A 14-month-old boy who consumes more than one litre of cow milk daily is found to have Hb 7.8 g/dL, MCV 62 fL, RDW 17%, and normal WBC and platelets. Peripheral smear shows microcytic hypochromic cells with pencil cells. His diet history also notes poor intake of solids. What is the most likely finding on iron studies?

• A High ferritin with low TIBC
• B Low serum iron with high TIBC ✓
• C High serum iron with saturated transferrin
• D Normal serum iron with high ferritin

Explanation

Excessive cow milk intake beyond 500 ml per day causes both occult gastrointestinal blood loss from milk protein-induced enteropathy and displacement of iron-rich foods, making it a leading cause of iron deficiency anemia in Indian toddlers. Deficiency produces low serum iron, raised total iron-binding capacity, and low ferritin. High iron with saturated transferrin suggests sideroblastic anemia or hemochromatosis, and high ferritin with low TIBC fits anemia of inflammation. The elevated RDW and pencil cells further support iron deficiency over thalassemia trait, where RDW stays normal.

Reference: Nelson Textbook of Pediatrics, 21st ed.

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Written and medically reviewed by the StethoPrep medical team.