A 12-month-old infant fed goat's milk and vegetarian diet is pale with a beefy-red tongue. Which tests should be ordered to evaluate this condition?

A 12-month-old infant fed goat's milk and vegetarian diet is pale with a beefy-red tongue. Which tests should be ordered to evaluate this condition?

• A. Reticulocyte levels
• B. RBC folate, iron, and B12 levels
• C. Serum lead levels
• D. Hemoglobin electrophoresis

Answer: (B)

Pale appearance with a beefy-red tongue points to nutritional anemia, especially in a 12-month-old whose diet relies on goat’s milk and vegetarian sources. The beefy tongue (glossitis) is a classic sign of megaloblastic anemia from folate or vitamin B12 deficiency, and the goat’s milk/vegetarian pattern raises concern for concurrent iron deficiency, since goat’s milk is low in iron and plant-based diets can be low in readily absorbable iron. To evaluate this presentation, test RBC folate to assess folate stores, B12 levels to detect cobalamin deficiency, and iron studies to evaluate iron status (such as ferritin, serum iron, and transferrin saturation). RBC folate is especially informative about long-term folate status in erythroid cells, while ferritin reflects iron stores; together they help distinguish iron deficiency from folate or B12 deficiency or a combination of deficiencies. Reticulocyte count can indicate whether the marrow is mounting a response, but it doesn’t identify which nutrient is deficient. Lead level is not indicated by this presentation, and hemoglobin electrophoresis is used for hemoglobinopathies rather than nutritional deficiencies.

Pale appearance with a beefy-red tongue points to nutritional anemia, especially in a 12-month-old whose diet relies on goat’s milk and vegetarian sources. The beefy tongue (glossitis) is a classic sign of megaloblastic anemia from folate or vitamin B12 deficiency, and the goat’s milk/vegetarian pattern raises concern for concurrent iron deficiency, since goat’s milk is low in iron and plant-based diets can be low in readily absorbable iron.

To evaluate this presentation, test RBC folate to assess folate stores, B12 levels to detect cobalamin deficiency, and iron studies to evaluate iron status (such as ferritin, serum iron, and transferrin saturation). RBC folate is especially informative about long-term folate status in erythroid cells, while ferritin reflects iron stores; together they help distinguish iron deficiency from folate or B12 deficiency or a combination of deficiencies.

Reticulocyte count can indicate whether the marrow is mounting a response, but it doesn’t identify which nutrient is deficient. Lead level is not indicated by this presentation, and hemoglobin electrophoresis is used for hemoglobinopathies rather than nutritional deficiencies.