Optimal treatment of Plasmodium falciparum-related paediatric anaemia can result in improved haematological recovery and survival. Clinical predictors are needed to identify children with anaemia in settings where laboratory measurements are not available. The use of conjunctival (eyelid), palmar, nailbed, and tongue pallor to detect children with moderate anaemia (haemoglobin, 5.0-7.9 g/dl) or severe anaemia (haemoglobin, < 5.0 g/dl) was evaluated among children seen at an outpatient and inpatient setting in a hospital in western Kenya. Severe nailbed or severe palmar pallor had the highest sensitivity (62% and 60%, resp.), compared with severe conjunctival pallor (sensitivity = 31%), to detect children with severe anaemia in the outpatient setting. Children with moderate anaemia were best identified by the presence of nailbed or palmar pallor (sensitivity = 90% for both signs), compared with conjunctival pallor (sensitivity = 81%). Clinical signs of respiratory distress, in addition to the presence of severe pallor, did not increase the recognition of children requiring hospitalization for severe anaemia. Among inpatients, the sensitivity of severe nailbed pallor (59%) was highest for detecting children with severe anaemia, although the sensitivity of severe conjunctival pallor and severe palmar pallor was the same (53% for both signs). Presence of conjunctival pallor (sensitivity = 74%) was similar in sensitivity to both nailbed and palmar pallor (70% for both signs) among children with moderate anaemia. The sensitivity of tongue pallor was low among all children evaluated. Low haemoglobin levels were significantly associated with the likelihood of being smear-positive for P. falciparum. This study demonstrates that clinical criteria can be used to identify children with moderate and severe anaemia, thus enabling implementation of treatment algorithms. Children aged < 36 months who live in an area with P. falciparum malaria should receive treatment with an effective antimalarial drug if they have pallor.
PIP: The ability of pallor of the conjunctiva, palms, nailbed, and tongue to identify children with Plasmodium falciparum-related anemia in developing country settings, where laboratory measurements are not available, was investigated in children attending Siaya District Hospital in western Kenya. Enrolled were all children 2 months to 5 years of age admitted to the hospital's inpatient unit in 1993-94 (n = 1048), and every fifth child presenting to the outpatient clinic (n = 1666). Severe nailbed or severe palmar pallor had the highest sensitivities (62% and 60%, respectively) in the detection of severe anemia in outpatients, while those with moderate anemia were best identified by nailbed or palmar pallor (90% sensitivity for both signs). The addition of clinical signs of respiratory distress to pallor did not increase the identification of children requiring hospitalization for severe anemia. Among inpatients, severe nailbed, conjunctival, and palmar pallor had sensitivities of 59%, 53%, and 53%, respectively, for detecting severe anemia. In the detection of moderate anemia, the sensitivities were 74%, 70%, and 70%, respectively, for conjunctival, nailbed, and palmar pallor. Tongue pallor had a low sensitivity among all children examined. Low hemoglobin levels were significantly associated with P. falciparum infection. It is recommended that all children under 36 months of age, in areas with P. falciparum malaria, should receive antimalarial treatment if they present with pallor.