Approach to Anemia
How to efficiently and accurately work up the anemic children
Anemia
Is a sign of diseaseNot a final diagnosis
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The goal of the diagnostic evaluation is to determine the cause of anemia
Definition of Anemia
Reduction in the hemoglobin concentration or red blood cells per
cubic millimeter.
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ANEMIA (WHO criteria)
Age Hb (g/dl)
6 mo - < 5 yrs < 11
> 5 yrs < 12
Anemic Child
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
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Physiologic classification of anemia
1. Disorders of effective red cell production2. Disorders of increased red cell
destruction3. Blood loss
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a. Marrow failureb. Impaired erythropoietin productionc. Abnormalities of cytoplasmic
maturationd. Abnormalities of nuclear maturatione. Dyserythropoietic.
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
The investigation of Anemia
1. Detailed history and physical examination
2. Complete blood count.3. Determination of morphologic
characteristics and RDW.4. BMP (if required).5. Determination of underlying cause
of anemia by additional test.
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Important features in the history of the anemic child
1. Maternal history 2. Family history3. Patient history
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Pregnancy/delivery complications
Drug ingestionPica/ nonfood product ingestionAnemic during pregnancy
Anemia Jaundice SplenomegalyGallstones Cancer TransfusionBleeding disorders
Hyperbilirubinemia, Prematurity, Diet history, Medications, Acute or recent infection, Evidence of chronic disease/ infection, Endocrinopathy, Liver disease, Easy bruising/blood loos
Physical examination
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
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Morphology classification of Anemia
BLOOD SMEAR Microcytic Anemia (MCV<80fl) Normocytic Anemia (MCV 80-
100 fl) Macrocytic Anemia (MCV >100
fl)
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Reference Range of MCV
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
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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
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ANEMIA
MCV
MICROCYTIC NORMOCYTIC MACROCYTIC
Reticulocyte
Leukocyte & Platelets
Low Normal Increased
Malignancy
Aplastic Anemia
Pure red cell aplasia Diamond Blackfan Transient erythroblastopenia
Infection
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ANEMIA
MCV
MICROCYTIC MACROCYTIC NORMOCYTIC
Folate deficiency Vit B12 defic. Aplastic anemia Preleukemia Liver disease
Other lab examination
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
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Anemia Mikrositik
Perhatikan : jumlah eritosit, RDW, retikulosit, gambaran sediaan apus darah tepi.
Juml Eri RDW Retik Slide
Trait Thal N poikilositosis (+)
ADB N / N / anisositosis (+),
hipokromThal poikilositosis,
anisositosis (++)hipokrom
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