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.
  • 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)
  • Padmanabh Reddy Professor and Director, Department of Pediatrics;
  • Uma Raju Head, Clinical and Academic Service, Nice Hospital For Women, Newborn & Children, Hyderabad, India.
Keywords: 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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1. J. P. Chalco, L. Huicho, C. Alamo, N. Y. Carreazo, and C. A. Bada. Accuracy of clinical pallor in the diagnosis of anemia in children: a metaanalysis. BMC Pediatrics 2005;5:5-46.
2. WHO, UNICEF, and UNU, Iron Deficiency Anemia: Assessment, Prevention and Control,A.GuideforProgrammeManagers,WHO,UNICEF,UNU,Geneva,Switzerland,2001
3. Gerardo Alvarez-Uria, Praveen K. Naik, ManoranjanMidde, Pradeep S. Yalla, and RaghavakalyanPakam, Prevalence and Severity of Anemia Stratified by Age and Gender in Rural India, Anemia,2014;10:1155-60.
4. Balarajan, Y., Ramakrishnan, U., Ozaltin, E., Shankar, A.H. and Subramanian, S.V. Anemia in Low-Income and Middle-Income Countries. The Lancet,2011;378:2123-35.
5. Chandrasekaran C, Senthil kumar K.M, Sivakumar K.V, Nandhini Balaji, Heber Anandan. Accuracy of clinical pallor in the diagnosis of moderate and severe anemia in children 6 months to 5 years. International Journal of Contemporary Medical Research 2016;3(7):2028-30.
6. RosemeriMaurici da Silva Silva RM et al. Clinical evaluation of the paleness: agreement between observers and comparison with hemoglobin levels. Rev Bras HematolHemoter. 2010;32(6):444-8
7. Balfour A. Estimation of Hemoglobin. 1988;25:279–83.
8. A. Zhao, Y. Zhang, Y. Peng et al., Prevalence of anemia and its risk factors among children 6–36 months Old in Burma, e American Journal of Tropical Medicine and Hygiene,2012;87(2):306–11.
9. Variyam JN, Blaylock J, Lin BH, Ralston K, Smallwood D. Mother’s nutrition knowledge and children’s dietary intakes. Am J Agric Econ 1999; 81:373-87.
10. Stoltzfus RJ, Edward-Raj A, Dreyfuss ML, Albonico M, Montresor A, Dhoj Thapa M, et al. Clinical pallor is useful to detect severe anemia in populations where anemia is prevalent and severe. J Nutr1999;129:1675-81.
11. Rasha A Salama ,Meray R Labib, Prevalence of anemia among informal primary school children: a community based study in rural Upper Egypt, Epidemiology Biostatistics and Public Health – 2016;13(1):133-40.
12. Sudhagandhi B, Sundaresan S William W E, Prema A. prevalence of anemia in the school children of Kattankulathur, Tamil Nadu, India. Int J NutrPharmacolNeurol Dis; 2011;1:184-8.
13. Desai MR, Phillips-Howard PA, Terlouw DJ, Wannemuehler KA, Odhacha A, Kariuki SK, et al. Recognition of pallor associated withsevere anaemia by primary caregivers in western Kenya. Trop Med Int Health 2002;7:831-9.
14. DeMaeyer EM, Dallman P, Gurney JM, Hallberg L, Sood SK, Srikantia SG. Preventing and controlling iron deficiency Anemia through primary health care. Geneva: World Health Organization; 1989:8-9.
15. Alemayehu N. Prevalence of hook worm infection and its association with anemia among students of Asendabo elementary school. Abstract, student research project, CBE program. 2. Jimma, Ethiopia: Jimma University; 2005:209.
16. Thi Le H,Brouwer ID, Burema J, Nguyen KC and Kok FJ. Efficacy of iron fortification compared to iron supplementation among Vietnamese school children. Nutr J. 2006;5: 32.
17. Zimmermann MB, Zeder C, Chaouki N, Saad A, Torresani T, Hurrell RF. Dual fortification of salt with iodine and microencapsulated iron: a randomized double blind controlled trial in Moroccan school children. Am J Clin Nutr. 2003; 77(2):425-32.
18. Stoltzfus RJ, Chwaya HM, Tielsch JM, Schulze KJ, Albonico M, Savioli L. Epidemiology of iron deficiency anemia in Zanzibari school children: the importance of hookworms. Am J Clin Nutr. 1997; 65(1):153- 9.
19. Assefa et al.: Prevalence and severity of anemia among school children in Jimma Town, Southwest Ethiopia. BMC Hematology 2014;14:3.
20. Leal LP. Diagnostic accuracy comparison between clinical signs and hemoglobin color scale as screening methods in the diagnosis of anemia in children. 2006;6(2):183–9.
21. Ritu S, Ashok D, Vithal TP, Shivani R, Rajaram N. A Hospital Based Study on Anemia Prevalence in Children of an Indian Island. Int J Pediatr 2017;5(12):6245-52.
22. Arnab Ghosh, DilasmaGhartimagar, Sushma Thapa, Brijesh Sathian, Asis De. Microcytic Hypochromic Anemia in Pediatric Age Group: A Hospital Based Study in Nepal. American Journal of Public Health Research.2015;3(4A):57-61.

23. Muhe L, Oljira B, Degefu H, Jaffar S, Weber MW. Evaluation of clinical pallor in the identification and treatment of children with moderate and severe anaemia. Trop Med Int Health 2000;5:805-10.
24. Kalantri A, Karambelkar M, Joshi R, Kalantri S, Jajoo U. Accuracy and reliability of pallor for detecting anaemia: a hospital-based diagnostic accuracy study. PLoS One 2010;5:e8545.
25. Kalter HD, Burnham G, Kolstad PR, et al. Evaluation of clinical signs to diagnose anemia in Uganda and Bangladesh, in areas with and without malaria. Bulletin of theWorld Health Organization. 1997;75(Suppl 1):103-111.
26. Sheth TN, Choudhry NK, Bowes M, Detsky AS. The relation of conjunctival pallor to the presence of anemia. J Gen Intern Med. 1997;12(2):102–6.
27. Nardone DA, Roth KM, Mazur DJ, McAfee JH. Usefulness of physical examination in detecting the presence or absence of anemia. Arch Intern Med 1990;150:201-4.
28. Gjorup T, Bugge PM, Hendriksen C, Jensen AM. A critical evaluation of the clinical diagnosis of anemia. Am J Epidemiol 1986; 124:657-65.
How to Cite
Ahmed N, Khan K, Reddy P, Raju U. Reliability and Validity of Palmar, Mucosal, Nail Bed and Conjunctival Pallor for Anemia Detection in School Children Aged 6-14 Years of Age. Int Arch BioMed Clin Res [Internet]. 2021Mar.30 [cited 2021May9];7(1):PD1-PD5. Available from: