Pediatric Acute Anemia Treatment & Management
- Author: Susumu Inoue, MD; Chief Editor: Robert J Arceci, MD, PhD more...
Acute anemia usually warrants immediate medical attention. Treatment depends on the severity and underlying cause of the anemia.
Initial treatment begins with careful assessment of the signs and symptoms of the anemia that indicate therapy. Guidelines for the treatment of patients with critical illness apply to children with severe anemia who are in acute distress and unstable. Supportive measures, such as supplemental oxygen for decreased oxygen-carrying capacity, fluid resuscitation for hypovolemia, and bed rest or activity restriction for fatigue, may be required. Inpatient care is indicated in patients with CHF who are severely anemic and in those with unstable vital signs (eg, hypotension, active bleeding). Most of these patients require admission to the intensive care unit (ICU). Patients who may be stable but who have severe anemia may also be admitted for diagnostic workup.
Except in cases of uncontrolled hemorrhage, surgery is very rarely indicated in acute anemia. Splenectomy is occasionally considered in persons with autoimmune hemolytic anemia that is refractory to medical treatment.
Activity restriction or bed rest may be indicated in symptomatic individuals with severe anemia.
Transfusion with packed RBCs (PRBC) is the universal treatment for most individuals with severe acute anemia. The British Committee for Standards in Hematology Transfusion Task Force has established guidelines for transfusions in neonates and older children. and its amendments The indication to transfuse should not be based solely on the hemoglobin or hematocrit levels; more importantly, one must consider the clinical effects or the signs and symptoms of the individual with anemia.
A recently published article summarizing 19 randomized controlled studies in adults concluded that transfusions at a low Hb threshold level (7-9) compared with transfusions at a high Hb threshold level (9-13.3) showed a significantly reduced risk of 30-day all-cause mortality. In another adult study with acute GI hemorrhage, restricted blood transfusion (Hb threshold of 7) versus a liberal transfusion strategy resulted in significantly reduced morbidity and mortality in the former group of patients. While these are adult studies, the same principle may apply to children. Thus, one may consider these clear-cut study results when considering blood transfusion for a patient.
If transfusion is indicated, the packed RBC (PRBC) dose is 10-15 mL/kg over 3-4 hours. The rate of transfusion can be modified according to the clinical situation. Transfusion can be administered faster in individuals with acute blood loss or slower or in smaller aliquots in persons with CHF. Be aware of the risks of of inciting heart failure by rapid transfusion in patients with severe chronic anemia and patients in a compromised cardiovascular state.
In individuals with autoimmune hemolytic anemia, blood must be given with extreme caution, using the blood unit that is least reactive on crossmatch.
Except for patients who have acute anemia secondary to blood loss from obvious trauma or injury, a hematology consultation is ideal for most patients with acute anemia to determine the underlying RBC disorder and provide the appropriate therapy.
In particular, the following features in an individual with acute anemia indicate the need for a hematology consultation:
Concomitant abnormality in WBC and/or platelet counts (eg, neutropenia, thrombocytopenia, presence of immature WBCs)
Positive Coombs test result
History of underlying hematologic disorder
Excessive blood loss relative to the degree of injury in individuals who may have an underlying bleeding disorder
Consider a gastroenterology consult for GI blood loss, particularly in suspected esophageal varices, inflammatory bowel disease, and other conditions.
Consider a surgical consult for possible trauma to spleen, liver, and/or kidneys.
Dowling MM, Quinn CT, Plumb P, et al. Acute silent cerebral ischemia and infarction during acute anemia in children with and without sickle cell disease. Blood. 2012 Nov 8. 120(19):3891-7. [Medline]. [Full Text].
Parkin PC, DeGroot J, Maguire JL, Birken CS, Zlotkin S. Severe iron-deficiency anaemia and feeding practices in young children. Public Health Nutr. 2015 Jun 1. 1-7. [Medline].
Niemeyer CM, Baumann I. Myelodysplastic syndrome in children and adolescents. Semin Hematol. 2008 Jan. 45(1):60-70. [Medline].
Ballin A, Hussein A, Vaknine H, Senecky Y, Avni Y, Schreiber L. Anemia associated with acute infection in children: an animal model. J Pediatr Hematol Oncol. 2013 Jan. 35(1):14-7. [Medline].
Sherry B, Mei Z, Yip R. Continuation of the decline in prevalence of anemia in low-income infants and children in five states. Pediatrics. 2001 Apr. 107(4):677-82. [Medline].
Cusick SE, Mei Z, Freedman DS, et al. Unexplained decline in the prevalence of anemia among US children and women between 1988-1994 and 1999-2002. Am J Clin Nutr. 2008 Dec. 88 (6):1611-7. [Medline].
Mujica-Coopman MF, Brito A, Lopez de Romana D, Ríos-Castillo I, Coris H, Olivares M. Prevalence of Anemia in Latin America and the Caribbean. Food Nutr Bull. 2015 Jun. 36 Suppl 2:S119-28. [Medline].
Cusick SE, Mei Z, Cogswell ME. Continuing anemia prevention strategies are needed throughout early childhood in low-income preschool children. J Pediatr. 2007 Apr. 150(4):422-8, 428.e1-2. [Medline].
Hare GM, Tsui AK, McLaren AT, Ragoonanan TE, Yu J, Mazer CD. Anemia and cerebral outcomes: many questions, fewer answers. Anesth Analg. 2008 Oct. 107(4):1356-70. [Medline].
Gibson BE, Todd A, Roberts I, Pamphilon D, Rodeck C, Bolton-Maggs P. Transfusion guidelines for neonates and older children. Br J Haematol. 2004 Feb. 124(4):433-53. [Medline].
Amendments and corrections to the 'Transfusion Guidelines for neonates and older children' (BCSH, 2004a); and to the 'Guidelines for the use of fresh frozen plasma, cryoprecipitate and cryosupernatant' (BCSH, 2004b). Br J Haematol. 2007 Feb. 136(3):514-6. [Medline].
Bateman ST, Lacroix J, Boven K, et al. Anemia, blood loss, and blood transfusions in North American children in the intensive care unit. Am J Respir Crit Care Med. 2008 Jul 1. 178(1):26-33. [Medline].
Carson JL, Carless PA, Hebert PC. Outcomes using lower vs higher hemoglobin thresholds for red blood cell transfusion. JAMA. 2013 Jan 2. 309(1):83-4. [Medline].
Villanueva C, Colomo A, Bosch A, Concepcion M, Hernandez-Gea V, Aracil C. Transfusion strategies for acute upper gastrointestinal bleeding. N Engl J Med. 2013 Jan 3. 368(1):11-21. [Medline].
Ohlsson A, Aher SM. Early erythropoietin for preventing red blood cell transfusion in preterm and/or low birth weight infants. Cochrane Database Syst Rev. 2006 Jul 19. CD004863. [Medline].