Pediatric Chronic Anemia Treatment & Management

Chronic anemia merits prompt, if not immediate, attention.

Common sense should prevail in recognizing that, although anemia may be quite profound, the patient is usually well. In this circumstance, it is prudent not to follow the hemoglobin level too closely and thereby create unnecessary apprehension in the family. When physiologic adaptive mechanisms are in place, most children do well, and what is abnormal in others becomes normal in these children. At this point, the art of medicine takes precedence over the science of medicine.

Patients with chronic anemias rarely need inpatient care, even during the diagnostic process. Deal with complications on an ad hoc basis.

Go to Anemia and Anemia of Prematurity for complete information on these topics.

Exclusion of impending high-output cardiac failure is the most important issue. High-output failure is the only reason that blood transfusion is necessary.

RBC transfusions must be performed cautiously; rapid expansion of intravascular volume may cause congestive heart failure in a well-compensated patient. Two or more small aliquots of RBCs may need to be administered, with a few hours of reequilibration between transfusions.

Elective surgery can usually be performed without preoperative transfusion as long as blood is available.

For patients who require long-term transfusional support, identification of a limited number of dedicated blood donors is desirable. Donors are selected on the basis of detailed antigenic crossmatching with the patient in hopes of avoiding development of immune-mediated hemolysis. Obtain serum ferritin values every 6-10 units of transfusion. If ferritin exceeds 1000 µg/L, start deferasirox or deferoxamine therapy.

Splenectomy is usually indicated in patients with HS, unless the degree of hemolysis is very minor (reticulocyte count of 5% or less). Delay splenectomy until patients are aged 8-9 years, by which time immunity to encapsulated bacteria is well established. Typically, this is also before hemolysis sufficient to result in bilirubin gallstones has occurred. However, in some patients, repetitive splenic sequestration occurs, necessitating earlier splenectomy.

Dietary iron deficiency anemia can be prevented by starting supplemental iron when infants are weaned off breast milk or regular formula at age 8-12 months; 1-2 mg/kg/d of elemental iron is usually sufficient to prevent iron deficiency anemia. (See current American Academy of Pediatrics guidelines.^[5] ) This should be continued until the child more or less eats regular table foods as the main source of calories. Treatment of iron deficiency anemia needs a higher dose of iron, usually 6 mg/kg/d of elemental iron, for at least 3 months.

Infants of vegan mothers who exclusively breast feed may develop megaloblastic anemia and neurologic signs due to B12 deficiency. These infants should be given B12 supplementation.

Many chronic anemias can be diagnosed and managed by generalists. However, when subtle distinctions in morphology or interpretation of laboratory data relative to hemolytic anemia are important, a pediatric hematologist is usually needed. Certainly, when bone marrow aspiration and biopsy are contemplated, the experience of a pediatric hematologist is essential.

Unless readily explained by an increased reticulocyte count or another physiologic condition, macrocytosis usually warrants consultation with a hematologist.

A number of children with hypochromic anemia outside the dietary iron deficiency age are ultimately found to have chronic GI bleeding. It is essential in this situation to work closely with a pediatric gastroenterologist.

Monitor growth and development, nutritional status, degree of splenomegaly, formation of gallstones, onset of puberty, endocrine status, and any potential complications related to underlying disorders.