Dr Rasnayaka M MudiyanseMBBS.DCH.MD.MRCP

Consultant pediatricianTeaching Hospital Peradeniya

Paediatric Hematology

Scope of Pediatric Hematology

• Introduction (1)• Red Cells– Anemias of Inadequate Production (2)– Hemolytic anemia (3)• Thalasaemia (4)

• Platelets (5) and Coagulation (5)• White cells and other topics (6)• Pediatric oncology (7)

Objectives of the Introductory Lecture

• Understand the Hematopoietic System• Normal Investigation Values for Children• Investigations and interpretation • Basic principals of evaluation of anemia's

and disorders of blood

Phases of Development of the Haemophoitic System

• Mesoblastic – (Yolk sack) – From 10-14 d of gestation up to 10-12 wk IU

• Hepatic– From 6-8 wk of gestation up to 20-24 wk IU– 80% of cells contribute for erythroid series – More macrophage than granulocytes ( same as

marrow)• Myeloid – Extra uterine– 40% of the cells contribute for erythroid series

The Hematopoietic System

Pluripotent Stem CellsCapable of self renewal and of clonal maturation in to all blood cell lineage

Granulocytopoiesis

G-CSF, M-CSF, GM-CSF, SCF

Thrombopoiesis

Megakariocyte progenitors and megakaryocytes Thrombopoitin TPO

Erythropoiesis

Erythropoitin (EPO)

Hematologic Values During infancy and Childhood

Hematologic Values During infancy and Childhood

Age HbGr/dl

HCT Retic % MCV WBC/mm3

N % L %

Cord 16.8 55 5 110 18 000 61 31

2 wk 16.5 50 1 12 000 40 63

3 mo 12( 9.5 – 14.5)

36 1 12 000 30 48

½ – 6 yr 12(10.5 – 14)

37 1 70-74 10 000 45 48

7-12 yr 13 38 1 76-80 8 000 55 38

Adult female

14 42 1.6 80 7 500 55(35- 70)

35

Adult male

16 47 80

5 liters of blood in an adult (in a Child 80ml/kg)

5 million red blood cellsin 1ml of blood

250 million Hemoglobin molecules in one red blood cell

5 lt of blood in an adults 80ml/kg in a child

5 million red cells in 1 ml of blood

250 million Hemoglobin molecules in one red cell

Organization of Globin Genes

•Gower 1 ζ2 ε2

•Gower 2 α2 ε2

•Gower 3 ζ2 γ2

Embryonic

•Hemoglobin F α2 γ2

Fetal

•Hemoglobin A1 α2 β2

•Hemoglobin A2 α2δ2

Adult

ψβ ε GγAγ δβ

ζ ψα α1α2

5 ‘ Chromosome 11 - beta like chains 3’

5 ‘ Chromosome 16 - alpha like chains 3’

Definition of Anaemia

Hemoglobin level below the normal range for the age and sex

• Neonate < 14 gr/dl• 1-12 months < 10 gr/dl• 1-12 years < 11gr/dl

• Hemoglobin at birth – cord blood = 16-18 gr/dl• 24-48 hour of age – Increase due to hemoconcentration• 3 months of age - Drop up to 9.5 – 11 gr/dl

Causes of Anemia

• Impaired Production of RBC– Red Cell Aplasia– Ineffective erythropoiesis

• Increased Destruction of RBC– Intra corpuscular– Extra corpuscular

• Blood Loss ( overt or apparent) – Internal– External

Impaired Production of RBC

• Red cell aplasia – Parvovirus B 19

infection, – Diamond-Blackfan, – Transient

erythroblastopenia of childhood,

– Fanconi anaemia, – Aplastic anaema, – Leukemia

• Ineffective erythropoiesis– Iron/ folic acid

deficiencies, – Chronic

Inflammation – CRF – Myalodisplasia – Lead poisoning

Increased Destruction of RBC

• Intra corpuscular– Membrane– Enzyme– Hemoglobin

• Extra corpuscular – Autoimmune– Fragmentation– Hyper spleenism– Plasma factors

Causes of Blood Loss

• Intra uterine – Feto-maternal bleeding– Feto-fetal bleeding

• Chronic gastrointestinal blood loss – Meckel’s diverticulum, – GOR– Peptic ulcer disease – Hook worm manifestation

• Inherited bleeding disorders - von Wilebrand’s disease• Chronic hematuria

1. History and Examination2. First Line Investigations3. Second Line Investigations

Clinical approach to a child with anemia

Clinical approach to a child with anemia – History and Examination

• Family History• Evidence bleeding ( overt and hook worm, urine) • Evidence of hemolysis ( Jaundice, pallor) • Involvement of other cell line ( petechea,

infections)• Dysmorphic features

Clinical approach to a child with anemia – Investigations

• First line investigations – FBC– Retic count– SBR– Blood picture

• Iron/vitamin status• Bone Marrow Biopsy• HPLC/Hb Electro..• RBC enzymes• Immune studies • Genetic studies• Radio isotopes

