The document discusses normal hematopoiesis and anemia. It begins by defining hematopoiesis as the formation of blood cellular components from hematopoietic stem cells in the bone marrow. It describes the three lineages of blood cells and the stages of hematopoiesis in embryo and postnatal life. The document then covers the clinical presentation, evaluation, classification, causes including nutritional deficiencies, and treatment of anemia. It provides details on iron deficiency anemia, including risk factors, etiology, and pathophysiology in infancy.
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Microcytic Anemia: Iron Deficiency Anemia
1. Dr. Salem F Gerbadi
Master Degree In Pediatrics
2. Normal Hematopoiesis
Is the formation of blood cellular
components.
All cellular blood components are derived
from haematopoietic stem cells (HSCs) .
HSCs are primitive stem cells have the
unique ability to give rise to all of the
different mature blood cell types .
3. NORMAL HEMATOPOIESIS
In Embryo Life
(before 16 days gestation) do not have
blood.
Intrauterine hematopoesis passes into 3
stages:-
1st 8 weeks → in yolk sac
8th week - 6th month → in the liver
after 6th month → in bone marrow
4. NORMAL HEMATOPOIESIS
At Birth &Infancy: it takes places in
bone marrow of all bones.
During Childhood: it takes place only in
red bone marrow in flat bones only (ends
of long bones (femur & tibia), , skull,
sternum and ribs).
the inactive yellow marrow in the long
bones can restore its activity in case of
excessive hematopoietic needs.
5. All blood cells are divided into three
lineages.
1. Erythroid
Are the oxygen carrying .
Both reticulocytes and
erythrocytes (functional )are
released into the blood.
Erythropoies
is
6.
7. HORMONAL CONTROL OF
ERYTHROPOIESIS
Erythropoietin (EPO) release by the liver & kidneys is
triggered by:
Enhanced erythropoiesis increases the RBC
count in circulating blood & Oxygen carrying
ability of the blood
Hypoxia &
anamia
9. 2. Lymphocytes
Are the cornerstone of the adaptive
immune system. They are derived from
common lymphoid progenitors.
The lymphoid lineage is primarily
composed of T-cells and B-cells .
Lymphopoiesis
10. 3. Myelocytes
which include granulocytes,
megakaryocytes and macrophages.
Are derived from common myeloid
progenitors
Involved in such diverse roles as
innate immunity, adaptive immunity,
and blood clotting.
Myelopoiesi
s
11. Decreased life span of neonatal RBCs
within the circulation (60-90 days)
In prematur, e remarkably shorter
RBCs life span (35-50 days)
In children = 100- 120 days (adult)
12. Hb molecule is composed of Heme
groups (ferrous iron containing) attached
to 4 polypeptide chains which define the
type of Hb.
Types
Fetal Hb (Hb F) → containing (α2 , ɣ2) chains , has
high affinity to 02.
Adult Hb → HB A (α2 & β2) , HB A2 (α2 & Δ2)
13. *At the 3 – 6 month after birth→ normal switch from ɣ to β
chain occurs
At 6 months
At birth
Intrauterine
Hb type
> 0.5 %
70 %
Dominant
Hb F
97%
30%
---
Hb A
2.5%
Trace
---
Hb A2
15. 3. Hematocrite value (Ht)
Packed red cell volume = percent
of RBCs volume in 100 ml blood →
33 -44%.
4. Mean corpuscular volume (MCV)
The average volume of a red blood
corpuscle.
If < 80 = RBCs are small (Microcytes).
If > 94 =RBCs are big (Macrocytes)
16. 5. Mean corpuscular hemoglobin (MCH)
Refers to the average quantity of hemoglobin
present in a single red blood cell.
Range = 27- 32 pg.
If < 27 pg → RBCs are hypochromic.
6. Mean corpuscular hemoglobin concentration
(MCHC)
The average amount of hemoglobin in a group of red
blood cells. Range → 32-36 g/dL.
17. 7. Reticulocytic count = account 1 %.
Reticulocytosis occur in:
Hemolytic anemias.
Hemorrhage
Response to hematinics e.g. (iron, folic
acid, B12)
Recovery of bone marrow from
suppression.
8. Platelet count= 150.000 - 400.000 /mm3
19. DEFINITION
Anemia is defined as a condition
where the hemoglobin conc. or
hematocrit (packed red cell volume) of
an individual is lower than the level
considered normal for the person’s
age and sex.
21. Prevalence Of Anemia
*40% In Children Aged 6ms -5yrs (269 Million Children With
Anemia)
Developed
nations
Developing
nations
Age group
17 %
42 %
Pre School Children
%
9
%
53
School children
22. Anemia Grades
*Who Classification Of Anemia 2021 In Pediatrics (NATIONAL FAMILY
HEALTH SURVEY)
Hb g/dl
Grade
10.9 – 10
Mild
9.9 – 7
Moderate
< 7
Severe
26. Causes Cont…
Anemia from blood loss ( post-hemorrhagic):
Acute post-hemorrhagic anemia after overt
bleeding
Chronic post-hemorrhagic anemia (occult
bleeding-iron deficiency). e.g. due to Ancylostoma
orcow's milk allergy)
31. Clinical Presentation
1. Common manifestations: Pallor,, exercise
intolerance, dyspnoea, palpitations, headache,
lack of conc., loss of appetite, irritability, excessive
sleeping, syncope, hemic murmurs.
