Hoppt 20 Sept

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Child with anemia

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Introduction
 Anaemia is defined as an Hb level below the normal range. The normal range
varies with age:
 Neonate: Hb <14 g/dl
 1–12 months: Hb <10 g/dl
 1–12 years: Hb <11 g/dl.
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Causes of anemia
Reduced red cell Increased red

production
- ineffective erythropoiesis cell destruction
- red cell aplasia (haemolysis)
Blood loss
– relatively
uncommon cause in
children.
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Approach to child
with anemia
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History
 Presenting complaint  Past medical history

 Common - lethargy, tachycardia, and pallor  Previous FBC result, chronic underlying infectious or
inflammatory conditions, travel to/from areas of
 Symptoms of hemolysis − Changes in urine color,
endemic infection (eg, malaria, hepatitis, tuberculosis)
scleral icterus, or jaundice
 Drug and toxin exposure - including homeopathic or
 Bleeding symptoms - changes in stool color, blood in
herbal supplements especially in patients with
stools, and change in bowel habit, severe / chronic
underlying G6PD deficiency
epistaxis, menstrual history in adolescent girls
 Dietary history
 Family history
 Assess iron intake from type of diet, type of formula (if
 GI problems eg IBD, intestinal polyps, CRC, bleeding
iron fortified), and age of infant at the time of
problems eg von Willebrand disease, platelet disorders,
discontinuation of formula or breast milk
thalassaemia, hemophilia, family members have
undergone blood transfusions or splenectomy  amount and type of milk (if exclusively fed goat's milk
(inherited haemolytic anemia, thalassaemia) can develop anemia due to folate deficiency)
 Birth history  Developmental history

 history of jaundice and/or anemia in the newborn  Developmental delay can be associated with iron
period, result of newborn screening ie. G6PD deficiency, vitamin B12/folic acid deficiency
deficiency
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Physical examination
 Pallor (skin, oral mucosa, nail beds, conjunctiva)
 Tachycardia
 Tachypnoea
 Orthostatic hypotension
 Systolic ejection murmur

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Findings Possible aetiology
Skin
Petechiae, purpura Autoimmune haemolytic anemia with
thrombocytopenia
Jaundice Haemolytic anemia, hepatitis, aplastic anemia
Ulcers on lower extremities Sickle cell disease, thalassaemia
Lymphadenopathy Leukaemia, lymphoma, hepatitis
Facies
Frontal bossing, prominent maxillary bone Congenital haemolytic anemia, thalassaemia
major
Eyes
Cataract G6PD deficiency
Mouth
Glossitis, angular stomatitis Vitamin B12, folate deficiency
Hands
Spoon nails Iron deficiency
Abdomen
Splenomegaly Congenital haemolytic anemia, leukaemia,
lymphoma
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Investigations
 Preliminary investigations
 Hb
 HCT
 Red cell indices
 Blood film
 Reticulocyte count
 Confirmatory testing
 Haemolytic anemia - serum indirect bilirubin, lactate dehydrogenase, and haptoglobin
levels, G6PD screening
 IDA - serum ferritin, iron, and total iron binding capacity (TIBC)
 Nutritional deficiency - serum folate, B12
 Bone marrow failure - Bone marrow aspirate and/or biopsy
 Thalassaemia - Hb electrophoresis, DNA analysis
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FBC
 Hemoglobin and hematocrit — Normal ranges for  high MCHC (≥35 g/dL) - Hyperchromic anemia
HGB and hematocrit (HCT) vary substantially with
age  White blood count and platelet count
 Leukocytosis suggests an infectious etiology or an
 Mean corpuscular volume (MCV)
acute leukemia.
 low MCV (<70fl)- Microcytic anemia  Thrombocytosis is a common finding in iron
 normal MCV - Normocytic anemia deficiency/infection and other inflammatory
conditions, particularly Kawasaki disease.
 high MCV (>85fl) - Macrocytic anemia
 Leukopenia, neutropenia, and/or thrombocytopenia
may signify abnormal bone marrow function or
 Mean corpuscular hemoglobin concentration
increased peripheral destruction of blood cells
(MCHC)
 low MCHC (≤32 g/dL) - Hypochromic anemia
 Normal MCHC - Normochromic anemia
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Reticulocytes count
 Reticulocyte response — The reticulocyte count is especially helpful

in evaluating children with normocytic anemia
 High reticulocyte count (>3%) reflects an increased erythropoietic
response to blood loss or hemolysis. Common causes include: hemorrhage;
autoimmune hemolytic anemia; membranopathies (eg, hereditary
spherocytosis); enzymopathies (eg, glucose-6-phosphate dehydrogenase
[G6PD] deficiency); hemoglobinopathies (eg, sickle cell disease)
 Low or normal reticulocyte count (<3%) − reflects deficient production
of RBCs (ie, a reduced marrow response to the anemia). Common causes
include infections, lead poisoning, hypoplastic anemias, drugs (eg.
Cisplatin)
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Blood film
 RBC size –microcytosis or
macrocytosis.
 Central pallor – Increased central

