A pale child
Most pale children have iron deficiency, malaria or worms, and get better with treatment. A child who stays pale, or keeps coming back pale, needs a different question: why has the treatment not worked?
- Setting: Health centre in a malaria area where sickle cell disease is common; no sickle cell test on site
- For nurses, clinical officers, doctors and community health workers trained in IMCI
- Reviewed October 2026
The presentation
Musa, 3 years and 4 months, is brought because his grandmother thinks he is 'white in the hands' and tires quickly when playing. He was given iron twice in the past year for 'low blood'. He weighs 13.5 kg.
| Sign | Value |
|---|---|
| Axillary temperature | 36.8 °C |
| Breathing rate | 30 per minute |
| Pulse | 124 per minute |
| Conscious level (AVPU) | Alert |
| Weight | 13.5 kg |
Tests at hand: Haemoglobin (Hb) · Malaria rapid diagnostic test (RDT) · Urine dipstick · Mid-upper arm circumference (MUAC)
- Iron deficiency (diet, worms, blood loss)Still possible
- MalariaStill possible
- Hookworm or schistosomiasisStill possible
- Sickle cell disease Must not missStill possible
- Severe anaemia with heart failure Must not missStill possible
- MalnutritionStill possible
- HIV or another chronic illnessLess likely
Work through it
Read each question and decide your own answer first. Then open the model answer and see how the differential changes.
- Step 1 of 7 · Look
First: is this child in danger now? What do you check?
Model answer
- General danger signs: not able to drink, vomits everything, convulsions, lethargic or unconscious.
- Breathing: fast or difficult breathing with pallor can mean the heart is failing from severe anaemia.
- Severe palmar pallor: palms white or nearly white.
- Fever in a malaria area: pallor with fever may be severe malaria.
Musa is alert and drinking, no danger sign. Breathing 30, no indrawing, no fever. His palms are clearly paler than his grandmother's but not white: some palmar pallor. He is not an emergency.
Differential now- Iron deficiency (diet, worms, blood loss)Still possible
- MalariaStill possible
- Hookworm or schistosomiasisStill possible
- Sickle cell disease Must not missStill possible
- MalnutritionStill possible
- Severe anaemia with heart failure Must not missLess likely (moved down)
- HIV or another chronic illnessLess likely
- Step 2 of 7 · Ask
What do you ask to find the cause of his anaemia?
Model answer
- Diet: how much meat, fish, eggs, beans or green leaves?
- Blood loss: blood or black colour in the stool; blood in the urine (schistosomiasis); nosebleeds.
- Worms seen in the stool; last deworming dose.
- Malaria: recent fevers, bed net, last malaria test.
- Yellow eyes at times? Episodes of pain, or painful swollen hands or feet as a baby?
- Family: brothers or sisters with the same problem; anyone known to have sickle cell disease; any child who died young of 'low blood' or infection.
- Iron courses: how many, for how long, and did the pallor improve?
He eats porridge and beans, little meat. No blood in stool or urine. Dewormed 4 months ago. No fever this month; he sleeps under a net. His grandmother says his eyes 'go yellow sometimes', and at 9 months both his hands swelled and he cried for days. An older brother died at 2 years after 'low blood and fever'. Each course of iron did not seem to help.
Differential now- Sickle cell disease Must not missLeading (moved up)
- MalariaStill possible
- MalnutritionStill possible
- Iron deficiency (diet, worms, blood loss)Less likely (moved down)
- Hookworm or schistosomiasisLess likely (moved down)
- Severe anaemia with heart failure Must not missLess likely
- HIV or another chronic illnessLess likely
- Step 3 of 7 · Look
What do you look for on examination?
Model answer
- Eyes for jaundice; inner eyelids and tongue for pallor.
- Heart rate, liver edge, swollen feet, crackles: signs of heart strain from severe anaemia.
- Spleen size: a rapidly enlarging spleen with sudden worsening pallor is an emergency in a child with sickle cell disease.
- MUAC and oedema; mouth for thrush, lymph nodes (HIV).
