Anemia in childhood (小儿贫血)Dept. of pediatrics李圭华第十五章Teaching purposeTo understand features of hematopoiesis and blood in children.To comprehend clinical features, diagnosis and therapy of anemia.To understand the definition, grade division and classification of anemia in children.To master etiology, pathogenosis, diagnosis, therapy and prevention of nutritional iron deficiency anemia and nutritional megaloblastic anemia.Features of hematopoiesis in children Hematopoiesis in fetal period（胎儿期造血）Developmental hematopoiesis occurs in three anatomic stagesmesoblastic（ 中胚层）, hepatic（肝）, and myeloid（ 骨髓）. Fig.Hematopoiesis in fetal periodyolk sac liverspleenBone marrowlymph nodeFeatures of hematopoiesis in childrenHematopoiesis after birth Hematopoesis in bone marrow Extramedullary hemopoiesis （骨髓外造血）Hematopoesis in bone marrowYellow bone marrow（黄骨髓） can come back to red bone marrow（红骨髓） when hematopoetic need increases . Yellow bone marrow is deficiency in children, especially in infant and toddler period. When hematopoietic demand increases, liver, spleen and lymph nodes come back to the Status to produce blood cells, hepatomegaly（ 肝肿大） and splenomegaly（脾肿大） appears, and maybe there are immature erythrocytes and granulocytes in circulating blood. Extramedullary hemopoiesis is the specific phenomena only appearing in infant and toddler. Extramedullary hemopoiesis（髓外造血 ）Features of blood in childrenErythrocyte and hemoglobin 76543210 12h 10d 3m6m1yRBC( 1012/L)YearsHemoglobin At birth1 yr2 yrLeucocyte countWBC109/L9h10d1y8y123%204060800 5d5y Differential count of WBC (白细胞分类计 数)Lymphocyte 淋巴细胞Granulocyte 粒细胞Morphological classification of anemiaTypesMCV（ fl）MCH (pg)MCHC (%)Normal809428323238macrocytic （大细胞性）94323238normocytic （正细胞性）809428323238microcytic （小细胞性）80283238hypochromic microcytic （ 小细胞低色素性）802832Blood routineHypochromic microcytic Macrocytic Normocytic （HbRBC） （HbRBC) （Hb =RBC）IDA （缺铁性贫血） megaloblastic acute bleedingThalassemia Vit B12 hemolytic anemiasideroblastic anemia folic acid aplastic anemiaChronic infection most of secondary anemiaAgeHb concentration (g/L) 28 d 14514 mon 9046 mon 1006 mon6 y 110614 y 120nThe criterion of anemia. Nutritional iron deficiency anemia (IDA) 营养性缺铁性贫血Zhou, male, 10 months old. Paleness in face and lips for 4 mons. His facial expression became more and more pale since 6 months of age. Without fever and bleeding. He was premature birth at 33 weeks of gestational age and fed with Mothers milk only. Case 1PE: Pallor. no jaundice and hemorrhagic spots in skin and sclera; Bilateral submandibular lymph nodes are 0.80.8cm. Breath sounds in lungs are distinct; there are no rhonchi and moist rale. HR 100/min.There is II/VI systolic murmur in precordial region. The liver and spleen enlarge to 4 cm and 3 cm below lower costa margin respectively.Case 1Blood routine testWBC4.0109/LLym2.4(60%)109/LGran1.6(40%)109/L RBC2.181012/LHb47g/LMCV70.4flMCH22.4pgMCHC176g/LRDW23.7%RC0.026 Plt194109/Lquestions Do an anemia exist? Which kind of anemia does it belong? answerHypochromic microcytic anemia(小细细胞低色素性贫贫血） questions What is the cause of anemia in the case above?answerThe cause of anemia in the case above is deficiency of iron because he is premature and is fed with Mothers milk only.etiologyThe etiological factors of nutritional iron deficiency anemia:v Stored iron deficiency at birth.v Inadequate diet. v Rapidly growth.v Malabsorption.v Excessive loss of iron.questions Next examinations?Smear of Blood normalThe patient Bone marrow Bone marrow examinationThe bone marrow is hypercellular, with erythroid hyperplasia（过度增生）. The normoblasts(幼红细胞) may have scanty, fragmented cytoplasm with poor hemoglobinization. Leukocytes and megakaryocytes are normal. Hemosidenin cannot be demonstrated in marrow specimens by Prussian blue staining.questions How do iron deficiency cause anemia?questionsPathogenesis of nutritional iron deficiency anemia .铁缺乏贮存铁 血清铁 血红蛋白铁 酶铁红细胞内合成 含铁酶 细胞分裂不受影响 铁依赖酶 ，RBC正常或 某些细胞功能紊乱，如 生物氧化、细胞呼吸 小细胞低色素性贫血 神经递质分解与合成等血液系统症状 非血液系统症状一般贫血表现 行为发育异常髓外造血表现 皮肤粘膜损害心血管系统症状 细胞免疫功能 缺铁性贫血发病机理Iron studyIron studyIDIDEIDA *serum ferritin(SF) Iron store FEP(红细 胞游离原卟啉）N sideroblastsN Serum ironNN orTherapy good nursing removal of etiological factors treatment with iron preparation Oral administration of simple ferrous salts ferrous sulfateferrous gluconateferrors fumaratepolysaccharide iron Dosage: 4-6mg/kg elemental iron per day Oral iron preparation Administration the iron prior to meals Administration ascorbic acid with iron preparation. Therapeutic course: withdrawal of iron