International Journal of Laboratory Hematology

The Official journal of the International Society for Laboratory Hematology

REVIEW INTERNAT IONAL JOURNAL OF LABORATO RY HEMATO LOGY

Bone marrow evaluation for pediatric patients

M. PROYTCHEVA

Department of Pathology,
College of Medicine, University
of Arizona, Tucson, AZ, USA
Correspondence:
Dr Maria Proytcheva, Depart-
ment of Pathology, College of
Medicine, University of Arizona,
1501 N. Campbell Avenue, Tuc-
son, AZ 85724, USA.
E-mail: mproytcheva@
pathology.arizona.edu
doi:10.1111/ijlh.12073
Received 25 January 2013;
accepted for publication 14
February 2013
S U M M A RY
Due to the immaturity of the hematopoietic system at birth and
different oxygenation and immune response needs of the growing
organism, the bone marrow composition at birth and early infancy
differs as compared to older children and adults. These age-related
differences, while generally recognized, are not well known to the
world of hematopathology. The purpose of this article is to address
the current limitation of the literature by reviewing the bone mar-
row ontology, its composition at birth, and the changes occurring
during early infancy, and to compare these findings to adults. The
review also provides a useful framework for bone marrow exami-
nation in children.

Keywords
Bone marrow, hematopoiesis,
normal, neonatal, pediatric

zation of the bones into areas of dense hematopoiesis

INTRODUCTION
The bone marrow (BM) is the last blood-forming tissue
that develops in ontogenesis and from birth, and there-
after, it is the major hematopoietic site. It is a function-
ally dynamic organ, and its composition depends
highly on the needs for oxygenation, fighting infec-
tions, and proper hemostasis. As such needs vary dras-
tically during different stages of development as well
as early childhood and later in life, the BM composi-
tion also changes to meet those needs. Therefore, it is
important when evaluating BM of a child to distin-
guish between the findings due to the normal develop-
ment and those that result from various diseases.
The hematopoiesis in the bone marrow begins in
the long bones at 6–8.5 weeks of gestation and is
completed by 16 weeks of gestation with final organi-
surrounded by areas of fully calcified bone [1, 2].
Between the 11th and 24th weeks of gestation, both
the liver and BM are hematopoietic organs concomi-
tantly, yet each supports a different set of hematopoi-
etic lineages: the erythropoiesis occurs mostly in the
fetal liver and the granulopoiesis and lymphopoiesis
mostly in the BM. The total marrow volume markedly
increases during the second trimester, and after the
24th week of gestation, the hematopoiesis shifts from
the fetal liver to the BM.
From birth onward, the BM is the major hemato-
poietic site. At birth, all cavities of the skeleton con-
tain red hematopoietic BM and almost no fat. In the
first year of life, the hematopoiesis occurs in both the
axial and appendicular skeleton, and thereafter, there
is a gradual decrease in the hematopoiesis in the long

