Anemia in newborns: hemolytic, iron deficiency, physiological anemia

Anemia in newborns is a condition characterized by a decrease in hemoglobin levels and disruption of red blood cells in their main functions. In infants, this condition deserves special attention, since they are not able to fully compensate for the lack of oxygen. This can negatively affect the development of the child's nervous system in the future, the work of the heart and all internal organs, leading to long-term consequences, some of which may be irreversible.

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Epidemiology

Statistics on the prevalence of anemia indicate that about 5% of newborn babies encounter this problem in the first month of life, and more than 40% of cases of anemia are etiologically associated with problems of pregnancy and childbirth. The prevalence of iron deficiency anemia ranges from 0.9 to 4.4%, depending on race, ethnicity, and socioeconomic status, but accounts for only about 40% of the total number of anemias in young children. The remaining 60% are hemolytic and aplastic anemias.

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Causes anemia in the newborn

Most anemias encountered today are anemias associated with iron deficiency. Other anemias are congenital aplastic, hemolytic, and also occur, but much less frequently and with a more pronounced clinical picture.

To understand the causes of anemia in newborns, we need to consider the role of iron in the blood. To simplify the diagram, we can imagine that iron is in the center of the heme molecule, which is externally surrounded by the globin protein. This is how hemoglobin itself is built, which is the basis for the red blood cell. It is hemoglobin that is responsible for binding the oxygen molecule in the lungs and transporting such a complex throughout the body, to each cell that requires oxygen. When the iron level decreases, the heme level also decreases, so the red blood cells cannot bind oxygen, which is the basis for the development of anemia and its manifestations. That is why it is so important for a newborn child that the mother, and then the child, have a sufficient amount of iron.

Iron sufficiency is a condition in which the iron content is sufficient to maintain normal physiological functions, in which case the pregnant woman must take into account the double need for it.

Iron deficiency is a condition in which iron levels are insufficient to maintain normal physiological functions. Iron deficiency results from inadequate iron absorption to meet the increased maternal needs during pregnancy, or from a prolonged negative iron balance. Either situation results in decreased iron stores, as measured by serum ferritin or bone marrow iron levels. Therefore, maternal iron deficiency during pregnancy is the first and main cause of iron deficiency anemia in the newborn, regardless of gestational age.

Total iron deficiency in premature infants is greater with decreasing gestational age. It is exacerbated by the rapid postnatal growth that many infants experience and by frequent phlebotomies without adequate blood replacement.

Of the iron available in the newborn, 80% is accumulated during the third trimester of pregnancy. Infants born prematurely miss out on this period of rapid gain and have a deficiency in total body iron. A number of maternal conditions, such as anemia, hypertension with intrauterine growth restriction, or diabetes during pregnancy, can also lead to decreased fetal iron stores in both term and preterm infants.

The concept of breastfeeding is very closely related to this, since breast milk contains as much iron as a baby needs in its first five months of life. And if a child is not breastfed immediately after birth, this can be one of the main reasons for the development of anemia.

Among other causes of anemia in a newborn that may be associated with pregnancy and childbirth, one can include pathology of the intranatal period. Fetoplacental transfusion and intranatal bleeding due to birth trauma and abnormal development of the vessels of the placenta and umbilical cord can lead to significant blood loss in the mother. This continuously affects the formation of red blood cells in the child.

Anemia can also develop for other reasons, which are more serious and are associated with pathological iron intake into the newborn's body due to organic pathology. Impaired iron absorption can be observed in malabsorption syndrome, congenital intestinal obstruction, short bowel syndrome. All this secondarily leads to the development of anemia. Iron losses in significant quantities can be observed in bleeding of various etiologies. In newborns, this is most often umbilical bleeding or intestinal bleeding in hemorrhagic disease.

Although iron deficiency is the main cause of anemia, we should not forget about other anemias that a newborn may have. These include congenital aplastic anemia and hemolytic anemia.

