Indian Pediatr 2012;49:
Factors Associated with Mortality in Under-Five Children with
Severe Anemia in Ebonyi, Nigeria
Vivian U Muoneke, Roland C Ibekwe, *Henrietta U Nebe-Agumadu and Bede C
From the Department of Pediatrics, Ebonyi State
University, Abakaliki, Ebonyi State; *Department of Pediatrics,
University of Abuja, Abuja; and +Department of Pediatrics, University of
Enugu Campus, Nigeria.
Correspondence to: Dr Vivian Uzo Muoneke, Department
of Pediatrics, Ebonyi State University,
Abakaliki, Ebonyi State, Nigeria.
Received: June 22, 2010;
Initial review: August 18, 2010;
Accepted: February 22, 2011.
Published online: 2011 May, 30.
Objective: To determine the risk factors associated with poor
outcome among under-five children with severe anemia in sub Saharan
Setting: University Teaching Hospital, Nigeria.
Participants: Under-five children presenting with
severe anemia (PCV
Methods: Between January and June 2006, children
admitted with severe anemia were recruited. The biodata, socio-economic
status, signs and symptoms were documented for each child after the
initial stabilization. Laboratory investigations using blood, stool and
urine samples were carried out. Data were analyzed using SPSS version
Results: 140 out of the 1,450 patients admitted
during the period of study had severe anemia (prevalence 9.7%). Malaria
either alone or in combination was the most common cause of severe
anemia [n=90 (64.3%)]. 117 patients (83.6%) recovered, while 4(2.8%)
left against medical advice and 19 died (case fatality rate 13.6%). The
variables associated with mortality were malnutrition (P=0.02),
tachycardia (P= 0.03), coma (P<0.001), and absence of
blood transfusion (P=0.001). On logistic regression analysis coma
(P=0.002), not receiving blood transfusion (P=0.002) and
female gender (P=0.04) predicted poor outcome.
Conclusions: The study revealed high mortality
rates among under-five children with severe anemia. Coma, malnutrition,
female gender and absence of blood transfusion were associated with
higher mortality in severe anemia.
Key words: Anemia, Causes, Death, Malaria, Nigeria.
Severe anemia is a common blood
disorder in children from developing [1,2]. Mortality rates from severe
anemia are high in these regions with high levels of poverty, infections
and malnutrition in addition to the problems of inaccessible and poorly
funded health facilities [3-6].
Urgent blood transfusion is generally the mainstay of
treatment however, despite blood transfusion, a number of children with
severe anemia still die [2,4,6-8]. We conducted this study to improve
our understanding of the
probable risk factors associated with poor outcome in children with
This cross-sectional study was conducted at the
Children’s Emergency Unit and the Children’s Outpatient Department of
Ebonyi State University Teaching Hospital, Abakaliki, Ebonyi State,
Nigeria. This hospital is a major referral center for other health
institutions located within and around the Abakaliki metropolis. About
60,000 patients are seen annually in the hospital and children
constitute about 10% of this population (unpublished hospital data).
The study area, Abakaliki, is the capital of Ebonyi
State and is located in the South Eastern part of Nigeria, covering an
area approximately 51 km2,
with an atmospheric temperature of 300C.
It has an estimated population of 255,000 people who are predominantly
small to medium-scale farmers, civil servants, and traders.
Between January and June 2006, a consecutive sample
of children aged 6 to 60 months who presented at the Outpatient
Department and the
Children’s Emergency Room with a primary diagnosis of severe anemia (defined as a hemoglobin concentration of
≤5.0g/dL or PCV of ≤15%) [8,9]
were recruited. A minimum
sample size of 110 was obtained using the formula for calculating sample
size in a finite population , based on severe anemia prevalence of 7%
in under-5 African children , attrition rate of 10% and the number
of under-5 presenting in the hospital in 2005 (5749). Children who had
received blood transfusion within the previous 3 months were excluded.
Recruited subjects with obvious life-threatening conditions were
stabilized before history was taken. The study was approved by the
ethics committee of the
Ebonyi State University Teaching Hospital, Abakaliki, and an written
informed consent was
obtained from the parent or the guardian of each child.
