Anemia Approach in Children 14aug2013
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Transcript of Anemia Approach in Children 14aug2013
Is a sign of disease Not a final diagnosis
The goal of the diagnostic evaluation is to determine the cause of anemia
Reduction in the hemoglobin concentration or red blood cells per cubic millimeter below the range of values occurring in healthy persons.
ANEMIA (WHO criteria)
Age Hb (g/dl)
6 mo - < 5 yrs < 11
> 5 yrs < 12
Biconcave shaped disc with no nucleus Large surface area facilitates the
uptake of O2 and CO2 25 trillion RBC’s in the human body
NORMAL BLOOD SMEAR
Erythropoetin Metals - Fe, Mangenese, cobalt Vitamins – B12, B6, folate, thiamine,
riboflavin, patethoic acid, C, E Amino acids Hormones – GM-CSF, Stem cell factor,
thyroxine and androgens
Hematopoiesis
It is important to establish : A single cell line problem (red blood
cells)Or
A multiple cell line problem (red cell, white cell, and platelets)
Usually indicates bone marrow involvement, immunologic
disorders, peripheral destruction of cells
1. Disorders of effective red cell productiona. Marrow failureb. Impaired erythropoietin productionc. Abnormalities of cytoplasmic
maturationd. Abnormalities of nuclear maturatione. Dyserythropoietic.
2. Disorders of increased red cell destruction
a. Defects of hemoglobinb. Defects of the red cell membranec. Defects of red cell metabolismd. Antibody-mediatede. Mechanical injury to the erythrocytef. Thermal injury to the erythrocyteg. Oxidant-induced red cell injuryh. Paroxysmal nocturnal hb-uriai. Hypersplenism
3. Blood Loss
1. Detailed history and physical examination2. Complete blood count.3. Determination of morphologic
characteristics and RDW.4. BMP (if required).5. Determination of underlying cause of
anemia by additional test.
1. Maternal history 2. Family history3. Patient history
Pregnancy/delivery complications Anemic during pregnancy Pica/ nonfood product ingestion Drug ingestion
Anemia Jaundice Splenomegaly Gallstones Cancer Transfusion Bleeding disorders
Anemia (acute or chronic) Acute or recent infection, Evidence of chronic disease/ infection, Easy bruising/blood loss, Prematurity, Hyperbilirubinemia, Diet history, Medications, Endocrinopathy, Liver disease
Several clues to the etiology : Tachycardia acute process with
poor compensation. Normal HR more chronic process Jaundice hemolytic process Splenomegaly inherited hemolytic
anemia, malignancy, portal hypertension
BLOOD SMEAR Microcytic Anemia (MCV<80fl) Normocytic Anemia (MCV 80-
100 fl) Macrocytic Anemia (MCV >100
fl)
Age (yrs) MCV (fl)
1 - 3 days 95 - 121
0.5 – 2 70 - 84
2 – 4 73 - 85
5 – 7 75 - 87
8 – 11 77 - 90
12 – 14 78 - 91
15 – 17 78 - 94
18 – 19 80 - 100
ANEMIA
MCV
MICROCYTIC NORMOCYTIC
MACROCYTIC
Iron Deficiency
Thalassemia
Chronic disease
Lead poisoning
Reticulocyte count
High
Bilirubin
Normal
Hemorrhage
High
Hemolytic
Coombs test
Coombs TestNegative Positive
Hb-pathy
Membrane defect
Secondary : drugs, infection
Autoimmune
Isoimmune
ANEMIA
MCV
MICROCYTIC NORMOCYTIC MACROCYTIC
Reticulocyte Leukocyte & Platelets
Low Normal Increased
Malignancy
Aplastic Anemia
Pure red cell aplasia Diamond Blackfan Transient erythroblastopenia
Infection
ANEMIA
MCV
MICROCYTIC MACROCYTIC NORMOCYTIC
Folate deficiency Vit B12 defic. Aplastic anemia Preleukemia Liver disease
RDW (Red cell distribution width) = variation of the erythrocyte volume distribution.
(N = 11.5 – 14.5%)Normal RDW = homogen, slight anisocytosis RDW = heterogen, anisocytosis (++)Reticulocyte = indicator of bone marrow activities
Anisocytosis = variation in sizePoikilocytosis = variation in shape
Look at : RBC count (erytrocyte count), RDW, retyculocytes, blood smear
Erytrocyte RDW Retic Slide
Trait Thal N poikilositosis (+)
ADB N / N / anisositosis (+),
hipokromThal poikilositosis,
anisositosis (++)hipokrom
Defects of hemoglobin : sickle cell Defects of the red cell membrane :
spherocytosis Defects in red cell metabolism : G6PD, pyrivate
kinase deficiency Immune hemolysis Physical / chemical damage to red cells Infectious agent-induced damage : malaria Paroxysmal nocturnal hb-uria (PNH)
History P.E. Lab : - elevated reticulocyte count
- Coombs test - Hb electrophoresis - osmotic fragility - specific enzyme assay - blood smear