pallor indicates hypochromic cells
(iron deficiency and thalassemia).
 Fragmented cells – indicating

haemolyic anemia
 Other features –Sickle cells,

Elliptocytes, Stomatocytes, Pencil
poikilocytes (iron deficiency
anemia or thalassemia) Target cells
(Thalassemia, liver disease, post-
splenectomy), etc…
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Iron deficiency anemia
 Laboratory findings  Maintain breastfeeding.

 Red cell indices : Low MCV, Low MCH values  Use iron fortified cereals.
 Low serum ferritin  Oral iron medication
 Give 6 mg/kg/day of elemental iron in 3
 Causes divided doses, continue for 6-8 weeks after
 Dietary deficiency haemoglobin level is restored to normal.
 Increased demand (growth)
 Syr FAC (Ferrous ammonium citrate): the
content of elemental iron per ml depends on
 Impaired absorption the preparation available.
 Blood loss (menstrual problems)  Tab. Ferrous fumarate 200 mg has 66 mg of
elemental iron per tablet
 Treatment  Blood transfusion
 Nutritional counseling  No transfusion required in chronic anaemia
unless signs of decompensation (e.g. cardiac
dysfunction) and the patient is otherwise
debilitated.
 In severe anaemia (Hb < 4 g/dL) give low
volume packed red cells (< 5mls/kg).
 If necessary over 4-6 hours with IV
Frusemide (1mg/kg) in between transfusion
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G6PD deficiency
 Inherited X-linked recessive disease  Persistent neonatal jaundice due to insufficient G6PD
activity in liver -> kernicterus
 Precipitating factors
 Intake of oxidant drugs
 Antibiotics
 Antimalarial
 Ingestion of fava beans
 Exposed to napthalene balls
 Investigations
 Newborn screening  Treatment
 G6PD assay  Jaundice – phototherapy, exchange transfusion
 Identification and avoidance of precipitating agent
 Presentation  Education
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Megaloblastic anemia
 Laboratory findings  Neurodevelopmental delay,

 Low Hb, high MCV irritability, numbness/tingling in
hands/feet, hypotonia
 Causes  Treatment
 Folic acid / vitamin B12 deficiency
 Vitamin B12 deficiency: 25-100ug
 GI disease eg. coeliac disease, lack vitamin B12
of intrinsic factor in gastric secretion
(pernicious anemia)
 Folate deficiency
 Correction of folate deficiency
 Malabsorption
(100-200ug/day)
 Infection
 Treat underlying causative
disorder
 Vitamin B12 deficiency
 Diet improvement
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References
 Paediatric Protocols for Malaysian Hospitals, 3rd Edition, 2012
 Lissauer, Tom.Clayden, Graham. (Eds.) (2007) Illustrated textbook of

paediatrics /Edinburgh ; Mosby/Elsevier,
 Flerlage J, Engorn B, eds. The Harriet Lane Handbook: A Manual for

Pediatric House Officers. 20th ed. Philadelphia, Pa.:
Saunder/Elsevier; 2015:305.
 Gallagher PG. The neonatal erythrocyte and its disorders. In: Nathan
and Oski's Hematology and Oncology of Infancy and Childhood, 8th
ed, Orkin SH, Fisher DE, Look T, Lux SE, Ginsburg D, Nathan DG
(Eds), WB Saunders, Philadelphia 2015. p.52.
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Child with anemia

Reduced red cell Increased red

 Presenting complaint  Past medical history

 Birth history  Developmental history

 Pallor (skin, oral mucosa, nail beds, conjunctiva)

 Systolic ejection murmur

Jaundice Haemolytic anemia, hepatitis, aplastic anemia

Ulcers on lower extremities Sickle cell disease, thalassaemia

Lymphadenopathy Leukaemia, lymphoma, hepatitis

 Reticulocyte response — The reticulocyte count is especially helpful

 Central pallor – Increased central

 Fragmented cells – indicating

 Other features –Sickle cells,

 Laboratory findings  Maintain breastfeeding.

 Laboratory findings  Neurodevelopmental delay,

 Paediatric Protocols for Malaysian Hospitals, 3rd Edition, 2012

 Lissauer, Tom.Clayden, Graham. (Eds.) (2007) Illustrated textbook of

 Flerlage J, Engorn B, eds. The Harriet Lane Handbook: A Manual for

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