PEDIATRIC PEDIATRIC ANEMIAS Gأ،bor Kovأ،cs MD, PhD Semmelweis University 2nd Dep. of Pediatrics

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  • PEDIATRIC ANEMIAS

    Gábor Kovács MD, PhD

    Semmelweis University

    2nd Dep. of Pediatrics

  • Diagnosis of anemia

    Age Hemoglobin (g/l)

    6 mo - 2 years < 100

    < 110

    6 - 14 years < 120

    Adult women < 120

    Adult man < 130

    2 - 5 years

  • CLASSIFICATION OF ANEMIAS

    MICROCYTAER

    HYPOCHROM

    NORMOCYTAER

    NORMOCHROM

    MACROCYTAER

    (MCV90 fl)

    Iron deficiency hemolysis megaloblastosis

    (B12-, folic acid def.)

    Thalassemia secunder anemia alcohol, liver disease

    Chronic. Illnes Blood loss MDS, aplastic anemia

    Plumb intox. Bone marrow insuff. CDA

    sideroblastyc (B6) Renal failure gravidity, myxoedema

  • Reticulocyte

     Increased: hemolytic anemias, blood loss,

    regeneration

    Decreased: bone marrow diseases,

    erythropoietine deficiency, other

    deficiencies (iron, Vitamin B12, folic acid)

    „Normal”: ineffective erythropoesis

    (thalassemia, MDS, CDA, myelofibrosis),

    chr. inflammation, malignancy

  • RDW

    Red cell distribution width (SD)

    Normal: 10-14 %

    increased: iron deficiency, cong. membrane

    disorders, burn, thrc. aggregation-s./DIC

  • Microcytaer anemias

    Iron Protoporphyrine

    iron deficiency anemia

    chr. infection sideroblastic

    malignancy anemia

    thalassemia

    Hem + globin

    Hemoglobin

  • DD of hypochrom (mikrocytaer)

    anemias

    iron def. inf, tumor thalassemia siderobl.

    MCV

    MCH

    MCHC

    all

    decreased

    slightly

    decreased

    all

    decreased

    decreased

    (MCV might

    be increased)

    SeFe decreased decreased norm. increased

    TVK increased decreased norm. norm.

    ferritin decreased norm. or

    increased

    norm. increased

    iron reserve decreased norm. or

    increased

    norm. norm. or

    increased

    Hb electro-

    phoresis

    norm. norm. pathol. norm.

  • Thalassemia

  • Thalassemia

  • Iron deficiency anemia

  • Hypochrom anemia

    (iron deficiency)

  • Daily iron requirement

    4 mo - 1 year 1.0 mg

    2 - 10 years 0.5-1.0 mg

    Puberty 2.0 mg

    Adult man 1.1 mg

    Adult women 2.4 mg

    Pregnant women -6 mg

  • Stages of iron deficiency

    Iron depot

    Transport

    iron

    Hb-iron

    Normal iron homeostasis:

    Malt train med II/3

  • Stages of iron deficiency

    Prelatent iron deficiency:

    Iron stores

    are empty

    Decreased serum ferritine; decreased

    transferrine saturation; increased IBC;

    hemoglobin normal

    Iron depot Transport iron

    Hb-iron

    Malt train med II/5

  • Stages of iron deficiency

    Latent iron deficiency:

    Transport

    iron

    decreased

    Decreased serum ferritine; decreased transferrine

    saturation; decreased serum iron, increased IBC;

    increased erythrocyte protoporphyrine, hemoglobin

    normal

    Iron depot Transport iron

    Hb-iron

    Malt train med II/6

  • Stages of iron deficiency

    Iron deficiency anemia:

    Iron depot Transport iron

    Hb-iron

    Microcytaer, hypochrom anemia

    Malt train med II/7

    Decreased serum ferritine; decreased transferrine

    saturation; decreased serum iron, increased IBC;

    increased erythrocyte protoporphyrine, decreased

    hemoglobin and MCH

  • Iron deficiency

     Hb low

     MCV400

     No infections

     + anamnesis

     PS: in Down-s: MCV and MCH higher

    http://www.google.hu/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwjF-Oziv4nLAhWBXQ8KHU6nDgcQjRwIBw&url=http%3A%2F%2Fwww.hazipatika.com%2Feletmod%2Ftudomanyos_erdekessegek%2Fcikkek%2Ffaradt_szedjen_vasat%2F20120713164107&psig=AFQjCNEbOvowKznKCfwdgDVda2uybpFJhw&ust=1456166104709800 http://www.google.hu/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwjF-Oziv4nLAhWBXQ8KHU6nDgcQjRwIBw&url=http%3A%2F%2Fwww.hazipatika.com%2Feletmod%2Ftudomanyos_erdekessegek%2Fcikkek%2Ffaradt_szedjen_vasat%2F20120713164107&psig=AFQjCNEbOvowKznKCfwdgDVda2uybpFJhw&ust=1456166104709800

  • Iron def.

  • Significance of iron

    Important for the synthese of

    hemoglobin and myoglobin.

    Basic for the oxydative phosphorilation

    (energy supply).

    Important for the normal mental

    functions and for the immune system.

  • The dopaminerg system

    normal: Iron def.:

    D-2 rec. sensitivity

    dopamine effect

    opiate effect

    Learning

    capacity

    dopamine

    opiate effect

    Learning

    capacity

    Malt train med II/46

  • Iron and the immune system

    Iron def.

    Lymphocyte proliferation

    Interleukin-2

    Immune response

    Malt train med II/54

  • Causes of iron deficiency 1.

    Decreased iron intake:

    Nutritional intake insufficient: not

    enough iron in the meal, breast-feeding

    after 6 months.

    Decreased absorption: gastrointestinal

    diseases, malabsorption

  • Causes of iron deficiency 2.

    Increased iron need:

    Chronic blood loss: ulcus, varix, GI

    malignancy, colitis, diverticulosis,

    menstruation, parasitosis, hematuria.

    Increased need: prematurity, growth,

    gravidity, breast feeding.

    Acute bleedings: Hemorrhagic

    diathesis, coagulation disorders.

  • Incidence of iron deficiency - USA

    •Infants: 14 %

    •3-5 y: 4 %

    •Adolescents (girls): 9-11 %

    •Women, 20-49 y: 9 %

  • AAP guideline 2010

    Preterm infants

    1 mo-12 mo: 2 mg/kg Fe/day

     (drug or Fe-rich formula)

    Pediatrics: 2010, 126: 1040-1051

  • AAP guideline 2010

    Brest-feeding infants

    >4 mo: 1 mg/kg/day extra Iron

    Until, half of the daily food is Fe-rich-

    food or Fe-rich-formula

  • AAP guideline 2010

    Formula-feed infants

    Need: 10-11 mg/day iron

    In formula Iron m in. 10-12 mg/l

    Until, half of the daily food is Fe-rich-

    food.

    NO cow milk until 1 year!!

  • AAP guideline 2010

    1-3 years

    Daily need: 7-8 mg

    Iron-rich food!

    Screening at 1 year: ferritin, CRP, Hb

    Later screening: for risk groups (14 %)

  • Risk groups

    •Preterm infants, SGA newborns

    •Only breast feeding after 4 mo (!)

    •Cow milk

  • AAP guideline 2011 for adolescents

    12-15 y: 9 % iron deficiency, 2 % anemia

    26-29 y: 11 % iron deficiency, 3 % anemia

    Boys< 1 % (more iron needed at puberty)

    Risk group: strong menses bleeding, chr.

    illness, malabsoprtion, obesity, sportsmen,

    veggie diet (veganism)

  • AAP guideline 2011 for adolescents

    Daily need: 9-13 y: 9 mg, 14-18 y: girls 15

    mg, boys 11 mg

    Gravid adolescents: 27 mg

    For girls: yearly blood picture vérkép

    (ferritin, CRP, Hb)! (in boys only 1x)

    If Hb< 110 g/l, treatment!!: 3-6 mg/kg

    per os iron

  • Treatment of iron deficiency

    Malt train med II/40

  • Treatment of iron deficiency 1.

    Disadvantage: gastrointestinal

    intolerance (nausea, vomitus, diarrhoea,

    obstipation)

    Uncontrolled absorption.

    Benefit: cheap, good absorption,

    quick effect.

    Iron-salts (sulfate)

  • Receptor-mediated, controlled absorption.

    Advantage:

    Few side effects.

    Decreased risk for free radicals.

    But slower and lower effect!

    Iron-carbohydrate-complex

    Treatment of iron deficiency 2.

  • Iv: 1-2 mg/kg/d for 5 days

    Dose: 5-6 mg/kg/d orally

    Timing: orally for 4-6 months (!)

    Treatment of iron deficiency 3.

  • http://www.google.hu/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwis2tnRuYnLAhUFcQ8KHSILCLgQjRwIBw&url=http%3A%2F%2Fwww.hotdog.hu%2Fangelgirl_1%2Fi--tavasz%2Ftavasz&psig=AFQjCNE78q_C0Orx029OIPibvAdn0zu-Xg&ust=1456164489646685 http://www.google.hu/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwis2tnRuYnLAhUFcQ8KHSILCLgQjRwIBw&url=http%3A%2F%2Fwww.hotdog.hu%2Fangelgirl_1%2Fi--tavasz%2Ftavasz&psig=AFQjCNE78q_C0Orx029OIPibvAdn0zu-Xg&ust=1456164489646685

  • Normocytaer anemias

  • Classification of anemias 2.

    B. Hemolysis

     1. Intracorpuscular or intrinsic

    membrane-defects (spherocytosis, elliptocytosis,

    st