Stay informed with the latest updates on coronavirus (COVID-19). Find out more >>


  • Statewide logo

    This guideline has been adapted for statewide use with the support of the Victorian Paediatric Clinical Network

  • See also

    Iron deficiency
    Patient Blood Management and surgery  
    Blood product prescription 
    The Australian Red Cross Blood Service anaemia and haemostasis overview

    Key Points

    1. In Australia, the prevalence of anaemia in children under the age of 5 years is about 8%, corresponding to over 100,000 preschool children.
    2. Iron deficiency is the most common cause of anaemia in children. 


    This guideline is adapted from the National Blood Authority (NBA) Patient Blood Management Guidelines: Module 6 Neonatal and Paediatrics (2016).


    Anaemia is defined as Haemoglobin (Hb) less than the lower limit of the reference range for age

    Age Lower limit of normal range Hb (g/L)
    2 months 90
    2 – 6 months 95
    6 – 24 months 105
    2 – 11 years 115
    >12 years female – 120                           male - 130



    • Ethnic background can be helpful in guiding workup for haemoglobinopathies and G6PD deficiency
    • Medication history: past and current, particularly those that may cause haemolysis in the instance of G6PD deficiency
    • Dietary history: iron intake (with particular attention to iron-rich foods, breast feeding and cow’s milk intake), vitamin B12 intake, recent fava/broad bean ingestion (may precipitate haemolysis in the case of G6PD deficiency)
    • Family history: anaemia, jaundice, gallstones or splenomegaly


    Clinical features suggestive of anaemia:

    • Pallor
    • Pale conjunctivae
    • Tachycardia
    • Cardiac murmur
    • Lethargy
    • Listlessness
    • Poor growth
    • Poor concentration
    • Weakness
    • Shortness of breath
    • Signs of cardiac failure
    • Signs of haemolysis include jaundice, scleral icterus, splenomegaly and dark urine



    • If anaemia is suspected begin with a full blood examination including blood film (FBC), ferritin and reticulocyte count.
    • Iron studies or serum iron should not be requested to diagnose iron deficiency. Serum iron reflects recent iron intake and does not provide a measure of the iron stores.   

    The initial classification is based on the Mean Corpuscular Volume (MCV):


    • For “Other features on the blood film appearance that prompt further investigation” see Additional Notes below 

    Red flags

    (consider admission) 

    • Hb <60 g/L  (including iron deficiency)
    • Tachycardia, cardiac murmur or signs of cardiac failure
    • Features of haemolysis (dark urine, jaundice, scleral icterus)
    • Associated reticulocytopenia
    • Presence of nucleated red blood cells on blood film
    • Associated thrombocytopenia or neutropenia may indicate malignancy or an infiltrative disorder
    • Severe vitamin B12 or folate deficiency
    • Need for red cell transfusion: Where possible defer transfusion until a definitive diagnosis is made.

    Microcytic Hypochromic Anaemia

    See Iron deficiency and treatment 

    Beta Thalassaemia minor/trait

    • Carrier of beta thalassaemia
    • Frequently seen in South East Asian, Mediterranean, Arabic families
    • Usually asymptomatic
    • There may be a positive family history
    • Microcytic hypochromic red cells with normal or borderline low Hb
    • Diagnosed on HPLC or Hb electrophoresis - HbA2 > 3.5%, often elevated Hb F
    • Red cell distribution width (RDW) is often normal
    • Pre-pregnancy carrier testing of partner is important (Ensure parents have been tested if likely to have more children)

    Note: HbA2 may not be elevated in the presence of concomitant iron deficiency, therefore give iron treatment (if ferritin low) before ordering test.

    Alpha Thalassaemia minor/trait

    • Carrier of alpha thalassaemia
    • Commonly seen in South East Asian, African, Mediterranean, Arabic families
    • Microcytic hypochromic red cells  with normal or borderline low Hb
    • Cannot be diagnosed on HPLC or Hb electrophoresis - DNA testing required for formal diagnosis (not a first-line investigation - exclude other causes first)
    • Pre-pregnancy carrier testing of partner is important

    Rare causes of Microcytic Anaemia

    • Chronic inflammation
    • Lead poisoning (high blood lead level)
    • Sideroblastic anaemia

    Normocytic Normochromic Anaemia

    Haemolytic anaemia

    • Acute haemolysis in childhood can be a life threatening illness and all cases should be discussed with a Haematologist.
    • Children with haemolytic anaemia should be admitted for observation, they need frequent heart rate assessment and monitoring looking for tachycardia which may indicate a further drop in Hb.
    • The FBC should be repeated within 6-12 hours to detect ongoing haemolysis.
    • In addition, reticulocyte count and bilirubin should be monitored.
    • Additional investigations will be guided by red blood film findings e.g. Coombs (DAT) Blood group and antibody screening (BGAB), G6PD assay and Eosin-5 maleimide red cell staining (diagnosis of hereditary spherocytosis). 

