Anemia: When Is it Not Iron Deficiency?

Annette Carley


Pediatr Nurs. 2003;29(3) 

In This Article

Definition of Anemia

Part 1 of this series, "Anemia: When is it Iron Deficiency?," presented an overview of red blood cell and hemoglobin physiology and specifically addressed iron deficiency anemia. Part II of this two part series will focus on additional causes of anemia in the infant and young child and present strategies for detection and management.

Definition of Anemia

Anemia refers to red blood cell (RBC) mass, amount of hemoglobin, and/or volume of packed RBCs less than normal, determined either as a hematocrit or hemoglobin concentration > 2 standard deviations below the normal mean for age (Abshire, 2001; Cohen, 1996; Korones & Cohen, 1997; Walters & Abelson, 1996). Application of reference normals for age is not always straightforward, however. Infants less than 2 months of age have not yet established steady state values for hemoglobin or hematocrit, hence reference ranges for normal are extensive. Those who meet the screening criteria by universal or targeted screening protocols will be identified. However, others may be functionally anemic despite having hematocrit and hemoglobin levels within the acceptable range. Chronic pulmonary or cardiac disease, for example, may create increased oxygen demands due to increased need for oxygen or impaired oxygen utilization; children with these conditions may, therefore, experience symptoms traditionally suggestive of anemia at hemoglobin and hematocrit levels above reference cutoffs (Segel, Hirsh, & Feig, 2002a).

Anemia may be mild, moderate, or severe in nature. Mild anemia, hemoglobin 9.5-11 g/dl, is often asymptomatic and frequently escapes detection. Moderate anemia, hemoglobin 8-9.5 g/dl, may present with other symptoms and warrants timely management to prevent long-term complications. Severe anemia, hemoglobin < 8 g/dl, will warrant investigation and prompt management. Dependent upon its etiology and the magnitude of the RBC deficit, it may be life threatening (Abshire, 2001; Lesperance, Wu, & Bernstein, 2002; Segel et al., 2002a; Tender & Cheng, 2002).

For anemia to be appropriately detected, hematocrit and/or hemoglobin values must be precisely obtained. Specimen reliability is affected by such factors as collection site and sample quantity. Venous blood samples are preferable, however appropriately obtained capillary specimens may be more practical in certain circumstances. For capillary sites to be used, as in a heelstick specimen in the neonate, the site must be warmed and the blood free flowing (Geaghan, 1999; Hermiston & Mentzer, 2002).


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