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  1. 1. Features of the blood in children
  2. 2. plasma fat globules chemical substances carbohydrates proteins hormones gases oxygen, carbon dioxide, nitrogen blood cells red blood cells white blood cells platelets
  3. 3. Hemopoiesis <ul><li>Definition : </li></ul><ul><li>Blood cells are short-lived, and they must be continually replaced by new cells formed in the generative process called hemopoiesis. </li></ul>
  4. 4. Features of hematopoiesis in children <ul><li>Hematopoiesis in fetal period </li></ul><ul><li>Hematopoiesis after birth </li></ul>
  5. 5. <ul><li>Hematopoiesis in fetal period </li></ul><ul><li>Developmental hematopoiesis occurs in three anatomic stage </li></ul><ul><li>mesoblastic hepatic myeloid </li></ul>
  6. 6. <ul><li>mesoblastic phase: The mesoblastic phase of hemopoiesis, occur in small islands of cells in the yolk sac and body stalk of the embryo. </li></ul><ul><li>hepatic phase: At about 6 weeks of gestation, round basophilic precursors of erythrocytes can be found in the primordium of the liver , and the spleen initiating the hepatic phase of hemopoiesis . </li></ul><ul><li>myeloid phase: After medullary cavities develop in the long bones, blood formation is initiated there, establishing the myeloid phase of hemopoiesis which continues throughout adult life. </li></ul>phase
  7. 7. mesoblastic hepatic spleen myeloid Lymph nodes gestation
  8. 8. Hematopoesis in bone marrow Extramedullary hemopoiesis     Hematopoiesis after birth
  9. 9. Hematopoesis in bone marrow <ul><li>Red bone marrow hematopoiesis </li></ul><ul><li>Yellow bone marrow is deficiency in children, especially in infant and toddler period. </li></ul><ul><li>Red marrow Yellow bone marrow (5-7yrs) </li></ul><ul><li>Yellow bone marrow can come back to red bone marrow when hematopoetic need increases . </li></ul>
  10. 10. Extramedullary hemopoiesis <ul><li>When hematopoietic demand increases, liver, spleen and lymph nodes come back to the status to produce blood cells, hepatomegaly and splenomegaly appears, and maybe there are immature erythrocytes and granulocytes in circulating blood. </li></ul><ul><li>Extramedullary hemopoiesis is the specific phenomena only appearing in infant and toddler. </li></ul>
  11. 11. The production of blood cells is known as hematopoiesis. In the fetus mesoblast, liver, spleen , bone marrow. By the time of birth and throughout life bone marrow.
  12. 12. The bone marrow contains pluripotent stem cells (CD34 cells) that develop into all the various types of blood cells.
  13. 13. HEMATOPOIESIS Lineages for Granulocyte Lymphocyte Monocyte Platelets RBC Lymphopoiesis Granulopoiesis Monocytopoiesis Erythropoiesis Thrombopoiesis Lymphoblast Monoblast Myeloblast Myelocyte Metamylelocyte Band granulocyte Pro-Myelocyte Reticulocyte Pro-erythroblast Basophilic erythroblast Orthocromatic erythroblast Polychromatic erythroblast Megakaryoblast Megakaryocyte Pluripotent stem cell (Hemocytoblast) stem cell
  14. 14. These messengers are released when the level of oxygen reaching the tissues is too low : Erythropoietin stimulates the production of red blood cells. when invading microorganisms : granulocyte colony-stimulating factor and granulocyte-macrophage colony-stimulating factor stimulate the production of different types of white blood cells. Stem cells and later precursor cells are stimulated by various chemical messengers
  15. 15. blood    Cells
  16. 16. Red blood cell system
  17. 17. RED BLOOD CELLS <ul><li>Red blood cells carry oxygen to body tissues and remove carbon dioxide. </li></ul><ul><li>They are red because they contain a protein called hemoglobin that is red in color. </li></ul><ul><li>Red blood cells are round and thinner in the middle, like a balloon that is partly filled with water. This lets them squeeze through tiny blood vessels without breaking. </li></ul>
  18. 18. Red blood cells perform the most important blood duty. The primary function of red blood cells is to carry oxygen and carbon dioxide. Hemoglobin (Hb) is an important protein in the red blood cells that carries oxygen from the lungs to all parts of our body. When they get to an area where the oxygen is needed, they give it up and pick up carbon dioxide which they carry back to the lungs.
