title: Anaemia and blood transfusion in African children presenting to hospital with severe febrile illness.
abstract: BACKGROUND
  Severe anaemia in children is a leading cause of hospital admission and a major cause of mortality in sub-Saharan Africa, yet there are limited published data on blood transfusion in this vulnerable group.
  
  
  METHODS
  We present data from a large controlled trial of fluid resuscitation (Fluid Expansion As Supportive Therapy (FEAST) trial) on the prevalence, clinical features, and transfusion management of anaemia in children presenting to hospitals in three East African countries with serious febrile illness (predominantly malaria and/or sepsis) and impaired peripheral perfusion.
  
  
  RESULTS
  Of 3,170 children in the FEAST trial, 3,082 (97%) had baseline haemoglobin (Hb) measurement, 2,346/3,082 (76%) were anaemic (Hb <10 g/dL), and 33% severely anaemic (Hb <5 g/dL). Prevalence of severe anaemia varied from 12% in Kenya to 41% in eastern Uganda. 1,387/3,082 (45%) children were transfused (81% within 8 hours). Adherence to WHO transfusion guidelines was poor. Among severely anaemic children who were not transfused, 52% (54/103) died within 8 hours, and 90% of these deaths occurred within 2.5 hours of randomisation. By 24 hours, 128/1,002 (13%) severely anaemic children had died, compared to 36/501 (7%) and 71/843 (8%) of those with moderate and mild anaemia, respectively. Among children without severe hypotension who were randomised to receive fluid boluses of 0.9% saline or albumin, mortality was increased (10.6% and 10.5%, respectively) compared to controls (7.2%), regardless of admission Hb level. Repeat transfusion varied from ≤2% in Kenya/Tanzania to 6 to 13% at the four Ugandan centres. Adverse reactions to blood were rare (0.4%).
  
  
  CONCLUSIONS
  Severe anaemia complicates one third of childhood admissions with serious febrile illness to hospitals in East Africa, and is associated with increased mortality. A high proportion of deaths occurred within 2.5 hours of admission, emphasizing the need for rapid recognition and prompt blood transfusion. Adherence to current WHO transfusion guidelines was poor. The high rates of re-transfusion suggest that 20 mL/kg whole blood or 10 mL/kg packed cells may undertreat a significant proportion of anaemic children. Future evaluation of the impact of a larger volume of transfused blood and optimum transfusion management of children with Hb of <6 g/dL is warranted.
authors: Sarah
authors: S
authors: Kiguli
authors: Kilifi Clinical Trials Facility, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya. k.maitland@imperial.ac.uk.
authors: Kathryn
authors: K
authors: Maitland
authors: Elizabeth C
authors: EC
authors: George
authors: Peter
authors: P
authors: Olupot-Olupot
authors: Robert O
authors: RO
authors: Opoka
authors: Charles
authors: C
authors: Engoru
authors: Samuel O
authors: SO
authors: Akech
authors: Richard
authors: R
authors: Nyeko
authors: George
authors: G
authors: Mtove
authors: Hugh
authors: H
authors: Reyburn
authors: Michael
authors: M
authors: Levin
authors: Abdel G
authors: AG
authors: Babiker
authors: Diana M
authors: DM
authors: Gibb
authors: Jane
authors: J
authors: Crawley
mesh_terms: D000351:Africa, Eastern / Q000453:epidemiology; D000740:Anemia / Q000453:epidemiology / Q000209:etiology / Q000401:mortality / Q000628:therapy*; D001803:Blood Transfusion / Q000706:statistics & numerical data; D002648:Child; D002675:Child, Preschool; D005260:Female; D005440:Fluid Therapy / Q000009:adverse effects; D019983:Guideline Adherence; D006760:Hospitalization; D006801:Humans; D007223:Infant; D008288:Malaria / Q000150:complications; D008297:Male; D017410:Practice Guidelines as Topic; D015995:Prevalence; D018805:Sepsis / Q000150:complications; D061665:Time-to-Treatment
references: Am J Trop Med Hyg. 1996 Nov;55(5):521-4
references: 8940984
references: Am J Trop Med Hyg. 2013 Apr;88(4):747-56
references: 23358640
references: Malar J. 2011;10:378
references: 22185615
references: PLoS One. 2013;8(12):e82455
references: 24358185
references: Blood. 2014 Jan 30;123(5):615-24
references: 24297872
references: BMC Med. 2014;12:67
references: 24767094
references: Br J Haematol. 2011 Sep;154(6):783-5
references: 21671896
references: BMC Med. 2013;11:68
references: 23496872
references: Cochrane Database Syst Rev. 2000;(2):CD001475
references: 10796646
references: Lancet. 2002 Feb 9;359(9305):494-5
references: 11853798
references: Vox Sang. 2004 Jul;87 Suppl 2:96-100
references: 15209890
references: Ann Trop Med Parasitol. 1971 Mar;65(1):1-20
references: 5575896
references: Lancet. 1992 Aug 29;340(8818):524-8
references: 1354285
references: Am J Trop Med Hyg. 1996 Nov;55(5):525-30
references: 8940985
references: Ann Trop Med Parasitol. 1996 Aug;90(4):395-402
references: 8944083
references: Clin Lab Med. 1996 Dec;16(4):895-906
references: 8974201
references: Trans R Soc Trop Med Hyg. 1997 Sep-Oct;91(5):557-61
references: 9463667
references: J Clin Pathol. 2005 Jan;58(1):56-60
references: 15623483
references: Br J Haematol. 2005 Feb;128(3):393-400
references: 15667544
references: Int J Epidemiol. 2006 Jun;35(3):691-704
references: 16507643
references: J Pediatr. 2006 Nov;149(5):676-81
references: 17095342
references: N Engl J Med. 2008 Feb 28;358(9):888-99
references: 18305266
references: BMC Pediatr. 2009;9:51
references: 19682362
references: PLoS One. 2010;5(1):e8545
references: 20049324
references: Crit Care Med. 2010 Mar;38(3):940-5
references: 20068463
references: N Engl J Med. 2011 Jun 30;364(26):2483-95
references: 21615299
references: N Engl J Med. 2011 Oct 6;365(14):1348; author reply 1351-3
references: 21991960
references: N Engl J Med. 2011 Oct 6;365(14):1349; author reply 1351-3
references: 21991962
references: Lancet. 2011 Nov 12;378(9804):1685-7
references: 21683436