ANEMIA IN CHILDHOOD

1. ANEMIA IN CHILDHOOD Presented by Ruth Anne Herring, RN, MSN, CPNP Pediatric Nurse Practitioner Texas Children�s Cancer Center

2. Overview Classifications of anemia Investigative tools Blood smear components case studies iron deficiency anemia lead poisoning

3. Classification of Anemia Blood loss Impaired red cell formation Hemolytic anemia

4. Classification of Anemia Impaired red cell formation deficiency bone marrow failure dyshematopoietic anemia

5. Classification of Anemia Hemolytic Anemia corpuscular membrane defects enzyme defects hemoglobin defects extracorpuscular immune isoimmune autoimmune idiopathic

6. Approach to Diagnosis of Anemia detailed history careful physical examination peripheral blood smear red cell morphology MCV RDW WBC and platelet morphology bone marrow evaluation additional testing

7. History diet family history environmental exposures symptoms (headache, exertion dyspnea, fatigue, dizziness, weakness, mood or sleep disturbances, tinnitis)

8. Physical Examination pallor jaundice tachycardia tachypnea orthostatic hypotension venous hum systolic ejection murmur t peripheral edema splenomegaly glossitis gingival pigmentation

9. Peripheral Blood Components RBC Hgb HCT MCV - a calculated value MCH RDW Reticulocyte Count

10. Red Cell Morphology anisocytosis poikilocytosis elliptocytes Howell-Jolly bodies Cabot�s rings Heinz bodies Sickled cells Spiculated/Crenulated red cells Target cells Basophilic stippling

11. Using MCV to Characterize Anemia Hypochromic Microcytic Iron deficiency anemia Thalassemia Sideroblastic anemia Chronic infection Lead poisoning Hemoglobin E trait Inborn errors of iron metabolism Copper deficiency Severe Malnutrition

12. Using MCV to Characterize Anemia Macrocytic Normal newborn Increased erythropoiesis Post-splenectomy Liver disease Obstructive jaundice Aplastic anemia Hypothyroidism Megaloblastic anemia Down�s syndrome

13. Using MCV to Characterize Anemia Normocytic Acute blood loss Infection Renal failure Connective tissue disorder Liver disease Disseminated malignancy Early iron deficiency Aplastic anemia Bone marrow infiltration Dyserythropoietic anemia

14. Using MCV and RDW

15. Using MCV and RDW

16. Differential diagnosis of microcytosis

17. Iron Deficiency Anemia causes Dietary deficiency Increased demand (growth) Impaired absorption Blood loss gut problems gall bladder lung nose heart kidney menstrual problems trauma

18. Iron Deficiency Anemia Symptoms GI anorexia pica atrophic glossitis guaiac positive stool CNS fatigue irritability Cardiac increased cardiac output cardiac hypertrophy Musculoskeletal impaired exercise performance radiographic changes

19. Iron Deficiency Anemia characteristics of peripheral blood smear microcytic hypochromic

20. Iron Deficiency Anemia additional diagnostic tests free erythrocyte protoporphyrin (elevated) serum ferritin (decreased) serum iron (decreased) Iron binding capacity (increased) Iron saturation (decreased)

21. Iron Deficiency Anemia Treatment oral iron supplementation: 6mg/kg/day of elemental iron for at least 3 months check retic count after 2 weeks side effects (educate family) goal: to replace iron stores, not just circulating Hgb

22. Iron Deficiency Anemia failure to respond to therapy non-compliance inadequate dose ineffective preparation unrecognized blood loss impaired GI absorption coexistence of disease incorrect diagnosis

23. Iron Deficiency Anemia parenteral therapy indications poor compliance severe bowel disease intolerance of oral iron chronic hemorrhage acute diarrhea disorder

24. Dosing of Parenteral Therapies Iron Dextran provides 50mg/ml elemental iron for weight >15kg: dose (ml) = 0.0442 (desired Hgb - Observed Hgb) x LBW + (0.26 x LBW) LBW (males)=50kg+2.3kg/inch of height over 5 ft. LBW (females )=45.5kg+2.3kg/inch of height over 5 ft. For weight 5 - 15kg: dose (ml) = 0.0442 (desired Hgb - Observed Hgb) x W + (0.26 x W) W = wt in kg

