Anemia in Children

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Anemia in Children

• Baystate Medical Center
• Drs. Dewey and Dunbar

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Objectives

• 1. Be able to define anemia and review the basic
  physiology of erythropoiesis
• 2. Outline a logical approach to establish the
  etiology of anemia in children
• 3. To review the most common types of anemia
  encountered in pediatrics
• 4. Develop a differential diagnosis based on age
  of patient

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What is Anemia?

• A reduced amount of hemoglobin per unit volume of
  blood
• Hgb norms vary with age, gender and pregnancy
• Remember Hgb x 3 Hct
• By the age of 18 yrs, 20 of children in US and
  80 of kids worldwide have had anemia

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The Red Cell

• Average life span 120 days
• Cleared by RES (spleen, liver primarily)
• homeostasis ?
• daily loss daily production
• Otherwise ? anemia

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A Normal Smear
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Normal Erythropoiesis

• Kidney ? peritubular interstitial cells ? produce
  EPO based on O2 delivery ? ?BM production of RBC
  ? released to peripheral blood
• BM requires adequate nutrients to do
  erythropoiesis including Fe, B12, and folate

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Anemia Basics

• All anemias are either due to.
• 1. Ineffective RBC production
• or
• 2. Accelerated destruction of the RBC
• The Reticulocyte count and RBC indices are key
  to breaking these large categories down into a
  manageable differential

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Developing your differential

• History and Physical
• certainly always important but rarely THE KEY in
  anemia
• Blood tests
• CBC
• indices
• retic count
• peripheral smear

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Reticulocytes

• Immature red blood cells (larger than mature
  RBCs)
• Corrected retic count retic(pts
  HCT/nl HCT)
• Retic Production Index corrected
  retic/maturation time
• gt3 adequate response
• lt2 poor response

• Maturation time
• HCT Mat time
• 40-50 1
• 30-39 1.5
• 20-29 2
• 10-19 2.5

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Mentzer index

• Calculated number to help differentiate between
  iron deficiency vs. thalassemia if have
  microcytic anemia
• MCV/RBC
• gt13 iron deficiency
• lt13 thal trait

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Differential of Anemia
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Hgb Norms

• Normal values vary by age and gender
• high in neonates,
• falls to lower-than-adult values by 3-6 months,
• rises gradually to adult value by the early
  teenage years
• On average, adult females have lower hemoglobin
  levels than adult males.

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MCV

• Mean Corpuscular Volume (MCV) - a direct
  measurement of red cell size.
• Microcytic vs macrocytic vs normocytic.
• Note (relative to adults) the MCV is high in
  neonates, and low in infants and children, rising
  to adult values by the teenage years.

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Hgb and MCV Variability
Contemporary Pediatrics, Vol 18, No. 9
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Hypochromic, Microcytic
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Normochromic, macrocytic
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Normochromic, normocytic
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History

• Pallor
• Energy
• Diet history, especially milk intake
• Pica, behavior problems, irritabiliby
• Evidence of blood loss (melena, hematochezia,
  BRBPR, hematemesis, menorrhagia

• Older children decreased exercise tolerance,
  palpitations, syncope, poor school performance
• Recent drug use
• Recent viral illness
• Recurrent diarrhea
• Possible lead
• Family history of anemia

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Physical Exam

• Vitals
• Activity
• Color (gums, conjunctiva, palmar creases)
• Murmur/tachycardia
• Lymphadenopathy, organomegaly
• Stool guaiac
• Skeletal anomalies
• Joint swelling/renal problems

• Acutely jaundice, tachypnea, tachycardia,
  splenomegaly, hematuria, congestive heart failure
• Chronically irritability, pallor, glossitis,
  systolic murmur, growth delay and nail bed
  changes

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Treatment

• Depends largely on etiology
• Fe
• Vitamin C
• Empty stomach
• Side effects

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Follow up

• Check retic 7-14 days (should see increase)
• Re-check CBC 4-6 weeks (should be approx normal)
• Continue iron 3-4 months (to replace stores)
• Generally, should not need treatment for more
  than 5 months unless there are ongoing losses

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Case 1

• 24 month old presents for well child check
• No parental concerns
• Meeting milestones
• Physical unremarkable

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Screening Lead CBC

• Lead lt3
• WBC 10.9
• RBC 4.5
• Hgb 8.5
• Hct 25.5
• MCV 66
• MCH 22
• RDW 20

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Questions

• What lab tests are abnormal?
• What additional history would you elicit?
• What are three ways milk can affect iron stores?
• How much milk should a 24 month old be allowed?

