Approach To Anemia in Children

Approach to anemia in children
By Samson Nadew (MD)

OBJECTIVES
 Define anemia with respect to age

 Understand variations in RBC indices in
different age groups
 Know possible etiology & epidemiology of
anemia In children
 Have adequate knowledge for diagnosing
anemia in children
DEFINITION
 DEFINITION OF ANEMIA — Anemia may be defined as a reduction

in red blood cell mass or blood hemoglobin concentration. In practice,
anemia most commonly is defined by reductions in one or both of the
following:
Hematocrit (HCT) — The hematocrit is the fractional volume of a
whole blood sample occupied by red blood cells .it is expressed in %.
Hemoglobin (HGB) — This is a measure of the concentration of the
RBC pigment hemoglobin in whole blood, expressed as grams per 100
mL (dL) of whole blood.
The age variation for HGB and HCT is pronounced in the pediatric
population; thus, it is particularly important to use age and sex
adjusted norms when evaluating a pediatric patient for anemia (
show table 1)
Table 1-values of different ages & sex
age Hgb (lowest) Hct (lowest) MCV (fl)

gm/dl In% (Lowest)
Cord blood 13.7(14-20) 45(45-65) 110
2wks 13(13-20) 42(42-58)
3 months 9.5(10-15) 31(31-41)
6months- 10.5(11-14) 33(33-41) 70-74

6yrs
7-12yrs 11(11-15) 34(34-42) 76-80
Adult-female 12 37 80
male 14 42 80
Epidemiology
 51% of under 5yr children in developing co. are anemic

(different degrees)-WHO estimate
 Leading causes- iron deficiency anemia (IDA)
malaria
HIV/AIDS
folate deficiency
sickle cell disease (not in Ethiopia)
Classification of anemia:
1) Physiologic classification-based on causes
-decreased production
-increased destruction or RBC loss (bleeding)
2) morphologic classification-based on RBC size, hgb content
& hgb concentration i.e. MCV ,MCH ,MCHC
physiologic classification-etiologic
An evaluation of the reticulocyte count aids in defining the etiology of the

anemia. An increased reticulocyte count generally is seen as a normal
bone marrow response to ongoing hemolysis or nonchronic blood loss.
On the other hand, a low reticulocyte count, which reflects decreased
production of red blood cells, is more consistent with bone marrow
depression.
These two categories are not mutually exclusive, however, and
although patients generally have one major etiology for their
anemia, hemolysis or blood loss may co-exist with bone marrow
suppression.
Eg. Malaria-there is both BM suppression &

RBC destruction (hemolysis)
1)Decreased production
 Nutritional deficiency ,infection &chronic illnesses are

common causes.
 Causes :
IDA
folate & VB12 def.
Anemia of chronic illness
physiologic anemia of infancy
Aplastic /hypoplastic anemia-secondary to infections
eg .parvovirus B19 ,drugs ,radiation ,immune mediated etc.
congenital hypoplastic anemia (diamond-Blackfan anemia)
2) Increased destruction & blood loss
 Hemolytic anemias:
cellular- membrane defects eg.heriditary spherocytosis
- enzyme defects G6PD deficiency ,piruvate kinase def.
-hemoglobinopathies
sickle cell anemia, thalasemias etc
extra cellular -autoimmune hemolytic anemias
hemolytic Dx of the new born
drug induced etc
-fragment hemolysis – DIC ,hemolytic uremic
syndrome, TTP ,prosthetic heart valve ,
thermal injury
-hypersplenism
plasma factors -liver Dx ,abetalipoprotienemia
infections, toxins &venoms etc
blood loss-occult in persistent diarrhea, malabsorption
syndromes ; overt as in leech infestation
 Morphologic classification
microcytic normocytic macrocytic
IDA- chronic Chronic illness Megaloblastic
blood loss ,poor (2/3rd cases) -folate def.
dietary intake Malignancies -VB12 def.
Thalasemias Acute blood loss
Chronic illness
Non- megalobl
Transient
Sideroblastic erythroblastopeni -Fanconi anem
Lead poisoning a of childhood -Diamond-
Copper deficiency BM aplasa/hypop. blackfan anem
hypothyroidism -pre-leukemia
Approach to a patient
 New born:
HX-age at onset- at birth usu. Hemolytic Dx of the newborn
ask maternal & NB blood group, any fam hx of bleeding
difficult delivery, gestational age ,hx of jaundice
P/E- vital signs-apnea ,tachypnea ,tachycardia ,hypotension

