Pallor
Stephen Ludwig
Approach to the Patient with Pallor
I. Definition of the Complaint
The complaint of pallor indicates a perceived decrease in rubor in the skin and
mucous membranes of a child. In general, the finding of pallor indicates color
that is associated with decreased blood flow to the skin. The lack of blood
flow may be regional (e.g., thrombosis) or systemic (e.g., shock), or there may
be normal flow with decreased oxygen-carrying capacity (e.g., anemia).
In most cases, the finding of pallor demands that anemia be ruled out. Some
children have a constitutional cause of pallor due to their fair complexion and
a lack of sunlight exposure. But most children with pallor should be considered
to have low hemoglobin, which should be measured. Ordinarily, a complete blood
count with differential count and RBC indices helps the clinician sort through
the many causes of anemia and recognize unusual situations in which pallor is
not related to anemia.
II. Complaint by Cause and Frequency
Pallor may be separated into those causes involving normal hemoglobin (Table
10-1) and those involving an abnormal hemoglobin level. An abnormal hemoglobin
level may be caused by decreased red blood cell (RBC) production, increased
destruction, or blood loss. Anemia may also be considered in relation to
mechanism, as trauma, toxin, metabolic tumor, congenital, or mixed etiology
(Table 10-2), or in relation to RBC morphology (Table 10-3).
III. Clarifying Questions
• What are the child's dietary habits?
— Because the most common cause of pallor is iron deficiency anemia, an important
clarifying question pertains to diet. Diets containing large quantities of cow
's milk are suspect for iron deficiency due to lack of iron intake and loss of
appetite for food rich in iron. Other related questions for iron deficiencies
have to do with sources of loss of iron or blood, such as recent heavy
menstruation, black or tarry stools, or multiple blood draws for diagnostic
testing.
• Is there a family history of anemia, splenectomy, or gall bladder surgery?
— A second clarifying question pertains to family history. Many of the membrane
disorders and other genetic diseases roots in the family history. Some
disorders, such as hereditary spherocytosis and elliptocytosis, frequently
necessitate splenectomy due to substantial RBC sequestration. Inherited
diseases causing hemolysis, such as sickle cell disease, may be recognized in
some families by a history of gall bladder surgery.
• Are there signs of systemic illness, fatigue, growth failure, weight loss, or
lymphadenopathy?
— For children whose anemia is based on an oncologic cause, look to questions
that identify other systemic signs of fatigue or of growth or
tenderness of lymph nodes.
• Was there exposure to certain medications or toxins?
— Some questions should be asked about exposure to toxins, which may act directly
on blood or bone marrow and may act in conjunction with a genetic defect (e.g.,
naphthalene exposure in a patient with glucose-6-phosphate dehydrogenase (G6PD)
deficiency, leading to anemia).
• Did the pallor develop quickly or gradually?
— Information about the speed of onset provides clues about the cause. Has there
been an insidious onset (e.g., iron deficiency) or an acute onset of pallor
with jaundice (e.g., hemolytic disorder)?
IV. References
1. Poncz M. Pallor. In: Schwartz MW, ed. Pediatric primary care: a problem-oriented approach, 2nd ed. Chicago: Year Book Medical Publishers, 1987.
2. Segel GB, Hirsh MG, Feig SA. Managing anemia in pediatric office practice:
part I.
Pediatr Rev 2002;23:75–84.
Pictures
Book Source Details
- Book Title: Pediatric Complaints and Diagnostic Dilemmas
- Author(s): Samir S Shah MD; Stephen Ludwig MD
- Year of Publication: 2003
- Copyright Details: Pediatric Complaints and Diagnostic Dilemmas, Copyright © 2003 Lippincott Williams & Wilkins.
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Copyright Details: Pediatric Complaints and Diagnostic Dilemmas, Copyright © 2008 Williams & Wilkins.
More About Causes of Paleness
» Next page: Pallor - Case 10-1: 3-Week-Old Boy (Pediatric Complaints and Diagnostic Dilemmas)
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