Whites of the eyes faintly yellow. No heart failure signs. Spleen not felt. MUAC 146 mm, no oedema. No thrush or lymph nodes.
Differential now- Sickle cell disease Must not missLeading
- MalariaStill possible
- Iron deficiency (diet, worms, blood loss)Less likely
- Hookworm or schistosomiasisLess likely
- Severe anaemia with heart failure Must not missLess likely
- MalnutritionSet aside for now (moved down)
- HIV or another chronic illnessSet aside for now (moved down)
- Step 4 of 7 · Test
Which tests do you do, and what would each result mean?
Model answer
- Haemoglobin: at 24 to 59 months, 110 g/L or more is normal, 100 to 109 mild, 70 to 99 moderate, below 70 g/L severe anaemia (refer urgently).
- Malaria RDT: in a malaria area, malaria is a common cause of anaemia and of jaundice, and can be present without much fever.
- Urine dipstick for blood: a pointer to schistosomiasis where it occurs.
- There is no sickle cell test here: that is a reason to refer, not to guess.
Results: Hb 76 g/L (7.6 g/dL), moderate anaemia, close to severe. RDT negative. Urine: no blood.
Differential now- Sickle cell disease Must not missLeading
- Iron deficiency (diet, worms, blood loss)Less likely
- Severe anaemia with heart failure Must not missLess likely
- MalariaSet aside for now (moved down)
- Hookworm or schistosomiasisSet aside for now (moved down)
- MalnutritionSet aside for now
- HIV or another chronic illnessSet aside for now
- Step 5 of 7 · Do
Put it together. What is the most likely cause, and why not simply give iron again?
Model answer
IMCI would classify anaemia (some palmar pallor) and give iron and mebendazole. But Musa has already had two courses of iron without improvement, and he has jaundice, painful swelling of both hands in infancy and a brother who died young. Together these suggest sickle cell disease, which IMCI asks you to assess for where it is common.
Without newborn screening, sickle cell disease is often first noticed after 6 months of age, with swollen hands or feet (dactylitis), a serious infection or a sudden drop in haemoglobin from the spleen trapping blood. Children under 5 with it are at high risk of serious bacterial infection.
Anaemia that keeps coming back after iron and deworming, or pallor still present after 2 months of iron, needs referral for assessment, not another course of iron.Differential now- Sickle cell disease Must not missLeading
- Iron deficiency (diet, worms, blood loss)Less likely
- Severe anaemia with heart failure Must not missLess likely
- MalariaSet aside for now
- Hookworm or schistosomiasisSet aside for now
- MalnutritionSet aside for now
- HIV or another chronic illnessSet aside for now
- Step 6 of 7 · Do
What do you do today, and how urgent is the referral?
Model answer
- Refer to a clinic that can test for sickle cell disease (a point-of-care test or a laboratory test) and enrol him in long-term care. He has no danger sign and Hb is above 70 g/L, so this is a planned referral within days, not an emergency.
- Write the history in the referral note: two iron courses, jaundice, dactylitis at 9 months, the brother's death, Hb 76 g/L, RDT negative.
- Mebendazole is not due (dewormed 4 months ago). Keep the bed net every night.
- If he is confirmed to have sickle cell disease, the clinic will start daily penicillin prophylaxis (recommended under 5 years), check vaccines and consider hydroxyurea, and the family will be offered testing.
Differential now- Sickle cell disease Must not missLeading
- Iron deficiency (diet, worms, blood loss)Less likely
- MalariaSet aside for now
- Hookworm or schistosomiasisSet aside for now
- Severe anaemia with heart failure Must not missSet aside for now (moved down)
- MalnutritionSet aside for now
- HIV or another chronic illnessSet aside for now
- Step 7 of 7 · Ask
Until he is seen, when must the family bring him back at once?
Model answer
- Any fever: in a child who may have sickle cell disease, fever can mean a serious infection.
- Suddenly paler, weak, or a swollen or painful belly.
- Fast or difficult breathing, chest pain.
