Haemoglobin 24 g/L and still alive

Case scenario

The presentation

A boy aged 1 year and 8 months was brought to see at me at my city practice. His mother was concerned because during the past four weeks he had lost his usual interest in running around and playing with toys, was more distressed than usual (crying when not clinging to her) and was eating less but drinking lots of milk.

On examination, the boy had a sallow appearance, but was otherwise morphologically normal, fully co-operative, smiling, orientated and helpful for his age. He was tachycardic and had a prominent pansystolic murmur. There was nothing otherwise of note. The boy had been born at term, his vaccinations were up to date and he had had an unremarkable history to then. Opportunistic physical examination of his 4-year-old sister, who was present at the appointment, was normal.