Anaemia - suspected in clinically well children


This guidance refers to children and young people up to 16th birthday, or 18th birthday if the young person prefers to be seen in a paediatric setting.


Anaemia is very common in pre-school children, particularly between 6 and 24 months of age. Anaemia is usually nutritional in pre-school children and these can benefit from input from universal services (health visitors). Children of school age with anaemia require referral for assessment.

Anaemia should be suspected in a child who appears pale. Fatigue, myalgia and breathlessness are very rarely due to anaemia.


Haemoglobin less than age-appropriate normal range.

Out of scope

Children with suspected leukaemia or who are unwell are not covered by this guidance.


History and Examination

History should include:

Antenatal risk factors

  • preterm
  • intra-uterine growth retardation
  • maternal anaemia

Diet history

  • late weaning
  • early introduction of "doorstep" milk
  • vegetarian/vegan
  • drinking more than a pint of milk a day if over one year old
  • pica (eating non-food items)

Ethnic history

  • Mediterranean/Arabic/Asian (thalassaemia, G6PDD)
  • African/Afro-Caribbean (Sickle cell, G6PDD)

Family history

  • Gallstones
  • Splenectomy
  • Blood transfusion
  • Consanguinity


  • GI disturbance including blood in stool
  • Frequent infection
  • Pruritus ani
  • Behaviour/learning problems
Examine for:
  • Pallor
  • Cardio-respiratory compromise
  • Lymphadenopathy
  • Hepatosplenomegaly
  • GI signs – bloating/distension, mouth ulcers, perianal disease
  • Height and weight essential plotted on growth chart (see RCPCH growth chart)

Red Flags

  • Severe pallor
  • Fever/signs of sepsis
  • Tachypnoea or tachycardia
  • Unexplained bruising or bleeding
  • Weight loss/faltering growth
  • Hepatosplenomegaly
  • Pancytopenia, blasts in film


What to do in primary care

FBC and film – only – ferritin is not indicated in initial assessment

If microcytic anaemia – treat with oral iron and repeat FBC, plus IgA and coeliac screen after 2 weeks – ensure correct dose and compliance

If Hb increased by more than 10g/l continue iron for 3 months and no further investigation (it is not necessary to repeat FBC at end of this provided symptoms resolved)

If history suggestive of helminth infection – worms in stool, pica, pruritus ani, travel – it is reasonable to empirically treat with mebendazole


Referral Criteria

Refer urgently to on-call team if:
  • Severe pallor
  • Fever/signs of sepsis
  • Tachypnoea or tachycardia
  • Unexplained bruising or bleeding
  • Hepatosplenomegaly
  • Pancytopenia, blasts in film
Refer general paediatric outpatients if:
  • Age 6 or over
  • GI symptoms (if blood in stool consider paediatric gastroenterology referral)
  • Faltering growth if weight loss refer as urgent
Refer paediatric haematology if:
  • Severe anaemia less than 80g/l without red flags
  • Failure to respond to iron therapy (ensure compliance first)
  • Concern re hereditary haemolytic anaemia – family history, ethnic origin, suggestive blood film
  • Normocytic/megaloblastic anaemia

Referral Instructions

e-Referral Service Selection

  • Priority: urgent/routine
  • Specialty: Children's & Adolescent Services
  • Clinic Type: Other medical/Haematology
  • Service: DRSS-Eastern-Paediatrics- Devon CCG-15N

Referral Forms

DRSS referral form

Supporting Information

Patient Information

NHS choices website


  1. Up To Date 2016
  2. Paediatric Haematology, 3rd Edition (Wiley) 2007; Robert J. Arceci (Editor), Ian M. Hann (Editor), Owen P. Smith (Editor)

Pathway Group

This guideline has been signed off by the Eastern Locality on behalf of NEW Devon CCG.

Publication date: December 2016


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