© 2013 Blackwell Publishing Ltd, Int. Jnl. Lab. Hem. 2013, 35, 283–289 283
284 M. PROYTCHEVA | BM EVALUATION IN CHILDREN
bones until about age 15. At that age, active hemato-
poiesis is confined to the proximal quarters of the
shafts of the femur, humerus, and the axial skeleton
[3].
The BM is a functionally dynamic structure, and if
the needs for erythrocyte, leukocyte, or platelet pro-
duction increase, the hematopoiesis expands, and the
fat is replaced by bone marrow. In young children,
however, an increase in hematopoiesis is accommo-
dated by a reduction in the proportion of marrow
sinusoids, and in severe congenital anemia, the
marrow cavities expand leading to bone deformity.
The BM is located between the bone trabeculae
and has a highly complex three-dimensional structure
composed of extracellular matrix, stromal cells includ-
ing osteoblasts, and capillary venous sinuses. The
localization of the various hematopoietic elements is
nonrandom, and in histologic sections, the cells with
proliferative activity are preferentially located near the
bone trabeculae, and the differentiated elements are
observed in the central, intertrabecular spaces [4].
The early myeloid progenitors are localized in the
paratrabecular areas close to the adventitia of the
small arteries. Normally, the layer of immature granu-
locytes does not exceed 2–3 rows of maturing cells.
With maturation, the cells migrate to the intertrabe-
cular spaces.
The erythroid progenitors mature and differentiate
in erythroblastic islands that consist of a central mac-
rophage – a key component of the erythroid differen-
tiation – surrounded by developing erythroblasts. As
the erythroblasts become more differentiated, the ery-
throid islands migrate toward sinusoids because they
are a mobile structure. The erythroid islands are not
readily observable on histologic section, but can be
seen on bone marrow aspirates, particularly in
patients with erythroid hyperplasia.
Megakaryocytes reside adjacent to marrow sinu-
soids, which allow easy shedding of platelets directly
into the circulation.
AG E - S P E C I F I C D I F F E R E N C E S I N T H E B M
Due to the immaturity of the hematopoietic system at
birth and the nature of hematopoiesis with its dynamic
response to the oxygenation needs and immune
response of the growing organism, several important dif-
ferences between the BM cellularity and composition in
children and adults exist (Table 1) [5–8]. At birth, the
bone marrow is almost devoid of fat (100%) and con-
tains only hematopoietic elements, and with advance of
age, the red hematopoietic marrow is replaced by fat.
The BM cellularity in normal infants – 3 months of age
or younger – is 80% or more. Particles obtained from
the iliac crest and the sternum have compatible cellular-
ity and, in normal children aged 18 months to 11 years,
ranged between 50% and 70% [7].
In a study of 448 healthy BM donors and children
with non-neoplastic hematologic disorders or nonhe-
matologic malignancies, Friebert et al. [6] found that
children younger than 2 years have the highest BM
cellularity (79.8  15.7%) and with age the cellularity
declined to 68.6% (16.5%) for children aged
2–4 years, to 59.1% (20.1%) for children aged 5–
9 years, and to 60% (17.9%) for children aged 10–
14 years. Thus, BM cellularity of 60% is achieved
during the first 5 years of life and remains relatively
constant compatible with other age groups after that.
Similar findings are obtained using imaging studies.
Ogawa et al. [9] found 60.0  20.0% cellularity in the
BM of children aged 0–9 years declining to
56.5  4.4% for ages 10–19 years. These findings
clearly demonstrate the inaccuracy of the concept of
BM cellularity determined by the formula 100%
minus the age of the patient. Using such an approach
will significantly overestimate the BM cellularity in
young children and underestimate the cellularity in
older adults. Thus, it should not be applied.
Similarly to the BM cellularity, the composition of
the marrow is also age dependent [5, 10–13]. In a pro-
spective study of BM composition of 88 clinically
healthy children with normal peripheral blood counts,
serum proteins, and transferrin saturation of at least
16%, Sturgeon found that at birth, the BM has a pre-
dominance of myeloid progenitors and relatively low
number of erythroid progenitors and lymphocytes. The
most significant changes take place during the first
month of life and are manifested by a decrease in the
percentage of myeloid progenitors and erythroblasts
and an increase in the number of lymphocytes
(Figure 1). The total myeloid component initially
decreases during the first 2 weeks of life followed by a
sharp drop around the 3rd week to reach a steady level
around 30–35% after the 1st month. The marrow
eosinophils range between 2 and 3%, the monocytes
remain below 2%, and the basophils remain below 1%
© 2013 Blackwell Publishing Ltd, Int. Jnl. Lab. Hem. 2013, 35, 283–289
 M. PROYTCHEVA | BM EVALUATION IN CHILDREN 285

Table 1. Bone marrow cellularity and cellular composition in children of various ages

Age Cellularity Cellular composition Bone trabeculae

Newborn 90–100% Myeloid hyperplasia with a shift to immaturity.