  19. 20. Men 4.3-5.4 average 5 x 10 12 women 3.8-4.8 4.2 x 10 12 newborn 5.0-7.0 infancy 4.0-4.3 child 4.0-4.5
  20. 21. At birth RBC is 5.0-7.0 x10 12 /l Hb is 150-220g/l
  21. 22. red cell and hemoglobin reaches its minimum at 2-3months of age, during this period, the red cell count and hemoglobin values drop to their lowest values of 3x10 12 /l and 110g/l , respectively. These are termed “ physiologic anemia ”. physiologic anemia
  22. 23. factors <ul><li>onset of respiration at birth, the arterial oxygen saturation rises toward 95%, levels of erythropoietin (EPO) are low </li></ul><ul><li>the sizable expansion of blood volume that accompanies rapid weight gain during the first 3 mo of life adds to the need for increased RBC production </li></ul><ul><li>Fetal RBC are bigger, destruction increase , shortened survival period </li></ul>
  23. 25. In full term infant the first three days : reticulocyte count is about 5% of total red cells. the end of the first week : It drops rapidly below 2% (0.5-1.5%) at 4-6weeks : the value is increased to 2-8% 5 months of age to adulthood : the value remains 0.5-2%. reticulocyte
  24. 26. <ul><li>Reticulocyte </li></ul>
  25. 27. Nucleated red cells can be seen at birth In full term infant is about 3-10% Premature is about 10-20% It is unusual to observe any nucleated red cell after the first week, especially in the normal term infant. Nucleated red cells
  26. 28. hemoglobina
  27. 29. They can be classified as embryonic : Gower-I, Gower-II, Portland fetal : HbF adult HbA and HbA 2 hemoglobina
  28. 31. Hemoglobin Synthesis in Fetus <ul><li>Gower 1 and 2 - present in yolk sac </li></ul><ul><li>- 75% of early Hgb </li></ul><ul><li>- undetectable after week 12 </li></ul><ul><li>Week 12 to 32  90% Hgb F </li></ul>
  29. 32. At birth HbF averages about 70% HbA accounts for 30% HbA 2 is less than 1% of the total hemoglobina
  30. 33. 6 months of age : HbF has decreased to less than 20% 1 year old : less than 5% 2 yrs of age to adulthood : HbF is only about 0-2% HbA are becoming 95% HbA 2 2-3% of the total Hb. hemoglobina
  31. 34. At birth 1 yr 2 yr hemoglobina
  32. 35. HB Birth 3m 1Y 2Y hemoglobina
  33. 36. Hemoglobin(g/dl) red cell count (10 12 /l ) Age mean -2SD mean -2SD Birth(cord blood) 16.5 13.5 4.7 3.9 1-3d 18.5 14.5 5.3 4.0 1wk 17.5 13.5 5.1 3.9 2wk 16.5 12.5 4.9 3.6 1mo 14.0 10.0 4.2 3.0 2mo 11.5 9.0 3.8 2.7 3-6mo 11.5 9.5 3.8 3.1 0.5-2y 12.0 10.5 4.5 3.7 2-6y 12.5 11.5 4.6 3.9 6-12y 13.5 11.5 4.6 4.0 12-18y-female 14.0 12.0 4.6 4.1 male 14.5 13.0 4.9 4.5
  34. 37. White blood cell system
  35. 38. The primary function of white blood cells is to fight infection There are several types of white blood cells, and each has its own role in fighting bacterial, viral, fungal, and parasitic infections. White blood cell
  36. 39. ·       help heal wounds not only by fighting infection but also by ingesting matter such as dead cells, tissue debris, and old red blood cells.   are our protection from foreign bodies that enter the bloodstream, such as allergens. are involved in the protection against mutated cells, such as cancer. White blood cell
  37. 40. Leukocytes include granulocytes , monocytes , and lymphocytes. eosinophil granulocytes basophil neutrophil White blood cell
  38. 41. This granulocyte has very tiny light staining granules (the granules are very difficult to see). The nucleus is frequently multi-lobed with lobes connected by thin strands of nuclear material. These cells are capable of phagocytizing foreign cells, toxins, and viruses. Neutrophil 50 ~ 70 %
  39. 42. eosinophil 2-3% This granulocyte has large granules (A) which are acidophilic and appear pink (or red) in a stained preparation. The nucleus often has two lobes connected by a band of nuclear material. The granules contain digestive enzymes that are particularly effective against parasitic worms in their larval form. These cells also phagocytize antigen - antibody complexes.
