A 2-year-old girl is brought to the clinic with pallor and microcytic anemia (Hb 8.2 g/dL, MCV 62 fL). Dietary history reveals that she drinks 1,200 mL (over 40 ounces) of cow's milk daily and refuses solid foods. What is the underlying mechanism of her anemia?

Answer and explanation

Correct answer: A. Iron deficiency anemia due to excessive cow's milk consumption

  1. Step 1: Excessive intake of whole cow's milk (> 500 mL/day) in toddlers causes iron deficiency through three mechanisms: cow's milk is low in iron, calcium and casein inhibit iron absorption, and microscopic occult intestinal blood loss occurs from bovine protein-induced enteropathy.
  2. Step 2: This results in microcytic, hypochromic anemia with low ferritin and high RDW.
Answer
Iron deficiency anemia due to excessive cow's milk consumption.
Why not the others: 'Beta-thalassemia major' presents in early infancy with severe transfusion-dependent anemia and hepatosplenomegaly; 'Lead toxicity' may coexist with iron deficiency but is not the primary nutritional etiology; 'G6PD deficiency' causes episodic acute hemolysis following oxidant triggers.

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