Less than 5% blasts
Neonate (birth 90% Decrease in the number of myeloid cells in the first 2 weeks
to 28 days) of life
Decrease in the number of erythroid progenitors
Megakaryopoiesis:
Monolobated small megakaryocytes
Gradual increase in the number of lymphoid cells, mostly
B cells
Infant (1 month 80–90% M:E ratio 5–12 : 1* Very active bone
to 1 year) Myelopoiesis: remodeling
Reaches a steady state level ~30–35% Incomplete ossification
Erythropoiesis: Prominent osteoblastic
After the initial drop, a transient peak in the 2nd month, rimming
there is a second decrease at 3–4 months with subsequent
stabilization of the total erythroblast count of 7–9%;
Relative erythroid hypoplasia is most pronounced during
the physiologic nadir
Megakaryopoiesis:
Monolobated small megakaryocytes
Diffuse interstitial lymphocytosis
Lymphoid cells, the major population after the 1st month
(47.2  9.2%)
Predominance of normal B cell progenitors (hematogones)
T-cells and NK-cells minor components
Lymphoid aggregates not normally present
Plasma cells – rare, polytypic, frequently associated with
various diseases
L:M:E ratio ~ 6 : 5 : 1*
Iron stores – absent in young children
2–5 years 60–80% M:E ratio 3–4 : 1 Prominent bone
Increase in the myeloid and erythroid component and remodeling
decrease in the number of B cells and hematogones and
slight increase in the number of T cells. Note, an increased
number of hematogones can be seen in infections or
children with congenital cytopenias due to primary bone
marrow failure.
Detectable stainable iron after age 4–5 years
6–12 years 50–70% M:E ratio 3–4 : 1 Bone remodeling
Less than 20% lymphocytes may be evident,
T cells exceed B cells particularly boys
Iron stores reach adult level
Older than 40–60% M:E ratio 3–4 : 1 Inconspicuous osteoblasts
12 years and Less than 20% lymphocytes and osteoclasts
adults T cells exceed B cells No bone remodeling
Lymphogranuloma and lymphoid aggregates may be
present, their number increases with age

*M:E, Myeloid to erythroid ratio; L:M:E, the relative proportions of lymphocytes, myeloid, and erythroid progenitor.
Based on data from Rosse, C. et al. – Bone marrow cell populations of normal infants: the predominance of lympho-
cytes. J Lab Clin Med 1977; 89:1225–40.

© 2013 Blackwell Publishing Ltd, Int. Jnl. Lab. Hem. 2013, 35, 283–289
286 M. PROYTCHEVA | BM EVALUATION IN CHILDREN

(a) (b)

(c) (d)

Figure 1. Bone marrow studies from a 4-month-old infant. (a) Bone marrow aspirate smear demonstrating
hematopoietic progenitors along with numerous mature and immature lymphoid cells (Wright–Giemsa stain).
(b–d) Multiparameter flow cytometry showing a significant population of CD19+/CD10+/CD38+ B cells with a
variable expression of CD20, a mature B-cell marker. Note, the CD20+ mature B lymphocytes comprise a large
proportion of all B cells. A small number of T cells is also present (not shown). This flow cytometric pattern is
consistent with normal B cell progenitors, hematogones.

at all times. The plasma cells and other marrow cells
comprise only a small fraction of the cellularity.
The number of erythroid progenitors also decreases
significantly during the first month of life and after a
transient peak at the end of the second month is fol-
lowed by more gradual but significant secondary
decrease through months 3 and 4 to stabilize and
account for 7–9% of total erythroblasts at various
stages of maturation. These changes are broadly
followed by the peripheral blood reticulocyte count.
The number of megakaryocytes in children is com-
patible with adults. However, there is a difference in
their size and lobulation. Small megakaryocytes with
uniform size and monolobated nucleus, occasionally
forming clusters, are characteristic for young children
and should not be mistaken for abnormal megakaryo-
poiesis. In a study of the size of megakaryocyte of 61
young children, Fuchs et al. [14] found a single peak sig-
nifying uniform small size at the youngest ages, which
diverges into separate clusters of smaller and larger cells
beginning at 2 years that is followed by an overall shift
toward larger megakaryocytes at age 4 years.
Another significant difference between the BM compo-
sition of infants and older children and adults is the pres-
ence of a high number of lymphocytes that increase
significantly in the immediate neonatal period to become
the largest population in the marrow (47.2  9.2%) by
the end of the first month [11]. During the next
17 months, the number of lymphocytes is relatively stable
whereupon it begins to decrease gradually. During the first
4 years of life, the B cells comprise 65% of the lympho-
cytes in contrast to adult marrow where T lymphocytes
predominate [12]. Most of the B cells, 80%, are normal
B-cell progenitors, hematogones. These cells comprise a
heterogeneous population of immature, surface immuno-
globulin-negative B cells that include early, intermediate,

