Patient Presentation
A resident in his pediatric continuity clinic curb-sided his attending pediatrician. “I saw a 15-month-old male this morning with one of the other attendings. He had a low hemoglobin and hematocrit when we tested him at 12 months and I started him on iron. He didn’t come back to check any labs and today I rechecked him. He’s still low for both and I’m not sure what to do next,” he asked.

“Iron deficiency anemia is still your most common cause. Do you think he even took the iron? Did his teeth look dark liked they were stained from the iron?” she asked.

“I’m not sure. But he looked well. No obvious bruising and mom didn’t complain of fatigue or bruising or bleeding. He should be absorbing the iron because he’s a healthy kid. He is Caucasian and didn’t have any weird hemoglobins on his newborn screen so I think a hemoglobinopathy is unlikely. I also think blood loss or hemolysis are also unlikely given his CBC today,” he answered.

‘I’m also going to assume that he had normal platelets and white blood cells and you aren’t worried about a malignancy, right?” she inquired.

“Yeah, platelets and white count are normal. His MCV is 83 so it is a little low but still a normocytic anemia,” he responded.

“Something else to consider is viral suppression. You should have more answers when the retics and iron studies come back later,” she added.

Later on that afternoon, the resident said that he had seen the other attending pediatrician who asked him to talk with the hematologist. He said the hematologist asked almost the same questions and added transient erythroblastopenia of childhood to the differential and also discussed next steps for other possible testing if the reticulocytes and iron studies didn’t support iron deficiency anemia.

The attending replied, “I sometimes forget about TEC as its one of those transient problems like viral suppression and gets better. That’s another one to add to the differential when we need to work up these kids. I still bet the mother didn’t give the iron though. The parents just often forget or the kid doesn’t like the taste,” she said.

Discussion
Transient erythroblastopenia of childhood (TEC) is an “…anemia with a hemoglobin level at least 2 [standard deviations] below normal and a low reticulocyte count in relationship to the anemia in the absence of evidence of alternative causes of anemia.” A bone marrow aspirate shows decreased or absent erythroid precursor cells if obtained. The etiology is not well understood but may have a stimulating cause such as a viral infection, an immune-related and/or genetic cause. Parvovirus causing bone marrow suppression has been implicated and there are cases of affected siblings.

TEC is most common in 1-4 year olds but can be seen after 6 months and as old as 10 years. The natural history is that it spontaneously resolves usually in a few weeks (usually 4-8 weeks) but it can be for up to a year. Invariably as many patients only come to attention if they have severe disease and with normal spontaneous resolution, the actual number of TEC cases is probably underreported. Treatment is supportive including transfusion if the anemia is causing hemodynamic or other effects. Patients with more severe disease may have pallor, anorexia, lethargy and irritability, and most are hemodynamically stable. Treatment is supportive including transfusion if the anemia is causing hemodynamic instability or other effects.

Learning Point
TEC is often a clinical and laboratory diagnosis of exclusion if it follows its natural history.

Laboratory testing usually shows a normocytic anemia with very low reticulocytes (often < 0.1), and an increase in reticulocytes heralds the beginning of the recovery phase. White blood cells are usually normal but some patients will show a mild neutropenia. Platelet counts are also normal, but again could be slightly low. Mean corpuscular volume (MCV) of the red blood cells is normal. Iron studies are also normal. Other studies to consider in evaluations for anemia are evidence of blood loss (i.e. gastrointestinal, urinary), hemolysis, oncological problems, or viral-induced bone marrow suppression.

As TEC is a pure red cell aplasia, it seems to occur in the first year of life and must be distinguished from Diamond-Blackfan anemia (a congenital red cell aplasia). Other normocytic anemias include:

• Blood loss
• Hemolysis
• Iron deficiency anemia, early
• Anemia of chronic disease
• Erythropoietin deficiency
• Aplastic anemia – Schwachman-Diamond or Fanconi anemia
• Myelodysplastic syndromes

Questions for Further Discussion
1. What are some congenital aplastic anemias? A review can be found here
2. Why is iron important to heme synthesis? A review can be found here
3. What are common hemoglobinopathies and how are they diagnosed?

Related Cases

Disease: Transient Erythroblastopenia of Childhood | Anemia

Symptom/Presentation: Abnormal Laboratory Test

Specialty: Hematology

Age: Toddler

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Anemia

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Shaw J, Meeder R. Transient erythroblastopenia of childhood in siblings: case report and review of the literature. J Pediatr Hematol Oncol. 2007;29(9):659-660. doi:10.1097/MPH.0b013e31814684e9

van den Akker M, Dror Y, Odame I. Transient erythroblastopenia of childhood is an underdiagnosed and self-limiting disease. Acta Paediatrica. 2014;103(7):e288-e294. doi:10.1111/apa.12634

Burns RA, Woodward GA. Transient Erythroblastopenia of Childhood: A Review for the Pediatric Emergency Medicine Physician. Pediatr Emerg Care. 2019;35(3):237-240. doi:10.1097/PEC.0000000000001760

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa