Anemia in Children

by Dr. Saul Greenberg

What is it? Anemia refers to a reduction in the number of red blood cells in the body. Red blood cells are responsible for carrying oxygen to the brain and to all the other organs and tissues in the body. New blood cells are produced in the bone marrow (the soft, spongy tissue inside bones) and then migrate to the bloodstream where they survive for about 120 days. What causes it? Anemia occurs for different reasons:

inadequate production of red blood cells by the bone marrow increased destruction of red blood cells (RBCs) increased blood loss from the body

Anemia Caused by Inadequate RBC Production Infants are born with high levels of hemoglobin and RBCs in their blood. After birth, the baby's hemoglobin level normally drops to a low point at about 2 months of age, a condition known as physiologic anemia of infancy. After this occurs, the infant's body gets the signal to increase RBC production. This temporary and expected drop in the blood count (called physiological anemia of the newborn) is considered normal and no treatment is needed. Anemia also occurs when the body isn't able to produce enough healthy red blood cells. This can happen because of a deficiency of iron or certain other substances in the body or from inherited defects or diseases that interfere with the production of red blood cells. Iron is essential for the production of hemoglobin in red blood cells. Poor dietary iron intake (or excessive loss of iron from the body) leads to iron-deficiency anemia, the most common cause of anemia in children. Iron-deficiency anemia can affect children at any age, but it is most commonly seen in children under 2 years of age, and in teens, particularly in adolescent girls who have started menstruating. Anemia can also be caused by deficiency in the nutrients folic acid and vitamin B12, both of which are necessary for normal blood production. Children will develop

megaloblastic anemia if one or both of these substances is deficient. People who eat little or no meat, vegetarians or vegans, may not have enough vitamin B12 in their diets. A folate deficiency can develop from eating too few folate-containing foods such as vegetables or infants drinking only goats milk. Some intestinal diseases such as celiac disease (gluten-sensitive enteropathy) can result in deficiencies of both Vitamin B12 and folate. These forms of anemia are rarely found in babies and young children. Aplastic anemia occurs when the bone marrow is unable to produce sufficient numbers of blood cells because of a problem with the primitive cells in the bone marrow called stem cells. Some aplastic anemias affecting only red blood cells (red cell aplasia) may be inherited, such as Diamond-Blackfan and Fanconis anemia, and causes other physical abnormalities. More often, aplastic anem ia is caused by a virus infection or exposure to certain toxic chemicals, radiation, or medications, such as antibiotics, antiseizure medications, or cancer medications. Some childhood cancers can cause anemia of this type, such as with certain types of leukemia in which abnormal cells crowd out the bone marrow cells needed to produce blood cells. In patients who have hemolytic disorders (e.g. sickle cell disease, thalassemia major), infections with a virus called Parvovirus B19 can cause severe anemia because virtually no production of erythrocytes occurs to compensate for hemolysis. This is known as an aplastic crisis. Healthy children can also develop a mild anemia for about one month following viral infections. Another less common form of anemia resulting in absence of red cell precursors in the bone marrow is transient erythroblastopenia of childhood (TEC). This is a slowly developing anemia of early childhood (usually 18-26 months old) characterized by gradual onset of pallor. As the name suggests, all patients with TEC recover completely without any treatment and with no sequelae. The cause is unknown, although researchers have proposed a number of viral and immunologic mechanisms. Chronic diseases of other organs can result in anemia. For example, in advanced kidney disease, hypothroidism, Addison's disease (deficiency of the adrenal gland), and pituitary gland diseases, the body does not produce adequate hormones necessary for red blood cell production. Lead poisoning can also cause anemia by interfering with the production of heme, the iron containing portion of the hemoglobin molecule. Anemia Caused by Destruction of Red Blood Cells (Hemolytic Anemia) Hemolytic anemia occurs when red blood cells are being destroyed prematurely and the bone marrow can't keep up with the body's demand for new cells. This can happen for a variety of reasons. It may occur spontaneously or can be triggered by stressors

such as infections, drugs, snake or spider venom, or certain foods. Toxins from advanced liver or kidney disease can also shorten the life of red blood cells. In a condition known as autoimmune hemolytic anemia, the immune system mistakes red blood cells for foreign invaders and begins destroying them. This can occur in the newborn period when a pregnant woman's immune system targets her baby's red blood cells, if those cells are different than the mothers such as in Rh or ABO incompatibility. The baby develops a specific type of anemia called hemolytic disease of the newborn. Other children inherit defects in the red blood cells, which may involve the RBC's structure or the production of hemoglobin. Common forms of inherited hemolytic anemia include sickle cell anemia, thalassemia, and glucose-6phosphate dehydrogenase deficiency. Vascular grafts, prosthetic heart valves, tumors, severe burns, chemical exposure, severe hypertension (high blood pressure), and clotting disorders can all damage normal red blood cells and mark them for early destruction. In rare cases, an enlarged spleen can trap red blood cells and destroy them before their circulating time is up. Anemia Caused by Blood Loss Blood loss can also cause anemia, whether it's because of excessive bleeding due to injury, surgery, intestinal bleeding, heavy menstrual periods or a problem with the blood's clotting mechanism. Any of these factors will also increase the body's need for iron because iron is needed to make new red blood cells.

What does it look like? The most common sign of anemia is pallor of the skin, along with decreased pinkness of the lips, the lining of the eyelids, and the nail beds. Other common signs of anemia may include irritability, fatigue, dizziness, lightheadedness, and a rapid heartbeat. Depending on the condition causing the anemia, other signs and symptoms may occur, such as jaundice (yellow-tinged skin), dark tea-colored urine, easy bruising or bleeding, and enlargement of the spleen or liver. In infants and preschool children, iron-deficiency anemia can result in developmental delays and behavioral disturbances such as problems with social interaction and attention to tasks.

How does one test for it?

Anemia is usually diagnosed by doing a complete blood count(CBC) that may indicate that there are fewer red blood cells than normal. Other diagnostic tests may include an examination of the blood smear, blood iron level, hemoglobin electrophoresis to diagnose sickle cell anemia or thalassemia, and bone marrow aspiration to determine whether cell production is happening normally in the bone marrow and to exclude leukemia.

How is it treated? Treatment for anemia depends on the cause of the condition. If your child has irondeficiency anemia, the doctor may prescribe iron medication. The doctor also may recommend adding certain iron-rich foods to your child's diet and restricting milk intake. Folic acid and vitamin B12 supplements may be prescribed if the anemia is due to a deficiency of these nutrients. Follow-up with the family doctor is important to ensure that the anemia is being treated adequately. Treatment for more severe or chronic forms of anemia depends on the cause. For some patients blood transfusions may be necessary. Some may need treatment with medications or removal of the spleen to prevent blood cells from being removed from the circulation or destroyed too rapidly. Others might need medications to fight infection or stimulate the bone marrow to make more blood cells. Bone marrow transplantation may be considered in some cases of severe sickle cell anemia, thalassemia, and aplastic anemia. This procedure involves taking bone marrow cells from a donor and injecting them into the child's vein; the donated cells then travel through the bloodstream to the child's bone marrow, where they begin producing new blood cells.