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ORIGINAL ARTICLE
Year : 2020  |  Volume : 11  |  Issue : 1  |  Page : 26-28

Interobserver agreement of pallor in detection of anemia


1 Department of Pediatrics, MES Medical College, Perinthalmanna, Kerala, India
2 Department of Pediatrics, Father Muller Medical College, Mangalore, Karnataka, India
3 Department of Neonatal Services, Princess Anne Hospital, Southampton, UK

Date of Submission08-Jul-2020
Date of Acceptance10-Aug-2020
Date of Web Publication23-Dec-2020

Correspondence Address:
Dr. K Shreedhara Avabratha
Department of Pediatrics, Father Muller Medical College, Mangalore, Karnataka
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mjmsr.mjmsr_28_20

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  Abstract 


Introduction: The diagnosis and management of anemia largely depends on clinical assessment of pallor. There are varied opinions regarding the subjective variation in the assessment of pallor. Objective: The objective is to study the interobserver agreement of pallor between two independent observers. Methodology: This observational study done in a medical college hospital on 50 children in the age group of 6 months to 5 years. Pallor was assessed in four sites namely conjunctiva, tongue, nail bed, and palm. When pallor was present, it was graded as definitely present and borderline. Second examiner independently assessed the pallor at all four sites within an hour. Statistical analysis was done by percentage and kappa value. Results: Out of 50 children aged between 6 months to 5 years, 30 were male and 20 were female. Eleven were infants of 6 months to 12 months, 19 children were between 1 and 3 years and 20 children were 3–5 years of age group. Twenty-eight children had anemia with hemoglobin <11 g/dl. Kappa value for conjunctival and nailbed assessment of pallor were 0.484 and 0.441, respectively, indicating good agreement. The value was 0.644 and 0.73 for tongue pallor and palmar pallor respectively suggesting very good agreement. Conclusion: Interobserver agreement was found to be good in the evaluation of pallor. Palmar and tongue pallor had better agreement than conjunctival and nailbed pallor in our study. By assessing in all four sites, for pallor interobserver variability can be minimized.

Keywords: Agreement, anemia, observer variation, pallor


How to cite this article:
Divyakrishnan K, Avabratha K S, D'Souza AJ. Interobserver agreement of pallor in detection of anemia. Muller J Med Sci Res 2020;11:26-8

How to cite this URL:
Divyakrishnan K, Avabratha K S, D'Souza AJ. Interobserver agreement of pallor in detection of anemia. Muller J Med Sci Res [serial online] 2020 [cited 2021 Apr 17];11:26-8. Available from: https://www.mjmsr.net/text.asp?2020/11/1/26/304592




  Introduction Top


Anemia is the most common hematological disease of childhood. It is defined as the decrease in hemoglobin concentration or red blood cell volume below the range of values for that particular age. The prevalence of anemia in children <5 years is around 58% as per the National Family Health Survey ([NFHS] 4: done in 2015–2016) data in India an improvement from 70% in NFHS3.[1],[2]

The diagnosis and management of anemia largely depends on clinical assessment of pallor. The assessment of pallor for anemia is an important part of general physical examination in every patient. Conjunctiva, tongue, nailbed, and palm are the main sites used for assessing pallor.

There are varied opinions regarding the subjective variation in the assessment of pallor. There are studies with conflicting findings and some of these studies are pertaining to assessment of pallor in specific sites. Hence, this comprehensive study was taken up to address these issues. The objective is to study the agreement about pallor in detecting anemia between two independent observers.


  Methodology Top


This is an observational study done in Father Muller medical college hospital in South India. The study group consisted of 50 children in the age group of 6 months to 5 years admitted to the hospital. Samples were selected using purposive sampling technique. Children were examined for pallor under day light. Pallor was assessed in four sites namely conjunctiva, tongue, nailbed, and palm. When pallor was present, it was graded as definitely present and borderline. Second examiner independently assessed the pallor at all four sites within an hour.

Hemoglobin estimation was done to diagnose anemia. Anemia was diagnosed according to the WHO criterion (Hb <11 g/dl in 6 months to 5 years).[3] The study was approved by institutional ethical committee. Statistical analysis was done by percentage and kappa value. Kappa value was interpreted as <0.20 poor agreement, 0.21–0.40 fair, 0.41–0.60 good, 0.61–0.80 very good, and 0.81–1 as excellent.


