PEDIATRIC HEMATOLOGY PEDIATRICS II

Cynthia Cantos - Castro || 02 December 2021 LT 03 TRANS 03 V.02

NOTES and REMINDERS Table 1. Cellular Elements

1. Contact your section’s TC (see footer) for any trans errata or Cellular Elements ⬆︎ INC ⬇︎DEC
clarifications Red Blood Cells polycythemia anemia
2. 20 points will be coming from this lecture for the semestral exam.
a
3. Please see the explanations under the iron study findings of each White Blood Cells leukocytosis leukopenia
anemia classification. The TCs did their best to rationalize the Platelets thrombocytosis thrombocytopenia
salient findings.
a: observed in leukemia or infection (leukopenia may also be seen in leukemia)
INSERT SPACE FONT SIZE

OUTLINE
I. Blood 1
A. Components Of Blood 1
B. Hematopoiesis 2
II. Anemia 2
A. Overview Of Anemia 2
B. Initial Diagnostic Approach To An Anemic Patient 3
C. Iron Deficiency Anemia (IDA) 5
III. Intrinsic Hemolytic Anemia 6
A. Thalassemia 7
B. Hereditary Spherocytosis 9
C. Glucose 6-Phosphate Dehydrogenase Deficiency 9
IV. Aplastic Anemia 10
V. Immune Thrombocytopenic Purpura(ITP) 10
VI. Defects In Hemostasis 11 Figure 1. Cellular Elements
A. Hemophilia 12 ● Cells of the bone marrow microenvironment produce cytokines that
B. Von Willebrand’s Disease 13 have overlapping actions during hematopoietic differentiation
Review Questions 14
● Specific cells respond to specific cytokines for proliferation and
References 17
maturation
Must Knows and Summary 18
○ Erythropoietin: red blood cells
Appendix 20
○ Thrombopoietin: platelets
Nice To Know 24
○ G-CSF: polymorphonuclear cells
OBJECTIVES
1. Choose the appropriate laboratory tests to diagnose common blood
disorders in children
2. Outline the management of common blood disorders
SUMMARY OF TERMINOLOGIES

Concept/Terminology Definition
ITP Immune Thrombocytopenic Purpura
APC Actual Platelet Count
PT Prothrombin Time
PTT Partial Thromboplastin Time
FFP Fresh Frozen Plasma
vWF von Willebrand Factor
vWD von Willebrand Disease
RDW Red Cell Distribution Width
MCV Mean Corpuscular Volume
MCH Mean Corpuscular Hemoglobin
Figure 2. Cytokines
I. BLOOD
○ Problems in the production, differentiation, and maturation of
● Blood is composed of the cellular elements and the liquid portion these bone marrow elements cause the majority of blood
called plasma diseases in children
A. COMPONENTS OF BLOOD PLASMA
CELLULAR ELEMENTS ● Contains the coagulation proteins which are responsible for
● Suspended in the plasma clotting and control of bleeding
○ Red blood cells: carry oxygen and nutrients ○ Factors I-XIII: imbalance will lead to bleeding or thrombosis
○ White blood cells: protection against infection
○ Platelets: stop bleeding and help heal wounds bleeding or thrombosis 💬
■ In balancing the coagulation factors, may either lead to

○ Majority of the coagulation proteins are produced in the liver

● Produced in the bone marrow
PED2 3.03 TG Silva, Siongco, Sison,Sison, Siena CORE Bautista, L., Bermejo, Ituralde, Santos, N. Page 1 of 25
 B. HEMATOPOIESIS
● Mature blood cells have a limited lifespan and must be continuously
replaced through a process called hematopoiesis which starts in
the red bone marrow
● All formed elements of the blood derive from a common progenitor,
the hematopoietic stem cells (HSCs)
● HSCs are multipotent
○ They can differentiate to all types of blood cells
○ Have the ability to multiply constantly to maintain their numbers
in the bone marrow
● Formation of blood cells from the hematopoietic stem cells is a
multi-step process involving several intermediate progenitors and is
regulated by a network of signalling molecules known as cytokines
○ Interleukins (ILs)
○ Stimulating factors
● Cytokines control the proliferation, differentiation, and survival or
death of the various progenitors
○ Maintain steady-state levels of blood cells in normal situations
○ Induce production of a particular cell type in response to certain
stimuli
○ Example: In response to blood loss, production of red blood cells
is accelerated
● Differentiation starts when progenitor cells develop surface
receptors for specific stimulating factors. Once this has happened,
the cells lose their potency and become committed to a certain cell
type
PRODUCTION OF RED BLOOD CELLS (ERYTHROPOIESIS)
● Production of red blood cells or erythrocytes is stimulated by
erythropoietin (EPO)
● During the differentiation process, the cells:
○ reduce in size
○ increase in number
○ start making hemoglobin
○ lose their nucleus
● EPO is produced predominantly by the liver during fetal
development and by the kidneys in adulthood
● Low levels of EPO are constantly secreted and are sufficient to
compensate for normal red blood cell turnover
● When the RBC count drops, such as during blood loss, the
resulting oxygen deficiency state (hypoxemia) is detected by the
kidneys.
○ The kidneys respond by increasing their EPO secretion which
leads to increased red blood cell production by the end of 3-5
days
● People living at high altitudes usually have a higher RBC count (7-8
million/uL) as a response to lower oxygen levels
● Athletes whose demand for oxygen is more elevated also have
higher RBC counts (6.6.5 million/uL)
PRODUCTION OF GRANULOCYTES AND MACROPHAGES
● Production of granulocytes and macrophages, they key players of
the body’s innate immune response, is controlled by several colony
stimulating factors (CSFs)
○ Granulocyte/macrophage colony-stimulating factor (GM-CSF)
○ Granulocyte colony-stimulating factor (G-CSF)
○ Macrophage colony-stimulating factor (M-CSF)
○ Multipotential colony-stimulating factor (interleukin-3)
● Normally, granulocytes and macrophages are kept at a more or less
constant number by relatively low levels of CSFs but their
production can increase greatly and quickly upon infection
● CSFs are commonly secreted by mature lymphocytes and
macrophages but can be produced if needed by virtually any organ
or cell type
● CSF production may increase a thousand fold in response to
indicators of infection such as bacterial endotoxins
PED 3.03 Pediatric Hematology
PRODUCTION OF PLATELETS
● Stimulated by thrombopoietin (TPO or THPO)
○ Hormone secreted by the kidneys and liver
● TPO is responsible for the formation of megakaryocytes, the
gigantic cells that develop as a result of multiple rounds of DNA
replication without cell division
● A megakaryocyte gives rise to a tens of thousands of platelets
which are essentially broken fragments of its cytoplasm
● Production of platelets is subject to a classic regulation of the
negative feedback loop
○ Reduced platelet levels in the blood promote their production
○ Elevated platelet levels inhibit their production
● Platelet Formation [supplementary video at 25:18]
○ Platelets are derived from megakaryocytes which are found in
bone marrow alongside leukocytes and erythrocytes
■ Megakaryocytes: the average megakaryocyte is 50-100µm in
diameter or 15x larger than most red blood cells; too large to
enter the sinusoidal vessels
○ Cytoplasmic processes of the megakaryocyte penetrate the
endothelial pores. The shear force of blood flow then stretches
these processes which eventually break off to form platelets and
proplatelets.
○ Proplatelets further differentiate into platelets by twisting and
pinching along the midline.
○ Platelets remain in the circulation for 5-9 days
○ Any platelets that are not utilized for thrombus formation are
eventually destroyed via phagocytosis in the spleen or liver.
○ After producing an average of 1000-3000 platelets, the
megakaryocyte is now small enough to meet the bloodstream
where they are subsequently consumed by alveolar
macrophages
CONCEPT CHECKPOINT
1. What stimulates the production of platelets?
a. Erythropoietin
b. Thrombopoietin
ANSWERS:
1. B. Recall, production of platelets is stimulated by thrombopoietin;
erythropoietin stimulated RBC production
.
II. ANEMIA
A. OVERVIEW OF ANEMIA
● Reduction in red cell mass or blood hemoglobin concentration
○ Usually 2 standard deviations below the mean for the normal
population
● Classification
○ Physiologic
○ Morphologic
● May be classified on the basis of physiology or morphology.
○ These two categories are not mutually exclusive
■ More than one mechanism may be present in some anemias
but one functional disorder is generally the major reason for
the patient’s anemia
PHYSIOLOGIC CLASSIFICATION OF ANEMIA
● Physiologic anemia falls into three categories of functional
disturbance:
○ Disorders of red cell production
■ rate of RBC production is less than expected for the degree of
anemia
○ Disorders of erythroid maturation and ineffective
erythropoiesis
○ Hemolytic anemia
● Classifying anemia physiologically may be aided by using a
laboratory test called the reticulocyte count
○ The reticulocyte count is an indirect measure of bone marrow red
cell activity
Page 2 of 25
Table 2. Reticulocyte Count
● Acute blood loss
Condition Reticulocyte Count ● Splenic pooling
for children 1 week and older normal values between ● Chronic renal disease (usually)
0.5-1.5%
● Morphologic classification refers to the size of the RBC which is
anemias with decreased low measured by the mean cell count (MCV)

📌
production ● Normal values of the MCV varies with age but as a rule of thumb,
the lower limit of MCV is 70 + age of the patient
anemias secondary to increased usually elevated
○ For example, a patient is a 2-year-old child, therefore, the lower
destruction, such as hemolysis
limit is 70 + 2 = 72
○ The normal values between 0.5-1.5% for children 1 week and
older
○ For anemias with decreased production, the reticulocyte count is
low
○ For anemias secondary to increased destruction, such as
hemolysis, the reticulocyte count is usually elevate

Figure 4. Morphological Classification of Anemia

CONCEPT CHECKPOINT
2. Vitamin 12 deficiency is classified as what morphological
kitypend of anemia?
Figure 3. Physiologic Classification of Anemia a. Microcytic anemia
MORPHOLOGICAL CLASSIFICATION OF ANEMIA b. Normocytic anemia

● Anemia may be classified in the basis of red cell size: 📌 c. Macrocytic anemia

○ Microcytic Anemia - Iron deficiency anemia, thalassemia, ANSWERS:

2. Macrocytic anemia.
Chronic disease, Lead poisoning
○ Macrocytic Anemia - Folate deficiency, Vitamin B12 deficiency,
Drug-induced, Acquired aplastic anemia B. INITIAL DIAGNOSTIC APPROACH TO AN ANEMIC PATIENT
○ Normocytic Anemia - Chronic disease, Infection, Malignancy, ● The initial diagnostic approach to an anemic patient would include:
Acute bleeding ○ A detailed history
Table 3. Morphological Classification of Anemia ○ Physical examination
Classification Disorders ○ Minimum of essential laboratory tests: CBC, reticulocyte count,
and a review of the peripheral blood smear (PBS)
Microcytic
Anemia
● Iron Deficiency Anemia (nutritional, chronic
blood loss) HISTORY 💬
● Thalassemia syndromes ● The important parts in the history are the following:
● Sideroblastic anemias ○ Age
● Chronic inflammation ○ Gender
● Some congenital hemolytic anemias with ○ Race
unstable hemoglobin ○ Ethnicity
Macrocytic ● With Megaloblastic Bone Marrow ■ Important because prevalence of hemoglobinopathies and
Anemia ○ Vitamin B12 deficiency thalassemia vary among different ethnic backgrounds
○ Folic acid deficiency ○ Neonatal
○ Hereditary orotic aciduria ○ Diet
○ Thiamine-responsive anemia ○ Intake of drugs
● Without Megaloblastic Bone Marrow ○ Infection
○ Aplastic anemia ○ Inheritance
○ Diamond-Blackfan syndrome ○ Any history of diarrhea
○ Hypothyroidism ● Transfusion in family members, with family history of anemia or
○ Liver disease symptoms that may be related to anemia like jaundice, gallstones,
○ Bone marrow infiltration cholecystectomy, or splenectomy should be investigated
○ Dyserythropoietic anemias ● Family history of blood loss like menorrhagia and epistaxis may
suggest that the anemia is due to the presence of an inherited
Normocytic ● Congenital hemolytic anemia bleeding disorder
Anemia ○ Hemoglobin mutants
● With almost universal newborn screening, many patients
○ Red cell enzyme defects
encounters are generated by identification of hemoglobinopathy by
○ Disorders of the red cell membrane
newborn screening tests in the absence of any symptomatology
● Acquired hemolytic anemias
● Menstrual history is crucial and should be obtained in all girls
○ Antibody mediated
○ Microangiopathic hemolytic anemias
● Dietary history is to identify conditions favoring folic deficiency or
○ Secondary to acute infections iron deficiency must also be elicited

