In this weeks’ online edition of NEJM the TRACT group, led by Kathryn Maitland from Imperial College who is based a KEMRI Wellcome Trust Research Programme, publish two important clinical trial papers addressing whether all children admitted to hospital with severe anaemia (haemoglobin (Hb) <6g/dl)should receive an immediate transfusion and whether a higher volume of transfused blood improves the poor outcomes.
In children with uncomplicated severe anaemia (Hb 4-6g/dl without severity features) the TRACT trial showed that they do not require an immediate transfusion, as long as they are closely monitored for signs of complications, or their haemoglobin levels dropping, and receive a transfusion at that point. By 48 hours 49% in the control group required a transfusion, this was given on average 24 hours after admission. (insert link to Immediate Transfusion paper)
Giving larger volumes of blood transfusions (30mls/kg whole blood equivalent) than current World Health Organisation (WHO) guidelines to children with severe anaemia in sub-Saharan Africa could halve the number of deaths, in children with complicated severe anaemia who do not have a fever. (insert link to Volume of Transfusion paper)
However, for children admitted to hospital with a fever (axillary temperature >37.5C), the amount recommended by guidelines (20mls/kg whole blood equivalent) is correct and they were about half the risk of dying compared to those who received a higher volume.
In sub-Saharan Africa severe anaemia is common and life-threatening for children. Around one in ten children in hospital because of severe anaemia die while in hospital. Thus children with severe anaemia place a large burden on the blood transfusion services, which often struggle to meet demand owing to the fact that not enough blood is donated. Therefore, WHO restrictive transfusion guidelines recommend giving blood only to children with Hb<4g/dl or Hb 4-6g/dl with severity features. As these are based on expert opinion and as outcomes are poor adherence on the ground to these guidelines is often poor.
The results of the TRACT trial suggests guidelines need to be updated to recommend different amounts of blood depending on whether a child has a fever. The guidelines for children with uncomplicated anaemia are correct but should also recommend monitoring Hb and clinical signs of severity. The no immediate transfusion strategy was significantly less costly to the health services but children stayed longer in hospital and require more haemoglobin monitoring. Recommending higher volumes in the two thirds of children with severe anaemia without fever would not mean more blood is required as the two strategies used the same amount of blood. The 20ml/kg transfusion strategy however resulted in more second or third transfusions require extra manpower resources.
For more information see TRACT video