Academic journal article Bulletin of the World Health Organization

Pallor as a Clinical Sign of Severe Anaemia in Children: An Investigation on the Gambia

Academic journal article Bulletin of the World Health Organization

Pallor as a Clinical Sign of Severe Anaemia in Children: An Investigation on the Gambia

Article excerpt


Anaemia is a major health problem in the Gambia and many other African countries (1), most cases in children being related to malaria. Although the pathogenesis of malarial anaemia is complex, there are two distinct types: (1) a chronic, low-grade anaemia associated with persistent parasitaemia; and (2) an acute malarial infection with haemolysis and a rapid drop in haemoglobin (2). The latter is especially dangerous when it occurs against a background of chronic anaemia, and can quickly lead to life threateningly low levels of haemoglobin.

In the Gambia, anaemia in children is strongly associated with the main malaria transmission season, which peaks in October and November (1). At the Royal Victoria Hospital (RVH) in Banjul, the only paediatric referral hospital in the country, the number of children receiving blood transfusions during the past few years because of malarial anaemia rose from 195 in 1991 to 567 in 1995, an annual increase of 24% (RVH, unpublished data, 1996). It is likely that this is due to increasing resistance of Gambian strains of Plasmodium falciparum to chloroquine, the first-line antimalarial drug (1, 3). Because blood is scarce and there is a risk of transmission of blood-borne infections (3-5), children admitted to the RVH are transfused only if it is considered life-saving. A study from Kenya (4) has shown that transfusion is only beneficial in children with a haemoglobin (Hb) level [is less than or equal to] 3.8g/dl. Accordingly, the routine management guidelines in the RVH are to transfuse children only if their haematocrit (packed cell volume, PCV) is [is less than] 12% or if they are in heart failure.

In developing countries, blood transfusion is available in only selected hospitals and severely anaemic patients who present at a peripheral health centre or peripheral hospital must be referred. Because it is frequently impossible to measure the PCV in peripheral health centres, decisions on referral for possible transfusion must be based on physical signs which can be detected by health professionals with limited training. The present study was carried out to evaluate the reliability of simple clinical signs to predict anaemia in children.

Patients and methods

The study was carried out in the children's ward of the RVH in Banjul between July and December 1994. The climate is typical of the West African sub-Sahelian savanna with two distinct seasons: a wet season from June to November, and a dry season from December to June. Transmission of malaria occurs throughout most of the year, but is highest from August to November.

The subjects were chosen from among children admitted to the children's ward during working hours. A maximum of 10 a day being enrolled in order of presentation. As most admissions during the time of the year of this study were related to malaria, a large number of study children were anaemic. A field assistant was trained to perform a limited physical examination of the patients on admission, before a PCV was carried out, without knowledge of the admission diagnosis. This examination included an assessment of pallor of the conjunctiva, the palms and the nailbeds using a semiquantitative scale (0 = no pallor, 1 = possible pallor. 2 = definite pallor. 3 = definite severe pallor). The respiratory rate was counted, the temperature and body weight were recorded, and the arterial oxygen saturation and heart rate were determined using a pulse oximeter. The presence or absence of nasal flaring and grunting was noted, and any enlargement of the liver and spleen was determined by palpation. It was also recorded whether the child looked "sick". To investigate interobserver variability, up to 5 children a day, already seen by the field assistant, were examined by one of the physicians (M. W. W.). This second observation, undertaken without access to the field assistant's records, was carried out in the hospital ward within approximately 2 hours of the first observation. …

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