Pallor: Advice for Referrers

RHC for Health Professionals
NHS GGC

Pallor can be present with any condition that decreases the haemoglobin concentration in blood or changes the distribution of blood away from the surface of the skin. 

Causes may be: 

  • Decreased erythrocyte or haemoglobin production
  • Increased erythrocyte destruction
  • Blood loss
  • Non-haematological
    • e.g. shock, respiratory failure, hypoglycaemia, oedema

Red Flags

  • Unexplained bruising
  • Bleeding
  • Weight loss
  • Shock
  • Arrhythmia
  • Murmur

Who to refer

  • Acute onset pallor and signs of haemorrhage or acute concerns

→ on the day discussion for potential same day admission 

  • Pallor with red flags or presence of associated features

→ consider same day or urgent outpatient referral

  • Unexplained pallor outwith expectations for skin pigmentation with no red flags or other concerns

→ routine outpatient referral including history and examination as below

Who not to refer

  • Pallor in keeping with family skin pigmentation and no red flags or other clinical concerns

History to include in letter (include negative findings)

General: 

  • Acute vs chronic
  • Signs of blood loss e.g. haematuria, haematemesis, blood in stools
  • Exercise tolerance
  • Growth / weight change
  • Polyuria / polydipsia(if suspect diabetes mellitus – refer same day for admission)
  • Any other associated features
    e.g. abdominal pain, sweatiness, nausea, tremor, headaches, change in urine colour 

Diet: 

  • Normal diet, including volume of usual milk consumed
  • Any dietary restrictions (including for parent if breastfed)

Background: 

  • Any antenatal or family haemoglobinopathy screening
  • Family history of splenomegaly, splenectomy or early cholecystectomy

Examination to include in letter (include negative findings)

Measurements:  

  • Heart rate
  • Respiratory rate
  • Blood pressure (if able)
  • Growth parameters – weight & length/height (if able)

Observation: 

  • Conjunctival pallor
  • Pallor of palmar creases
  • Jaundice
  • Bruises, petechiae or purpura
  • Haemangiomas
  • Frontal bossing(sign of extramedullary haematopoiesis)

Examination: 

  • Cardiac murmurs
  • Hepatosplenomegaly
  • Lymphadenopathy
  • Oedema

Any other positive findings. 

Suggestions for management whilst waiting for outpatient appointment

Children who fill up on milk do not have a healthy balanced diet and often do not get enough iron.

If drinking large volumes of milk advise to reduce to:

  • 7-9 months: ~600mls infant formula per day or breastfeed on demand
  • 10-12 months: ~400mls infant formula per day, ideally before naps or after meals, or breastfeed on demand
  • >12 months: 300-350mls per day

Resources for parents whilst waiting for outpatient appointment

First Steps Nutrition Trust. Eating well the_first_year

NHS. What to feed young children

Parent Club. Feeding your baby

Resources for health professionals

Nil specific. See also resources for parents.

Editorial Information

Last reviewed: 17/03/2025

Next review date: 31/03/2028

Author(s): Dr Robynne Simpson (senior trainee, post CCT), Dr Ruth Bland (consultant paediatrician).

Version: 1

Approved By: RHC Medical Paediatrics Department