Approach to Anemia

How to efficiently and accurately work up

the anemic children

Anemia
Is

a sign of disease
Not a final diagnosis
The goal of the diagnostic evaluation is
to determine the cause of anemia

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Definition of Anemia
Reduction in the hemoglobin
concentration or red blood cells per cubic
millimeter.
ANEMIA (WHO criteria)
Age

Hb (g/dl)

6 mo - < 5 yrs < 11

> 5 yrs

< 12

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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.
2.
3.

Disorders of effective red cell production

Disorders of increased red cell
a. Marrow failure
destruction
b. Impaired erythropoietin production
Blood
loss
c. Abnormalities
of cytoplasmic

a. Defects of hemoglobin
maturation
b. Defects
of the red cell membrane
Abnormalities
of nuclear
c.d. Defects
of red cell metabolism
d.e. Antibody-mediated
Dyserythropoietic.
e. Mechanical injury to the erythrocyte
f. Thermal injury to the erythrocyte
g. Oxidant-induced red cell injury
h. Paroxysmal nocturnal hb-uria
i. Hypersplenism
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maturation

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The investigation of Anemia

1.
2.
3.
4.
5.

Detailed history and physical

examination
Complete blood count.
Determination of morphologic
characteristics and RDW.
BMP (if required).
Determination of underlying cause of
anemia by additional test.

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Important features in the history

of the anemic child
Maternal history
2. Family history
Pregnancy/delivery
3. Patient
history
complications
Anemia Jaundice Splenomegaly
Drug ingestion
Gallstones Cancer Prematurity,
TransfusionDiet history,
Hyperbilirubinemia,
Pica/ nonfood
product ingestion
Medications,
Acute or recent infection, Evidence of
Bleeding disorders
Anemic
during
pregnancy
chronic
disease/
infection,
Endocrinopathy, Liver
1.

disease, Easy bruising/blood loos

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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 80100 fl)
Macrocytic Anemia (MCV >100
fl)
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Reference Range of MCV

Age (yrs)
1 - 3 days
0.5 2
24
57
8 11
12 14
15 17
18 19
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MCV (fl)
95 - 121
70 - 84
73 - 85
75 - 87
77 - 90
78 - 91
78 - 94
80 - 100
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ANEMIA
MCV
MICROCYTIC

NORMOCYTI
C
Reticulocyte
count

Iron
Deficiency
High
Coombs Test
Negative
Thalassemia
ChronicBilirubin
Hb-pathy
disease
Normal
High
Membrane
defect
Lead
poisoning
Hemolyti
Secondary : drugs,
infection
Hemorrhag
c
e
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MACROCYTI
C

Positive
Autoimmune
Isoimmune

Coombs
test
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ANEMIA
MCV
MICROCYTIC

NORMOCYTIC
Reticulocyte

Leukocyte &
Platelets

Increased

Low

Normal

Malignancy

Pure red cell aplasia

Diamond Blackfan
Transient
erythroblastopenia

Aplastic
Anemia

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MACROCYTI
C

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Infection

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ANEMIA
MCV
MICROCYTIC

MACROCYTIC

NORMOCYTI
C

Folate
deficiency Vit
B12 defic.
Aplastic
anemia
Preleukemia
Liver disease

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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 size
Poikilocytosis = variation in shape
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Anemia Mikrositik
Perhatikan

: jumlah eritosit,
RDW, retikulosit, gambaran
sediaan apus darah tepi.
Juml Eri RDW

Retik

Trait Thal

N
ADB
N /

hipokrom
Thal

anisositosis (++)
hipokrom
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Slide

N /

poikilositosis (+)
anisositosis (+),

poikilositosis,

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