Reliability and Validity of Palmar, Mucosal, Nail Bed and Conjunctival Pallor for Anemia Detection in School Children Aged 6-14 Years of Age


  • Natasha Ahmed (DNB, Pediatrics), Department of Pediatric, Nice Hospital For Women, Newborn & Children, Hyderabad, India. Author
  • Khurshida Khan Assistant Professor, Department of Pediatric Medicine, Government PDU Medical College, Churu, Rajasthan, India. (Ex fellow, Department of Neonatology, Nice Hospital For Women, Newborn & Children, Hyderabad) Author
  • Padmanabh Reddy Professor and Director, Department of Pediatrics; Author



Anemia, Pallor, Conjunctiva, Observer


Background:Anemia is widely prevalent in developing world and also is a public health challenge in India. Children in India remain affected with anemia. It is a serious concern because it can result in impaired cognitive performance, behavioral and motor development, coordination, language development, and scholastic performance. It also leads to increased morbidity from infectious diseases. The present study was designed to assess the accuracy for various sites in screening for anemia in school children.

Methods: A descriptive observational cross-sectional study was conducted in urban school going children in government schools aged 6-14 years. This study was conducted over a period of 1 year in the government schools of Hyderabad city, this study was completed during 5 planned visits to school. The 450 children were enrolled on planned visits to school out of which 394 students were included in study. Detailed history and clinical examination was carried out in all children. Pallor be graded as No anemia, Mild, Moderate and Severe. In all children haemoglobin estimation done by Sahli’s hemoglobinometer. Two technicians were given the task to assess the hemoglobin level in the children examined for pallor.  Data entry and statistical analysis was performed with the help of Microsoft excel 2016 and R Project v3.5. A Regression Model was built, between Lab Bracket & Site Readings for the 2 observers using 85% of the sample set using a random distribution logic.

Results: In this study out of 450 students, 394 urban government school children in age group of 6-14 years were included. The incidence of anemia was 60% i.e. 237 children out of 394. Both doctors found that palm pallor had highest sensitivity when anemia was severe whereas sensitivity for mild & moderate was quite low. Specificity of all sites was high and for severe pallor was 100%. Fleiss Kappa was used as a measure to review inter observer reliability at the different sites. It is to be noted that the Kappa for all sites are above 0.8 which indicates an almost perfect agreement on the pallor between the 2 observers.

Conclusion: In this study prevalence of anemia was high in school children. According to our study conjunctiva and palm were the most sensitive to assess the severity of anemia. Clinical assessment of pallor can be used as initial screening tool for diagnosing anemia in school children especially in places where prevalence in high and early incorporation of treatment. 


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