A detailed history including socio-demographic data
was collected from all patients; social class was determined using the
highest educational qualification and occupation of both parents as
suggested by Oyedeji . Complete physical examination including vital
signs and anthropometric assessment were Taken according to standardized
procedure [12,13]. The
nutritional status was assessed using Wellcome classification .
Presence of tachycardia, tachypnea, tender hepatomegaly, abnormal
cardiac rhythm (gallop rhythm), with or without peripheral pedal edema
(in the older children) were taken as indicators of congestive cardiac
Samples of blood, urine, and stool were collected
according to standard techniqueand sent to the laboratory for analysis
within 24 h or refrigerated at temperatures between 4 and 8ºC.
5mL of blood was collected from the median antecubital vein. Peripheral
blood films were examined for determination of presence of asexual form
of malaria parasites. Hematological parameters namely packed cell volume
(PCV), hemoglobin concentration, white blood cell (WBC) count and
hemoglobin electrophoresis were estimated for all children. PCV and
hemoglobin were assessed using the micro-hematocrit technique and
cyanmethemoglobin method respectively. Hemoglobin electrophoresis was
carried out using the cellulose acetate electrophoresis method. The mean
cell hemoglobin concentration (MCHC) was used as suggesting the presence
or absence of iron deficiency. Iron studies were not done. Children with
low MCHC were assumed to have iron deficiency anemia . Biochemical
and direct microscopic analysis of all stool and urine samples was done.
Cultures of blood and urinewere done for selected subjects based on
their presenting history, clinical condition and on the outcome of their
initial laboratory tests. Blood culture was done according to standard
methods  for only subjects with a history of fever, abnormal white
cell count/differentials on admission and in other subjects who
continued to have fever despite initial medical treatment. All study
subjects with positive cultures were regarded as having septicemia.
Urine samples with positive dipstick findings
(positive urine nitrate) and microscopic findings (high WBCs per high
power field and presence of bacteria) qualified for urine culture using
blood agar. All those with fever and positive urine cultures were
regarded as having urinary tract infections. Stool culture was not done
in any participant. All subjects were admitted and managed according to
a standardized protocol.
Outcome following treatment/blood transfusion was categorised as
survived, died or left against medical advice.
The data collected were entered into the data editor
of Statistical Package for Social Sciences (SPSS) software package
version 11.0. Analysis was based on simple percentages, proportions,
charts and tables. The influence of sex, age, socio-economic status of
the parents, certain clinical findings and disease presence (malaria,
septicemia, malnutrition and hemoglobinopathies) on the outcome of
severe anemia was assessed. Differences in proportions were compared
using the chi square statistic. Where figures in the table were too few
for the chi square test, Yates correction test was used. Logistic
regression was done to determine the factors that are predictive of poor
outcome among the study population. Statistical significance was set at
A total of 140 under-five children were enrolled.
There were 76 (54.2%) boys. The mean age of the patients was 25.1±16.7
months with majority of the patients(89, 63.6%) below 2 years of age.
Most patients (114, 81.4%) belonged to the lower social classes. The PCV
levels ranged between 5-15 % with a mean level of 11.8±3.0%. Temperature
ranged between 34.3ºC with a
mean of 38.12±1.0ºC; 71.4%
of patients (n=100) had pyrexia. Presenting features of enrolled
children are depicted in Table I. 13 (9.3%) children were comatosed on admission. Based on the defined criteria, 74 (52%) children
were in congestive cardiac failure on presentation. Antropometric
assessment revealed that 104 patients (74.3%) had normal weight
measurements, 33 (23.6%) were undernourished while 3 (2.1%) were
severely malnourished. 126 (90.0%) children were transfused.
TABLE I Clinical Features of the Participants with Severe Anemia (n=140)
| Gallop rhythm
| Pedal edema
Malaria was the commonest condition causing severe
anemia among the enrolled children (77, 55%) while 13 (9.3%) patients
had malaria in combination with other causes. Other common causes
include sepsis 19 (13.6%), sickle cell anemia 13 (9.3%) and
malnutrition/ iron deficiency anemia 10 (7.1%).
