Pallor
David T. Teachey, MD
Pallor - BASICS
Pallor - description
- Pallor is defined as paleness of the skin and may be a reflection of anemia or poor peripheral perfusion.
- The normal range for hemoglobin is age dependent.
- Anemia can be defined functionally as the inability of hemoglobin to meet cellular oxygen demand.
- Parents often fail to notice pallor of gradual onset.
- Grandparents or others who see child less often may be the 1st to suspect pallor.
Pallor - risk factors
- Age between 6 months and 3 years, or adolescent females:
- Peak age ranges for iron deficiency
- Sex:
- Some red cell–enzyme X-linked defects, such as glucose-6-phosphate dehydrogenase (G6PD) and phosphoglycerate kinase deficiencies are sex linked.
- Race:
- Black: Hemoglobins S and C, α- and β-thalassemia trait, G6PD deficiency
- Southeast Asian: Hemoglobin E and α-thalassemia
- Mediterranean descent: β-thalassemia and G6PD deficiency
Pallor - genetics
Familial history:
- Some of the congenital hemolytic anemias are autosomal dominant.
Pallor - DIAGNOSIS
- Determine 1st that the child appears pale, not simply fair skinned. 2nd, decide if there is a medical emergency associated with circulatory failure. If not, the goal is to investigate the etiology and intervene appropriately.
- Phase 1: Assess for signs of shock.
- If present, initiate emergency procedures as required to stabilize the patient, such as airway, breathing, and circulation.
- Phase 2: If patient is stable, perform history, physical examination, and CBC with reticulocyte count to establish time of onset of pallor, associated symptoms, and level of anemia.
- Phase 3: Specific diagnostic workup based on findings in phase 2.
Pallor - signs & symptoms
- Pallor
- Other signs and symptoms dependent on etiology
Pallor - history
- Acute versus chronic onset:
- Helps with differential diagnosis.
- Associated symptoms: Weight loss, fever, night sweats, cough, and/or bone pain:
- Suggest an underlying systemic illness, such as leukemia, infection, or rheumatologic disorder
- Jaundice, scleral icterus, dark urine:
- Age <6 months:
- May represent a congenital anemia or isoimmunization
- Premature infant:
- Increased risk of both iron and vitamin E deficiency.
- Exaggerated hyperbilirubinemia can be the presenting symptom of isoimmune hemolytic or other congenital hemolytic anemia.
- Pica:
- Often associated with plumbism and iron deficiency
- Medications:
- Can cause bone marrow suppression and/or hemolysis
- Milk intake:
- Cow’s milk <12 months of age and high milk intake are associated with iron deficiency.
- Recent trauma and/or surgery:
- Blood loss can result in iron deficiency.
- Recent infection:
- Can be associated with hemolysis or bone marrow suppression
- Most common form of mild anemia in childhood
- Family history:
- Familial history of splenectomy and/or early cholecystectomy can be a clue for a previously undiagnosed hemolytic anemia.
Pallor - physical exam
- Rapid respiratory rate, decreased BP, weak pulses, slow capillary refill
- Indications of uncompensated anemia and/or shock
- Frontal bossing and prominence of the malar and maxillary bones:
- Extramedullary erythropoiesis
- Enlarged spleen:
- Hemolytic anemias, malignancy, infection
- Glossitis:
- Vitamin B
- Scleral icterus or jaundice:
- Systolic flow murmur:
- Bruits:
- May indicate vascular malformations
- Petechiae and bruising:
- May indicate an associated thrombocytopenia, coagulopathy, or vasculitis
- Dysmorphic features:
- Diamond-Blackfan and Fanconi anemia are associated with other congenital defects, including thumb abnormalities, short stature, and congenital heart disease.
Pallor - tests
Pallor - lab
- CBC with red cell indices:
- Establishes the diagnosis of anemia, distinguishes by size: Normocytic, macrocytic, microcytic
- Reticulocyte count:
- Distinguishes between decreased production and increased destruction of red cells
- Coombs test and antibody screen:
- Identifies immune-mediated red cell destruction
- Can have false positives and negatives
- Peripheral blood smear:
- Specific morphologic findings can be diagnostic.
