SYNOPSIS

Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore

“THE UTILITY OF PALLOR IN DETECTING ANEMIA IN UNDER FIVE CHILDREN”

Name of the candidate : Dr. Divya Krishnan K

Guide : Dr. K Shreedhara Avabratha

Course and Subject : M.D. (Paediatrics)

Department of Paediatrics,

Father Muller Medical College Hospital,

Kankanady, Mangalore – 575002

2012

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA, BANGALORE

ANNEXURE – II

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1. / Name of the Candidate and Address / DR. DIVYA KRISHNAN K
post Graduate Resident
Dept of Paediatrics
Father muller medical college
Kankanady
Mangalore – 575002
2. / Name of the Institution / Father muller medical college
Kankanady
Mangalore – 575002
3. / Course of study and subject / MD (Paediatrics)
4. / Date of admission to Course / 30/05/2012
5. / TITLE OF THE TOPIC:
“THE UTILITY OF PALLOR IN DETECTING ANEMIA IN UNDER FIVE CHILDREN”
6. / BRIEF RESUME OF THE INTENDED WORK:
6.1 NEED FOR THE STUDY:
Anemia is defined as reduction in haemoglobin concentration or RBC volume below range of values occurring in healthy persons.1 It is associated with impaired physical growth and mental development. Anemia has been a big problem in India and the National Family Health Survey ( NFHS III ) data showed around 70% prevalence of anemia in children less than 5years of age. 2
Assessment of pallor for anemia is an important part of general physical examination of every patient. The diagnosis and management of anemia largely depends on clinical assessment for pallor.3 The Integrated Management of Childhood Illness (IMCI) strategy developed by the World Health Organization recommends the use of palmar pallor as the initial screening tool.4 There are hardly any studies assessing the accuracy of pallor for detection of anemia in Indian paediatric population .This study evaluates the validity of pallor at four anatomic sites (conjunctiva, nail bed, tongue and palm) to identify anemia. Also, the grading of pallor and its correlation with the etiology of anemia are included in this study.
6.2 REVIEW OF LITERATURE
Pallor is useful in evaluation of patients suspected of anemia, although it may be misleading for a variety of reasons including increased pigmentation with iron, melanin or bilirubin.4 Getaneh T and colleagues3 studied the utility of pallor detecting anemia in underfive children and reported that palmar pallor had the highest sensitivity (58%) to detect moderate anemia as compared to other anatomic sites. The use of either palmar or conjunctival pallor in detecting anemia increased the sensitivity to 73%.
A study conducted by Zucker JR5 in Western Kenya reported that tongue pallor had low sensitivity among all children examined. Weber MW and colleagues6 from their study in children in Gambia came to a conclusion that the best predictor, a combination of definite pallor of conjunctiva and definite pallor of palms had a positive predictive value of 67%, a sensitivity of 80%, a specificity of 85%.
Butt Z 7 did a study in hospitalized patients and reported that pallor is not proven as an accurate sign for mild anemia. Pallor of conjunctiva, palm & nailbed has moderate accuracy in detecting severe anemia. Absence of pallor of conjunctiva and palm convincingly rules out severe anemia.
Children younger than 2 years were found to have a higher prevalence of anemia as compared to older children (p < 0.001).3 There are very few studies correlating the grading of pallor with etiology. According to a study by Kalter et al 8 anemia was more easily diagnosed in children with malaria. Yalgin et al 4 studied the validity of pallor in beta thalassemic patients and reported that conjunctival pallor has adequate sensitivity and specificity to detect anemia.
6.3  OBJECTIVES OF THE STUDY:
1.  To study the utility of pallor in four sites (conjunctiva, tongue, nail bed and palm) in detecting anemia in children.
2.  To study clinical profile of anemia in these children to correlate with its etiology.
7. / MATERIAL AND METHODS
7.1  SOURCE OF DATA :
Father Muller Medical College, paediatrics department.
All admitted children with age group 6 months to 5 years within study period (October 2012 to March 2014)
