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FOCUS ON ANEMIA by ANNE G. NEPO, M.D. Mrs. Smith was shocked. The pediatrician’s office had just called and asked her to bring her son back to be rechecked because his blood test showed he was slightly anemic. “I don’t understand,” Mrs. Smith said. “He doesn’t seem sick and has plenty of energy. I thought you could tell when someone was anemic because he or she would be pale and weak.” Mrs. Jones brought her teenage daughter, Mary, to the emergency room after the young girl fainted in gym. Mary was pale and had a rapid heart rate. When the physician asked how she had been feeling lately, Mary said she felt faint when standing up, became short of breath if she walked half a block and could feel her heart pounding when climbing stairs. A blood count showed that her hemoglobin was only 6, and Mary confided that she had noticed blood in her bowel movements about two weeks earlier. She was admitted to the hospital. Although the cases described above vary in terms of the individual’s symptoms and severity, in both situations the patient is diagnosed as anemic. Anemia is defined as a condition in which the blood is deficient in hemoglobin. Blood is made up of red cells, white cells, platelets and plasma. Red blood cells contain hemoglobin, a protein that carries oxygen. If a person does not have enough red cells or if his red cells do not contain enough normal hemoglobin, he is anemic. The normal hemoglobin level (Hgb) and size of the red cells change with a child’s age. By age one, a child’s Hgb and red cell size are at their lowest normal values (a one-year-old can have Hgb of 11 and still be normal); then both gradually increase. After passing through puberty, men have a higher Hgb than women. A man is considered anemic if his Hgb is less than 13.5; a woman should have an Hgb above 12. Mild anemia alone does not usually make a child look or act ill and is detected only because the child has a Complete Blood Count (CBC) performed. Moderate anemia can be suspected if a child looks somewhat pale or tires easily. If a child becomes anemic slowly, he may just appear pale but not look or act ill. Severe anemia that occurs over a short period of time can cause a child to be extremely ill, very pale, overly tired and suffer from fainting, rapid heart rate and rapid breathing. Extremely severe anemia can cause unconsciousness and heart failure. Anemia can have many different causes. Acute infection with a fever can cause temporary, mild anemia. Blood loss can cause anemia as well. Some anemic conditions are hereditary; some of these, such as sickle cell anemia, can be diagnosed at birth or earlier. Many hereditary anemias are chronic, meaning the child is anemic all the time. Still other inherited conditions, such as hereditary spherocytosis or G-6-PD deficiency, may only cause anemia when the affected person takes certain medications or gets certain viral illnesses. Other anemias, particularly from iron deficiency, are usually caused by diet and children get better with simple treatment. This article will focus on anemia from iron deficiency since it is still a relatively common problem in children and can often be successfully diagnosed and treated without complicated tests. Iron deficiency can cause anemia at any age, but is more common in infants, toddlers and adolescent girls. Babies are born with most of their iron stores in their red blood cells. Anything that causes a baby to be born with a smaller amount of blood can lead to iron deficiency when he starts to grow and needs to make more blood. This situation can occur because of prematurity, the birth of twins or more, caesarean section and abruptio placentae (bleeding from the placenta before the baby is delivered). Most infant formulas and baby cereals are now fortified with iron and these products help prevent iron deficiency if the baby stays on them at least until a year of age. Breast milk does not contain much iron, but the iron it has is almost completely absorbed by the baby. Many pediatricians recommend a small iron supplement for breast-fed babies; others check the baby’s hemoglobin level at intervals. Cow’s milk does not contain iron, can interfere with the absorption of iron, and can cause tiny amounts of bleeding from the bowel in some babies. Babies who are changed to cow’s milk at an early age (less than a year of age), especially babies who love cow’s milk and refuse to take any other foods, can become severely iron deficient and very anemic. Since this anemia happens slowly and insidiously—the baby may appear active and normal—parents may not realize the extent of their baby’s anemia. Often these toddlers may be somewhat irritable or crabby but will calm down when they are given a bottle of milk. Occasionally these toddlers have hemoglobin levels that creep down as low as Hgb 2 or 3. This is a critical level and such children need to be admitted to the hospital. Sometimes they can still be treated with iron alone, but require close monitoring because they are at risk for heart failure and neurologic problems when their hemoglobins fall. If a child is not severely anemic but the pediatrician suspects iron deficiency, he or she may give the baby a trial of iron therapy and re-check the Hgb level. Specific blood tests for iron are not necessary if there is a good response to treatment. If the child’s Hgb does not improve, additional tests should be done. Teenagers (often girls) who are iron deficient sometimes have a craving to eat crushed ice or other crunchy items. It is interesting to note that this craving usually goes away when their iron stores have been replenished. Young women who have started to menstruate have a source of blood loss, and if they become vegetarians or diet aggressively they may become iron deficient. In addition to eating a balanced diet, young women may take a standard adult multivitamin with iron each day as a simple method to manage iron loss. The body relinquishes almost all of its iron stores before the child becomes anemic. Therefore, when a child is treated for iron deficiency and gets a good response, the treatment needs to be continued for three to six months after the Hgb has returned to normal to fully replenish the body’s supply of iron. If a child’s CBC shows severe anemia, your physician will do more tests to look for the cause right away. If your child was doing well before, then suddenly becomes ill and shows signs and symptoms of severe anemia, he or she will need to be hospitalized. As noted above, mild anemia is not an emergency and a trial treatment of iron is often a reasonable approach. Your physician may refer your child to a pediatric hematologist if the condition does not improve with iron therapy, if there are other unusual findings on the CBC or if there is not an obvious reason for the child’s anemia. For a referral to a Saint Barnabas Medical Center pediatrician or pediatric subspecialist, please call 1-888-SBMC-DOC. [ top ] |
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