Aplastic anemia is a condition characterized by a decrease in hemoglobin levels due to a disruption in the formation of red blood cells in the bone marrow. In newborns, aplastic anemia is often congenital. The main cause of congenital aplastic anemia can never be determined accurately. Children are born with pathology, and the cause cannot be determined accurately. Risk factors include ionizing radiation, genetic mutations, medications, viral and bacterial agents, etc.

The pathogenesis of aplastic anemia is based on the disruption of the development of the stem cell, which gives rise to all blood cells. And depending on which sprout is involved, there may be a decrease in the level of other blood cells.

Hemolytic anemia occurs in children more often due to hereditary reasons. This occurs due to a mutation of the gene that is responsible for the structure of the red blood cell. Therefore, its membrane cannot function normally and is periodically destroyed, which is called hemolysis. Minkowski-Chauffard anemia is most common in newborns. This anemia occurs due to a genetic mutation of the red blood cell membrane proteins spectrin and ankyrin. Therefore, the main cause of anemia in this disease is a violation of the cell membrane due to a lack of these proteins.

Anemia in newborns has similar clinical manifestations, but it is necessary to know the cause and understand the pathogenesis of development for the correct treatment tactics.

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Symptoms anemia in the newborn

When talking about the clinical manifestations of anemia, it is necessary to understand the stages of its development. If we are talking about iron deficiency anemia, then it has its own stages of development. At first, the baby is born absolutely healthy, because immediately after birth, he has a physiological increase in the level of red blood cells. But at this time, the number of red blood cells that should be formed in the bone marrow decreases due to a lack of iron. This corresponds to the hidden or latent stage of anemia. At the same time, there are no clinical manifestations yet, but the lack of iron leads to a critical decrease in hemoglobin and red blood cells.

The next stage is long-term iron deficiency which leads to the appearance of clinical symptoms, so this is a clear stage of anemia.

Symptoms of anemia in a newborn baby are very difficult to detect, especially for the mother. Since the baby is still very small and sleeps most of the time, the mother is unable to notice any signs. It also often happens that the baby develops physiological jaundice, which can make it difficult to see the symptoms. This proves the importance of preventive examinations of the child during this period.

The first signs of anemia vary depending on the etiology. Iron deficiency anemia in newborns is the most common, and its first symptom is the paleness of the skin and mucous membranes of the child. All newborn babies are usually red at first, then pink, and with anemia, a little pale. This symptom is very subjective, but it can be the first sign of anemia.

Other clinical manifestations may be associated with serious hypoxia caused by lack of oxygen. This may be the appearance of cyanosis of the skin and shortness of breath during feeding, anxiety of the baby.

All symptoms of anemia can be generalized and divided into several groups. The main syndromes of anemia in newborns are anemic-hypoxic and sideropenic, and when talking about hemolytic anemia, hyperbilirubinemia syndrome is also added.

The first syndrome occurs due to lack of oxygen and is manifested by pallor, especially of the mucous membranes, poor health, loss of appetite, and lack of strength. All this is manifested in a child by the fact that he eats poorly and does not gain weight. Sideropenic syndrome occurs due to a malfunction of enzymes that depend on oxygen. This disrupts the work of all cells and is manifested by dry skin against the background of pallor, the fontanelle does not close well in newborns, there is no hypertonicity of muscles inherent to them, but on the contrary, hypotension occurs.

Hemolysis syndrome occurs due to increased breakdown of red blood cells in the vascular bed, which causes the release of bilirubin and an increase in its concentration. Then, against the background of anemia and all the above symptoms, yellowing of the child's skin and sclera occurs. Hemolytic anemia in a newborn is most often genetic. One of the types of such pathology is Minkowski-Chauffard anemia. This disease is present in one of the family members, which simplifies the diagnosis a little. All syndromes are the same, and it is important not to confuse jaundice with such hemolytic anemia with physiological.

Congenital anemia in newborns is often aplastic in nature and is the most severe type of anemia. There are several types. One of them is Blackfan-Diamond anemia. With this pathology, the number of red blood cells decreases due to damage to this germ in the red bone marrow. In the first month of life, it rarely manifests itself, clinical signs are more visible closer to the sixth month of life.

