Iron deficiency anaemia

1
Appraoch to a child with anaemia
Dr. Pushpa Raj Sharma Professor of Child
Health Institute of Medicine
13.11.2060
2
Definition of anaemia

• The condition of having too few red blood cells.
• It is a reduction of the red cell volume or
  hemoglobin concentration below -2SD for age, race
  and sex.
• Microscopic
• normocytic,microcytic,normochromic
• macrocytic or specific abnormalities
• (spherocyte,sickle cell,target cell)

3
Case

• Nine months old Rai female, single child
• Recurrent fever
• Mass in abdomen with pallor
• No history of rash, bleeding, persistent
  diarrhoea, drug, jaundice, pica,
• Had blood transfusion 2 days back
• No consanguity of marriage
• No family history of gall stones, jaundice.
• No loss of weight, exclusive breast feeding

4
Summary of examination finding

• 9 Kg.
• Mild pallor
• No purpuric rash, lymphadenopathy, abnormal
  facies,
• Gross spleenomegaly

5
Diagnostic Approach-History

• Age Iron def rare without blood loss before
  6mo in term infants.
• Family Hist Genetics
• (1)X-linked G6PD def
• (2)Aut dominant Spherocytosis
  (3)Aut recessive Sickle cell,Fanconi anemia
  
• (4)Family member with early age of
  cholecystectomy/splenectomy (5)Ethnicity
  Thalassemia G6PD def

6
Diagnostic Approach-History

• Diarrhoea
• -Malabsorption of VitB12/E/Fe.
  Inflammatory bowel disease and anemia of
  chronic disease with or without blood loss.
  -Milk protein intolerance induced blood loss
  -Intestinal resection Vit B12 def
• Infection
• - Giardia iron malabsorption
  
• -Intestinal bacterial overgrowth VitB12def
  -EBV,CMV,Parvovirus BM suppression
  -Mycoplasma,Malaria hemolysis
  -Hepatitis aplastic anaemia
  
  -Endocarditis, HIV

7
Diagnostic Approach-History

• Nutrition
• (1)Cows milk dietiron def.
• (2)Strict vegetarianVit B12 def.
  (3)Goats milk Folate def.
  (4)Pica Plumbism,Iron def.
  (5)Cholestasis,malabsorptionVitE def
  
• Drugs (1)G6PDoxidants(sulfa, primaquine, henna)
  (2)Immune mediated hemolysis (penicillin)
  (3)Bone marrow suppression (chemotherapy)
• (4)Phenytoin increase folate requirement

8
Physical exam reveals presence and potential
causes of anaemia

• Fever-acute infection,intravascular
  disease,collagen vascular disease
• Jaundice suggests hemolysis
• PetechiaPurpurableeding tendency
• Hypertensionoedema-renal disease
• Hepatosplenomegaly and lymphadenopathyinfiltrativ
  e disease
• Growth failure or poor wt. gainAnemia of chronic
  disease or organ failure
• Examine stool for blood urine for hemoglobinuria

9
Physical Findings in Anaemia

• SkinHyperpigmentation,café au lait spots-
  Fanconi anemia
  -Jaundice-hemolysis
  
  -Petechiapurpura- BMinfiltration, autoimmune
  hemolysisthrombocytopenia
  -Erythematous rash- Parvovirus,EBvirus
  -Butterfly rash-SLE
  Vitiligo-VitB12def
• HeadFrontal bossing-Thalassemia major
  -Microcephaly-Fanconi anemia

10
Physical Findings in Anaemia

• Eyes Microphthalmia-Fanconi anemia
  -Retinopathy-Sickle cell disease
  -Optic atrophy-Osteopetrosis
  -KF ring-Wilson disease
• Ears Deafness-Osteopetrosis
• Mouth Glossitis-B12 def,iron def
  - Angular stomatitis-Iron def
  -Pigmentation-Peutz Jeghers
  syndrome -Telangiectasia-Osler
  Weber Rendu syndrome

11
Physical Findings in Anaemia

• Chest Cardiac murmur-Endocarditis,prosthetic
  valve hemolysis
• Abdomen Hepatomegaly-hemolysis, infiltrative
  tumour,chronic disease, hemangioma,cholecystitis
  
  -Splenomegaly -hemolysis,sickle cell
  disease,thalassemia,malaria,EBvirus, portal
  hypertension
  -Kidney
  anomaly-pelvic/absent kidney

12
Physical Findings in Anaemia

• ExtremitiesAbsent thumb-Fanconi anemia -Spoon
  nails-Iron deficiency
  -Dystrophic nails-Dyskeratosis congenita
• CNS-Irritable,apathy-Iron def.
  -Peripheral neuropathy-lead poisoning
  -Ataxia,post.column signs-Vit B12def -
  Stroke-Sickle cell anemia
• Short stature-Fanconi anemia, Malnutrition

13
COMPLETE BLOOD COUNT

• Hb Conc (g/dl)
• Hematocrit(PCV)
• MCV (fl)
• MCH (pg)
• MCHC (detects red cell dehydration)
• RBC Count (x10 )
• WbC Count (x10 )
• Platelet Count (x10 )
• Reticulocyte Count ( )

14
Normal values
AGE Hgb Mean/ (-2SD) HCT Mean/ (-2SD) MCV Mean/ (-2SD)
Newborn 16.5 (13.5) 51 (42) 108 (96)
1 Month 13.9 (10.7) 44 (33) 101 (91)
2 Months 11.2 (9.4) 35 (28) 95 (84)
6 Months 12.6 (11.0) 36 (31) 76 (68)
gt 6 Months 12.5 (11.0) 36 (33) 81 (70 age per yr)
Adult Male Female 15.5 (13.5) 14.0 (12.0) 47 (40) 41 (36) 90 (80) 90 (80)
Harriet Lane Handbook, The John Hopkins
Hospital,15th edition
15
Reticulocyte Production Index

• RPI corrects the retics for the degree of anaemia
• RPI indicates whether bone marrow is responding
  appropriately to anaemia
• RPI Retic x Hb(o) x 0.5 divided by Hb(n)
• RPI gt 3 increased production (hemolysis or blood
  loss)
• RPI lt 2 decreased production or ineffective
  production for the degree of anaemia
• Reticulocytopeniaacute onset of anaemia,
  antibody mediated destruction, BMdisease

16
AETIOLOGY

• (1) Inadequate response RPI lt 2
• A. Hypochromic microcyctic
• B. Normochromic Normocytic
• C. Macrocytic
• (2)Adequate response RPI gt 3 R/O blood
  loss---Includes Hemolytic disorders

17
Microcytic Anaemia

• TEST Iron def ThalMin
• S.Iron - low normal
• S.Ferritin - low N/H
  
• Marrow iron - low N/H
• Hb A2or F - N HBthal
• NAthal
• MCV RBC - gt13 lt 13
• Sickle/B-thal Hb S gt Hb A
• Absence of microcytosis in both parents excludes
  B-thal or Sickle/B-thal but not A-thal

18
Macrocytic anaemia

• Vit.B12 def.- (1) pernicious anaemia (2) ileal
  resection (3) abnomal intestinal transport
• Folate def.- (1) malnutrition (2) malabsorption
  (3) chronic hemolysis (4)drugs - phenytoin, sulfa
• Hypothyroidism
• Chronic liver disease
• Marrow failure-Fanconi anaemia,Aplastic A

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Haemolytic anaemia

• Hemoglobinopathy Hb SS,SC,S-B thal
• Enzymopathy--G6PD def, PK def
• MembranopathyHereditary spherocytosis,
  elliptocytosis
• Extrinsic factorsDIC,HUS,Abetalipoproteinemia,Wil
  sons disease,Vit E def
• Immune hemolytic anaemia-Autoimmune,Isoimmune,Drug
  induced

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THALASSEMIA-Lab

• Thal traitHb 9-10 g/dl
• HbH diseaseHb 6-7 g/dl
• Thal intermediaHb 7-8 g/dl
• Thal majorHb less than 5 g/dl
• Peripheral smearhypochromic,microcytic,
  anisopoikilocytosis,target cells
• Hb electrophoresis (1)Thal trait-HbF 1-5,
  HbA2 3.5-8,rest HbA (2)Thal major- HbF
  20-100,HbA2 2-7,HbA 0-60

21
Pure Red Cell AplasiaReticulocytopenia Absent
marrow erythroid precursors.
Congenital (Blackfan-Diamond) Acquired (Transient Erythroblastopenia of Childhood-TEC)
- 1st year of life - congenital anomalies - defective erythroid stem cell - high MCV - treatment prednisone blood transfusion - life long - healthy child - mean age dx 25 mo. - serum inhibitor of erythropoiesis (? virus) - normocytic - treatment transfusion PRBCs (no steroids) - recovery is rule
22
Aplastic anaemia

• Severe reduction
• in platelets and
• granulocyte
• series

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Anaemia of chronic disease Normal morphology
Chronic inflammatory disease(1)infection
(2)collagen vascular disease (3)inflammatory
bowel disease Recent blood loss Malignancy/Marrow
infiltration Chronic renal failure Transient
erythroblastopenia of chidhood Marrow
aplasia/hypoplasia HIV infection Hemophagocytic
syndrome
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24
Haemolytic anaemia

• Polychromasia (Wright-Geimsa).