117 (83.6%) patients recovered, 4 (2.8%) were
discharged against medical advice and 19 (13.6%) died. Fourteen of the
19 children (73.68%) died within 24 hours of admission. Severe malaria
was the most common diagnosis in the deceased (n=11) septicemia (n=5).
Next being 13 (68.42%) were tranfused while 6 (31.58%) did not receive
blood transfusion. All the children that were not transfused died within
2 hours of presentation while those that were transfused survived for
longer periods. Table II highlights the factors associated
with poor outcome in children with severe anemia. Logistic regression
analysis of factors with predictive influence on mortality in severely
anemic children revealed that presence of coma (P=0.002), not
receiving blood transfusion (P=0.002) and sex (P=0.04)
increased the likelihood of mortality in severely anemic children.
Association Between Clinical And Laboratory Variables And Mortality Of Severely Anemic Children In Ebsuth, Abakaliki
Malaria + combined
Not in cardiac failure
The hospital case fatality rate of 13.6% in the
present report is within the reported range in Africa [3,4,6,7,] but is
higher than the 5.6% reported by Ojukwu  from this facility. This
difference could be due to the differences in subjects’ selections as
their definition of severe anemia was packed cell volume of less than
20% and the age category was for children below 12 years, this
postulation is supported by the finding that most of the deaths in that
report occurred in children less than five years old.
Existing guideline in managing severe anemia
highlight that mortality in children with severe anemia is high at
hemoglobin lower than 4g/dL or the presence of respiratory distress at
higher hemoglobin levels . However, in this report, neither
tachypnea nor hemoglobin level was found to have any influence on
outcome. Tachycardia on the other hand was found to be significantly
associated with poor outcome. In view of the lack of association between
cardiac failure and outcome, how tachycardia alone leads to poor outcome
is not clear.
The importance of blood transfusion in the management
of childhood severe anemia is supported by the finding of increased
fatality among untransfused children in the present report [7,8,17].
However, those who died without transfusion, died within two hours of
presentation. This supports the contention of Lackritz, et al.
 that these children were very ill and their deaths may not have been
prevented by blood transfusion. With the risk of transmission of the
human immunodeficiency virus type-I (HIV-I), the use of blood
transfusion in the management of severe pediatric anemia has become an
important clinical decision problem in Africa [18,19].
The association of the syndrome of severe anemia,
respiratory distress and coma, and poor outcome in African children with
severe malaria has been previously reported . This is partly
supported by the finding of a significant association between poor
outcome and the presence of coma in the present report. Since most of
the cases that presented in coma had malaria, they were likely to be
cases of cerebral malaria which is known to be associated with poor
Various studies in sub Sahara Africa report that
about 50% of under-five deaths can be attributed to malnutrition and the
contribution of malnutrition to mortalitly in children with diarrhea,
pneumonia, measles and malaria has also been well documented . It is
imperative to further elucidate the contribution of the complex
interplay of malaria, malnutrition and anemia in morbidity and mortality
of children in sub-Sahara Africa [23-25].
Though more males presented with severe anemia, there
were more female deaths. Previous studies from United States of America
(Blacks)  and India  have confirmed this trend. In India, it was
reported that due to cultural preference for males, female children were
brought to health facilities in more advanced stages of illness than
males, less money were spent on drugs for them, and they were taken to
less qualified health practitioners [27,28]. There is a need to conduct
local studies to elucidate if the same reasons are responsible for the
gender difference in mortality in Nigeria.
Severe under-five anemia in this area is associated
with significant fatality. Mortality appears to be worse when it is
associated with coma, malnutrition, female gender and absence of blood
transfusion. Health workers should therefore seek out these children for
improved attention, so that if the high case fatality rate can be
Contributors: All authors contributed to study
design, data acquisition and drafting the manuscript.
Funding: None; Competing interests:
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