EVALUATION OF CLINICAL SIGNS TO DIAGNOSE ANEMIA IN UGANDA AND BANGLADESH, IN AREAS WITH AND WITHOUT MALARIA

The object of this study was to assess the ability of pallor and other clinical signs, including those in the integrated Management of Child hood Illness (IMCI) guidelines developed by WHO and UNICEF, to identif y severe anaemia and some anaemia in developing country settings with and without malaria. A total of 1226 and 668 children aged 2 months to 5 years were prospectively sampled from patients presenting at, respe ctively a district hospital in rural Uganda and a children's hospital in Dhaka, Bangladesh. The study physicians obtained a standardized his tory and carried out a physical examination that included pallor, sign s of respiratory distress, and the remaining IMCI referral signs. The haematocrit or haemoglobin level was determined in all children with c onjunctival or palmar pallor, and in a sample of the rest. Children wi th a blood level measurement and assessment of pallor at both sites we re included in the anaemia analysis. Using the haematocrit or haemoglo bin level as the reference standard, the correctness of assessments us ing severe and some pallor and other clinical signs in classifying sev ere and some anaemia was determined. While the full IMCI process would have referred most of the children in Uganda and nearly all the child ren in Bangladesh with severe anaemia to hospital. few would have rece ived a diagnosis of severe anaemia. Severe palmar and conjunctival pal lor, individually and together, had 10-50% sensitivity and 99% specifi city for severe anaemia; the addition of grunting increased the sensit ivity to 37-80% while maintaining a reasonable positive predictive val ue. Palmar pallor did not work as well as conjunctival pallor in Bangl adesh for the detection for severe or some anaemia, Combining ''conjun ctival or palmar pallor'' detected 71-87% of moderate anaemia and half or more of mild anaemia. About half the children with no anaemia were incorrectly classified as having ''moderate or mild'' anaemia. Anaemi a was more easily diagnosed in Uganda in children with malaria. Our re sults show that simple clinical signs can correctly classify the anaem ia status of most children. Grunting may serve as a useful adjunct to pallor in the diagnosis of severe anaemia. Conjunctival pallor should be added to the IMCI anaemia box, or the guidelines need to be adapted in regions where palmar pallor may not readily be detected.