Anemia in children of different age.

Lecturer:

Sakharova Inna.Ye., MD, PhD.

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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 rare), -Drugs

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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

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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 necessaryHb < 100 g/L with anemia symptoms (younger

than 10 days of life), > 10 days – Hb < 90 g/LHb < 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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