Referral

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.

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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

Pre-choice Triage is currently active for this specialty.

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-Northern-Child & Adolescent Services- Devon ICB - 15N

Referral Form

DRSS referral form

Patient Information

NHS choices - Eat Well

Evidence

  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 on behalf of NHS Devon.

Publication date: February 2017