PED 3.03 Pediatric Hematology Page 3 of 25

● Detailed medication history is of great importance to identify Table 5. Physical Findings as Clues to the Cause of Anemia
drugs that may directly produce anemia or may contribute to anemia Finding Cause
via increased blood loss such as aspirin and NSAIDs
Skin Hyperpigmentation Fanconi’s aplastic anemia
Table 4. Historical Factors of Importance in Evaluating Patients with Anemia Petechiae, Purpura Autoimmune hemolytic
Factors Information anemia with
thrombocytopenia,
Age ● Nutritional iron deficiency is never responsible for
hemolytic-uremic syndrome,
anemia in term infants before 6 months of age and
bone marrow aplasia, bone
rarely seen in premature infants before the time that
marrow infiltration
they have doubled their birth weight
Carotenemia Suspect iron deficiency in
● Anemia occurring in the neonatal period is generally
infants
the result of recent blood loss, isoimmunization, or
Jaundice Hemolytic anemia, hepatitis,
initial manifestation of a congenital hemolytic anemia
aplastic anemia
or congenital infection
Cavernous hemangioma Microangiopathic hemolytic
● Anemia first detected at 3 to 6 months of age anemia
suggests a congenital disorder of hemoglobin Ulcers on lower extremities S and C hemoglobinopathies,
synthesis or hemoglobin structure thalassemia
Gender ● Consider X-linked disorders in males (G6PD Facies Frontal bossing, prominence Congenital hemolytic
deficiency, pyruvate kinase deficiency) of the malar and maxillary anemias, thalassemia major,
Race ● Hemoglobins S and C more common in African bones severe iron deficiency
Americans Eyes Microcornea Fanconi’s aplastic anemia
● Beta-thalassemia more common in Caucasians Tortuosity of the conjunctival S and C hemoglobinopathies
● Alpha-thalassemia more common among African and retinal vessels
Americans and Asians Microaneurysms of the retinal S and C hemoglobinopathies
Ethnicity ● Thalassemia syndromes most common among vessels
patients of Mediterranean origin Cataracts G6PD deficiency,
galactosemia with hemolytic
● G6PD Deficiency observed more often among
anemia in the newborn period
Sephardic Jews, Filipinos, Greeks, Sardinians, and
Vitreous hemorrhages S hemoglobinopathies
Kurds
Retinal hemorrhages Chronic, severe anemia
Edema of the eyelids Infectious mononucleosis,
Neonatal ● A history of hyperbilirubinemia in the newborn period exudative enteropathy with
suggests the presence of congenital hemolytic IDA
anemia, such as hereditary spherocytosis of G6PD Blindness Osteoporosis
deficiency
Mouth Glossitis Vit B12 deficiency
● Prematurity predisposes to the early development of
Angular stomatitis Iron Deficiency
iron deficiency
Chest Unilateral absence of the Poland’s syndrome
Diet ● Document sources of Iron, Vit B12, folic acid, or
pectoral muscles
Vitamin E in the diet
Shield chest Diamond-Blackfan syndrome
● A history of pica, geophagia, or phagophobia
suggests the prevalence of iron deficiency Hands Triphalangeal thumbs Red cell aplasia
Hypoplasia of the thenar Fanconi’s aplastic anemia
Drug ● Oxidant-induced hemolytic anemia, phenytoin eminence
(Dilantin)-induced megaloblastic anemia, Spoon nails Iron deficiency anemia
drug-induced aplastic anemia
Spleen Enlargement Congenital hemolytic anemia,
Infections ● Hepatitis-induced aplastic anemia, infection-induced leukemia, lymphoma,
red cell aplasia, hemolytic anemia portal hypertension
Inheritance ● Family history of anemia, jaundice, gallstones, or
splenomegaly
Diarrhea ● Suspect small bowel disease with malabsorption of
folate or vitamin B12
● Suspect inflammatory bowel disease with blood loss
● Suspect protein-losing enteropathy with blood loss

PHYSICAL EXAMINATION 💬
● The presence of congenital defect is an important feature of
congenital anemia such as Fanconi’s anemia
○ Skeletal abnormalities such as hypoplastic or absent thumb or
radius are present in at least half of the patients with Fanconi’s
anemia
○ Many of these patients also have short stature.
■ Short stature and skeletal changes induced by expansion
of the erythroid mass should be noted because they are
often the result of anemia and expansion of the erythroid
marrow

PED 3.03 Pediatric Hematology Page 4 of 25

LABORATORY TESTS ● Aside from the MCV, a review of the PBS can establish whether the
anemia is hypochromic, microcytic, or normochromic

Figure 7. Peripheral Blood Smear. Normal PBS which is normochromic and

normocytic (L). PBS seen in IDA which is hypochromic and microcytic (R).

CONCEPT CHECKPOINT
3. Which of the following findings are seen in a patient with
Fanconi’s anemia?
a. Short stature
b. Hyperpigmentation of the skin
c. Hypoplastic or absent thumb
d. All of the above
4. What are the minimum essential laboratory tests done as part of
the initial diagnostics of a patient with anemia?

Figure 5. Laboratory Investigation of Anemia (see appendix for larger picture)
● Initial laboratory tests should always include a CBC, reticulocyte
count, and an examination of the peripheral blood smear (PBS)
● Based on the initial assessment of the patient and the first round of
laboratory tests, additional disease-specific tests should be
considered
● Bone marrow studies may be performed when there is clear
evidence of a hypoproliferative anemia except for cases of transient
virus induced erythroblastopenia
ANSWERS:
3. d. All of the above are PE findings in Fanconi’s anemia patients including short stature,
hypoplastic or absent thumb, hyperpigmentation of the skin, and microcornea, .
4. The minimum essential laboratory tests done as part of the initial diagnostics of an
anemia patient are CBC, reticulocyte count, and PBS.
C. IRON DEFICIENCY ANEMIA (IDA)
● The most common cause of microcytic anemia is Iron Deficiency
Anemia (IDA)
● IDA is the most widespread and common nutritional disorder in
the world

📌
● Complete Blood Count ● The peak prevalence of IDA occurs during late infancy and early
○ Hemoglobin and Hematocrit childhood when the following may occur:
○ WBC ○ Rapid growth with exhaustion of gestational iron
○ Platelets ■ The change in quantity of iron from birth (0.5 g) to adulthood
○ Red cell Indices (MCV, MCH) (5 g) means that an average of 0.8 mg of iron per day must
■ MCV: Mean Corpuscular Volume be absorbed during the 1st 15 years of life. [Nelson's]

●
■ MCH: ​Mean Corpuscular Hemoglobin
Reticulocyte count - indirect measure of the red cell activity of the
■ It is therefore necessary to absorb approximately 1 mg daily
to maintain positive iron balance in childhood.[Nelson's]
■ Breastfed infants have an advantage because they absorb
📌
bone marrow
● Peripheral Blood Smear (PBS) - RBC morphology, adequacy of 2-3 times more efficiently than infants fed with cow’s milk
platelets, abnormal cells [Nelson's]
● However, breastfed infants are at risk of developing iron
deficiency without regular intake of iron-fortified foods by 6
mo of age. [Nelson's’s]
○ Low levels of dietary iron
■ Because <10% of dietary iron is usually absorbed, a dietary
intake of 8-10 mg of iron daily is necessary to maintain iron
levels [Nelson's]
○ Blood loss due to internal or external bleeding
○ Complicating effect of cow’s milk induced exudative enteropathy
due to whole cow’s milk ingestion
○ Other causes of IDA found in the appendix
● A second peak is seen during the adolescent period due to the
rapid growth and suboptimal iron intake
○ This is amplified in females due to menstrual blood loss
● Best screening age for Iron Deficiency Anemia is 9-12 months.

● Sequence of biochemical and hematologic events in IDA [Nelson's]
Figure 6. Algorithm on the Characterization of Anemia based on MCV (see appendix
for larger picture)
● The algorithm above provides an initial characterization of anemia
based on the MCV (mean corpuscular volume)
○ The most common cause of microcytic anemia is Iron
Deficiency Anemia (refer to the next part about IDA)
● The PBS is very helpful in diagnosis of anemia
📌
1. First, tissue irons are depleted → reduced serum ferritin
■ Serum ferritin: iron storage protein that provides an estimate
of body iron stores in the absence in the absence of
inflammatory disease
2. Next, serum iron levels decrease, serum transferrin increases,
transferrin saturation falls below normal
3. As iron stores decrease, iron becomes unavailable to complex
with protoporphyrin to form heme → impaired hemoglobin
synthesis → less hemoglobin → smaller RBCs with varying sizes

PED 3.03 Pediatric Hematology Page 5 of 25

 4. The variation in RBC size is measured by an increasing red cell ○ A daily total dose of 3-6 mg/kg of elemental iron in 1 or 2 doses
distribution width (RDW). These changes are associated with a is adequate, with the higher dose used in more severe cases
decrease in mean corpuscular volume (MCV) and mean [Nelson's]
corpuscular hemoglobin. The RBC count also decreases. ■ Based on the 2020 feedback, the maintenance dose is 3 mg/kg/d
5. The reticulocyte percentage may be normal or moderately given for 1-3 months to replenish iron stores
elevated, but absolute reticulocyte counts indicate an insufficient ○ If the patient is iron deficient, there will be avid intake of iron
response to the degree of anemia. ○ There will be rapid correction of hemoglobin. If not deficient, then
no matter how many liters of iron you give then there will be no
Table 6. RBC indices of IDA. All are decreased in IDA except for increased RDW,
change in the hemoglobin
TIBC, and transferrin. The Mentzer Index of >13 is indicative of IDA while <13 is
indicative of Thalassemia ● Adequate Oral Response
○ The most reliable criterion of IDA is the hemoglobin response
IRON DEFICIENCY ANEMIA to an adequate therapeutic trial of iron
○ Subsequently to be 0.5 g/week until the hemoglobin is normal
Hemoglobin ↓ [2021/2022]
○ Ferrous sulfate at a dose of 6/mg/kg/day given for one month
MCV ↓ ○ Reticulocytosis with a peak occurring between 5th and 7th
day followed by a significant rise in the hemoglobin level occurs
RBC ↓ ■ A rise more than 1g/dL in one month
○ The absence of these changes implies that iron deficiency is not
the cause of anemia
RDW ↑
■ Iron therapy should be discontinued then further diagnostic
tests implemented
Reticulocyte count ↓ ■ If a positive response is seen, iron supplementation must be
continued for 1-3 months or even 6 months to replenish
Mentzer index >13 iron stores

Serum iron ↓

Serum ferritin ↓

TIBC ↑

Transferrin ↑

Transferrin ↓ Figure 8. Adequate Oral Response to Iron Therapy

Saturation

TC NOTE 📌 CONCEPT CHECKPOINT

5. True or False. A Mentzer index of >13 is indicative of Iron
deficiency anemia.
In the lecturer’s summary table, it was not specified if the transferrin 6. Peak prevalence of IDA occurs during what phase in children?
being referred to is “transferrin saturation” or transferrin as the 7. Which of the following RBC indices are increased in Iron
carrier protein. For purposes of a simpler understanding of IDA, Deficiency Anemia?
since TIBC is HIGH, transferrin SATURATION should logically be a. MCV
LOW. This was also corrected by the lecturer in her b. RDW
announcement via Canvas. This is because the binding sites for c. Ferritin
iron have NOT been fully occupied (LOW TRANSFERRIN d. Hemoglobin
SATURATION) = increased capacity for binding (HIGH TIBC). ANSWERS:
However, if in the exam, the one asked is transferrin ONLY, it should 5.True. A Mentzer Index of >13 is indicative of IDA, while <13 is indicative of Thalassemia.
be HIGH. 6.Peak prevalence of IDA occurs during the late infancy and early childhood, while the
second peak occurs during the adolescent period.
7. B. The RBS indices that are increased in IDA are RDW, TIBC, and transferrin, while
● In IDA, aside from low hemoglobin for age, the MCV, RBC count, other indices are decreased.
and reticulocyte count are likewise low
○ The reticulocyte count is an indirect measure of the bone marrow III. INTRINSIC HEMOLYTIC ANEMIA
red cell activity
● The Red Distribution Width (RDW) is elevated as the red cells ● Hemolysis [2021/2022]
are far apart in distribution because of its low number ○ Defined as premature destruction of RBCs
■ Rate of destruction exceeds the capacity of the marrow to
● The serum ferritin is low in IDA

