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Pediatric Acute Anemia Treatment & Management

  • Author: Susumu Inoue, MD; Chief Editor: Robert J Arceci, MD, PhD  more...
Updated: Oct 09, 2015

Approach Considerations

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.[10] and its amendments[11] 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.[12]

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.[13] 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.[14] 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
  • Hepatosplenomegaly
  • 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.

Contributor Information and Disclosures

Susumu Inoue, MD Professor of Pediatrics and Human Development, Michigan State University College of Human Medicine; Clinical Professor of Pediatrics, Wayne State University School of Medicine; Director of Pediatric Hematology/Oncology, Associate Director of Pediatric Education, Department of Pediatrics, Hurley Medical Center

Susumu Inoue, MD is a member of the following medical societies: American Academy of Pediatrics, American Society of Clinical Oncology, American Society of Hematology, American Society of Pediatric Hematology/Oncology, Society for Pediatric Research

Disclosure: Nothing to disclose.


Margaret T Lee, MD Associate Professor, Department of Pediatrics, Division of Pediatric Hematology/Oncology/SCT, Children's Hospital of New York, Columbia University College of Physicians and Surgeons

Margaret T Lee, MD is a member of the following medical societies: American Society of Hematology

Disclosure: Nothing to disclose.

Chief Editor

Robert J Arceci, MD, PhD Director, Children’s Center for Cancer and Blood Disorders, Department of Hematology/Oncology, Co-Director of the Ron Matricaria Institute of Molecular Medicine, Phoenix Children’s Hospital; Editor-in-Chief, Pediatric Blood and Cancer; Professor, Department of Child Health, University of Arizona College of Medicine

Robert J Arceci, MD, PhD is a member of the following medical societies: American Association for the Advancement of Science, American Association for Cancer Research, American Pediatric Society, American Society of Hematology, American Society of Pediatric Hematology/Oncology

Disclosure: Nothing to disclose.


Steven K Bergstrom, MD Department of Pediatrics, Division of Hematology-Oncology, Kaiser Permanente Medical Center of Oakland

Steven K Bergstrom, MD is a member of the following medical societies: Alpha Omega Alpha, American Society of Clinical Oncology, American Society of Hematology, American Society of Pediatric Hematology/Oncology, Children's Oncology Group, and International Society for Experimental Hematology

Disclosure: Nothing to disclose.

J Martin Johnston, MD Associate Professor of Pediatrics, Mercer University School of Medicine; Director of Pediatric Hematology/Oncology, Backus Children's Hospital; Consulting Oncologist/Hematologist, St Damien's Pediatric Hospital

J Martin Johnston, MD is a member of the following medical societies: American Academy of Pediatrics and American Society of Pediatric Hematology/Oncology

Disclosure: Nothing to disclose.

John T Truman, MD, MPH Professor Emeritus of Clinical Pediatrics, Columbia University College of Physicians and Surgeons

John T Truman, MD, MPH is a member of the following medical societies: American Academy of Pediatrics, American Association for the History of Medicine, American Society of Pediatric Nephrology, and New York Academy of Medicine

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

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Algorithm for diagnostic approach and workup of anemia in children. Hb=hemoglobin; Hct=hematocrit; HS=hereditary spherocytosis; HE=hereditary elliptocytosis; G-6-PD=glucose-6-phosphate dehydrogenase; PK=pyruvate kinase; HUS=hemolytic uremic syndrome; TTP=thrombotic thrombocytopenic purpura; DIC=disseminated intravascular coagulation; DBA=Diamond-Blackfan anemia.
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