兒童貧血全英文

1、Anemia in childhood (小兒貧血),,To understand features of hematopoiesis and blood in children. To comprehend clinical features, diagnosis and therapy of anemia. To understand the definition, grade division

2、 and classification of anemia in children. To master etiology, pathogeny, diagnosis, therapy and prevention of nutritional iron deficiency anemia and nutritional megaloblastic anemia.,Disease of he

3、matopoietic system,,,infantile anemia（1）nutritional iron deficiency anemia(IDA)（2）nutritional megaloblastic anemiaPrimary/immunity thrombocytopenia Purpura(ITP)Leukemia,haematogenesis of children,,,hematopoiesis --pr

4、oduced blood extramedullary before birth and postnatal   mesoblast hepatic medullary 3-15w

5、 6w-6ms 3ms,,,,,,Embryo stage,,,Mesoblastic haematogenesis：3ws begin，8ws weaken, 12-15ws disappears。liver：8ws begin，6months gradually weaken ,erythroblast、granular cell and megakaryocyte.,Embryo stage,3、sple

6、en：12ws begin erythrocyte, granule ,lymphocyte4、Haematogenesis of lymphatic organ1.thoracic gland:8ws 2.lymphatic nodes:11ws,,Embryo stage,5、myelo-haematopoiesis：6mons Haematogenesis function emphasis，make

7、 various kinds of blood cells，unique hematogenic organ after birth.,Haematopoiesis postnatal,,,1、marrow：2、extramedullary：when requirement of haemopoiesis increase，liver、spleen、lymphadenectasis，hepatomegaly and sple

8、nomegaly, in circulating blood immature erythrocytes and granulocytes .,Physiological haemolysis,Normal newborns have higher hemoglobin(HB) and hematocrit levels and a shortened survival period of the fetal RBCs

9、 contributes to the development of physiologic anemia.,Physiological haemolysis,erythropoiesis abruptly ceases with onset of respiration at birth, when the arterial oxygen saturation rises toward 95%. levels of er

10、ythropoietin (EPO) are low. EPO has a decreased half-life and an increased volume of distribution in newborns. A shortened survival of the fetal RBC also contributes to the development of physiologic anemia. the sizab

11、le expansion of blood volume that accompanies rapid weight gain during the first 3 mo of life adds to the need for increased RBC production.,blood characteristics – ages,red blood cells(RBC) and HbPhysiological haemol

12、ysis and anemiawrite blood cells(WBC) and classification 4-6 crossPlatelets 150-250×109/Lblood volume 8-10%,Red blood cell (RBC),Term newborns have a red cell mass that is higher than at any

13、 other time of life.an appropriate condition for the low oxygen environment of intrauterine life.The RBC count is 5.0×1012～7.0×1012, hemoglobin concentration is about 150～220g/L at birth. The RBC and hemoglo

14、bin concentration in preterm infants are slightly lower than those in term infants.,Red blood cell (RBC),The wide range of hemoglobin concentration is accounted for by:Variation in how rapidly the umbilical cord is clam

15、ped.An infant’s position after delivery. If cord clamping is delayed and the baby is held lower than placenta, both hemoglobin and blood volume are increased by a placental transfusion.,Change of HB after birth,,,Ret

16、iculocyte,,,,Reticulocyte,Reticulocyte is 0.04-0.06 in the first 3 days.Reticulocyte decreases to 0.005-0.015 after 4-7 days.Reticulocyte rises to 0.02-0.08 in 4-6 weeks.Reticulocyte is equal to an adult’s after 5 mo

17、nths.,White blood cell(WBC),The normal number of WBC is higher in infancy and early childhood than later in life.WBC count is 15×109～ 20×109 at birth.After 6～12 hours, it rise to 21×109～ 28×109 and

18、then begins to decrease to 12×109 by 1 week.WBC count maintains about 10×109 at infant period and approach adult’s WBC count level by 8 years.,White blood cell(WBC),The change in WBC classification is the prop

19、ortion between lymphocyte and granulocyte.Lymphocyte is about 30% and granulocyte is about 65% at birth, but the later lymphocyte contrary to neutrophile granulocyte decreases.The proportion between lymphocyte and gra

20、nulocyte is equal at 4～6 days after birth..,White blood cell(WBC),Lymphocyte is about 60% and granulocyte is about 35% subsequently .They are equal at 4~6 years.After 7 years white cell classification in infants is sim

21、ilar to that in adult.,,,,,,,,4-6 Days,Granulocyte,Lymphocyte,4-6 years,Change of proportion in Lymphocyte and Granulocyte,Platelet count,Normal value for the platelet count are about 150~250×109/L and vary little

22、 with age.,Blood volume,Blood volume in infants is more than in adults.The newborn’s blood volume is 10% of his weight and about 300ml on average.A child’s is about 8%~10% of his weight.,Anemia,Defination : A

23、nemia is defined as a reduction of the red blood cell volume or hemoglobin concentration below the range of values occurring in healthy persons. Anemia is an absolute decrease in hematocrit , hemoglobin concen