●
○ reflects the level of iron body stores
PBS: hypochromic, microcytic RBCs with substantial variation in
produce additional RBCs [Nelson's]
○ Normal RBC survival time: 120 days 📌
●
cell size
Clinical Manifestations: [2021/2022]
■ 110-120 days (Half-life: 55-60 days) [Nelson's]
○ In hemolysis, the following are expected:
■ Shortened RBC survival
[Nelson's] 📌
○ Asymptomatic until hemoglobin reaches 7-9 g/dL ■ Fall in RBC count
○ Neurocognitive deficits - very common in infants (low IQ, ■ Increase in erythropoietin (EPO)
sleepiness, poor performance in school) ■ Stimulation or marrow erythropoietic activity
○ Epithelial changes - angular stomatitis, glossitis, and spoon nail
○ Pica - propensity of eating non-nutritive substances like soil, HEMOLYTIC ANEMIA
starch, or ice
📌
● Characterized by shortened red cell survival
● Therapeutic goal of Iron: [2021/2022]
● Can be classified in several ways: [Nelson's]
○ Give 6 mg/kg/d of oral iron
○ Intrinsic or extrinsic (to the RBC)
○ Inherited or acquired
○ Immune or non-immune
PED 3.03 Pediatric Hematology Page 6 of 25
 ○ Acute or chronic ■ Non-transfusion dependent thalassemia
○ Intravascular or extravascular (reticuloendothelial) ■ Less severe clinical phenotype that usually does not require
● Classification of Hemolytic Anemia [2021/2022] regular transfusion therapy
○ Intrinsic (Cellular Defects): ● ɑ-Thalassemia Syndromes [Nelson's]
■ Membrane defects - Hereditary Spherocytosis ○ Absence or reduction in the ɑ-globin production usually due to
■ Enzymopathies - G6PD Deficiency deletions of ɑ-globin genes
■ Hemoglobinopathies -Thalassemia ■ Normal individuals have four (4) ɑ-globin genes
○ Extrinsic (Extracellular Defects) ● The more genes are affected, the more severe the disease
○ Autoimmune Hemolytic Anemia DIAGNOSIS OF THALASSEMIA
○ Erythroblastosis Fetalis
● CBC
● May result from cellular abnormalities such as: ● Newborn Screening Test
○ Membrane disorders (ex. Hereditary Spherocytosis) ● High Performance Liquid Chromatography Test
○ Enzyme disorders ○ Confirms the diagnosis after newborn screening
○ Hemoglobin abnormalities (ex. Thalassemia) ● Hemoglobin Electrophoresis
○ Extracellular abnormalities involving the immune system (ex. ● Molecular Genetic Studies
Immune Hemolytic Anemia ○ Done to identify the specific genotype involved
Table 7. Clinical and Laboratory Features Suggestive of Hemolytic Anemia
[Nelson's] CLINICAL CLASSIFICATION OF THALASSEMIAS
HEMOLYTIC ANEMIA: CLINICAL AND LABORATORY FEATURES
● Pallor ● Abnormal RBC morphology
● Icterus ● ↑ Indirect bilirubin
● Splenomegaly ● Normal direct bilirubin
● Gallstones ● ↓ Serum haptoglobin
● History of neonatal icterus ● ↑ Urinary urobilinogen level
● Positive family history of anemia, ● Hemoglobinuria (positive
splenectomy, cholecystectomy dipstick test for blood; no
● ↑ Reticulocyte count RBCs in urine)
● ↑ Red cell distribution width (RDW) ● ↑ LDH
due to ↑ in reticulocyte count

A. THALASSEMIA
THALASSEMIA AND IRON DEFICIENCY ANEMIA (IDA)
● The absence of the expected changes after a trial of iron
supplementation implies that iron deficiency anemia is not the cause
of anemia Figure 10. Clinical classification of thalassemias
○ Iron therapy is discontinued and further diagnostic tests are
Table 8. RBC Indices of Thalassemia
implemented

📌 THALASSEMIA
● The first differential diagnostic of microcytic anemia unresponsive
to adequate iron therapy is thalassemia
● Thalassemia refers to a group of genetic disorders of globin-chain Hemoglobin ↓

📌
production in which there is an imbalance between the ɑ-globin
and β-globin chain production [Nelson's]
○ The normal adult hemoglobin is a tetramer of two α and two β
MCV ↓

chains RBC ↑

RDW N

Reticulocyte count ↑

Mentzer index <13

Serum iron ↑

Figure 9. Tetramer of Two α- and Two β-chains Serum ferritin ↑

● The primary pathology in the thalassemia syndromes stems from
the QUANTITY of the globin produced [Nelson's] TIBC ↓
○ The hallmark of thalassemia syndromes is a DECREASED OR
ABSENT SYNTHESIS of one or more globin chains [PPT] 📌 Transferrin ↓
● β-Thalassemia Syndromes
○ Result from a decrease in β-globin chains, which results in a Transferrin ↑
relative excess of ɑ-globin chains Saturation
○ Require a mutation in the β-globin genes
■ Carriers with a SINGLE β-globin mutation are generally
asymptomatic TC NOTE 📌
○ β-Thalassemia Major [Nelson's]
■ Transfusion-dependent thalassemia In the lecturer’s summary table, it was not specified if the transferrin
■ Severe β-Thalassemia that requires early transfusion therapy being referred to is “transferrin saturation” or transferrin as the
○ β-Thalassemia Intermedia [Nelson's] carrier protein. For purposes of a simpler understanding of

PED 3.03 Pediatric Hematology Page 7 of 25

 Thalassemia, since TIBC is LOW, transferrin SATURATION should Treatment: monitoring
logically be HIGH. This is because the binding sites for iron have of growth and organ
already been fully occupied (HIGH TRANSFERRIN SATURATION) function, folate and
= decreased capacity for binding (LOW TIBC). However, if in the multivitamins without
exam, the one asked is transferrin ONLY, it should be LOW. iron, vitamin D
supplementation (if
α- THALASSEMIA level is low), adequate
calcium intake,
● The 4 alpha syndromes of silent carrier, trait, hemoglobin H disease, intermittent
and hydrops fetalis reflect the inheritance of molecular defects transfusion,
affecting the output of one, two, three, or four of the α-chains splenectomy
respectively
○ ONE CHAIN DELETION results in a carrier state where the Profound anemia
patient is hematologically normal during fetal life
○ TWO CHAIN DELETION results in thalassemia trait where the
patient has mild microcytic anemia No normal
○ THREE CHAIN DELETION is hemoglobin H disease with the hemoglobins at birth
patient having symptomatic microcytic anemia with
splenomegaly HYDROPS FETALIS 4 α-globin genes Intrauterine
○ FOUR CHAIN DELETION α-thalassemia is incompatible with transfusions may
life, and is also known as hydrops fetalis rescue the fetus, but
■ Two causes of hydrops fetalis: congenital
● 4-chain deletion α-thalassemia abnormalities and
● Erythroblastosis fetalis caused by Rh incompatibility neurodevelopmental
delay often result

β-THALASSEMIA
● Includes four clinical syndromes of increasing severity:
○ Silent Carrier
○ Trait
○ Intermedia
○ Major

Figure 10. Genetics of α-thalassemia
Table 9. Pathophysiology of α-thalassemia
📌
● The clinically significant thalassemia is the transfusion dependent
β-thalassemia major [PPT]
○ Transfusion-dependent β-thalassemia major
■ Also called Cooley’s Anemia
■ Characterized by severe anemia that ranges from 1-7g/dL
hemolysis, and massive intramedullary erythropoiesis
■ Clinical characteristics manifest in infancy and include:
● Severe anemia: extreme pallor, jaundice, failure to thrive
● Poor feeding
● Irritability
● Decreased activity
● Increased somnolence
● Hepatosplenomegaly and frontal bossing are the early
📌 [Nelson's] (see appendix for larger table)
signs of thalassemia facies, and are usually present

MANIFESTATION AND
CLASSIFICATION DELETION
TREATMENT
Not identifiable
hematologically
SILENT TRAIT 1 α-globin gene
Usually diagnosed
after birth of a child
with 2-gene deletion
Microcytic anemia
α-THALASSEMIA (can be mistaken as
2 α-globin genes
TRAIT IDA due to low MCV Figure 11. β-thalassemia major facies
and MCH)
● Management of β-thalassemia major
Marked microcytosis, ○ Transfusion [Nelson's]
anemia, mild ■ Periodic blood transfusion to prevent age related
splenomegaly, scleral complications associated with anemia
icterus, cholelithiasis ■ Patients should receive RBCs depleted of leukocytes and
matched for D,C,c,E,e, and Kell antigens
Chronic transfusion ■ Generally given at 3-4wk intervals with a goal of being able to
HbH DISEASE 3 α-globin genes
isn’t usually required, maintain a pretransfusion Hb level of 9.5-10g/dL [Nelson's]
but intermittent ■ If the child is growing poorly and has developed facial or other
transfusions may be bone abnormalities, or the hemoglobin level is below 7g,
needed for worsening regular transfusion will be beneficial
anemia

PED 3.03 Pediatric Hematology Page 8 of 25

 ○ Chelation
■ In cases of ongoing transfusion therapy, with each cc of
packed RBCs containing 1 mg of iron, cumulative iron
overload is an inevitable consequence
● Serial serum ferritin levels provide useful screening, but
may not accurately predict quantitative iron stores [Nelson's]
■ If iron overload is not addressed, complications of
cardiomyopathy, endocrinopathy, bone disease, and problems
in growth and development may ensue
■ Iron-chelation should be done as soon as the patient
becomes significantly overloaded, usually 1 year after
transfusion therapy, and with serum ferritin of >1,000 ng/mL
and/or liver concentration of >5,000 ug/g dry weight [Nelson's]
■ Not done for children <2 years old [Kliegman, 21st],
■ Three iron-chelators: [Nelson's]
● Deferoxamine: most studied, subcutaneous or IV, poor oral
bioavailability and short half-life, continuous infusion for 8
hrs daily 5-7 days/wk, started at 35mg/kg, poor adherence
● Deferasirox: oral, OD administration, half life of >16hr
● Deferipone: oral, second-line agent, 3hr half life, dosing 3
times daily, starting dose of 75mg/kg/day
■ Combination chelation therapy may be indicated for high iron
burden [Nelson's]
■ Close monitoring is required as chelation toxicity
increases as iron stores decrease [Nelson's]
○ Preventive Care
■ In countries where abortion is accepted, prenatal diagnosis
with termination of pregnancy has been available for two
decades
■ Future therapies such as the use of fetal hemoglobin inducers
and gene therapy are being investigated
○ With optimal transfusion and chelation programs, thalassemia
patients are living longer and maintaining a good quality of life
○ A select few are cured with bone marrow transplant
IDA VS. THALASSEMIA VS. ACD
Table 10. Comparison of IDA, Thalassemia, and ACD (See Appendix for larger table)
IDA THALASSEMIA ACD
■ Low transferrin saturation
■ Increased transferrin and hepcidin [Synch Session]
TC NOTE 📌
On hemoglobin and MCV:
In ACD, some patients have modest hypochromia and
microcytosis, hence the low hemoglobin and normal-to-low MCV
in its iron study findings (Table 10). Do not be confused with what is
depicted in Table 10 for the hemoglobin and MCV findings of ACD.
In Nelson, it is indeed a mild to moderate NORMOCYTIC
NORMOCHROMIC anemia, however some patients have low
hemoglobin and low MCV (MICROCYTIC HYPOCHROMIC), as
what is depicted in the lecturer’s summary table (Table 10).
On iron studies findings:
In ACD, FERRITIN is the only factor that will increase (Table 10).
As opposed to the previous explanations regarding the TIBC and
transferrin saturation of IDA and Thalassemia, the logic does not
apply to ACD. In this case, all will decrease EXCEPT for
FERRITIN.
● Best approach to ACD is the treatment of underlying disorder
CONCEPT CHECKPOINT
8. What is the fist differential diagnostic of microcytic anemia
unresponsive to adequate iron therapy
9. Describe the clinical presentation of a patient with the most
clinically significant type of β-thalassemia
ANSWERS:
8.Thalassemia. Thalassemia would not respond to iron.
9. The most clinically significant type is transfusion dependent β-thalassemia major or
Cooley’s Anemia. These patients have severe anemia, poor feeding, irritability,
decreased activity, increased somnolence, hepatosplenomegaly, and thalassemia
facies.
B. HEREDITARY SPHEROCYTOSIS
HEREDITARY SPHEROCYTOSIS

