Anemia in newborns: hemolytic, iron deficient, physiological

Anemia in newborns is a condition characterized by a decrease in the level of hemoglobin and a violation of its main functions by erythrocytes. In infants, this condition deserves special attention, because they are not able to fully compensate for the lack of oxygen. This can adversely 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.

[1], [2], [3], [4],

Epidemiology

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

[5], [6], [7], [8], [9], [10],

Causes of the anemia in the newborn

Most of the anemias that we face today are anemia associated with iron deficiency. Other anemias are congenital aplastic, hemolytic also have a place, but much less often and with a more vivid clinical picture.

To understand the causes of the development of anemia in newborn babies you need to consider the role of iron in the blood. If we simplify the scheme, then we can imagine that iron is in the center of the heme molecule, which is externally surrounded by a protein globin. This is how hemoglobin itself is constructed, which is the basis for the erythrocyte. It is hemoglobin that is responsible for binding the oxygen molecule in the lungs and transporting such a complex throughout the body, to every cell that requires oxygen. When the level of iron decreases, the level of heme also decreases, therefore red blood cells can not bind oxygen, which is the basis for the development of anemia and its manifestations. That's why it's so important for a newborn baby that his mother, and then he also has enough iron.

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

Iron deficiency is a condition in which the iron content is insufficient to maintain normal physiological functions. Iron deficiency is the result of insufficient absorption of iron to meet the increased needs of the mother during pregnancy, or is the result of a prolonged negative iron balance. Any of these situations leads to a decrease in iron stores, which is determined by measuring serum ferritin concentration or iron content in the bone marrow. Therefore, iron deficiency in mother during pregnancy is the first and main cause of iron deficiency anemia in a newborn, even regardless of the gestational age.

Deficiency of total iron in the body in preterm infants is greater, the smaller the gestational age. It increases with rapid postnatal growth, which is observed in many children, and with frequent phlebotomies without adequate blood replacement.

Of the iron present in the body of a newborn, 80% accumulates during the third trimester of pregnancy. Infants born prematurely lose this period of rapid growth and have a deficiency in total iron in the body. A number of conditions of the maternal organism, such as anemia, hypertension with restriction of intrauterine development or diabetes during pregnancy, can also lead to a reduction in fetal iron stores in both full-term and preterm infants.

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

Among other causes of the development of anemia in the newborn, which can be associated with pregnancy and childbirth can be attributed to the pathology of the intranatal period. Fetoplacental transfusion and intrapartum bleeding due to birth trauma and anomalies in the development of the vessels of the placenta and umbilical cord can lead to significant maternal blood loss. This continuously affects the formation of erythrocytes and in the child.

Anemia can develop for other reasons, which are more serious and are associated with the pathology of iron entering the body of a newborn due to organic pathology. Disturbance of iron absorption can be observed in the syndrome of malabsorption, congenital intestinal obstruction, and syndrome of the small intestine. All this again leads to the development of anemia. Loss of iron in significant amounts can be observed with bleeding of various etiologies. In newborns, it is most often bleeding from the navel or intestinal bleeding with hemorrhagic disease.

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

Aplastic anemia is a condition that is characterized by a decrease in the level of hemoglobin due to disruption of the formation of erythrocytes in the bone marrow. In newborns, aplastic anemia is more often congenital in nature. The main cause of congenital aplastic anemia has never been established accurately. Children are already born with pathology, and the cause can not be precisely established. Among the risk factors are ionizing radiation, genetic mutations, medicines, viral and bacterial agents, and others.

At the heart of the pathogenesis of the development of aplastic anemia is a violation of the development of the stem cell, which gives rise to all cells of the blood. And depending on which germ is involved, there may be a decrease in the level of other blood cells.

Hemolytic anemia occurs in a child more often because of hereditary causes. This is due to the mutation of the gene, which is responsible for the structure of the erythrocyte cell. Therefore, its membrane can not function normally and periodically it is destroyed, which is called hemolysis. The most common is Minkowski-Schoffar anemia in newborns. This anemia arises from the genetic mutation of the proteins of the erythrocyte membrane of spectrin and ankirin. Therefore, the main cause of anemia in this disease is the disruption 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.

[11], [12], [13], [14]

Symptoms of the anemia in the newborn

Talking about the clinical manifestations of anemia, you need to understand the stages of its development. If it is iron deficiency anemia, then it has its own stages of development. At first the baby is born absolutely healthy, because right after birth, it has a physiological increase in the level of red blood cells. But at this time the number of red blood cells that should form in the bone marrow is reduced because of a lack of iron. This corresponds to a latent or latent stage of anemia. At the same time, there are no clinical manifestations, but a lack of iron leads to a critical decrease in hemoglobin and red blood cells.

The next stage - prolonged iron deficiency 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 identify, especially for the mother. Since the child is still very small and he sleeps most of the time, then no signs of mum can not be noticed. It often happens that the child has physiological jaundice, because of which it can be difficult to see the symptoms. This proves the importance of preventive examinations of the child during this period.

The first signs of anemia are different, depending on the etiology. Iron deficiency anemia in newborns is most common, and the first symptom is the pallor of the skin and mucous child. All newborn babies usually first red, and 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 severe hypoxia due to lack of oxygen. This may be the appearance of cyanosis of the skin and shortness of breath during feeding, anxiety of the baby.

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

The first syndrome arises from a lack of oxygen and is manifested by pallor, especially mucous, poor health, decreased appetite, lack of energy. This is all the child manifested by the fact that he does not eat well and does not gain weight. Sideropenic syndrome occurs due to disruption of enzymes, which depend on oxygen. This disrupts the work of all cells and is manifested by dry skin on a background of pallor, in newborns the fontanel is poorly overgrown, there is no inherent hypertonic muscle, but on the contrary hypotension occurs.

The hemolysis syndrome arises from the increased disintegration of erythrocytes in the vascular bed, which causes the release of billingrubin and an increase in its concentration. Then, against the background of anemia and all of the above symptoms, yellow coloring of the baby's skin and sclera occurs. Hemolytic anemia in a newborn usually has a genetic character. One of the types of such pathology is the anemia of Minkowski-Schoffar. This disease is in someone from family members, which a little simplifies the diagnosis. All syndromes are the same, and it is important not to confuse jaundice with such hemolytic anemia from a physiological one.

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

Congenital anemia of Estrena-Dameshek is a decrease in the level of all cells of the bone marrow. 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 other than anemic, are congenital malformations in the form of microcephaly, other malformations of the skull, underdevelopment of the fingers, underdevelopment of internal organs.

Also, it should be noted the state in which there may also be a decrease in the amount of hemoglobin - this is anemia in newborn preterm infants. This is due to the immaturity of the bone marrow and the lack of readiness for the processes of breathing through the lungs. This is considered normal and such anemia can be resolved without treatment. The physiological anemia of a newborn can also be observed in a full-term child, and the exact cause of this is not established. This may be due to the destruction of fetal hemoglobin and low dynamics of the growth of hemoglobin type A, as in an adult. This state should also not cause concern and is transient.

The consequences of anemia in a newborn can be very serious if the pathology has not been noticed in time. After all, the 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 function impairment, delayed psycho-motor development, behavioral abnormalities and speech delays in the future. As for other complications, anemia increases the risk of other infectious diseases. The consequence of the inadequately diagnosed hemolytic anemia can be brain damage and the development of biliary carcinoma encephalopathy.

[15], [16], [17], [18], [19]

Stages

Analyzes also make it possible to classify anemia in terms of severity:

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

Anemia of 1 degree in a newborn is considered easy and can be a sign of physiological processes, but it necessarily requires control and observation. Anemia of mild degree in a newborn preterm baby can also be regarded as transient and requires observation.