- Weakness of an arm or leg, a crooked face, trouble speaking, or a fit.
- Severe pain in the hands, feet, back or limbs that paracetamol does not relieve.
- Not able to drink, vomiting everything, very sleepy.
Musa's blood is low and the iron has not fixed it. The way it is happening makes me think of sickle cell disease, which runs in families. The clinic can test for it, and if he has it, daily medicine will protect him from infections. If he gets a fever, his belly swells or he suddenly looks paler, bring him straight away, day or night.
Must-not-miss conditions
| Condition | Clues | What to do at first-level care |
|---|---|---|
| Severe anaemia | Severe palmar pallor; Hb below 70 g/L at 6 to 59 months; breathless, fast pulse, enlarged liver or swollen feet. | Refer urgently for possible transfusion. |
| Severe malaria | Pallor with fever in a malaria area; prostration, jaundice, dark urine, convulsions. | Pre-referral artesunate, prevent low sugar; refer urgently. |
| Acute splenic sequestration (sickle cell disease) | Sudden worsening pallor and weakness with a rapidly enlarging spleen. | Emergency: refer at once. |
| Serious infection in sickle cell disease | Any fever in a child with known or suspected sickle cell disease, especially under 5. | Assess at once; first dose of antibiotic and refer if any sign of severe illness. |
| Stroke (sickle cell disease) | Sudden weakness, facial droop, speech difficulty or a fit. | Refer urgently: urgent transfusion is needed. |
Decision at first-level care
Musa has moderate anaemia (Hb 76 g/L) that has not responded to two courses of iron, with jaundice, dactylitis in infancy and a brother who died young. Malaria and worms are unlikely today. Suspected sickle cell disease: refer within days for a diagnostic test and enrolment in care, with clear advice on when to return at once.
Source: WHO IMCI chart booklet (2014); WHO guideline on haemoglobin cutoffs (2024); WHO consolidated guidelines for the management of common childhood illness: sickle-cell disease (2026).
- Some palmar pallor with a likely simple cause, first episode: iron for 14 days repeated for 2 months, mebendazole if due, malaria test and treatment, review in 14 days.
- Positive malaria test without severity: ACT, then treat the anaemia.
- Iron started: review at 14 days, and again at 2 months to check the pallor has gone.
- Severe palmar pallor, Hb below 70 g/L, or breathless with pallor: urgently.
- Suspected sickle cell disease, or still pale after 2 months of iron: within days.
- Anaemia with blood in the stool or urine.
- Anaemia that keeps coming back despite treatment and deworming.
Key learning points
- Look at the palms of every sick child: severe pallor means urgent referral; some pallor means find and treat the cause.
- Haemoglobin below 70 g/L at 6 to 59 months is severe anaemia.
- Test for malaria in every pale child in a malaria area.
- Anaemia that does not respond to iron is a reason to look for another cause, such as sickle cell disease, not to repeat iron.
- Dactylitis, jaundice and a family history point to sickle cell disease; children under 5 with it need protection from infection.
Sources
- World Health Organization. Integrated Management of Childhood Illness (IMCI) chart booklet. 2014. Palmar pallor classification; iron and mebendazole; assess for sickle cell anaemia where common; refer if still pale after 2 months; general danger signs.
- World Health Organization. Guideline on haemoglobin cutoffs to define anaemia in individuals and populations. 2024. Anaemia severity at 24 to 59 months.
- World Health Organization. WHO consolidated guidelines for the management of common childhood illness: management of sickle-cell disease in children and adolescents. 2026 (ISBN 9789240122666). Late diagnosis after 6 to 12 months with dactylitis, serious infection or acute splenic sequestration; high risk of infection under 5; point-of-care tests for diagnosis; family testing; penicillin prophylaxis under 5; hydroxyurea; transfusion for suspected stroke.
- World Health Organization. Pocket book of hospital care for children: guidelines for the management of common childhood illnesses, second edition. 2013. Transfusion criteria in severe anaemia; signs of heart failure.