You are seeing a nine month old male for a regular checkup. He has a hematocrit of 28% on a spun specimen in your office. How would you evaluate this patient for anemia?

History

1. Birth History
1. preterm infants have less iron stores and they grow faster requiring their diets to be supplemented with iron.
2. full term infant has enough iron stores for 4 months.
3. Any significant loss of blood at birth may affect the amount of iron stores.
2. Family history
1. history of anemias
2. splenectomies
3. S-S disease
4. G6PD
5. gallstones
6. transfusions
   
3. Diet
1. formulas with iron have approximately 12 mg.of iron per liter. They sould be continued for 12 months. 
2. Breast milk is an adequate source of iron for 6 months without any supplements
3. Only about 10% of iron in whole milk is available for absorption and it may cause GI bleeding and loss of iron. 
4. as infants get older, good sources of iron are cereals, greens, and meat. Ascorbic acid enhances the absorption of dietary iron. 
4. Ethnicity
1. Mediterranean area- thalassemia
2. Sephardic Jews, Filipinos, Greeks, and Kurds- G6PD
5. Race
1. Blacks- Hb. S and C, alpha thalassemia
2. Asians- alpha thalassemia
6. Growth history- chronic diseases are often associated with anemia. Normal height and weight gain usually eliminate chronic disease as etiology of anemia
7. History of bleeding- unusual in infants and toddlers, more significant in older children and especially teenage females.
8. Pica- eating dirt, paint chips, and any unusual substances, often associated with iron deficiency
9. Drug exposure- may suppress bone marrow, induce megoblastic anemias, G6PD

1. Skin- check for petechiae, purpura, jaundice, hemangiomas
2. Enlarged liver-malignancies, extrameduallary hematopoesis, chronic diseases
3. Significant adenopathy- leukemias and lymphomas, chronic diseases, HIV
4. Heart rate and presence of murmur
5. Evidence of chronic disease
6. Extremities- radial anomalies associated with congenital anemias-Fanconi's
7. Oral cavity- glossitis associated with B12 and iron deficiency
8. Facies- thalassemia patients have frontal bossing
9. Splenomegaly- hemolytic anemias, ALL, lymphomas, extrameduallry hematopoiesis

 

 
 
 
 
 
 
 
 
 
 
 
 
 

If the physical exam, thorough history, and diet history are suggestive of iron deficiency, a therapeutic trial of iron, 6 mg./kg/day is advisable before embarking on an extensive laboratory evaluation. The hematocrit should be rechecked in one month and if there is a rise of greater than 3%, the diagnosis is iron deficiency and the patient should be treated for 2 more months with iron. Also, diet advice must be given to the parents.

If there is not a significant rise in the hematocrit, further evaluation is necessary including an electronic cell count that would include:

1. hemoglobin and hematocrit
2. platelet, white cell count, and differential
3. Blood cell smear- evaluate RBC, WBC, and platelet morphology
4. Reticulocyte count- evaluation of bone marrow activity
5. RDW- evaluate anisocytosis. 11.5-14.5 is normal. Usually increased with Fe deficiency.

1. Oski, F. Iron Defiency in Infancy and Childhood. NEJM Vol. 329 No. 3 190-193 1993.
2. Sackey K. Hemolytic Anemia: Part 1. Pediatrics in Review. 1999; 20:152-159.
3. Sackey K. Hemolytic Anemia: Part 2. Pediatrics in Review. 1999; 20:204-208.
4. Segel George et.al. Managing Anemia in a Pediatric Office Practice Part 2.  Pediatrics in Review April 2002
5. Segel George et.al. Managing Anemia in a Pediatric Office Practice Part 1  Pediatrics in Reiview. March 2002
6. Crocetti M, Hawit F, and Kato G.  Transient erythropenia of childhood: Listening for the quiet anemia. Contemporary Pediatrics April 2002
7. Shah S. and Vega R. Hereditary Spherocytosis.  Pediatrics in Review May 2004
8. Bain B. Diagnosis from the Blood Smear. NEJM 353;5 Pg 498 August 4, 2005