Congenital anemia of Estren-Dameshek is a decrease in the level of all bone marrow cells. Therefore, in addition to anemia and hypoxia, there will be bleeding and early infectious lesions. Another type of aplastic congenital anemia is Fanconi anemia. Symptoms of this disease, in addition to anemic ones, are congenital malformations in the form of microcephaly, other malformations of the skull, underdevelopment of the fingers, underdevelopment of internal organs.

It is also necessary to highlight conditions in which a decrease in the amount of hemoglobin can also be observed - this is anemia in premature newborns. This is caused by the immaturity of the bone marrow and unpreparedness for the processes of breathing through the lungs. This is considered a normal phenomenon and such anemia can resolve on its own without treatment. Physiological anemia of the newborn can also be observed in a full-term child, and the exact reason for this has not been established. This may be due to the destruction of fetal hemoglobin and low dynamics of the increase in hemoglobin type A, as in an adult. This condition should also not cause concern and is transient.

The consequences of anemia in a newborn can be very serious if the pathology is not noticed in time. After all, constant hypoxia leads not only to a lack of body weight, but also the lack of oxygen affects the brain. It is known that iron is necessary for the normal development of the nervous system. Iron deficiency anemia affects the energy metabolism of neurons, the metabolism of neurotransmitters, myelination and memory function. Therefore, anemia in the neonatal period can cause irreversible memory impairment, delayed psychomotor development, behavioral abnormalities and speech delays in the future. As for other complications, anemia increases the risk of other infectious diseases. The consequence of hemolytic anemia not diagnosed in time can be brain damage and the development of bilirubin encephalopathy.

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Stages

Tests also allow us to classify anemia according to its severity:

1. first degree – hemoglobin level within 120 (110) – 91 T/L;
2. second degree anemia – 90 - 71 T/L;
3. third degree – hemoglobin level 70-51 T/L;
4. fourth degree – hemoglobin level less than 50 T/L.

Anemia of the 1st degree in a newborn is considered mild and may be a sign of physiological processes, but it definitely requires monitoring and observation. Mild anemia in a newborn premature baby can also be considered transient and requires observation.

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Diagnostics anemia in the newborn

The main criterion of anemia is certainly laboratory confirmation of a decrease in the level of hemoglobin and red blood cells. But the main task of the mother and the doctor is timely diagnosis of anemia, so it should begin with general clinical signs. Pale skin and mucous membranes should already suggest the idea of possible anemia. If the child is not gaining weight well, then you also need to look for the cause and think about anemia. It is important to ask the mother about pregnancy and childbirth, whether she took vitamins and whether there was massive blood loss. All these thoughts can lead to a diagnosis. Even if the child is premature, then, in most cases, he has a hidden iron deficiency and this is potentially dangerous for the development of anemia in the future.

During examination, in addition to pallor, there may be a systolic murmur at the apex of the heart during auscultation, which also requires attention. This occurs due to turbulence of the blood flow with a low concentration of red blood cells relative to the liquid part of the blood. There are practically no other objective symptoms.

Laboratory diagnostics of anemia is the most accurate and necessary for an accurate diagnosis. A complete blood count allows you to determine a decrease in the level of red blood cells and hemoglobin. And such a diagnostic number is:

1. decrease in hemoglobin levels below 145 T/L in children in the first two weeks of life;
2. hemoglobin level less than 120 T/L in newborns after the second week of life;
3. in children under five years of age less than 110 T/L;
4. for children over five years old – less than 120 T/L.

In a general blood test, if anemia is suspected, it is also necessary to determine the level of reticulocytes. These cells are responsible for the formation of red blood cells in the red bone marrow and are their precursors. The level of reticulocytes is subsequently needed to assess the response to treatment.

To establish a diagnosis of iron deficiency anemia, one or more tests should be added to the determination of hemoglobin concentration. Three parameters that provide final information on the iron status are the concentrations of ferritin, chromium and transferrin. Ferritin concentration is a sensitive indicator for assessing iron stores in healthy individuals. Measuring ferritin concentration is widely used in clinical practice and is available abroad. But in Ukraine, only the transferrin level is used of these indicators.

