Clinical signs for the recognition of children with moderate or severe anaemia in western Kenya.

Introduction Plasmodium falciparum-related anaemia in children is a major public health problem in the malaria-endemic areas of sub-Saharan Africa, where it affects as many as one-third of paediatric admissions (1-3). The causes of this anaemia include haemolysis and dyserythropoiesis, but the disease has also been associated with chloroquine drug resistance (4-7). Optimal treatment of children with falciparum-related anaemia can result in improved haematological recovery and survival (8, 9). However, the implementation of guidelines for treatment of anaemia depends on the ability of health workers to recognize that a child is anaemic. Recommendations based on haemoglobin levels are useful for managing children when the haemoglobin can be measured; however, laboratory measurements are often not available in the usual clinic settings of sub-Saharan Africa. Hence, health workers often depend on clinical signs, such as conjunctival pallor, to identify anaemic children. Standardized clinical criteria to identify children who are anaemic need to be developed and field tested. The present study evaluates the sensitivity and specificity of clinical predictors to identify children with moderate or severe anaemia Patients and methods The study was conducted in the outpatient and inpatient departments of Siaya District Hospital, a 200-bed Ministry of Health hospital serving a population of 600 000 in western Kenya. Children aged 2 months to 5 years who attended the outpatient department (OPD) or who were admitted to the 40-bed paediatric ward of this hospital were included in our evaluation. Informed consent was obtained from the parent or guardian at the time of enrolment. Data were collected from June 1993 through September 1994 in the OPD and from June through September 1994 in the inpatient service. This study was approved by the scientific steering and ethical review committees of the Kenya Medical Research Institute and the investigational review board of the Centers for Disease Control and Prevention (CDC). Recognition of children with anaemia Outpatients. Every fifth child seen in the OPD for illness was systematically enrolled as part of a study to evaluate an algorithm for integrated management of childhood illness (IMCI) (10). Before the study began, an experienced trainer from the World Health Organization conducted on-site training for the study physician and health workers. After the informed consent of the parent or guardian had been obtained, a trained health worker evaluated each child for clinical signs of anaemia including the presence or absence of conjunctival (eyelid) and palmar pallor.(a) The study physician then examined each child for pallor at four sites: conjunctiva, palm, nailbed, and tongue, and for nailbed blanching under pressure.(a) Pallor was graded as severe, present, or none. The study physician also assessed the child for the severity of illness and signs of respiratory distress including general appearance, quality of cry, respiratory rate, presence of grunting, nasal flaring,(a) chest indrawing, stridor, increased depth of respiration,(a) Use of accessory muscles of respiration,(a) liver tenderness,(a) and cold extremities.(a) All the enrolled children had their haemoglobin measured and a blood smear was taken for malaria parasites. Based on the history and a physical examination, the study physician determined the final diagnosis and treatment plan, including the need for hospital admission. The study physician and the health workers did not have access to each other's results of examination and assessment. Haemoglobin was measured after the clinical examination was completed and recorded. Inpatients. Children admitted to the inpatient service were enrolled after informed consent was obtained. For each child, a trained examiner assessed and recorded the presence or absence of conjunctival (eyelid), nailbed, palmar and, tongue pallor, as well as nailbed blanching under pressure;(a) pallor was graded as severe, present, or none. …