Hemoglobin ↓ ↓ ↓

MCV ↓ ↓ N-↓

RBC ↓ ↑ N-↓

RDW ↑ N N-↑

Reticulocyte ↓ ↑ ↓
count

Mentzer index >13 <13

Serum iron ↓ ↑ ↓ Figure 12. Normal Red Blood Cell vs Spherocyte

● From the supplementary video:
Serum ferritin ↓ ↑ ↑ ○ Genetic mistakes cause RBCs to become misshapen as they
travel through blood system
TIBC ↑ ↓ ↓ ○ Become sphere-shaped, like rigid basketballs
○ When the cells pass through spleen, they are mistaken as
Transferrin ↑ ↓ ↓ damaged and get destroyed, thereby causing anemia
● Classic example of MEMBRANE DEFECT

📌
● Present with alterations in quality or quantity of red cell membrane
Transferrin ↓ ↑ ↓
proteins involved in the maintenance of the biconcave shape
Saturation
[PPT]

● IDA and thalassemia are further differentiated from anemia of

chronic disease (ACD) or anemia of inflammation by ACD being:
protein 📌
○ The most common mutation is in the ankyrin membrane
[PPT]

○ Found in sick and hospitalized children

○ Mild to moderate normochromic normocytic hypoproliferative
anemia associated with:
■ Low serum iron

PED 3.03 Pediatric Hematology Page 9 of 25

● When the RBCs pass through the spleen, a part of their membrane ○ In other words, there is pancytopenia
of aplastic anemia
📌
which is the hallmark
is pinched off
○ Decrease in the membrane surface area results in the formation ■ Pancytopenia = decrease in all three blood cell types (RBC,
of microspherocytes which, when tested in the laboratory, have WBC, platelets)

📌
an increased tendency to lyse in hypertonic solution, resulting ● Aplastic anemia is characterized by a marked decrease or absence
in an increased osmotic fragility test (OFT) of blood forming elements with resulting pancytopenia and can be
● Eosin-5-maleimide staining and analysis by flow cytometry of inherited or acquired

📌 📌
the RBCs ● Splenomegaly, hepatomegaly and lymphadenopathy do not
○ Test of choice generally occur in this condition
○ Only available in special reference laboratories ● At least 70% of acquired aplastic anemia is idiopathic
● Family history of anemia with jaundice, and history of splenectomy SEVERE APLASTIC ANEMIA
are usually seen

📌
● Treatment includes folic acid supplementation, blood transfusion, ● Severe aplastic anemia is defined by bone marrow cellularity
and splenectomy <25% and at least 2 of the following cytopenias:
○ Granulocyte count <500/mm3
C. GLUCOSE 6-PHOSPHATE DEHYDROGENASE DEFICIENCY(G6PD
○ Platelet count < 20,000/mm3
DEFICIENCY)
○ Reticulocyte count < 20,000/m3
● The resulting signs and symptoms reflect the effect of the cytopenia
present (Note: Those in bold below were emphasized by the
lecturer)
● Anemia
○ Pallor
○ Easy fatigability
○ Weakness
○ Loss of appetite
Figure 13. G6PD in Pentose Phosphate Pathway ● Thrombocytopenia
○ Petechiae
● G6PD is the first enzyme in the Pentose Phosphate Pathway of ○ Easy bruising
glucose metabolism. ○ Bleeding
● Deficiency diminishes the reductive energy of the red cell and ● Leukopenia
may result in hemolysis ○ Fever
● Episodes of hemolysis may be produced by drugs or infection ○ Increased susceptibility to infection
● It may diagnosed at birth through the newborn screening test or ● Supportive Care
later in life by an enzyme assay ○ Treatment of children with Aplastic anemia requires
● Management would be avoidance of agents known to cause comprehensive supportive care coupled with an attempt to treat
oxidant stress to red blood cells the underlying bone marrow failure [Nelson's]
● During brisk hemolysis, blood transfusion may be needed and the ○ Transfusion
patient adequately hydrated and monitored to prevent acute ■ The patient may invariably need transfusion of component
kidney injury therapy
○ Antibiotics
CONCEPT CHECKPOINT ● Definitive Therapy of Severe Aplastic Anemia
10.How does hemolysis occur in G6PD deficiency? ○ HSCT (Hematopoietic stem cell transfusion)
■ For patients with a human leukocyte antigen-matched family
member donor [Nelson's]
ANSWERS:
.
■ 90% chance of long term survival
10. The reductive energy of the red blood cell is decreased which may result to hemolysis ○ Immunosuppression
when induced by agents causing oxidant stress ■ ATG (Anti-thymocyte globulin) and Cyclosporine [Nelson's]
● Main treatment for patients without a sibling donor
IV. APLASTIC ANEMIA ● 30% of patient responders experience relapse after
discontinuation of immunosuppression

CONCEPT CHECKPOINT
11.What type of cytopenia may be exemplified by Aplastic Anemia?
12. How is severe aplastic anemia defined?
13.What is the definitive therapy for severe aplastic anemia?

ANSWERS:
11. Pancytopenia where there is decrease in red blood cells, platelets and white blood
cells.
12. Severe aplastic anemia is defined as bone marrow cellularity <25% and at least 2 of
the following cytopenias: Granulocyte count < 500/mm , Platelet count <20,000/m3,
3

reticulocyte count <20,000/m3

13. Hematopoietic Stem Cell Therapy and Immunosuppression by ATG(Anti-thymocyte
globulin) or cyclosporine

Figure 14. Aplastic Anemia vs Normal Bone marrow. Absence of hematopoietic

cells with replacement by fatty tissues (L). Normal Cellular Marrow (R).
● Sometimes, it is not only the red blood cells that are decreased in
number but the other cellular elements as well namely the platelets
and the WBC

PED 3.03 Pediatric Hematology Page 10 of 25

 V. IMMUNE THROMBOCYTOPENIC PURPURA(ITP)
● The most common platelet disorder is a quantitative disorder which
is thrombocytopenia
● The most common cause of thrombocytopenia in children is ITP
○ ITP is an autoimmune disorder characterized by immunologic
destruction of otherwise normal platelets most commonly
📌
occurring in response to an unknown stimulus
● APC(Actual Platelet Count) <100,000
○ Thrombocytopenia is usually defined as a platelet count
<100,000
● Primary ITP: thrombocytopenia in the absence of other causes of
disorders
● Secondary ITP: Occurs as a result of other disorders
Table 11. Causes of Secondary ITP
Causes of Secondary ITP
Antiphospholipid syndrome
Autoimmune thrombocytopenia (eg Evans syndrome)**
Common variable immune deficiency
Drug administration side effect
Infection with cytomegalovirus, Helicobacter pylori, hepatitis C,
human immunodeficiency virus, varicella zoster
Lymphoproliferative disorders
Bone marrow transplantation side effect
● At diagnosis, there are clinical clues whether the ITP is acute or
chronic
● These are not absolute but may guide the clinician on the possible
outcome of the ITP and help with the monitoring of the patient
DIAGNOSIS OF ITP
● Diagnosis of exclusion
● History: isolated bleeding symptoms without constitutional s/sx;
antecedent history of infection 1-2 weeks prior
○ The child is clinically well
○ may or may not have a history of Upper Respiratory Tract
Infection 1-2 weeks prior
● Physical Exam: isolated bleeding signs in the absence of
hepatosplenomegaly
● Complete Blood Count: isolated thrombocytopenia
● Peripheral Blood Smear: decreased platelets
● Bone marrow aspiration is unnecessary if the typical features above
are present
MANAGEMENT OF ITP
● Goal of therapy in ITP: to increase the platelet count enough to
prevent serious hemorrhage and at the same time prevent adverse
effects of treatment
● Observation (Initial Treatment)
○ Generally, patients with actual platelet count >30,000 with no
only 📌
signs of bleeding do not need treatment and may be observed

● Patients with actual platelet count <20,000 and with moderate

Vaccination side effect bleeding, and those with <10,000 should be treated
● The following may be employed in treatment of ITP
Systemic lupus erythematosus ○ First line: corticosteroids, IVIg, anti-D
** Evans syndrome is associated with autoimmune thrombocytopenia with ■ Used especially in children who present with mucocutaneous
coincident hemolytic anemia bleeding
● The peak occurrence of ITP is between 2 and 5 years of age 📌 ■ A single dose of IVIG (0.8-1.0 g/kg) for 1-2 days induces a
rapid rise in platelet count in 95% of patients within 48 hr
● In most children, the disease is self-limited, with resolution in
[Nelson's]
60-80% within 6-12 months from the time of diagnosis ■ Prednisone at 1-4 mg/kg/24 hr for a short course until a rise in
CLASSIFICATION OF ITP platelet count >20x10^9/L has been achieved [Nelson's]
○ Splenectomy
■ Should be reserved for 2 circumstances: [Nelson's]
● Older children (≥ 4 y.o.) with severe ITP that has lasted > 1
year (chronic ITP) and symptoms not easily controlled with
therapy
● Life threatening hemorrhage (ICH) complicates acute ITP,
if the platelet count cannot be corrected rapidly with
transfusion and first line treatment (IVIG, corticosteroids)
○ Rituximab
○ Eltrombopag:thrombopoietic agents
○ High dose dexamethasone
○ Immunosuppression
● Platelet transfusion may be transiently effective and is required for
Figure 15. Classifications of ITP emergency situations including:
● Newly diagnosed ITP: thrombocytopenia at the time of diagnosis up ○ Intracranial hemorrhage
to 3 months ○ Internal bleeding
○ Emergency surgery
● Persistent ITP: if thrombocytopenia is still present up to 12 months
● Chronic ITP : if thrombocytopenia persists beyond 12 months
CONCEPT CHECKPOINT
📌
Table 12. Acute vs Chronic ITP 14.What is the most common cause of thrombocytopenia in
Acute Chronic children?
15. What are the features necessary for diagnosis of ITP?
Onset Abrupt, dramatic insidious
16.When is observation as management done for ITP?
Age Young children adolescents
History Acute viral illness none ANSWERS:
13. Immune Thrombocytopenic Purpura.
Platelet count <20 50 14. The child is clinically well; isolated bleeding symptoms without constitutional s/s, may
or may not have infection 1-2 weeks prior, CBC: isolated thrombocytopenia, PBS:
Course Self limiting SLE,HIV, H pylori decreased platelets
.15. Generally, patients with APC >30,000 with no signs of bleeding do not need treatment
Treatment Observation Observation
Steroids Immunosuppressant
IVIg Splenectomy

PED 3.03 Pediatric Hematology Page 11 of 25

 VI. DEFECTS IN HEMOSTASIS
● Primary Hemostatic Defect
● The plasma contains the coagulation factors responsible for ○ Involves the vessels and platelet
maintaining hemostasis
📌
○ Characterized by superficial bleeding in the skin and mucous
membranes exemplified by petechiae
○ Bleeding after minor cuts and immediate bleeding after
trauma/surgery are common
● Clotting Factor Deficiency

hemarthrosis are common

○ Characterized by delayed bleeding
📌
○ Deep seated bleeding like dissecting hematoma and

● Susceptibility to increased bruising (hemostasis defects) vs.