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Leukaemias

• Blast cells

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Laboratory Evaluation

• HematologyComplete Blood Count, Retic
  count,Peripheral smear,ESR,G6PD
  Sickling(/-inf),Hb electrophoresis,Group,DCT,
  Osmotic fragility test,BMaspiration
• BiochemistryLFT,UE,RFT,S.Ferrtin,
  S.Haptoglobin,Iron,VitB12,Folate,Ceruloplasmin
• SerologyHeterophil antibody,ANA,Viral t
• Urinalysis,microscopy,culture/sensitivity
• Stool exam.for ova,parasites,occult blood
• Endoscopy upper and lower bowel
• ImagingUS Abdomen,Skeletal radiographs, Tc
  pertechnetate scan for Meckels
  diverticulum
• Tissue biopsyskin,lymph node,liver

27

• Nine months old female, single child
• Recurrent fever
• Mass in abdomen with pallor
• No rash, bleeding, persistent diarrhoea, drug
• Had blood transfusion 2 days back
• No consanguity of marriage
• No loss of weight, exclusive breast feeding

• 9 Kg.
• Mild pallor Hb9.4 g
• No purpuric rash, lymphadenopathy, abnormal
  facies,
• Gross spleenomegaly
• Blood report
• TLC 9,600/ cmm P 44 L 56
• Platelets 30.000/cmm Anisocytosis, hypochromic,
  reticulocyte 0.8, occasional NRC.

28
The diagnosis

• Reticulocyte production index
• Retic x Hb(o) x 0.5 divided by Hb(n) 0.3
• RPI lt 2 decreased production or ineffective
  production for the degree of anaemia
• Metabolic
• Malignancy
• Further work up
• Bone marrow

29
Bone marrow report

• Normal values
• Cell Type Range
• Myeloblasts 0-2
• Promyelocytes 2-5
• Myelocytes (neutrophilic)9-16 Metamyelocytes
  7-23
• Band forms 8-15
• Neutrophils 4-10
• Myelocytes (eosinophilic)0-2
• Band 0-2
• Mature 0-3 Monocytes/macrophages0-
  3 Basophils 0-1
• Mast cell 0-2
• Plasma cells 3-6 

• This patient
• Cell Type
• Blast 10
• Promyelocyte 1.5
• Myelocyte 12
• Metamyelocyte 18
• Neutrophils 31

30
Final diagnosis

• Malignancy
• Juvenile Chronic Myelogenous Leukemia

31
The commonest cause

• Iron def. is common in children 9mo-3yr
• Iron def. anemia in a child over 3yr should
  prompt consideration of occult blood loss.
• Infants less than 6months generally do not
  develop iron def. the exception to this rule is
  premature infants,who are at risk of iron def.at
  4mo, if iron supplementation is not given.

32
Iron deficiency Anemia

• Dietary iron def is the usual cause
• Manifestations of anemia
• CNS abnormalitiesapathy,irritability,poor
  conc,cognitive deficits
• Poor muscle endurance
• GIT dysfunction
• Impaired WBC and T-cell function

33
Iron deficiency hypochromic anaemia

• Iron def.-(1)chronic blood loss (2)poor diet
  (3)cows milk protein intolerance
• Chronic inflammatory disease

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34
Differential Features of Iron Deficiency vs Acute
and Chronic Inflammation
Iron Deficiency Anemia Acute and Chronic Inflammation
Red Cell Indices Blood Smear Serum Iron TIBC Transferrin Saturation S. Ferritin B.M. Iron Stores MCV, MCH Microcytic, hypochromic Decreased Increased Decrease (lt7) Decreased (lt12 mg/ml) MCV N or , MCHC N or Normocytic/microcytic Decreased Normal or decreased Decreased (lt16) Normal or increased Normal or increased
35
Iron deficiency Anemia

• TreatmentResponse to oral iron includes
  24-48hr-subjective improvement inCNS
  48-72hr-reticulocytosis
  4-30days-increase in Hb
  1-3 mo-repletion of
  iron stores
• Therapeutic dose3-6 mg/Kg/day of elemental
  iron.---Induces an increase in Hb of 0.25-0.4
  g/dl per day or 1/day rise in hematocrit.
• Failure of response after 2 weeks of oral iron
  requires reevaluation for ongoing blood
  losses,infection,poor compliance or other causes
  of microcytic anaemia.