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Anemia in Children
Initial Evaluation
Most infants and children with mild anemia do not exhibit overt clinical signs and
symptoms. Initial evaluation should include
a thorough history, such as questions to
determine prematurity, low birth weight,
diet, chronic diseases, family history of anemia, and ethnic background. A complete
blood count is the most common initial
diagnostic test used to evaluate for anemia,
and it allows for differentiating microcytic,
normocytic, and macrocytic anemia based
Age
2 standard deviations
1 month
2 months
3 to 6 months
6 months to 2 years
2 to 6 years
11.5 g per dL
6 to 12 years
13.5 g per dL
11.5 g per dL
Males
Females
12 g per dL
12 to 18 years
Microcytic
Normocytic
Macrocytic
Neonates
Congenital aplasia
Concurrent infection
Concurrent infection
Hypothyroidism
Thalassemia
Hypersplenism
Congenital aplasia
Hypothyroidism
Thalassemia
NOTE:
Anemia in Children
Low MCV
Normal MCV
High MCV
Microcytic anemia
Normocytic anemia
(see Figure 2)
Macrocytic anemia
(see Figure 3)
Yes
No
Hemoglobin increased by
>1.0 g per dL (10 g per L)?
No
Yes
Diagnosis confirmed; counsel
about cows milk consumption;
and continue treatment for an
additional one to two months
Thalassemia
No cause found
Counsel or refer
as needed
Refer to pediatric
hematologist
Figure 1. Algorithm for the evaluation of low hemoglobin levels in children. (MCV = mean corpuscular volume.)
Adapted with permission from Janus J, Moerschel SK. Evaluation of anemia in children. Am Fam Physician. 2010;81(12):1468.
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Toddlers 1 to 3 years
Children 4 to 8 years
Ferrous fumarate
Ferrous gluconate
Ferrous sulfate
Polysaccharide-iron
complex and ferrous
bisglycinate chelate
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Anemia in Children
Iron is important for the neurologic development of infants and children. Iron is
required for proper myelinization of neurons, neurogenesis, and differentiation of
brain cells that can affect sensory systems,
learning, memory, and behavior.2,26-29 Iron is
also a cofactor for enzymes that synthesize
neurotransmitters.26,27
A landmark study of Costa Rican children concluded that iron deficiency anemia
increases the risk of long-lasting developmental disadvantages.30 However, whether
iron supplementation can affect psychomotor development or cognitive function
in children is unclear. A Cochrane review
concluded that there is no evidence that iron
supplementation improves psychomotor or
Amount of elemental
iron (mg)
4.4
3.3
3.2
2.5
1.8 to 2.2
1.8
1.8
1.6
1.1 to 2.0
1.0 to 1.2
0.9
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Anemia in Children
enzymop
athies, metabolic defects, and
immune-mediated destruction.3,35 Other
testing, such as an osmotic fragility test for
hereditary spherocytosis and a glucose-6phosphate dehydrogenase assay to check for
a deficiency, may also be useful.3,36
Sickle cell disease, caused by a genetic
defect in the -globin, is a hemoglobinopathy that results in normocytic anemia. In
the United States, it is typically diagnosed
through newborn screening.3,37 A review
of the management of sickle cell anemia
was recently published in American Family
Physician.38
A low reticulocyte count with normocytic anemia in infants and children suggests impaired bone marrow function. This
can be due to anemia of chronic inflammation; acquired red blood cell aplasias; and
bone marrow disorders, such as leukemia.5
Acquired aplasias can have an infectious
Medical disease
suspected
Underlying
inflammation
Perform laboratory
testing for renal, hepatic,
or thyroid disease
Cause unknown
Abnormal smear
Consider bone
marrow disorders
(e.g., leukemia,
myelofibrosis)
Positive
Negative
Consider blood
loss, hypersplenism,
or mixed disorder
Refer to pediatric
hematologist
Cause unknown
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References
1, 2, 8
2, 26-29
1, 2
Clinical recommendation
Macrocytic Anemia
The evaluation of macrocytic anemia in
children (Figure 3) begins with examination
of a peripheral blood smear for hypersegmented neutrophils, which indicate megaloblastic anemia.5 If megaloblastic anemia
is shown, folate and vitamin B12 measurements are indicated. Low vitamin B12 levels
may be nutrition/absorption related or congenital and have neurologic consequences,
Megaloblastic anemia
Nonmegaloblastic anemia
No improvement
Low
High
Evaluate for
hemolysis or
hemorrhage
Cause unknown
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Anemia in Children
The Author
MARY WANG, MD, is an associate professor of family
medicine and public health at the University of California
San Diego.
Address correspondence to Mary Wang, MD, University
of CaliforniaSan Diego, 9333 Genesee Ave., #200, San
Diego, CA 92121 (e-mail: mjw011@ucsd.edu). Reprints
are not available from the author.
REFERENCES
1. World Health Organization. Worldwide prevalence of
anaemia 1993-2005. 2008. http://whqlibdoc.who.int/
publications/2008/9789241596657_ eng.pdf. Accessed
October 27, 2015.
2. Baker RD, Greer FR; Committee on Nutrition American
Academy of Pediatrics. Diagnosis and prevention of
iron deficiency and iron-deficiency anemia in infants
and young children (0-3 years of age). Pediatrics.
2010;126(5):1040-1050.
3. Flerlage J, Engorn B, eds. The Harriet Lane Handbook: A
Manual for Pediatric House Officers. 20th ed. Philadelphia, Pa.: Saunder/Elsevier; 2015:305.
4. Short MW, Domagalski JE. Iron deficiency anemia:
evaluation and management. Am Fam Physician.
2013;87(2):98-104.
5. Janus J, Moerschel SK. Evaluation of anemia in children.
Am Fam Physician. 2010;81(12):1462-1471.
6.
World Health Organization. The global prevalence of anaemia in 2011. http://apps.who.int/iris/
bitstream /10665/177094 /1/ 9789 241 5 64 9 60 _ eng.
pdf?ua=1. Accessed November 16, 2015.
7. Dalenius K, Borland E, Smith B, Polhamus B, GrummerStrawn L. Centers for Disease Control and Prevention.
Pediatric Nutrition Surveillance 2010 Report. 2012.
http: / /w w w.cdc.gov /pednss /pdfs / PedNSS _ 2010_
Summary.pdf. Accessed October 27, 2015.
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Anemia in Children
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