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ANEMIA in Children, Assessment and

Management

Audace NIYIGENAIntern in pediatrics

In King Faisal Hospital in KigaliSupervised by

Dr SABITI Stephen

PLANOverviewEtiologiesAssessmentManagmentPrognosis Conclusion

ANEMIA

is a decrease in number of red blood cells(RBCs) or less than the normal quantity of hemoglobin in the blood.

The normal range varies with age, so anaemia can be defined as: Neonate: Hb <14g/dl 1-12 months: Hb <10g/dl 1-12 years: Hb <11g/dl. ˃12years: Hb <12g/dl

Anemia is not a disease, but an expression of an underlying disorder or disease.

ETIOLOGIESProduction defects:

Nutritional deficiencies - Vitamin B12, folate or iron deficiency.

Inflammation/chronic disease. bone marrow disorders- pure red cell

aplasia,myelodysplasia. Blood loss

HemorrhageChronic GI blood loss

Blood destruction. haemolysisSequestration (hypersplenism)-usually associated

with mild pancytopenia

ASSESSMENTdiagnosis is made by:

Patient historyPatient physical examHematologic lab findings

Identification of the cause of anemia is important so that appropriate therapy is used to treat the anemia.

Patient History

Dietary habitsMedicationPossible exposure to chemicals and/or toxinsDescription and duration of symptomsTirednessHeadache and vertigo (dizziness)Dyspnia from exertionG I problemsOvert signs of blood loss such as hematuria

(blood in urine) or black stools

Physical Exam

Hepato or splenomegalyHeart abnormalities

tachycardiaGallop rhythmBounding pulse

Skin pallormalnutrition and neurological changesJaundiceAnginaTrauma evidence

Patients with acute and severe anemia appear in distress, with tachycardia, tachypnea, and hypovolemia.

Patients with chronic anemia are typically well compensated and usually asymptomatic

Hematocrit (Hct) or packed cell volume in %The normal range is 42-60%

Hemoglobin (Hgb) concentration in grams/deciliterThe normal range is 13.5-20 g/dl

An RBC count: The normal range is 13.5-20 g/dl

Reticulocyts :The normal range is 0.5% to 1.5%

Hematologic Lab Findings

Mean corpuscular volume (MCV)Hct (in %)/RBC (x 1012/L) x 10At birth the normal range is 98-123In old child and adults the normal range is 80-

100The MCV is used to classify RBCs as:Normocytic (80-100)Microcytic (<80)Macrocytic (>100)

Mean corpuscular hemoglobin concentration (MCHC) – is the average concentration of hemoglobin in g/dl (or %)Hgb (in g/dl)/Hct (in %) x 100 The normal range is 30-36The MCHC is used to classify RBCs as:Normochromic (30-36)Hypochromic (<31)hyperchromic, not (>37), they just have

decreased amount of membrane.

Mean corpuscular hemoglobin (MCH) – is the average weight of hemoglobin/cell in picograms (pg= 10-12 g)Hgb (in g/dl)/RBC(x 1012/L) x 10At birth the normal range is 31-37In adults the normal range is 26-34This is not used much anymore because it does

not take into account the size of the cell.

Red cell distribution width (RDW) – is a measurement of the variation in RBC cell sizeStandard deviation/mean MCV x 100The range for normal values is 11.5-14.5%A value > 14.5 means that there is increased

variation in cell size above the normal amount A value < 11.5 means that the RBC population

is more uniform in size than normal.

CLASSIFICATION

Using MCV to Characterize Anemia

Microcytic

Iron deficiency anemia

ThalassemiaSideroblastic

anemiaChronic infectionSevere

Malnutrition

Macrocytic

Normal newbornIncreased

erythropoiesisPost-splenectomyLiver diseaseObstructive

jaundiceHypothyroidism

Normocytic

Acute blood loss

InfectionRenal failureLiver diseaseEarly iron

deficiency

management

ManagmentAcute anemia usually warrants immediate

medical attention. Treatment depends on the severity and

underlying cause of the anemiaSupportive measures, such as supplemental

oxygen for decreased oxygen-carrying capacity, fluid resuscitation for hypovolemia, and bed rest or activity restriction for fatigue, may be required

When to transfuse? PRBC dose is 15-20 ml/kg over 3-4 hours. the rate of transfusion can be modified according to the clinical situation.

Give PRBCs if:

Hb ≤7 g/dl with clinical signs of

anemia

Hb˂5g/dl regardless of

clinical signs of anemia

Iron Deficiency AnemiaDx:

Smear: microcytic & hypochromicadditional diagnostic tests

serum ferritin (decreased)serum iron (decreased)Iron binding capacity (increased)Iron saturation (decreased)

Tx:oral iron supplementation: 6mg/kg/day of elemental

iron for at least 3 monthscheck retic count after 2 weeks

Iron Dextranprovides 50mg/ml elemental ironDose(ml) =0.0442 (desired Hgb - Observed Hgb) x Wt +

(0.26 x W)Ferrlecit (sodium ferrous gluconate)

each 10cc provides 125mg elemental irondilute 10ml in 100ml 0.9NS and administer IV over 1 hour repeat for up to 8 sessions

B12/Folate DeficiencyDx:

Smear: Macrocytic (High MCV) RBCs, B12

Low serum B12, Anti-IF Abs,

Folate Serum folate level-- can normalize with a single good meal

Tx:B12 deficiency: B12 1 mg/month IM, or 1-2 mg/day POFolate deficiency: Improved diet, folate 1 mg/day

ThalassemiasGenetic defect in hemoglobin synthesis

synthesis of one of the 2 globin chains ( or )“Ineffective erythropoiesis”

Dx:Smear: microcytic/hypochromic, RBCsFe stores are usually elevated

Tx:Mild: NoneSevere: RBC transfusions + Fe chelation, Stem cell

transplants

PrognosisThe prognosis depends on the severity and

acuteness with which the anemia develops and the underlying cause of the anemia.

Mortality and morbidity rates vary according to the underlying pathologic process causing the anemia, the degree of severity, and the acuteness of the process.

CONCLUSIONAnemia is not a desease but, a condition

caused by various underlying pathologic processes

A proper history and physical examination is more important in an easy way of approaching a child with anemia

Lab exams leads to definitive cause of anemiaAll cases of anemia are not necessary to be

transfused

REFERENCESIllustrated textbook of paediatrics 3rd edition,

Tom Lissauer and Graham Clayden, 2010First aid for Pediatric clerkship, LATHA G.

STEAD et alPocket medicine 4th edition, Mare S.

Sabatine, 2011Emedicine.medscape.com/article/954506Pedinreview.com