  Results Top


Of 50 children aged between 6 months and 5 years, 30 were male and 20 were female. Eleven were infants of 6 months to 12 months, 19 children were between 1 and 3 years and 20 children were 3 and 5 years of age group. First observer examined the children, assessed for pallor, and noted down the findings. Second examiner independently assessed the pallor and separately noted down the findings. Twenty-eight children had anemia with hemoglobin <11 g/dl. The findings of two investigators were compared [Table 1].
Table 1: Comparison between two investigators' observations

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[Table 2], [Table 3], [Table 4], [Table 5] show the variation between two observers at each site when pallor was graded as definitely present and as borderline.
Table 2: Agreement between 2 observers in conjunctival pallor

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Table 3: Agreement between 2 observers in tongue pallor

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Table 4: Agreement between 2 observers in nailbed pallor

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Table 5: Agreement between 2 observers in palmar pallor

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  Discussion Top


There are varied opinions regarding the subjective variation of pallor in anemia. To check agreement, physicians and medical students assessed pallor independently[4] and found that experience is important in detecting anemia, whereas similar study by Leal and Osório[5] concluded that experience is not so important in the evaluation of anemia by clinical examination. In this present study, the two observers were of similar degree of experience. Although the sample size is small the results are compelling. The inter observer agreement varied from good to very good in four sites. Palmar and tongue pallor were found to have very good agreement.

Study by Kalantri et al.[6] reported that interobserver agreement of pallor assessment in all these four sites were uniformly poor with Kappa value of <0.2. Whereas study by Muhe et al.[7] in Ethiopia found that agreement was good at all the four sites. In their study, agreement was highest for conjunctival pallor and lowest for palmar pallor. Nardone et al.[8] in their study reported that agreement was fair for conjunctiva and nailbed and good for palmar pallor.

Some amount of interobserver variability is bound to occur as there is a high chance of missing mild anemia cases by merely looking for pallor. There is a suggestion that sensitivity can be improved over clinical assessment of conjunctival pallor using digital photography of the conjunctiva.[9]


  Conclusion Top


Interobserver agreement of pallor in detecting anemia was found to be good. Palmar and tongue pallor had better agreement than conjunctival and nailbed pallor in our study. By assessing in all four sites, for pallor interobserver variability can be minimized.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Rchiips.org. 2020 [20]. Available from: http://rchiips.org/nfhs/NFHS-4Reports/India.Pdf. [Last accessed on 2020 May 10].  Back to cited text no. 1
    
2.
Bharati S, Pal M, Bharati P. Prevalence of anaemia among 6- to 59-month-old children in India: The latest picture through the NFHS-4. J Biosoc Sci 2020;52:97-107.  Back to cited text no. 2
    
3.
Who.int. 2011 [20]. Available from: https://www.who.int/vmnis/indicators/haemoglobin. Pdf [Last accessed on 2020 May 19].  Back to cited text no. 3
    
4.
Maurici R, Machado C. Clinical evaluation of the paleness: Agreement between observers and comparison with hemoglobin levels. Revista Brasileira de Hematologia e Hemoterapia. 2009;32:444-48.  Back to cited text no. 4
    
5.
Leal LP, Osório MM. Validity and reproducibility of the clinical signs for the diagnosis of anemia in children. Cad Saude Publica 2005;21:565-72.  Back to cited text no. 5
    
6.
Kalantri A, Karambelkar M, Joshi R, Kalantri S, Jajoo U. Accuracy and reliability of pallor for detecting anaemia: A hospital-based diagnostic accuracy study. PLoS One 2010;5:e8545.  Back to cited text no. 6
    
7.
Muhe L, Oljira B, Degefu H, Jaffar S, Weber MW. Evaluation of clinical pallor in the identification and treatment of children with moderate and severe anaemia. Trop Med Int Health 2000;5:805-10.  Back to cited text no. 7
    
8.
Nardone DA, Roth KM, Mazur DJ, McAfee JH. Usefulness of physical examination in detecting the presence or absence of anemia. Arch Intern Med 1990;150:201-4.  Back to cited text no. 8
    
9.
Collings S, Thompson O, Hirst E, Goossens L, George A, Weinkove R. Noninvasive detection of anaemia using digital photographs of the conjunctiva. PLoS One 2016;11:e0153286.  Back to cited text no. 9
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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