24、tration, or the RBC count. Anemia is not a diagnosis, but a sign of underlying disease.,The criteria of anemia,Anemia,1.       Classification 1）  degree : mild moderate s

25、evere Very severe 2） Morphology of RBC3）Causes: lost blood , hemolytic , deficiency of forming Hb and RBC,degree,RBC (van /mm3 ) Hb (g/L)Mild 300-400 90-110Moderate 200-300

26、 60-90Severe 100-200 30-60Very severe <100 <30,Morphology,anemia with microcytosis and hypochromiaAnemia with macrocytosisAnemia with normalcytosis A

27、nemia,More anemia,MCV MCH MCHCNormal 80-94 28-32 32-38Micro-hypochromia 94 >32 32-38microcytosis <80 <28 32-38 mean corpuscul

28、ar volume(MCV), means corpuscular hemoglobin (MCH), mean corpuscular hemoglobin concentration(MCHC),Causes,1.lost blood :acute chronic2. hemolysis Intrinsic membrane hereditary spherocytosis

29、 Glycolysis pyruvate kinase hemoglobin sickle cell,unstable Hb oxidation G6PD extrinsic : immune, infection, DIC,,,Causes,3.deficiency of f

30、orming Hb and RBCdeficiency of hematopoiesis substance medullary hematopoiesis disorder (Aplastic anemia)The inhibition of haematopoiesis induced by: Inflamation Chronic nephritis Toxi

31、city Cancer cells invasion bone marrow,Symptoms of anemia,Asymptomatic: particularly if the anemia develops over a long time.General manifestation: pallor of the skin and mucous membranes, lethargy, malnutri

32、tion, growth retardation.liver, spleen and lymph nodes expansion.Digestion system: anorexia, nausea and constipation.,Symptoms of anemia,Cardiovascular and respiratory system: tachycardias, increased artery pressure, w

33、heeze and increased pulse. severe anemia may cause heart expansion and congestive cardiac failure.Nerver system: vertigo, tinnitus, irritability, and disorders of attention.,2.  Diagnosis,History –positive

34、 manifestation –laboratory tests Blood smear BM Hb ananysis Growth development nutrition nails fairs liver spleen and lymph notes  5 points: age, course, symptoms, feeding,

35、past medical history ,family history Morphology of RBC, reticulocyte count, WBC, platelet count, bone marrow cell smear, HB ,special examination,,,,3.Treatment,Elimination etiologyGeneral Medicine Intravenous b

36、loodTransplantations : BM , stem cellsOther,nutritional anemia with microcytosis and hypochromia,Definition nutritional iron deficiency anemia (IDA) Hb、 most common 、 6-24ms、 special prevention,Iron metabo

37、lism,Iron content and distribution: 2/3 of the iron is present in HB and 1/3 in tissue and transport form.,Iron metabolism,Iron absorption: The primary regulator of iron homeostasis is intestinal iron absorption. Iron

38、 absorption takes place primarily in the duodenum by the enterocytes at the tip of the intestinal villa. Iron must pass though the apical and the then the basolateral membranes of these cells to reach the circulation.,I

39、ron metabolism,Iron storage:Most body iron is contained in HB, with smaller amounts bound to ferritin(鐵蛋白) and hemosiderin（含鐵血黃素） in the reticuloendothelial system, myoglobin in muscle, circulating transferring, and iro

40、n-containing enzymes.The major iron stores are in the form of ferritin.As iron continues to accumulate in the cell, a second storage form, hemosiderin appears.,Iron metabolism,Iron characteristics:The fetus absorbs ir

41、on from the mother across the placenta.Term infants have adequate reserves for the first 4 months of life. Preterm infants have limited iron stores and because of their higher rate of growth, they outstrip their reserv

42、es by 8 weeks of age.,Iron metabolism,Iron characteristics:At birth, because of “physiological haemolysis”, much iron is released to plasma and little iron is absorbed from food,During the second stage (about 2 months

43、old), hematopoiesis is increased and more iron is absorbed from food, so iron deficiency is rare in this stage.After 4months, development increase, iron in food is deficient and iron stores exhaust, so most iron deficie

44、ncy anemia occurs in 6 months to 2 years or 3 years old child.,causes,1.inadequate iron stores: preterm infant, twin2.intake iron deficiency3.growth and development increased iron requirement4.iron absorb abnormal5.a

45、 amount of iron loss: hookworm infestation, repeated venesection, Meckel’s diverticulum, recurrent epistaxis(反復(fù)鼻出血).,pathogenesis,IRON Hb  

46、 microcytosis and hypochromia RBC,,,,,,,,Three stage of iron deficiency,Deficiency of iron progresses in stagesiron depletion(ID): tissue iron stores are deleted, under normal condition, th

47、is correlates directly with decrease in the ferritin lever, reticulocyte percentage decreases. Iron deficient erythropoiesis(IDE): loss of circulating iron. Low serum iron less than 30ug/dl, low transferring satura

