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Updated: Jul 6, 2026
A Point-of-Care Method with Integrated Decision Support Tool to Estimate Anemia at Population Level
Published on: January 19, 2024
Validity of using pallor to detect children with mild anemia
Kadriye Yurdakök1, Sükrü N Güner, S Songül Yalçin
1Institute of Child Health, Hacettepe University, Ankara, Turkey. siyalcin@hacettepe.edu.tr
Insights
Palmar pallor is a reliable indicator of mild anemia in children under two, showing high sensitivity and specificity when assessed by trained pediatricians. This simple examination aids in anemia detection at primary care levels.
Area of Science:
- Pediatrics
- Hematology
- Public Health
Background:
- Anemia is prevalent in children under 5, with pallor assessment recommended by WHO for detection.
- Primary care settings often lack resources for definitive anemia testing.
- Validating simple clinical signs like pallor is crucial for early anemia recognition.
Purpose of the Study:
- To evaluate the accuracy and consistency of pallor examination in identifying anemia in children under two years.
- To compare the diagnostic value of pallor assessment at different anatomical sites.
Main Methods:
- 141 healthy children (6-24 months) were examined for pallor (palm, conjunctiva, buccal mucosa) by two blinded observers.
- Anemia was defined as hemoglobin <11 g/dL; children with acute/chronic illness or recent anemia treatment were excluded.
- Interobserver agreement was assessed using kappa statistics.
Main Results:
- 23% of children had anemia (hemoglobin <11 g/dL).
- Palmar pallor demonstrated the highest sensitivity (72%) and specificity (75%) for detecting anemia when assessed by an IMCI-trained pediatrician.
- Buccal and conjunctival pallor showed the highest interobserver agreement (kappa=0.64 and 0.63).
Conclusions:
- Palmar pallor is a sensitive and specific clinical sign for mild anemia in young children.
- The assessment of palmar pallor by an IMCI-trained pediatrician is a valuable tool for anemia screening.
- While interobserver agreement varies by site, palmar pallor shows significant diagnostic utility.
Background:
The World Health Organization recommends the assessment of pallor as an indicator for the presence of anemia in children under 5 years of age at a primary care level where anemia is prevalent. The aim of the present study was to study the validity and interobserver agreement of pallor examination in recognition of anemia in children under 2 years of age.
Methods:
Healthy children aged 6-24 months (n = 141) admitted to well baby clinic were assessed for the presence of pallor at three anatomic sites (palm, conjunctiva, buccal mucosa) on admission by two blinded observers (Integrated Management of Childhood Illness [IMCI] certificate pediatrician and a pediatric resident). Clinical examination for pallor was made without having the information on the child's hemoglobin level or of the other observer's assessment for pallor. Anemia was defined as hemoglobin level <11 g/dL. The exclusion criteria included the presence of any acute or chronic illness on admission, and treatment for anemia within the 3 months preceding the study.
Results:
The mean age of the children was 8.0 +/- 2.7 months; 71 (50%) were boys. Blood samples indicated anemia in 33 children (23%). Palmar pallor alone significantly had highest sensitivity (sensitivity 72% and specificity 75%, positive predictive value 48%) to detect anemia for the IMCI-trained pediatrician. The interobserver agreement was highest for buccal and conjunctival pallor (kappa = 0.64 and 0.63, respectively), and lowest for palmar pallor (kappa = 0.49).
Conclusion:
Palmar pallor is a sensitive and specific sign of mild anemia when used by the IMCI-trained pediatrician.
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