Today, most blood tests are performed on special analyzers that allow, in addition to the formula, to evaluate the size of red blood cells and their structure. In pranemia, the average hemoglobin content in red blood cells is reduced, the average size of red blood cells is reduced, and the average hemoglobin concentration in red blood cells is also below normal.

Among other tests, a microscopic examination of the smear is also carried out, which in case of anemia has characteristic changes in the form of anisocytosis, inclusions and granules in erythrocytes.

If a child has jaundice combined with anemia, then a study of total bilirubin and its value by fractions is mandatory. This is also necessary to exclude hemolytic anemia or differentiate from hemolytic disease of the newborn. The level of total bilirubin should be within 8.5 - 20.5 micromol.

These are the main laboratory indicators that can confirm the diagnosis of anemia and establish the etiology.

Instrumental diagnostics for iron deficiency anemia is not used, but if hereditary hemolytic anemia is suspected, an ultrasound examination may be performed. It shows the condition of the spleen, which affects the child's condition with this pathology and indicates treatment options.

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Differential diagnosis

Differential diagnostics of anemias should be carried out primarily on the basis of the etiological principle. It is necessary to distinguish between the symptoms of anemia in a child with physiological jaundice and the manifestations of hemolytic anemia. In the first case, a decrease in the hemoglobin level will be accompanied by an increase in bilirubin below critical values - this is below 100 micromol. If we are talking about congenital hemolytic anemia, then bilirubin will be above 100, even up to 250 and higher. There will also be hyperchromia of the blood (an increase in the color index above 1.05).

Treatment anemia in the newborn

Of course, the approach to treating anemia of different etiology is different. That is why it is so important to know the cause of a particular type of pathology. If we are talking about iron deficiency anemia, which arose after prolonged bleeding in a child or as a result of a congenital pathology of iron absorption disorder, then in this case the first step to treatment is to exclude the cause of the anemia.

Speaking about iron deficiency anemia as the most common problem, it should be noted that the main element of treating such anemia is replenishing iron reserves. Therefore, the medications used in treatment are iron preparations. Iron is absorbed most easily from the trivalent form, so iron preparations, especially for newborns, should be in this form. Preparations based on trivalent iron are better absorbed, better assimilated and have fewer negative and side effects.

Treatment of anemia begins not with calculating the drug, but with calculating the dose of iron that the child needs. After all, each drug contains a certain amount of iron, which must also be taken into account when choosing this drug. The therapeutic dose of iron is 3-5 milligrams per kilogram of the child's body weight, which must be taken per day. The minimum period of treatment for anemia is one month. Then, if the blood counts are within normal limits, then a prophylactic dose is given for another six months. The prophylactic dose is half of the therapeutic dose, and it is given ten days each month for six months. The drugs used to treat iron deficiency anemia are the following:

1. Aktiferin is an iron preparation that also includes the amino acid serine, which ensures its better absorption. The drug acts when it enters the intestines and bloodstream by binding to the protein transferrin. In this way, iron is transported to the liver, bone marrow, where it is released and takes part in the synthesis of hemoglobin and the formation of new red blood cells. The drug is available in the form of drops, syrup and capsules. For newborns, the form of drops is used. One milliliter of the drug in this form contains 9.8 milligrams of iron, which corresponds to 20 drops. Therefore, the dosage is calculated first 3-5 milligrams per child's weight, and then the drug itself. Side effects in babies may be colic, increased gas formation, diarrhea or constipation. These are the first signs that indicate the need to reduce the dose of the drug. Precautions - do not use the drug for hemolytic anemia.
2. Hemoferon is also an iron preparation, which additionally contains other vitamins - folic acid and cyanocobalamin. The drug contains citric acid, which helps the iron molecule to be better absorbed. One milliliter of the drug contains 8.2 milligrams of iron. The dosage of the drug is standard, but for newborns, on average, it is 2.5 milliliters per day. Side effects may include vomiting, indigestion and stool disorders, and dark stool coloration. Precautions - do not use the drug if the child has liver damage or if hepatitis is suspected.
3. Hemofer is a drug that contains a molecule of divalent iron and citric acid. It is most suitable for treatment in which it is necessary to quickly achieve results in increasing the hemoglobin level, with a subsequent transition to trivalent drugs. The dosage of the drug is 1 drop contains 1.6 milligrams of iron, and for newborns about 1 drop per kilogram of body weight. Side effects are decreased appetite and refusal to breastfeed, diarrhea.
4. Ferramin-Vita is a trivalent iron preparation that works on the principle of slowly restoring the iron level in the child's body. The preparation is available in the form of a solution and its dosage is 3 drops per day for newborns. Side effects occur less frequently than when taking divalent iron and may be limited to dyspepsia.
5. Maltofer is a trivalent iron preparation that is slowly absorbed in the intestine, and due to this, its physiological concentration in the blood serum is established. The dosage of the preparation is 1 drop per kilogram for newborns. The preparation in the form of drops can be used for newborns, including premature babies. Side effects can be in the form of allergic reactions and stool coloring.

