1. Ruth Namazzi, Amos Odiit, Heather Hume, Chandy John, Robert Opoka .
Post Transfusion Changes in Haemoglobin Concentration of Children with Severe Anaemia at a Tertiary Hospital: A prospective study
Ruth Namazzi, Amos Odiit, Heather Hume, Chandy John, Robert Opoka .
Makerere University, Kampala Uganda

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Introduction
Severe anaemia (hemoglobin ≤ 5g/dL) contributes to 8 to 17% of in hospital mortality in African children
Severe anaemia is usually managed by blood transfusion and a course of haematinics.
As per WHO guidelines, children should receive 10mL/kg of packed red cells or 20mL/kg of whole blood.
Whether these children achieve haematological recovery after blood transfusion is not well documented .
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Introduction
Studies suggest high blood transfusion failure rates, poor haematological recovery and recurrence of severe anaemia in the post discharge period.
Due to the difficulties in getting blood to health units, children do not always get the recommended amounts of blood.
In addition, blood preparation techniques (sedimenation) used to prepare “packed red cells” may result in units of lower haematocrits(“ red cell concentrate”)
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Rationale
Studies suggest high blood transfusion failure rates, poor haematological recovery and recurrence of severe anaemia in the post discharge period.
We carried out this study to assess the haematological recovery of children with severe anaemia transfused at Mulago Hospital.
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Objectives
To describe the change in Hb concentration of children with severe anaemia within:
24 hours of blood transfusion
6 weeks after blood transfusion
To describe the factors associated with adequate haematological recovery 6 weeks after blood transfusion.
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Methods
Study design: A Prospective, cohort study of 188 children
Study site: Paediatric Acute Care unit , Mulago National Referral Hospital, Kampala ,Uganda
Inclusion criteria: All children 6 to 60 months with Hb ≤ 5g/dL
Exclusion criteria:
sickle cell anaemia
chronic kidney disease
malignancies.
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Measurements
Lab testing:
Haemoglobin: pre & post transfusion, at discharge and 6 weeks after blood transfusion
Complete blood count
Peripheral film for red cell morphology
Blood smear for malaria.
HIV serological tests
Volume of blood transfused: volume per kilogram body by weighing blood bags.
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Procedures
Managed according to Mulago National Referral Hospital guidelines.
Daily ward follow-up till discharge.
All participants discharged home on haematinics.
Post discharge follow up
Hb and blood smear at all hospital sick visits
6 weeks - Hb, complete blood count, peripheral film comment and blood smear for malaria
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Data Analysis
Average overall mean change in hemoglobin computed at 24 hours and 6 weeks after discharge
Linear regression used to computed unit increase in Hb per unit volume of packed red blood cells
Logistic regression used to computed factors associated with hematological recovery
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10. Results: Baseline characteristics
Percent (%)
Age <24 months 89
47.4
Sex (male)
103
54.8
Fever at admission
181
96.3
Passing dark urine 87
46.3
Positive blood smear for malaria at admission
128
68.1
HIV status (positive) 5
2.1
Hook worm in stool 4
2.7
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11. Results: Mean Change in Haemoglobin
Mean pre and post transfusion Hb was 3.7g/dL (SD 0.8)and 6.3 (SD1.5) respectively.
Mean volume of “red blood cell concentrate” transfused was 12.1mL/kg (S.D 4.1)
24 hours after blood transfusion
Mean change 24 hours and 6 weeks after blood transfusion was 2.6g/dL (SD 1.5) and 7.2 (SD2.4) g/dL
Unit increase in haemoglobin per 10ml/kg of blood was 1.5g/dL
47/188(25%) required a second transfusion within 24 hours
At 6 Weeks: mean change was 7.3g/dL (SD 1.6)
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12. Change in Hemoglobin by Type of blood received.
Variable
RCCs (n=169)
Whole Blood (n=19)
P-valuea
Mean volume/kg of blood (mL) (SD)
12.7 (4.2)
19.9 (5.6)
<0.001*
Mean (SD) Hb change within 24 hours of blood transfusion
2.5(1.4)
3.6(1.9)
0.001*
Mean (SD) post-transfusion Hb (g/dL)
6.2 (1.5)
7.6 (1.9)
Mean (SD) Hb 6 weeks after blood transfusion c( (g/dL)
11.0 (2.2)
10.4 (3.2)
0.210
Mean (SD) Hb change 6 weeks after blood transfusion (g/dL)
7.4(2.2)
6.5(3.4)
0.127
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Multivariate Analysis for Factors associated with Haematological Recovery
Variable
Un adjusted OR,95% CI
P value
Adjusted OR
95% CI
P Value
Positive malaria slide in the post discharge period
0.3(0.13,0.58)
0.01*
0.3(0.12,0.87)
0.026*
No mosquito net use
0.5(0.23,1.05)
0.068
0.8(0.3,2.3)
0.724
HIV Status Negative
6.9(0.75,63.1)
0.088
7.7(0.42,142.6)
0.169
Age ≤24 months
0.4(0.26,0.77)
0.005*
0.3( )
0.002*
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Discussion
Mean change in haemoglobin within 24 hours of blood transfusion of 2.6g/dL (SD 1.5) is within estimates of WHO(2-3g/dl)
Increase per 10mL/kg of red cell concentrate much lower than WHO estimates.
Haemocrit of the ‘red cell concentrate ‘is much lower than for packed cells, hence higher volumes of blood needed to correct anaemia adequately.(0.55 vs 0.75)
Blood packs are not of standardised volumes.
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Discussion
Malaria infection during the post discharge retards recovery
Malaria causes varying degrees of bone marrow suppression .
Child younger than 24 months is 70% less likely to attain adequate haematological recovery.
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Conclusions
Current transfusion practices do not correct severe anaemia adequately in the immediate post transfusion period.
Post discharge malaria infection hinders recovery of haemoglobin levels in children discharged after an episode of severe anaemia.
Children younger than 2 years are less likely to recover fully after an episode of severe anaemia.
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Recommendations
We recommend a review and/or further study of current transfusion guidelines with respect to transfusion volumes and preparation of blood products.
Efforts to prevent malaria in the post discharge period, especially in children younger than 24 months should be strengthened.
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Acknowledgements
Funding: D43 NSO78380 training grant
Study participants and caretakers
Makerere University/University of Minnesota Research Collaboration
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