anemia in children, by audace niyigena
TRANSCRIPT
ANEMIA in Children, Assessment and
Management
Audace NIYIGENAIntern in pediatrics
In King Faisal Hospital in KigaliSupervised by
Dr SABITI Stephen
PLANOverviewEtiologiesAssessmentManagmentPrognosis Conclusion
ANEMIA
is a decrease in number of red blood cells(RBCs) or less than the normal quantity of hemoglobin in the blood.
The normal range varies with age, so anaemia can be defined as: Neonate: Hb <14g/dl 1-12 months: Hb <10g/dl 1-12 years: Hb <11g/dl. ˃12years: Hb <12g/dl
Anemia is not a disease, but an expression of an underlying disorder or disease.
ETIOLOGIESProduction defects:
Nutritional deficiencies - Vitamin B12, folate or iron deficiency.
Inflammation/chronic disease. bone marrow disorders- pure red cell
aplasia,myelodysplasia. Blood loss
HemorrhageChronic GI blood loss
Blood destruction. haemolysisSequestration (hypersplenism)-usually associated
with mild pancytopenia
ASSESSMENTdiagnosis is made by:
Patient historyPatient physical examHematologic lab findings
Identification of the cause of anemia is important so that appropriate therapy is used to treat the anemia.
Patient History
Dietary habitsMedicationPossible exposure to chemicals and/or toxinsDescription and duration of symptomsTirednessHeadache and vertigo (dizziness)Dyspnia from exertionG I problemsOvert signs of blood loss such as hematuria
(blood in urine) or black stools
Physical Exam
Hepato or splenomegalyHeart abnormalities
tachycardiaGallop rhythmBounding pulse
Skin pallormalnutrition and neurological changesJaundiceAnginaTrauma evidence
Patients with acute and severe anemia appear in distress, with tachycardia, tachypnea, and hypovolemia.
Patients with chronic anemia are typically well compensated and usually asymptomatic
Hematocrit (Hct) or packed cell volume in %The normal range is 42-60%
Hemoglobin (Hgb) concentration in grams/deciliterThe normal range is 13.5-20 g/dl
An RBC count: The normal range is 13.5-20 g/dl
Reticulocyts :The normal range is 0.5% to 1.5%
Hematologic Lab Findings
Mean corpuscular volume (MCV)Hct (in %)/RBC (x 1012/L) x 10At birth the normal range is 98-123In old child and adults the normal range is 80-
100The MCV is used to classify RBCs as:Normocytic (80-100)Microcytic (<80)Macrocytic (>100)
Mean corpuscular hemoglobin concentration (MCHC) – is the average concentration of hemoglobin in g/dl (or %)Hgb (in g/dl)/Hct (in %) x 100 The normal range is 30-36The MCHC is used to classify RBCs as:Normochromic (30-36)Hypochromic (<31)hyperchromic, not (>37), they just have
decreased amount of membrane.
Mean corpuscular hemoglobin (MCH) – is the average weight of hemoglobin/cell in picograms (pg= 10-12 g)Hgb (in g/dl)/RBC(x 1012/L) x 10At birth the normal range is 31-37In adults the normal range is 26-34This is not used much anymore because it does
not take into account the size of the cell.
Red cell distribution width (RDW) – is a measurement of the variation in RBC cell sizeStandard deviation/mean MCV x 100The range for normal values is 11.5-14.5%A value > 14.5 means that there is increased
variation in cell size above the normal amount A value < 11.5 means that the RBC population
is more uniform in size than normal.
CLASSIFICATION
Using MCV to Characterize Anemia
Microcytic
Iron deficiency anemia
ThalassemiaSideroblastic
anemiaChronic infectionSevere
Malnutrition
Macrocytic
Normal newbornIncreased
erythropoiesisPost-splenectomyLiver diseaseObstructive
jaundiceHypothyroidism
Normocytic
Acute blood loss
InfectionRenal failureLiver diseaseEarly iron
deficiency
management
ManagmentAcute anemia usually warrants immediate
medical attention. Treatment depends on the severity and
underlying cause of the anemiaSupportive measures, such as supplemental
oxygen for decreased oxygen-carrying capacity, fluid resuscitation for hypovolemia, and bed rest or activity restriction for fatigue, may be required
When to transfuse? PRBC dose is 15-20 ml/kg over 3-4 hours. the rate of transfusion can be modified according to the clinical situation.
Give PRBCs if:
Hb ≤7 g/dl with clinical signs of
anemia
Hb˂5g/dl regardless of
clinical signs of anemia
Iron Deficiency AnemiaDx:
Smear: microcytic & hypochromicadditional diagnostic tests
serum ferritin (decreased)serum iron (decreased)Iron binding capacity (increased)Iron saturation (decreased)
Tx:oral iron supplementation: 6mg/kg/day of elemental
iron for at least 3 monthscheck retic count after 2 weeks
Iron Dextranprovides 50mg/ml elemental ironDose(ml) =0.0442 (desired Hgb - Observed Hgb) x Wt +
(0.26 x W)Ferrlecit (sodium ferrous gluconate)
each 10cc provides 125mg elemental irondilute 10ml in 100ml 0.9NS and administer IV over 1 hour repeat for up to 8 sessions
B12/Folate DeficiencyDx:
Smear: Macrocytic (High MCV) RBCs, B12
Low serum B12, Anti-IF Abs,
Folate Serum folate level-- can normalize with a single good meal
Tx:B12 deficiency: B12 1 mg/month IM, or 1-2 mg/day POFolate deficiency: Improved diet, folate 1 mg/day
ThalassemiasGenetic defect in hemoglobin synthesis
synthesis of one of the 2 globin chains ( or )“Ineffective erythropoiesis”
Dx:Smear: microcytic/hypochromic, RBCsFe stores are usually elevated
Tx:Mild: NoneSevere: RBC transfusions + Fe chelation, Stem cell
transplants
PrognosisThe prognosis depends on the severity and
acuteness with which the anemia develops and the underlying cause of the anemia.
Mortality and morbidity rates vary according to the underlying pathologic process causing the anemia, the degree of severity, and the acuteness of the process.
CONCLUSIONAnemia is not a desease but, a condition
caused by various underlying pathologic processes
A proper history and physical examination is more important in an easy way of approaching a child with anemia
Lab exams leads to definitive cause of anemiaAll cases of anemia are not necessary to be
transfused
REFERENCESIllustrated textbook of paediatrics 3rd edition,
Tom Lissauer and Graham Clayden, 2010First aid for Pediatric clerkship, LATHA G.
STEAD et alPocket medicine 4th edition, Mare S.
Sabatine, 2011Emedicine.medscape.com/article/954506Pedinreview.com