://s3-euw1-ap-pe-df-pch-content-public-u.s3.eu-west-1.amazonaws.com/9780429170423/236ca68c-f283-4df8-88b2-3b8ff49bccc9/content/fig12.jpg" xmlns:xlink="https://www.w3.org/1999/xlink"/>

What are the possible causes of her profound anaemia?

How would you manage the case?

Iron deficiency is a well-recognized cause of childhood anaemia. It can be due to blood loss, especially from the gut, but in early childhood, nutritional causes are more common, especially between the ages of 1 and 3 years. Around these ages, iron-fortified infant formulae and cereals are replaced by cow’s milk and family foods. Often cow’s milk intake is excessive at over 2 pints per day.

In addition, this child had a prolonged infestation of untreated head lice. These feed on the blood of their host. Although each individual louse ingests only a minute amount of blood each day, the accumulated effect in a patient with iron deficient anaemia can be particularly profound, was true for this patient. 1 , 2

The patient was given a blood transfusion and then treated for the head lice infestation, a particularly difficult task due to the matted hair and excoriated scalp. She was also started on a balanced diet with iron supplements. The child’s parents knew that she had head lice and failed to treat them and had also failed to give her a balanced diet rich in iron. A child protection investigation was initiated into the neglect of the child and her sister and they were placed together in foster care. Their parents accepted instruction into appropriate parenting and with support and supervision regained the care of their daughters.