Childhood Anaemia

Background/Epidemiology

  • Not uncommon
  • Can be a cause of growth failure and slow development
  • Can be defined as either <5th centile for age OR (easier)
    • <140g/l in a newborn; <110g/l in children 6 month – 4 years; <115g/l in children 5-11 years and <120g/l in children >12

Aetiology/Risk factors

  • Remember that anaemia is not a diagnosis but a sydrome of signs which usually has an underlying cause.
    • In children, usually either decreased RBC production or increased turnover
  • Risk factors
    • Decreased RBC production
      • Chronic disease e.g. renal disease, hypothyroidism, chronic inflammation/infection, IBD/Coeliac disease
      • Iron Deficiency
      • Poor diet
      • Prematurity
    • Increased RBC turnover
      • Drugs e.g. sulfamethoxazole, nitrofurantoin, phenytoin
      • Family history e.g. Thalassaemia, sickle cell,
      • Mechanical heart valve

Causes and Presentation

  • Neonate
    • Haemorrhage (e.g. placental abruption; traumatic haematoma; subgaleal (scalp) haematoma; maternal-foetal and twin-twin transfusion)
      • ~5-10% of severe neonatal anaemia; usually normocytic with initially normal reticulocyte count (increasing); check Kleihauer-Betke test in maternal-foetal haemorrhage
      • Tachypnoea, pallor, irritability, poor feeding.  In severe cases, shock and cardiorespiratory collapse
    • Isoimmunisation (e.g. ABO incompatibility/Rh incompatibility)
      • ~10/10,000 births (Rh incompatibility)- half of which develop anaemia
      • Jaundice with mild anaemia; severe cases may present with hydrops fetalis (severe oedema)
      • Positive Coombs test; raised bilirubin; normocytic anaemia with raised reticulocytes
    • Congenital Haemolytic anaemia (e.g. Spherocytosis, G6PD deficiency)
      • Hyperbilirubinaemia and moderate jaundice
      • May show poikilocytosis (spiky RBCs), reticulocytosis, Heinz bodies and Bite cells or Spur cells
    • Congenital Infection (e.g. Parvovirus B19; HIV; syphilis; rubella; sepsis)
    • Rarely- congenital disorders such as Diamond-Blackfan syndrome (very rare; causes macrocytic anaemia); Fanconi anaemia
  • Infancy- toddler
    • Iron Deficiency (e.g. poor diet, chronic occult blood loss (excessive cow’s milk consumption, IBD, Meckel’s diverticulum))
      • Not uncommon in this age group (up to 15%)
      • Usually asymptomatic; severe cases can present with fatigue, pallor, shortness of breath
      • Microcytic, hypochromic anaemia; low iron (low ferritin and iron saturation; with raised transferrin)
    • Chronic/recurrent infection (anaemia of chronic disease)
      • Presents usually with symptoms of infection
      • Normocytic, normochromic anaemia
    • Blood loss (e.g. trauma, GI bleed)
      • Usually presents with acute signs e.g. tachypnoea, tachycardia, pallor, hypotension
      • Haemoglobin may initially be normal but will fall (normocytic, normochromic)
    • Inherited disorders (e.g. Thalassaemia, sickle cell disease)
      • See pages- usually present in the first year of life
    • Other causes
      • RBC enzyme defects (G6PD, pyruvate kinase deficiencies)
      • RBC membrane defects (e.g. spherocytosis)
      • Acquired haemolytic anaemias (e.g. antibody mediated (incompatibility disease); drug-induced; Haemolytic uraemic syndrome; DIC)
      • Leukaemia
  • Late childhood and adolescence
    • Iron deficiency can occur during growth spurts, menstruation, and change of diet (as above)
    • Chronic disease (renal, liver, hypothyroid and others)
    • Blood loss (as above (+ menstruation))
    • Blood disorders; haemolytic anaemias and leukaemias (as above)

Approach to the newborn with anaemia

  • Newborn
    • Take a history of pregnancy/delivery (any suggestion of trauma or maternal-foetal haemorrhage; infections etc)
    • Check reticulocyte count to check marrow function (decreased RBC production e.g. Fanconi anaemia, Diamond Blackfan syndrome, congenital infections)
    • Look for signs of haemorrhage e.g. irritability/low conscious level, tachycardia/tachypnoea, jaundice
      • also check head circumference (subgaleal or intracranial bleed)
    • Check bilirubin (haemolysis) and then Coomb’s test

For older children

  • Take a full history including family, past medical (including pregnancy, neonatal, development etc), travel, social (including diet)
  • Check FBC, reticulocytes and blood film; iron studies; bilirubin; TFTs; and then investigate as required for conditions in the differential diagnosis
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