• Why is iron important?
• Is it surprising the child was asymptomatic?
• How would you treat this patient?
• How long before you recheck labs and what would
  you expect?

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Case 2

• The patient has a twin with similar dietary
  habits
• H H are performed and are 11.5/33.5
• An extra tube is on hold for any other studies
  you might want
• What labs do you want to add on?

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Case 3

• Another 2 year old with excessive milk intake
• Routine labs today Hgb 11.3, MCV 64.9, RDW 16.3
• Labs from 1 year ago Hgb 12.2, MCV 74.8.
• Iron deficiency was presumed, family counseled on
  reducing milk intake
• Patient started on Poly-vi-sol with iron
• 6 weeks later Hgb 11.3, MCV 68.2, RDW 16.9 and
  retic 0.8

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Questions

• Should you do an electrophoresis on this patient?
• How much does this cost?
• Why is this test not worth doing in this patient?
• What would you suggest?

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Case 4

• The family of the twins returns with their 6 y.o.
  daughter and 9 month old son requesting they be
  screened for iron deficiency
• The baby has had a fever for the last 2 nights
  and the family asks you to check his ears as
  well.
• The baby is still being breast fed, but has taken
  solid foods since age 5 months.

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Labs

• 6 year old girl
• WBC 8.7
• Hgb 10.2
• Hct 30.6
• MCV 75
• RDW 15
• Plts 225

• 9 month old boy
• WBC 17.2
• Hgb 10.6
• Hct 31.8
• MCV 72
• RDW 14
• Plts 290

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Questions

• Should these patients be started on iron?
• What other tests would you like?

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• The girl is found to have guaiac positive stools,
  work-up of which leads to diagnosis of Meckles
  diverticulum.
• The boy was diagnosed with otitis media and had a
  neg w/u. He is started on Fe replacement. You
  see him again in 8 weeks for re-check of his
  ears, and repeat the CBC, which is essentially
  unchanged. Parents say they have been compliant
  with Fe supplementation
• What is the diagnosis treatment?

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Cases 6 7

• 6 month old male with PMH of cleft palate repair,
  presents with pallor, lethargy, and difficulty
  feeding. He seems to be getting gradually worse
  over the previous few weeks. O/E tachypnea,
  wheezing, tachycardia. CBC WBC 3.9, Hgb 2.7,
  Hct 8.1, MCV 90, Plts 412, Retic 0.3
• 3 yo female with no PMH presents for WCC. She
  has recently suffered for a viral URI, but now
  all symptoms have resolved. Exam is normal,
  other than significant pallor. CBC reveals WBC
  2.5, ANC 750, Hgb 6.1, Hct 18.3, MCV 76, Plts
  550, Retic 0.4

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Questions

• What is the differential diagnosis?
• Which is most likely in case 6? Case 7?
• What additional labs can help make the diagnosis?
• What is known about the pathogenesis of these
  anemias?
• What is the treatment of these anemias?
• What is the prognosis for these anemias?

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Case 8

• A 4 year old boy presents with fever,
  irritability and pallor of several days duration.
  
• On examination he has petechiae and a palpable
  liver and spleen.
• Discuss your differential diagnosis and initial
  assessment of this patient.

