CLINICAL

APPROACH:
ANEMIA IN
CHILDHOOD
Dian Puspita Sari
Hematology-Oncology Division
Moh. Hoesin Hospital-University of Sriwijaya

Objective:
outline a clinical approach to
establish the diagnosis of anemia

Introduction
Anemia:
The most common problem in children (80%)
Most commonly, incidental finding
Asymptomatic found on routine screening
Consequences: impaired growth and
development
It is a sign, not a final diagnosis
Key historical points, findings on physical
examination and laboratory evaluation can
reveal the underlying cause of the anemia
Irwin, 2001
Hermiston,Mentzer, 2002

Anemia
Reduction in the hemoglobin
concentration, hematocrit, or number
of RBC per cubic milimeter.
WHO criteria:
Age

Hb below
(g/dL)

Ht below
(%)

6 mos-5 yrs

11

33

5 yrs 11 yrs

11.5

34

12 18 yrs

12

36

Normal Erythropoiesis

Erythroid marrow maturation

RBC precursor maturation proceeds through a series of morphologically distinct stages. Identifiable populations in
this maturation sequence include pronormoblast; basophilic, polychromatic and orthochromatic normoblasts; and
the marrow reticulocytes. With development, there is a progressive reduction in cell size, a shrinkage of the cells
nucleus, a loss of cellular mitochondria and RNA, and a dramatic increase in hemoglobin. Specific red blood cell
disorders can be identified from disruption in this normal maturation sequence.

Etiology of anemia

Clinical approach to
diagnosis

Hermiston,Mentzer 2003

.clinical approach to
diagnosis (2)

Signs and symptoms vs

diseases
Pallor

Bleeding

Organomeg
aly

IDA

Acute hemolytic anemia

-/+

Aplastic anemia

+/++

Chronic hemolytic
anemia/thal

Acute leukemia

-/+

Hypersplenisme

Liver disease

-/+

Metastatic tumor

-/+

-/+

Chronic infection

Diseases

Hemorrhage anemia

Initial evaluation

Wintrobes 2007

Laboratory
Refining the differential diagnosis of anemia:
Use of the
CBC
RBC indices (MCV,MCH,MCHC, RDW)
Reticulocyte count
Blood smear
History and physical examination

to guide selection of further diagnostic test

Reticulocyte

Type of Anemia
Based on the MCV

Microcytic

Microcytic Anemia (MCV<

80fl)
Defect in the production of hemoglobin

Differential diagnosis in pediatrics:

iron deficiency anemia (most common)
thalassemia
lead poisoning
anemia of inflammation
sideroblastic anemia (rare)
Irwin 2001
Rossbach 2005
Wintrobes 2007

microcytic anemia....
IDA:
Peak prevalence: late infancy, early childhood,
adolescence
Etiology: rapid body growth, low levels of
dietary iron, menstrual blood loss (females)
Th/ trial of oral iron initial diagnostic test
evaluation :
Response (+)
Reticulocyte count in 5-10 days
Hb by 1 g/dl/month

Response (-)
Poor compliance, poor absorption, incorrect
diagnosis, etiology still persist

microcytic anemia......
Further laboratory needed if:
No history suspicious of IDA
Severe anemia
Atypical hematologic findings
No response to initial trial of iron therapy

Additional test
Ferritin
Free erythrocyte protoporphyrin (FEP)
Serum iron
Iron binding capacity

To screen for IDA

IDA vs Thal trait

RBC
Reticulocyte
RDW
MCV/RBC

IDA

Thal trait

/N
/N
> 13

N
< 13

+
++

++
+

PBS
microcytic
hypochromic
poikilocytosis
anisocytosis

Thalassemia trait

Iron Deficiency

Thalassemia trait

Thalassemia major

Normocytic

Normocytic anemia (MCV

82-97 fL)

Macrocytic

Macrocytic anemia (MCV >

97 fL)
Evaluate smear for oval macrocytes and
hypersegmented neutrophils
present

absent
Reticulocyte
count

Decreased
or normal

Megaloblastic anemia
Check B-12/folate

increased
Hemolysis
Hemorrhage
Hyperslenisme
Wintrobes 2007

Medication
Liver/thyroid disease
No

Aplastic
anemia

low

deficiency

normal

idiopathic
BMA

Management approach
Depend on the underlying disease
Emergency: Hb 5 g/dl give PRC
transfusion 5 ml/kg/BW/X, then 10-15 ml/kg
BW/X
The rules: Hb X BW X 4
Transfusion are given in multiple small
volumes, separated by several hours
Suggested to collect blood sample before
transfusion for further laboratory
examination

Summary
1. Anemia is a symptom , not a final diagnosis. The
clinician must define the underlying disease
2. The anemia may be due to decreased
production, increased destruction or blood loss
3. Important : anamnesis,physical
examination,CBC, RBC indices, reticulocyte,
blood smear evaluation
4. Consider to do bone marrow aspiration if 2 or
more cell line affected.
5. PRC transfusion given if Hb 5 g/dl, if possible
collect blood sample for further examination