See also
Iron deficiency
Patient Blood Management and surgery
Blood product prescription
The Australian Red Cross Blood Service anaemia and haemostasis overview
Key
Points
- In Australia, the prevalence of anaemia in children under the age of 5 years is about 8%, corresponding to over 100,000 preschool children.
- Iron deficiency is the most common cause of anaemia in children.
Background
This guideline is adapted from the National Blood Authority (NBA) Patient Blood Management Guidelines: Module 6 Neonatal and Paediatrics (2016).
Definition
Anaemia is defined as Haemoglobin (Hb) less than the lower limit of the reference range for age
Age |
Lower
limit of normal range Hb (g/L) |
2 months |
90 |
2 – 6 months |
95 |
6 – 24 months |
105 |
2 – 11 years |
115 |
>12 years |
female – 120 male - 130 |
Assessment
History
- Ethnic background can be helpful in guiding workup for haemoglobinopathies and G6PD deficiency
- Medication history: past and current, particularly those that may cause haemolysis in the instance of G6PD deficiency
- Dietary history: iron intake (with particular attention to iron-rich foods, breast feeding and cow’s milk intake), vitamin B12 intake, recent fava/broad bean ingestion (may precipitate haemolysis in the case of G6PD deficiency)
- Family history: anaemia, jaundice, gallstones or splenomegaly
Examination
Clinical features suggestive of anaemia:
- Pallor
- Pale conjunctivae
- Tachycardia
- Cardiac murmur
- Lethargy
- Listlessness
- Poor growth
- Poor concentration
- Weakness
- Shortness of breath
- Signs of cardiac failure
- Signs of haemolysis include jaundice, scleral icterus, splenomegaly and dark urine
Management
Investigations
- If anaemia is suspected begin with a full blood examination including blood film (FBC), ferritin and reticulocyte count.
- Iron studies or serum iron should not be requested to diagnose iron deficiency. Serum iron reflects recent iron intake and does not provide a measure of the iron stores.
The initial classification is based on the Mean Corpuscular Volume
(MCV):
- For “Other features on the blood film appearance that prompt further investigation” see
Additional Notes below
Red flags
(consider admission)
- Hb
<60 g/L (including iron deficiency)
- Tachycardia, cardiac murmur or signs of cardiac failure
- Features of haemolysis (dark urine, jaundice, scleral icterus)
- Associated reticulocytopenia
- Presence of nucleated red blood cells on blood film
- Associated thrombocytopenia or neutropenia may indicate malignancy or an infiltrative disorder
- Severe vitamin B12 or folate deficiency
- Need for red cell transfusion: Where possible defer transfusion until a definitive diagnosis is made.
Microcytic Hypochromic Anaemia
Beta Thalassaemia minor/trait
- Carrier of beta thalassaemia
- Frequently seen in South East Asian, Mediterranean, Arabic families
- Usually asymptomatic
- There may be a positive family history
- Microcytic hypochromic red cells with normal or borderline low Hb
- Diagnosed on HPLC or Hb electrophoresis - HbA2 > 3.5%, often elevated Hb F
- Red cell distribution width (RDW) is often normal
- Pre-pregnancy carrier testing of partner is important (Ensure parents have been tested if likely to have more children)
Note: HbA2 may not be elevated in the presence of concomitant iron deficiency, therefore give iron treatment (if ferritin low) before ordering test.
Alpha
Thalassaemia minor/trait
- Carrier of alpha thalassaemia
- Commonly seen in South East Asian, African, Mediterranean, Arabic families
- Microcytic hypochromic red cells with normal or borderline low Hb
- Cannot be diagnosed on HPLC or Hb electrophoresis - DNA testing required for formal diagnosis (not a first-line investigation - exclude other causes first)
- Pre-pregnancy carrier testing of partner is important
Rare causes of Microcytic Anaemia
- Chronic inflammation
- Lead poisoning (high blood lead level)
- Sideroblastic anaemia
Normocytic Normochromic Anaemia
Haemolytic anaemia
- Acute haemolysis in childhood can be a life threatening illness and all cases should be discussed with a Haematologist.
- Children with haemolytic anaemia should be admitted for observation, they need frequent heart rate assessment and monitoring looking for tachycardia which may indicate a further drop in Hb.