Such treatment of anemia with iron preparations is carried out for a month, then preventive therapy is given. It is very important during this period if the mother is breastfeeding, then her food should contain the maximum amount of iron and all useful microelements. If the child is bottle-fed, then it is necessary that the mixture is also enriched with iron. It should be said that in the presence of anemia, the cause of which is a violation of iron absorption, it is necessary to use its injection forms. The same applies to those cases when the child has had surgery on the stomach or intestines and oral forms of iron cannot be used.

The effectiveness of the treatment should be assessed on the 7-10th day after the start, when it is necessary to repeat the blood test. In this case, an increase in the number of reticulocytes will be evidence of positive dynamics of the treatment. An increase in hemoglobin will be observed by the end of the course of treatment in the third or fourth week.

Nursing care for neonatal anemia is very important if the anemia is congenital. If we are talking about hemolytic anemia or congenital aplastic anemia, it is very important to properly organize the child's daily routine and nutrition. Considering that complications can occur when bilirubin affects the central nervous system, it is important that medical personnel monitor the child. After all, there may be symptoms that threaten the child's life, and the mother may simply not notice them due to inexperience. Therefore, the issue of treating congenital anemia in a hospital is so important.

Speaking about surgical treatment of anemia, it should be noted that severe anemia, in which the hemoglobin level is less than 70, requires blood transfusion. This is considered an intervention at the same level as surgery. The child's blood type and Rh factor are determined.

Surgical treatment of congenital hemolytic anemia is performed on children at an older age, closer to five years. It is performed in severe cases of anemia with frequent hemolytic crises. The essence of the operation is to remove the spleen. The spleen is an immunocompetent organ in which the destruction of red blood cells occurs and in hemolytic anemia it is constant. Therefore, splenectomy leads to fewer exacerbations, since fewer red blood cells are destroyed. But before such an operation, the child is necessarily vaccinated unscheduled, since such an operation disrupts the normal immune status.

Vitamins for a child with anemia are considered essential, as they increase iron absorption and have a good effect on appetite. Vitamins from the carnitine group can be used for newborns, which promote weight gain, which is important for anemia. One of these drugs is Steatel.

Steatel is a vitamin that contains the metabolically active substance levocarnitine. It promotes the absorption of biologically useful substances and accelerates metabolism in cells, which especially affects the synthesis of new red blood cells. The drug is available in the form of a syrup. One milliliter of syrup contains 100 milligrams of the substance, and the dosage is 50 milligrams per kilogram. The drug can be used even in premature babies. Side effects can be in the form of stool disorders, colic, convulsive syndrome.

Physiotherapeutic treatment of anemia in the acute period in newborns is not used.

Folk treatment of anemia

Of course, a newborn cannot take anything except mother's milk and medications, because any herbs or folk remedies can cause allergies. Therefore, all folk remedies are aimed at ensuring that a young mother who is breastfeeding a child follows the advice of folk medicine, taking certain remedies.

