Definition

Anaemia is defined as a condition in which the concentration of haemoglobin (the red blood cells) in the blood is decreased below normal either singly or in combination.

Anaemia is a serious condition.

Anaemia is the reduction in the number of red blood cells or haemoglobin or both leading to low oxygen carrying capacity in blood.

At birth, normal values of haemoglobin (central venous) in infants >34 weeks gestation are 14–20 g/dL with an average value of 17 g/dL.

Central venous haemoglobin level <13 g/dL in an infant of >34 weeks gestation is considered anaemia.

Pathophysiology

Anaemia in the newborn infant may be due to any one of the following four pathologies: a. Physiologic anaemia of infancy: This is due to a shorter lifespan of red blood cells (RBCs) and lesser erythropoietin production, occurring between 6 and 8 weeks of age. b. Loss of RBCs (Hemorrhagic anemia): Anemia resulting from blood loss. c. Destruction of RBCs (Hemolytic anemia): Anemia caused by the excessive breakdown of red blood cells. d. Underproduction of RBCs (Hypoplastic anaemia): Anaemia due to insufficient red blood cell production by the bone marrow.

Causes

The main causes are:

1. Haemorrhage:
   • Failure in the production of the red blood cells. Anaemia present at the time of birth is usually due to haemolysis, but anaemia becomes apparent after 24 hours of life. Additional causes must be considered, such as:
     • Prematurity.
     • Anaemia in the mother (severe anaemia) but rarely causes anaemia in a baby.
   • Haemorrhage:
     • Bleeding from the placenta or cord.
     • Placenta previa may cause severe blood loss from the fetus.
     • Accidental hypo-vaguary causes anoxia & intrauterine death.
     • Incision of the placenta during Caesarean section.
     • Tunician cervix.
     • Rupture of the cord – this very rarely seen.
     • Velamentous insertion of the cord.
     • Cutting the cord of the fetus before birth of the baby during Caesarean section is a serious condition.
     • Stripping off of the cord ligature especially if the cord is fat. It shrinks rapidly. This is the commonest cause of external haemorrhage.
     • Haemorrhage from one twin to another twin through placental circulation.
     • Haemorrhage in peritoneal cavity due to rupture of the spleen and liver in difficult delivery of the breech.
2. Haemolysis:
   • May be due to:
     • ABO incompatibility.
     • Rh incompatibility. This one is more likely to cause anemia than ABO incompatibility.
     • Septicemia – haemolytic anemia may occur.
     • Infections – severe.
     • Drugs eg. Sulphadimidine taken by pregnant women.
     • Rarely seen – chloramphenicol or VK.
3. Prematurity:
   • The baby is delivered before term and has not been able to store enough iron in the liver like a full term baby.
   • Anaemia may also occur after the first 2 to 3 weeks of life.
4. Decreased Red Blood Cell Production:
   • Prematurity: Preterm infants have lower red blood cell production capacity.
   • Nutritional deficiencies: Iron deficiency is common, particularly in premature or low-birth-weight infants.
   • Congenital anomalies affecting red blood cell production.
   • Maternal infections such as Parvovirus B19.
   • Chronic diseases.
   • Severe hypoxia.
5. Other Causes:
   • Twin-twin transfusion syndrome.
   • Maternal use of certain medications during pregnancy (e.g., some anticonvulsants).

Assessment/Diagnosis/Investigations

(1) History

• Family history of bleeding disorders.
• Maternal medications (phenytoin, warfarin, other medications that may affect hematopoiesis).
• Maternal infections during pregnancy.
• Exposure to environmental toxins.

(2) Clinical Examination

• Pallor.
• Jaundice.
• Splenomegaly (enlarged spleen).
• Hepatomegaly (enlarged liver).
• Skin bruises or petechiae.
• Tachycardia and tachypnea (potentially indicating the body’s attempt to compensate for reduced oxygen-carrying capacity).

