Anemia

Dr.M.KULANDAIVEL MD DCH

Definition
Reduction in oxygen carrying capacity of blood as a result of : Red cell mass

Red Cell count / HCT

Hb concentration

Average Normal Blood Values In Infancy And Childhood

Classification
Aetiological
Production: e.g. aplastic anemia Hemolysis: e.g. G6PD deficiency Hemorrhage: e.g. rectal polyp

Rate of onset
Acute: e.g. malaria with hemolysis Chronic: e.g. Iron deficiency anemia

Severity
Mild 10 gm % Moderate 7-10 gm% Severe < 7 gm%

Nutritional Anemia
Iron Folic acid Vit. B12 Others: Protein, Zinc, Copper, Vit. C Deficiency of any of these will lead to a chronic state of nutritional anemia

Anemia Global Problem Incidence WHO 1990 30% of world population 1500 million people
Region Children 0-4 yr Developed Region 1200 million Developing Region 3800 million World 5000 million 5-12 yr Mean Women 17- 40 yr Pregnant All

12 51 43

7 46 37

3 26 18

14 59 51

11 47 35

Preschool children - 70% Chakraborty et al 1990, Choudhary S.N. 1990 - ICMR - 1-3 yrs-63.2%, 3-5 yrs - 44%

Approach To Any Anemia

Detailed History Detailed head to toe examination Screening laboratory tests

Confirmatory tests

Anemia - History
Age / Sex / Inheritance Infections & Worms Drugs Diet, Pica Community

History in Nutritional anemia

Symptoms of anemia: Fatigue, shortness of breath, lassitude, weakness, Dyspnea on Exertion
Age of onset: 6 mo-36 months Sex: Both sexes equally affected in childhood, after adolescence females > males

Diet: Lack of breast feeds, excess of milk based diet, bottle fed, poor weaning food, predominantly vegetarian diet, pure vegan (B12 def.)

History in Nutritional anemia Contd..

H/O Pica: Altered appetite for mud, chalk, pencil, color, raw food items etc. Both cause and effect H/O irritability, crankiness, stubbornness, listlessness H/O breath holding spasms, Infections: Common as a cause of anemia, rule out worms infestation esp. hook worm, round worms, giardia,

Anemia Physical Exam

Signs of anemia: Pallor, Puffiness, Edema feet, hemic murmer
Tongue: Pallor, Bald & shining tongue, loss of papillae, Angular cheilosis (IDA) Nails: Platynychia, Koilonychia (IDA) Hyperpigmented knuckles (Megaloblastic anemia) Fidgety, irritable, cranky, listless child, Resents strangers and examination

Anemia Physical Exam Contd..

To rule out other causes of anemia look for: Absence of abnormal facies (e.g. Hemolytic facies) No Hepatosplenomegaly (e.g. Thalassemia) No LN pathy (infections, tuberculosis) No petichae/purpura (aplastic anemia, leukemia) No weight loss (malignancies) No skeletal changes (e.g. Fanconis anemia)

No bony tenderness (e.g. leukemia)

Common Manifestations
Glossitis, Stomatitis, Angular cheilosis

Koilonychia, Platynychia usually in older children/adolescent females Plummer-Winson syndrome (Patterson Kelly syndrome)
Pica altered and perverted appetite

Common Manifestations

Loss of Papillae

Pale & Bald tongue

Platynychia

Hyperpigmented knuckles

Laboratory Investigations
Screening tests
Hb, HCT
Red cell indices Reticulocyte count P.S. examination

Confirmatory tests

RDW values in various diseases

RDW Normal Low MCV Normal MCV Normal High MCV

Thalassemia trait

Aplastic anemia

High

IDA

Chronic liver disease, Megalo. An., malignancies, Imm. Hem. myelofibrosis, An. myelotoxic drugs

Reticulocyte Count
Count 500 cells - supravital staining Normal : 1-2% corrected retic count

Low count: BM depression like aplastic anemia, BM infiltration, PRCA High count: Good BM response like in hemolysis, hemorrhage, post-treatment

Advantages of PS examination
Bedside, easily available

Cost effective, Imp. Info.

Types of anemia At times diagnostic need for further tests

PS examination

Normocytic Normochromic

Microcytic Hypochromic IDA

Microcytic Hypochromic Thalassemia (Target cells, NRs)

Macrocytic Megaloblastic anemia

Morphological Classification
Blood Film

Red cell Indices Hypochromic

Normochromic MCV < 803

Normocytic
Microcytic

Macrocytic
MCV > 953

MCH < 29 g MCHC < 32 %

MCV 75-95 3

Microcytic, Hypochromic Anemia D.D.

