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Anemia and Bleeding Disorders

in Newborn Infants
RinawatiRohsiswatmo
SubBag.Neonatologi
IlmuKesehatanAnak(IKA)
FKUIRSCM

Hemoglobin (Hb) Concentration

Cord Hb concentration :
* Term infants : 17 g/dl (14 20 g/dl)
* Preterm infants : 14 g/dl (13 18 gl/dl)

HB concentration :
* Delayed clamping of the cord.
* Holding the infant below the level of the
placenta at birth.

Erythropoiesis After Birth


Erythropoietin production is switched off
by the greater availability of oxygen.
Reticulocytosis
from 5% (at birth) <
1%.
Hb level
to a nadir of 7-10 /dl by 8 10
weeks., remaining stable for several weeks,
before gradulally .

Erythropoiesis After Birth/


Pretrem infants : Hb level
more rapid
and more marked; sometimes need to be
transfused (anemia of prematurity is
labelled non physiological).
Term infants : as long as they are
asymptomatic
physiological.

The Type of Anemia


Early onset anemia :
* Hb level of < 13 g/dl (Ht < 40%) during
the first week of life.
* Primarilly a hemorrhagic anemia.
Late onset anemia :
* Hb level of < 10 g/dl after the first week
of life.

The Type of Anemia/

Primarily a hyporegenerative anemia


resulting from the inability of the immature
hematopoietic tissue to react adequately to
hypoxia.

Etiology of Early Onset Anemia


Twin to twin transfusion.
Fetomaternal transfussion.
Fetal hemoorhage : placenta previa,
abruption, vasa previa or placental incision
at caesarian section.
Fetoplacental transfusion at birth.
Chronic or acute fetal hemolysis : rhesus
disease, thalassemia.

Etiology of Early Onset Anemia/

Perinatal neonatal hemorrhage :


intracranial, subaponeurotic fractures,
ruptured spleen or liver, umbilical cord
rupture or accidents.
Iatrogenic losses : repeated blood sampling.

Clinical Features of Early Onset Anemia


A.

B.

Acute blood loss :


pallor, hypotension, poor capillary refill,
tachycardia, tachypnoea.
Chornic blood loss :
pallor, tachycardia, congestive cardiac
failure, hepato splenomegaly, jaundice,
hydrops fetalis.

Investigation
Full blood count and film.
Blood group and coombs test.
Maternal kleihauer test.
Coagulation screen.
Cranial USG.
Exclude red cell abnormalities.
Serum bilirubin.

Management
Look for the underlying cause.
Acute blood loss and shock : rapid
resuscitation, give blood of group O.
Rhesus negative or blood harvested from
placenta at once.
Maintain the airway and if necessary give
oxygen.

Etiology of Later Onset Anemia


Anemia of prematurity.
Iatrogenic : repeated blood sampling.
Chronic hemolysis.
Hemoglobin abnormalities.
Bleeding.
Severe infection.
Iron deficiency (6-8 weeks).

Etiology of Later Onset Anemia/


Vit. E deficiency (hemolytec anemia), folic
acid/Vit. B12/copper and Zinc deficiencies.
Maternal autoimmune disease.
Failure of red cell production.

Clinical Features
Apnoeic attacks.
Tachy cardia.
Poor feeding.
Poor weight gain.
O2 requirements
in O2 dependent infants.

Investigations
Full blood count, film and reticulocyte
count.
Serum bilirubin (total and conjugated).
Coagulation screen (if actively bleeding).
Serum bioten, copper and zinc (periorel
dermatitis).
Check stools for occult blood.

Management
Transfuse with PRC if symptomatic to raise
the Hb to 12 14 g/dl ( Ht > 45% ).
Volume of PRC to be transfused =
desired rise in Hb x weight in kg x 4

Bleeding Disorders

Common during the neonatal period,


particularly in preterm infants.

Normal hemostasis requires vascular


integrity, normal platelet function and a
functional coagulation system.

Etiology

In otherwise healthy infants, the commonest


causes of bleeding are :
* Thrombocytopeni to secondary to
transplacental passage of maternal
platelet antibodies.
* Vit. K deficiency.
* Less commonly, congenital coagulation
factor deficiencies.

Investigating The Bleeding Infant


Careful history of family bleeding
problems, outcome of previous pregnancies,
maternal illnesses, maternal and neonatal
drug administration and ascertainment of
Vit. K administration.
F B C and film ( screen platelat numbers,
presence of fragmented red cells ).
Coagulation screen ( PT, PTT ).

Management
F F P 1020 ml/kg.
Platelet concentrates 1020 ml/kg.
Cryoprecipitate (~ factor VIII)