Anemia

Definition
Decrease in circulating red cell mass, leading to impaired ability to meet demand for oxygen

Clinical symptoms
Fatigue, dyspnea, dizziness, blackouts
Irritability, poor feeding

Signs of hemolysis
Jaundice, scleral icterus or dark urine

Common scenario
- 1 year old anemia
- 15 year old Hb=10
o Menses - losses

Classification (Based on MCV mean corpuscle volume)

1. Microcytic
a. Fe deficiency
b. Thalassemia
c. lead poisoning/sideroblastic (rare in sg)
d. Seen more often
2. Normocytic 75 - 80 85 chronic, acute loss, hemolysis, viral induced suppression,
anemia of prematurity
3. Macrocytic 90 100 B12 folate, spherocytosis

Life span of RBC 120 days

Learning point
- Tx Fe deficiency first
- Can get complete resolution

Decreased production
History/PE
Nutritional deficit Iron Hx
Vegetarian diet
Sources: Completely fully breast fed baby
Green leafy veg Picky eater, dont like meat
Red meat
Developmental delay
Breast milk low in
Fe Bloody stools
VS Hematemesis
Formula milk high severe epistaxis
in Fe severe menstrual bleeding

PE
Koilonychia
Vitamin B12/folate Only vitamin B12 produces neurological changes
Hx
Sources Jaundice and anemia
Cereal Mental sluggish
grains Glossitis

PE
Loss of vibration and proprioception
 Spasticity
Cerebellar ataxia
Ascorbic acid Scurvy
(vitamin C)
Weakness, anemia, bruising, bleeding gums, loose
teeth

4Hs
- Hemorrhage
- Hyperkeratosis
- Hypochondriasis
- Hematological abnormalities

Lead poisoning

Reduction in Aplasia Insidious onset

precursors pallor, headache, palpitations, dyspnea, fatigue, or
foot swelling
mucosal and gingival bleeding or petechial rashes
Recurrent infection

Recent infection parvovirus B19 (Most well-

known), EBV, CMV
Hematological Insidious
malignancies Unintentional LOW, LOA
Family Hx of malignancy
(ALL, AML, Constitutional symptoms
lymphoma) Night sweats, fever
Pallor
Exertional dyspnea
Recurrent infections
Easy bruising (petechiae, purpura)
Epistaxis

PE
Petechiae, purpura
hepatosplenomegaly
Myelofibrosis Presence of excessive collagen and reticulin fibers
in bone marrow

Uncommon

Predisposing factors: family Hx, exposure to

ioninsing radiation
Symptoms: mild, related to bone marrow
dysfunction, cytopenias
Ineffective Anemia of chronic PmHx of chronic illness
erythropoiesis disease Renal failure
hypothyroid
 Thalassemia More common in Mediterranean and Southeast
Asian descent

PE
Chipmunk/Thalassemic facies
prominence of malar and maxillary bones
Flat nasal bridge
Frontal bossing
Dental malocclusion
Widely spaced teeth

Needle marks from blood transfusion

- Abdomen - feroxemid
- arms

Hepatosplenomegaly extramedullary
hematopoiesis

Family Hx
- Any issues of anemia? Needed blood
transfusion
- Anyone with thalassemia?
- When mother was pregnant, did she have low
blood count?

Sideroblastic Rare

Myelodysplastic Clonal disorder of stem cells ineffective

syndrome hematopoiesis with dysplastic changes in marrow

Rare in childhood
- Primary: Can arise in previously healthy
child, or with unknown genetic defect
- Secondary: Known predisposition ie
previous cytotoxic chemotherapy, inheritied
bone marrow disorder, acquired aplastic
anemia, Downs syndrome

Similar presentation to leukemia

Increased destruction/loss
Blood loss GI PR stool
- Any coagulopathy? Easy bleeding
- Abdominal symptoms
Trauma
Menses adolescent girl
- Number of pads/day
- How many days of heavy bleeding?
- Other bleeding tendencies?
Haemolysis Hemoglobinopathie Prior episodes of anemia
(Intrinsic to s (sickle cell
RBCs) disease Changes in urine color (tea-coloured), scleral icterus,
membrane defect) or jaundice

Enzyme Family members with jaundice, gallstones, or

deficiencies (G6PD hepatosplenomegaly suggests an inherited hemolytic
deficiency, pyruvate anemia
kinase deficiency)
Anemia detected at 3-6 months suggests a
 Red cell membrane hemoglobinopathy
defects
(hereditary Note: In neonates and young infants, immune
spherocytosis, hemolytic disease, infection, and hereditary disorders
elliptocytosis) are most common

Haemolysis Autoimmune or Birth 3 months

(extrinsic to isoimmune (Rh or
RBCs) ABO incompatibility) SLE joint pain, photosensitivity
Infection Infectious symptoms
Fever, cough
Travel Hx
Travel to/from areas of endemic infection
suggests infectious etiology such as malaria
or tuberculosis
Physical or Exposure to paint, home renovations, or use of
chemical agents imported or glazed ceramics suggest lead toxicity

Occupation

Structural lysis Mechanical heart valve

PDA

Age Comments
Birth to three Most common cause
months Physiological anemia of infancy (physiologic nadir)
(6-9 weeks Hb=11g/dL)
- Erythropoiesis decreases dramatically after birth due to increased
oxygenation and reduced production of erythropoietin

Pathological anemia
jaundice, scleral icterus, or dark urine
irritability or poor feeding

Common cause
blood loss
immune hemolytic disease (ie, Rh or ABO incompatibility)
congenital infection, twin-twin transfusion
congenital hemolytic anemia
o hereditary spherocytosis
o G6PD deficiency Neonatal hyperbilirubinemia

Approach to anemia in newborn

Infants three to Hemoglobinopathy

six months
Nutritional iron deficiency is an unlikely cause of anemia before the age of six
months in term infant
Toddlers, Fe deficiency anemia
children, and
adolescents