Accuracy of clinical pallor in the diagnosis of anaemia in children: a meta-analysis

BACKGROUND: Anaemia is highly prevalent in children of developing countries. It is associated with impaired physical growth and mental development. Palmar pallor is recommended at primary level for diagnosing it, on the basis of few studies. The objective of the study was to systematically assess the accuracy of clinical signs in the diagnosis of anaemia in children. METHODS: A systematic review on the accuracy of clinical signs of anaemia in children. We performed an Internet search in various databases and an additional reference tracking. Studies had to be on performance of clinical signs in the diagnosis of anaemia, using haemoglobin as the gold standard. We calculated pooled diagnostic likelihood ratios (LR's) and odds ratios (DOR's) for each clinical sign at different haemoglobin thresholds. RESULTS: Eleven articles met the inclusion criteria. Most studies were performed in Africa, in children underfive. Chi-square test for proportions and Cochran Q for DOR's and for LR's showed heterogeneity. Type of observer and haemoglobin technique influenced the results. Pooling was done using the random effects model. Pooled DOR at haemoglobin <11 g/dL was 4.3 (95% CI 2.6–7.2) for palmar pallor, 3.7 (2.3–5.9) for conjunctival pallor, and 3.4 (1.8–6.3) for nailbed pallor. DOR's and LR's were slightly better for nailbed pallor at all other haemoglobin thresholds. The accuracy did not vary substantially after excluding outliers. CONCLUSION: This meta-analysis did not document a highly accurate clinical sign of anaemia. In view of poor performance of clinical signs, universal iron supplementation may be an adequate control strategy in high prevalence areas. Further well-designed studies are needed in settings other than Africa. They should assess inter-observer variation, performance of combined clinical signs, phenotypic differences, and different degrees of anaemia

Doença celíaca: avaliação da obediência à dieta isenta de glúten e do conhecimento da doença pelos pacientes cadastrados na Associação dos Celíacos do Brasil (ACELBRA) Celiac disease: evaluation of compliance to a gluten-free diet and knowledge of the disease in celiac patients registered at the Brazilian Celiac Association (BCA)

Racional &#151; A obediência à dieta isenta de glúten previne a ocorrência de complicações malignas e não-malignas. Objetivo - Avaliar a obediência à dieta isenta de glúten e o conhecimento teórico acerca da doença celíaca e seu tratamento pelos pacientes cadastrados na Associação dos Celíacos do Brasil (ACELBRA). Métodos - Foi enviado por correio um questionário a respeito da obediência à dieta isenta de glúten e do conhecimento teórico da doença celíaca e seu tratamento a 584 membros cadastrados na ACELBRA. Resultados - Dos 534 (91,4%) questionários recebidos, foram analisados 529 (90,6%). Quanto à obediência à dieta, 69,4% dos pacientes responderam que nunca ingerem glúten e 29,5% que não obedecem à dieta. A proporção de pacientes que ingerem glúten freqüentemente ou sem restrição alguma é maior entre aqueles com idade igual ou maior a 21 anos (17,7%) do que os com idade menor (9,9%). A freqüência de obediência à dieta foi maior quando o intervalo de tempo em que foi estabelecido o diagnóstico da doença foi inferior a 5 anos. O intestino delgado foi assinalado como o principal órgão afetado na doença celíaca por 82% dos pacientes. Os principais sintomas assinalados foram diarréia (96,6%), emagrecimento (93,4%), barriga inchada (90,4%), anemia (68,1%) e vômitos (59,6%). Apenas 59,0% concordaram com a existência de predisposição genética. Segundo 90,4% das respostas, a doença é permanente e 96,2% assinalaram que a dieta deve ser totalmente isenta de glúten; 67,1% responderam que o glúten é uma proteína que está presente, segundo 92,1% dos inquéritos, no trigo, centeio, cevada e aveia. Observou-se maior proporção de obediência à dieta quando há conhecimento da doença e dieta. A biopsia de intestino delgado foi considerada necessária por apenas 67,5% dos pacientes, observando-se maior freqüência de obediência à dieta nos pacientes que realizaram pelo menos uma biopsia de intestino delgado. Conclusões - Quanto maior o grau de conhecimento da doença e seu tratamento, maior a obediência à dieta isenta de glúten.<br>Background &#151; The compliance to a gluten-free diet may prevent the development of both non-malignant and malignant complications. Aim - To evaluate compliance to a gluten-free diet and knowledge of the disease in celiac patients registered at the Brazilian Celiac Association (BCA). Methods - A structured questionnaire was designed to assess compliance to a gluten-free diet as well as knowledge of the celiac disease. It was mailed to 584 members of BCA. Results - Five hundred and twenty nine (90.6%) of a total of 534 (91.4%) answered questionnaires were analyzed; 69.4% were classified as compliant patients whereas 29.5% were classified as noncompliant. The proportion of patients age 21 or older who consume gluten frequently or without any restriction is larger (17.7%) than those who were younger than 21 years (9.9%). Frequency of dietary compliance was higher when the diagnosis had taken less than 5 years to be established; 82% of the patients replied that the small intestine was the part of the body affected by the disease. The most common symptoms of the disease according to the answers were diarrhea (96.6%), weight loss (93.4%), protuberant abdomen (90.4%), anemia (68.1%) and vomiting (59.6%). Only 59.0% agreed with the existence of genetic predisposition; 90.4% answered that the disease is permanent and 96.2% stated that the diet should exclude gluten absolutely; 67.1% answered that the gluten is a protein and according to 92.1% questionnaires this protein is present in wheat, rye, barley and oat. Greater compliance was observed when there was an understanding of the disease and diet. The small intestine biopsy was considered necessary for just 67.5% of the patients, and greater compliance was observed in patients who had undergone at least one small intestine biopsy. Conclusion - Our findings indicate that the more the patients know and understand about the disease, the better able they are to comply with the diet

