Childhood Anemia Ghada Saad Abdelmotaleb Assistant Professor of Pediatric

Objectives : 1-To know what is anemia. 2-To know different types of anemia. 3-How to diagnose and treat anemia?

Anemia Definition :reduction of the red cell volume or HB concentration below the normal range for age. 1- Hemorrhagic Anemia. 2- Decrease RBCs production. 3-Hemolytic Anemia.

Classification of anemia

Symptoms of anemia in children Non-specific symptoms --Pallor. –Irritability. –Poor sleep quality. –Anorexia. –Poor concentration and school work. –Failure to thrive. Dizziness / syncope. Malaise, easy fatigue, impaired exercise. tolerance -Palpitation. - Systolic murmur at base. -Cardiomegaly. - Congestive HF in (sever cases).

Anemia manifesting in neonatal period is usually result of recent blood loss, iso-immunization, congenital hemolytic anemia or congenital infection. Significant jaundice suggest congenital hemolytic anemia (e.g. Hereditary spherocytosis, G6PD, Pyruvate kinase deficiency). Nutritional iron deficiency is seldom responsible for anemia before 6 months of age in term infants (earlier in preterm infants).

Thalassemia syndrome more common in South East Asians and Mediterranean. Sickle cell disease more common in Africans. Diet Assess for dietary sources of iron, folic acid and vitamin B12. Pica suggest iron deficiency.

Laboratory investigations

CBC Haemoglobin : 8.8 g/dl Haemotocrite: 32% Red cell count: /cmm Red cell indices: MCV:68.0 fl MCH:26.3 pg MCHC: 28.7% Leucocytic count: 6100 Basophils: 0% Esinophils: 2% Staff : 2% Segmented:53% Lymphocytes:41% Monocytes:2% Platelet count : /cmm

The red cell indices in CBC MCV (mean corpuscular volume) –The only red cell index directly measured by the electronic counter. –Reflects a quantitative defect in the production of Hb due to ↓hemoglobin synthesis. – Classify anemia into microcytic, normocytic and macrocytic types –Value must be interpreted with age.

MCHC & MCH are calculate values & therefore less accurate. RDW (Red cell volume distribution width): –Reflects the variability in cell size and measures the degree of anisocytosis. –Normal < 14.5% –↑ ↑ in Fe deficiency anemia –Normal in thalassemia trait

Physiological changes in red cell indices (Hb, Hct, RBC) with age Very high level at birth –Relative hypoxemia in fetal life Physiological anemia at 2 –3 month of age –Dramatic reduction in erythropoiesis after birth –Rapid growth in early infancy Gradual rise from childhood to adolescent Higher level in male vs female in adulthood [Effect of androgens vs estrogen, menstruation].

Reticulocyte count (RC) Reflects the rate at which new RBC are produced; Normally < 2% after 3 months; at birth up to 10%. Reticulocytosis :in hemolysis and occur as response to treatment with iron after 48-72h from start == active BM

Causes of iron deficiency anaemia 1-Low birth weight and perinatal hemorrhage. 2-Inadequate dietary iron intake (cow milk, ↓supplementation). 3-Impaired absorption :chronic diarrhea, malabsorption, excessive tea, high phytate intake, antacids, low gastric acidity. 4-Chronic blood loss e.g. ankylostoma, cow milk allergy, peptic ulcer.

Microcytic anemia (DD) Get Iron panel: serum iron, TIBC, ferritin

Treatment Prophylactic : 1-adequate iron to pregnant mother. 2- Breast feeding (exclusive). 3- Iron supplementation after 3 rd month, earlier in premature. Curative : 1-ttt cause 2-Oral iron 6mg elemental/kg /day for 3-6m. 3-Parental iron therapy. 4-Packed RBCs in sever cases ---??HF.

Folic acid deficiency anemia Asynchrony between nuclear and cytoplasm maturation→ ↓DNA,↑RNA → ↑ RBCs size. ↓ Serum folate, thrombocytopenia, hemorrahage Vit. B12 deficiency (juvenile pernicious anemia). {AR} - tongue smooth,red, painful. Neurological [sensory ataxia, parathesias, hyporeflexia, +ve Babiniski, clonus, coma]

Hemolytic anemias (general features) Pallor (acute, chronic) + previous general features of anemia. Tinge of jaundice {indirect hyper-bilirubinaemia} Hepato-splenomegaly. Stool may be dark. Urine (acute crisis →hemoglobinuria)

How to diagnosis? Reticulocytosis >2% + nucleated RBCs in peripheral blood. Hyper- bilirubinamia (indirect). High serum iron +low iron binding capacity. Low RBCs life span. low serum Haptoglobin. High urobilinogin. X-ray : skull, long and short bones, chest and heart

Diagnosis of the cause Shape of RBCs in blood smear. Enzymatic assay. Fragility test sickling preparation (Na metabisulfite). Hemoglobin electrophoresis. Coombs test. Alkaline denaturation test.

Hereditary Spherocytosis AD, abnormal cell membrane. Due to abnormal in sub-membrane protein skeleton (Spectrin) → ↑ permeability to Na →spherical RBCs + ↑ ATP use in Cation pump → premature aging, especially in spleen → destruction and chronic hemolysis. C/P: Early onset (jaundice, neonatal anemia). Aplastic crisis (Human Parvo-virus). Gall bladder stone (pigment stone).

Splenomegaly ??splenectomy Investigations : All as previous + Blood smear Osmotic fragility test. Treatment: 1- Splenectomy ??overwhelming sepsis [capsulated org.] 2- Blood transfusion

G.6.PD deficiency XL- recessive (Glutathione) Oxidizing agents or infection. Acute hemolysis (abdominal pain, nausea, vomiting, hemoglobinuria). Anemia,jaundice. Early neonatal presentation. Diagnosis: Low Hb, high retic. Blood smear [Heinz inclusion bodies+ tear drop RBCs]. Enzymatic activity assay(3m).

Treatment Prophylactic : avoid???????? Curative : 1-Mild : observation. 2-Sever: packed RBCS (10-20ml/kg)