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.
Etiology of anemia
Clinical approach to diagnosis

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

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

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)
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