non-medical causes (child abuse)
○ Bruises associated with primary hemostasis defects are
usually located over areas of typical childhood traumas such as
bony protuberances of extremities or spinous process
○ Inflicted trauma is most likely seen over the head, chest, back
and long bones and may retain the outline of the instrument used
to inflict them
APPROACH TO PATIENTS WITH DEFECTS IN HEMOSTASIS
Figure 16. Coagulation Cascade
● Clinician’s challenges in patients with defects in hemostasis:
REVIEW OF HEMOSTASIS ○ Differentiating mild and common symptoms of bleeding disorders
● Hemostasis is maintaining blood inside the blood vessels from those encountered in healthy children
● 3 events that take place concurrently when there is injury and ○ Determining when additional laboratory is needed
bleeding ● For careful clinical history of bleeding in patients with suspected
○ Vascular Phase defects of hemostasis
■ Vasoconstriction of injured blood vessel ○ Initial set of questions should establish:
○ Platelet phase ■ The most common site and type of bleeding
■ Platelet plug formation of the primary hemostatic mechanism ■ Bleeding on hemostatic challenge such as surgeries or
○ Fibrin thrombus formation trauma
■ End product of coagulation cascade [asked in 2022 review questions] ■ Family history of bleeding
● Abnormal bleeding results from disturbances in these 3 phases ○ Relevant clinical history include:
■ Age of onset of clinical bleeding
● Plasmin - activated form of plasminogen which is responsible for
■ Family history of bleeding
clot lysis
■ Intake of medications

Figure 17. Events in Hemostasis

PRIMARY HEMOSTATIC DEFECTS VS. CLOTTING FACTOR
DEFICIENCIES

and Clotting Factor Deficiencies📌

Table 13. Differences in Clinical Manifestations of Primary Hemostatic Defects Figure 18. Algorithm for Bleeding (see appendix for larger picture)
● When a child presents with bleeding:
Clinical Primary Hemostatic Clotting Factor ○ Step 1: Characterize if it is superficial or deep-seated bleeding
Characteristic Defect Deficiency ■ Examples of superficial bleeding are:
● Skin bleeding such as petechiae, purpura, ecchymosis
Site of bleeding Skin, mucous Soft tissues, muscles,
● Mucosal bleeding such as epistaxis, gingival bleeding and
membranes joints
menstrual bleeding
Bleeding after minor Yes Rare ○ Step 2:
cuts ■ In the presence of skin and mucosal bleeding (superficial
bleeding), check the platelet count
Petechiae Present Absent
● ITP (IgM auto Ab against GP2B3A rec) is the most
Ecchymosis Small, superficial Large, deep, palpable common cause of thrombocytopenia in children
■ In the presence of hematomas and hemarthrosis (deep
Hemarthrosis Rare Common seated bleeding), check the PT and PTT
Bleeding after Immediate Delayed ● Hemophilia is the most common example with PT/PTT
trauma/surgery abnormalities

PED 3.03 Pediatric Hematology Page 12 of 25

 A. HEMOPHILIA MANAGEMENT OF HEMOPHILIA
● Hemophilia is an X-linked recessive disorder attributable to
● Factor replacement - mainstay of hemophilia treatment
decreased blood levels of functional pro-coagulant factor VIII or IX
○ Hallmark of excellent hemophilia care[Nelson's]
leading to delayed clot formation.
○ Factor concentrates (Factor 8 or Factor 9)
○ Should be suspected when unusual bleeding is encountered in a
○ For life-threatening bleeding [Nelson's]
male patient
■ Levels of 80-100% of normal factor 8 or factor 9 are
● The clot formations is delayed and not robust
necessary
● Soft and friable clot
○ For mild to moderate bleeding episodes (hemarthrosis)[Nelson's]
● 2% of neonates with intracranial bleeding ■ A 40% level for factor VIII or a 30-40% level for factorIX9 is
● 30% bleed with circumcision appropriate
● High rate of spontaneous mutations ● Blood products (fresh frozen plasma (FFP), cryoprecipitate,
● Easy bruisability and hematoma as the child begins to cruise] cryosupernate)
● Hallmark is hemarthrosis ○ Provide hemostatic control
○ The median age for the first joint bleed is 10 months ○ Used in centers where where the availability of factor
■ Corresponding to the age at which the infant becomes mobile concentrates is a challenge
○ “Target” joint - recurrent bleeding ● Packed RBC
TYPES OF HEMOPHILIA ○ May be given for significant blood loss causing symptomatic
anemia
● Hemophilia A ● Desmopressin acetate
○ Lack of factor VIII ○ Increases plasma factor VIII levels 2-5 folds in hemophilia A
○ More common than hemophilia B patients
○ 85% of cases ○ Commonly used in selected hemorrhagic episodes in mild
● Hemophilia B hemophilia A patients
○ Lack of factor IX ● Prophylaxis
○ Less common than hemophilia A ○ Starting in infancy has greatly diminished the likelihood of
○ 10 - 15% of cases chronic arthropathy in children with hemophilia[Nelson's]
● Hemophilia C ○ Given if you don’t want patient to have target joints[2022A]
○ Rare genetic bleeding disorder ○ Problem with development of antibodies directed against factor
○ Lack of factor XI concentrate[2021]
● Clinical presentation of Hemophilia A and B are indistinguishable ● Monoclonal antibodies
and the severity and frequency of bleeding are usually related to the ○ Used especially in patients with inhibitors
plasma levels of factor VIII or IX. ■ Inhibitors are IgG antibodies directed against transfused
Table 14. Types of Hemophilia factor 8 or factor 9 in congenitally deficient patients[Nelson's;s]
Type of Hemophilia Lacking Factor Note ○ Emicizumab
● Gene therapy
Hemophilia A VIII ○ Has been experimented on
Hemophilia B IX B. VON WILLEBRAND’S DISEASE
Hemophilia C XI ● Second most common inherited bleeding disorder
Contact Factor Deficiency XII, HMWK, prekallikrein No bleeding
● Von Willebrand Factor (vWF)
○ A multimeric glycoprotein that is synthesized in megakaryocytes
Table 15. Factor Levels of Hemophilia (those in bold were emphasized by the lecturer) and endothelial cells
Condition/ Severity of Percentage of Manifestations ○ After vascular injury, plasma vWF binds to the subendothelial
Hemophilia Factor Levels matrix
■ In the first step towards clot formation, platelets are recruited
Normal lower limit 50% to the site of vessel injury by now exposed molecules of
Hemostatic level F8 > 30 - 40% vessel wall such as collagen and vWF[video]
○ Under shear stress, vWF changes conformation which enables
Hemostatic level F9 > 25 - 30% adherence of circulating platelets through the glycoprotein
Mild > 5% Requires significant receptor, glycoprotein 1B
trauma ○ Platelets are activated and recruit other platelets through platelet
aggregation
Moderate 1 - 5% Requires mild ■ vWF mediates the linking of collagen to platelets via specific
trauma receptor in platelet membrane[video]
○ Activated platelets alter their surface phospholipids so factor VIII
Severe < 1% Spontaneous
binds and interacts with factor IXa to activate tenase complex
bleeding episodes
and facilitate formation of fibrin clot
DIAGNOSIS OF HEMOPHILIA[Nelson's] ○ Deficiency results in mucocutaneous bleeding and
prolonged oozing following trauma or surgery
● The diagnosis of hemophilia is based on a prolonged aPTT.
○ In the aPTT, a surface-active agent activates the intrinsic system
of coagulation, of which factors 8 and 9 are crucial components.
○ For screening
● Specific Factor Assays
○ Are needed to make a precise diagnosis to determine the
appropriate factor replacement therapy
○ Definitive diagnostic test for hemophilia
● Prenatal diagnosis and carrier diagnosis are possible using
molecular techniques.

PED 3.03 Pediatric Hematology Page 13 of 25


Figure 19. Diagram of VWF interaction and action on clot formation[PPT]
CLINICAL MANIFESTATION OF VON WILLEBRAND’S DISEASE
● Primary clinical presentations of VWD:
○ Epistaxis
○ Ecchymosis
○ Menorrhagia
○ Post-operative or postpartum bleeding
● Because this is often mild, the initial manifestations may be
bleeding after a surgery like tonsillectomy
● Specific assays for vWF disease are required for diagnosis in
patients with a history of significant bleeding
○ Ristocetin cofactor assay (VWFR:Co), which uses the
antibiotic ristocetin to induce VWF to bind to platelets, measures
the vWD activity[Nelson's]
○ VWF multimer testing is done to assess the protein structure
and assists in the diagnosis of the qualitative disorders (type 2 =
dysproteinemia)[Nelson's]
MANAGEMENT OF VON WILLEBRAND’S DISEASE
● Plasma levels of vW factor can usually be increased by
administering desmopressin which induces release of vWF factor
from endothelial cells
○ Desmopressin is the treatment of choice for most bleeding
episodes in patients with type 1 disease and some patients with
type 2 disease[Nelson's]
● Factor VIII concentrates contain significant amount of vwF and
may be used to treat bleeding
● Antifibrinolytics provide hemostatic control
● Virally attenuated VWF-containing concentrate (Humate
P)[Nelson's]
○ When high levels of VWF are needed but cannot be achieved
satisfactorily with desmopressin.
● As in all bleeding disorders, aspirin and nonsteroidal
antiinflammatory drugs should be avoided.
CONCEPT CHECKPOINT
17. What factor does Hemophilia A lack?
a. Factor XI
b. Factor VIII
c. Factor IX
18.What is the treatment of choice for Von Willebrand’s Disease?

ANSWERS:
17. B. Factor VIII.
Factor XI: Hemophilia C
Factor IX: Hemophilia B
18. Desmopressin

REVIEW QUESTIONS
SYNCHRONOUS SESSION
1. At what age in weeks does physiologic anemia occur in full
term infants?
a. 4-8
Figure 20. Von Willebrand Function b. 8-12
● A careful family history may identify symptoms seen in parents or c. 12-16
siblings that are similar to the patient d. 16-20
● Types of vWD[Nelson's] 2. A one month old infant born preterm at 28 weeks gestation
○ Quantitatively deficient was diagnosed to have anemia of prematurity. The infant is
■ Partial = vWD type 1 feeding well and growing normally. The infant is feeding well
● Approximately 80% of patients with von Willebrand and growing normally. Which of the ff may be instituted?
disease have classic type 1 disease a. Blood transfusion
● Typical symptoms: mucosal bleeding such as epistaxis, b. EPO administration
menorrhagia as well as easy bruising and potential c. Iron supplementation
surgical bleeding d. Vit E administration
■ Absolute = vWD type 3 3. Which of the ff statements about iron absorption is true?
● Most severe form and presents with symptoms similar in a. Breastfed infants poorly absorb iron
mild hemophilia b. Excessive consumption of cow’s milk can cause iron deficiency
○ Qualitatively abnormal anemia
■ Dysproteinemia = vWD type 2 c. It is absorbed in the proximal jejunum
d. It is necessary to absorb 10mg of iron daily to maintain a
DIAGNOSIS OF VON WILLEBRAND’S DISEASE positive iron balance in childhood
● Laboratory evaluation of Von Willebrand disease often requires 4. Screening for iron deficiency anemia in children is best done
multiple assays to quantitate vWF and characterize its function and at what age?
structure a. At birth
● Confirmatory testing is through vWD antigen assay[2021] b. 3-6 months
● The disease cannot be ruled out on the basis of normal PTT or c. 9-12 months
bleeding time d. 24 months onwards

