Anatomical and physiological

features of the hematopoietic

system of children

• Лекция: Малахова Жанна Леонидовна

•
Перевод: Арутюнян Т. Г. 5курс 2а группа
 Blood
• Liquid tissue that washes almost all cells of the body !!!

• Saturates tissues with oxygen

• Provides all types of exchange

• Carries out a protective function (phagocytes,

immunocompetent cells)
 Hematopoietic tissue
Dynamic, constantly renewing cellular system of the body

30 million cells are formed per minute, during a person's

life - about 7 tons

1x10¹¹ blood cells are lost daily, which is replenished by the

"cell factory" - bone marrow

With an increase in the demand for mature cells (blood

loss, acute hemolysis, inflammation), production can be
increased 10-12 times within a few hours
 Intrauterine hematopoiesis
• I period - Megaloblastic (embryonic)
• II period - Hepatic
• III period - bone marrow
According to the periods of hematopoiesis,
there are 3 types of Hb
• embryonic - HbP ("primitiv" - primitive)
• О2
• fetal - HbF ("fetus" - fetus)
• Hb of an adult type - HbA ("adult" - an adult)
• At birth, HbF is 60-85%,
• gradually replaced by HbA
• By 1 year about 15% of HbF remains, by 3 year -
• does not exceed 2%
 Extrauterine period
• The main source of formation of all types of blood cells
(except lymphocytes) is red bone marrow
 red bone marrow
• Flat and tubular bones are filled in n / a

• This is important when choosing a site for bone marrow puncture:

• To obtain bone marrow, usually punctured:
• - n / a - calcaneus
• - in children under 1 year - the epiphysis of the tibia
• - in older children - the iliac crest

• From the 1st month life, the red bone marrow gradually begins to
be replaced by fatty (yellow), and by 12-15, hematopoiesis is
preserved only in flat bones
Life span of mature blood cells
9-11 дней 14 дней

120 8-12
дней дней

12 ч.

неск.сут.-неск.лет
 Coagulation system
• Keeps the blood fluid

• Prevents blood clots

• Prevents bleeding

• Provides a stop to already developed hemorrhages

A necessary condition for the vital

activity of the human body is the liquid
state of blood
The main components of the hemostasis
system
1. Vascular link of hemostasis
Physiological conditions - Tr does not attach to the
endothelial cells of the vascular wall, since they produce
prostacyclin, which inhibits Tr function
In case of violation of the integrity of the vascular wall, a
thrombus is formed

2. Platelet link - provides adhesion and aggregation of Tr

3. Plasma link - 13 blood coagulation factors

Features of hemostasis in children
• In the early neonatal period, there is a physiological decrease:
• - the level of plasma coagulation factors (II, YII, IX, X, XI, and
XII)
• - physiological anticoagulants (antithrombin III, protein C, etc.)
• - the main components of fibrinolysis and kallikrein-kinin
system.

Defense mechanism - activation of this

system is inevitable in a child at birth
and in the first hours of life
• In premature infants, a more pronounced
decrease in procoagulant and
anticoagulant levels

The risk of both hemorrhagic and

thrombotic complications
increases significantly, especially
DIC
 The state of the hemostasis system of newborns is
significantly affected

• Timing of cord ligation - early cord ligation before complete

blood flow from placental vessels into the baby's bloodstream
leads to a significantly greater decrease in K-vitamin-
dependent coagulation factors by 3-4 days of life

• Timing of the first attachment to the breast - reduces

postpartum depression of blood coagulation components
Blood counts at different age periods
Newborn
Functional lability and rapid depletion of the activity of
the red bone marrow

Under the influence of adverse influences (infection,

severe anemias, etc.), a return to the embryonic type of
hematopoiesis is possible

The blood volume is:

- n / a - 14.7% of body weight (140-150 ml / kg)
- in an adult - 5.0-5.6% of body weight (50-70 ml / kg)
 Newborn
• In the peripheral blood of a healthy person, the n / a is
increased, compared with the blood parameters of an adult:
• - concentration of Hb (180-240 g / l)
• - the content of erythrocytes (5 - 7 x 10¹² / l)
• - CPU value (up to 1.1)

