Approach to Anemia

How to efficiently and accurately work up the

anemic children
Anemia

 Is a sign of disease
 Not a final diagnosis

The goal of the diagnostic evaluation is to

determine the cause of anemia

9/9/2018 www.brainybetty.com 2
Definition of Anemia
Reduction in the hemoglobin
concentration or red blood cells per cubic
millimeter.

ANEMIA (WHO criteria)

Age Hb (g/dl)
6 mo - < 5 yrs < 11
> 5 yrs < 12

9/9/2018 www.brainybetty.com 3
Anemic Child

It is important to establish :
 A single cell line problem (red blood cells)
Or
 A multiple cell line problem (red cell, white
cell, and platelets)

Usually indicates bone marrow involvement,

immunologic disorders,
peripheral destruction of cells
9/9/2018 www.brainybetty.com 4
Physiologic classification of anemia

1. Disorders of effective red cell production

2. Disorders of increased red cell
a. Marrow failure
destruction
b. Impaired erythropoietin production
Blood
3. a.c. loss
Abnormalities
Defects of hemoglobin
of cytoplasmic maturation
b.d. Defects
Abnormalities of nuclear maturation
of the red cell membrane
c.e. Defects
Dyserythropoietic.
of red cell metabolism
d. Antibody-mediated
e. Mechanical injury to the erythrocyte
f. Thermal injury to the erythrocyte
g. Oxidant-induced red cell injury
h. Paroxysmal nocturnal hb-uria
i. Hypersplenism
9/9/2018 www.brainybetty.com 5
The investigation of Anemia

1. Detailed history and physical examination

2. Complete blood count.
3. Determination of morphologic
characteristics and RDW.
4. BMP (if required).
5. Determination of underlying cause of
anemia by additional test.

9/9/2018 www.brainybetty.com 6
 Important features in the history of the
anemic child
1. Maternal history
2. Family history
Pregnancy/delivery complications
3. Patient history
Drug ingestion
Anemia Jaundice Splenomegaly
Pica/ nonfood product ingestion
Gallstones Cancer
Hyperbilirubinemia, Transfusion
Prematurity, Diet history,
Anemic
Medications,
during pregnancy
Acute or recent infection, Evidence of
Bleeding disorders
chronic disease/ infection, Endocrinopathy, Liver disease,
Easy bruising/blood loos

9/9/2018 www.brainybetty.com 7
Physical examination

Several clues to the etiology :

 Tachycardia acute process with poor
compensation.
 Normal HR more chronic process
 Jaundice hemolytic process
 Splenomegaly inherited hemolytic anemia,
malignancy, portal hypertension

9/9/2018 www.brainybetty.com 8
Morphology classification of Anemia

BLOOD SMEAR
 Microcytic Anemia (MCV<80fl)
 Normocytic Anemia (MCV 80-100 fl)
 Macrocytic Anemia (MCV >100 fl)

9/9/2018 www.brainybetty.com 9
Reference Range of MCV
Age (yrs) MCV (fl)
1 - 3 days 95 - 121
0.5 – 2 70 - 84
2–4 73 - 85
5–7 75 - 87
8 – 11 77 - 90
12 – 14 78 - 91
15 – 17 78 - 94
18 – 19 80 - 100

9/9/2018 www.brainybetty.com 10
 ANEMIA

MCV

MICROCYTIC NORMOCYTIC MACROCYTIC

Iron Deficiency Reticulocyte count

High
Thalassemia
Negative Coombs Test Positive
Chronic disease
Bilirubin
Lead poisoning
Hb-pathy Autoimmune
Normal High
Membrane defect Isoimmune
Hemorrhage Hemolytic
Secondary : drugs, infection Coombs test

9/9/2018 www.brainybetty.com 11
 ANEMIA

MCV

MICROCYTIC NORMOCYTIC MACROCYTIC

Reticulocyte 

Leukocyte &
Platelets

Low Normal Increased

Malignancy Pure red cell aplasia Infection

Diamond Blackfan
Aplastic
Transient
Anemia
erythroblastopenia
9/9/2018 www.brainybetty.com 12
 ANEMIA

MCV

MICROCYTIC MACROCYTIC NORMOCYTIC

Folate deficiency
Vit B12 defic.
Aplastic anemia
Preleukemia
Liver disease

9/9/2018 www.brainybetty.com 13
Other lab examination

RDW (Red cell distribution width) =

variation of the erythrocyte volume distribution.
(N = 11.5 – 14.5%)
Normal RDW = homogen, slight anisocytosis
RDW  = heterogen, anisocytosis (++)
Reticulocyte = indicator of bone marrow
activities

Anisocytosis = variation in size

Poikilocytosis = variation in shape
9/9/2018 www.brainybetty.com 14
Anemia Mikrositik

 Perhatikan : jumlah eritosit,

RDW, retikulosit, gambaran
sediaan apus darah tepi.

Juml Eri RDW Retik Slide

Trait Thal  N  poikilositosis (+)
ADB N /  N / anisositosis (+),
hipokrom
Thal    poikilositosis,
anisositosis (++)
hipokrom

9/9/2018 www.brainybetty.com 15