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Pediatric AnemiaAka: Anemia in Children

See Also
1. Anemia
Epidemiology
1. Iron Deficiency Anemia present in 10% of ages 1-3 years
2. Eden (1997) Arch Pediatr Adolesc Med 151:986
Causes: Common Pediatric Anemias
1. See Anemia Evaluation
2. Microcytic Anemia
  1. Iron Deficiency Anemia (most common cause)
    1. Rare before age 6 months in term infants
    2. Rare until birth weight doubles in Preterm Infants
  2. Lead Poisoning
  3. Hemoglobinopathy
    1. Sickle Cell Anemia
    2. Thalassemia
3. Normocytic Anemia
  1. Physiologic Anemia of Infancy
    1. Requires no work-up unless below expected levels
  2. Hemolytic Anemia
    1. Hemolytic Disease of the Newborn
    2. Glucose-6-Phosphate Dehydrogenase Deficiency (G6PD)
      1. X-Linked Anemia (consider in male children)
    3. Pyruvate Kinase Deficiency
      1. Results in chronic Hemolytic Anemia
4. Macrocytic Anemia (uncommon in children)
  1. Folate Deficiency
    1. Inadequate intake of human or cow's milk
    2. Inadequate intake of vegetables and fruits
  2. Vitamin B12 Deficiency (rare in U.S.)
    1. Consider in breast fed infant of vegan mother
Risk Factors for Anemia (esp. Iron Deficiency Anemia)
1. Black, Native American or Alaskan native
2. Infants living in poverty
3. Immigrants from developing countries
4. Preterm Infant or low-birth weight infant
5. Main dietary intake is unfortified cow's milk
  1. Cow's milk within first year is greatest risk factor
6. Infant formula with low or no iron (<6.7 mg/Liter iron)
7. Breastfeeding without Iron Supplementation
Screening recommendations:
1. See Screening Tests under labs below
2. AAFP and US Preventive Task Force Recommendations
  1. Screen newborns with Hemoglobin electrophoresis
  2. Selective Anemia screening as needed
    1. Preterm and low birth weight infants (6 months)
    2. Other Anemia risk factors above (9-12 months)
    3. Toddlers of recent immigration (15 and 24 months)
    4. Toddlers with inadequate diet (15 and 24 months)
3. AAP Recommendations
  1. Screen Hemoglobin or Hematocrit on schedule
  2. Screening schedule
    1. Routine Newborn Screening not warranted
    2. Infancy (age 6 to 12 months)
    3. Early childhood (age 1 to 5 years)
    4. Late childhood (age 5 to 12 years)
    5. Adolescent (age 14 to 20 years)
Signs and Symptoms
1. See Anemia Clinical Clues
2. Fatigue
3. Apathy
4. Growth delay
5. Developmental delay
6. Increased infection rate
Labs
1. Prevention
  1. Goal: Diagnose iron deficiency prior to Anemia
2. See Anemia Labs
3. Sample acquisition
  1. Do not draw within 2-3 weeks of fever or infection
  2. Venipuncture
  3. Capillary Puncture
4. Initial Anemia screening labs
  1. Precaution
    1. Hemoglobin and Hematocrit are not accurate
      1. Poorly detect Iron Deficiency Anemia
      2. Poor Test Sensitivity and Test Specificity
    2. Some authors recommend empiric Iron Supplementation
      1. White (2005) Pediatrics 115:315
  2. More accurate Anemia screening measures
    1. Reticulocyte Hemoglobin content
      1. Iron Deficiency Anemia suggested when <27.5
      2. Test Sensitivity: 83%
      3. Test Specificity:72%
    2. Reference
      1. Ullrich (2005) JAMA 294:924
  3. Cutoffs for Anemia
    1. See Hematocrit Cutoffs for Anemia
    2. See Hemoglobin Cutoffs for Anemia
Evaluation
1. See Anemia Evaluation
2. Consider causes above
Management: General
1. See below for Microcytic Anemia
2. See Anemia topics in adults
Management: Microcytic Anemia
1. See Iron Deficiency Anemia
2. Criteria for empiric treatment in young child
  1. Findings consistent with iron deficiency
3. Protocol
  1. Ferrous Sulfate 3-6 mg/kg/day before breakfast
  2. Anticipate Hgb increase 1.0 g/dl by 4 weeks
    1. Increase appropriate: Continue iron for 2-3 months
    2. Not appropriate
      1. Evaluate other causes (blood loss)
      2. Consider Hemoglobin electrophoresis
  3. Consider Differential Diagnosis (See above)
    1. See Microcytic Anemia
    2. Thalassemia (See Mentzer Index)
Complications
1. Pediatric Anemia may result in life-long deficits
  1. Effects persist despite correction of Anemia
  2. Prevent deficits by diagnosing iron deficiency early
2. Motor Effects
  1. Decreased gross and fine motor coordination
3. Cognitive effects
  1. Lower scores on Intelligence Testing
  2. Longterm functional Impairment in school
4. Behavioral effects
  1. Fearfulness and unhapiness
  2. Early Fatigue, less playful, clingy
5. References
  1. Lozoff (2000) Pediatrics 105:E51
Prevention
1. Formula-fed infants should use only full iron formula
  1. Never use low iron infant formula (no GI benefit)
  2. Do not use with iron-containing vitamins
2. Limit unfortified cow's milk
  1. No cow's milk should be given under age 1 year
  2. Limit cow's milk to <24 ounces ages 1-2 years
3. Supplement Breast Feeding
  1. Term infants need 1 mg/kg/day elemental iron
    1. Start supplement at 6 months of age
  2. Preterm and low-weight infants need 2 mg/kg/day
    1. Start supplement at 2-4 weeks of age
  3. Options
    1. Ferrous Sulfate drops
    2. Infant Vitamin Drops (10 mg elemental iron/dropper)
4. Other measures
  1. Maintain varied diet
  2. Iron fortified cereal
  3. Avoid excessive juice intake
Resources
1. MMWR Iron Deficiency Anemia Prevention
  1. http://www.cdc.gov/mmwr/pdf/rr/rr4703.pdf
References

Hematology and Oncology Book

Anemia

Sarcomas

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Pediatric AnemiaAka: Anemia in Children

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