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Referral
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Anaemia - suspected in clinically well children
Scope
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.
Background
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.
Definition
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
Symptoms
- 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)
- 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 ICB-15N
Referral Form
Patient Information
Evidence
- Up To Date 2016
- 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 on behalf of NHS Devon.
Publication date: December 2016
