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Approach to Childhood Anemia

Approach to Childhood Anemia. H. Tamary Hematology, Schneider Children’s Medical Center of Israel. Normal Hemoglobin and MCV Values in Term Infant. Hb MCV (g/dL) (fl) Day 1 19.0±2.2 119 ±9.4 12 weeks 11.3 ±0.9 88 ±7.9. Regulation of Erythropoiesis.

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Approach to Childhood Anemia

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  1. Approach to Childhood Anemia H. Tamary Hematology, Schneider Children’s Medical Center of Israel

  2. Normal Hemoglobin and MCV Values in Term Infant HbMCV (g/dL) (fl) Day 1 19.0±2.2 119 ±9.4 12 weeks 11.3 ±0.9 88 ±7.9

  3. Regulation of Erythropoiesis

  4. Hemoglobin Concentration- Different Gestational Age

  5. Globin Synthesis in Embryo, Fetus and Adult

  6. Decline in Fetal Hemoglobin

  7. Criteria for Identifying Children with Low Hemoglobin Values Age Hemoglobin (g/dL) 6ms –11 years <11 >11 male <13 >11 female <12

  8. Etilogical Classification of Anemia (I) A. Blood loss B. Excessive blood destruction 1. Intrinsic factors a. Defects of membrane: spherocytosis, elliptocytosis b. Defects of hemoglobin • Structural anomaly: HbS • Synthesis anomaly: thalassemia

  9. Etilogical Classification of Anemia (II) c. Enzymatic defect: G6PD deficiency, pyruvate kinase 2. Extrinsic factors a. Immune mechanisms: Rh, ABO incompatibility, autoimmune hemolytic anemia b. non-immune mechanisms: infections

  10. Etilogical Classification of Anemia (III) C. Decreased production 1. Deficiency of substance: iron, Vit B12, folic acid 2. Mechanical interference: malignant replacement 3. BM failure a. Primary: aplastic anemia b. Secondary: renal, liver disease

  11. Etiological Classification of Neonatal Anemia • A.Blood loss-fetal to fetal, feto-maternal, traumatic delivery • B.Increased blood destruction-Rh, ABO or minor blood group incompatibility, enzymopathy, hemoglobinopathy a-thalassemia • C.Decreased production-pure red cell aplasia

  12. Anemia Historical Factors • Age-Neonatal period initial manifestation of hemolytic disease, 6 m-iron deficiency, b-thalassemia • Ethnic group-Thalassemia syndromes, G6PD def • Diet- documented sources of iron • Drugs- oxidant-induced hemolytic anemia, drug induced aplastic anemia • Inheritance-family history of anemia, jaundice, gall stones

  13. Anemia Physical Findings Skin Hyperpigmentation Fanconi Anemia (FA) Facies Frontal bossing Thalassemia Prominence malar Major &maxillary bone Eyes Microphthalmia FA Hands Abnormal thumb FA Spleen Enlargement Hemolytic anemia, infection, leukemia

  14. Features of Ineffective Erythropoiesis

  15. FA Congenital Anomalies

  16. Complete Blood Count • Hemoglobin • MCV • WBC and differential count • PLT • RDW- red cell distribution width • CHr - hemoglobin concentration in reticulocytes

  17. Microcytic AnemiasMCV<80fl • Iron deficiency anemia • Thalassemia syndromes • Chronic inflammation • Siderblastic anemias • Lead poisoning

  18. Normocytic AnemiasMCV 80-90fl • Congenital hemolytic anemia • Acquired hemolytic anemia • Acute blood loss • Splenic pooling • Chronic disease

  19. Macrocytic AnemiasMCV>90fl With megaloblastic bone marrow • Vitamin B12 deficiency • Folic acid deficiency • Hereditary orotic aciduria Without meglaoblastic bone marrow • Aplastic anemia • Pure red cell aplasia • Liver disease • Congenital Dyserythropoietic Anemia

  20. Direct antiglobulin test (Coombs’)

  21. Bone Marrow Aspiration

  22. Acute Lymphoblastic Leukemia

  23. Bone Marrow Biopsy Normal Aplastic anemia

  24. Erythroid BM Colonies

  25. Iron Deficiency Anemia in Children

  26. Human Hemoglobin

  27. Distribution of Iron in Man Cytochromes 3% Myoglobin 10% Ferritin & Hemosiderin 22% Hemoglobin 65%

  28. Nutritional Iron Deficiency

  29. Increment of RBC Mass as Function of Age

  30. Stages of Iron Depletion

  31. Absorption of Food Iron

  32. Iron Absorption in Infants

  33. Mental &Psychomotor Development According to Hb Concentration

  34. Prevention of Nutritional Iron Deficiency Anemia • Encourage breast feeding for the first 6 months • Avoid cow’s milk at least for the first year of life • Iron fortified formula (12mg/l) • Solid food: cereals, meat • Oral iron 2mg/kg 4-12months • CBC: 9-12 months and 15-18 months

  35. Iron Doses for Low Birth Weight Infants Starting at 1 Month of Age Iron Birth weight mg/kg/day (g) 4 1000 3 1000-1500 2 1500-2500

  36. “The tragedy of iron deficiency during infancy and early childhood” • Brain injury as a result of iron deficiency caused by improper nutrition • Iron deficiency affects mental development and motor functioning • Reduced activity of iron-containing enzymes in CNS, appear to be irreversible Buchanan G, J of Ped 135:413, 1999

  37. Nutritional Iron Deficiency • No iron prophylaxis • No introduction of meat products • Increased tea consumption

  38. Stages of Iron Depletion

  39. Iron Depletion • Hb, MCV, RDW, CHr-Normal • SI, TIBC-Normal • Serum Ferritin- Low

  40. Iron Deficiency – No Anemia • Hb, MCV- Normal • RDW- High • CHr- Low • Serum Ferritin- Low • Serum Iron – Low • TIBC- High

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