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Referral and warning signs
When to refer
Urgent Referral: Severe Anaemia (Severe Palmar Pallor). Child classified with 'Anaemia' who is still pale after 2 months of iron treatment.
Red flags
- Severe Palmar Pallor.
- Any General Danger Sign.
- Signs of heart failure (oedema, enlarged liver, gallop rhythm).
- Jaundice (suggests haemolysis).
Signs and symptoms
- Ask:
- - Family history of sickle cell anaemia?
- Look:
- - Look at the palms of the hands for pallor (paleness). Compare with your own palm or another child's.
- - Is there Severe Palmar Pallor (very pale, almost white)?
- - Is there Some Palmar Pallor (paler than normal)?
Risk factors
- Iron deficiency (dietary, hookworm).
- Malaria.
- Sickle Cell Disease.
- HIV infection.
- Chronic illness.
- Malnutrition.
Diagnosis
Clinical assessment
Assessment based on visual inspection of palmar pallor.
Investigations
- Haemoglobin (Hb) measurement (confirms anaemia severity, done at higher levels).
- Peripheral blood smear (check morphology, malaria parasites).
- Sickle cell test / Hb Electrophoresis (if suspected).
- Stool for ova/parasites (hookworm).
Diagnostic criteria
IMCI Classification based on palmar pallor: - Severe Anaemia: Severe Palmar Pallor. - Anaemia: Some Palmar Pallor. - No Anaemia: No Palmar Pallor.
Management
Non-pharmacological management
- Anaemia: Advise mother on iron-rich foods. Counsel on malaria prevention.
- No Anaemia: If child <2 years, assess feeding and counsel.
- Advise mother when to return immediately (danger signs).
Pharmacological treatment
- Severe Anaemia:
- - Refer URGENTLY to Hospital (likely needs transfusion).
- Anaemia:
- - Give Iron: Ferrous Sulphate syrup/tablets. Dose: 1ml syrup (25mg elemental Fe) OD (2-12m); 1/2 tab (approx 30mg elemental Fe) OD (1-5y). Continue for 14 days initially.
- - *Exception:* If child has SAM and is receiving RUTF, DO NOT give iron (RUTF contains iron).
- - Give Folic Acid 2.5mg daily if child has known Sickle Cell Disease.
- - Give Deworming: Mebendazole (500mg single) or Albendazole (400mg single; 200mg if 12-23m) if child >=1 year and not treated in last 6 months.
- - Follow up in 14 days (reassess pallor, continue iron if needed). If still pale after 2 months, refer.
- No Anaemia: No iron needed unless specific indication.
Monitoring
Follow up 'Anaemia' classification in 14 days. Reassess palmar pallor. If still pale, continue iron and review again in 14 days. If pallor persists after 2 months total treatment, refer. If pallor resolved, counsel on diet.
Complications
- Severe anaemia -> Heart failure, Shock, Death.
- Impaired growth and cognitive development.
- Reduced immunity.
Prevention
- Iron-rich diet.
- Malaria prevention (LLINs).
- Deworming.
- Iron/Folic acid supplementation in high-risk groups (as per national policy).
Patient education
- Explanation of anaemia.
- How to give iron supplements correctly (dose, duration).
- Explain side effects (black stools are normal).
- Importance of iron-rich foods.
- Need for deworming.
- Malaria prevention.
- Importance of follow-up.
Uganda-specific notes
Anaemia is highly prevalent. Palmar pallor assessment is the standard IMCI screening tool at primary level. Iron deficiency, malaria, and hookworm are major contributors. Sickle cell disease prevalence is high in certain regions. Hb testing capacity is limited at lower levels.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 17, Section 17.3.7
- IMCI Chart Booklet, MOH Uganda
(Anaemia Assessment Algorithm)