Type of study-. Case control study
7.2  METHOD OF COLLECTION OF DATA:
Data will be collected from a sample of 300 patients (150 cases and 150 controls) after taking written informed consent from parent . Samples will be selected using purposive sampling technique. Children will be assessed for pallor at four sites by the investigator. Pale conjunctiva are those with very or no evidence of red color on the anterior rim, which matched the fleshy color of the posterior aspect of palpebral conjunctiva.9 The tongue pallor will be assessed on the dorsum of the tongue. Palmar pallor will be assessed by the intensity of the colour of the palmar creases. Nailbed pallor will be assessed by the colour of the nail.
Detailed history, clinical examination will be done in all children. Those children with pallor will be considered as study group and others as control. Pallor will be graded as present, absent or borderline. In all children haemoglobin estimation will be done by electronic cell counter. Children who are found to be anemic after the haemoglobin estimation (haemoglobin <11g%),2 will be further investigated for the etiology of anemia . It includes RBC indices, peripheral smear, bone marrow examination, HPLC as relevant. Anemia will be graded according to WHO criteria.10
Mild (10-10.99), Moderate (7-9.99) and Severe ( <7 ).
Inclusion criteria:
1. Children 6 months to 5 years
2. Those with clinical pallor in any of the four sites as study group
3. Equal number of age and sex matched children without pallor as control group
Exclusion criteria:
1. Children >5 years, < 6 months
2. Children in shock
3. Already diagnosed cases of anemia.
Statistical analysis:
Collected data will be analysed by t test, Chi square test, Karl Pearson correlation coefficient.
7.3. Does the study require any investigation or interventions to be conducted on patients or other human or animals if so please describe briefly.
No.
7.4. Has ethical clearance been obtained from your institution in case of 7.3
Yes.
8. / LIST OF REFERENCES:
1.  Lerner NB. The Anemias In: Kliegman, Stanton, St. Geme, Schor, Behrman, editors. Nelson textbook of Pediatrics. 19thed.Philadelphia: Elsevier: p1648.
2.  Kotecha PV. Nutritional anemia in young children with focus on Asia and India. Indian J Community Med.2011; 36(1) :8-16.
3.  Getaneh T, Girma T, Belachew T, Teklemariam S. The utility of pallor detecting anemia in under five years old children. Ethiop.Med.J. 2000; 38(2):77-84.
4.  Yalgin SS, Unal S, Gumruk F, Yurdakok K. The validity of pallor as a clinical sign of anemia in cases with beta thalassemia. Turk.J. Pediatric.2007; 49(4): 408-12.
5.  Zucker JR, Perkins BA, Jafari H, Otieno J, Obonyo C, Campbell CC. 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.
6.  Weber MW, Kellingray SD, Palmer A, Jaffer S, Mulholland EK, Greenwood. 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.
7.  Butt Z , Ashaf U, Sherazi SFH, Jan NU, Shahbaz U. Diagnostic accuracy of pallor for detecting mild and severe anemia in hospitalised patients. J Pak Med Assoc. 2010;60(9):76-5.
8.  Kalter H D, Burnham G, Kolstad PR, Hossain M, Schillinger JA, Khan NZ 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(1): 103-11.
9.  Sheth TN, Niteesh KC, Bowes M, Detsky AS. The relation of conjunctival pallor to the presence of anemia. J Gen Intern Med 1997;12(2) :102-6.
10.  DeMaeyer EM, Dallman P, Gurney JM, Hallberg , Sood SK, Srikantia SG 1989. Preventing and controlling iron deficiency anemia through primary health care: A guide for health administrators and programme managers. Geneva: World Health Organization.p26.
9. / SIGNATURE OF THE CANDIDATE:
10. / REMARKS OF THE GUIDE:
11. / NAME AND DESIGNATION OF THE
11.1 GUIDE: / Dr K Shreedhara Avabratha MD, DNB.
Associate Professor,
Department of Paediatrics,
Father Muller Medical College,
Kankanady, Mangalore - 575002
11.2 SIGNATURE :
11.3 CO-GUIDE:
11.4 SIGNATURE:
11.5 HEAD OF THE DEPARTMENT: / Dr. Pavan Hegde MD.
Professor and HOD,
Department of Paediatrics,
Father Muller Medical College,
Kankanady, Mangalore – 575002
11.6 SIGNATURE:
12. / 12.1REMARKS OF THE CHAIRMAN & PRINCIPAL:
12.2 SIGNATURE:

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