25. Dosing of Parenteral Therapies Ferrlecit (sodium ferrous gluconate) each 10cc provides 125mg elemental iron dilute 10ml in 100ml 0.9NS and administer IV over 1 hour repeat for up to 8 sessions test dose recommended

26. Anemia of Lead Poisoning epidemiology air water food soil paint folk remedies miscellaneous (cosmetics, pottery, live near lead industry) Risk factors age nutrition pica developmental delay

27. Anemia of Lead Poisoning symptoms NONE! With levels >60 mcg/dl lead colic constipation anaorexia hyperirritability anemia

28. Anemia of Lead Poisoning fetus and infant more vulnerable to damaging effects more susceptible with concurrent iron deficiency anemia effects of prolonged exposure to mild elevations neurologic deficits decreased in IQ (2-3 points for every 10mcg/dl of lead) speech and language delays hearing loss

29. Anemia of Lead Poisoning characteristics of smear hypochromic normocytic or microcytic sideroblasts basophilic stippling

30. Anemia of Lead Poisoning diagnostic tests blood lead level X-rays of long bones

31. Anemia of Lead Poisoning prevention is the cure! Primary prevention: removal of lead from gasoline removal of lead from paint Secondary prevention edcuation soil abatement dust abatement pain hazard remediation (18-23% decline in lead levels >25mcg/dl)

32. Anemia of Lead Poisoning treatment - chelation Chelation: decreases blood lead levels, does not decrease lead already in tissues <10 mcg/dl: non-toxic 10-14 mcg/dl: low lead level exposure parental education 15-19 mcg/dl: mild lead poisoning risk of neurodevelopmental effects parental education for lead exposure reduction

33. Anemia of Lead Poisoning treatment > 20 mcg/dl: medical evaluation and identification of environmental sources 20-44 mcg/dl: lead hazard control, involvement of Case Mgr or Social Worker consider oral chelation if levels persist after environmental intervention

34. Anemia of Lead Poisoning 45-69 mcg/dl Abdominal X-ray for enteral lead deposits DMSA (for children without encephalopathy) 30mg/kg/day divided TID x 5 days followed by 20mg/kg/day divided BID x 2 weeks may repeat course every 2 weeks or CaNa2EDTA (requires hospitalization) 25mg/kg/day x 5 days by continuous infusion or in divided doses repeat if lead level >45mcg/dl within 7-14 days of tx

35. Anemia of Lead Poisoning 70-90 mcg/dl MEDICAL EMERGENCY requiring immediate hospitalization monitor for increased ICP monitor hemodynamic stability osmotic therapy and drug therapy chelation therapy BAL and CaNa2EDTA combination therapy Initiate therapy with BAL only 25mg/kg/day in 6 divided doses by IM injection 4 hours after initial BAL injection, begin CaNa2EDTA 50mg/kg/day either as continuous IV infusion or divided doses IV over 4-6 hours IM injections are simpler but more painful

36. Anemia of Lead Poisoning 5-7 days after initial tx with BAL / CaNa2EDTA if lead level is 45-69mcg/dl give second course of CaNa2EDTA if lead level is >70mcg/dl repeat course of BAL / CaNa2EDTA 48 hours after second course, if lead level remains 45-69mcg/dl 7 days after second course, begin course of CaNa2EDTA

37. Lead Chelation BAL chelates lead in the brain given IM side effects: febrile reactions, elevated liver enzymes, N/V, headache, conjunctivitis, rhinorrhea, lacrimation, salivation contraindicated for persons with peanut allergy G6PD deficiency

38. Lead Chelation CaNa2EDTA only agent proven to improve IQ scores usually given as slow IV infusion; rapid IV infusion may case encephalopathy IM painful if not mixed with procaine side effects: proteinuria, urinary sedimentation, elevated BUN, Creatinine, and liver enzymes adequate hydration is essential

39. Lead Chelation Succimer (DMSA) only oral chelation agent 43-60% reduction in blood levels with fewer side effects �rotten egg� odor side effects: abdominal pain, N/V, diarrhea, elevated LFTs

40. Lead Chelation D-Penicillamine reduces moderately elevated blood lead levels by 33% only recommended for use when patients have had unacceptable reactions to DMSA and CaNa2EDTA side effects: rash, leukopenia, thrombocytopenia, hematuria, proteinuria, eosinophilia, nephrotoxicity contraindicated for persons with PCN allergy