1. Less commonly: anorexia, nausea, flatulence,
constipation, mild proteinuria, fever
2. Severe cases: C.O, CHF
32. 3. Manifestations of etiology :
Hge, occult blood
Growth failure: Chronic Dis.
Acute hemolysis: beans, dark urine
Chr. Hemolysis → jaundice, skeletal changes,
organomegally
Acute hemolysis: beans, dark urine
Veno-occlusive crisis: SCA
Iron def.: PEM, nail, glossitis
Neurologic signs: ataxia, + ve Babinski: PA
Short stature, sk., cardiac, renal :Aplastic
33. Clinical Evaluation
A. History
1. Symptoms of anaemia: lethargy, shortness of
breath on exertion.
2. Age: Iron deficiency anaemia, Neonatal anaemia
3. Sex: G6PD.
4. Race: Sickle cell anaemia
5. Family history: G6PD deficiency, sickle cell,
Fanconi anaemia, spherocytosis, family member
with early cholecystectomy or splenectomy,
ethnicity, race.
34. .
1. Nutrition: cow’s milk, strict vegetarian, goat’s
milk, pica, cholestasis, malabsorption.
2. Overt blood loss: epistaxis, haematemesis,
haematuria, blood in stools.
3. Drugs: cytotoxics, antibiotics, antimalarial,
anticonvulsants, NSAIDs
4. Diarrhea: malabsorption of Vit.B12 or E or
iron, inflammatory bowel disease, milk protein
intolerance, intestinal resection
5. Infection: giardia, fish tapeworm, mycoplasma,
HIV, malaria, blind loop, EBV, CMV,
parvovirus, endocarditis, hepatitis
45. IDA
Due to deficiency of specific nutrients (iron)
Most common nutritional deficiency in
children and is worldwide. WHY???
Prevalence : it is estimated that roughly 5%
of the world population
Highest :
6 - 24 months
Artificially fed infants.
low socioeconomic status.
46. Physiology
Storage Iron :
Newborn→ about 0.5 gm of iron.
Child → 70 mg/kg
Iron stores are built up in the last trimester of
pregnancy.
Sufficient for 4 ms of term newborn
Preterm and low birth wt. infants are associated with
decreased Fe stores.
The transport and storage of iron is largely mediated
by 3 proteins:
Transferrin
Transferrin receptor (TR)
Ferritin
47. Normal Daily Requirements Of Iron
Term breast fed: starting from 4 ms.
PT & Formula fed: from 1 - 2 months.
1 mg/kg/day elemental iron for normal
infants and children (max 15 mg/day).
2 mg/kg/day elemental iron: LBW,very low
Hb
48. Dietary Iron
I. Heme iron compounds (hemoglobin and
myoglobin) :
High bioavailability (20‐30%)
Foods of animal origin: 1.5 - 6 mg iron /100 g
meat, liver, poultry, fish, etc.
Easily digested and readily absorbed.
Absorption is not affected by diet.
49. II. Non-heme iron ( ferric iron salts ) :
Poor bio availability (2‐5%)
Egg yolk, green vegetables, whole grains,
legumes, nuts ( + 1.5 mg/100 g). ferric
ferrous before absorption.
Absorption (50% : breast milk , 10% of
cow’s milk iron
51. Functions Of Iron
Critical element in function of
cells
Hb facilitates O2 transfer to
tissues
Myoglobin transfer O2 to
muscle cells
52. Risk Factors In Infancy
Maternal iron deficiency
Breastfeeding beyond 6 ms without
complementary food
Complementary food low in iron or
poorly bioavailable.
53. Etiology of IDA
Inadequate iron stores at
birth:
Premature.
Multiple births.
Severe maternal iron def.
Fetal blood loss.
Impaired absorption of iron:
chronic diarrhea and celiac
disease.
Blood loss during infancy:
Cow milk allergy.
Acute or chronic
hemorrhages.
Parasitic infestations as
hook worms.
Inadequate dietary intake
Early cow milk.
Exclusive breast feeding
after 6 months.
Low intake
Failure to meet increased
demands for growth:
premature.
adolescence.
54. Stages Of The Development Of Iron Deficiency
Prelatent
Reduction in iron stores without reduced serum iron levels
Hb (N), MCV (N), iron absorption (), transferin saturation
(N), serum ferritin (), marrow iron ()
Latent
Iron stores are exhausted, but the blood haemoglobin level
remains normal
Hb (N), MCV (N), TIBC (), serum ferritin (), transferin
saturation (), marrow iron (absent)
Irondeficiencyanemia
Blood haemoglobin concentration falls below the lower limit
of normal
Hb (), MCV (), TIBC (), serum ferritin (), transferin
saturation (), marrow iron (absent)
55. Clinical manifestations
1. General manifestations of anemia
2. particular findings of effect of iron def. on
systems:
GIT: Anorexia, atrophic glossitis, dysphagia, Pica
(ingestion of wall plaster, clay), Geophagia (earth),
Pagophagia (ice), malabs.lactose int.
