Pediatric Anemia (Megaloblastic or Pernicious)

Anemia is a problem in which there are not enough red blood cells or hemoglobin. Hemoglobin is the part of red blood cells that carries oxygen throughout the body. In megaloblastic anemia, the bone marrow, where the cells are formed, makes fewer cells. And the cells that are formed don’t live as long as normal. The red blood cells:

• Are too large
• May be abnormally shaped

There are many causes of megaloblastic anemia. The most common cause in children is lack of folic acid or vitamin B-12. Other causes include:

• Digestive diseases. These include celiac disease, chronic infectious enteritis, and enteroenteric fistulas. Pernicious anemia is a type of megaloblastic anemia. It’s caused when the body can't absorb vitamin B-12. A substance called intrinsic factor is normally made in the stomach. This substance helps the body absorb B-12. A person with pernicious anemia does not have enough of this substance.
• Inherited congenital folate malabsorption. A genetic problem in which infants can’t absorb folic acid.
• Medicines. Certain medicines, like those that prevent seizures, can interfere with how folic acid is absorbed.
• Diet. Certain restrictive diets can lead to low levels of folate or B-12 because the child does not get enough of these nutrients.

These are some of the symptoms associated with megaloblastic anemia:

• Pale or yellow skin
• Fast heart beat
• Shortness of breath
• Lack of energy, feeling tired
• Decreased appetite
• Irritability or fussiness
• Hair color changes (rare)
• Stomach upsets, nausea, diarrhea, gas, constipation
• Trouble walking
• Numbness or tingling in hands and feet
• Smooth and sore tongue
• Weak muscles

The symptoms of megaloblastic anemia may look like other conditions or health problems. Always check with your child's healthcare provider for a diagnosis.

Your healthcare provider will ask about your child’s symptoms and health history. He or she will give your child a physical exam. Your child may also have tests, such as:

• Hemoglobin and hematocrit. This is often the first screening test for anemia in children. It measures the amount of hemoglobin and red blood cells in the blood. 
• Complete blood count or CBC. A complete blood count checks the red blood cells, white blood cells, blood clotting cells (platelets), and sometimes, young red blood cells (reticulocytes). It includes hemoglobin and hematocrit and more details about the red blood cells. 
• Peripheral smear. A small sample of blood is examined under a microscope. Blood cells are checked to see if they look normal or not. 
• Other blood tests. For example, your child may need bilirubin or other liver tests, folate and B-12 blood tests, and iron tests. 

Rarely, a bone marrow aspiration, biopsy, or both may be done to look at the number, size and maturity of blood cells and abnormal cells.

Treatment will depend on the specific cause of the anemia, your child’s symptoms, age and general health. It will also depend on how severe the condition is.

Your child's healthcare provider may refer you to a hematologist. This is an expert in blood disorders. If the anemia is caused by a digestive tract problem, it may need to be treated first. Your child's provider may also refer you to a gastroenterologist for this reason. He or she is an expert in digestive system problems. 

Most children with megaloblastic anemia are given B-12 or folic acid supplements. Vitamin B-12 supplements are best absorbed when given by injection. Folic acid supplements are given by mouth.

Foods that have natural folate include:

• Oranges, orange juice
• Dark green and leafy vegetables
• Liver
• Barley
• Sprouts
• Wheat germ
• Beans, peas, lentils
• Peanuts

Cereals, breads, pastas and rice are fortified with man-made folic acid.

Meat and dairy products have the most vitamin B-12.

In general, anemia may cause:

• Problems with growth and development
• Fatigue
• Poor exercise tolerance
• An enlarged heart or heart failure, if the anemia is severe

Call your child's healthcare provider if your child has decreased energy, increased tiredness or other symptoms of anemia.