© 2013 Blackwell Publishing Ltd, Int. Jnl. Lab. Hem. 2013, 35, 283–289

and late forms (Figure 1). The early, stage I, hematogones
express CD34 and TdT and are mostly CD20 negative. The
stage II and stage III hematogones loose CD34 and TdT
and gradually acquire CD20. Furthermore, stage III hemat-
ogones acquire cytoplasmic l and loose CD10. During the
first 2 years, the CD20 and surface immunoglobulin-posi-
tive na€ıve B cells comprise a minor population, and with
age, their number gradually increases, whereas the num-
ber of hematogones decreases. After the age of 4 years, the
overall number of B cells gradually decreases, and this
decline is accompanied by an increase in the number of
CD3+ T lymphocytes. These T cells are mature and express
either CD4 or CD8, and the percent of CD8+ cells is at least
twice the percentage of CD4+ cells. The number of NK cells
in the marrow is low and does not depend on age.
The proliferative capacity of BM in children and
young adults determined by Ki-67 appears to be higher
and the apoptotic rate lower as compared to older peo-
ple [9]. Active bone remodeling, prominent osteoblastic
rimming, osteoid seams, and incomplete ossification are
frequent in children and do not signify pathology.
B O N E M A R R OW E X A M I N AT I O N I N C H I L D R E N
The bone marrow diagnosis in children as well as in
adults is based on the integration of data from various
diagnostic studies, including peripheral blood count and
film evaluation, BM aspirate smears, particle clot sec-
tions, BM trephine biopsy, and imprint morphology
along with the results of cytochemistry, immunopheno-
typic analysis, cytogenetics, and molecular studies [15].
The most frequent indication for bone marrow examina-
tion in children includes investigation of abnormal blood
counts suggestive of BM pathology; initial workup for a
child with peripheral cytopenias and suspected primary
bone marrow failure or occult malignancy; unexplained
organomegaly in children with mass lesions inaccessible
for biopsy; following response to therapy for acute
leukemia and detection of minimal residual leukemia; to
determine BM engraftment following a stem cell
transplant; and staging for Hodgkin or non-Hodgkin
lymphoma, neuroblastoma, or rhabdomyosarcoma. Of
note, unlike neuroblastoma and rhabdomyosarcoma
that metastasize to the BM frequently, other small blue
cell tumors such as the Ewing sarcoma family of tumors,
Wilms tumor, and nonrhabdomyosarcoma soft tissue
sarcomas rarely involve the BM; thus, BM examination
is not part of the routine staging for those tumors.
© 2013 Blackwell Publishing Ltd, Int. Jnl. Lab. Hem. 2013, 35, 283–289
M. PROYTCHEVA | BM EVALUATION IN CHILDREN 287
In young children, BM studies are not indicated for
the determination of iron stores, as stainable iron is
absent from the marrow during the first year of life
and storage iron progressively increases and reaches
adult levels only by the fifth to 6th year [16]. Simi-
larly, BM studies are not required in the initial evalu-
ation of children with thrombocytopenia prior to
initiation of steroid therapy as such studies have been
shown to contribute little and not to change signifi-
cantly the quality-of-life years of such children.
In children with suspected acute leukemia, the diag-
nosis can be established on BM aspirate and peripheral
blood alone, and BM biopsy may not be necessary. How-
ever, in children with suspected aplastic anemia, BM
involvement by small blue cell tumor, or staging for
Hodgkin or non-Hodgkin lymphoma, a BM biopsy will
be necessary to establish the diagnosis. In such studies,
sampling both, the BM aspirates and biopsy, will
enhance the chances of arriving to the right diagnosis.
The iliac crest is the most frequent BM sampling site
in children. In newborns and neonates, conventional
BM biopsies may be difficult to perform, so alternative
techniques, such as obtaining marrow clot sections,
can be successfully utilized [17, 18]. The BM particles
in clot sections contain preserved marrow architecture,
so that they provide information on the overall BM
cellularity and the number and morphology of megak-
aryocytes. Such sections can also be used for immuno-
histochemical stains or other special stains. While the
adult requirement for the size of BM biopsy of at
least 1.5–2 cm may not be achievable in very young
children, an effort should be made so that sufficient
material is provided for proper examination [15].
After chemotherapy, BM aspirates may be paucicel-
lular and may not contain hematopoietic elements. In
the absence of particles or megakaryocytes, or other
hematopoietic precursors, the sample should be
reported as ‘dry tap’ or peripheral blood [15]. In
such instances, fresh BM biopsy is suitable for flow
cytometry that will provide valuable information on
the presence or absence of minimal residual disease.
Examination of BM aspirate smears at low-power
magnification is essential for determining the number
and cellularity of marrow particles, megakaryocytes as
well as presence of tumor clumps or abnormal cells that
may be of low incidence. This is particularly important
in paucicellular BM smears in children with suspected
neuroblastoma or rhabdomyosarcoma.
288 M. PROYTCHEVA | BM EVALUATION IN CHILDREN

