Anemia (Case 15)

Chapter 45 Anemia (Case 15)



Hal C. Byck, MD




Case


A 15-month-old girl with pneumonia is noted to have a hemoglobin level of 8 g/dL.




Differential Diagnosis




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Speaking Intelligently


When evaluating a child with anemia, I first check for signs of blood loss and assess hemodynamic stability. Anemia is a clinical sign; my task is to determine the cause and institute treatment where indicated. The mean corpuscular volume (MCV) classifies the anemia as normocytic, microcytic, or macrocytic. A careful history, including diet and ethnicity, is important. A reticulocyte count helps assess production and destruction of red blood cells. Infections such as pneumonia or viral syndromes can cause transient bone marrow suppression and anemia.



Patient Care



Clinical Thinking



• Does the child need immediate support or transfusion?

• Are there signs of congestive heart failure?

• If neither of the above is true, there is time to consider the differential and plan the workup.

• Hemoglobin levels vary by age, and in adolescents, by gender (Table 45-1).

• Physiologic anemia of infancy (resulting from multiple factors related to transition to extrauterine life) results in a progressive drop in hemoglobin in the first 8 weeks of life in term infants to 9 to 11 g/dL. In preterm infants, the drop occurs in the first 3 to 6 weeks and is more severe—to 7 to 9 g/dL. No treatment is required: iron stores are adequate, and recovery occurs as erythropoietin increases.

Table 45-1 Age-Specific Hemoglobin
















































Age Hemoglobin (g/dL)*
1-3 days 18.5 (14.5)
2 weeks 16.6 (13.4)
1 month 13.9 (10.7)
2 months 11.2 (9.4)
6 months 12.6 (11.1)
6 months-2 years 12 (10.5)
2-6 years 12.5 (11.5)
6-12 years 13.5 (11.5)
12-18 years  
Male 14.5 (13)
Female 14 (12)
Adult  
Male 15.5 (14)
Female 14 (12)

* Data are mean (−2 SD).


Data from Oski FA, Naiman JL: Hematological problems in the newborn infant, Philadelphia, Saunders, 1982; Nathan D, Oski FA: Hematology of infancy and childhood, Philadelphia, Saunders, 1998; Matoth Y et al: Postnatal changes in some red cell parameters. Acta Paediatr Scand 1971;60:317; and Wintrobe MM: Clinical hematology, Baltimore, Williams & Wilkins, 1999.



History



• Review newborn screen results: note G6PD deficiency, sickle cell disease, or Bart’s hemoglobin (indicating α-thalassemia trait).

• What is the child’s diet? Is there excessive intake of whole milk (≥24 ounces daily)?

• Any family history of anemia?

• What is the child’s ethnicity? African, Asian, and Mediterranean ancestry is associated with β-thalassemia trait; and Southeast Asian, Chinese, and African heritage with α-thalassemia trait.

• Is there family history of splenectomy or cholecystectomy?

• Does the child live or attend day care in an old house or one being renovated?

• Have any siblings had lead poisoning?

• Is there pica?

• Has the child had prior episodes of anemia or any treatment?

• Has there been a recent respiratory or gastrointestinal illness?

• Is there evidence of blood loss such as tarry stools, hematochezia, or hematemesis?

• Has there been fever, poor appetite, weight loss, or other constitutional symptoms?

• Is there bone pain?

• Does the child bruise easily?


Physical Examination



• Vital signs: Check for tachycardia and hypotension (a very late finding) with blood loss.

• Assess capillary refill.

• Note pallor or pale sclerae.

• A systolic flow murmur is common and not indicative of cardiovascular compromise.

• Signs of heart failure (gallop, hepatomegaly, crackles) suggest severe anemia.

• Bruising, petechiae, or significant lymphadenopathy suggest an oncologic etiology.

• Splenomegaly occurs with hereditary spherocytosis, splenic sequestration, or malignancy.

• Jaundice suggests a hemolytic process.


Tests for Consideration



• Complete blood count (CBC) with differential: To check hemoglobin, MCV, platelets, and white blood cells to distinguish anemia from pancytopenia $116

• Peripheral blood smear: To check red blood cell (RBC) shape, central pallor $75

• Reticulocyte count: To check bone marrow response; increased with hemorrhage, hemolysis, or recent treatment of iron deficiency $74

• Ferritin: To check tissue iron stores; may be falsely elevated with any inflammatory process $177

• Hemoglobin electrophoresis: To identify abnormal hemoglobin (see Table 45-1) $135

• Lead level $34

• Coombs test: For autoimmune hemolysis $87

• Osmotic fragility test: For hereditary spherocytosis $954

• If macrocytic anemia:
• Vitamin B12 $196
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Jul 18, 2016 | Posted by in PEDIATRICS | Comments Off on Anemia (Case 15)

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