1. Anemia in Children: When to Transfuse
Adekunle Adekile, MD, PhD
Professor
Department of Pediatrics
Kuwait University

2. Outline Normal Hb levels at different ages Classification
History and Physical Examination
Indications for transfusion
Case studies
Practical Precautions

3. Normal Values at Different Ages
Hb (g/dl)
RBC
WBC
Birth
2 weeks
2 months
6 months
1 year
2-6 years
6-12 years
12-18 years (F)
12-18 years (M)

4. Morphologic Classification
Microcytic Anemias
Iron deficiency
Chronic lead poisoning
Thalassemias
Chronic inflammation

5. Classification Contd. Macrocytic anemias With megaloblastic marrow
vitamin B12 deficiency
folic acid deficiency
Without megaloblastic marrow
aplastic anemia
Diamond-Blackfan anemia

6. Classification Contd. Normocytic Anemias Congenital hemolytic anemias
hemoglobin mutants
RBC enzyme defects
RBC membrane defects
Acquired hemolytic anemias
antibody mediated
microangiopathic hemolytic anemias
Secondary to acute infections
Acute blood loss
Splenic pooling
Chronic renal disease

7. History Taking Age – Fe deficiency common in infants
Sex – X-linked traits e.g. G6PD deficiency
Ethnicity- hemoglobinopathies common in Mediterranean and Middle East
Neonatal History - ?early hemolysis
Diet - any evidence of malnutrition; exclusive breastfeeding in older infant
Drugs - bone marrow suppression, hemolysis
Infection - bone marrow suppression, hemolysis
Inheritance - X-linked, autosomal recessive or dominant
Diarrhea - ?malabsorption

8. Physical Examination Skin - pallor
Facies – skull bossing, maxillary hyperplasia
Eyes - jaundice
Mouth – glossitis, cheilosis etc
Heart – tachycardia, functional murmurs
Hands - koilonychia
Spleen/Liver - enlargement

9. RBC Transfusion: Indications
Basic Rule: age, how rapid and how severe?
Acute Blood Loss
10 – 15%
Pre- or peri-surgical operation
Hb <10 g/dl
Symptomatic Anemia, usually with fall of 2 g/dl from baseline
Hb <7 – 8gdl
Suboptimal O2 Capacity (hypoxia, cyanotic heart disease)
Hb < 12 – 13%
Exchange (in neonates to prevent kernicterus or in HbSS for primary or secondary prevention of stroke)
Special considerations in premature babies and critically ill

10. Case I Previously well 1-year-old male
2 day’s history of pallor and mild jaundice
Recent febrile illness
No other pertinent findings except for mild splenomegaly
HR 100/min; ESM, RR 20/min
Hb 6 g/dl, normocytic, normochromic; retics 5%, LDH 500 iu/l, total bilirubin 35 mmol/l
DCT +ve
What’s the diagnosis?
Do you transfuse?

11. Case II
1-year-old boy
1-day history of pallor, jaundice and dark urine
No previous episode
History of fava bean ingestion
Hemodynamically stable
Hb 8 g/dl
Do you transfuse?

12. Case III 1-year-old Poor feeder, still breastfed
Presents with pallor of 2 months duration
No other pertinent findings
Hemodynamically stable
Active child
Hb 4 g/dl, MCV 48 fl, MCH 18 pg, RDW 20%
Ferritin 4 ng/ml
?Transfuse

13. Case IV 1-year-old boy Known thalassemia major patient since 4 months
Not regularly seen in the clinic
Presents in the ER with Hb 9 g/dl
Mother requests admission for transfusion
What do you do?

14. Case V 1-year-old known HbSS patient
Presents with cough, fever and chest pain
CXR show bilateral infiltrates
O2 sat 92%
Hb 9 g/dl (her usual Hb is 11g/dl)
Do you transfuse?

15. Acute Transfusion Reactions
Hemolytic Reactions (AHTR)
Febrile Reactions (FNHTR)
Allergic Reactions
TRALI
Coagulopathy with massive transfusions
Bacteremia

16. Products for Transfusion
Leukoreduced
Prevention of CMV, febrile reaction and WBC alloimunization
CMV-negative
Infants <6 months, transplant candidates, immunodeficiency
Irradiated RBCs
Infants < 6 months, malignancies, chemo or radiation, transplant, immunodeficiency
Washed RBCs
Hyperkalemia with poor renal function, anaphylaxis, PNH
Extended phenotyping
Hemoglobinopathy on chronic transfusion therapy
Dose
10 – 15 ml/kg; rate depends on the clinical condition and age

17. Precautions Prescribing doctor Administering doctor
State indication for Tx
Volume and rate to be transfused
Any anticipated problems and precautions
Fever
Allo or autoantibodies
Administering doctor
Check the name and identity of receiving patient
Cross-check the blood group and X-matching
?any antibodies (DCT, auto/allo)
Liaise with the nurse and give clear written instructions as indicated

18. Precautions Contd Nurses Two nurses
Reconcile the unit and the patient to make sure there’s no mix-up
Look at all orders from the prescribing doctor
In case of any doubt, check with the doctor again
Bring blood to room temperature
Monitor patient’s subjective feelings
Itching, rash
Lightheadedness, chest tightness
Nausea, vomiting or diarrhea
Headache
Monitor vital signs and promptly alert doctor if there’s any problem
Jaundice, pallor, dark urine
Clear record of the transfusion events

19. Thank you