Clinical investigations from the RACP

The pale child: remember the basics and keep it simple

Shairbanu S Zinna, Paul Monagle



Isolated pallor is common in children, either as a primary presentation or an incidental finding. A simple clinically-based approach can often make diagnosis and management of the pale child straightforward. A careful history and clinical examination will frequently lead to the underlying diagnosis of anaemia, and assessment of vital signs and consideration of the acuity of the anaemia ensures the safety of the patient.

Key Points

  • Children are pale for many reasons but true pallor of the mucous membranes and palmar creases usually represents anaemia.
  • There are many causes of anaemia. Arriving at the appropriate clinical response is usually straightforward if the process is broken down into a few simple decisions.
  • Acute anaemias, such as acute blood loss or haemolysis, are medical emergencies and almost always require immediate transfer of the patient to hospital, potentially for transfusion support.
  • The haemoglobin level is never the determinant of the need for transfusion. Rather, it is the ability of the cardiovascular system to maintain oxygen delivery.
  • Chronic anaemias, especially iron deficiency, are often well tolerated and have minimal symptoms, but the long-term effects are significant, so a high index of suspicion is appropriate.
  • Iron deficiency is easy to treat in principle but often much more difficult in practice, requiring considerable time and effort to help parents with toddler behaviour and appropriate dietary patterns. Simply prescribing iron supplements is inadequate.
  • Megaloblastic anaemia is insidious in its presentation and has potential marked impact on long-term neurodevelopmental outcome. It should be considered early in children with neurodevelopmental delay, failure to thrive and abnormal haematology.

    Picture credit: © Bibica/ Model used for illustrative purposes only