  40. 43. Basophil <1% The granules in this cell are large, stain deep blue to purple, and are often so numerous they mask the nucleus. These granules contain histamines (cause vasodilation) and heparin (anticoagulant). they represent less than 1% of all leukocytes. If the count showed an abnormally high number of these cells, hemolytic anemia or chicken pox may be the cause.
  41. 44. lymphocyte 25-35% The lymphocyte is an agranular cell with very clear cytoplasm which stains pale blue. Its nucleus is very large for the size of the cell and stains dark purple. These cells play an important role in our immune response. The T-lymphocytes act against virus infected cells and tumor cells. The B-lymphocytes produce antibodies.
  42. 45. Monocyte 3-9% This cell is the largest of the leukocytes and is agranular. These cells leave the blood stream (diapedesis) to become macrophages. As a monocyte or macrophage, these cells are phagocytic and defend the body against viruses and bacteria. These cells account for 3-9% of all leukocytes. In people with malaria, endocarditis, typhoid fever, monocytes increase in number.
  43. 46. neutrophil eosinophil basophil lymphocyte monocyte
  44. 47. Granulocytes and monocyte functions include phagocytosis and destruction of foreign particles. Lymphocytes participate in the immune response. White blood cell
  45. 48. At birth, white cell counts is about 15-20x10 9 /l 6-12 hours after birth it reaches the highest value (21-28x10 9 /l), followed by a rapid fall until 10 days of age., there is a slow steady fall in white cell count throughout childhood. At 8 years of age, it will approach the adult values (6-8x10 9 /l). White blood cell
  46. 49. h White blood cell
  47. 50. Leucocyte count WBC × 10 10 /L 9h 10d 1y 8y 1 2 3
  48. 51. neutrophils at birth, neutrophils account for about half of the white cells. 2-24 hours, a transient rise to 65% occurs. Immature neutrophils are common in the peripheral blood of the newborn.
  49. 52. Lymphocytes account for about 35% of white cell in newborn the proportion of lymphocytes increases as rapidly within the first month . Lymphocytes During infancy, lymphocytes are often large and may contain nucleoli. Their immature appearance and increased number, particularly during mild, nonbacterial infectious may give the false impression of malignancy .
  50. 53. Neutrophils and lymphocytes are equal at 4-6 days Neutrophils decrease to a mean of 35% and lymphocytes remain near an average of 60% in infancy. Neutrophils and lymphocytes are equal again at 4-6 years then neutrophils increase lymphocytes decrease they approach the adult values White blood cell
  51. 54. % 20 40 60 80 0 5d 5y Differential count of WBC Lymphocyte Granulocyte
  52. 55. The absolute count /mm 3 = the total white cells x that cell type % Absolute values for neutrophils and lymphocytes have more clinical meaning than relative values. A neutrophil count below 1.0x10 9 /l is associated with increased risk of infections White blood cell
  53. 56. Metamyelocytes and myelocytes may be as high as 2.0±0.75 x10 9 /l respectively during the first three days In the premature baby an occasional myelocyte may be found up to 2 weeks after birth. Metamyelocytes and myelocytes
  54. 57. promyelocyte and blast cells are seen in healthy neonate. they are often found in the severely infectious baby, even the total value of white cell count is no higher than in the normal infant. White blood cell
  55. 58. Monocyte have not change in different stage. It count is about 5% of total WBC Monocyte
  56. 59. Platelet system
  57. 60. Mature platelets are small cells approximately 1-4μm in diameter. Platelets survive 7-10 days once released from the marrow. At birth, The platelet count is 150 x10 9 /l The platelet count in childhood is 150-350x10 9 /l, which is similar to that in adulthood. Platelet system