Indicates intense
erythropoiesis
 Newborn
• After birth, in connection with the establishment of external
respiration, hypoxia is replaced by hyperoxia - this leads to a
decrease in the production of erythropoietins and, as a
consequence, to the suppression of erythropoiesis, a decrease
in the number of erythrocytes and the concentration of Hb

• Red blood cells containing HbF have a shorter lifespan (12

days) and are more prone to hemolysis (transient jaundice)
 Newborn
• Erythrocytes are polychromatophilic (immature), have a
different size (anisocytosis) with a predominance of macrocytes

• Reticulocytosis reaches 2.2-4.2% (in adults and children over 1

month old - 0.6-0.8%)

• Normally, nuclear forms of erythrocytes - normoblasts can

circulate in the blood

• Fluctuations in the total number of leukocytes:

• - in the first days of life - 10-30 x 10 9 / l
• - from the 2nd week. life - 10-12 x 10 9 / l
 Newborn
• Neutrophilia with a shift of the leukocyte formula to the left to
myelocytes, which occurs at birth, begins to decrease rapidly,
and the number of lymphocytes increases

• On the 5-6th day of life, the number of neutrophils and

lymphocytes is compared, accounting for 40-45% - the first
physiological crossover

• Since that time, the number of lymphocytes, equal to 50-60%,

becomes a normal indicator in children under 5 liters.
 Newborn
• The content of Tr averages 150-400 x 10 9 / l

• ESR is slowed down and is 1-2 mm / h (low content of cholesterol,

fibrinogen; natural blood clotting)

• Hematocrit in the first days of life is higher - about 54%, in older

children and adults - 40-45%

• The duration of bleeding in children is the same as in adults (no

longer than 5 minutes).

• The clotting time can be accelerated or normal, with severe jaundice

- lengthened

• Clotting times depend on the technique used and average 1.5-5

minutes.
 Premature baby
• There are also foci of extramedullary hematopoiesis (liver, less -
spleen)

• Characterized by an increased content of young nucleated forms of

erythrocytes with a higher concentration of HbF in them (the higher
the less mature the child is born)

• The increased concentration of Hb and a large number of

erythrocytes at birth decrease much faster than in full-term, which
leads to the development of early anemia (1.5-2 months)
erythrocyte formation
 Premature baby
• The second decrease in Hb concentration in premature infants is
characterized by signs of hypochromic iron deficiency anemia (this is
late anemia of premature infants - 4-5 months).

• Unlike early anemia, the pathogenesis of which is not fully

understood, late anemia can be prevented or alleviated by
prophylactic iron supplementation

• The leukocyte formula depends on the degree of maturity of the

child and is characterized by an increase in the number of young cells
(a shift to myelocytes is expressed)

• ESR reduced to 1-3 mm / h.

 Children of the 1st year of life
• Gradual reduction in content:
• - erythrocytes up to 4.5 - 3.5 x 10 ¹²
• - Hb concentration up to 110 - 120 g / l
• - hematocrit up to 36%
• - CPU - less than 1.0

• By 5-6 months. the lowest indicators are observed (body weight,

blood volume, insufficient Fe intake ...)

• Leukocytes - 8 - 10 x 10 9 / l

• Lymphocytes predominate in the leukocyte formula

• ESR - 5 - 8 mm / h
 Anemic syndrome
• Anemia - a decrease in HB below the age norm (often with a simultaneous
decrease in the content of erythrocytes)

• Allocate: 3 degrees of severity (HB - 110 - 90, 89 - 70, less than 69 g / l)

• Taking into account the change in CPU, there are:

• • Normochromic - a uniform decrease in the content of erythrocytes
and Hb, CP approaches 1.0 (acute blood loss)

• • Hypochromic - CPU below 0.86 (IDA)

• • Hyperchromic - a decrease in the content of erythrocytes and Hb at

• CPU more than 1.05 (with a deficiency of vitamin B1, less often with
a deficiency
• folic to - you) forms of helminthic invasion.
• In children of the first 3 years. the most common iron
deficiency anemias

