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Approach to Anemia in Children
paediatrics - haematology & oncology
Approach to anaemia
Reduction in the RBC mass or blood Hb concentration
Useful to know the normal values for the population; for the value to be abnormal it should be 2SD below the mean
Normal values at different ages
12-18 years (F)
12-18 years (M)
Physiological classification of anaemia
Morphological classification of anaemia
Age – Fe deficiency common in infants
Sex – X-linked traits e.g. G6PD deficiency
Ethnicity- thalassemias common in Mediterranean and Middle East
2. CURRENT HISTORY
Severity and initiation of symptom – Because of the body's compensatory abilities, patients with chronic anemia may not be as symptomatic as patients with acute anemia with similar hemoglobin values. Prior episodes of anemia may indicate inherited forms, whereas anemia in a patient with previously documented normal blood counts suggests an acquired etiology.
Questions relating to hemolytic episodes – Specific questions regarding changes in urine color, scleral icterus, or jaundice associated with the symptoms of anemia should be asked. Hemolytic episodes that occur only in male family members may indicate the presence of a sex-linked disorder, such as G6PD deficiency.
Prior therapy or anemic episodes – Prior anemic episodes, duration, etiology, and resolution, as well as all prior therapy for anemia, should be reviewed. Patients with haemoglobinopathies resulting in the production of small (microcytic) and pale (hypochromic) RBCs, such as HbE or the various thalassemias, may have a history of treatment on multiple occasions for an erroneous diagnosis of iron deficiency anemia, in which the RBCs are also hypochromic and microcytic.
Questions about possible blood loss – Specific questions related to bleeding from the gastrointestinal tract, including changes in stool color, the identification of blood in stools, and history of bowel symptoms, should be reviewed. Teenagers may have excessive menstrual losses without realizing it, and, therefore, information regarding the menstrual history including duration of periods, flow, quantitation and saturation of tampons or pads, should be obtained.
3. PAST MEDICAL HISTORY
Chronic underlying infectious or inflammatory conditions
Intestinal worm infections
Travel to/from areas of endemic infection
4. PRIOR DRUG OR TOXIN EXPOSURE
History of oxidant-induced haemolysis
Type and duration of homeopathic or herbal medications (risk for exposure to lead and other toxins)
Environment, housing, paint exposure, cooking materials, and use of poorly glazed ceramic pots in order to evaluate for possible lead exposure.
5. DIETARY HISTORY
Iron content in the diet and to a lesser degree, folate and B12 content.
Type of diet, type of formula (if iron fortified), and age of infant at the time of discontinuation of formula or breast milk
Amount and type of milk
Symptoms consistent with pica may aid with the diagnosis of lead poisoning and/or iron deficiency
6. BIRTH HISTORY
Infant and mother's blood type
History of exchange or intrauterine transfusion, and a history of anemia in the early neonatal period Gestational age at birth is important, as premature infants may have iron or vitamin E deficiencies resulting in anemia.
The presence of jaundice or need for phototherapy may signify the presence of an inherited hemolytic anemia.
7. DEVELOPMENTAL MILESTONES
Parents should be asked questions to determine if the child has reached age-appropriate developmental milestones.
Loss of milestones or developmental delay in infants with megaloblastic anemia may signify abnormalities in the cobalamin pathway.
8. FAMILY HISTORY
Family history of anemia
Asking if family members have undergone cholecystectomy or splenectomy may aid in the identification of additional individuals with inherited hemolytic anaemias.
Race and ethnic background are helpful in guiding the workup for haemoglobinopathies and enzymopathies. For example, thalassemia syndromes are more common in individuals of Mediterranean and Southeast Asian descent; Hemoglobin S and C are most commonly seen in Black populations.
Skin, mucosae – pallor, dryness, purpura
Hands – koilonychias, palmar crease pallor
Facies – skull bossing, maxillary hyperplasia
Eyes – jaundice, pallor
Mouth – glossitis, cheilosis, ulcers
Heart – tachycardia, functional murmurs, CCF
Lungs – breathlessness
Abdomen – hepatosplenomegaly
PR – bleeding, occult blood
Others – lymphadenopathy
RBC indices: MCV, MCH, MCHC
Peripheral blood film
2. URINE ANALYSIS
Appearance : Color, pH, clarity, specific gravity
Test for protein, bence jones protein
3. STOOL ANALYSIS
Appearance : color, consistency
Examination for ova, parasites
4. BIOCHEMICAL ANALYSIS
Urea, electrolytes and creatinine
Bilirubin, direct and indirect
Serum Fe, TIBC, ferritin
5. SPECIAL TESTS
Hb typing/Coombs’ test, G6PD, autohemolysis test, haptoglobin etc
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