Endang Windiastuti

Division of Hematology-Oncology
Department of Child Health
Dr Cipto Mangunkusumo Hospital, FMUI

1. Outline a logical approach to establish the

etiology of anemia in children
2. To review the most common types of
anemia encountered in pediatrics
3. Develop a differential diagnosis based on
age of patient

Hemoglobin level below normal range.

Anemic child when the Hb is 2 SD< mean

Hb for that age

Hb norms vary with age and gender

Development of Hematopoietic in
Fetal
Placenta

Allantois (?)

Umbilical artery
Primitive
streak

Umbilical vein

Fetal liver

AGM
Vitellie Artery

Vitellie Vein
Yolk-sac

Gestational age
(weeks)

7.
5

10.
5

12.
5

15.
5

Bone
Marrow

Birt
h

Aorta-Gonad-Mesonefros (AGM) merupakan tempat yang sangat

potensial dalam menunjang proses diferensiasi sel induk hematopoietik

 Age

Hb (g/dl)

Eritrosit (x1012/l) Hematokrit

Term Baby 14.9 23.7

100-125
2 weeks
13.4 - 19.8
88-110
2 months 9.4 13.0 3.1-4.3
6 months 10.0 13.0 3.8-4.9
1 yr
10.1 13.0 3.9-5.1
2-6 yrs
11.0 13.8
72-87
6-12 yrs 11.1 -14.7 3.9-5.2
12-18 yrs
F
12.1 15.1 4.1-5.1
M
12.1 16.6
77-92

MCV (fl)

3.7 6.5

0.47-0.75

3.9-5.9

0.41-0.65

0.28-0.42
84-98
0.30-0.38
73-84
0.30-0.38
70-82
3.9-5.0
0.32-0.40
0.32-0.43

76-90

0.35-0.44
77-94
4.2-5.6
0.35-0.49

Peritubular interstitial cells of Kidney

produce EPO based on O2 content
increase production of RBC from Bone
marrow
released to peripheral blood

Adequate nutrients importnant for

erythropoiesis including Fe, B12, and folate

Anemia due to reduced red cell production

Anemia due to increased red cell

destruction (hemolytic anemia)

Anemia due to blood loss

Red cell aplasia

- Aplastic anemia
-

Congenital red cell aplasia

Infection
Transient erythroblastopenia
Leukemia

Ineffective erythtropoiesis
- Iron deficiency, folate deficiency
- Chronic inflammation
- Chronic renal failure

 corpuscular
Red cell membrane disorders (spherocytosis)
Red cell enzyme disorders (G6PD deficiency)
Hemoglobinopathies (thalassemia)

extracorpuscular
immune
isoimmune
autoimmune

idiopathic

Fetomaternal bleeding

Chronic gastrointestinal blood loss

Inherited bleeding disorders

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

Detailed anamnesis

Careful physical examination

Peripheral blood smear

Bone marrow evaluation

Additional testing

diet
family history
environmental exposures
symptoms (headache, exertion dyspnea,
fatigue, dizziness, weakness, mood or sleep
disturbances, tinnitis)

1. Maternal history

Pregnancy/delivery complications
Drug ingestion
Pica/ nonfood product ingestion
Anemic during pregnancy

2. Family history Anemia

Splenomegaly
Gallstones
Cancer
Bleeding disorders

3. Patient history

Jaundice
Transfusion

Hyperbilirubinemia, Prematurity, Diet

history,
Medications, Acute or recent infection,
Evidence of chronic disease/ infection,
Endocrinopathy, Liver disease, Easy
bruising /blood loos .

Pallor
Jaundice
Tachycardia
Tachypnea
Orthostatic hypotension
Systolic ejection murmur
Glossitis
Splenomegaly

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

 RBC
Hemoglobin
Hematocrit
MCV
MCH
RDW
Reticulocyte

Count

BLOOD SMEAR

Microcytic Anemia (MCV<80fl)

Normocytic Anemia (MCV 80-100 fl)

Macrocytic Anemia (MCV >100 fl)

 Hypochromic

Microcytic

Iron deficiency anemia

Thalassemia
Sideroblastic anemia
Chronic infection
Lead poisoning
Hemoglobin E trait
Severe Malnutrition

 Macrocytic

Normal newborn
Post-splenectomy
Liver disease
Obstructive jaundice
Aplastic anemia
Hypothyroidism
Megaloblastic anemia

 Normocytic

Acute blood loss

Infection
Renal failure
Liver disease
Malignancy
Early iron deficiency
Aplastic anemia
Dyserythropoietic anemia

Hypochromic microcytic

Hyperchromic Macrocytic

Normochromic normocytic

ANEMIA

MCV
MICROCYTIC
Iron Deficiency

NORMOCYTIC

MACROCYTIC

Reticulocyte count

Thalassemia
High
Chronic
disease
Negative

Coombs Test

Positive

Lead poisoning
Bilirubin
Hb-pathy
Normal
Membrane defect
Secondary : drugs, infection
Hemorrhage

High

Hemolytic

Autoimmune
Isoimmune
Coombs test

ANEMIA
MCV
MICROCYTIC

NORMOCYTIC

MACROCYTIC

Reticulocyte
Leukocyte &
Platelets

Low

Malignancy
Aplastic
Anemia

Normal

Pure red cell aplasia

Diamond Blackfan
Transient
erythroblastopenia

Increased

Infection

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ANEMIA
MCV
MICROCYTIC

MACROCYTIC

NORMOCYTIC

Folate deficiency Vit

B12 defic. Aplastic
anemia Preleukemia
Liver disease

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RDW (Red cell distribution width) =

variation of the erythrocyte volume distribution.
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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