PED 3.03 Pediatric Hematology Page 14 of 25

5. The first iron compartment to be depleted in iron deficiency 17. Splenectomy in ITP is reserved for:
is the storage iron reflected by: a. Acute ITP lasting 6 months
a. Decreased MCV b. Asymptomatic children
b. Decreased serum iron c. Children aged 4 years and below
c. Decreased serum transferrin d. Life threatening hemorrhage complicates acute ITP
d. Decreased serum ferritin 18. Which of the ff is the hallmark of hemophilia?
6. Which of the ff is reflective of IDA? a. Gum bleeding
a. Low MCV, low RDW, low reticulocyte count b. Hemarthrosis
b. High MCV, low RDW, high reticulocyte count c. Intracranial hemorrhage
c. Low MCV, high RDW, low reticulocyte count d. Petechiae
d. High MCV, high RDW, high reticulocyte count 19. Which of the following is the definitive diagnostic test for
7. Which of the following is a differential diagnosis for hemophilia?
microcytic anemia that does NOT respond to oral iron? a. Bleeding time
a. Aplastic anemia b. Factor assay
b. Leukemia c. PT
c. Megaloblastic anemia d. PTT
d. Thalassemia 20. Which of the following factors is lacking in hemophilia B?
8. Which of the following is an early response to iron therapy? a. VII
a. Erythroid hyperplasia b. VIII
b. Increase in hemoglobin level c. IX
c. Repletion of iron stores d. X
d. Reticulocytosis
Answer Key:
9. Which of the ff statements is TRUE about anemia of chronic
Full term: 8-12 weeks
disease? 1 B Preterm: 4-6 weeks
a. There is a decreased uptake of iron in the reticuloendothelial Longer than 12 weeks - not physiologic already
cells Iron supplementation is enough since the patient is growing and feeding well.
2 C
b. There is competitive binding of iron with hepcidin. Blood transfusion is recommended if there is cardiac decompensation.
c. The mainstay of treatment is blood transfusion. A. breastfed infants have better absorption of iron
d. It is associated with increased serum iron and high transferrin 3 B C. absorbed in the proximal duodenum
saturation. D. only 1 mg is needed to maintain a positive iron balance in childhood

10. The normal adult hemoglobin consists of: The peak prevalence of IDA occurs during late infancy (9-12 mos) and early
childhood. The 2nd peak is in adolescence.
a. 2 alpha 2 beta
4 C Not done for children 6 months and below: at birth, the baby is replete with iron
b. 2 alpha 2 delta and is still enough until 6 months. If it occurs beyond 24 months, it is not IDA
c. 2 alpha 2 epsilon but another problem (e.g. intestinal parasitism, etc.)
d. 2 alpha 2 gamma First, tissue iron stores are depleted. This depletion is reflected by reduced
11. The most common adverse effect of chronic blood serum ferritin, an iron-storage protein, which provides an estimate of body iron
stores in the absence of inflammatory disease.
transfusion in thalassemia is:
Iron deficiency may occur in the absence of anemia. The storage
a. Allergic reaction compartments of iron are plasma, hemoglobin, and tissue (ferritin). So if
b. Congestion 5 D there’s iron deficiency, the first that depletes is ferritin (Storage).
c. Hemolysis
Once you give iron supplements, the first that repletes is hemoglobin →
d. Iron overload plasma → lastly, storage (ferritin). That’s why you need to continue taking iron
12. Excess body iron in thalassemia may be removed through: supplements for 3 months (even if hemoglobin is corrected) to replenish iron
a. Chelation stores.
b. Massive doses of ascorbic acid See Table 6. IDA: microcytic anemia (low MCV)
c. Phlebotomy Low MCV (average size of your red blood cells): small because of impaired
heme synthesis
d. Splenectomy 6 C
High RDW: measurement of the range in the volume and size of your red
13. The final product of the coagulation cascade is: blood cells (magkadikit dikit -low- or kung magkahiwalay -high-)
a. Fibrin Low Reticulocyte count
b. HMWK 7 D
Recall (Page 7). The first differential diagnostic of microcytic anemia
c. Kallikrein unresponsive to adequate iron therapy is thalassemia.

d. Thrombin Recall (Figure 8, Page 6) The earliest among the choices is erythroid
hyperplasia at 36-48 hours after administration. The rest of the choices occur
14. Which of the following is responsible for clot lysis?
later.
a. Fibrin
b. Thrombin
c. Tissue factor
8 A
d. Plasmin
15. Which of the following is the most common cause of acute
onset of thrombocytopenia in an otherwise well child?
a. Dengue fever
b. Evan’s syndrome
c. Immune thrombocytopenic purpura A. False. Reticuloendothelial cells take up so much of the iron stores.
d. Thrombocytopenia with absent radii There is “starvation amidst plenty” because there is actually abundant
16. The initial approach to a 3-year-old child with ITP presenting iron, but it is in the reticuloendothelial cells.
B. True. Hepcidin protein binds the iron, therefore the latter is not available
to your clinic with mild symptoms of bruising and a platelet 9 B for the bone marrow to make RBCs. Hepcidin is ELEVATED in ACD.
count of 50,000 will include: C. False. Unless Hemoglobin is 3-5mg/dL.
a. IVIg infusion D. False. Since this is chronic, iron is already low, hence the transferrin is
LESS SATURATED with iron (should be “decreased transferrin
b. No therapy saturation”).
c. Platelet infusion
Recall.
d. Splenectomy 10 A ● 2 alpha, 2 delta - HbA2
● 2 alpha, 2 gamma - Fetal Hb
In cases of ongoing transfusion therapy, with each cc of packed RBCs
11 D
containing 1 mg of iron, cumulative iron overload is an inevitable

PED 3.03 Pediatric Hematology Page 15 of 25

 consequence. If iron overload is not addressed, complications of indirect indicator for anemia. MCV and MCH are RBC indices. RDW measures
cardiomyopathy, endocrinopathy, bone disease, and problems in growth and the variation in RBC size and volume.
development may ensue. Allergic reactions are rare since patients are already
Most of the hematopoietic cell lines except for the lymphoid cell lines can be
chronically transfused at this point.
4 A stimulated by GM-CSF. EPO, IL-12, and thrombopoietin can stimulate the
Iron-chelation should be done as soon as the patient becomes significantly production of RBCs, small lymphocytes, and platelets respectively.
overloaded, usually 1 year after transfusion therapy, and with serum ferritin of
If it is an IDA, it should be responsive to iron therapy. If it presents with
>1,000 ng/mL and/or liver concentration of >5,000 ug/g dry weight. Recall that
5 B microcytic hypochromic anemia but is unresponsive to iron therapy,
12 A this is not done for children <2 years old. Likewise, close monitoring is
thalassemia is the first thing to consider.
required as chelation toxicity increases as iron stores decrease.
Phlebotomy is CONTRAINDICATED since the patient already lacks Folic acid deficiency and Vit B12 deficiency causes macrocytic anemia. Lead
hemoglobin, so there is no need to extract more blood. poisoning cannot be considered unless there was any mention of lead
exposure in the patient's history of present illness (e.g. putting objects in his
Recall. HMWK and Kallikrein are not the answer since they are part of the 6 B
mouth or touching lead-based paint). Exclusively breastfed infants start to
13 A earlier parts of the coagulation cascade. The same goes for thrombin which is
have lower iron reserves by 6 months of age, making IDA to be the best
formed EARLIER than the fibrin clot.
answer.
Recall. Thrombin and fibrin are not the answer since it participates in
14 D CLOTTING. Tissue factor lies in the earlier parts of the cascade. By rule of
elimination, plasmin is the answer. 7. ​Which of the following satisfies the criteria for severe
15 C When platelet count drops in ITP, the patient must be a well-child. aplastic anemia?
a. Bone marrow cellularity < 25%
NOT C: will just kill the platelets
16 B NOT D: not recommended for children below 6 years old b. ANC > 500/mm3
Initial approach: no therapy c. Reticulocyte count 30/mm3
Splenectomy is usually reserved for chronic ITP not responding to other d. Platelet count 100,000
17 D
medical treatment and when there is life threatening bleed. 8. What is the end product of the coagulation cascade?
18 B Recall. a. Thrombin clot
PT/PTT: for screening b. X-ase complex
19 B
Bleeding time: not done in patients with hemophilia c. Platelet plug
Factor VIII deficiency: hemophilia A d. Fibrin clot
20 C
Factor IX deficiency: hemophilia B 9. A 12-year-old boy has an increased Osmotic Fragility Test.
2022 REVIEW QUESTIONS | Same lecturer What is the most likely diagnosis?
1. Which of the following is true regarding iron deficiency a. G6PD deficiency
anemia? b. Thalassemia
a. TIBC is low c. Iron deficiency
b. Serum ferritin is low d. Hereditary spherocytosis
c. MVC is high 10. Macrocytic anemia is a characteristic finding in:
d. Reticulocyte count is high a. Acute blood loss
2. At what hour is reticulocytosis observed in iron replacement b. Iron deficiency anemia
therapy? c. Vit B12 deficiency
a. 36 d. Thalassemia
b. 24 11. Excess body iron can be removed through the process of:
c. 48 a. Centrifugation
d. 12 b. Condensation
3. Which of the following indirectly measures the red blood cell c. Chromatography
activity of the bone marrow? d. Chelation
a. Reticulocyte count 12. Which of the following corresponds to hemoglobin H
b. RDW disease?
c. MCV a. Death in utero
d. MCH b. Moderately severe hemolytic anemia and splenomegaly
4. Which cytokine exerts its action on almost all hematopoietic c. Mild hypochromic microcytic anemia
cells? d. Hematologically normal
a. GM-CSF 13. The lower limit of the MVC of a 4-year-old child is:
b. Erythropoietin a. 74
c. IL-2 b. 73
d. Thrombopoietin c. 71
5. A 3-year-old boy with microcytic hypochromic anemia is d. 72
unresponsive to adequate iron therapy. What is the most 14. Which of the following is a diagnostic test for thalassemia?
likely diagnosis? a. Hemoglobin electrophoresis
a. Iron deficiency anemia b. BMA
b. Thalassemia c. Enzyme assay
c. Aplastic anemia d. OFT
d. Megaloblastic anemia
Answer Key:
6. A 1-year old boy who was purely breastfed since birth was
Criteria for severe aplastic anemia includes bone marrow cellularity of < 25%
noted to have hypochromic microcytic anemia. What is the 7 A and at least 2 of the following: granulocyte count <500/mm3, platelet count
most likely diagnosis? <20,000/mm3, and reticulocyte count <20,000/mm3.
a. Lead poisoning Platelet plug is not part of the coagulation cascade. Initially, there would be
b. Iron deficiency 8 D formation of a tenase complex followed by a thrombin clot, then a more stable
fibrin clot.
c. Vitamin B12 deficiency
d. Folic acid deficiency OFT is the diagnostic test for hereditary spherocytosis. Enzyme Assay is used
Answer Key: to diagnose G6PD. Hemoglobin electrophoresis is used in thalassemia.
9 D Therapeutic trial or iron study is used in IDA.
In IDA, the RBC indices are all decreased except for RDW, TIBC, and
1 B transferrin which are increased. RBC indices include Hgb, MCV, RBC,
reticulocyte count, serum iron, and serum ferritin.
Among the choices, only Vit B12 deficiency can present with macrocytic
Reticulocytes will remain more than 48 hours in the peripheral blood until they 10 C anemia. Acute blood loss causes normocytic anemia. IDA and thalassemia
2 C turn into red blood cells. Also, initial bone marrow response and erythroid causes microcytic anemia.
hyperplasia is observed 36-48hrs after administration of iron supplementation.
You have to remove the excess iron by chelation using iron chelators like
3 A Reticulocytes are produced in the bone marrow, hence can be used as an 11 D
deferoxamine either through oral or IV routes.

