Preoperative Anaemia in the Paediatric Patient:
A South African Perspective
Dr. Heidi MeyerRed Cross War Memorial Children’s Hospital
DISCLOSURESNone
Comprehensive Anaemia
Management
MinimisingBlood Loss
Rationale Management of Haemotherapy
Patient Blood Management
“Red-cell-containing components should not be used to
treat anaemias that can be corrected with specific
haematinic medications such as iron, vitamin B12, folic
acid, or erythropoietin.”1
Preoperative Anaemia in Paediatric Patients
Worse outcomes?How common is it?Screening?Effectively treat anaemia?
Does correcting anaemia improve outcomes?
WHO Definition of Anaemia2
Preoperative Anaemia and Outcomes:Paediatric Noncardiac Surgery
Increased postoperative mortality(OR 1.75, 95% CI, 1.15–2.65)3
Increased postoperative morbidity(OR 1.99, 95% CI 1.28-3.10)4
Increased perioperative transfusion(OR 3.60, 95% CI 1.83-7.05)4
Anaemia46.2%
No Anaemia53.8%
Anaemia No Anaemia
Mild Anaemia36.9%
Moderate Anaemia60.0%
Severe Anaemia 3.1%
Mild Anaemia Moderate Anaemia Severe Anaemia
Prevalence of Preoperative Anaemia in SAPSOS4
Variables Anaemic (n = 505) Nonanaemic (n = 589) P ValueHaemoglobin (median, IQR) 10.2 (9.4 - 10.8) 12.4 (11.9 - 13.5) <0.001 Age group (y), n/N (%)
³0.5-1 29/53 (54.7) 24/53 (45.3)³1-4 147/262 (56.1) 115/262 (43.9)³4-13 279/669 (41.7) 390/669 (58.3)³13-16 50/110 (45.5) 60/110 (54.5) 0.001
ASA physical status, n/N (%)1 310/720 (43.1) 410/720 (56.9)2 105/228 (46.1) 123/228 (53.9)³3 87/141 (61.7) 54/141 (38.3) <0.001
Co-morbidity, n/N (%)HIV/AIDS 23/34 (67.6) 11/34 (32.4) 0.013
Grade of surgery, n/N (%)Minor 244/529 (48.5) 285/529 (53.9)
Intermediate 227/491 (45.0) 264/491 (53.8)Major 31/71 (43.7) 40/71 (56.3) 0.199
Urgency of surgery, n/N (%)Elective 279/647 (43.1) 368/647 (56.9)Urgent 134/261 (51.3) 127/261 (48.7)
Emergency 92/186 (49.5) 94/186 (50.5) 0.918
Prevalence (%) of Anaemia in South African Hospitals
47.8
28
71
40.8
24
46.2
0 10 20 30 40 50 60 70 80
Marsicano D et. al. 2018, Noncardiac Surgery (8)
Conradie W et. al. 2020, Noncardiac Surgery (7)
Jadhunandan K et. al. 2020, Open intraabdominal Surgery (6)
ADULT STUDIES
Wege M 2015, 6m to 36m Acute Hospital Admissions (5)
(Faraoni D et. al. 2016, 1yr to <18yrs, Noncardiac Surgery) (3)
Meyer HM et. al. 2020, 6m to <16yrs, Noncardiac Surgery (4)
PAEDIATRIC STUDIES
SAVACG survey (1994)9
Anaemia 21.4%IDA 5%
n= 4 494
Primary Schools Feeding Scheme
(1994)
SAVACG survey (1994)Anaemia 21.4%
IDA 5%n= 4 494
Primary Schools Feeding Scheme
(1994)
Food Fortification Programme
(2003)
SAVACG survey (1994)Anaemia 21.4%
IDA 5%n= 4 494
NFCS-FB-I (2005)10
Anaemia 28.9%IDA 7.6%
n= ?
Primary Schools Feeding Scheme
(1994)
Food Fortification Programme
(2003)
SANHANES-1 (2013)11
Anaemia 18.8%IDA 8.1%
n= 511
SAVACG survey (1994)Anaemia 21.4%
IDA 5%n= 4 494
NFCS-FB-I (2005)Anaemia 28.9%
IDA 7.6%n= ?
Primary Schools Feeding Scheme
(1994)
Food Fortification Programme
(2003)
SAVACG survey (1994)Anaemia 21.4%
IDA 5%n= 4 494
NFCS-FB-I (2005)Anaemia 28.9%
IDA 7.6%n= ?
SANHANES-1 (2013)Anaemia 18.8%
IDA 8.1%n= 511
Primary Schools Feeding Scheme
(1994)
Food Fortification Programme
(2003)
DHS (2016)12
Anaemia 61.3%IDA ?
n= 1 094
National School Deworming Programme
(2016)
13
Screening ForIron Deficiency Anaemia in Children
Bone marrow
MCV
Serum Ferritin
Transferrin Saturation
Reticulocyte Haemoglobin Content
Serum Ferritin
WHO definitions14
< 12 μg/L in children < 5 years< 15 μg/L in children ≥ 5 years
If CRP > 5
< 30 μg/L in children < 5 years < 70 μg/L in children ≥ 5 years
Biomarkers Reflecting Inflammation and Nutritional Determinants of Anaemia15
Adjusted ferritin = unadjusted ferritin − β1(CRPobs − CRPref) − β2(AGPobs − AGPref)
Estimating the Burden of Iron Deficiency Anaemia Among African Children16
• 4853 children aged 0–8 years• Kenya, Uganda, Burkina Faso, South
Africa, and The Gambia
WHO definition vs BRINDA
Other iron biomarkers vs BRINDA
Reticulocyte Haemoglobin Content (CHr) to Detect Iron Deficiency in Hospitalised Children in SA17
• Functional iron available for erythropoiesis
• Not affected inflammation
69% anaemic58% IDACHr <29 pg vs TSAT ≤25% (Sensitivity 86%, Specificity 50%)
“ the simplest answer is most often correct.”
Helminths
HookwormSchistosomesAscariasisTrichuris
Mebendazole• Single dose 30.8% vs Multiple dose 96.1%18
Albendazole + Praziquantel
Craniosynostosis Studies
Author Type of Study
Study Size Intervention (n) Control (n) Results
Helfaer et al 199819Case-Control 60 EPO + Iron (30)
No Intervention (30)
Decreased Transfusion,
Increased Hct
Meneghini et al 200320
Case-Control 25 EPO + Iron + ANH (16)
No Intervention (9)
Decreased Transfusion,
Meara et al 200521Case-Control 19 EPO + Iron + Vit K(10)
No Intervention (9)
Decreased Transfusion,
Increased Hct
Krajewski et al 200822Case-Control 79 EPO + CS + Iron (41) Iron (38)
Decreased Transfusion,
Increased Hct
Vega et al 201423Case-Control 60
CHoR Protocol: EPO + Iron + CS (32)
No Intervention (28)
Decreased Transfusion,
Increased Hb
Escher et al 201924Case-Control 36
Minnesota Protocol: EPO + Iron + TXA (14)
No Intervention (22)
Decreased Transfusion,
Increased Hb
Preoperative Haemoglobin and Perioperative Transfusion in Scoliosis Surgery After Iron Supplementation25
382 patientsIron Clinic4mg.kg-1.day-1
Duration of iron therapy
Hb>13.0 associated with decreased transfusion requirements
Transfusion vs No Transfusion46 days 55 days
[IQR 35-85] [IQR 32-70]
Primary Endpoint27:
Days alive and out of hospital from surgery to 30 days following operation
Primary Endpoints26:
Requirement for allogenic red cell transfusion
Mortality up to 30 days after surgery
Preoperative IV Iron to Treat Anaemia in Major Surgery25
No difference• Transfusion 68 (29%) vs. 67 (28%), p = 0.92• Death 2 (1%) vs. 2 (1%), p = 1.0• Anaemia was corrected in 42 (21%) of 244 patients in the IV iron group
Dose?Timing?Included anaemia due to other causes?
Craniosynostosis Studies
Author Type of Study
Study Size Intervention (n) Control (n) Results
Helfaer et al 199819Case-Control 60 EPO + Iron (30)
No Intervention (30)
Decreased Transfusion,
Increased Hct
Meneghini et al 200320
Case-Control 25 EPO + Iron + ANH (16)
No Intervention (9)
Decreased Transfusion,
Meara et al 200521Case-Control 19 EPO + Iron + Vit K(10)
No Intervention (9)
Decreased Transfusion,
Increased Hct
Krajewski et al 200822
Case-Control 79 EPO + CS + Iron (41) Iron (38)
Decreased Transfusion,
Increased Hct
Vega et al 201423Case-Control 60
CHoR Protocol: EPO + CS (32)
No Intervention (28)
Decreased Transfusion,
Increased Hb
Escher et al 201924Case-Control 36
Minnesota Protocol: EPO + Iron + TXA (14)
No Intervention (22)
Decreased Transfusion,
Increased Hb
Erythropoetin?
600 U/kg weekly for 3-4 weeks19-24
e.g. 10kg child 18 000 units
EPOPrice (Rand) Adjust
1 April 2018
2 000 IU 48.62
4 000 IU 72.23
10 000 IU 221.93
30 000 IU 726.32
18 000 IU 870.78
Red Cell Concentrate = R1 426.73
The Future….
Prevalence of iron deficiency anaemia in paediatric surgical patients in SA?
The role of iron (PO/IV) in preoperative anaemia in children?
Preoperative clinic an opportunity for screening for anaemia?
Introduce screening for Hb for anaemia, oral iron, and deworming?
The role of EPO?
SAPSOS-2?
Thank You
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27. ITACS trial (NCT02632760)