Approach to Anemia in Children - UG MBBS

Diagnosis, treatment of various types of anemia in children

1. Approach to anemia in children
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Dr SwatiPatel Jain
MD (Pediatrics) FNB (Pedhem onc)
Assistant Professor
Department of Pediatrics
SAMC & PG institute

2. DEFINITION
Anemia refers to reduction in the oxygen
carrying capacity of blood
•reduced levels of Hb
•reduced red cell mass
Hbor red cell mass less than 2SD below mean
for normal
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3. WHOvalues for diagnosis of anemia
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4. Grades of severity of anemia
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5. Clinical presentation
Symptoms depend upon the type of onset
pallor
tiredness
lassitude
easy fatigability
weakness
shortness of breath/ CCF
behavior changes
growth retardation
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6. 6
Detailed history, thorough physical examination,
laboratory tests : screening and confirmatory
essential to establish the diagnosis
Etiology
Cause of
anemia
Blood loss
Decreased
production
Increased
destruction

7. History
Acute onset
•hemorrhage
internal/external
•hemolysis
association of significant
icterus with acute onset
anemia suggests hemolysis or
internal haemorrhage
Chronic /insidious onset
•obvious blood loss
•occult blood loss
asymptomatic for long
duration
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8. Family history –PEDIGREE!
•Thalassemia
•Sickle cell anemia
•enzyme deficiency-g6pd, pk, pfketc
•membrane defects -HS
•bone marrow hypofunction
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9. Dietary history
•bottle feeding
•complementary feeds
•intake of goat’s milk
•decreased intake of iron, folic acid, B12,
proteins, vitamin C & E.
•food fads
•picas
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10. History of drugs
hypoplasia
chloramphenicol
salicylates
analgesics
NSAID’s
hemolysis
•penicillin
•cephalosporin
•methyldopa
•stibophen
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G6PD deficiency : Sulfa’s, nalidixicacid, nitrofurantoin, antimalarials

11. History of bleeding
•ITP
•aplasticanemia
•malignancies
•marrow infiltration
•malaria
•anemia of chronic disease
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History of infections

12. Physical examination
•vital signs
•puffiness
•edema feet/sacral edema
•raised JVP
•tender liver
•hepatojugularreflex
•basal crepitations
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13. Physical examination (cont)
Skeletal changes
hemolytic facies or box like facies
absent radii
absent/bifid thumb/triphalangealthumb
short stature
microcephaly
mental retardation
hypogonadism
skin hyperpigmentation
renal abnormalities
high arched palate
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14. Physical examination (cont)
Eyes
•microcornea
•tortuosityof
conjunctival vessels
•retinal hemorrhages
•microaneurysm
•blindness
Nails
•platynychia
•koilonychia
•brittle nails
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Nail dystrophy, skin pigmentation & leucoplakia
Dyskeratosis Congenita

15. Physical examination (cont.)
Lymphadenopathy
•Tuberculosis
•HIV
•Infectious mononucleosis
Generalized lymphadenopathy, anemia and
hepatosplenomegaly : rule out leukemia
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16. Physical examination (cont)
Hepatosplenomegaly
leukaemia
thalassemia
HIV
malaria
kala-azar
tropical splenomegaly
immune hemolytic
anemia
storage disorder
portal hypertension
enteric fever
CML
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17. Mucosal changes
glossitis/angular stomatitis/bald tongue :
nutritional anemia
atrophic gastritis/ achlorhydria
esophageal mucosal web ? Plummer Vinson
Syndrome
non healing ulcer : chronic hemolytic anemia
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Physical examination (cont)

18. Physical examination (cont.)
Disseminated intravascular coagulation
Giant cavernous hemangioma : KasabachMerritt Syndrome
Rare disorder
Decreased platelet counts
Progress to DIC
Microangiopathic hemolytic anemia often associated
PBF : helmet cells, broken cells, crenatedRBC’s, tumors over trunk,
extremities, retroperitoneum, cervical and facial area.
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19. Laboratory approach to childhood anemia
•Hb
•CBC
•Reticulocytecount
•Hct
•Blood indices
MCV
MCH
MCHC
RDW
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Screening tests
Thoroughperipheral smear examination
essential!

20. Classification of anemia
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RDW Mean Corpuscular volume
low normal high
Normal •Heterozygous
αand β
thalassemia
•Normal
•Lead poisoning
•Aplastic
anemia
High •Iron deficiency
anemia
•HbHdisease
•Sβ-thalassemia
•Early iron
deficiency
•Liver disease
•Mixed
nutritional
deficiencies
•Myelofibrosis
•Myelotoxic
drugs
•Newborns,
prematurity
•Vitamin B12
or folate
deficiency
•Immune
hemolytic
anemia

21. Normocytic normochromic anemia
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22. Microcytic hypochromic anemia
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23. Macrocytic anemia
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24. •Reticcount
•Ferritin
•Iron profile
•LDH
•VitB12
•Homocysteine
•Red cell folate
•HPLC/ hemoglobin electrophoresis
•Bone marrow test
•Stool for occult blood
•S. TTG IgA
•UGI/LGI scopy
•RBC techniciumscan
•Thyroid profile
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Specific investigations

25. Reticulocyte count
•reflects bone marrow activity
•expressed as percentage of total RBC’s
•correction needed in severe anemia
Corrected reticulocytecount = actual count x PCV
0.45 (normal PCV)
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26. Specific investigations
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TIBC
Increased
Iron deficiency anemia
Normal
Anemia of chronic
disease
Decreased
Thalassemia
Sideroblastic anemia
Serum ferritin
Assesses iron stores
Falsely elevated in inflammation and liver diseases

27. Specific investigations
Transferrin saturation
Calculated from serum iron and TIBC
Measures iron trafficking and availability for erythropoiesis
Does not measure iron stores
Normal or reduced in iron deficiency and anemia of chronic diseases
Elevated in condition associated with iron loading
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28. Bone marrow examination
•often needed to confirm the diagnosis e.g.
megaloblastic anemia
•diagnostic for aplastic anemia, leukemia,
secondary metastasis
•hyperplasia seen in hemolytic anemia,
hypersplenism
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29. Thank you
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