PED 3.03 Pediatric Hematology Page 16 of 25

 Hemoglobin H disease is an alpha thalassemia. It will depend on the number Answer Key:
12 B of genes deleted. It is a 3-gene deletion that will result in moderately severe B. Partial Thromboplastin Time Example of delayed bleeding is when a
anemia, jaundice, and splenomegaly. patient comes in for tooth extraction and there is no bleeding because of the
1 B presence of platelets. Three days after, the patient comes in for bleeding at
Normal values of the MCV values with age but as a rule of thumb, The lower
13 A the extraction site, then for sure the patient has a problem with the
limit of MCV is 70 + age of the patient.
coagulation phase of hemostasis.
Thalassemia is a hemoglobin problem therefore hemoglobin Electrophoresis is
2 D Factor 9 replacement is the treatment of choice
the diagnostic test. BMA would be normoblastic hyperplasia and not the first
14 A test to be done. G6PD can be diagnosed through an enzyme assay because it A factor level of less than 1% already indicates a severe hemophilia that
3 D
is usually the one with enzyme problems. OFT is for hereditary spherocytosis; manifests as spontaneous bleeding episodes
if you do this to thalassemia, the cells are resistant to this test.
4 A Factors affected by Vitamin K deficiency are factors II, VII, IX and X (1972)

15. Which of the following conditions can cause hemolytic 5. Desmopressin is a treatment modality in what type of
anemia? disease?
a. Folic acid deficiency a. G6PD deficiency
b. Thalassemia b. Haemophilia
c. Aplastic anemia c. ITP
d. Iron deficiency d. Von Willebrand disease
16. A 14-year-old male underwent dental extraction. He was 6. What is the hallmark of haemophilia?
asymptomatic until 3 days later bleeding was noted from the a. Bleeding after circumcision
extraction site. What phase of hemostasis is most likely b. Gum bleeding
defective? c. Hemarthrosis
a. Platelet d. Intracranial bleeding
b. Coagulation 7. Which blood product should be stored at room
c. Vascular temperature with constant agitation?
d. Fibrinolytic a. Cryoprecipitate
17. A 10-month-old boy was given an antibiotic for fever. He b. FFP
was subsequently noted to be pale with red-colored urine. c. Platelet concentrate
What is the most likely diagnosis? d. pRBC
a. G6PD deficiency 8. What is the most common cause of febrile non hemolytic
b. Thalassemia transfusion reaction?
c. Iron deficiency a. ABO incompatibility
d. Hereditary spherocytosis b. IgA deficiency
Answer Key: c. Lymphocyte cytokine
Only thalassemia can cause hemolytic anemia among the given choices. d. Serum protein
15 B A & C - Both present with macrocytic anemia.
D - IDA causes microcytic anemia.
9. A newborn was given a 100cc FFP transfusion. A few
minutes later he was noted to have DOB. What is the
Patient presents with delayed bleeding. Problems with vascular and platelet phase
16 B are primary hemostatic defects which are characterized by immediate bleeding. most likely complication of this treatment?
Clotting factor deficiencies manifest with delayed bleeding. a. ABO incompatibility
This patient presents a classical picture of G6PD. Fever and any b. Allergic transfusion reaction
17 A antibiotics may induce oxidative stress and causes paleness and c. Circulatory overload
red urine in G6PD patients. d. Haemolytic transfusion reaction
10. A 2-month old infant was brought for her well baby
2020 REVIEW QUESTIONS | Same lecturer check-up. The infant appeared well with good suck and
1. A 6 year old had a dental extraction. He was good activity and weight gain. PE was essentially normal
asymptomatic until 3 days later when profuse bleeding except for mild pallor. What is the most likely cause of
from the extraction site was noted. Which of the following the pallor?
laboratory tests will most likely be abnormal? a. Aplastic anemia
a. Fibrin degradation product b. G6PD deficiency
b. Partial thromboplastin time c. Iron deficiency anemia
c. Platelet count d. Physiologic anemia
d. Protime 11. Pre-latent iron deficiency is characterized by low __.
2. Which of the following statements regarding Hemophilia a. Ferritin
B is true? b. Haemoglobin
a. Cryoprecipitate may be given in the absence of factor c. Iron
concentrate d. TIBC
b. Desmopressin is a therapeutic option 12.A 15-kg child being treated for IDA will need how many
c. Factor 8 replacement is the treatment of choice mg of iron as maintenance therapy?
d. Factor 9 replacement is the treatment of choice a. 30
3. A patient with factor level activity of less than 1% will b. 45
exhibit one of the following? c. 60
a. Bleeding after mild trauma d. 90
b. Bleeding after significant trauma 13. Correction of haemoglobin in IDA will take how many
c. No risk of bleeding days?
d. Spontaneous bleeding a. 7
4. John has vitamin K deficiency. Which of the following b. 14
factors will be affected? c. 21
a. II d. 28
b. VIII
c. XI
d. XII

PED 3.03 Pediatric Hematology Page 17 of 25

14. The CBC of a 4 year old male revealed microcytic anemia
with a slightly elevated reticulocyte count. What is the According to the 2021 asynchronous lecture, “a decrease in the membrane
surface area results in the formation of microspherocytes which, when
most likely problem? tested in the laboratory, have an increased tendency to lyse in hypertonic
a. Aplastic anemia solution, resulting in an increased osmotic fragility test (OFT)” and “the test
b. Iron deficiency anemia of choice is Eosin-5-maleimide staining of red cells and analysis by flow
cytometry”, but this is only found in special reference laboratories.
c. Megaloblastic anemia
d. Thalassemia
ITP is an autoimmune disorder characterized by immunologic destruction
15. A 5- year old boy was brought for consultation because 17 A
of platelets
of jaundice. History revealed that for 2 days PTC, he was
If a patient has skin bleeding(ex. Petechiae, purpura or ecchymosis) or
diagnosed to have URTI for which he was prescribed 18 B mucosal bleeding(epistaxis, gingival bleeding, menstrual bleeding), check
Cotrimoxazole. Which of the following laboratory tests the platelet count which is included in a CBC
would likely be abnormal? Refer to Table 11. Chronic ITP has an insidious onset compared to Acute
a. Bone marrow aspirate 19 C ITP which is abrupt and dramatic, has an extremely low platelet
b. Platelet count count(<20), and is self limiting.

c. PTT 20 A
Refer to Table 11. Treatment for Acute ITP includes observation, steroids or
IVIg.
d. Reticulocyte count
16. Which of the following is the diagnostic test of choice for
hereditary spherocytosis?
a. BMA REFERENCES
b. Electrophoresis 2022 3.03 Pediatric Hematology
c. Enzyme assay Nelson's Textbook of Pediatrics
d. Osmotic fragility test ERRATA
17. Thrombocytopenia in acute ITP is secondary to:
a. Antibodies directed against platelets
b. Decreased bone marrow production of platelets Scan QR code at left or click this link:
c. Excessive platelet agglutination
d. Intravascular coagulation PEDIATRICS II ERRATA SHEET
18. A 3-year old girl was brought to the ER because of
generalized petechiae. The rest of the PE was
unremarkable. Which of the following will you request
first?
a. BMA
b. CBC
c. PT
d. PTT
19. Chronic ITP is characterized by which of the following?
a. Dramatic onset
b. Extremely low platelet count
c. Insidious onset
d. Self-limiting course
20. What treatment is appropriate for acute ITP?
a. Prednisone
b. Rituximab
c. Splenectomy
d. Vincristine

Answer Key:
Plasma levels of vW factor can usually be increased by administering
5 D
desmopressin which induces release of vWF factor from endothelial cells
6 C Recall
Platelet concentrate is then suspended on a 30CC of plasma and stored on
7 C
room temp. Only with constant agitation, life span is 5 days.
8 C
9 A
Physiologic anemia of infancy Increase in oxygenation → kidney will
produce lesser EPO; less stimulation to the Bone marrow → less
10 D production of RBC→ This will persist until tissue needs oxygen. It should
not be more than 8-12 weeks and it should be within the range of 10-11
g/dL Starts at 6-8 weeks but persists until 8-12 weeks
From 2020 trans: Pre-latent iron deficiency is characterized as low serum
11 A ferritin, which is also the first storage to be affected, and the patient is
asymptomatic.
From 2020 trans: Maintenance iron therapy is given at 3 mg/kg/d for 1-3
12 B
months to replenish iron stores. 3 mg/kg/d x 15 kg (wt) = 45 mg/d
Correction of IDA is done by giving 6 mg/kg/day of oral iron/Ferrous sulfate
13 D for one month. Increase in hemoglobin levels would be evident 4-30 days
after administration of iron.
First differential diagnosis of hypochromic microcytic anemia unresponsive
14 D to iron. Hereditary hemolytic anemia- expect higher reticulocyte count
compared to IDA
The patient has Immune Thrombocytopenic Purpura due to a history of
15 B
URTI. ITP has an actual platelet count <100,000
This was the answer provided in the 2020 samplex. No rationale was
16 D
provided.

PED 3.03 Pediatric Hematology Page 18 of 25

 MUST KNOWS & SUMMARY
BLOOD
● Blood is composed of cellular elements and plasma
● Cellular elements
○ Red blood cells (anemia, polycythemia)
○ White blood cells (leukopenia, leukocytosis)
○ Platelets (thrombocytosis, thrombocytopenia)
● Plasma
○ Contains coagulation proteins
■ Factors I-XIII: bleeding or thrombosis
● Mature blood cells are continuously replaced through hematopoiesis
○ Starts in the red bone marrow
● All formed elements of the blood derive from hematopoietic stem
cells (HSCs)
● Production of RBCs
○ Stimulated by erythropoietin (EPO)
○ Cells reduce in size, increase in number, start making
hemoglobin and lose their nucleus
● Fetal development: EPO produced in liver
● Adulthood: EPO produced in kidneys
● Production of granulocytes and macrophages
○ controlled by several colony stimulating factors (CSFs)
● Production of platelets
○ Stimulated by thrombopietin (TPO or THPO)
ANEMIA
● Anemia is the reduction in red cell mass or blood hemoglobin
concentration
● Anemia may be classified as physiologic or morphologic
● Physiologic classification of anemia
○ may be aided by using a laboratory test called the reticulocyte
count
● Morphological Classification of Anemia may be classified based on
red cell size
○ Microcytic Anemia - Iron deficiency anemia, thalassemia,
Chronic disease, Lead poisoning
○ Macrocytic Anemia - Folate deficiency, Vitamin B12 deficiency,
Drug-induced, Acquired aplastic anemia
○ Normocytic Anemia - Chronic disease, Infection, Malignancy,
Acute bleeding
● Normal values of the MCV varies with age but as a rule of thumb,
the lower limit of MCV is 70 + age of the patient
● The initial diagnostic approach to an anemic patient would include:
○ A detailed history
○ Physical examination
■ Fanconi’s anemia - hypoplastic or absent thumb or radius,
short stature
○ Minimum of essential laboratory tests: CBC, reticulocyte count,
and a review of the peripheral blood smear (PBS)
IRON DEFICIENCY ANEMIA
● Iron Deficiency Anemia is the most common cause of microcytic
anemia and most widespread and common nutritional disorder in
the world
● Peak prevalence of IDA - late infancy and early childhood
○ necessary to absorb approximately 1 mg daily to maintain
positive iron balance in childhood
● Second peak of IDA - adolescent period
● All RBC indices are decreased in IDA except for increased RDW,
TIBC, and transferrin.
● The most reliable criterion of IDA is the hemoglobin response to an
adequate therapeutic trial of iron - Ferrous sulfate at a dose of
6/mg/kg/day given for one month
○ If a positive response is seen, iron supplementation must be
continued for 1-3 months or even 6 month to replenish iron
stores
PED 3.03 Pediatric Hematology
INTRINSIC HEMOLYTIC ANEMIA
● Hemolytic anemia results from abnormalities in the RBC membrane,
enzymes, and hemoglobin.
● Thalassemia is the first differential diagnosis for microcytic anemia
unresponsive to iron therapy
● There are 4 α-thalassemia syndromes with increasing number of
α-globin deletions and increasing severity: silent trait,
α-thalassemia trait, HbH disease, hydrops fetalis
● There are 4 β-thalassemia syndromes with increasing severity, the
most significant being transfusion-dependent β-thalassemia major
(Cooley’s anemia)
○ Present with severe anemia, hepatosplenomegaly, and
thalassemia facies
● β-thalassemia major is managed with periodic RBC transfusion and
iron chelation
● Anemia of chronic disease/ anemia of inflammation presents as Mild
to moderate normochromic normocytic hypoproliferative anemia
associated
HEREDITARY SPHEROCYTOSIS
● Hereditary spherocytosis is a membrane-defect caused by a genetic
mutation that produces misshapen RBCs that lyse in the spleen,
causing anemia.
● In hereditary spherocytosis, a mutation in the ankyrin protein is most
common, osmotic fragility test is increased, and the test of choice is
the Eosin-5-maleimide staining of red cells and analysis by flow
cytometry (but only available in reference laboratories).
● G6PD is an enzyme in the Pentose Phosphate Pathway
● G6PD deficiency diminishes the reductive energy of the cell and
may result in hemolysis, which can be induced by drugs or infection
● Management is avoiding agents that can cause oxidant stress to
RBC
● Blood transfusion, hydration and monitoring are needed during brisk
hemolysis to prevent acute kidney injury
APLASTIC ANEMIA
● Aplastic anemia is characterized by pancytopenia which is decrease
in red blood cells, platelets and white blood cells
● The bone marrow smear of aplastic anemia shows absence of
hematopoietic stem cells with
● At least 70% of aplastic anemia is idiopathic
● Severe aplastic anemia is defined as <25% cellularity and at least 2
of the following cytopenias
○ Granulocyte count <500/mm3
○ Platelet count <20,000/mm3
○ Reticulocyte count <20,000/mm3.
● The signs and symptoms reflect the type of cytopenia present
○ Anemia
■ Pallor, easy fatigability, weakness, loss of appetite
○ Thrombocytopenia
■ Petechiae,easy bruising, bleeding
○ Leukopenia
■ Fever, increased susceptibility to infection
○ Treatment of Aplastic Anemia
■ Supportive Care
● Transfusion
● Antibiotics
■ Definitive Therapy
● Hematopoietic Stem Cell Therapy
● Cyclosporine
Page 19 of 25
IMMUNE THROMBOCYTOPENIC PURPURA DEFECTS IN HEMOSTASIS
● Thrombocytopenia, a quantitative disorder, is the most common ● Three phases in hemostasis
platelet disorder ○ Vascular Phase
● The most common cause of thrombocytopenia in children is ■ Vasoconstriction of blood vessel
Immune Thrombocytopenic Purpura ○ Platelet Phase
○ The peak occurrence is between 2 and 5 years of age ■ Platelet plug formation of the primary hemostatic mechanism
○ Self-limited in most children(60-80%) within 6-12 months from ○ Fibrin thrombus formation
time of diagnosis ● Primary Hemostatic defect is characterized by:
● ITP is an autoimmune disorder with destruction of otherwise normal ○ Superficial bleeding in skin and mucous membrane
platelets ○ Bleeding after minor cuts and immediate bleeding after
● ITP has an APC(actual platelet count)< 100,000 trauma/surgery
● Primary ITP: thrombocytopenia in absence of other causes of ● Clotting Factor deficiency bleeding is characterized by:
disorders ○ Deep seated bleeding like dissecting hematoma and
● Example causes of secondary ITP hemarthrosis
○ Antiphospholipid syndrome ● Increased bruising must be differentiated from non-medical causes
○ Autoimmune thrombocytopenia(eg.Evans syndrome) such as child abuse
○ Drug administration side effect ○ Inflicted trauma will have an outline of the instrument used over
● Newly diagnosed ITP: At time of diagnosis up to 3 months head,chest, back and long bones
● Persistent ITP: 3-12 months ○ Bruises due to primary hemostasis are located over typical areas
● Chronic ITP:>12 months of childhood trauma such as bony protuberances
● Acute vs Chronic ITP ● Skin bleeding examples
○ Acute is abrupt and dramatic, chronic is insidious ○ Petechiae, purpura, ecchymosis
○ Acute occurs in young children, chronic occurs in adolescents ● Mucosal bleeding examples
○ Acute has a history of viral illness, while chronic has none ○ Epistaxis, gingival bleeding and menstrual bleeding
● Diagnosis of ITP ● If there is skin and mucosal bleeding, check the platelet count
○ Almost remains entirely one of exclusion
■ History: isolated bleeding symptoms without constitutional s/s; HEMOPHILIA
antecedent history of infection 1-2 weeks prior ● Hemophilia
■ PE: isolated bleeding signs ● An X - linked recessive disorder attributable to decreased blood
■ CBC: isolated thrombocytopenia levels of functional pro-coagulant factor VIII or IX leading to delayed
■ PBS: decreased platelets clot formation.
○ If these features are present, bone marrow aspiration is not ● Types of hemophilia and deficiencies
indicated ○ Hemophilia A: factor VIII
○ Hemophilia B: factor IX
○ Hemophilia C: factor XI
○ Contact Factor Deficiency: XII, HMWK, prekallikrein
● Hallmark is Hemarthrosis
● The diagnosis of hemophilia is based on a prolonged aPTT.
● Factor replacement is the mainstay of hemophilia treatment

