Validity of using pallor to detect children with mild anemia

Abstract

The World Health Organization recommends the assessment of pallor as an indicator for the presence of anemia in children under 5 years of age at a primary care level where anemia is prevalent. The aim of the present study was to study the validity and interobserver agreement of pallor examination in recognition of anemia in children under 2 years of age. Healthy children aged 6-24 months (n = 141) admitted to well baby clinic were assessed for the presence of pallor at three anatomic sites (palm, conjunctiva, buccal mucosa) on admission by two blinded observers (Integrated Management of Childhood Illness [IMCI] certificate pediatrician and a pediatric resident). Clinical examination for pallor was made without having the information on the child's hemoglobin level or of the other observer's assessment for pallor. Anemia was defined as hemoglobin level <11 g/dL. The exclusion criteria included the presence of any acute or chronic illness on admission, and treatment for anemia within the 3 months preceding the study. The mean age of the children was 8.0 +/- 2.7 months; 71 (50%) were boys. Blood samples indicated anemia in 33 children (23%). Palmar pallor alone significantly had highest sensitivity (sensitivity 72% and specificity 75%, positive predictive value 48%) to detect anemia for the IMCI-trained pediatrician. The interobserver agreement was highest for buccal and conjunctival pallor (kappa = 0.64 and 0.63, respectively), and lowest for palmar pallor (kappa = 0.49). Palmar pallor is a sensitive and specific sign of mild anemia when used by the IMCI-trained pediatrician.