Anemia in children of
different age.
Lecturer:
Sakharova Inna.Ye., MD, PhD.
Anemia is defined as hematocrit
(Hct), hemoglobin (Hb), red blood
cells (RBC) concentration >2 SD
below mean for age.
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Prevalence of anemia in INDIA (WHO
reports 2002-2003)
• 7 states (Assam, HP, Hy, Kerala, MP, Orissa, TN )
– 86.1% of pregnant women have anemia
(Hb <70g/L- 9.5%);
- 81.7 % of women during lactation have anemia
(Hb <70g/L - 7.3%)
• 90% adolescents are also anemic
(Teoteja et al 2003)
• > 80% children younger than 3 years are anemic
(NFHS-II& Agarwal et al., 2003)
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Anemia criteria (capillary blood) in
newborns
In newborns of the first and the second weeks
of life
• Hb < 145 g/L
• Hct < 45 %
• RBC < 4,5 * 1012/L
The third week and fourth weeks of life
• Hb < 120 g/L
• Hct < 40 %
• RBC < 4,0* 1012/L
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Normal values of Hb according WHO criteria
(capillary blood) :
• In infants from 2 to 6 months – > 95 g/L
• In children from 6 months to 5 years - > 110 g/L
• Elder than 5 years - > 120 g/L
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CAUSES OF NEONATAL ANEMIA:
1. BLOOD LOSS (POSTHEMORRHAGIC), the
commonest cause of anemia, including:
A. Obstetrical causes: placental abruption,
placenta previa, trauma to placenta or
umbilical cord during delivery and rupture of
anomalous placental vessels
B. Feto-maternal transfusion: 8% of normal
pregnancies have some blood admixture.
C. Feto-placental transfusion due to positioning
of infant above level of placenta after delivery,
partial cord occlusion
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D. Twin-twin transfusion Occurs only with
monochorionic (i.e., monozygotic) twins and
when there are placental vessels which allow
shunting of blood from one twin to the other.
•Donor will have anemia of variable severity.
•Recipient will have polycythemia of variable
severity.
E. Internal hemorrhage such as intracranial
hemorrhage, subgaleal hemorrhage,
cephalohematoma, adrenal hemorrhage,
subcapsular hematoma of liver etc.
F. Iatrogenic blood loss secondary to sampling
of blood for laboratory tests. This is the
commonest cause of anemia in newborns
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2. INCREASED RBC DESTRUCTION
(HAEMOLYTIC):
A. Intrinsic causes: Hereditary RBC disorders
(rare), including:
•RBC Enzyme defects (e.g., G6PD deficiency)
•RBC membrane defects (e.g., hereditary
spherocytosis)
•Hemoglobinopathies (e.g., α-thalassemia)
B. Extrinsic causes:
•Immune hemolysis: -Rh incompatibility, -ABO
incompitability, -Minor blood group
incompatibility (e.g., Kell, Duffy), -Hemangiomas
(Kasabach-Merritt syndrome)
•Acquired hemolysis: -Infection, -Vitamin E
deficiency (of historical interest, now it is very
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rare), -Drugs
3. DECREASED RBC PRODUCTION
(HYPOPLASTIC, DEFICIENCY):
A. Anemia of prematurity due to transient
deficiency of erythropoietin
B. Aplastic or hypoplastic anemia (e.g.,
Diamond-Blackfan)
C. Bone marrow suppression (e.g., with
Rubella or Parvovirus B19 infection)
D. Nutritional anemia (e.g., iron deficiency),
usually after neonatal period
E. Megaloblastic anemia (B12 and/or folic
acid deficiency)
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Physiological anemia of infancy
• Normal newborn- High Hb level progressively
declines by 8-12 wk -9-11g/dl.- Hypoxia
stimulates Renal and Hepatic oxygen sensors –
erythropoietin production increases.
• Preterm- Hb decline is extreme & rapidly falls
to 7-9 g/dl by 3-6 wk of age.- Sampling for Lab
tests. There are relatively insensitive Hepatic
oxygen sensors; as Renal Oxygen sensors
switch on at 40 wk of gestation.
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CLINICAL FINDINGS IN ANEMIA
•Pallor
•Tachycardia, tachypnea
•Apnea
•↑ O2 requirements
•Lethargy
•Poor feeding
•Hepatosplenomegaly (hemolytic disease)
•Jaundice
•Hypotension
•Metabolic acidosis with severe anemia
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DIAGNOSTIC EVALUATION OF ANEMIA:
1. History:
• Family: Anemia during pregnancy,
ethnicity, jaundice in anamnesis
• Maternal and perinatal: Blood type and
Rh; anemia; complications of labor or
delivery
• Neonatal: Age of onset; presence of other
physical findings
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2. Laboratory Evaluation
• CBC with platelets, smear and reticulocyte count
• Blood group and type, direct antiglobulin test
(Coombs test)
• Bilirubin (total and indirect)
• Kleihauer-Betke Test (on maternal blood to look
for fetal red cells as evidence of feto-maternal
transfusion)
• Ultrasonogram for internal bleeding (head,
abdomen)
• Rarely, haemoglobin electrophoresis and RBC
enzymes
• Bone marrow aspiration is exclusively rare
necessary to diagnose anemia in a newborn 18
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Mentzer Index
• MCV/RBC > 14 = Iron Deficiency
• MCV/RBC < 13 = Thalassemia Minor
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MANAGEMENT will depend on cause
and severity of anemia:
1. Prenatal:
Diagnosis of significant fetal anemia is
unusual except in hemolytic disease of the
newborn and Parvovirus B-19 infection.
Fetal transfusion may be needed for severe
anemia.
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2. Postnatal:
A. Anemia of prematurity: The main methods
of management are:
• Limit blood taking for laboratory tests
• Treatment with recombinant human
erythropoietin (r-Hu-EPO), Epoetin  - 150
– 200 units/kg subcutaneously three times
per week
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Indications for transfusion with packed
red blood cells (PRBCs) in neonatal
anemia
Rule № 1.
All transfusions that are not strictly
indicated are strictly contra-indicated
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Indications for transfusion with packed
red blood cells (PRBCs) in neonatal
anemia
• For premature babies:
Hb < 70 g/L, Hct < 30 % BUT
can be indicated although in higher Hb
level (not more than 90 g/L usually) if
newborn has is tachycardia > 170 per
minute, tachypnea > 60 per minute or
cardiomegaly on X-ray
only because of anemia (other reasons
have to be excluded)
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Indications for transfusion with packed
red blood cells (PRBCs) in neonatal
anemia
• For term babies (European Transfusiologists
Society, 1998)
 Anemia with acute heart insufficiency
- 5 ml/kg slowly during 2-4 hours
- repeated transfusions if necessary
 Hb < 100 g/L with anemia symptoms (younger
than 10 days of life), > 10 days – Hb < 90 g/L
 Hb < 130 g/L in severe respiratory diseases
 Hb < 130 g/L immediately after birth
 > 5-10 % of volume of blood circulation loss
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Treatment of hypoplastic anemia
• Glucocorticoids (prednisolone 2 mg/kg/day,
metipred, solupred – 10 mg/kg/day 3-5 days)
• In Fanconi anemia – prednisolone + androgens
• Bone marrow transplantation
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Megaloblastic Anemia
• Hypersegmented Neutrophil – 98% had one
cell with >6 lobes;
• Oval macrocytes.
• Bone-marrow- Large Erythrocyte and
Leucocyte series; Megaloblasts have sieve like
chromatin- dissociation between nucleus and
cytoplasm maturity.
• Vitamin B12 and folate levels to differentiate.
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Peripheral blood smear showing
hypersegmented neutrophils, characteristic
of megaloblastic anemia.
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Treatment of deficiency neonatal anemia
• Fe-deficiency:
After 1 months of life – combination of
iron 3-6 mg/kg in 2 or 3 devided doses
for a minimum of 2 months + folic acid
0,4 mg/kg daily
Before 1 month only folic acid
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Feeding in early infancy
• Baby should be breast fed colostrum and
mature milk, both have 49% absorbable iron
this is sufficient with available fetal stores till
baby doubles the birth weight.
• Weaning foods from 6 months onwards should
have one iron rich dietary item and iron
supplementation be given as recommended.
Cook in iron vessels.
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Iron fortified food.
• Iron supplements have been highly effective in
fortification trials with Egyptian flat breads,
curry powder in South Africa, fish sauce in
Thailand, and sugar in Guatemala.
• In Grenada , flour used in commercial baking is
enriched with iron and B vitamins,.
• Indian researchers have field tested with success
iron fortified salt
• Pasteurized milk (iron 15 mg/ L and vitamin C
100 mg/L)-is used in GB, USA
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Availability of dietary iron by cooking in
cast iron utensils:
• WHO 1992 prevalence of pregnancy anemia
report, records that lowest, rates of all the sub
regions of the developing world were observed in
southern Africa, due to wide spread use of iron
cooking pots by indigenous people.
• It was demonstrated that cooking in cast iron
utensils, for boiling milk, cooking vegetables etc,
provided extra dietary iron. This available dietary
iron is well absorbed.
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Dietary sourses of iron
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