48、tion and/or elevated total iron binding capacity.,Three stage of iron deficiency,iron deficiency anemia (IDA): iron deficiency following depletion of both marrow store and circulating iron.,ID,IDE,IDA,clinical manifestat

49、ion,1.  general manifestation: mild iron deficiency is Asymptomatic , pallor of the skin and mucous mebranes are most evident and lethargy, malnutrition, growth retardation.2.  liver spleen and lymph

50、 nodes enlarge3. digestion system: anorexia（食欲差）, nausea（惡心）, constipation（便秘）. diarrhea,clinical manifestation,4. cardiovascular and respiratory manifestation: tachycardia, increased artery pressure, wheeze, increase

51、d pulse. Severe anemia may cause heart expansion and congestive cardiac failure. 5. nervous system manifestation: vertigo, irritability.,clinical manifestation,Main signs may be pallor of the skin and mucous membranes.

52、Severe anemia may cause congestive cardiac failure.IDA in infancy and early childhood is associated with developmental delay and poor growth.,laboratory test,1.blood smear2.bone marrow3.iron metabolism,,Inequality of

53、 size of erythrocytes，small cell，Central olistherozone obviously,hypercellular , erythroid hyperplasia , the development of cytoplasm falls behind nucleus. leukocytes and megakaryocytes are normal.,Bone marrow iron sta

54、in：ferrugination grains in the erythocytes.,,,Normal bone marrow iron stain正常骨髓鐵染色,IDA iron stain鐵缺乏骨髓鐵染色,laboratory test,The decrease of HB concentration is more than the decrease of red cells count.Blood smear reveals

55、 the more feature of microcyte and hypochromia. MCV＜80fl, MCH＜26pg, MCHC＜0.31.Reticulocyte is normal or slightly decreases.WBC and platelets are normal..,Blood count in iron deficiency,laboratory test,Bone marrow reve

56、als increased basophilic normoblast and polychromatic normoblast.Granulocyte system and megakaryocyte system are normal.,Iron metabolisms,Serum ferritin (SF) (血清鐵蛋白)Free erythrocyte protoporphyrin(FEP)Serum iron, tot

57、al iron binding capacity Iron in bone marrow,Iron metabolisms,diagnosis,first consider --- history + clinical manifestation + blood smear Decide diagnosis---bone marrow + iron metabolismMay be see treatment with iron

58、 (The bone marrow is hypercellular, with erythroid hyperplasia, the normoblasts may have scanty, and the development of cytoplasm falls behind one of nucleus. leukocytes and megakaryocytes are normal.),treatment,1.

59、60;      nursing feeding 2.       get rid of etiology 3.       iron medicine 4.       interfusions bl

60、ood,,Oral administration of simple ferrous salts 　ferrous sulfate(硫酸亞鐵) 　ferrous gluconate（葡萄糖酸亞鐵）　ferrous fumarate　polysaccharide iron Dosage: 4-6mg/kg elemental iron per day,Oral iron preparation,,Administration t

61、he iron prior to meals /between to meals.Administration ascorbic acid with iron preparation. Therapeutic course: withdrawal of iron preparation 6-8 weeks after hemoglobin recover to normal level or when SF(Serum ferrit

62、in) and FEP(Free erythrocyte protoporphyrin) is normal.,Oral iron preparation,Parenteral iron preparation,To be administered only for gastrointestinal malabsorption or severe intolerance prevents effective oral iron ther

63、apy.,Parenteral iron preparation,A parenteral iron preparation (iron dextran) is an effective form of iron and is usually safe when given in a properly calculated dose, but the response to parenteral iron is no more rapi

64、d or complete than that obtained with proper oral administration of iron, unless malabsorption is a factor.,Blood Transfusion,With a severe anemia, immediate red blood cell transfusion may advisable, especially in cardia

65、c failure or severe infection, but volume and speed of transfusion must be controlled well. We may transfuse, severely anemia children should be given only 2-3ml/kg of packed cells at any one time. If there is

66、evidence of frank congestive failure, a modified exchange transfusion using fresh-packed RBCs should be considered.,Iron therapy,Notice : 3 points1.Injection iron in danger 2.Reaction : 12-24h(irritability ↓,appetite

67、↑)--- 36-48h(erythroid hyperplasia )---48-72h(reticulocytosis↑)---5-7ds(peaking ) 2-3ws to reticulocytes3.Times: 6-8ws,Prevention,4 points—mother milk feeding specter food with iron –preterm infant,Nutritional

68、megaloblastic anemia,Folic acid and vitamin B12 deficiency are primary causes of megaloblastic anemia.,,The clinical features include anemia， the decrease of red cell is more than that of HB， the volume of red cell is la

69、rger than normal.,Causes,1.less intake2.absorb abnormal3.drug interactions4.requirement increased,Pathogenesis,folic acid folic acid with 4 hydrate vitamin B12