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1 Chapter 17 Pediatric and Geriatric Hematology PEDIATRIC HEMATOLOGY Dramatic changes occurs in the blood and bone marrow

ow of the newborn infant during the first hours and days after birth, and there are rapid fluctuations in the quantities of hematologic elements Significant hematologic differences are seen between term and preterm infants and among newborns, infants, young children, and older children Prenatal Hematopoiesis Begins in the first weeks of embryonic development Three phases of development: a) Mesoblastic (yolk sac) b) Hepatic (liver) c) Myeloid (bone marrow) First cells produced in the developing embryo are primitive erythroblasts formed in the yolk sac By the second month of gestation, hematopoiesis ceases in the yolk sac, and the liver becomes the center for hematopoiesis, reaching its peak activity during the third and fourth gestational month During the fourth and fifth gestational months, the bone marrow emerges as a major site of blood cell production, and it becomes the primary site by birth Hematopoiesis of the New Born Active bone marrow is referred to as the red marrow Inactive fatty bone marrow is referred to as the yellow marrow In a full term infant, hepatic hematopoiesis has ceased and continues to develop in the bone marrow Postembryonic extramedullary hematopoiesis is abnormal in a full term infant In a premature infant, the center of activity of hematopoiesis are frequently seen in the liver and occasionally observed in the spleen, lymph nodes or thymus Pediatric Developmental Stages Neonatal period: first 4 weeks of life Infancy: first year of life Childhood: age 1 to puberty(8 to 12yo) Pediatric patients has higher normal values on hematologic test NRBC are usually found on peripheral blood smears of babies Gestational Age Full term: 37 to 42 weeks Premature or preterm: less than 37 weeks Postterm: 42 weeks Low birth weight (micropreemies): 24 to 26 weeks Birth Weight Classification Appropriate size for gestational age Small for gestational age (2.5 kg or less) Very low birth weight (1.5 kg or less) Extremely low birth weight (0.5 kg or less) Large for gestational age (4kg or more) Red Blood Cell Values at Birth Neonatal hematologic values are affected by the gestational age of the infant, the age in hours after delivery, the presence of illness and the level of support required The presence of fetal hemoglobin (HbF), bilirubin, and lipids in newborn can also interfere with hematology testing Red Blood Cell Count RBC count is increased during the 1st 24 hours of life, and remains steady for 2 weeks, then slowly declines, this is called polycythemia of the newborn Polycythemia of the newborn can be explained by in utero hypoxia Physiologic anemia is seen in 5 to 8 weeks of life

2 RBC reaches its lowest count at 7 weeks of age Hemoglobin reaches its lowest concentration at 9 weeks of age Erythrocyte Morphology of the Neonate Erythrocyte remains macrocytic from the first 11 weeks of gestation until day 5 of postnatal life Orthochromic normoblasts frequently are observed in the full term infant on the first day of life but disappear within postnatal days 3 to 5 NRBC may persist longer than a week in immature infants Average number of NRBCs ranges from 3 to 10 per 100 WBCs in a normal full term infant to 25 NRBCs per 100 WBCs in a premature infant The presence of NRBCs for more than 5 days suggests hemolysis, hypoxic stress or acute infection Additional erythrocytic differences (biconcave disk relative to stomatocytes): a) Neonates (43% disk, 40% stomatocytes) b) Adults (78% disk, 18% stomatocytes) c) Premature infants (40% disk, 30% stomatocytes, 27% additional poikilocytes) Reticulocyte Count 90% reticulocytes during 12 weeks of gestation 15% reticulocytes during 6 months gestation 4% to 6% reticulocytes at birth Reticulocytosis persist for 3 days after birth, then declines abruptly to 0.8% reticulocytes on postnatal day 4 to 7 At 2 months the number of reticulocytes increase slightly, followed by a slight decline from 3 months to 2 years, when adult levels of 0.5% to 1.5% are attained Reticulocyte count of premature infants is typically higher that that of term infants Significant polychromasia is indicative of postnatal Reticulocytosis Hemoglobin Full Term Infants At birth HbF constitutes 70% to 80% of the total hemoglobin HbF declines from (90% - 95%) at 30 weeks to 7% at 12 weeks after birth HbF stabilizes at 3.2 + 2.1% at 16 to 20 weeks after birth The switch from HbF to HbA is genetically controlled and determined by gestational age Capillary samples from new born have higher hemoglobin concentration than venous samples, which can be attributed to circulatory factors The average Hb for a full term infant at birth is 16.5 to 12.5 g/dl Less than 14 g/dl are considered abnormal for full term infants Average Hb value for a preterm infant who is small for gestational age is 17.1 g/dl Hb values less than 13.7 g/dl is considered abnormal for preterm infants Physiologic Anemia for Neonate Hb concentration of term infants decreases during the first 5 to 8 weeks of life, a condition known as physiologic anemia od infancy Infants born prematurely also experience a decrease in Hb concentration, which is termed physiologic anemia of prematurity Contributing to the physiologic anemia is the shortened life span of the fetal RBC Chromium labeled newborn RBCs estimate a survival time of 60 to 70 days Life span of RBCs in premature infants is about 35 to 50 days The more immature the infant, the greater the degree of reduction Hemodilution related to the increased blood volume that accompanies the

3 rapid weight gain can be seen in the first few months of life is not thought to paly a key role in anemia Hb levels of premature infants are typically 1g/dl or more bellow the values of full term infants Very low weight infants show a progressive decline in Hb, RBC count, MCV, MCH, MCHC, and have a slower recovery than other preterm and term infants Hematocrit The average Hct at birth for full term infants is 53% Newborn with increased Hct, especially values greater than 65% experience hyperviscousity of the blood Hct increases approximately 5% during the first 48 postnatal hours followed by a slow linear decline to 46% to 62% at 2 weeks and 32% to 51% between the second and fourth months Normal adult values of 47% (males) and 42% (females) are achieved during adolescence Very low birth weight preterm infants are frequently anemic at birth Red Blood Cell Indices Mean Cell Volume Erythrocytes of newborn infants are marked macrocytic at birth Average MCV for full term infants is 110 + 15 fL A sharp decrease occurs during the first 24 hours of life MCV continues to decrease to 90 + 12fL in 3 to 4 months The more premature the infant, the higher the MCV A newborn with an MCV of less than 94 fL should be evaluated for a-thalassemia or iron deficiency Mean Cell Hemoglobin MCV is 30 to 42 pg in healthy neonates MCV is 27 to 41 pg in premature infants Mean Cell Hemoglobin Concentration Average MCHC is 33 g/dl for infants and adults Red Blood Cell Distribution Width RDW is markedly elevated in newborns, with a range of 14.2% to 19.9% in the first 30 days of life then it gradually decreases and reaches normal adult levels in 6 months Anemia in Infants and Children Iron Deficiency Anemia Most common pediatric hematologic disorder Most frequent cause of anemia on childhood Prevalence is still 2% in toddlers 1 to 2 years of age and 3% in children 3 to 5 days of age Ancillary Tests for Anemia in Infants and Children Haptoglobulin level is low as to be undetected in neonates Transferrin levels are also low in neonates, increasing rapidly after birth and reaching normal adult values in 6 months Serum ferritin and serum iron are high at birth, rise during the first month, drop to their lowest level between 6 months and 4 years of age and remain low through out childhood White Blood Cell Values in the Newborn