-measure HC- subgalial hemorrhage ,cephalhematoma etc
-look for pallor , organomegaly ,edema , jaundice signs of internal
bleeding
-check for level of consciousness- intraventricular hemorrhage,
hypotension
 Infants and children:
Hx – hx of febrile illness, risk of malaria
-Hx of barefoot walking (hookworm infestation rate is 25%in
children under 5yr of age
-age at onset
anemia at 2-3 months o age- usu physiologic anemia
LBWt infants are at risk of IDA & folate def. early
peak age for folate def. 4-7 months
peak age for IDA 9-12 months
Thalasemias &sickle cell dx usu after the 3rd month of age
-nutritional hx
unmodified cows milk –IDA
Goat milk – deficient in folate (Afar &Somali region)
kwashiorkor- folate and other micronutrient def
-drug intake -penicillin, chloramphenicol ,sulfonamides,
anticonvulsant like phenytoin ,chemotherapy ,zidovudine etc
-Hx of jaundice –hemolytic disease
-Hx of blood loss
GI-hookworm infection, severe dysentery ,IBD ,PUD
diverticular dx ,hemorrhoids , leech infestation
GU - hematuria, schistosomiasis
-Hx of any bleeding tendency ,any swelling on the neck or
abdominal swelling ,bone pain arthralgia etc
may suggest possibility of malignancies like leukemia
,neuroblastoma etc
-Hx of pica
Physical examination
 General condition
acutely sick looking with anemia and fever
consider infectious causes like malaria ,sepsis etc
leukemia & neuroblastoma usually present with infection
increased RR, PR & hypotension –case could be acute blood loss due
to occult OR overt bleeding or severe infection
anthropometric assessment –nutritional def.
HEENT
frontal bossing –due to chronic hemolysis
silky or easily pluckable hair- HIV, malnutrition
eye –pallor ,icterus –indicate hemolysis, severe malaria or liver Dx
tongue & bucal mucosa-pallor
papillary atrophy in tongue -IDA
 LGS
thyroid-hypothyroidism
LN enlargement- TB, Leukemia ,HIV ,IMN ,lymphoma etc
parotid enlargement- HIV
CHEST &CVS
symptoms of heart failure
bounding pulse ,wide pulse pressure- found in anemia
weak pulse –acute blood loss
ABDOMEN
organomegally -HSM
in infants suggest- congenital infections (usually associated with
jaundice ,anemia & thrombocytopenia )
causes- toxo ,syphilis, CMV ,Rubella &parvovirusB19
splenomegaly -common in malaria
in infants & children
integumentary system:
petechiae & purpura – suggest cause of BM failure
bruising
MSS:
fracture- CHRONIC hemolysis ,malignancy etc
bone tenderness- leukemias also ass. with joint swelling
Laboratory features
HCT , Hgb
peripheral smear – morphology
-reticulocytes
-parasites
-blast cells
-platelets
-differential count
RBC indices MCV, MCH & MCHC
 CBC count & differential
 Reticulocyte count
 Hemosiderin in urine
 LDH
 Stool examination
ova or parasite
occult blood
Iron level
Transferin saturation
Free erythrocyte protoporphyrin
ferittin level
Bone marrow aspiration- cellularity, fibrosis
,malignant infiltration, storage diseases etc

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Approach to anemia in children

By Samson Nadew (MD)

 Define anemia with respect to age

 DEFINITION OF ANEMIA — Anemia may be defined as a reduction

age Hgb (lowest) Hct (lowest) MCV (fl)

2wks 13(13-20) 42(42-58)

3 months 9.5(10-15) 31(31-41)

6months- 10.5(11-14) 33(33-41) 70-74

 51% of under 5yr children in developing co. are anemic

An evaluation of the reticulocyte count aids in defining the etiology of the

Eg. Malaria-there is both BM suppression &

 Nutritional deficiency ,infection &chronic illnesses are

P/E- vital signs-apnea ,tachypnea ,tachycardia ,hypotension

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