Approach to Anemia

How to efficiently and accurately work up

the anemic children

Rogatianus Bagus P
 Anemia

• Is a sign of disease
• Not a final diagnosis

The goal of the diagnostic evaluation is to

determine the cause of anemia

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 Definition of Anemia

Reduction in the hemoglobin

concentration or red blood cells per cubic
millimeter.

ANEMIA (WHO criteria)

Age Hb (g/dl)
6 mo - < 5 yrs < 11
> 5 yrs < 12

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 Anemic Child

It is important to establish :
• A single cell line problem (red blood cells)
Or
• A multiple cell line problem (red cell, white
cell, and platelets)

Usually indicates bone marrow involvement,

immunologic disorders,
peripheral destruction of cells
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 Physiologic classification of anemia

1. Disorders of effective red cell production

2. a.Disorders of increased red cell
Marrow failure
destruction
b. Impaired erythropoietin production
3.a.c.Blood
Abnormalities
Defects loss
of hemoglobin
of cytoplasmic maturation
b.d. Defects
Abnormalities
of the red cell of nuclear maturation
membrane
c.e. Defects
Dyserythropoietic.
of red cell metabolism
d. Antibody-mediated
e. Mechanical injury to the erythrocyte
f. Thermal injury to the erythrocyte
g. Oxidant-induced red cell injury
h. Paroxysmal nocturnal hb-uria
i. Hypersplenism
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 The investigation of Anemia

1. Detailed history and physical examination

2. Complete blood count.
3. Determination of morphologic
characteristics and RDW.
4. BMP (if required).
5. Determination of underlying cause of
anemia by additional test.

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 Important features in the history of the
anemic child
1. Maternal history
2. Family history
Pregnancy/delivery complications
3. Patient history
Drug ingestion
Anemia Jaundice Splenomegaly
Pica/ nonfood product ingestion
Gallstones Cancer
Hyperbilirubinemia, Transfusion
Prematurity, Diet history,
AnemicAcute
during pregnancy
Bleeding disorders
Medications, or recent infection, Evidence of
chronic disease/ infection, Endocrinopathy, Liver disease,
Easy bruising/blood loos

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 Physical examination

Several clues to the etiology :

 Tachycardia acute process with poor
compensation.
 Normal HR more chronic process
 Jaundice hemolytic process
 Splenomegaly inherited hemolytic
anemia, malignancy, portal hypertension

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 Morphology classification of Anemia

BLOOD SMEAR
• Microcytic Anemia (MCV<80fl)
• Normocytic Anemia (MCV 80-100 fl)
• Macrocytic Anemia (MCV >100 fl)

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 Reference Range of MCV
Age (yrs) MCV (fl)
1 - 3 days 95 - 121
0.5 – 2 70 - 84
2–4 73 - 85
5–7 75 - 87
8 – 11 77 - 90
12 – 14 78 - 91
15 – 17 78 - 94
18 – 19 80 - 100

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 ANEMIA

MCV

MICROCYTIC NORMOCYTIC MACROCYTIC

Reticulocyte count
Iron Deficiency
High
Thalassemia
Negative Coombs Test Positive
Chronic disease
Bilirubin
Lead poisoning
Hb-pathy Autoimmune
Normal High
Membrane defect Isoimmune
Hemorrhage Hemolytic
Secondary : drugs, infection Coombs test

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 ANEMIA

MCV

MICROCYTIC NORMOCYTIC MACROCYTIC

Reticulocyte 

Leukocyte &
Platelets

Low Normal Increased

Malignancy Pure red cell aplasia Infection

Diamond Blackfan
Aplastic
Transient
Anemia
erythroblastopenia
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 ANEMIA

MCV

MICROCYTIC MACROCYTIC NORMOCYTIC

Folate deficiency
Vit B12 defic.
Aplastic anemia
Preleukemia
Liver disease

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 Other lab examination

RDW (Red cell distribution width) =

variation of the erythrocyte volume distribution.
(N = 11.5 – 14.5%)
Normal RDW = homogen, slight anisocytosis
RDW  = heterogen, anisocytosis (++)
Reticulocyte = indicator of bone marrow activities

Anisocytosis = variation in size

Poikilocytosis = variation in shape

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 Anemia Mikrositik

• Perhatikan : jumlah eritosit, RDW,

retikulosit, gambaran sediaan apus
darah tepi.

Juml Eri RDW Retik Slide

Trait Thal  N  poikilositosis (+)
ADB N /  N / anisositosis (+),
hipokrom
Thal    poikilositosis,
anisositosis (++)
hipokrom
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