Validação e reprodutibilidade de sinais clínicos no diagnóstico de anemia em crianças Validity and reproductibility of the clinical signs for the diagnosis of anemia in children

Este trabalho teve como objetivo avaliar a validade e reprodutibilidade dos sinais clínicos (palidez palmar e conjuntival) no diagnóstico de anemia em crianças de 6-23 meses, no Nordeste do Brasil, por meio de estudo transversal com amostra de 421 crianças, realizado nos ambulatórios de pediatria e puericultura do Instituto Materno Infantil de Pernambuco. Os sinais clínicos foram avaliados por dois examinadores. A reprodutibilidade foi avaliada pelo coeficiente de kappa e a validação (sensibilidade e especificidade) foi realizada utilizando-se a hemoglobina como padrão. Os sinais clínicos demonstraram baixa reprodutibilidade (kappa de 0,24-0,25). A maior sensibilidade para diagnosticar anemia (Hb < 11g/dl) e anemia moderada/ grave (Hb < 9g/dl), respectivamente, foi apresentada pela combinação de palidez palmar ou conjuntival (39,7% e 53,5%), seguida pela palidez palmar isoladamente (29,9% e 40,0%). A maior especificidade foi para a palidez palmar comparada à palma da mão da mãe (95,5% e 90,1% para Hb < 11g/dl e Hb < 9g/dl, respectivamente). A sensibilidade dos sinais clínicos foi melhor para diagnosticar a anemia moderada/grave, especialmente quando a palidez palmar e conjuntival são combinadas, sugerindo que a utilização dos mesmos não se constitui em um bom instrumento para diagnosticar anemia leve.<br>This study aimed to assess the validity and reproducibility of clinical signs (palmar and conjunctival pallor) in the diagnosis of anemia in children 6-23 months of age in Northeast Brazil. This was a cross-sectional study with a sample of 421 children in the child care and pediatric outpatient wards at the Mother and Child Care Institute of Pernambuco. Two examiners evaluated clinical signs using the Kappa coefficient, and validation (sensitivity and specificity) was performed using hemoglobin as the standard. Clinical signs demonstrated low reproducibility (kappa 0.24-0.25). The highest sensitivity for diagnosing anemia (Hb < 11g/dl) and moderate/ severe anemia (Hb < 9g/dl), respectively, was provided by combining palmar and conjuntival pallor (39.7% and 53.5%), followed by palmar pallor alone (29.9% and 40.0%). The highest specificity was provided by palmar pallor in the child as compared to the mother (95.5% and 90.1%, Hb < 11g/dl and Hb < 9g/dl, respectively). Sensitivity of clinical signs was better in diagnosing moderate/severe anemia, especially when combining palmar and conjunctival pallor, suggesting that their utilization does not provide a good instrument for diagnosing mild anemia