This document discusses physiological anemia of infancy, which is a normal adaptation to extrauterine life characterized by a progressive decline in hemoglobin levels within the first weeks after birth. It presents the types of hemoglobin, pathophysiology involving decreased erythropoietin production and suppression of erythropoiesis, clinical findings, laboratory tests, treatment including observation or transfusion depending on symptoms, and differential diagnosis. For preterm infants, the physiological anemia is often more severe due to factors like blood loss from phlebotomies and lower erythropoietin levels from liver production. The aim of another study presented was to evaluate using recombinant erythropoietin to stimulate erythropoiesis and reduce

1. PHYSIOLOGICALANEMIA
OF INFANCY
PRESENTER:DR.IRA K.C.
MODERATOR: DR ANAMIKA MAHATO

3. Role of Erythropoietin

4. Types of Hemoglobin
1. Embryonic Hemoglobin:
• Gower-1
• Gower-2
• Portland
2. Fetal Hemoglobin (HbF)
3. Adult Hemoglobin
• HbA1
• HbA2

7. Physiological Anemia of Infancy
• Physiological adaptation to extrauterine life
• Characterized by progressive decline in Hb
level within 1st week of life
• Persists for 6-8 weeks
• Hb level reaches 11g/dl (rarely falls below
10g/dl)

8. Pathophysiology
With the onset of respiration, more O2 becomes available for binding to
Hb
Hb-O2 saturation increases from 50%to 95% or more
Normal developmental switch from HbF to HbA
Increase in Blood O2 content and delivery
Downregulation of EPO production and suppression of Erythropoiesis
RBC removed from circulation not replaced
Hb level decreases

9. When will erythropoiesis resume?
• Hb concentration continues to decline until O2
needs become greater than O2 delivery
• Normally reached between 8-12 weeks of age
• O2 delivery to tissue decreases Renal EPO
production is stimulated and erythropoiesis
increases

11. Iron levels
• The supply of stored reticuloendothelial Iron,
derived from previous degraded RBC remains
sufficient for renewed Hb synthesis
• Even in absence of dietary Iron,until 20 weeks
of age
• No Iron supplements required before 4 months
of life

12. Treatment
In full term infants:
• Ensuring that the diet contains essential
nutrients for hematopoiesis
• No other treatment required

13. Physiological anemia of Prematurity
• Exaggerated physiological Hb decline
• Hb decline more extreme and rapid
• 7-9g/dl reached by 3-6 weeks
Causes:
• Blood loss from repeated phlebotomies
• Shortened life span of RBC (40-60 days)
• Rapid growth
• Lower plasma EPO levels for the degree of
anemia

14. During fetal life, EPO produced by liver
Liver’s O2 sensor relatively insensitive to hypoxia
compared to kidney
Preterm babies rely primarily on liver for EPO
synthesis
Diminished responsiveness to anemia
Decline in Hb

16. History and Physical Examination
Clinical findings are neither specific or diagnostic.
Includes:
• Poor weight gain despite adequate caloric intake
• Cardiorespiratory symptoms like tachycardia, tachypnea
and flow murmurs
• Decreased activity, lethargy, difficulty oral feeding
• Pallor
• Increase in apneic and bradypneic episodes and
worsened periodic breathing
• Metabolic acidemia- Increased lactic acid secondary to
increased cellular anaerobic metabolism in relatively
hypoxic tissues

17. Lab Findings
• CBC count- Low Hb, below 10g/dl. Normal
WBC and Platelets
• PBS- Normocytic, normochromic
• Reticulocyte count- low
• Serum EPO- low
• Serum Lactic acid- used as an aid to determine
the need for transfusion

18. Treatment
1. Observation and supportive care
• For asymptomatic infants,not acutely ill,
receiving adequate nutrition
• Routine checks done only after steady increase
in hematocrit level established
2. PRBC transfusion
• Depending on clinical picture of infants
3. Recombinant EPO

19. Differential Diagnosis
• Conditions that diminish RBC synthesis:
 Substrate Deficiencies (Iron, Vitamin E, Folic Acid)
 Congenital fetal infection (CMV, Parvovirus, Syphilis)
 Bone marrow depression (Pancytopenia, drugs)
• Hemolytic Anemias
• Conditions that reduce blood volume
 Twin-to-twin transfusion syndrome
 Iatrogenic (excessive blood sampling)
 Hemorrhage (GI, CNS, Subcutaneous tissue)

20. Aim: To estimate the blood level of Erythropoietin(EPO) in neonates with anemia of
prematurity (APO) and in late hypo-regenerative anemia and to clarify role of EPO in correction
of anemia and reducing the number of blood transfusions.
Methods: This study was carried out on 60 neonates divided into; group I (30 preterm
neonates) with AOP received EPO (250 IU/kg/dose subcutaneously 3 times weekly for 4 weeks),
compared to group II (30 neonates) with AOP treated only with blood transfusion. CBC
parameters and transfusion requirements were followed during therapy. Serum level of EPO
was measured by ELISA technique.
Results: By the end of the 4th week of therapy, there was significant increase in group I post r-
Hu EPO compared to group II regarding reticulocyte counts (P < 0.001) leading to rise of the Hb
(P < 0.001), Hct levels (P < 0.001) with subsequent reduction in the overall number of blood
transfusions (P < 0.001).
Conclusion: EPO therapy in conjunction with iron, vitamin E and folic acid,
stimulated erythropoiesis and significantly reduced the need for blood transfusion in AOP.
The role of recombinant Human erythropoietin in neonatal
anemia
Dalia M. El-Lahony , Nagwan Y. Saleh , Mona S. Habib , Mohammed A. Shehata , Mahmoud A. El-Hawy
Received 15 March 2019, Revised 29 June 2019, Accepted 30 August 2019, Available online 11 October 2019, Version of
Record 24 August 2020

21. Bibliography
• Nelson Textbook of Pediatrics, 21st edition
• Cloharty and Stark’s manual of Neonatal Care
• Medscape
• Uptodate

22. THANK YOU!!!