[20], [21], [22], [23], [24]

Diagnostics of the anemia in the newborn

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

On examination, except for pallor, there may be a systolic murmur on the apex of the heart during auscultation, which also requires attention. This is due to the turbulence of the blood flow with a small concentration of red blood cells relative to the liquid part of the blood. There are practically no other objective symptoms.

Laboratory diagnosis of anemia is the most accurate and necessary for an accurate diagnosis. A general blood test can establish a reduction in the level of red blood cells and hemoglobin. And such a diagnostic number is:

1. decrease in hemoglobin level below 145 T / L in children of the first two weeks of life;
2. The hemoglobin level is less than 120 T / L in newborns after the second week of life;
3. in children under five years less than 110 T / L;
4. in children after five years - 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 erythrocytes in the red bone marrow and are their precursors. The level of reticulocytes is further required to evaluate the response to treatment.

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

To date, most blood tests are performed on special analyzers, which allow you to estimate the size of red blood cells and their structure in addition to the formula. During anemia, the average content of hemoglobin in the erythrocyte is reduced, the average size of red blood cells is reduced, and the average concentration of hemoglobin in the erythrocyte is also below normal.

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

If the child has jaundice combined with anemia, then it is mandatory to examine the total bilirubin and its significance by fractions. It is also necessary to exclude hemolytic anemia or differentiation with hemolytic disease of the newborn. The level of total bilirubin should be within 8.5 - 20.5 micromolar.

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

Instrumental diagnostics in iron deficiency anemia is not used, but if there is a suspicion of hereditary hemolytic anemia, ultrasound can be performed. It shows the state of the spleen, which affects the child's condition in this pathology and indicates treatment options.

[25], [26]

Differential diagnosis

Differential diagnosis of anemia should be carried out primarily on an etiologic basis. It is necessary to distinguish the symptoms of anemia in a child with physiological jaundice and the manifestation of hemolytic anemia. In the first case, a decrease in hemoglobin level will be accompanied by an increase in bilirubin below the critical values - it is below 100 micromolar. If it is a question of hemolytic anemia congenital, then bilirubin will be above 100, even up to 250 and above. There will also be blood hyperchromia (an increase in color index above 1.05).

Treatment of the anemia in the newborn

Undoubtedly, the approach to treating anemia of different etiologies is different. That is why it is so important to know the cause of this or that type of pathology. If it is iron deficiency anemia that has occurred after a prolonged bleeding in a child or due to a congenital pathology of iron absorption abnormalities, then the first step to treatment is to exclude the cause of anemia.

Speaking about iron deficiency anemia, as the most common problem, it should be noted that the main element of the treatment of such anemia is the replenishment of iron reserves. Therefore, the medications used in the 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 ferric iron are better absorbed, better absorbed and have less negative and side effects.

Treatment of anemia begins not with the calculation of the drug, but with the calculation of the dose of iron, which is necessary for the child. After all, each drug contains a certain amount of iron, which should also be considered when choosing this drug. The therapeutic dose of iron is 3-5 milligrams per kilogram of body weight of the child, which must be taken for a day. The minimum duration of treatment for anemia is one month. Further, if the blood counts within the limits of the norm, then they give a prophylactic dose for another six months. The prophylactic dose is half of the treatment dose, and it is given for ten days of each month for six months. Medicines that are used to treat iron deficiency anemia are as follows:

1. Aktiferin  - an iron preparation, which also includes an amino acid serine, which provides a better absorption. The drug acts upon ingestion into the intestine and bloodstream due to binding with the protein transferrin. So iron is transported to the liver, bone marrow, where it is released and takes part in the synthesis of hemoglobin and in the formation of new erythrocytes. The drug is available in the form of drops, syrup and capsules. For newborns use the form of drops. One milliliter of the drug in this form contains 9.8 milligrams of iron, this corresponds to 20 drops. Therefore, the dosage is calculated first 3-5 milligrams per child's weight, and then the drug itself. Side effects can be in children in the form of colic, increased gas production, 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 composition of the drug includes citric acid, which helps better absorb the iron molecule. 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 daily dose. Side effects can be in the form of vomiting, digestion and stool, staining the feces in a dark color. Precautions - do not use the drug if the liver is damaged in the child or if there is a suspicion of hepatitis.
3. Hemofer  is a drug that contains an iron molecule of divalent and citric acid. It is most suitable for treatment, in which it is necessary to quickly achieve the results of increasing hemoglobin levels, with the subsequent transition to trivalent preparations. Dosage of the drug - 1 drop contains 1.6 milligrams of iron, and for newborns about 1 drop per kilogram of body weight. Side effects: decreased appetite and rejection of the breast, diarrhea.
4. Ferramin-Vit  is a preparation of ferric iron, which acts according to the principle of slow restoration of iron level in the child's body. The drug is released in the form of a solution and dosage it - by ZO drops per day for newborns. Side effects occur less frequently than during the reception of ferrous iron and can be limited to dyspepsia.
5. Maltofer  is a preparation of ferric iron, which has a slow absorption in the intestine, and thanks to this, its physiological concentration is established in the serum. Dosage of the drug 1 drop per kilogram for newborns. The drug in the form of drops can be used by newborns, including preterm infants. Side effects can be in the form of allergic manifestations and staining of the stool.

Such treatment of anemia with iron preparations is carried out a month, then they are given preventive therapy. It is very important during this period if the mother feeds the baby, then her food should contain the maximum amount of iron and all the useful microelements. If the child is on artificial feeding, then it is necessary that the mixture also be 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 injectable forms. The same applies to those cases when the child had an operation on the stomach or intestine and the oral forms of iron can not be used.

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

Nursing care for newborn anemia is very important if anemia is congenital. If it is a question of hemolytic anemia or congenital aplastic, it is very important to correctly organize the regime of the child's day, its nutrition. Given that complications can be caused by the influence of bilirubin on the central nervous system, it is important that the medical staff monitor the child. After all, there may be symptoms that threaten the child's life, and mom can simply not notice them because of inexperience. Therefore, the issue of treating congenital anemia in a hospital is so important.

Speaking about the surgical treatment of anemia, it should be noted that severe anemia, in which the hemoglobin level is less than 70, requires a blood transfusion. This is considered an intervention at the surgical level. It is mandatory to determine the blood type of the child and Rh factor.

Surgical treatment of congenital hemolytic anemia is carried out by children at an older age, closer to five years. It is performed in severe anemia with frequent haemolytic crises. The essence of the operation is to remove the spleen. The spleen is an immunocompetent organ in which the destruction of erythrocytes occurs and in the case of hemolytic anemia it is constant. Therefore, splenectomy results in fewer exacerbations, since fewer red blood cells are destroyed. But before such an operation, the child should be vaccinated outside the plan, since such an operation disrupts the normal immune status.

Vitamins for a child with anemia are considered mandatory, as this increases the absorption of iron and has a good effect on appetite. For newborns, vitamins from the carnitine group can be used, which contribute to weight gain, which is important for anemia. One of these drugs is Steatel.

Stevatel  - a vitamin, which includes a metabolically active substance levokarnitin. It promotes the assimilation of biologically useful substances and accelerates metabolism in cells, which especially affects the synthesis of new red blood cells. The drug is available as 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 disorders of stool, colic, convulsive syndrome.

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

Alternative treatment of anemia

Undoubtedly, a newborn can not take anything but mother's milk and medicines, because all herbs or alternative medicine can have allergies. Therefore, all alternative means are aimed at ensuring that the young mother who feeds the child follows the advice of alternative medicine, taking some of the funds.

