International Journal of Contemporary Pediatrics Regina D et al. Int J Contemp Pediatr. 2016 Aug;3(3):872-877 http://www.ijpediatrics.com pISSN 2349-3283 | eISSN 2349-3291 DOI: http://dx.doi.org/10.18203/2349-3291.ijcp20162357 Research Article Correlation of pallor with hemoglobin levels and clinical profile of anemia in primary and middle school children of rural Telangana Divya Regina, Sudharshan Raj C.*, Raghav Rao Department of Pediatrics, MediCiti Institute of Medical Sciences, Ghanpur, Medchal, Hyderabad, India Received: 23 March 2016 Revised: 10 May 2016 Accepted: 14 May 2016 *Correspondence: Dr. Sudharshan Raj C., E-mail: [email protected] Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. ABSTRACT Background: The World Health Organization (WHO) estimates that about 2 billion individuals or about 40% of the world’s population suffer from anemia. The population groups with the highest prevalence of anemia are: pregnant women and the elderly (about 50%), infants and children 1 to 2 years (48%), school children (40%), non-pregnant women (35%), and preschoolers (25%). Methods: The study was conducted at MediCiti Institute of Medical Sciences. 1007 children were screened clinically and their blood samples collected and analyzed by hemocue instrument. A complete physical examination was done for all these children. Results: The maximum number of subjects belongs to the nine year old category. Boys constituted 46% of the study population while girls constituted 54% of the study population. Anemia is more prevalent in female subjects than males. In the present study, clinical pallor was present in 16.48% of the subjects. In specific, conjunctival pallor was noted in 9.43%, generalized pallor of skin noted in 4.96% and palmar crease pallor was noted in 1.88% of subjects. The sensitivity and specificity of clinical pallor in diagnosing anemia is 94.02% and 93.71% respectively. The sensitivity and specificity of palmar pallor in diagnosing severe anemia is 100% and 98.21% respectively. Conclusions: The clinical finding of pallor in a child is a reliable indicator of anemia. The presence of clinical pallor in any of the body sites (conjunctival pallor, skin pallor, palmar pallor) is a reliable indicator of anemia. The presence of palmar crease pallor is a good indicator of severe anemia in children. By effective implementation of mid-day meal scheme, the incidence of anemia could be brought down effectively. Keywords: Anemia, Children, Clinical pallor, Palmar crease pallor INTRODUCTION study conducted by the Nutrition Foundation of India (1999), including 520 urban and 185 adolescent girls The World Health Organization (WHO) estimates that (aged 11- 19 years), nearly 17% of the rural and 9.6% of about 2 billion individuals or about 40% of the world’s the urban adolescent girls had Hemoglobin (Hb) levels population suffer from anemia. The population groups <10g/dl.5 with the highest prevalence of anemia are: pregnant women and the elderly (about 50%), infants and children This study was conducted to identify clinical pallor in 1 to 2 years (48%), school children (40%), non-pregnant school children between 6-11 years and to correlate with women (35%), and pre-schoolers (25%).1-3 the blood hemoglobin levels, in the rural district of Medchal. This district has got the mid-day meals At a meeting of the International Nutritional Anemia programme well implemented in the schools. Hence, it Consultative Group (INACG, 1999), it was stated that was also a motive to identify the impact of mid-day meal school children aged 5 to 14 years must be recognized as programme in preventing the anemia in this high risk age a high risk group because the percentage of anaemic group. children is as high as that of the pregnant women.4 In the International Journal of Contemporary Pediatrics | July-September 2016 | Vol 3 | Issue 3 Page 872 Regina D et al. Int J Contemp Pediatr. 2016 Aug;3(3):872-877 METHODS Significance was assessed at 5% level of significance. The following assumptions on data were made – The study was conducted at MediCiti Institute of Medical Sciences, Ghanpur, Medchal, Hyderabad, India from 1. Dependent variables should be normally distributed October 2014 - September 2015. 2. Samples drawn from the population should be random. An outreach programme was conducted for children between 6-11 years. An informed consent was obtained Student t test was used to find the significance of study from all study participants before enrolling them in the parameters on continuous scale between two groups on study. 