VON WILLEBRAND’S DISEASE

● Second most common inherited bleeding disorder
● Von Willebrand Factor (vWF) is multimeric glycoprotein that is
synthesized in megakaryocytes and endothelial cells
● The clinical presentations of VWD are primarily epistaxis,
ecchymosis, menorrhagia and post-operative or post-partum
bleeding.
● Desmopressin is the treatment of choice for most bleeding
episodes in patients with type 1 disease

PED 3.03 Pediatric Hematology Page 20 of 25

 CONCEPT CHECKPOINT

BLOOD 10. How does hemolysis occur in G6PD deficiency?

1. What stimulates the production of platelets? ○ Reductive energy of RBC is reduced, resulting to hemolysis
○ Thrombopoietin. which may be induced by agents causing oxidative stress
ANEMIA 11. Type of cytopenia exemplified by Aplastic Anemia?
2. Vitamin B 12 is classified as what morphological type of anemia? ○ Pancytopenia
○ Macrocytic anemia. 12. Definition of severe aplastic anemia
3. Which of the following findings are seen in a patient with Fanconi’s ○ bone marrow cellularity <25% and at least 2 of the following
anemia? cytopenias: Granulocyte count < 500/mm3, Platelet count
○ Short stature, hyperpigmentation of the skin, hypoplastic or <20,000/m3, reticulocyte count <20,000/m3
absent thumb 13. Definitive therapy for severe aplastic anemia?
4. What are the minimum essential laboratory tests done as part of the ○ HSCT and Immunosuppression by ATG
initial diagnostics of a patient with anemia?
○ CBC, reticulocyte count and PBS IMMUNE THROMBOCYTOPENIC PURPURA
5. True or False. A Mentzer index of >13 is indicative of iron deficiency 14. Most common cause of thrombocytopenia in children?
anemia ○ ITP
○ True. 15. Features necessary for diagnosis of ITP?
6. Peak prevalence of IDA occurs during what phase in children? ○ Clinically well child, Isolated bleeding symptoms, isolated
○ Late infancy and early childhood while the second peak occurs thrombocytopenia, CBC: isolated thrombocytosis PBS
during the adolescent period decreased platelets
7. Which of the following RBC indices are increased in Iron Deficiency 16. Observation as management for ITP is done when?
Anemia? ○ Patients with APC>30,000 with no signs of bleeding
○ All are decreased in IDA except for increased RDW, TIBC, and
transferrin DEFECTS IN HEMOSTASIS
17. Factor lacking in Hemophilia A?
INTRINSIC HEMOLYTIC ANEMIA ○ Factor VII
8. What is the first differential diagnostic of microcytic anemia 18. Treatment for Von Willebrand’s Disease?
unresponsive to adequate iron therapy? ○ Desmopressin
○ Thalassemia
9. Describe the clinical presentation of a patient with the most clinically
significant type of β thalassemia
○ Cooley’s Anemia presents with severe anemia, poor feeding,
irritability, decreased activity, increased somnolence,
hepatosplenomegaly and thalassemia facies.

APPENDIX
DELETE AFTER]

Figure 5. Laboratory Investigation of Anemia

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 Figure 6. Algorithm on the Characterization of Anemia based on MCV

Figure 18. Algorithm for Bleeding

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 Figure 21. Causes of Iron Deficiency Anemia.

Table 9. Pathophysiology of α-thalassemia [Nelson's]

CLASSIFICATION DELETION MANIFESTATION AND TREATMENT

Not identifiable hematologically
SILENT TRAIT 1 α-globin gene
Usually diagnosed after birth of a child with 2-gene deletion
Microcytic anemia (can be mistaken as IDA due to low MCV
α-THALASSEMIA TRAIT 2 α-globin genes
and MCH)
Marked microcytosis, anemia, mild splenomegaly, scleral
icterus, cholelithiasis

Chronic transfusion isn’t usually required, but intermittent

transfusions may be needed for worsening anemia
HbH DISEASE 3 α-globin genes
Treatment: monitoring of growth and organ function, folate
and multivitamins without iron, vitamin D supplementation (if
level is low), adequate calcium intake, intermittent
transfusion, splenectomy
Profound anemia during fetal life

No normal hemoglobins at birth

HYDROPS FETALIS 4 α-globin genes
Intrauterine transfusions may rescue the fetus, but congenital
abnormalities and neurodevelopmental delay often result

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 Table 10. Comparison of IDA, Thalassemia, and ACD*

IDA THALASSEMIA ACD

Hemoglobin ↓ ↓ ↓

MCV ↓ ↓ N-↓

RBC ↓ ↑ N-↓

RDW ↑ N N-↑

Reticulocyte count ↓ ↑ ↓

Mentzer index >13 <13

Serum iron ↓ ↑ ↓

Serum ferritin ↓ ↑ ↑

TIBC ↑ ↓ ↓

Transferrin ↑ ↓ ↓

Transferrin ↓ ↑ ↓
Saturation
*See explanations in the body of the trans.

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 NICE TO KNOW
A. DISSEMINATED INTRAVASCULAR COAGULATION (DIC)
● DIC is a disorder in which widespread activation of the coagulation mechanism is usually associated with shock
● Hemostasis is altered by the severe illness, so the patient has activation of coagulation (thrombosis) mediated by thrombin and fibrinolysis mediated
by plasmin (bleeding)
● Coagulation factors and anticoagulant proteins are consumed
● Endothelial injury, tissue release of thromboplastic procoagulant factors, or, rarely, exogenous factors (snake venoms) directly activate the coagulation
mechanism
CLINICAL MANIFESTATION OF DIC
● decline in platelets and fibrinogen
● elevated prothrombin time, partial thromboplastin time, and elevated levels of D-dimer
○ formed when fibrinogen is clotted and then degraded by plasmin
● In a severely ill patient, the sudden occurrence of bleeding from a venipuncture or incision site, gastrointestinal or pulmonary hemorrhage, petechiae,
or ecchymosis or evidence of peripheral gangrene or thrombosis suggests the diagnosis of DIC
MANAGEMENT OF DIC
● Supportive management
○ correcting hypoxia, acidosis, and poor perfusion; and replace depleted blood-clotting factors, platelets, and anticoagulant proteins by transfusion
● Heparin may be used to treat significant arterial or venous thrombotic disease unless sites of life-threatening bleeding coexist
B. THROMBOSIS
● Deficiency of an anticoagulant protein (protein C or S, antithrombin, or plasminogen) caused by a/an
○ abnormality of a procoagulant protein making it resistant to proteolysis by its respective inhibitor (factor 5 Leiden)
○ mutation resulting in an increased level of a procoagulant protein (prothrombin 20210)
○ damage to endothelial cells (homocysteinemia).
● Neonates with deficiency syndromes may be particularly vulnerable to thrombosis.
○ Neonates with homozygous protein C deficiency present with purpura fulminans or thrombosis of the major arteries and veins or both
● Factor 5 Leiden is the most common hereditary cause of a predisposition to thrombosis
○ 3-5% of whites
● Acquired antiphospholipid antibodies (anticardiolipin and lupus anticoagulant) also predispose to thrombosis.
CLINICAL MANIFESTATION OF THROMBOSIS
● Neonates and adolescents are the most likely pediatric patients to present with thromboembolic disease.
● Manifestations of pulmonary emboli vary from no findings to chest pain, diminished breath sounds, a loud S2, cyanosis, tachypnea, and hypoxemia
DIAGNOSIS OF THROMBOSIS
● ultrasound Doppler flow compression studies
○ Non-invasive
● Venogram
○ Gold standard
● Helical CT Scan
○ An abnormal (high probability) ventilation-perfusion scan or detection of an intravascular thrombus is diagnostic of pulmonary emboli.
● Diagnosis of a congenital or acquired predisposition to thrombosis requires a battery of specific assays
MANAGEMENT OF THROMBOSIS
● Depends on the underlying condition
○ usually involves standard or low molecular weight heparin followed by longer term anticoagulation with warfarin.
● New agents, including the direct thrombin inhibitors, are currently under active investigation
● Fibrinolytic agents
○ Major vessel thrombosis, life-threatening thrombosis, or arterial thrombosis
○ Recombinant tissue plasminogen activator
● Replacement with plasma, antithrombin III concentrates, or protein C concentrates
○ Inherited deficiency syndromes

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