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Differential Diagnosis for Infants

• Physiology
• Enzymothapy
• Hemoglobinopathy
• malignancy

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Differential Diagnosis for Children

• Iron deficiency
• Aplastic crisis
• Blood loss
• Transient erythroblastopenia of childhood
• malignancy

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Differential Diagnosis for Adolescents

• Iron deficiency
• Chronic diseases
• B12/folate deficiency
• Blood loss
• Malignancy

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Fast CasesFrom Contemporary Pediatrics,
September 2001
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• The CBC of an 8 yo girl reveals the following
  Hgb 11.5, MCV 102, Retic 0.4, WBC normal, Plts
  125.
• She is slightly short, has several large
  café-au-lait spots, is performing below average
  in school and has short thumbs. The smear shows
  large RBCs, some of which are tear-drop shaped
• What does she have?
• Fanconis Anemia

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• An 18 month old girl was in good health until she
  developed a cold 10 days ago.
• Now she is pale but without visible jaundice.
• The CBC shows a Hgb of 6.8, MCV of 78 and retic
  of 0.1, WBC Plts are normal as is the
  peripheral blood smear.
• What does she have?
• Transient Erythroblastopenia of Childhood

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• A 6 month old boy has fever and irritability and
  a WBC of 20 x 103 (67 polys, 24 bands, 9
  lymphs), Hgb 9, MCV 82 and a retic of 1
• The smear shows rouleaux formation (stacking of
  RBCs atop one another) but is otherwise normal
• What does he have?
• Anemia of inflammatory disease

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• A 3 yo Hispanic-American girl has had diarrhea,
  sometimes bloody, for several days. Now, she has
  fever, edema, petechiae hypertension.
• The CBC shows Hgb 7.5, MCV 79, Retic 15, Plts
  35, and WBC 13.5 with a normal differential. The
  smear shows several helmet cells and
  polychromasia and confirms the thrombocytopenia
• What does she have?
• Hemolytic Uremic Syndrome

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• A 9 month old Caucasian boy comes the Dr.s
  office for evaluation of a cold. Further hx
  reveals introduction of whole cows milk at 5
  months with copious quantities (40oz/day) and no
  well baby visits.
• He appears quite pale and has the following
  findings Hgb 5.3, MCV 48, plts 780, WBC 12.5
  and retic 1.7
• What does he have?
• Iron Deficiency

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• You are asked to assist in the care of political
  refugees from south China. On the screening
  entrance exam you note that one of them, a 2 yo
  girl, is very pale and lethargic. Her spleen is
  down to the level of the umbilicus.
• The labs reveal Hgb 6.3, Retic 12, MCV 55,
  with normal WBC plts.
• The smear shows many target cells, polychromasia,
  basophilic stippling, pseudopods and hypochromia.
• What does she have?
• Hemoblobin EE ? thalassemia

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• A 3 month old African-American boy is brought to
  the ED lethargic and with a fever of 40 C.
  While attending to the airway, correcting
  hypotension and initiating antibiotics, the nurse
  informs you of the CBC results Hgb 5.8, MCV 81,
  Retic 16, WBC 23.5 (56 polys, 24 bands, 10
  lymphs, 10 atypical lymphs) and plts of 35.
• He has blood on dipstick analysis of his urine
  with no RBCs on microscopic analysis.
• The blood shows several spherocytes, moderate
  blister cells, and several bite cells.
• What does he have?
• G-6PD Deficiency

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• A 15 yo Hispanic-American girl with a history of
  systemic lupus erythematosus comes to the clinic
  for evaluation of fatigue and pallor.
• Hgb is 7.2, MCV 85, Retic 3.5, WBC 3.5 (50
  polys, 40 lymphs, 10 atypicals), and plts of
  125.
• The smear shows microspherocytes and rouleaux
  formation. She does not have a history of blood
  loss.
• What does she have?
• Autoimmune hemolytic anemia

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Resources

• Abshire, T. Sense and sensibility Approaching
  anemia in children. Contemporary Pediatrics, Vol
  18, No. 9.
• Hermiston, M. A practical approach to the
  evaluation of the anemic child. Pediatric
  Clinics of North America, Vol 49.
• Irwin, J. Anemia in Children. American Family
  Physician, Oct 15, 2001.
• Segel et al. Managing Anemia in a Pediatric
  Office Practice - Part 1. Pediatrics in Review,
  Vol 23, No.3, March, 2002.
• Segel et al. Managing Anemia in a Pediatric
  Office Practice - Part 2. Pediatrics in Review,
  Vol 23, No.4, April, 2002.