1007 children were screened clinically and their metric parameters. Levene’s test for homogeneity of blood samples were also collected and analyzed by variance was performed to assess the homogeneity of hemocue instrument. A complete physical examination variance. was also done for all these children. Statistical software: SAS 9.2, SPSS 15.0, STATA 10.1, An observer sequentially examined conjunctiva, tongue, Medcalc 9.0.1, Systat 12.0 and R environment ver.2.11.1 skin, palm and nail bed of each study patient. were used for data analysis. The conjunctiva was considered pale, if the anterior rim RESULTS of the lower palpebral conjunctiva looked as pale as the deeper posterior rim. The tongue pallor was assessed on Table 1: Age wise distribution of subjects. the dorsum of the tongue. Palmer pallor was assessed by Age in Anemia Anemia the intensity of the palmar creases. Nail bed was assessed Total by the color of the nail. years present absent 6 21 98 119(11.8%) Clinical grading of pallor6 7 23 129 152(15.1%) 8 24 180 204(20.3%) Mild: pallor of conjunctiva and/or mucous membrane. 9 18 204 222(22%) 10 21 181 202(20.1%) Moderate: pallor of conjunctiva and/or mucous 11 10 98 108(10.7%) membrane + pallor of skin. 117 890 1007 Severe: pallor of conjunctiva and/or mucous membrane + A total of 1007 subjects belonging to 6-11 years were pallor of skin + pallor of palmar creases. included in this study. The maximum numbers were 9 years old (22%, 222) (Table 1). Statistical analysis Out of 1007 subjects, 463 were males, and 544 females. Descriptive and inferential statistical analysis was carried Anemia was found among 117 subjects (11.6%) and was out in this study. Results on continuous measurements more prevalent in females (76, 64.95%) which was found were presented on Mean+Sd and results on categorical to be statistically significant (p=0.015). measurements were presented in number (%). Table 2: Comparison of haemoglobin levels with various clinical grades of pallor. Clinical pallor at various body sites P value Hb Conjunctival Skin pallor vs Values No Conjunctival Pallor Palmar Palmar pallor pallor vs No Conjunctival (g/dl) pallor pallor of skin pallor vs Skin pallor pallor pallor Mean 13.08 11.63 10.74 9.11 SD 0.82 0.70 0.72 0.88 <0.001 <0.001 <0.001 Numbers 843 95 50 19 Hindus, Christians and Muslims constituted 55.0%, 61.96% subjects belonged to class IV, while 38.04% 26.9% and 18.1% of the study population respectively. belonged to class V of updated socio economic There is no statistically significant difference in the classification of Prasad, used for rural areas.no significant prevalence of anemia among the subjects belonging to association was observed between socio-economic status various religions mentioned above (p=0.2741). and prevalence of anemia (p=0.1562). International Journal of Contemporary Pediatrics | July-September 2016 | Vol 3 | Issue 3 Page 873 Regina D et al. Int J Contemp Pediatr. 2016 Aug;3(3):872-877 There is a strong statistical significance between DISCUSSION hemoglobin levels and clinical pallor at various body sites (p <0.001). The study analyses the various socio demographic variables with prevalence of anemia. 9 year old subjects Table 3: 2 X 2 tables between clinical pallor and formed the majority (22 %) of the study subjects. Singh C anemia. conducted a similar community based study in Reddy R district in school children, in which 11 year olds (26.5%) Anemia formed the majority of the study subjects followed by 10 Total Present Absent year old subjects.7 however the study subjects are Clinical Present 110 56 166 homogenous in distribution and it doesn’t affect the pallor Absent 7 834 841 results by bias. Total 117 890 1007 Males and females constituted 46% and 54% respectively The sensitivity and specificity of clinical pallor in in the present study. The distribution of the subjects is diagnosing anemia is 94.02% and 93.71% respectively. homogenous as there is no statistical significance (fig.1) the positive and negative likelihood ratios of between the two groups. clinical pallor in diagnosing anemia are 14.94% and 0.064% respectively. In the study by Mohapatra et al, out of the 385 subjects in the less than 12 years category, 62% were males and 38% were females.8 In the study by Jain N et al, out of the 113 subjects in the 5 years to 16 years category, 33.4% were males and 66.6% were females.9 In the study by Gupta S et al, out of the 172 children in the 6 years to 16 years category, 58.13% were males and 41.86% were females.10 In the study by Singh C et al, out of the 412 subjects in the 6 years to 11 years category, 43.9% were males and 56.1% were females.7 This study is very unique and comparable to the present study as the subjects in the study fall into the same age group as the present study.