1. The main thing for treating anemia is to eat right for the mother to improve hematopoiesis for herself and the child. Therefore, if the newborn has iron deficiency anemia, the mother should include in her diet the maximum amount of products that contain iron. Such products include: red meat, fish, buckwheat porridge, parsley and spinach, legumes, pomegranate. These products must be in the diet.
2. Pomegranate is known for its beneficial effect not only on blood vessels, but also on the heart and the formation of formed elements. Therefore, to stimulate erythropoiesis, you need to take 150 grams of fresh pomegranate juice, add 50 grams of beet juice and the same amount of carrot juice. You need to take this vitamin mix four times a day. These products are very allergenic, so you need to start with a small amount - ten to twenty grams. You can drink for a month.
3. Another folk remedy is the use of blueberry extract. To do this, take two hundred grams of fresh berries and pour 50 grams of water. Let it sit for two hours, then beat with a blender. Mom should take a tablespoon five times a day between feedings.

Herbal treatment for anemia is also widely used:

1. The hellebore and yarrow herbs should be taken in equal proportions and poured with hot water. This tincture should be left to stand for two days, and then you can take a teaspoon in the morning and evening, adding a little lemon juice.
2. Rose hips should be filled with hot water and left for ten to twenty minutes. The mother should drink a glass throughout the day instead of tea. This tea not only accelerates the synthesis of red blood cells, but also accelerates the work of the liver, which synthesizes proteins, including transferrin. Such a complex effect brings recovery closer.
3. Birch leaves need to be dried in the oven and made into a decoction. To do this, take thirty grams of dry leaves and pour a liter of hot water. After infusion for two hours, you can take the decoction, one tablespoon twice a day.

Homeopathic remedies can also be used by the mother:

1. Natrium chloratum is a homeopathic medicine based on organic elements. It is produced as a single drug in granules or in combination with succinic acid, which has a better effect on iron absorption. The dosage of the drug for the mother depends on the severity of anemia - at the first stage, two granules three times, and for more severe ones, the dose is doubled. There may be side effects in the form of pale skin and mucous membranes of the child, which is caused by the action of the drug and will disappear after a few days.
2. Poetam is a multicomponent preparation, which mainly includes different types of antibodies to erythropoietin in homeopathic concentrations. The effect of the preparation is to stimulate the work of cells that are precursors of erythrocytes. The dosage of the preparation is 1 tablet per day or six drops once a day. Side effects - an increase in body temperature to subfebrile numbers.
3. Cuprum metalicum is a homeopathic remedy that contains copper molecules that accelerate the maturation of red blood cells in the red bone marrow. The drug is used for the mother in a dose of one grain six times a day. Side effects can only occur if the mother is intolerant, and the newborn may have problems with stool.
4. Galium-Hel is a combination remedy in homeopathy, which is used to treat anemia, which is accompanied by weight loss in the child, poor appetite, stool disorders in the form of diarrhea. The drug is dosed five drops three times a day for the mother, since it is not recommended for the child in the acute period. The first three days, you can take five drops every three hours. Side effects were not found.

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Prevention

Prevention of anemia must be carried out by the mother during pregnancy. It should start with the correct daily routine and diet of the mother, as well as taking vitamins containing iron. But for a newborn, prevention should consist of taking iron preparations for premature babies and babies from the risk group. All premature babies should consume iron in a dose of at least 2 mg / kg per day up to and including 12 months of age (this is the amount of iron obtained from consuming iron-fortified milk formulas). Premature babies who are breastfed should receive iron supplements in a dose of 2 mg / kg per day no later than 1 month of age and until the child is transferred to feeding with iron-fortified milk formula or begins to receive complementary foods that will provide iron intake in a dose of 2 mg / kg. An exception should be made for babies who have received iron loads due to several transfusions of red blood cells.

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Forecast

The prognosis for anemia is favorable with proper and timely treatment, if we are talking about iron deficiency. Congenital aplastic anemia has an unfavorable prognosis, children, as a rule, live five to six years. Congenital hemolytic anemia has a good prognosis for life, if all crises are correctly corrected and concomitant pathologies are treated.

Anemia in newborns is quite common, especially if the mother had certain problems during pregnancy or childbirth. Most often, we have to deal with iron deficiency anemia, which is well corrected with the right treatment tactics. But if there is congenital anemia in the family, then you need to consult a doctor even during pregnancy planning.

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