Evaluation
Hb electrophoresis Osmotic fragility, Morphology
Enzyme deficiencies
PK/G6PD screen, reduction of methemoglobin
Autoimmune
Coombs test
Microangiopathic PNH
Who has anemia?
•①. 1d, 130 g/L; •②. 1y, 130 g/L; •③. 2m, 95 g/L; •④. 2y, 95 g/L.
How to work up an anemic patient ?
• History: age, duration, diet, complaint • PE: pale, jaundice, hepatomegaly, thrill • CBC:
Normal children
The change of RBC and Hb
(180) 6 (150) 5 (120) 4 (90) 3 (60) 2 (30) 1
Hb RBC
birth 10d 2～3m
12y (age)
The Diagnostic Criteria
Age
Hb (g/L)
At birth
Posteriority
microangiopathic DIC/TTP/HUS mechanical heart valve
snake venoms
Differentiation of Hemolytic anemia
Diagnosis
Hemoglobinopathy Membrane disorder
Aplastic anemia
Vit B 12
Tumor infiltration
Folic acid
MDS
Differentiation of microcytic anemia
IDA
Sideroblastic Thalassemias Anemia
Chronic disease
serum iron
145
1-4 m
90
4-6 m
100
6 m -6 y
110
6-14 y
120
Who has anemia?
•①. 1d, 130 g/L√; •②. 1y, 130 g/L; •③. 2m, 95 g/L; •④. 2y, 95 g/L√.
2nd step:
Reticulocyte production index=?
1yr old boy:
Hb 7.8 g/dL;
Reticulocyte count 4.2%;
MCV 60.4fl, MCH 24.6 pg/L, MCHC 30.5%.
RPI ???
• RPI=[Ret (%)×(Patient Hb) / (Normal Hb)]
=4.2×7.8/15 = 2.2
ABO, Rh
transfusion
non-immune hemolysis
congenital
membrane defects (Hereditary spherocytosis)
Unstable hemoglobins (Thalassemias)
Enzyme deficiencies (G-6-PD)
3rd step: Size of RBC ?
• Iro • Lead poison • Sideroblastic
Anemia
• Chronic infections
Bone marrow disorder: Megaloblastic anemia:
Approach to Childhood Anemia
Important to Remember on Anemia
• Anemia is a clinical sign of disease. • It is not a single disease by itself. • Need to look for the underlying cause ! • Will we ignore a fever with out investigation? • Drug Administration depends on the cause.
• idiopathic pulmonary hemosiderosis
Hiatus hernia & Meckel diverticulum
Approach to anemia
N,
serum ferritin
N,
Hb electrophoresis
N
HbF/HbA2
N
N
4th step: immune-related ?
RPI>2
hemolysis
Coombs (+)
Coombs (-)
immune
non-immune
Primary
AIHA
Secondary
allogenic
Morphology, History,BUN/Cr Ham test, flow cytometry
Last but not least-Hemorrhage
• Peptic ulcer • Hiatus hernia • Meckel diverticulum • Parasitic infection • Pulmonary hemorrhage
1st step: Anemia?
Measurement Normal
RBC count 5 million/mm3
Hemoglobin (Hb) 15 g/dL
Hematocrit (Hct)
45%
Range
4.0 ~ 5.7 12 ~17 38 ~ 50
A x 3 = B x 3 = C - This is the rule of thumb
• Hb, Hct, RBC • MCV, MCH, MCHC • Ret & RPI (Reticulocyte production index):
RPI=Ret(%)×(Patient Hb)/(Normal Hb)
• Peripheral smear examination
Reticulocyte production index