- Iron studies: Iron-binding capacity, serum iron, ferritin, transferrin
- Iron-deficiency anemia or anemia of chronic disease
- Hemoglobin electrophoresis with quantification:
- Lead studies: Serum lead, free erythrocyte protoporphyrin:
- Stool guaiac:
- Osmotic fragility:
- Red cell membrane defects (spherocytosis)
- Any spherocytic anemia may be positive
- Quantitative red cell–enzyme assays:
- Inherited RBC enzyme deficiencies
- Serum folate, RBC folate, and serum vitamin BDeficiency
Pallor - diag proced-surgery
Bone marrow aspiration and biopsy:
- Malignancy or bone marrow failure syndrome
Pallor - differencial diagnosis
- Congenital:
- Hemoglobinopathies: Sickle cell syndromes, thalassemia syndromes, other unstable hemoglobins
- Erythrocyte membrane defects: Hereditary spherocytosis, elliptocytosis, stomatocytosis, pyropoikilocytosis, infantile pyknocytosis
- Erythrocyte enzyme defects: G6PD deficiency, pyruvate kinase deficiency
- Diamond-Blackfan anemia: Congenital pure red cell aplasia (rare)
- Fanconi anemia: Constellation of varied cytopenias, multiple congenital anomalies, abnormal bone marrow chromosomal fragility
- Infectious:
- Septic shock
- Can get mild anemia after mild infections in childhood (anemia of inflammation)
- Infection-related bone marrow suppression: Parvovirus B19 infection
- Infection-related hemolytic anemias: Epstein-Barr virus, influenza, Coxsackievirus, varicella, cytomegalovirus, Escherichia coli, Pneumococcus species, Streptococcus species, Salmonella typhi, Mycoplasma species
- Nutritional/Toxic/Drugs:
- Iron-deficiency anemia: Common cause of anemia in children, especially those <3 years of age and in female adolescents
- Plumbism: Anemia usually due to coexisting iron deficiency. Very high lead levels associated with altered heme synthesis
- Vitamin BMedication-induced bone marrow suppression: Chemotherapy; antibiotics, especially trimethoprim–sulfamethoxazole
- Drug-related hemolytic anemia: Antibiotics, antiepileptics, azathioprine, isoniazid, nonsteroidal anti-inflammatory drugs
- Trauma:
- Tumor:
- Leukemia with bone marrow infiltration
- Metastatic tumors with bone marrow infiltration
- Genetic/Metabolic:
- Metabolic derangements: Severe electrolyte disturbance, pH disturbance, inborn errors
- Schwachmann–Diamond syndrome: Marrow hypoplasia with associated pancreatic insufficiency and associated failure to thrive
- Other:
- Transient erythroblastopenia of childhood: Acquired pure RBC aplasia
- Aplastic anemia: Bone marrow failure syndrome with at least 2 of the 3 blood cell lines eventually affected
- Systemic diseases: Anemia of chronic disease, chronic renal disease, uremia
- Hypothyroidism
- Sideroblastic anemia: Defective iron utilization within the developing erythrocytes
- Autoimmune and isoimmune hemolytic anemias
- Microangiopathic hemolytic anemias: Thrombotic thrombocytopenic purpura (TTP), hemolytic uremic syndrome (HUS), disseminated intravascular coagulation (DIC)
- Mechanical destruction: Vascular malformation, abnormal or prosthetic cardiac valves
Pallor - TREATMENT
Pallor - initial stabilization
- Severe anemia of unclear etiology with hemodynamic instability:
- Transfuse with packed RBCs cautiously.
- In an autoimmune hemolytic process, the child is at risk for a transfusion reaction and there may be delay in obtainingcrossmatched blood
- Obtain blood for diagnostic studies before transfusion if possible.
- Circulatory failure without anemia:
- Requires intensive monitoring and access to critical care in an emergency department or intensive care unit
- Fluid resuscitation and/or inotropic pressor support as needed
- Acute blood loss:
- Treat circulatory failure as described.
- Transfuse with packed RBCs, platelets, and fresh frozen plasma as needed.
- Malignancies:
- Emergency care should be directed toward treatment of circulatory failure and possible associated infection, and then to rapid diagnosis and treatment of the malignancy.
- Consultation with an oncologist should be sought as soon as possible.
Pallor - general measures
- Treat underlying cause
- Consider packed RBC transfusion if in extremis or severe anemia and low likelihood of recovery in near future
- Consider emergent plasmapheresis if microangiopathic hemolytic anemia
- Consider immunosuppresive medications (corticosteroids, intravenous immunoglobulin (IVIgG) if autoimmune hemolytic anemia
- Iron-deficiency anemia:
Pallor - medication
Elemental iron:
- 4–6 mg/kg divided b.i.d.–t.i.d.
- Absorbed best with acidic drinks, including orange juice; dairy products decrease absorption.
- Reticulocyte should improve 72 hours after starting iron therapy; the hemoglobin may take a week to rise.
- Iron should be continued for at least 3 months to replenish iron stores.
Pallor - FOLLOW UP
Based on determination of etiology
Pallor - disposition
Pallor - issues for referral
- Severe or unexplained anemia
- Anemias other than dietary iron deficiency or thalassemia trait
- Recurrent iron deficiency
- May suggest ongoing bleeding or iron malabsorption.
- All bone marrow failure or infiltrative processes
Pallor - bibliography
- Glader BE. Hemolytic anemia in children. Clin Lab Med. 1999;19:87–111.
- Graham EA. The changing face of anemia in infancy. Pediatr Rev. 1995;15:175–183.
- Monzon CM, Beaver D, Dillon TD. Evaluation of erythrocyte disorders with mean corpuscular volume (MCV) and red cell distribution width (RDW). Clin Pediatr. 1987;26:632–638.
- Segal G, Hirsh M, Feig S. Managing anemia in pediatric office practice, 1. Pediatr Rev. 2002;23;75–84.
- Sills RH. Indications for bone marrow examination. Pediatr Rev. 1995;16:226–228.
Pallor - CODES
Pallor - icd9
783.61 Pallor
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Book Source Details
- Book Title: The 5-Minute Pediatric Consult
- Author(s): M. William Schwartz MD; et al.
- Year of Publication: 2008
- Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.
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- "Nursing: Interpreting Signs and Symptoms" (2007)
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- "Pediatric Complaints and Diagnostic Dilemmas" (2003)
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- "The 5-Minute Pediatric Consult" (2008)
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Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Williams & Wilkins.
More About Causes of Paleness
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More About This Book:
Title: The 5-Minute Pediatric Consult
Authors: M. William Schwartz MD; et al.
Publisher: Lippincott Williams & Wilkins
Copyright: 2008
ISBN: 0-7817-7577-9
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