    Sickle cell anaemia

    See Sickle cell disease

    Hypoplastic/Aplastic Anaemia

    (eg acute leukaemia, aplastic anaemia, infiltrative disorders)

    • May be due to drugs eg cytotoxics, chloramphenicol, sulfonamides or viral infection
    • May be seen in severe nutritional deficiencies (vitamin B12 or folate deficiency) but usually children present with macrocytic red cells.
    • Reticulocyte count is usually low
    • Consider bone marrow infiltration if neutrophils and/or platelets also decreased
    • If isolated anaemia with low reticulocyte count with normal platelet and neutrophil counts consider transient erythroblastopenia of childhood (TEC) or congenital forms (eg Diamond-Blackfan anaemia)
    • Bone marrow aspirate is usually required for diagnosis

    Chronic disease

    • Normochromic normocytic anaemia can be seen with chronic inflammation and chronic disease such as renal disease.
    • Reticulocyte may be low
    • Platelet count may be elevated.
    • Further investigation with UEC, LFT and ESR may be indicated depending on clinical history.

    Blood loss

    • Normochromic normocytic anaemia can be seen with acute blood loss
    • Reticulocyte count may be normal or elevated.
    • Suggest correlation with any bleeding symptoms

    Macrocytic Anaemia

    Vitamin B12 and folate deficiency

    • Can be associated with failure to thrive or neurodevelopmental problems. (regression, seizures, irritability, poor feeding)
    • Vitamin B12 deficiency may be seen in exclusively breast-fed infants of mothers with vitamin B12 deficiency, children with a vegan or vegetarian diet, pernicious anaemia and metabolic disorders.
    • Characteristic blood film findings include teardrop red cells and hypersegmented neutrophils and often neutropenia or thrombocytopenia
    • Needs urgent investigation with red cell folate and active vitamin B12
    • If low active vitamin B12 suggest serum homocysteine and urine methylmalonic acid.
    • Treatment must be commenced urgently, particularly if neurological symptoms or regression. 

    Other causes of red cell macrocytosis with or without anaemia

    • Myelodysplasia
    • Medications
      • Secondary to medications such as anticonvulsants, immunosuppressives and zidovudine.
    • Liver disease
    • Hypothyroidism

    Consider consultation with local paediatric team when:

    • When red flags identified (see list above)

    Consider transfer when:

    Children requiring care beyond the level of comfort of the local hospital.

    For emergency advice and paediatric or neonatal ICU transfers, call the Paediatric Infant Perinatal Emergency Retrieval (PIPER) Service: 1300 137 650.  

    Information specific to RCH and Monash Children’s Hospital 
    Consider discussion with clinical haematology. 

    Additional Notes

    Other features on the blood film appearance that prompt further investigation.

    Film features Cause Investigation
    Target cells

    Iron deficiency anaemia



    Haemoglobinopathy testing (HPLC/Hb Electrophoresis)

    Elliptocytes or pencil cells

    Iron deficiency anaemia



    Haemoglobinopathy testing (HPLC/Hb Electrophoresis)

    Spherocytes Hereditary spherocytosis Autoimmune haemolysis


    BGAB (Blood group)

    Eosin 5 maleimide (E5M)

    Fragmented red cells Haemolysis

    Platelet count

    Bilirubin, Reticulocyte count

    Urea + Creatinine

    Coagulation profile

    Bite and blister cells G6PD deficiency G6PD assay
    Nucleated red blood cells

    Bone marrow infiltration


    Consider bone marrow examination

    Thalassaemia testing (HPLC/Hb Electrophoresis)

    Sickle cells Sickle cell anaemia Haemoglobinopathy testing (HPLC/Hb Electrophoresis)
    Tear drop cells

    Bone marrow infiltration

    Vitamin B12 deficiency

    May need bone marrow examination

    Active vitamin B12

    Last updated January 2019