Anemia

Anemia is decreased concentration of red cells or hemoglobin in the peripheral blood, resulting in decreased oxygen-carrying capacity of blood. It results from blood loss, decreased or failed production of red blood cells, or increased destruction/utilization in the peripheral blood. The clinical impact of anemia depends on degree, rate of development, and cardiopulmonary status of the patient. Common time points for anemia to arise are during the physiologic nadir of development (at about age 2 months) and during growth spurts.

Differential Diagnosis

• Often multifactorial
  Hypochromic, microcytic
• Common
  –Iron deficiency
  –Thalassemias
  –Lead poisoning
• Less common: Acute infection or chronic disease, renal disease (decreased erythropoietin), sideroblastic anemia, protein-calorie malnutrition/anorexia, metabolic defects of iron metabolism

Normocytic, Normochromic
• Blood loss (acute blood loss due to trauma, occult blood loss such as GI, periodic blood loss such as occurs with menstruation)
• Marrow failure
  –Diamond-Blackfan anemia
  –Fanconi anemia
  –Transient erythroblastopenia of childhood
• Increased destruction of RBCs
  –Sickle cell disease
  –Membrane abnormalities
  –Enzyme deficiencies (G6PD, pyruvate kinase)
• Hemolysis: Drug-induced, immune
• Microangiopathic hemolytic anemia
• Hormone deficiencies (e.g., thyroid, growth)
• Acquired pure red cell aplasia
• Pregnancy/obstetric accident
• Marrow invasion or dysfunction
• Early iron deficiency
  Macrocytic
• Common
  –Vitamin B12 and/or folate deficiency
• Less common: Drug-induced, Diamond-Blackfan anemia, Fanconi anemia, congenital heart disease, Down syndrome, myelodysplastic syndromes, erythroleukemia, reticulocytosis (hemolysis, blood loss, marrow recovery), pure red cell aplasia, hypothyroidism, liver disease, metabolic disease, asplenia, spurious

Workup and Diagnosis

• Symptoms are rare unless severe and vary by age
  –Younger: Pallor, irritability, sleepiness, failure to thrive
  –Older: Shortness of breath, exercise intolerance, pallor, palpitations, syncope, headache
• History: Age, gender, race/ethnicity, gestation, blood group; strenuous exercise, previous anemia, travel, jaundice; diet history (especially high milk intake); pica, age of home (older homes used lead-based paint); dark urine, transfusions; symptoms of malignancy (fever, weight loss, night sweats, bone pain), menorrhagia
• Family history: Anemia, cholecystectomy, splenectomy
• Physical exam: Vital signs, growth; nodes, murmur, edema, liver/spleen ascites, masses; spoon nails, frontal bossing, triphalangeal thumbs, hypoplasia of thenar eminence; vibratory and position sense (for B12 deficiency); hyperpigmentation, petechiae, purpura, jaundice
• Labs: CBC, peripheral smear, RBC indices (MCV, RDW, RBC, Mentzer index); reticulocyte count, hemoglobin electrophoresis; stool for occult blood; lead level in younger children; Coombs test and haptoglobin if suspicious of blood loss; iron studies (serum iron, ferritin, total iron binding capacity, % saturation)
• Less often: Urinalysis, G6PD screen, folic acid and vitamin B12 levels, ESR, osmotic fragility
• Bone marrow exam

Treatment

• Dependent upon etiology; if secondary, treat underlying cause or remove offending drug/agent
• Iron deficiency
  –Iron (6 mg/kg/day elemental iron) for 3 months
  –Decrease milk and tannic acid intake
  –Increase vitamin C intake (helps iron absorbtion)
  –Response to therapy is diagnostic
• Thalassemias, hemoglobinopathies, and membrane abnormalities: Referral to pediatric hematologist, may require chronic transfusions
• Folic acid/vitamin B12 deficiency
  –Identify cause (pernicious anemia, drugs, malnutrition, malabsorption, alcoholism, hemolysis, pregnancy)
  –Provide repletion
  –Treat B12 deficiency early to prevent neurologic damage

Book Source Details

• Book Title: In A Page: Pediatric Signs and Symptoms
• Author(s): Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan
• Year of Publication: 2007
• Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: In A Page: Pediatric Signs and Symptoms Authors: Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 1-4051-0427-9

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