Hemoglobin below age appropriate norms (Reduction in O2 transport to tissues –> tissue hypoxia –> compensation (increased CO, increased 2,3DPG))


  1. Decreased production
  2. Increased loss
  3. Increased destruction

Differential Diagnosis

  • Nutrition (Fe, folate, B12)
  • Autoimmune hemolysis = jaundice
  • Toxins (Pb)
  • Neoplasm
  • Trauma (hemorrhage)
  • Infection (malaria, parvovirus)
  • Metabolic (decreased Epo, TSH)
  • Ischemia
  • Congenital/Degenerative
    • Hgb (thalassemias, sickle cell)
    • Structural (hereditary spherocytosis – AD, cholecystectomy at early age, jaundice…)
    • Enzymopathies (G-6-P)


  • Onset, duration, symptoms (eat, sleep, irritability, bruise/bleed, B symptoms, transfusions) – CNS, Resp, CVS, GI (blood loss), GU
  • Acutely: pallor, fatigue, irritability, lethargy, SOB, poor exercise tolerance, headache, syncope, bone pain
  • Past medical history – birth (ABO/Rh, jaundice, GA, IUGR), surgeries, chronic problems (renal)
  • Family history and nationality
  • Nutritional history
  • Medications and allergies

Physical Exam

  • Vitals
  • Growth
  • HEENT ( conjunctiva, LA)
  • CVS – CHF if severe
  • Abdominal – rectal for occult blood
  • Lymph nodes
  • Extremities (palms, nailbeds, bruise/petechiae, edema)
  • CNS


  • CBCD (Hgb, MCV, WBC, plt)
  • Blood smear
  • Reticulocyte count
  • Ferritin (acute phase reactant if low helpful, if high do Fe panel)
  • Fe panel: TIBC (high), Fe saturation index (low)
  • RBC folate
  • DAT – if positive then haemolytic disease of newborn

Microcytic: Fe, Thalassemia, Pb
Normocytic: Hemolytic anemia, ACD, hemorrhage
Macrocytic: Folate, B12


  • 6mg/kg/d elemental Fe (divided TID)
  • Will see increased reticulocytes in 1 wk, if not consider poor absorption (Celiac, IBD)
  • Hgb should increase 10-20g/week, normal in 4-6wk but continue for 3 more months
  • May cause dark teeth, constipation, dark stools

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