Blood transfusion and mortality in children with severe anaemia in a malaria-endemic region

Paediatr Int Child Health. 2021 May;41(2):129-136. doi: 10.1080/20469047.2021.1881270. Epub 2021 Apr 19.


Background: In children in sub-Saharan Africa, severe anaemia (SA) is an important cause of mortality, and malaria is a primary cause. The World Health Organization (WHO) recommends blood transfusion for all children with haemoglobin (Hb) <4 g/dL and for those with Hb 4-6 g/dL with signs of instability. In sub-Saharan Africa, evidence of the effect on mortality of transfusion in children with SA with and without malaria is mixed.

Aim: To determine in children with and without malaria whether receipt of transfusion was associated with lower mortality at WHO transfusion thresholds.

Methods: This was a retrospective cohort study of 1761 children with SA (Hb ≤6 g/dL) admitted to Kamuzu Central Hospital in Malawi. In those whose Hb was 4-6 g/dL, mortality was compared by transfusion, stratified by haemoglobin, malaria status and signs of instability.

Results: Children with profound anaemia (Hb <4 g/dL) and malaria were the only subgroup who had a significant decrease in the odds of in-hospital death if they received a transfusion (OR 0.43, p = 0.01). Although children with Hb 4-6 g/dL and at least one sign of instability had higher mortality than children with none, there was no difference in the odds of mortality between those who received a transfusion and those who did not (OR 1.16, p = 0.62).

Conclusions: This study suggests that transfusion of children with profound anaemia and malaria may confer increased in-hospital survival. An understanding of the factors associated with mortality from SA will allow for interventions to prioritise the provision of limited blood.

Keywords: Severe anaemia; blood transfusion; malaria; mortality; profound anaemia; sub-Saharan Africa.

MeSH terms

  • Anemia* / complications
  • Anemia* / therapy
  • Blood Transfusion
  • Child
  • Hospital Mortality
  • Humans
  • Malaria* / complications
  • Malawi / epidemiology
  • Retrospective Studies