Differential Diagnosis of Anemia Part 1 - Tala Talks NICU

Good afternoon, welcome to Tala Talks NICU. I am Dr. Tala, where we cover complicated medical concepts and make them easy for you to understand. Today, we are talking about the differential diagnosis of anemia in neonates, or another way of saying that is the different reasons why a baby might have a low red blood cell count. Now, for the purposes of understanding the different causes of anemia, I've tried very hard to come up with an analogy for you so that you can kind of break it down and... Here we go. Okay, I'm a little nervous about this one. Imagine you're a chimpanzee and you are in the zoo. The only food that you get is a bunch of bananas. Every day, the zookeeper comes and brings a bunch of bananas and puts them in a sack. The sack is hanging from a branch and the branch is over a creek. Okay, this is a very complicated analogy here. So if the bananas fall from the sack or before reaching the sack or afterwards, they fall into the creek and the chimpanzee can't get them. Now, the red blood cells of a baby are the... Bananas. The bananas, right. So the baby needs the red blood cells to live. So the first whole category of why the chimpanzee isn't getting bananas is that the zookeeper just doesn't deliver them, right? So he's run out of gas, he hasn't bought the bananas, he didn't wake up in time, whatever. He doesn't deliver the bananas. So that is when the bone marrow does not produce the red blood cells. So let's start with the different reasons for why the zookeeper isn't bringing the bananas. The first reason is that he might not have all the building blocks that he needs to bring the bananas. So he might have run out of gas, he might not have the money to go buy them. In infants, the main thing that you need in anybody, the main thing that you need is iron to build up the hemoglobin to make the red blood cells. The hemoglobin is the component that actually binds the oxygen. All premature infants have some level of iron deficiency. So if they really don't have enough iron and for whatever reason, they have an exceptionally low amount of iron, then those babies are going to be anemic because of that. So that's kind of one reason why the babies are going to be anemic because they all are a little bit iron deficient so they literally can't make their red blood cells. The other thing that babies are deficient in is a hormone called erythropoietin. It's a hormone that's produced by the kidneys. And erythropoietin basically is the hormone that goes to the bone marrow and stimulates the bone marrow to go and make more red blood cells. So in preemies especially, they're relatively deficient in iron and relatively deficient in erythropoietin. So two big reasons why they're not producing red blood cells and why they do end up with anemia of prematurity. So going back to the zookeeper analogy, that is the same as the zookeeper forgetting, so the zookeeper's wife is the hormone in this situation. So the zookeeper's wife's forgetting to tell the zookeeper to wake up in the morning. So every day she has to nudge him and be like, hey, go feed the chimpanzees, go feed the chimpanzees, go get bananas. And if the zookeeper doesn't do it, the zookeeper's had enough, she's decided she doesn't want to be married to a man any longer, that she literally has to wake up in the morning to go do the job and she's like, I'm leaving. So she leaves, you no longer have that hormone, so the zookeeper is no longer going in and buying the chimpanzees their bananas. So that's the first reason. When you don't have the building blocks, just to actually buy the bananas and get them to the chimpanzees. The second reason why the bone marrow might stop producing red blood cells is leukemia. So going back to the zookeeper, let's say that the upper management in the zoo suddenly decided that the same chimpanzee zookeeper now has to feed all the tigers and they just bought like 1,000 tigers from China and now the zookeeper, that same zookeeper is responsible for feeding them. So all day long, all he's doing is just feeding these tigers loads and loads of meat. He doesn't have time anymore to actually feed, to get the bananas to the chimpanzees because he's so busy with the tigers. That's a very similar scenario in a ridiculous way to leukemia in that another cell in the bone marrow, so specifically the white blood cells and most often it would be the myelogenous line, so like all the neutrophils, rapidly, rapidly multiplying, completely out of control. So basically, they're so busy, the bone marrow is so busy putting out all these white blood cells that it literally doesn't have the time or the energy or the resources to make the red blood cells. So in leukemia, you're also going to end up with anemia. You also end up with lower platelets as well because again, the bone marrow is too busy producing the white blood cells. So the first one is the anemia from the iron deficiency. The second one is a leukemia. The third one is an infection. So the zookeeper is really ill. He's got corona or the flu or whatever and he's just lying in bed unable to move. So same thing with the bone marrow. If the bone marrow, if the baby has sepsis, so like a bacterial sepsis, like a huge GBS that just wipes out the bone marrow, or a torch infection, and remember, we spoke about torch infections before. They're kind of the viruses and the bacteria that are vertically transmitted. The two that we worry about the most that cause suppression of the bone marrow is one, rubella, and two, and this is the one that we always get asked about on boards and we worry a lot about in preemies, and that's parvovirus. In older kids, it's called fifth disease. And in older kids, very often it's just a bad cold, but they can end up with a picture of really red cheeks. So it's also called slapped cheeks, the image that they get, so their cheeks can go really, really red. That is very often a parvovirus illness. In older kids and adults, it's just a bad cold most of the time, but in neonates, that can be really, really bad and completely suppress the bone marrow. They can get very severe anemia. So again, insufficient iron, two, leukemia, three, when you have a bad infection. And then the last one is a genetic cause for the aplastic anemia. For example, the upper management just tells the zookeeper, randomly calls him one day and says, don't bother going in. No other explanation needed, doesn't make any sense. That's the same as some cells in the body just randomly choosing not to make the red blood cells appropriately. And those are part of a syndrome. For example, Diamond-Blackman syndrome, Pearson syndrome, and Fanconi's anemia. And they're very often related or associated with other anomalies as well, skeletal anomalies or Pearson syndrome is associated with the pancreas as well. So those are the four big reasons why the bone marrow is not producing enough red blood cells. The first part of anemia in neonates, please go ahead and watch the second episode on the different reasons why babies can get anemia in the neonatal period. And please like and subscribe so that you can stay up to date with all these fascinating neonatal videos that we are producing. Thank you.