Higher magnification provides valuable information
on the composition of marrow particles, cytological
details, and cell inclusions. As with adults, both quan-
titative and qualitative evaluation of all cell lineages is
important in generating a differential diagnosis. The
myeloid-to-erythroid ratio should also be docu-
mented. The BM trephine biopsies provide valuable
information on the overall cellularity, abnormal locali-
zation of progenitors, fibrosis, and presence of
extrinsic cells or lymphoid aggregates. In children,
lymphoid aggregates are rare and often present in
individuals with underlying immune deficiency, auto-
immune disorders, or other systemic diseases.
The adult guidelines for BM reporting are applicable
to children [15, 19]. The BM report should include BM
cellularity described as acellular, reduced, normal,
increased, or markedly increased along with quantitative
and qualitative comments on all cell lineages – myeloid
and erythroid progenitors with M:E ratio, megakaryo-
cytes, lymphocytes, plasma cells – and any abnormal
cells such as cells extrinsic to the bone marrow, leuke-
mic blasts, increased number or abnormal mast cells,
and the presence of histiocytes displaying hemophago-
cytosis. It is important to note that histiocytes displaying
hemophagocytosis is a nonspecific finding, and while in
proper clinical settings, it may be indicative of hemo-
phagocytic lymphohistiocytosis, it may also be seen in a
variety of disorders including but not limited to infec-
tions, after chemotherapy, and red cell transfusion. The
presence of stromal damage, chemotherapy effect, or
other stromal changes should be noted. Flow cytometric
findings, cytogenetics, and molecular studies should be
incorporated in the pathology report and should corre-
late with the BM morphologic findings. Lastly, the find-
ings should be correlated with the previous results if the
studies are carried out to monitor the disease progression
or response to therapy. The final BM interpretation
should be made in the context of the clinical and preli-
minary diagnostic findings. The BM diagnosis and/or dif-
ferential diagnosis, when applicable, should be in accord
with the international consensus guidelines [20].
In summary, the bone marrow is a dynamic organ,
and its composition depends on the needs for oxygen-
ation, immune response, and hemostasis. Because
such needs vary significantly during fetal life and
early childhood, the marrow composition will vary as
well. Knowledge of the normal bone marrow findings
at various ages is essential for the proper interpreta-
tion of bone marrow studies in children.
AC K N OW L E D G E M E N T
The author thanks Dr Deborah Fuchs for the critical
reading and comments of the manuscript.

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