Pediatric Acute Anemia Treatment & Management

Updated: Sep 22, 2021
  • Author: Susumu Inoue, MD; Chief Editor: Robert J Arceci, MD, PhD  more...
  • Print

Approach Considerations

Acute anemia usually warrants immediate medical attention. Treatment depends on the severity and underlying cause of the anemia.

Initial treatment begins with careful assessment of the signs and symptoms of the anemia that indicate therapy. Guidelines for the treatment of patients with critical illness apply to children with severe anemia who are in acute distress and unstable. Supportive measures, such as supplemental oxygen for decreased oxygen-carrying capacity, fluid resuscitation for hypovolemia, and bed rest or activity restriction for fatigue, may be required. Inpatient care is indicated in patients with CHF who are severely anemic and in those with unstable vital signs (eg, hypotension, active bleeding). Most of these patients require admission to the intensive care unit (ICU). Patients who may be stable but who have severe anemia may also be admitted for diagnostic workup.

Except in cases of uncontrolled hemorrhage, surgery is very rarely indicated in acute anemia. Splenectomy is occasionally considered in persons with autoimmune hemolytic anemia that is refractory to medical treatment.

Activity restriction or bed rest may be indicated in symptomatic individuals with severe anemia.



Transfusion with packed RBCs (PRBCs) is the universal treatment for most individuals with severe acute anemia. The British Committee for Standards in Hematology Transfusion Task Force has established guidelines for transfusions in neonates and older children. [19] and its amendments [20] The indication to transfuse should not be based solely on the hemoglobin or hematocrit levels; more importantly, one must consider the clinical effects or the signs and symptoms of the individual with anemia. [3]

A published article summarizing 19 randomized controlled studies in adults concluded that transfusions at a low Hb threshold level (7-9) compared with transfusions at a high Hb threshold level (9-13.3) showed a significantly reduced risk of 30-day all-cause mortality. [21] In another adult study, with acute GI hemorrhage, restricted blood transfusion (Hb threshold of 7) versus a liberal transfusion strategy resulted in significantly reduced morbidity and mortality in the former group of patients. [22]  In contrast, however, in a pediatric intensive care unit study by Lacroix et al in which anemic but hemodynamically stable children were randomized to a restricted (overall average lowest Hb level 8.7 g/dL) or liberal (overall average lowest Hb level 10.8 g/dL) transfusion group, medical outcomes were found to be the same. [23]

If transfusion is indicated, the packed RBC (PRBC) dose is 10-15 mL/kg over 3-4 hours. The rate of transfusion can be modified according to the clinical situation. Transfusion can be administered faster in individuals with acute blood loss or slower or in smaller aliquots in persons with CHF. Be aware of the risks of inciting heart failure by rapid transfusion in patients with severe chronic anemia and patients in a compromised cardiovascular state.

In an extremely urgent situation, such as massive hemorrhage due to trauma, or in neonates who have experienced severe blood loss, emergency-release blood transfusion can be performed. The blood used in this situation is O-negative type and can be released by a blood bank without cross matching. [24]

In individuals with autoimmune hemolytic anemia, blood must be given with extreme caution, using the blood unit that is least reactive on crossmatch.



Except for patients who have acute anemia secondary to blood loss from obvious trauma or injury, a hematology consultation is advised for most patients with acute anemia to determine the underlying RBC disorder and provide the appropriate therapy.

In particular, the following features in an individual with acute anemia indicate the need for a hematology consultation:

  • Concomitant abnormality in WBC and/or platelet counts (eg, neutropenia, thrombocytopenia, presence of immature WBCs)

  • Positive Coombs test result

  • Hepatosplenomegaly

  • History of underlying hematologic disorder

  • Excessive blood loss relative to the degree of injury in individuals who may have an underlying bleeding disorder

  • Patients who are actively treated for an underlying malignancy

Consider a gastroenterology consult for GI blood loss, particularly in suspected esophageal varices, inflammatory bowel disease, and other


Consider a surgical consult for possible trauma to spleen, liver, and/or kidneys.