University of the

Witwatersrand
Department of Paediatrics
Division of Community Paediatrics
Assignment A: Is Conjunctival Pallor Useful in
Detecting Anaemia?

Yahya Atiya
 Anaemia
Title

Is conjunctival pallor a reliable sign for the detection of anaemia?

Scenario

Olivia is an 11 year old African girl who presented to paediatric casualty in mid-January
2004 complaining of fever, lethargy and general weakness. A diagnosis of acute
Plasmodium falciparum malaria was made on the basis of a positive travel history to
Malawi and general examination which revealed palmar and mild conjunctival pallor. It
was confirmed by urinalysis, which revealed frank haematuria, and a peripheral blood
smear, which showed parasites in the erythrocytes. Her full blood count revealed a
haemoglobin level of 7.8 g/dl, and a mean cell volume of 75fl. Clearly she is anaemic,
but the question is how reliable is conjunctival pallor in detecting this?

Clinical Question

In children assessed as being anaemic, how reliable is conjunctival pallor in detecting the
anaemia?

Search

Cochrane Database of Systematic Reviews and Pubmed:

Search criteria: anaemia +pallor +conjunctiva
Limits: All child 0-18yrs
Search outcome:
Cochrane – None relevant
Pubmed –
14 hits
 7 relevant
 6 in English
 1 in Portuguese translated to English.
 7 irrelevant
 4 related to adults
 1 assessed usefulness of haemoglobin colour scales
 1 assessed maternal anaemia in obstetrics patients
 1 referred to ocular findings in G6PD deficiency
Summary of Relevant Papers

Author, Study type

date and Patient group (level of Outcomes Key results Study weaknesses
country evidence)
Possible selection bias d/t
Thaver IH, 951 children Conjunctival, palmar, nail Combinations yielded better
Validation rural setting resulting in more
Baig L 1994 Aged 6-60mo bed & tongue pallor results than any one site alone
patients with anaemia
Severe anaemia is easier to detect
Possible selection bias d/t
Luby SP et 1104 children Conjunctival, palmar, nail than moderate anaemia
Validation rural setting resulting in more
al 1995 Aged <5yrs bed & tongue pallor Clinical findings can be used to
patients with anaemia
detect anaemia
1048 inpatient
Nail bed pallor was best for Possible selection bias d/t
children
Zucker JR Conjunctival, nail bed, assessing severe anaemia No hospital setting Was
1666 outpatient Validation
et al 1997 palmar & tongue pallor significant difference noted for confirmation of anaemia
children
mod anaemia done?
Aged 2mo-5yrs
1226 children
Conjunctival pallor is more useful
in Bangladesh
Kalter HD Std history & exam incl than palmar pallor Anaemia is Possible selection bias d/t
668 children in Validation
et al 1997 pallor easier to detect in children with hospital setting
Uganda
malaria
Aged 2mo-5yrs
Weber MW Conjunctiva, nail bed and Ages not provided
368 children Validation Conjunctival pallor alone is useful
et al 1997 palmar pallor Exam not done by physician
Conjunctiva, tongue & The cut-off for det. of
Getaneh T 574 children Palmar pallor had highest
Validation buccal mucosa, nail bed anaemia is not given
et al 2000 Aged 2-60mo sensitivity
and palm; Hb results Exam done by nurses
Low levels of agreement.
Spinelli MG 135 children Palmar and conjunctival Comparatively few subjects.
Validation Conjunctival pallor more sensitive
et al 2003 Aged 3mo-6yrs appearance, Hb results Actual figures are not given
than palmar.
Commentary

Most studies assessed conjunctival pallor in association with other sites of pallor i.e.
palm, nail bed, tongue and buccal mucosa. While this is clinically useful, it does not
answer the question of whether conjunctival pallor alone is sufficient to diagnose
anaemia. This is important because most clinicians rely on it almost exclusively, ignoring
the other sites. As medical students, we find ourselves in a similar situation; we are never
faulted, even in exams, for not checking elsewhere. Weber et al addressed this situation,
and found that conjunctival pallor alone was useful. The only problem is that the ages of
the children are not provided. Hence, is conjunctival pallor useful in older, younger, or all
children?

On the other hand, Kalter et al did not even specify where they checked for pallor, merely
stating that a “standard history & exam incl pallor” was conducted. This raises the
question of how reliable their data really is. It was quite a large study by comparison, but
this subtle mistake brings the validity (or rather reliability) of the validation study under
scrutiny! Further, this and several other studies may have had a selection bias due to the
fact that they were conducted in a hospital setting. This is more than a technical issue
because staff at tertiary institutions tend to be better trained and more skilled than staff at
lower-level institutions.

Spinelli et al found that conjunctival pallor was more sensitive than palmar pallor.
Getaneh et al dispute this, but has no support from any other studies. However, they,
along with Spinelli and others, did assess the inter-observer variation in assessment of
pallor, using kappa values. They found that agreement was best for conjunctival pallor
and lowest for palmar pallor. This suggests, to me, that conjunctival pallor probably is a
better indicator of anaemia.

One thing that all the studies seem to agree upon is that assessment at several sites is
definitely better than assessment at any single site. This again goes back to what was first
stated at the beginning of this review. Another is that severe anaemia, as can be expected,
was easier to detect than mild or moderate anaemia.

Weber, Kalter and Zucker et al assessed pallor in a malaria setting. This is probably not
as important for us as it is for those working in malaria endemic areas, but it is significant
that they felt that in a malarial setting, conjunctival pallor alone is a useful estimate of
anaemia. Zucker et al go so far as to recommend malaria treatment for any child less than
36 months presenting with pallor.

As a practical issue, most studies, including Kalter, Weber, Zucker and Luby et al, found
that clinical examination can be a useful indicator of the status of the child, especially in
resource-poor settings such as much of the rural areas of Southern Africa.
Clinical Bottom Line

In children presenting with pallor, conjunctival pallor, alone or in combination with

pallor at other sites, is a useful indicator of anaemia.

References

1. Thaver IH, Baig L. Anaemia in children: Part I. Can simple observations by

primary care provider help in diagnosis? J Pak Med Assoc. 1994;44:282-4.
2. Luby SP, Kazembe PN, Redd SC et al. Using clinical signs to diagnose anaemia
in African children. Bull World Health Organ. 1995;73(4):477-82.
3. Zucker JR, Perkins BA, Jafari H et al. Clinical signs for the recognition of
children with moderate or severe anaemia in western Kenya. Bull World Health
Organ. 1997;75 Suppl 1:97-102.
4. Kalter HD, Burnham G, Kolstad PR et al. Evaluation of clinical signs to diagnose
anaemia in Uganda and Bangladesh, in areas with and without malaria. Bull
World Health Organ. 1997;75 Suppl 1:103-11.
5. Weber MW, Kellingray SD, Palmer A et al. Pallor as a clinical sign of severe
anaemia in children: an investigation in the Gambia. Bull World Health Organ.
1997;75 Suppl 1:113-8.
6. Getaneh T, Girma T, Belachew T et al. The utility of pallor detecting anemia in
under five years old children. Ethiop Med J. 2000 Apr;38(2):77-84.
7. Spinelli MG, Souza JM, Souza SB et al. Reliability and validity of palmar and
conjunctival pallor for anemia detection purposes. Rev Saude Publica.
2003;37:404-8.