how to reach diagnosis in anemic child

1. Approach to Anemia
Dr. Farhad Shaker

2. Definition
• Anemia is defined as a decrease in
hemoglobin concentration of more than 2
standard deviations below the mean.
• Normal values of hemoglobin and hematocrit
vary with age and gender so it is important to
use age and sex adjusted normal values.
• Race may also influence normal values.

4.  Females often have lower hemoglobin than
males of the same age range.
 A term infant has a normal hemoglobin level
of 15 to 21 g/dl, followed by a physiologic
nadir of 9.5 to 10 g/dl around 2 months of age.
This is exaggerated in premature infants.

5. History and examinations
 History should include iron sources in the
diet. Infants with excessive intake (24 oz. per
day) of cow’s milk or low-iron formula are at
risk.
 Allergy to cow’s milk may also cause occult
gastrointestinal blood losses.
 Goat’s milk is associated with folate
deficiency.
 Vitamin B12 deficiency occurs in those on
macrobiotic diets.

6.  Increased iron requirements occur as a result
of increased menstrual blood losses,
pregnancy, and in prematurity.
 Impaired absorption of iron may be
associated with malabsorptive syndromes
such as inflammatory bowel disease or celiac
disease.
 Pica may suggest lead poisoning.
 A neonatal history of hyperbilirubinemia may
indicate a congenital hemolytic anemia,
especially if there is a family history of
anemia, splenectomy, or cholecystectomy.

7. • Medications may lead to hemolysis, as in
glucose-6-phosphate dehydrogenase (G6PD)
deficiency.
• Infections and chronic disease are also
associated with anemia.
• Travel history may reveal infections such as
malaria.

8. CLINICAL EXAMINATIONS
• In general, anemia (unless acute) may be
asymptomatic until the hemoglobin level is
less than 7 to 8 g/dl.
• Clinical features can include pallor, fatigue,
irritability, and decreased exercise tolerance.
• A flow murmur may be present.

9. • Severe anemia may cause tachypnea,
tachycardia, and ultimately heart failure.
• Chronic anemia may affect growth.
• Chronic hemolytic anemias may cause
expansion of bone marrow with prominent
cheek bones, frontal bossing, and dental
malocclusion.

10. • Splenomegaly may be present.
• Lymphadenopathy and hepatosplenomegaly
occur with infiltrative disease of the bone
marrow.
• Examination may also reveal signs of
systemic disease.
• A careful skin examination may reveal
bruising or purpura.

11. LABORATORY TESTS
• Laboratory testing should include a CBC
including red blood cell indices, a review of
the peripheral blood smear, and a reticulocyte
count.
• 1st step is to look to hemoglobin or PCV
(Hematocrit).
• 2nd step is look to reticulocyte count.

13. • Anemias may be categorized based on
reticulocyte counts, which are affected
by the underlying cause.
• Low reticulocyte counts are seen with
decreased production of red blood
cells.
• Increased reticulocyte counts with
hemolysis or blood loss.

14. • In patients with moderate to severe
anemia, this may appear elevated.
• It is therefore expressed as the corrected
reticulocyte count
• corrected reticulocyte count =
reticulocyte count X observed
hemoglobin/normal hemoglobin for age.
• The reticulocyte count is expressed as a
percent of the total number of RBCs.

15. Classifications of anemia

16. • Anemias may be classified based on red
blood cell size by using the mean
corpuscular volume (MCV) to categorize
anemias into microcytic, normocytic, and
macrocytic.

19. • The American Academy of Pediatrics
recommends universal screening for
anemia at age 1 year with determination
of hemoglobin concentration.
• In addition, selective screening is
recommended at any age for those with
additional risk factors (e.g., prematurity or
low birth weight, exclusive breast feeding
beyond 4 months of age, early weaning to
cow’s milk).

20. Iron deficiency anemia
• Iron deficiency is the most common cause
of anemia in children. If it is suggested by
history and CBC (decreased hemoglobin,
increased red blood cell distribution width
and low MCV),
• A therapeutic trial of iron may be
considered (3 to 6 mg/kg/day of elemental
iron).

21. • Iron-deficiency anemia may be normocytic
in the early stages.
• An increase in hemoglobin of 1 g/dl within
2 to 4 weeks confirms the diagnosis.

22. • Anemia of chronic disease may be
microcytic or normocytic, with increased
erythrocyte sedimentation rate and
decreased serum iron and total iron
binding capacity (TIBC). The ferritin may
be increased due to an inflammatory
state. Because ferritin is an acute phase
reactant and may be influenced by
concurrent infection or inflammation,
some experts recommend also obtaining
a C-reactive protein (CRP) test.

26. • Hemolytic disorders are characterized by
shortened RBC survival and
reticulocytosis. There may be icterus,
splenomegaly, gallstones, and significant
family or neonatal history.
• Laboratory findings include abnormal cell
morphology; increased red blood cell
distribution width, indirect bilirubin, urine
urobilinogen, and lactate dehydrogenase;
decreased serum haptoglobin; and
hemoglobinuria.

28. • A positive antiglobulin (Coombs) test
indicates an immunemediated anemia.
Isoimmune hemolytic anemia is the most
common cause of neonatal anemia. Rh
incompatibility is rare because of
administration of Rh immune globulin to
Rh-negative mothers. When it occurs it
causes severe hemolysis and can occur
as intrauterine hydrops fetalis or severe
jaundice. The direct Coombs test is
strongly positive.

29. • ABO incompatibility occurs when the
mother is blood group O and the fetus is
blood group A or B, and is usually less
severe.

30. COOMBS POSITIVE