• In school-age children - post-hemorrhagic

• In children with anemia it is important to know the

REGENERATIVE capacity of the bone marrow

• Reticulocytosis - adequate regenerative function of the

bone marrow

• Lack of reticulocytes or low numbers are important

signs of hypoplastic anemia
 Классификации анемий

По цветовому По количеству По количеству

показателю эритроцитов ретикулоцитов

< 0,86 - гипохромная < 7 мкм - < 1% -

микроцитарная гипорегенераторная

0,86 - 1,05 - 7 - 7,8 мкмн - 1-3%-

нормохромная нормоцитарная норморегенераторная

> 1,05 - гиперхромная > 7,8 мкм - > 3% -

макроцитарная гиперрегенераторная
 Erythrocytosis
• transport carbon dioxide to the lungs, where
• as a result of gas exchange, it is replaced
oxygen

• Erythrocytosis - an increase in the content of red blood cells in

the peripheral blood - occurs in severe hypoxia (CHD)

• True erythremia (polycythemia) is rare and is caused by

hyperplasia of the red bone marrow, mainly of the erythrocyte
lineage
 Pathological changes in erythrocytes
• Depending on the change in the shape or size of red blood
cells, various types of anemias may occur.
 Reticulocytosis

• An increase in the number of young erythrocytes with a

basophilic reticulum and polychromatophilia (the ability of
erythrocytes to stain with several colors) indicate an increased
regeneration of the red bone marrow

• M. b. physiological in the early period of newborns,

subsequently serves as an indicator of the increased work of
the red bone marrow under the influence of any pathological
stimuli
 Changes in leukocytes
• absorb and recycle foreign
• particles that have entered the human body
• Agranulocytes - do not contain granules (lymphocytes, monocytes)
• Granulocytes - cells with specific granules and the presence of
irregularly shaped nuclei (neutrophils, basophils, eosinophils)

• Leukocytosis - an increase in the number of leukocytes per unit of

blood volume compared to the age norm

• Leukopenia - a decrease in the number of leukocytes per unit of

blood volume
• Leukocytosis and leukopenia are possible as concomitant
reactions of the body in a variety of diseases and physiological
conditions of the body (leukocytosis - in infants after a cry, n / a
in the first days of life)

• Hyperleukocytosis - an increase in the level of leukocytes more

than 50 x 10 9 / l

• Leukocyte formula - the ratio of m / d by individual forms of

leukocytes, expressed as a percentage in relation to all
leukocytes
Neutrophilic leukocytosis

• An increase in the number of leukocytes per unit of blood

volume due to neutrophils - most often occurs when:
• - bacterial inflammation
• - non-infectious inflammatory diseases (including
• number of autoimmune)
• - leukemia.
 Leukemoid reactions
• A temporary significant increase in the number of leukocytes in
response to any stimulus, accompanied by the appearance in
the blood of immature forms of leukocytes

• The number of leukocytes can reach 50,000 or more in 1 mm3

of blood

• The peripheral blood pattern resembles that of leukemia

• True leukemia can be distinguished from a leukemoid reaction

based on bone marrow findings.
 Leukopenia
• Decrease in leukocytes below the age norm

• More often observed with: - with viral infections

• - with hypersplenism (increased f-tion
• spleen)
• - after exposure to radioactive substances,
• x-rays
• - after taking certain medicinal
• drugs (cytostatics, sulfonamides)

• A sharp decrease (up to the complete disappearance) of the content of

granulocytes is called agranulocytosis

• In some cases, all functions of the hematopoietic organs are affected: leuko-,
erythro-, thrombocytopoiesis

• Depletion of the red bone marrow sets in - panmyeloftis

 Eosinophilia
• are involved in numerous inflammatory
• processes, especially related
• allergic reactions

• Eosinophilia - an increase in the percentage of the proportion

of eosinophils> 4% in the leukocyte blood count

• With: - helminthiasis
• - bronchial asthma
• - serum sickness
• - other allergic conditions
 Eosinopenia
• Decrease in percentage of the proportion of eosinophils <3% in
the leukocyte blood count

• Possible in severe acute infectious diseases

• Has an unfavorable prognostic value

 Lymphocytosis
• immune cells
•

• An increase in the percentage of the proportion of

lymphocytes above the age norm in the leukocyte blood count

• Typical for: - viral infections

• - whooping cough
• - tuberculous intoxication
• - lymphoblastic leukemia
 Lymphopenia
• A decrease in the percentage of the proportion of lymphocytes
below the age norm in the leukocyte blood count