MCV < 803, MCH < 29 g., MCHC < 32%

IDA
Hemoglobinopathies Anemia of chronic infections Sideroblastic Anemia Lead poisoning

Etiology of Iron Def.

Requirements periods of rapid growth Availability poor diet, poor source Absorption : GI diseases Losses : Pregnancy, Lactation, Menstruation, Ext. Bleeds GI : Polyp, Piles, Fissure, Worms, Meckel, Varices

Vicious Cycle
Top fed infant bottle Improper BF Poor weaning Cows milk Recurrent infections Worms, Malaria

Role of Iron
Hemoglobin 70% Myoglobin Enzymes Storage Iron
4-5% earths crust is iron Child 70 mg/kg Male 4.0 gms, Female 3.0 gms

Clinical Manifestations
Multisystemic disease Hematological Anemia Muscles, Cerebral Cortex, Epithelial tissues, Myocardium, Peri. nerves, Kidney, Liver, Immune system

Non - Hemat. Manifestations

Neurological: Intellect, Cognition, Behavioural changes Epithelial (rare in children) Tongue: Glossitis, Chelosis Nail: Platiy / Koilonychia Esophageal: Webs Exercise intolerance Immune dysfunction

Anemia History - Diet

Prolonged bottle feeding - improper weaning Cow's milk - IDA, Goat's milk - Folate deficiency H/o Pica - cause & effect both Food fads in adolescents Exclusively breast-fed babies do not develop IDA till 6 months of age

Laboratory Diagnosis IDA

Screening tests :
RBC compartment Hb, PS, RBC Indices, RDW

Confirmatory tests :
Plasma/storage compartment S.Iron, TIBC, TS, S.Ferritin, B M iron staining

When to suspect IDA ?

Microcytic, Hypochromic anemia

During period of growth / food fads

Bottle-fed, Cranky child, Pica

Associated chronic bleeding / Worms

Low iron status / S.Ferritin High RDW / Low FEP HbA2 - N (Repeat after iron therapy)

Treatment
Correct diagnosis Diet modification Treat the cause Iron supplementation Prevention

Oral Iron Therapy

Dose: 3-6 mg/kg of elemental iron Divided in 1-2 doses On empty stomach ideal On full stomach if intolerance

Duration : 3 mo after Hb has normalised

Daily Vs twice a week therapy

Oral Iron Side Effects

Nausea, Vomiting, Pain in abdomen, Diarrhea, constipation Discoloration of stool Staining of tongue / teeth Rarely poisoning True intolerance rare

Failure of Oral Iron

Wrong diagnosis Wrong formulation Wrong dosage Poor compliance Poor diet Basic cause not treated esp. bleeding

Monitoring of Response
Retic 8-10 % at day 7 Hb es by 0.1 gm/day Normal by 2-3 mo. PS mixed population Indices : 2-3 mo to normalise Imm. subjective well being Epithelial changes : 2-3 mo.

Megaloblastic anemia etiology

Folate deficiency: Mainly nutritional, Food fads, Goats Mlik (poor in folate), Malabsorption, drugs (antimetabolites) B12 deficiency: Mainly dietary food fads, pure vegan, worms, rarely Pernicious anemia in children Rare: Congenital enzyme deficiency Orotic aciduria

Investigations
CBC: Macrocytic anemia with high RDW PS: Macrocytic, ovalocytosis, basophilic stippling, polychromasia, Howell Jolly bodies Increased indirect bilirubin, high LDH Bone marrow: Megaloblastic changes

Treatment
Oral folic acid: 1-5 mg/day for 3-6 mo Oral B12: 10 mcg/Kg/day for 3-6 mo Give both folate and B12, B12 deficiency treated only with folate Hb will raise but CNS changes will worsen If pernicious anemia: Injectable B12 initially 1 mg daily IM for 2 weeks followed by 1 mg monthly life long Deworm, improve diet

Response to treatment
Bone marrow may totally revert in 24 hours Patient starts feeling well in days Retic response will peak at 5-7 days Hb starts rising after 1-2 weeks Hb normalizes by 3 months PS becomes normal after 1-2 months as old macrocytic RBCs will persist till their life

Treat the Cause

Breast feeding advice Proper weaning Avoid bottle feeding Restrict top milk intake calories in diet Improve type of diet De-worming Treat GI dis, bleeding

Prevention of Anemia
Diet modification Iron supplementation

Food fortification
Control infections, worms

National Nutritional Anemia Prevention Programme (NNAPP)

National Nutritional Anemia Control Program (NNACP)

Launched in 1970 Target eradication by 2000 Target : Infants, Preschool & School Children, Pregnant & Lactating Mothers, Adolescents System: PHC, ICDS, Maternity homes, F P centres Drug : IFA tablet 100 days /yr.

Thank you