ANEMIA CLASSIFICATION AND

ASSESMENT

KEBIRUNGI CAROLINE

BMS/0077/133/DU
 outline
• Definition
• Etiology
• Classifications
• Investigations
• Treatment
• Case study
– Iron deficiency anemia
 definition of anemia

• Hemoglobin concentration less than the

normal for age and sex
• Strictly speaking anemia refers to when total
RBC volume is lower than normal, but
practically, hb concentration is considered
 NORMAL HAEMOGLOBIN LEVELS
BY AGE
CATEGORY NORMAL MILD MODERATE SEVERE
VALUE ANAEMIA ANAEMIA ANAEMIA
Child 12-14yrs >12g/dL 11-11.9g/dL 8-10.9g/dL <8g/dL

Child 5-11yrs >11.5g/dL 11-11.5g/dL 8-10.9g/dL <8g/dL

Child 6months- >11g/dL 10-10.9g/dL 7-9.9g/dL <7g/dL

5years
REFERANCE RANGE IN NEWBORNS
AND INFANTS
AGE NORMAL RANGE
Birth >13.5g/dL

2 weeks >12.5g/dL

1-6 months >9.5g/dL

 etiology
• Increased Blood loss
– GI bleeds
• worm infestation
• IBD
• Milk-protein allergy
• peptic ulcers
– Menstrual flow problems
– Trauma
 etiology…
• Increased RBC destruction
– Intrinsic RBC problems
• Hereditary (membrane, enzyme and hemoglobin
problems)
• Acquired (PNH).
– Extrinsic (extra corpuscular) abnormalities.
• Antibody mediated (autoimmune, drug-
related(dapsone, cotrimoxazole and AZT),
transfusion reactions)
• Mechanical (microangiopathic hemolytic anaemias,
DIC
• Infections: malaria
 etiology…
• Decreased red cell production
– Bone marrow infections/infiltration
• Infections (viral(HIV), bacterial(TB), parasitic(visceral
leishmaniasis))
• Cancers (leukemia, aplasia)
– Nutritional i.e. Iron,Vit B12 and folate def
 classifications
• Stages of severity • RBC morphology
– Compensated – Microcytic
– Decompensated – Normocytic
– Life-threatening – Macrocytic
• Onset • Physiological
– Acute – Normal bone-marrow
– Chronic response
– Abnormal bm response
 CLINICAL FEATURES
• Fatigue/ low exercise intolerance
• Dizziness
• Palpitations
• Headache
• Dyspnea
• Sweating, restlessness and thirst if due to acute bood
loss.
• Jaundice
• General body weakness
 approach to diagnosis of anemia
• detailed history
• careful physical
examination
• Investigations
– Specific
– Additional
 history
• Age, sex, origin.
• Diet, pica, viral infections, recurent diarrhea
• Personal and family history, PMH
• environmental exposures
• Associated symptoms (yellowing, headache,
exertion dyspnea, fatigue, dizziness,
weakness, mood or sleep disturbances,
tinnitis)
 physical examination

• pallor • Smooth tongue

• Jaundice • tachycardia
• Petichae & purpura • tachypnea
• Hepatosplenomegaly • orthostatic
• Lymphadenopathy hypotension
• Growth parameters • systolic ejection
• peripheral edema murmur
 investigations
• Full blood count
– Total RBC
– Heamoglobin
– HCT
– Mean Corpusular Volume.
– MCH
– MCHC
– RDW (red cell distribution width)
– Reticulocyte Count
 red cell morphology (thin film)