• Occurs at the onset of most infectious diseases accompanied

by fever, with lymphogranulomatosis, lymphosarcomatosis, HIV
infection
 Monocytosis
• able to remove bacteria from the body,
• dead and damaged cells,
• have a cytotoxic effect on
• tumors and malaria pathogens

• Monocytosis - An increase in the percentage of monocytes

above 8% in the leukocyte blood count

• Typical for infectious mononucleosis, some viral diseases

 Monocytopenia
• Decrease in percentage of the proportion of
monocytes <6% in the leukocyte blood
count

• Often develops in severe septic and

infectious diseases, leukemia
 Thrombocytosis
• participate in hemostasis, nutrition of the endothelium
• human circulatory system

• Thrombocytosis - an increase in the number of platelets>

400x10 9 / l of blood

• Can be observed with polycythemia, a number of rheumatic

diseases, sepsis

• Platelet count increases after splenectomy

 Thrombocytopenia
• Decreased platelet count <150 x 10 9 / L
of blood

• It can be as an independent disease and

as a syndrome in a number of
pathologies
 Hemorrhagic syndrome
• This is increased bleeding in the form of bleeding from the
mucous membranes of the nose, the appearance of
hemorrhages in the skin and joints, gastrointestinal bleeding,
etc.

• Distinguish between acquired and hereditary hemorrhagic SD.

• In children with hereditary defects, individual episodes of

increased bleeding can be separated from each other for
months or even years, and then occur quite often.
If you suspect hereditary hemorrhagic SD.

• It is important to collect information not only about the

patient, but also about his relatives!

• It is necessary to find out the type of bleeding:

• - hematoma
• - petechial-spotted
• - vasculist-purple
• - mixed
• - angiomatous
 Hematoma type
• Extensive hemorrhages in the subcutaneous tissue, under the
aponeuroses, in the serous membranes, in muscles, joints

• Usually after injuries, operations and entail deforming arthrosis,

muscle spasms, pathological fractures

• Expressed late nature of bleeding (after a few hours)

• Very rarely, bleeding is spontaneous

• Hemophilia A and B (deficiency of factors

• coagulability of blood VIII and IX)
 Petechial-spotted (bruised) or
microcirculatory type
• Small, spontaneous hemorrhages (asymmetric, mainly at night) or
arising from the slightest trauma to the skin, mucous membranes,
nasal, gingival, uterine, renal

• Hematomas are rare, the musculoskeletal system does not suffer

• Frequent and dangerous cerebral hemorrhages

• Postoperative bleeding is not

• noted (exception - tonsillectomy)

• Typical for ITP

Mixed (microcirculatory-hematoma) type

• It is characterized by a combination of two forms, but has some

features:

• the microcirculatory type usually predominates, the

hematoma is not very pronounced, mainly only hemorrhages
in the subcutaneous tissue

• joint hemorrhages are rare

• Observed in von Willebrand disease, sd. Willebrand - Jurgens

 Von Willebrand disease
• Genetic blood disease (autosomal dominant inheritance)

• Blood clotting is impaired - a lack or absence in the blood of a

protein responsible for this function (von Willebrand factor)

• In the clinic - hemorrhagic sd. varying degrees of severity

Vasculitic purple type
• It is caused by exudative-inflammatory phenomena in
microvessels against the background of immunoallergic and
infectious-toxic disorders

• Hemorrhagic sd. represented by symmetrically located, mainly

on the limbs in the area of ​large joints, elements. Clearly
separated from healthy skin, protruding above its surface
(papules, vesicles) - hemorrhagic vasculitis
 Angiomatous type
• Typical for telangiectasias (persistent dilation of superficial
vessels), benign tumors from blood or lymphatic vessels,
arteriovenous shunts

• This type of bleeding is most common with SD. Osler-Randu -

hereditary hemorrhagic vasopathy with focal thinning of the
walls and expansion of the lumen of microvessels (autosomal
• dominant type of inheritance)