CNS: Short attention span, irritability, breath holding,
↓ alertness, ↓ learning ability and school performance.
56. Immunological:
URTI common but bact. infections↓.
Spleen slightly enlarged in 15%
Growth retardation and signs of other deficiencies
CVS: HR , cardiac hypertrophy
Plasma volume
Musculoskeletal System:
Impaired performance
Rapid lactic acidosis
Physical signs
pallor, hemic murmur
tongue: pallor, bald & shining tongue, loss of
papillae
angular stomatitis
Nails: platynychia, koilonychia
.
57. Laboratory findings
.
↓↓
Serum Iron Concentration
↑↑
Total Iron-binding Capacity
↓↓
Saturation Of Transferrin
↓↓
Serum Ferritin Levels
↑↑
Serum Transferrin Receptors
58. Hypochromic Microcytic Anemia, Anisocytosis (variation
in size) & Poikilocytosis (variation in shape).
59. Treatment Of IDA
Hb below 5 g/dl: Risk of cardiac failure; Hospitalization is
desirable.
If Hb is below 3 g/dl (< 4 g/dl with infection and in young
children): Blood transfusion is usually required; packed red cell
transfusion 2‐3 ml/kg at one time.
For treatment dose of oral iron is 3 - 6 mg/kg/day; ferrous
sulphate, gluconate and fumarate are most commonly used and
cost effective. Newer iron compounds like ferrous glycine
sulphate, carbonyl iron are costly and have not been studied
adequately in children
60. Oral Iron Therapy
Dose: 3‐6 mg/kg of elemental iron
Divided in 1‐2 doses
On empty stomach –ideal
On full stomach if intolerance
Duration : 3 ms after Hb has
normalized
61. Oral Iron Side Effects
Nausea, vomiting, pain in abdomen,
diarrhea, constipation in about 14%
cases
Discoloration of stool
Staining of tongue / teeth
True intolerance rare
62. Response To Iron Therapy
24‐48 hrs Erythroid hyperplasia
Reticulocytosis 48 - 72 hrs, peak: 5th - 10th d.
↑ Hb after 4-30 days ( 0.25 - 0.4 g / dl/ day).
↑ hematocrit (1 % / day).
Repletion of Iron stores in 1 - 3 ms.
63. Non Responders To Iron Therapy
Wrong formulation and dosage
Poor compliance
Basic cause not treated esp. bleeding
Thalassemia
Red cell aplasia
64. Treatment cont…
Parenteral iron therapy: Iron dextran mixture
(Imferon) 50 mg elemental iron / ml: only in
intolerance or malabsorption or severe GIT
disease.
Blood transfusion: Severely anemic children
with Hb < 4 g/dl given packed RBCs
Partial exchange transfusion: surgical
emergency, CHF
Treatment of etiology correct diet and
Ancylostoma.
65. Acute Iron Intoxication
Accidental ingestion of large doses of iron:
mortality rate 50%.
Early symptoms : Vomiting, diarrhea, dehydration,
corrosive iron on stomach,intestines.
Later : Severe irreversible CV collapse, shock, coma.
marked in plasma iron.
Treatment: Forced vomiting & gastric lavage with
sodium bicarbonate.
Desferrioxamine (Desferal) specific chelator of iron
(antidote).
Blood and plasma transfusion, oxygen, and electrolyte
correction.
67. Definition
Anemiawith megaloblasts in BM
and macrocytes (Hypersegmented
neutrophils) in peripheral blood.
All blood components may affected
Common in infancy…why ???
72. The Schilling test
Is used to determine whether the body absorbs vitamin
B12 normally.
Two doses of vitamin B12 (cobalamin). The first dose
is radioactive and taken by mouth. The second dose is
not radioactive and is given as a shot 2 - 6 hours later
to saturate transcobolamin.
Urine will then be collected over the next 24 hours to
measure whether vitamin B12 was absorbed normally
or not.
Normal Values:
-Urinating 8 - 40% of the radioactive vitamin B12 within
24 hours is normal.
73. Treatment
1. Folic acid deficiency:
- Folic acid tablet 0.5 - 1 mg/day for 3-4 weeks.
- If diagnosis of folic acid deficiency is doubtful use smaller
dose 0.1 mg/day for a week & look for reticulcytosis
(therapeutic test).
(large dose of folic acid worsen neurologic manifestation of
vitamin B12 deficiency)
2. Vitamin B 1 2 deficiency:
1- Without SCD: B12 1 mg IM monthly for life.
2- With SCD: B12 1mg IM daily for 2 weeks then 1 mg IM
monthly for life.
* With successful treatment; reticulocytosis is seen in 2- 4 days.
Editor's Notes
Normal daily requirements : 30 - 60 g per day (10 times that of adult).