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 cell’s
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.
 Increased
destruction

Decreased
Blood loss
production

Etiology
of
anemia
 Etiology of anemia

• Drugs : TMP-sulfamethoxazole, amphotericin B, ganciclovir,

dapsone
Decreased • Deficiencies : Erythropoietin, iron, folate, vitamin B-12
• Infection: HIV, Parvovirus B-19, Histoplasma capsulatum
production • Marrow failure/replacement: Aplastic anemia, pure red cell
aplasia, malignancy
• Anemia of chronic disease

• Hemolysis : TTP, G6PD, AIH

Increased • Defect of hemoglobin : hemoglobinopathy,
thalassemia
destruction • Defect of the red cell membrane (spherocytosis)
or loss • Hypersplenisme
• Acute or chronic blood loss
Clinical approach to diagnosis
Anamnesis

• Chronic anemia or anemia in the family

• Medical history : chronic infection, renal, malignancy
• Social history : nutritional
• Surgical history : partial or total gastrectomy
• Medications
• Chemical/physical exposure
• Bleeding manifestation : acute/chronic
• Prematurity, twin, anemia in pregnancy
• Bone pain

Hermiston,Mentzer 2003
….clinical approach to diagnosis (2)
Physical Examination

• Pallor
• Palmar crease pallor suggest Hb < 7 g/d
• Volume status : orthopneu, tachycardia, ejection
murmurs, urine output
• Skin : jaundice (hemolysis), petechiae/ecchymoses
(bleeding manifestations),
• Lymphadenopathy (malignancy)
• Oral : glossitis, macroglossia (pernicious anemia),
angular cheilitis (Fe deficiencies)
• Face : frontal bossing/facies cooley  thalassemia
• Bloody stool (GI bleeding)
• Organomegaly (hemolysis, malignancy, hypersplenisme)
 Signs and symptoms vs diseases

Diseases Pallor Bleeding Organomegaly

IDA + - -
Acute hemolytic anemia + - -/+
Aplastic anemia + + -
Hemorrhage anemia +/++ + -
Chronic hemolytic anemia/thal + - +
Acute leukemia + + -/+
Hypersplenisme + + +
Liver disease + + -/+
Metastatic tumor + -/+ -/+
Chronic infection + - -
 Initial evaluation

Other cell lines (ie. WBC, PLT)

decreased

Yes No

Depending on history physical + blood Evaluate by

smear indicies
Consider bone marrow exam

Microcytic Normocytic Macrocytic

Wintrobe’s 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
Wintrobe’s 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

Ferritin can be elevated in :

• Infection
• Inflammation
• Malignancy
 IDA vs Thal trait
IDA Thal trait
RBC  
Reticulocyte /N 
RDW /N N
MCV/RBC > 13 < 13
PBS
• microcytic hypochromic + +
• poikilocytosis + ++
• anisocytosis ++ +
Thalassemia trait Iron Deficiency
Thalassemia trait Thalassemia major
Normocytic
Normocytic anemia (MCV 82-97 fL)

Hemolysis :
Blood smear
Increased
Blood loss
Reticulocyte
No
count Anemia of
Bi-/
chronic
pancytopenia disease
Yes BMA Decreased
infection
(parvo-
virus,HIV)
Macrocytic
 Macrocytic anemia (MCV > 97 fL)
Evaluate smear for oval macrocytes and
hypersegmented neutrophils

absent present

Reticulocyte Decreased Megaloblastic anemia

count or normal
Check B-12/folate

increased
low normal
Medication
Liver/thyroid disease
Hemolysis
Hemorrhage idiopathic
deficiency
Hyperslenisme No Aplastic
anemia BMA
Wintrobe’s 2007
 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