1-year-old girl with severe pallor and irritability. Points to remember in children who present with very low haemoglobin.
1/7. Child will be in CCF. It may be difficult to document. Do not start IV fluids unless absolutely needed. If starting, give 1/2- 2/3 maintenance.
1/7. Child will be in CCF. It may be difficult to document. Do not start IV fluids unless absolutely needed. If starting, give 1/2- 2/3 maintenance.
2/7. Many children present with cardiogenic shock. Clinically - severe pallor, absent pulses, respiratory distress. Start inotropes early. They do not tolerate fluid boluses as in other shocks.
3/7. There is no "blood-bolus". Always transfusion is given in small aliquots of 5-10 ml/kg slowly over 4-6 hours with ample frusemide. Monitor HR and RR closely. Start O2 for all shocks.
4/7. Cannulation may be difficult for these kids. Do not waste time. Try "sure shot" veins such as saphenous. An intraosseous needle is often helpful as a life-saving measure to give transfusion.
5/7. Now, regarding diagnosis. Look for splenomegaly, and other cell lines in CBC. Presence of splenomegaly - always rule out thalassemia. Take HPLC sample prior to transfusion. If no splenomegaly, rule out nutritional anemia, AIHA, PRCA if only red cell series is affected.
6/7. Nutritional anemia can present with such low Hb and CCF. In most cases, the tipping point is an infection. Make sure child is able to take oral hematinics once stabilised. If diarrhea, fever etc, wait for recovery before oral hematinics are added. Treat mother also.
7/7. High MCV anaemias are not always nutritional. If there are no features of megaloblastic (hypersegmented PMN) on the smear, then it is worthwhile to get a bone marrow study. It may turn out to be BM failure/ AIHA etc.
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