(3) Laboratory Tests

• Complete blood count (CBC): To determine Hb concentration, hematocrit, red blood cell indices (MCV, MCH, MCHC), and white blood cell count.
• RBC indices: Mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH), mean corpuscular hemoglobin concentration (MCHC) provide information about the size and hemoglobin content of red blood cells, helping to differentiate types of anemia.
• Blood smear: To examine red blood cell morphology and identify any abnormalities.
• Reticulocyte count: To assess bone marrow erythropoietic activity. An elevated count suggests increased RBC production in response to anemia. A low count indicates inadequate bone marrow response.
• Kleihauer-Betke test: Detects fetal hemoglobin in maternal blood, helping to quantify fetomaternal hemorrhage.
• Coagulation profile: Prothrombin time (PT), partial thromboplastin time (PTT), fibrinogen levels, and other tests to evaluate bleeding disorders.
• Direct and indirect Coombs test: Detects antibodies attached to red blood cells, indicating autoimmune hemolytic anemia.
• Serum bilirubin levels: Elevated levels suggest hemolysis.
• Testing for specific inherited blood disorders (e.g., hemoglobin electrophoresis for hemoglobinopathies, genetic testing for other inherited anemias).
• Ultrasound of abdomen and head: To detect intracranial or visceral hemorrhage.
• TORCH (Toxoplasmosis, Other infections, Rubella, Cytomegalovirus, Herpes simplex virus) serology: Screens for infections that can cause anemia.

Prophylaxis or Preventive Treatment

1. Prevent anemia in pregnant women:
   • Good antenatal care.
   • Advising mothers to report vaginal discharge affecting during pregnancy.
   • Mal-presentations like breech. Should be corrected as it’s likely to be injured.
   • Breech delivery.
   • Internal organs of the baby are likely to be injured.
   • Prevent prematurity.
2. During Labour:
   • Prevent ante-partum haemorrhage and report to doctor immediately.
   • Cesarean sections should be done by expert doctors.
   • Breech delivery. Should be conducted properly.
3. During Puerperium:
   • Umbilical cord should firmly ligatured.
   • Prevent infections from the newborn baby eg. from the cord which may lead to septicemia.
   • The cord injured babies are nursed properly to prevent cerebral haemorrhage.

Management of Anaemia in Newborn

Maternity Centre (Initial Management)

• Assess for clinical signs of anaemia (pallor, lethargy, tachycardia, tachypnea).
• If there’s any bleeding site, arrest haemorrhage.
• Give injection Vit-K – 0.5 mg to 1 mg intramuscularly.
• Write a well detailed note and transfer the baby to hospital.
• Stabilise the infant, addressing any immediate life-threatening conditions.
• Assess for causes (history, physical examination, preliminary investigations).
• Initiate supportive care (oxygen, fluid management).
• Provide education to the parents.

Referral Criteria

Referral to a higher level of care is crucial for infants with:

• Severe anaemia (Hb significantly below normal range).
• Suspected hemolytic anaemia.
• Signs of significant blood loss.
• Unclear aetiology.
• Failure to respond to initial management.

Hospital Management

• Doctor is informed.
• Comprehensive assessment, including specialized tests to pinpoint the etiology.
• Specific treatment directed at the underlying cause:
  • Paediatric iron (40 mg) 4mls tds – given in mild cases.
  • In severe cases blood transfusion of packed cells is given.
  • Blood transfusion for severe anemia or significant blood loss.
  • Phototherapy for hyperbilirubinemia.
  • Exchange transfusion for severe hemolytic disease.
  • Iron supplementation for iron deficiency anemia.
  • Management of underlying infections.
  • Treatment of inherited disorders.
• Close monitoring of vital signs, Hb levels, and other relevant parameters.

Nursing Care

• Monitor vital signs, intake and output, and weight.
• Assess for signs of anemia and complications (e.g., heart failure, shock).
• Administer medications as prescribed.
• Monitor transfusion reactions.
• Provide supportive care (e.g., feeding assistance, thermoregulation).
• Educate parents about the cause, management, and prognosis of the anemia.