  58. 62. PLATELETS <ul><li>If a blood vessel is cut, platelets stick to the edges of the cut and to one another, forming a plug that stops bleeding. </li></ul><ul><li>They then release chemicals that react with fibrinogen and other clotting proteins, leading to the formation of a blood clot. </li></ul><ul><li>The blood vessel can then heal over the cut area. </li></ul>
  59. 63. Blood volume
  60. 64. In the newborn and infant, the average blood volume is about 10% of body weight. It is only 8-10% in child and 6-8% in adult. Platelet system
  61. 65. Anemia
  62. 66. Blood Smear - Normal
  63. 67. Introduction of anemia <ul><li>In anemia status, Hb and RBC are lower than normal </li></ul><ul><li>Anemia is a syndrome, not a name of a disease </li></ul><ul><li>Anemia is a common symptoms in many diseases </li></ul><ul><li>Decreases of Hb is more important in judge degree of anemia </li></ul>
  64. 68. <ul><li>Congenital disorders: </li></ul><ul><ul><li>Membrane, Hb & enzyme disorders. </li></ul></ul><ul><li>Acquired disorders : </li></ul><ul><ul><li>Decreased production </li></ul></ul><ul><ul><li>Increased loss </li></ul></ul>Anemia is decreased red cell mass affecting tissue oxygenation
  65. 69. <ul><li>decreased red cell production </li></ul><ul><li>Marrow failure; </li></ul><ul><li>Impaired erythropoietin production </li></ul><ul><li>Defect in red cell maturation </li></ul><ul><li>increased red cell destruction (hemolysis) </li></ul><ul><li>Extracellular causes </li></ul><ul><li>Intracellular causes </li></ul><ul><li>blood loss </li></ul>Causes and mechanisms of anemia
  66. 70. WHO suggested that anemia occurs: Hb The newborn <145g/l 6m-6yr < 110g/l >6yr <120g/l Anemia is defined as a hemoglobin (Hb) and red cell level below the normal range for a child of that age.
  67. 71. Hb red cell Mild 90-120g/l (>6yr) 3-4 x 10 12 /l 90-110g/l (<6yr) Moderate 60-90g/l 2-3 x 10 12 /l Severe 30-60g/l 1-2 x 10 12 /l Very severe <30g/l <1 x 10 12 /l According to Hb and red cell count , anemia is divided 4 degrees
  68. 72. Red blood cell indices <ul><li>MCH Mean Corpuscular Hemoglobin </li></ul><ul><li>Indicates the hemoglobin content per cell. </li></ul><ul><li>MCV Mean Corpuscular Volume </li></ul><ul><li>Indicates the size of RBC </li></ul><ul><li>MCHC Mean Corpuscular Hemoglobin concentration </li></ul><ul><li>Indicates the Hb content per volume of </li></ul><ul><li>RBC </li></ul>
  69. 73. MCH <ul><li>Mean Corpuscular Hemoglobin </li></ul><ul><li>Indicates the hemoglobin content per cell. </li></ul><ul><li>Formula </li></ul><ul><ul><li>Hb (g/dl) x 10 </li></ul></ul><ul><ul><li> Number of RBC (millions per mm 3 ) </li></ul></ul><ul><li>Results are given in picograms </li></ul><ul><li>Low value would indicate hypochromic anemia from iron deficiency since the RBC is small </li></ul><ul><li>It is high in megaloblastic anemia since the RBC is large </li></ul>MCH (pg)=
  70. 74. MCV <ul><li>Mean Corpuscular Volume Indicates the size of RBC </li></ul><ul><li>Hct x 10 </li></ul><ul><ul><ul><ul><li>Number of RBC (millions per mm 3 ) </li></ul></ul></ul></ul><ul><li>A low value would indicate a small red blood cell such as in </li></ul><ul><li>microcytic anemia from an iron or copper deficiency. </li></ul><ul><li>A high value would indicate a larger red blood cells such as </li></ul><ul><li>in macrocytic anemia of a folacin deficiency or pernicious </li></ul><ul><li>anemia from a B 12 deficiency. </li></ul><ul><li>Results are recorded in femtoliters (FL). </li></ul><ul><li>Normal 80-94 fl </li></ul>MCV (u 3)=
  71. 75. MCHC <ul><li>Mean Corpuscular Hemoglobin Concentration </li></ul><ul><li>Indicates the Hb content per volume of RBC </li></ul><ul><li>A low value is obtained when Hb is decreased more than Hct. </li></ul><ul><li>Hb (g/dl) </li></ul><ul><li> Hct </li></ul><ul><li>In iron deficiency anemia, the MCV, MCH and MCHC are low </li></ul><ul><li>In the macrocytic anemias of B 12 or folate they may be high or normal. </li></ul>MCHC % = x 100