- The FBC should be repeated within 6-12 hours to detect ongoing haemolysis.
- In addition, reticulocyte count and bilirubin should be monitored.
- Additional investigations will be guided by red blood film findings e.g. Coombs (DAT) Blood group and antibody screening (BGAB), G6PD assay and Eosin-5 maleimide red cell staining (diagnosis of hereditary spherocytosis).
Sickle
cell anaemia
See
Sickle cell disease
Hypoplastic/Aplastic Anaemia
(eg acute leukaemia, aplastic anaemia, infiltrative disorders)
- May be due to drugs eg cytotoxics, chloramphenicol, sulfonamides or viral infection
- May be seen in severe nutritional deficiencies (vitamin B12 or folate deficiency) but usually children present with macrocytic red cells.
- Reticulocyte count is usually low
- Consider bone marrow infiltration if neutrophils and/or platelets also decreased
- If isolated anaemia with low reticulocyte count with normal platelet and neutrophil counts consider transient erythroblastopenia of childhood (TEC) or congenital forms (eg Diamond-Blackfan anaemia)
- Bone marrow aspirate is usually required for diagnosis
Chronic disease
- Normochromic normocytic anaemia can be seen with chronic inflammation and chronic disease such as renal disease.
- Reticulocyte may be low
- Platelet count may be elevated.
- Further investigation with UEC, LFT and ESR may be indicated depending on clinical history.
Blood loss
- Normochromic normocytic anaemia can be seen with acute blood loss
- Reticulocyte count may be normal or elevated.
- Suggest correlation with any bleeding symptoms
Macrocytic Anaemia
Vitamin
B12 and folate deficiency
- Can be associated with failure to thrive or neurodevelopmental problems. (regression, seizures, irritability, poor
feeding)
- Vitamin B12 deficiency may be seen in exclusively breast-fed infants of mothers with vitamin B12 deficiency, children with a vegan or vegetarian diet, pernicious anaemia and metabolic disorders.
- Characteristic blood film findings include teardrop red cells and hypersegmented neutrophils and often neutropenia or thrombocytopenia
- Needs urgent investigation with red cell folate and active vitamin B12
- If low active vitamin B12 suggest serum homocysteine and urine methylmalonic acid.
- Treatment must be commenced urgently, particularly if neurological symptoms or regression.
Other causes of red cell macrocytosis with or without anaemia
- Myelodysplasia
- Medications
- Secondary to medications such as anticonvulsants, immunosuppressives and zidovudine.
- Liver disease
- Hypothyroidism
Consider
consultation with local paediatric team when:
- When red flags identified (see list above)
Consider
transfer when:
Children requiring care beyond the level of comfort of the local hospital.
For emergency advice and paediatric or neonatal ICU transfers, call
the Paediatric Infant Perinatal Emergency Retrieval (PIPER) Service: 1300 137
650.
Information specific to RCH and Monash Children’s Hospital Consider discussion with clinical haematology. |
Additional
Notes
Other features on the blood film appearance
that prompt further investigation.
Film features |
Cause |
Investigation |
Target cells |
Iron deficiency anaemia
Haemoglobinopathies |
Ferritin
Haemoglobinopathy testing (HPLC/Hb Electrophoresis) |
Elliptocytes or pencil cells |
Iron deficiency anaemia
Haemoglobinopathies |
Ferritin
Haemoglobinopathy testing (HPLC/Hb Electrophoresis) |
Spherocytes |
Hereditary spherocytosis Autoimmune haemolysis |
DAT
BGAB (Blood group)
Eosin 5 maleimide (E5M) |
Fragmented red cells |
Haemolysis |
Platelet count
Bilirubin, Reticulocyte count
Urea + Creatinine
Coagulation profile |
Bite and blister cells |
G6PD deficiency |
G6PD assay |
Nucleated red blood cells |
Bone marrow infiltration
Haemolysis |
Consider bone marrow examination
Thalassaemia testing (HPLC/Hb Electrophoresis) |
Sickle cells |
Sickle cell anaemia |
Haemoglobinopathy testing (HPLC/Hb Electrophoresis) |
Tear drop cells |
Bone marrow infiltration
Vitamin B12 deficiency |
May need bone marrow examination
Active vitamin B12 |
Last updated January 2019