Doctors Revision

IMCI · Age: 2 months - 5 years

Anaemia

Classification for a child presenting with some palmar pallor (palms look pale, but not severely white). Requires investigation for malaria, treatment with iron (unless contraindicated), and follow-up.

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Care priority and warning signs

Care priority

Routine Management / Treat with Iron / Assess for SCD

Red flags

  • Development of severe pallor.
  • Signs of heart failure.
  • History or signs highly suggestive of Sickle Cell Disease crisis (requires specific management/referral).
  • Failure to respond to iron therapy after 2 months (refer).

Assessment

  • Look/Feel: Look at the child's palms. Are they pale? (Some Palmar Pallor).
  • Confirm absence of Severe Palmar Pallor.
  • If palmar pallor (some or severe) is present, assess for history and symptoms suggestive of Sickle Cell Disease (SCD):
  • Ask: Family history of SCD or sibling death from anaemia?
  • Ask: History of painful joints/bones, episodes of severe pain (abdomen, chest, bones)?
  • Ask: History of previous blood transfusion?
  • Look/Feel: Swelling of hands & feet (dactylitis, esp. in infants)?
  • Look/Feel: Features suggestive of stroke (weakness of one side)?
  • Look/Feel: Bossing (prominence) of skull?

Classification

  • Some palmar pallor -> ANAEMIA

Key features

  • Presence of Some Palmar Pallor.
  • Absence of Severe Palmar Pallor.
  • Requires malaria testing.
  • Requires iron treatment (unless contraindicated by confirmed SCD + RUTF, or SAM + RUTF).
  • Requires assessment for underlying causes, including SCD.

Management

Non-pharmacological management

  • Counsel on iron-rich foods.
  • If SCD confirmed, provide specific counselling and link to care.

Pharmacological treatment

  • Do Malaria Test (RDT or Microscopy). Treat if positive (see Malaria classification).
  • Give Iron: Provide Iron/Folate supplement (e.g., Ferrous sulfate 200mg + Folic acid 250mcg tablet, containing ~60mg elemental iron) or Iron Syrup (e.g., Ferrous fumarate 100mg/5ml, containing ~20mg elemental iron/5ml) once daily for 14 days initially. Syrup Dose: 2-3m (<6kg): 1.0ml (<1/4 tsp). 4m-<12m (6-<10kg): 1.25ml (1/4 tsp). 12m-<3y (10-<14kg): 2.0ml (<1/2 tsp). 3y-5y (14-19kg): 2.5ml (1/2 tsp). Tablet Dose: 12m-<3y: 1/2 tablet. 3y-5y: 1/2 tablet. (Note: Doses match syrup/tab given on page 17, continue for 14 days initially).
  • Give Folic Acid (5mg tablet) if giving plain iron (not iron+folate compound). Dose: 1/2 tablet daily for 2-3m, 1 tablet daily for 4m-5y.
  • IMPORTANT Iron Contraindications: If child has confirmed Sickle Cell Disease AND/OR Severe Acute Malnutrition AND is receiving RUTF, DO NOT give iron supplement. Give Folic Acid instead.
  • Give Mebendazole 500mg single dose if child >= 1 year and not dewormed in past 6 months (Page 20).
  • If child has history or symptoms suggestive of SCD: Recommend testing for SCD (e.g., Hb electrophoresis). If child already confirmed with SCD and has pallor/illness, REFER.

Pre-referral treatment

  • If referring due to confirmed SCD needing assessment: Manage pain, ensure hydration.

Follow-up

  • Follow-up in 14 days.
  • At follow-up (Day 14): Reassess palmar pallor. If still some pallor, continue giving iron daily for 2 months total. If severe pallor, refer urgently. If no pallor, stop iron.
  • Advise mother when to return immediately (develops severe pallor, danger signs).

Counselling points

  • Explain the child has anaemia (pale blood) and needs iron medicine.
  • Teach how to give iron supplement correctly (dose, frequency, duration - 14 days initially, then reassess).
  • Advise iron can make stools black.
  • Advise on iron-rich foods.
  • Explain importance of deworming (Mebendazole).
  • If SCD suspected: Explain the need for testing and potential for inherited condition.
  • If SCD confirmed: Provide specific counselling (link to SCD clinic, avoid iron unless prescribed, importance of folic acid, recognize crisis signs).
  • Advise when to return immediately (severe pallor, danger signs).
  • Advise on follow-up in 14 days.

Differential diagnosis

  • Severe Anaemia
  • No Anaemia
  • Causes of anaemia: Iron deficiency, Malaria, Hookworm, Sickle Cell Disease, Other haemoglobinopathies, Chronic infection/inflammation, Malnutrition.

Complications

  • Progression to severe anaemia
  • Impaired cognitive development (iron deficiency)
  • Reduced exercise tolerance
  • Increased susceptibility to infection
  • Complications related to underlying cause (e.g., SCD crisis)

Prevention

  • Malaria prevention.
  • Routine iron supplementation in high-risk populations/ages.
  • Deworming.
  • Diet rich in iron and enhancers of iron absorption (Vitamin C).
  • Delayed cord clamping at birth.
  • Newborn screening and management for SCD.

References

IMCI Chart Booklet - Page 7, Page 17 (Iron/Folate Dosing), Page 20 (Mebendazole), Page 25 (Follow-up Anaemia)

For learning and professional reference. Use current local guidance and clinical judgement.

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