Anemia in Children

Iyad Sultan, MD
Tel 079-6102051
Images were taken from this lecture

isultan@khcc.jo
 History
• Age: Anemia is most common in toddlers 1-3 years old
and in menstruating teenagers
• Diet: meat, Milk ↓ absorption, tea ↓ absorption, vit C ↑
absorbtion
• Blood loss: Milk allergy, GI problems.
• Perinatal history: maternal diet, jaundice at birth, LBW.
• Pagophagia: the desire to ingest unusual substances
such as ice or dirt indicating iron deficienc
• R.O.S.: Recurrent pain, swelling of hands and feet
(sickle cell anemia).
• Chronic illness, previous infections (anemia of chronic
disease)
• FH of hemolytic anemia: anemia, blood transfusion,
gallstones, G6PD.
 P/E
• Pallor. General conditions.
• Vital signs. Height, Weight.
• Irritability.
• Lymphadenopathy.
• Hepatosplenomegaly.
• Stigmata of bone marrow
failure syndrome (Fanconi
anemia): skin pigmentation,
skeletal deformities, short
stature, abnormal faces.
 CBC
• Hemoglobin level: is the child anemic?
• WBC ↓ , platelet ↓ : Pancytopenia.
• Indices: MCV –Normocytic,microcytic,
macrocytic.
– Lowest MCV = 70 + age in years
• RDW: RBC disribtution width: Variation in
size of RBCs: Typically increased with iron
deficiency anemia >14.5
• Reticulocyte count Should be appropriately
increased
 So … you have a patient with anemia. It is
iron deficiency anemia unless:
• Wrong age ( an adolescent boy with anemia).
• Symptoms suggestive of hemolysis (jaundice,
abnormal urine color).
• FH.
• Abnormal P/E: organomegaly,
lymphadenopathy.
• Severe anemia (Hb<8 gm/dL).
• Normocytic anemia or Low RDW.
• Pancytopenia
• Failure to respond to therapeutic iron trial.
 Approach to Anemia

•CBC:MCV, RDW
•Retic
•Blood film

Normocytic Normocytic
Microcytic
Decreased production Increased destruction
•Confirm iron deficiency •Confirm hemolysis.
(ferritin). •Bone marrow •Blood film.
•Search for an etiology aspirate/biopsy. •G6PD.
of Fe deficiency. •Osmotic fragility.
•Hb electropheresis for
•Hb electropheresis
thallassemia
•Coomb’s
•Start PO iron
 Iron deficiency anemia
• WHO: approximately 2 billion
people worldwide with iron U.S. data - Fe deficiency
deficiency anemia.
• (UNRWA) reported maternal and 14
infant iron deficiency anemia in 12
50-65% of the Palestinian
population with highest 10
prevalence in infants 6-12 mo. 8
COOK R. UNRWA Annual Report 1990 %
• In 192 preschool children 6
between 3-60 mo of age, 11.5% 4
had subclinical iron def (low
TIBC and/or low ferritin) and 2
34.4% had iron def anemia 0
(hb<10.5). Madanat, F. Acta Haematol 1984 1 year 2 year adolescent women
girls
 Anemia (Hb<10.5)

70
60
50
40
%
30 Subject
20 Control
10
0
6mo 9mo 12 mo
Age

Kilbride, European J. of Haematology 2000

 Counseling
• Encourage breast feeding (human milk for
human babies, cow milk for cow babies).
• Avoid introduction of tea.
• Teach proper feeding techniques (one feeding
per day with vit C rich item, iron-fortified cereal
by 6 mo, pureed meat by 9mo, be careful with
greens)
• Avoid early introduction of whole cow milk. Limit
milk consumption for toddlers to 500ml/day
• No use of iron free formula.
• Screen for anemia at 6 and 12 months of age.
• Mothers should be on iron supplement.
• Iron supplement (maintenance dose) for babies
at risk.
Ferrous sulphate Iron(III)-hydroxide polymaltose

Fertonic ® Ram pharma Maltofer ® Vifor

1.390 JD /30ml
1ml=full microdropper
/ 125 mg FeSO4 =
25 mg elemental iron
Tastes horrible
3.480 JD/150 ml
1ml=10mg elemental iron
Tastes like candy

Therapeutic Therapeutic
1ml TID 5ml Q day
Prophylactic Prophylactic dose
0.5ml TID 2.5ml PO Qd
No safety cap No safety cap
Supply lasts only for 10 days Supply lasts for 30 days
Unstable>25 C Unstable > 25 C
 Response to iron
Time After Iron Response
Administration
12–24 hr Replacement of intracellular iron
enzymes; subjective improvement;
decreased irritability; increased
Appetite
36–48 hr Initial bone marrow response;
erythroid hyperplasia
48–72 hr Reticulocytosis, peaking at 5–7 days

4–30 days Increase in hemoglobin level

1–3 mo Repletion of stores

 Failure to respond to oral iron
• Continuing bleeding.
• Noncompliance.
• Small dose.
• Wrong dx: Thalassemia trait.
• Mixed deficiency: vit B12, folate.
• Malabsorbtion.
• Mixing iron with milk.
 Normocytic anemia
Destruction

Production

• Anemia of chronic • Hemorrhage

disease • Hypersplenism
• Bone marrow failure • Hemolysis
• Transient H Hemoglobinopathies
erythoblasopenia of
E Enzymopathies
childhood
M Membrane defects
O “O”Autoimmune
 Hemolysis

• Normocytic anemia
• Elevated reticulocyte count
• Elevated bilirubin
• Elevated LDH
• Decreased Haptoglobin
• Urine: Blood +ve with no RBCs.
• Blood film
• Specific tests: Direct coomb’s test, G6PD level,
hemoglobin electrophoresis, Osmotic fragility
 Case 1
• A 2 year old girl comes to your clinic for
regular checkup.
• Her mother noticed that her color is
different from her siblings.
• Height, weight and HC on 25th percentile.
• Patient is pale with mild icterus.
• Mild splenomegaly (1cm BCM).
• You suspect hemolytic anemia
 History
• Headache, fatigue, decreased appetite
• Jaundice, color of urine
• Recent infections
• PMHx:
– Jaundice at birth
– Recurrent infections, rash, arthritis, mouth ulcers
• FHx:
– Hx of gallstones, anemia, Favism, transfusions,
consanguinity, Splenectomy
 Labs
• CBC: Hemoglobin 8.3, MCV 67, MCHC 40
g/dL, RDW 16%, Platelet 160k, WBC 7.4,
Lym 61%, Neu 33%
• Reticulocytes: 6%

• Direct Coomb’s –
ve
• Osmotic fragility:
– Increased
 Spherocytosis
• caused by a defect in the skeleton of the
RBC membrane that generally affects the
spectrin component.
• HS is the most common cause of
hemolytic anemia in people of Northern
European heritage, with a prevalence of 1
in 5,000,
• Inheritence: Autosomal dominant 75%
 Spherocytosis: Management
• Folate supplementation 1mg/d
• Splenectomy
• Cholecystectomy
• PRBCs transfusion
 Case #2
• Patient is a 9 month old boy who
presented to your office with severe pallor
and decreased activity.
• No FH, Normal perinatal hx
• History of a “Cold” 2 weeks prior to
presentation
• PE shows mild icterus, pallor, no
hepatosplenomegaly
•CBC: Hemoglobin 5.6, MCV 73, MCHC 31
g/dL, RDW 18%, Platelet 196k, WBC 11.4,
Lym 69%, Neu 22%
•Reticulocytes: 12%

•Direct Coomb’s
+ve
Direct Coomb’s test
Indirect Coomb’s test
 Autoimmune Hemolytic Anemia
AIHA : Management
• Hb level: Q4 hours- Q week
• Reticulocyte count, spleen size,
Haptoglobin level
• PRBC transfusion.
• Prednisone 2-10mg/kg/day

• Others: IVIG, Plasmapharesis,

Cyclosporin, Danazol, Rituximab,
Splenectomy
 Case#3
• A 4 year old boy comes to ER with severe
pallor, jaundice. He looks critically ill and
stat labs are ordered showing Hb 3.2,
Reticulocytes 5%, WBC 14000, platelet
480k
• Direct Coomb’s test: -ve
• A blood film is ordered
 special stains (supravital stains) such as methyl
violet, inclusion bodies called Heinz bodies (denatured
hemoglobin)
 G6PD
• X-linked
• G6PD level is inaccurate in the presence
of hemolysis.
• Agents that cause hemolysis:
– Fava beans
– Infections
– Drugs (more in the A-)
– Naphthelene (moth balls).
G6PD
G6PD: Favism

• Fava beans contain the beta glycosides vicine and convicine.

• may undergo auto-oxidation as part of their natural metabolism 
free oxygen radicals
• Characterized by:
1. unpredictability (only 25% of adults at risk develop hemolysis, and the
risk may vary in the same individual from one exposure to another)
2. Influence of dose and body weight
3. Quality of beans (raw beans are more likely to cause the reaction than
cooked, frozen, or canned beans)
4. maturity of the beans (young beans that have a much higher content of
beta glycosides are more likely to induce hemolysis)
5. Activity of beta glycosidases in the beans as well as in intestinal
mucosa, which influences the rate and amount of active aglycones
released.
G6PD: Drugs
 Case #4
• A 7 year old lives in Al-Ghoor with very
poor medical care.
• Comes to your clinic for first visit
• C/O history of intermittent pain in his
extremities.
• History of swelling and pain in hands and
feet when he was 9 months old
• Pallor, mild icterus
Sickle cell anemia
 Case#4 continue
• Patient presented with cough,
shortness of breath and fever.
• O2 sat 85%
• Left base: decreased AE,
crackles, RR 35, mild
retractions
• CXR: LLL consolidation +
pleural effusion
• CBC: Hb 6, baseline
hemoglobin 8
 Management of acute chest
• Admission to hospital
• Oxygen
• Transfusion
• Antibiotics: zithromax + ceftriaxone
• Moderate fluids
• Pain management
• Incentive spirometry
Incentive Spirometry
# Hb MCV Retic A1 A2 F C S

1. 10 80 3% 55% 3% 10% 0 32%

2. 6.5 78 12% 0 3% 10% 0 83%

3. 8 65 10% 20% 5% 10% 0 65%

4. 9 65 10% 30% 3% 10% 0 57%

5. 10 79 4% 0 3% 25% 0 72%

6. 11 81 7% 0 3% 10% 40% 50%

7. 11 75 5% 0 2.5% 7.5% 90% 0

8. 7 65 15% 0 5% 10% 0 85%