1. The main thing for the treatment of anemia is to eat properly for the mother, in order to improve the hemopoiesis to yourself and the baby. Therefore, if a newborn has iron deficiency anemia, then the mother should include in her diet the maximum number of products that contain iron. Such products include: red meat, fish, buckwheat porridge, parsley and spinach, beans, pomegranate. These products must be in the diet.
2. Garnet is known for its beneficial effect not only on the vessels, but also on the heart and on the formation of shaped 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. Take this vitamin mix four times a day. These products are highly allergenic, so you need to start with a small amount - ten to twenty grams. You can drink for a month.
3. Another alternative means - the use of blueberry extract. To do this, take two hundred grams of fresh berries and pour 50 grams of water. You need to insist for two hours, and then whip with a blender. Take Mom on a tablespoon five times a day in intervals between feedings.

Herbal treatment for anemia is also widely used:

1. Grass hellebore and yarrow should be taken in equal proportions and pour hot water. This tincture should be allowed to stand for two days, and then you can take a teaspoon in the morning and evening, adding a little lemon juice.
2. The rose hips should be filled with hot water and on top and insist for ten to twenty minutes. Take a mom should a glass throughout the day instead of tea. Such tea not only accelerates the synthesis of red blood cells, but also speeds up the work of the liver, which synthesizes proteins, including transferrin. This complex action brings healing closer.
3. Leaves of birch should be dried in the oven and make a decoction of them. To do this, take thirty grams of dry leaves and pour a liter of hot water. After insisting after two hours, you can take the decoction on a tablespoon twice a day.

Homeopathic remedies can also be used in the mother:

1. Natrium chloratum is a homeopathic medicine based on organic elements. Produced in the form of monopreparation in granules or in combination with succinic acid, which affects the absorption of iron better. The dosage of the drug for the mother depends on the severity of the anemia - at the first degree, two pellets three times, and with a heavier dose, it doubles. There may be side effects in the form of pale skin and mucous baby, which is caused by the drug and will disappear after a few days.
2. Poets are a multicomponent drug, which mainly includes different types of antibodies to erythropoietin in homeopathic concentrations. The effect of the drug is to stimulate the work of cells, which are the precursors of red blood cells. Dosage of the drug - 1 tablet per day or six drops once a day. Side effects - increase in body temperature to low-grade figures.
3. Kuprum metalikum - homeopathic remedy, which includes copper molecules, which accelerate the maturation of red blood cells in the red bone marrow. The drug is applied to the mother in a dose of one pellet six times a day. Side effects can only be with mum's intolerance, and a newborn can have problems with a stool.
4. Galium-Hel is a combined remedy in homeopathy, which is used to treat anemia, which is accompanied by a decrease in the weight of the child, poor appetite, disorders of stools in the form of diarrhea. The drug is dosed five drops three times a day for the mother, since the child is not recommended in the acute period. The first three days you can take five drops every three hours. No side effects were found.

[27], [28], [29]

Prevention

Prevention of anemia must necessarily be carried out by the mother during pregnancy. You need to start with the correct regime of the day of mother and nutrition, as well as taking vitamins that contain iron. But for a newborn, prevention should consist of taking iron supplements for premature infants and children from the risk group. All premature babies should consume iron at 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 when iron-enriched formula is consumed). Preterm infants who are breastfed should receive iron supplements at a dose of 2 mg / kg per day no later than 1 month of age and until the baby is taken to breast-feeding with an iron fortified formula or begins to receive complementary foods, which will ensure the use of iron in a dose of 2 mg / kg. An exception should be made for infants who received iron loads due to several transfusions of erythrocyte mass.

[30], [31], [32], [33], [34], [35],

Forecast

The prognosis of anemia is favorable with proper and timely treatment if it is iron deficiency. Congenital aplastic anemia has an unfavorable prognosis, babies, as a rule, live five to six years. Congenital hemolytic anemia has a good prognosis for life, if correctly correct all crises and treat associated pathologies.

Anemia in newborns is very common, especially if the mother had certain problems during pregnancy or childbirth. Most often you have to deal with iron deficiency anemia, which, with the correct treatment tactics, is well-balanced. But if the family has congenital anemia, then you need to consult a doctor while planning pregnancy.

[36], [37],