Academic journal article Bulletin of the World Health Organization

Evaluation of Clinical Signs to Diagnose Anaemia in Uganda and Bangladesh, in Areas with and without Malaria

Academic journal article Bulletin of the World Health Organization

Evaluation of Clinical Signs to Diagnose Anaemia in Uganda and Bangladesh, in Areas with and without Malaria

Article excerpt


Anaemia, which is common in young children in developing countries in areas of both high and low malaria prevalence (1, 2), is most often caused by nutritional iron deficiency, helminth infection or malaria infection in endemic settings. Severe anaemia contributes to an increased risk of death (3), while children with milder anaemia have increased susceptibility to infection (4), delayed growth (5, 6), impaired cognitive and psychomotor development (7-9), and behavioural problems (10). Treating children who have severe anaemia and respiratory distress with a blood transfusion can prevent death (3), and treating milder anaemia can reverse some of the related ill effects and may often avoid the progression to severe anaemia and the dangers associated with blood transfusion.

The diagnosis of anaemia in a developing country without adequate laboratory facilities is difficult. WHO/UNICEF therefore included the diagnosis of anaemia and severe anaemia in children aged 2 months to 5 years in their recent guidelines for the Integrated Management of Childhood Illness (IMCI). The IMCI algorithm, using simple clinical signs and criteria, enables health workers at first-level facilities to diagnose and manage the illnesses that are responsible for about 70% of child deaths in developing countries (11). These include pneumonia, diarrhoea, measles, malaria, and malnutrition. Children classified by the algorithm as having a severe condition are referred to hospital after receiving any needed urgent treatment, while those with non-serious illnesses are treated at the first-level facility.

To diagnose severe anaemia, the IMCI algorithm relies on the finding of severe palmar pallor, while anaemia is diagnosed by the finding of some palmar pallor. Studies in Africa (12, 13) and of Whites in the USA (14) suggest that the palm and nailbeds are the best sites for assessing pallor. However, palmar pigment may vary in other regions, such as the Indian subcontinent, so there is a need to assess the use of palmar pallor to detect anaemia in developing countries outside of Africa.

While pallor in various anatomical sites has been the principal clinical sign studied to diagnose anaemia (12-16), attention has recently been focused on the usefulness of signs of respiratory distress to help identify children with severe anaemia who require blood transfusion (3, 12). However, because this diagnosis could be complicated by concurrent pneumonia or malaria, which often present with fever, cough and difficult breathing, many children without severe anaemia might needlessly be referred for this condition, and referred children with pallor might not receive treatment needed for a lesser degree of anaemia. The IMCI algorithm avoids these potential complications by placing the signs for respiratory distress, fever, and nutrition problems in separate boxes or sections. Thus, children with both pallor and respiratory distress, with or without fever, can be appropriately treated for their anaemia as well as referred for any suspected severe illnesses. A potential difficulty remains with this approach. The IMCI algorithm does not identify which children without severe pallor who are referred for respiratory problems have severe anaemia, and the care of these children might be delayed or the diagnosis might also be missed at the referral centre.

Some prior studies have examined the validity of clinical signs for diagnosing severe and moderate anaemia, but have not determined how well the signs differentiate these conditions from each other (12, 13). With this approach, severe pallor may indicate severe anaemia, while moderate anaemia may be diagnosed by any degree of pallor, including severe. It is important, however, to diagnose and appropriately treat both severe and lesser degrees of anaemia. This approach, adopted by the IMCI algorithm, requires that diagnostic criteria should be restricted to specific categories. …

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