  72. 76. According to cell modality Anemia MCV(fl) MCH(pg) MCHC(%) (80-94) (28-32) (32-38) Macrocytic >94 >32 32-38 Normocytic 80-94 28-32 32-38 Microcytic <80 <28 32-38 Hypochromic <80 <28 <32 microcytic
  73. 77.            Blood routine Hypochromic microcytic Macrocytic Normocytic ( Hb↓ > RBC↓ ) ( Hb↓ < RBC↓) ( Hb↓ =RBC↓ ) IDA megaloblastic   acute bleeding Thalassemia       Vit B 12 ↓↓ hemolytic anemia sideroblastic anemia folic acid ↓   aplastic anemia Chronic infection most of secondary anemia
  74. 78. at birth hemorrhage twin to twin fetomaternal transfusion following placental abruption hemolysis from rhesus isoimmunisation Anemia
  75. 80. The most common sign of anemia mild paleness of the skin General signs in children poor feeding dyspnea irritability inactivity faintness change in behavior poor school performance jaundice Anemia
  76. 81. The symptoms of anemia depend on the degree of reduction in the oxygen- carrying capacity of the blood the change in blood volume the rate at which these changes occur the ability of the cardiovascular and hematopoietic systems to compensate. Anemia
  77. 82. diagnose <ul><li>history taking </li></ul><ul><li>physical examination </li></ul><ul><li>laboratory examination </li></ul>
  78. 83. <ul><li>age, sex, race, ethnicity, diet </li></ul><ul><li>neonatal history, drug exposure </li></ul><ul><li>infections , inheritance </li></ul><ul><li>history of gastrointestinal dysfunction </li></ul>diagnose careful medical history
  79. 84. <ul><li>physical examination </li></ul><ul><li>growth and development </li></ul><ul><li>Nutrition </li></ul><ul><li>Skin mucosa </li></ul><ul><li>Nail 、 hair </li></ul><ul><li>  Liver 、 spleen 、 lymph node </li></ul>diagnose diagnose
  80. 85. In many cases, doctors don't discover anemia until they run blood tests as part of a routine physical examination. A complete blood count (CBC) may indicate that there are fewer red blood cells than normal.   laboratory examination diagnose
  81. 86. <ul><li>Complete blood count (CBC) </li></ul><ul><li>red blood cell count (RBC) </li></ul><ul><li>white blood cell count (WBC) </li></ul><ul><li>platelet count </li></ul><ul><li>hematocrit red blood cell volume (Hct) </li></ul><ul><li>hemoglobin (Hgb) concentration - the </li></ul><ul><li>oxygen-carrying pigment in red blood cells </li></ul><ul><li>differential blood count </li></ul><ul><li>. </li></ul>
  82. 87. <ul><li>blood smear : it’s perhaps the simplest, and most </li></ul><ul><li>often overlooked. </li></ul><ul><li>Hb This test identifies various abnormal </li></ul><ul><li>hemoglobin in the blood. </li></ul><ul><li>red cell indices MCV MCH MCHC </li></ul><ul><li>bone marrow aspiration and biopsy : This test </li></ul><ul><li>can help determine whether cell </li></ul><ul><li>production is happening normally in the </li></ul><ul><li>bone marrow </li></ul>Laboratory procedures
  83. 88. <ul><li>reticulocyte count is useful in determining the </li></ul><ul><li>rate of red cell destruction and in monitoring </li></ul><ul><li>response of treatment. </li></ul><ul><li>iron status vitaminb12 when nutritional anemia </li></ul><ul><li>are suspected, measurements of iron status, </li></ul><ul><li>vitaminb12, and folic acid </li></ul><ul><li>the osmotic fragility test is used to measure the </li></ul><ul><li>osmotic resistance of red cells </li></ul><ul><li>immunologic tests in patients in whom hemolytic </li></ul><ul><li>anemia is suspected , such as the direct and </li></ul><ul><li>indirect coombs tests are required. </li></ul>Laboratory procedures
  84. 89. QUESTIONS T he time of neutrophils and lyphocytes are equal H ow do hemoglobin change? P hysiologic anemia A nemia’s 4 degrees
  85. 90. <ul><li>Thank you </li></ul>