SBR in anemia with high or normal reticulocyte count

• SBR normal – Blood loss– Treated iron deficiency

• SBR High Hemolysis – Look at the blood picture• MCV and MCH related • Specific

Blood Picture in Anemia

• Spherocytosis – Hereditary , Autoimmune Hemolysis, Wilsons

• Sickle Cells– Sickle or beta sickle

• Target cells– Hemoglobin SC disease

• Micro angiopathic blood picture – HUS, thrombotic thrombocytopenia

• Bite Cells – G6PD deficiency

Blood Picture or FBC Report in patients with normal or high reticulocyte Counts

• Microcytic ( MCV less than 80) – Iron deficiency– Thalassemia – α, β,& E– Lead poisoning – Sideroblastic anemia

• Macrocytic ( MCV more than 100) – Megaloblastic + Folate/B12 deficiency – No megaloblast – Diamond -Blackfan, congenital dyserythropoietic anemia

• Normocytic ( MCV 80-100) – Chronic disease– Renal disease– Transient erythroblastopenia of child hood ( TEC)– Anemia associated with hypothyroidism

HPLC – High Performance Liquid Chromatography ( Hb electrophoresis can be used )

1. Beta Thalassaemia major – Only Hb F present2. Alpha Thalassaemia – HPLC normal3. Beta Thalassaemia trait – Increased HbA24. Sickle disease – Hbs – No HbA present

Anemia of Inadequate Production

• Congenital Hypo plastic Anemia ( Diamond -Blackfan)

• Pearson Marrow – Pancrease syndrome• Acquired Pure Red Blood Cell Anemia• Anemia of chronic Disorders and renal disease• Congenital Dyserythropoietic Anemias• Physiologic anemia of infancy• Megaloblastic anemia• Iron deficiency anemia

3 year old boy presented with fatigue and shortness of breath for two weeks duration. He is pale and jaundiced. Results of his initial investigations are as follows; Hb – 6.5 gr/dl, Reticulocute count 6%.

1. What is your DD (15)2. Tabulate other clinical features that you would like to

elicit in order to arrive at a diagnosis and their relevance in a table (45)

3. Tabulate investigations and their relevance (40)

DD

• Hemolytic anemia– Membrane defects – hereditary Spherocytosis – Enzyme defect - G6 PD deficiency– Extracellular causes – Immune hemolytic anaemia – Thalassaemia – Beta thalasaemia intermedia or E-beta thalasaemia

• Blood loss • Treated for iron deficiency

3 year old boy presented with fatigue and shortness of breath for two weeks duration. He is pale. Results of his initial investigations are as follows; Hb – 5.5 gr/dl, Reticulocute count 0.5 %.

1. What is your DD (15)2. Tabulate other clinical features that you would like to

elicit in order to arrive at a diagnosis and their relevance in a table (45)

3. Tabulate investigations and their relevance (40)

DD for Anaema with low retic count

• Congenital Aplastic anaemia – Fanconi – Pure red cell aplasia

• Acquired bone marrow suppression– Infections – Parvo virus– Drugs – radiation, chemotheraphy

• Bone marrow infiltration – Leukemia or other infiltrative disease

3 year old boy admitted from the OPD for evaluation. He is pale. Hb – 5.5 gr/dl

1. List 5 features elicited from the history that help to arrive at a diagnosis (30)

2. Tabulate 5 clinical examination finding that help to arrive at a diagnosis and their relevance in a table (30)

3. List 5 initial investigations and their relevance (40)

Clinical feature in history Relevance

1. Family history of inherited anaemia Consider Thalassaemia, Hereditary Spherocytosis,

2. Birth weight maturity, iron supplement Anaemia of prematurity . Iron deficiency anaemia

2. Dark urine Intra vascular Hemolysis , hematuria

2. History of bleeding rectal , vomiting, hematuria

Anaemia due to blood loss

3. Dietetic history Nutritional anaemia

4. Jaundice Hemolytic anemia

5. Bruises and echymosis Evidence of low platelets

6. Recurrent infections Involvement of white cell line

7. Taking drugs Bone marrow suppression

8. General ill health, bone pain and fever Leukemia

Clinical feature in examination Relevance

1. Dismorphic features Fanconi anemia other inherited aplastic anaemia

2. Jaundice Haemolytic anaemia

3. Hepatomegaly Hemolytic anaemia, Leukemia

4. Splenomegaly Hemolytic anaemia, Leukemia Very large spleen - Hyperspleenism

5. Patichie and echymoses Low platelets; Bone marrow suppression, leukemia

6. Bone tenderness Leukemia

7. Emaciated and Chronically ill looking Anaemia of chronic disease or CRF

8. Acute and critically ill child DIC, hemolytic disease

Investigation Relevance

1. Hb Establish base line Hb, consider need for transfusion

2. Reticulocyte count Low count – bone marrow failureHigh count – Hemolysis or treated iron deficiencyNormal count – deficiency anaemia

3. Full blood count Involvement of other cell lines - Aplastic anaemiaAbnormal cells - leukemia

4. Serum bilirubin Increase – Hemolysis

5. Blood picture Leukemia, Categorize Microcytic, Normocytic and Macrocytic , Red cell morphology

6. HPLC or Hb Electrophoresis To establish diagnosis in Thalassaemia

7. Bone marrow biopsy Aplastic anaemia, leukemia

8. G-6-PD assay

9. Osmotic fragility test