• Anisocytosis (many • Sickled cells

sizes) • Schizocytes
• Poikilocytosis (many • Howell-Jolly bodies
shapes) (nuclear reminants)
• Elliptocytes, • Heinz bodies
spherocytes (denatured
heamoglobin)
using MCV to characterize anemia
• Macrocytic anemia
• Microcytic anemia – folate deficiency
– Iron deficiency anemia – vitamin B12 deficiency
– Thalassemia and pernicious anemia
– Sideroblastic anemia
– Chronic infection
– Lead poisoning
 using MCV to characterize
anemia…
• Normocytic
– Acute blood loss
– Early iron deficiency
– Infection
– Aplastic anemia
– Renal failure
– Bone marrow
– Liver disease
infiltration
 additional tests…
• Coombs test
• Blood cultures
• Malarial tests
• Stool (worms, occult blood)
• Urine exams
• Bone marrow exams
• Serum Iron levels tests,
• Sickle cell tests
• etc., etc., depending on suspected etiology
 MANAGEMENT
General principles
• Determine and treat the cause
• Consider need of blood transfusion according to:
• Level of hemoglobin( ie less than 10g/dL in
neonates, less than 5g/dl in older children)
• Clinical condition( hemodynamic status of pt,
presence of heart failure, ongoing blood loss.)
 Iron Deficiency Anemia
• Importance:
– About 50% of children and pregnant mothers and
25% of men affected in Africa.
– Directly related with:
• Reduced work productivity
• Severe anemia and child mortality
• Severe anemia and maternal mortality
• Impairment of child growth and development
 Iron Deficiency Anemia
• Causes
– Dietary deficiency – Chronic blood loss
– Increased demand • gut problems (IBD,
worm infestations)
(growth)
• kidney
– Impaired absorption
• menstrual problems
• trauma
 Iron Deficiency Anemia
• Features – Cardiac
– GI • increased cardiac
• anorexia output
• pica • cardiac
• atrophic glossitis hypertrophy
– CNS • Systolic murmur,
gallop
• fatigue – Musculoskeletal
• Irritability • exercise intolerance
• Short attention
 Iron Deficiency Anemia

• characteristics of peripheral blood

smear
– microcytic
– Hypochromic
– thrombocytosis
 Iron Deficiency Anemia

• additional diagnostic tests

– serum ferritin (decreased)
– serum iron (decreased)
– Iron binding capacity (increased)
– Iron saturation (decreased)
– Reticulosytosis days after starting treatment
 Iron Deficiency Anemia
• Treatment
– oral iron supplementation
• Adolescents and adults: 200mg Feso4 bd or tds
• Children 2-12 years: 200mg once daily
• Children below 2 years :3-6 mg/kg/day.
• for at least 2-3 months after Hb is normal.
• check retic count after 2 weeks
• side effects (educate family)
• Give an anti-helminthic, albendazole 400mg single dose
 Iron Deficiency Anemia
• failure to respond to therapy
– non-compliance
– inadequate dose
– ineffective preparation
– unrecognized blood loss
– impaired GI absorption
– coexistence of disease
– incorrect diagnosis
 MEGALOBLASTIC ANAEMIA
• Anemia characterized by large red blood cells.
 Causes • Malabsorption of folate
•Low dietary intake of and B12(severe gastritis,
folate/increased need giardia infection)
(e.g. children, pregnancy) • Medicines e.g.
•Low dietary intake of vit metformin, zidovudine,
B12(vegeterians without hydroxyurea.
any animal protein) • Multiple myeloma,
hypothyroidism,
myelodysplasia.
Clinical features Investigations
•General anemia signs •Blood smear;
•Vit B12 def; neuropsychiatric macrocytosis
abnormalities e.g. impaired
vibration and position sense, •Elevated MCH/MCV
abnormal gait, weakness, •CBC; thrombocytopenia,
decreased muscle strength, hyper segmentation of
memory loss
neutrophil
•Decreased serum vit B12
or folate
 MANAGEMENT
• Identify and treat • Folic cid: 5mg daily until
underlying cause of Hb levels return to
anemia normal.
• Dietary modifications to • vitaminB12: 1mg IM daily
ensure adequate intake for 5 days , then weekly
of folate and vit B12 for a further 3 doses
• Folic acid and vitB12 • Follow with 1mg every
supplementation second month for life in
pts with pernicious
anemia.
 NORMOCYTIC ANAEMIA
• Anemia characterized by normal sized red
blood cells.
Causes
• Acute blood loss
• Hemolysis e.g. auto-immune disorder,
hypersplenism, SCD, thalassemia
• Decreased reticulocytosis (formation of new
blood cells), e.g. chronic kidney disease
 Clinical features

•General features of anemia

•Investigations
•Evidence of hemolysis
•Peripheral blood smear: spherocytosis
•HIV serology
 MANAGEMENT
• Identify and treat the cause of anemia
• Transfusion
• Do not use folic acid or vit B12 unless there is
clear documented deficiency.
• Treat all patients with folic acid 5mg daily in
hemolytic anemia.
THANKS FOR LISTENING
 PREVENTION AND HEALTH
EDUCATION FOR ANAEMIA
• Dietary measures; encourage exclusive breastfeeding for 6
months and use of iron rich foods for weaning like red meat,
beans, peas, dark leafy vegetables
• Hygiene
• Medical; screening for children and pregnant mothers
• Routine iron supplementation for pregnant mothers
• Early treatment for malaria and helminthic infections
• The life long effects of anaemia on health nd cognitive
development.