Protocol · WHO IMCI
Worms and anaemia in children
Anaemia is common in young children and harms growth, learning and resistance to infection. The main causes at first-level care are poor iron intake, malaria and intestinal worms (hookworm and whipworm), with sickle cell disease in some areas. Palmar pallor finds most children who need treatment; a haemoglobin test, where available, confirms the severity.
- Based on WHO IMCI
- For doctors, clinical officers, nurses and community health workers
- Reviewed October 2026
1Who / when
- Every sick child aged 2 months to 5 years: check for anaemia as part of the IMCI assessment.
- Older children with tiredness, poor school performance, pallor, or worms seen in the stool.
- Children in areas where soil-transmitted worms or anaemia are common (for deworming and iron programmes).
2Red flags: refer now
- Severe palmar pallor (palms very pale or white).
- Haemoglobin below 70 g/L (7 g/dL) at 6 to 59 months, or below 80 g/L (8 g/dL) at 5 to 11 years.
- Any general danger sign: unable to drink or breastfeed, vomits everything, convulsions, lethargic or unconscious.
- Fast breathing or difficulty breathing with pallor (possible heart failure), or fever with pallor in a malaria area (possible severe malaria).
- Severe acute malnutrition.
Refer urgently: the child may need a blood transfusion. Follow IMCI pre-referral treatment for any other severe classification.
3Assess
- Palmar pallor: compare the child's palm with your own and the mother's. Severe pallor, some pallor, or none?
- Haemoglobin where available (see the table); it confirms severity.
- Fever: test for malaria in malaria areas (RDT or microscopy).
- Ask about worms in the stool, blood in the stool or urine (schistosomiasis areas), diet and breastfeeding; check weight and MUAC.
- Where sickle cell disease is common, assess for it (IMCI), including family history.
- Check when the child last had mebendazole or albendazole, and vitamin A.
4Classify
| Sign | IMCI classification | Action |
|---|---|---|
| Severe palmar pallor | SEVERE ANAEMIA | Refer urgently to hospital |
| Some palmar pallor | ANAEMIA | Iron; mebendazole if 1 year or older and none in the last 6 months; review in 14 days |
| No palmar pallor | NO ANAEMIA | Under 2 years: assess feeding and counsel |
| Age | No anaemia | Mild | Moderate | Severe |
|---|---|---|---|---|
| 6 to 23 months | 105 or more | 95 to 104 | 70 to 94 | below 70 |
| 24 to 59 months | 110 or more | 100 to 109 | 70 to 99 | below 70 |
| 5 to 11 years | 115 or more | 110 to 114 | 80 to 109 | below 80 |
5Treat
Anaemia (IMCI): iron daily for 14 days, repeated every 14 days for 2 months
| Age or weight | Iron syrup (ferrous fumarate 100 mg per 5 mL, 20 mg iron per mL) | Iron/folate tablet (60 mg iron) |
|---|---|---|
| 2 to 4 months (4 to under 6 kg) | 1 mL | - |
| 4 to 12 months (6 to under 10 kg) | 1.25 mL | - |
| 12 months to 3 years (10 to under 14 kg) | 2 mL | Half a tablet |
| 3 to 5 years (14 to 19 kg) | 2.5 mL | Half a tablet |
Worms
- In the clinic (IMCI): mebendazole 500 mg as a single dose if the child is 1 year or older, hookworm or whipworm are a problem locally, and no dose in the last 6 months.
- Deworming programmes (WHO 2017): single-dose albendazole 400 mg (200 mg at 12 to 23 months) or mebendazole 500 mg, once a year where 20% or more of children are infected, twice a year where more than 50% are.
- Schistosomiasis and other worms: treat per your national programme.
Treat the other causes
- Malaria test positive: treat with an ACT (see the malaria protocol). In malaria areas, give iron only alongside malaria prevention, diagnosis and treatment, and promote bed nets.
- Suspected sickle cell disease: refer for diagnosis and long-term care.
6Follow-up
- Anaemia: review every 14 days and give more iron; continue for 2 months.
- Still pale after 2 months of iron: refer for assessment.
- Feeding problem: review in 5 days.
- Record deworming and vitamin A on the child health card; next deworming dose in 6 or 12 months per the local schedule.
7Counsel
- Give the iron every day for as long as advised, and keep it out of reach of children.
- From 6 months, give a variety of family foods alongside breastfeeding, following the IMCI feeding advice for the child's age.
- Use a latrine and wash hands with soap: clean water, sanitation and hygiene stop worms coming back.
- Sleep under an insecticide-treated net in malaria areas.
Your child's blood is weak, which is why the palms are pale. Give this iron medicine every day and come back in two weeks for more. Bring the child back at once if they become very tired, breathe fast or cannot drink.
8When to refer
- Urgently: severe palmar pallor or severe anaemia by haemoglobin, or any red flag above.
- Still pale after 2 months of iron treatment.
- Suspected sickle cell disease, or anaemia with blood in the stool or urine.
- Anaemia that keeps coming back despite treatment and deworming.
9Sources
- World Health Organization. Integrated Management of Childhood Illness (IMCI) chart booklet. 2014. Anaemia classification by palmar pallor; iron dosing table and 14-day schedule for 2 months; mebendazole 500 mg rule; no iron with RUTF; sickle cell assessment; general danger signs; feeding follow-up.
- World Health Organization. Guideline: preventive chemotherapy to control soil-transmitted helminth infections in at-risk population groups. 2017 (ISBN 9789241550116). Albendazole 400 mg (200 mg under 24 months) or mebendazole 500 mg; annual at 20% prevalence or more, twice yearly above 50%.
- World Health Organization. Guideline: daily iron supplementation in infants and children. 2016 (ISBN 9789241549523). Preventive iron schemes; iron in malaria areas only with malaria prevention, diagnosis and treatment; national guidelines for treatment of diagnosed anaemia.
- World Health Organization. Guideline on haemoglobin cutoffs to define anaemia in individuals and populations. 2024 (ISBN 9789240088542). Table of cutoffs by age; adjustment for altitude.
Adapted from WHO guidance; not endorsed by WHO. This page paraphrases and adapts the WHO publications listed under Sources, which are licensed CC BY-NC-SA 3.0 IGO; the adapted text is shared under the same licence for non-commercial education. Reasoning GP is not affiliated with WHO or any other organisation named here. Use it alongside your national guidelines, essential medicines list and formulary, and your clinical judgement. Doses are given only where they come from a WHO source; otherwise follow your national guideline or formulary.