Anemia in Children: DR - Muthulakshmi

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Anemia in children

Dr.Muthulakshmi

Definition
A reduction in number of RBCs, blood hemoglobin
concentration, or hematocrit per cubic millimeter,
2SDs below mean for normal population or <5th
percentile for age & sex.

Normal values

Causes of anemia
Blood loss
Decreased production of red blood cells (Marrow
failure)
Increased destruction of red blood cells
hemolysis.

Anemia is merely a sign of


disease.
the goal of the work-up is to
determine the cause

Dietary History

Early and excessive cows milk- >24


oz/d
< 5 servings/wk of meat, grains, fruit,
&
vegetables
Daily fatty foods, snacks, sweets
>16 oz. of soft drinks/d
Strict vegetarian- vit B12 deficient
Goats milk- Folate deficient
Also suggests iron deficiency: Pica

Medications
antibiotics
anti-inflammatories
anticonvulsants

Family History
Maternal history during pregnancy
Anemialow blood, transfusions,
iron supplements

Symptoms
Depends on how rapidly the anemia
develops
Constitutional: fatigue, etc
pallor of mucous membranes
CVS: tachycardia, postural changes,
flow murmurs

Physical examination
Pallor
Petechiae, purpura
Jaundice
Cavernous hemangioma
Glossitis
Angular stomatitis
Splenomegaly
Hepatomegaly, lymphadenopathy

Iron Deficency
World Health Organization - IDA
affects up to 50% of women &
children in developing countries.

Causes of IDA
Poor dietary sources of iron
Rapid growth (infancy, adolescence,
pregnancy)
Exhaustion of gestational iron stores
Early introduction of cows milk
Occult blood loss secondary to cows milk
intolerance, parasitic infestation, chronic GI
loss.
Blood loss (esp. with menses)
Malabsorption states

Iron Deficiency Anemia


Most common anemia in 1-3 year olds
55-60% of 1-2 year olds not getting allowance for
iron
Cows milk is major staple diet which is poor
source of iron 0.7mg/L
30% of daily iron needs in children must come
from diet vs. 5% in adults.

Sequelae of Iron Deficiency


Anemia
Decreased exercise/work tolerance
Irritability, fatigue, and developmental delay
Impaired immunity
CNS Dysfunctionimpaired motor/mental function
Decreased verbal learning

Taking a Diet History

Diet in a typical day


Then, GET THE FACTS!
Ounces of Milk &Juice
Cereals
Vegetables & Meats
Junk

Iron Studies
Gold Standard?
Bone marrow aspirate

Lab studies?
Hb,retic count, blood picture and MCV
ferritin
Serum iron
Total Iron Binding Capacity
Fe Saturation

Microcytic Anemia

Ferritin

Hepatocytes are main site


of storage

Also an acute phase


reactant elevated in
inflammatory disease, liver
disease, neoplasm,
hyperthyroidism

Single most important


blood test for iron stores

Most specific indicator of low


iron stores
Low in iron deficiency (<15
g/L)
Normal in thalassemia
Normal to high: -Lead poisoning,
Chronic inflammation
Infection
Malignancy

Serum iron
Varies significantly daily
A measure of all non-heme Fe in
blood
Virtually all serum iron is bound to
transferrin
Only a trace of serum Fe is free or
complexed in ferritin

TIBC
High specificity for decreased iron,
low sensitivity
measure of total amount of
transferrin present in blood

Saturation

Serum Fe
TIBC
As a percentage or proportion

Free Erythrocyte
Protoporphyrin

Immediate precursor of Hb
Accumulates in RBC s when iron is unavailable
Detects iron deficiency prior to onset of anemia
Used as a screen for lead poisoning
Can be falsely elevated in infection and
inflammation

Iron studies in Microcytic


Anemia
Ferritin

Serum
Fe

TIBC

Fe defic

RDW
(>15)

AOCD

N/

Sideroblastic

N/

Thalassemia

N/

N/

N/

Treatment of Iron Deficiency


Reduce milk consumption -16 oz/d
Trial of iron: 3-6mg/kg/day divided BID-TID
Re-check retic and hemoglobin in 1 week
Treat until Hb in normal range and for at least an
additional 1-2 months to replenish iron stores

Sources of Iron
Dietary sources of heme iron - Meat, fish, Poultryabsorption 10-20%.
Dietary sources of non-heme iron - Cereal, bread,
fruit,vegetables - absorption 2-7%.

Prevention of Iron Deficiency

Promote breastfeeding
Iron fortified foods at 4-6 months
Iron fortified formula through 1 year
Iron supplementation for infants at risk
Discuss cows milk volume limitations, max
400ml/day
Encourage iron rich foods at each well check up
regardless of age.

Current Screening
recommendations
Infants

Universal screening at 9-12 months, and again at 15-18


months
Selective screening of at risk infants:
Preterm
Low birth weight
Infant of a diabetic mother
Not receiving iron fortified formula
Breastfed, >6mos of age, insufficient iron containing diet

Current Screening
Recommendations

Pre-school age: Special health care needs,

Low-iron (non-meat) diet


Poverty/limited access to food

School age: Strict vegetarians


Adolescents: Male: Peak growth period
Females: All routine physical exams

Treatment
Prophylaxis 3mg/kg/day
Deficiency 6mg/kg/day
Iron containing food meat, leafy
green egetables, dates, beans, lentils
and liver.

Megaloblastic anemia
Folate or Vitamin B 12 DEFICIENCY
BP RBCs are large, oval and hyper
segmented neutrophils.
MCV >100fl.
Nuclear maturation is delayed than the
cytoplasmic maturation.

Folate deficiency
Alone, it is very rare
Deficiency occurs in exclusive goats
milk feeds, chronic diarrhoeal state,
anticonvulsants, methotrexate and
defective folic acid metabolism

Diagnosis
Typical BP
LDH elevated
BM megaloblastic maturation at all
levels
Folate level in the serum is reduced
<3ng/ml (5 -20ng/ml)

Treatment
0.5 1.0mg/day of folate for 3-4 weeks
and maintenance of 0.2mg /day after
that.

Vitamin B12
Cannot be synthesized by humans
Mainly derived from animal product
Cyanocobalamin stomach( R pr +
IF)Absorbed in the ileum in the
plasma binds to Transcobalamin II
Liver, BM and storage sites.

Causes
Inadequate intake strict
vegetarians,
Lack of IF, imapaired
absorption,absence of B12 transport
protein.

Manifestations
Irritability,weakness,failure thrive
Vomiting, diarrhoea,glossitis,pallor
and icterus
CNS paraaesthesia, sensory
deficits, hypotonis,seizures, devel
delay/ regression and
neuropsychiatric manifestations.

Diagnosis
Exactly like folate deficiency

Treatment
Vit B12 1mg IM stat
To see response within 2-4days.
CNS manifestations 1mg IM daily
for 2 weeks followed by monthly
injections.

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