Abstract
Background
Paediatric anaemia is a major public health problem affecting millions of children globally, with a high prevalence in low- and middle-income countries. There is limited data on the prevalence of preoperative anaemia in healthy paediatric surgical patients presenting for routine surgery. The primary aim of the study was to describe the prevalence and severity of anaemia. Secondary aims were to describe the association between anaemia and demographic variables, nutritional status, and deworming status in these children.
Methods
This was a prospective, cross-sectional study and included children aged 6 months to 11 years, American Society of Anaesthesiologists (ASA) physical status classification 1 and 2, presenting for elective surgical and diagnostic procedures performed under sedation or general anaesthesia at two tertiary hospitals in Johannesburg between January and May 2024. Anaemia was defined using age-specific cohorts according to the 2001 World Health Organization (WHO) definition of paediatric anaemia. Screening was done using the point-of-care haemoglobin device HemoCue®. Univariate statistical associations were performed using χ2 tests for categorical variables, and Wilcoxon rank sum tests for continuous variables. Multivariable logistic regression was used to assess associations between demographic variables (age, sex, nutritional status, deworming status) and the presence of anaemia. In addition, Spearman’s correlation was performed as an exploratory test. P-values <0.05 were considered statistically significant.
Results
A total of 290 children with a median age of 4.2 (2.2–7.1) years were included in the study. The prevalence of anaemia was 31.4% (95% confidence interval [CI] 26.1–37.1). Anaemia was classified as mild in 57.1% (95% CI 46.3–67.5), moderate in 40.7% (95% CI 30.5–51.5), and severe in 2.2% (95% CI 0.3–7.7). A significant association was found between age and the likelihood of anaemia (adjusted odds ratio 0.61, 95% CI 0.35–1.05). There were no significant associations found with sex, nutritional status, and deworming status.
Conclusions
There is a notable prevalence of preoperative anaemia in paediatric patients in this South African middle income country. Children under the age of 5 years have the highest prevalence overall. The majority of patients have mild anaemia. Identifying anaemia at the surgical visit provides a valuable opportunity for health education and promotion.
Keywords: anaemia, elective, general anaesthesia, paediatric anaesthesia, preoperative, sedation
Paediatric anaemia is a major public health problem. It is particularly prevalent in low- and middle-income countries (LMICs) owing to factors such as poor nutrition, high infection rates, and poor socioeconomic circumstances.1 Worldwide, children under the age of 5 years are the most vulnerable population, with the highest prevalence of anaemia being 39.8%, according to the World Health Organization (WHO) publication in 2019.2
Anaemia is defined as a reduction in blood haemoglobin concentration.3 The WHO describes it as an inadequate number of red blood cells and therefore insufficient oxygen-carrying capacity to meet the physiological demands of the body.4 The following thresholds are used by the WHO (2001) to define anaemia in children: haemoglobin concentration <11 g dl–1 in children aged 6–59 months, <11.5 g dl–1 in children aged 5–11 yr, and <12 g dl–1 in children aged 12–14 yr (Supplementary Table 1).4,5
Several methods for testing haemoglobin concentrations are available but often require expensive laboratory equipment which may not be readily available in resource-limited settings. Making use of a point-of-care haemoglobin testing device such as the HemoCue® can be of great value in these circumstances.
The burden of paediatric anaemia varies widely across different geographical regions. Children from the African region have the highest prevalence of anaemia overall.2 In South Africa, the prevalence of anaemia in children varies widely with limited data on surgical patients (10.7–75%).6, 7, 8, 9, 10, 11 This can be attributed to different study designs, geographical regions, and small unrepresentative samples. There is a paucity in the literature with regards to the prevalence of preoperative anaemia in healthy paediatric surgical patients.
Despite the high prevalence of childhood anaemia in LMICs, routine preoperative haemoglobin testing in patients with American Society of Anesthesiologists (ASA) physical status classification 1 and 2 undergoing elective procedures is not performed in our setting. The surgical visit provides a unique opportunity to screen for undiagnosed and untreated anaemia. The primary aim of this study was to determine the prevalence and severity of anaemia in paediatric patients undergoing elective noncardiac surgical and diagnostic procedures. The secondary aims were to describe the association between anaemia and demographic variables, nutritional status, and deworming status.
We hypothesised that there would be a significant burden of undetected anaemia in the generally healthy paediatric patients presenting for elective noncardiac surgical and diagnostic procedures in our setting.
Methods
The approval to conduct this study was obtained from the University of Witwatersrand Human Research Ethics Committee (Medical) (M230663) and other relevant departments including the Chief Executive Officer of Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) and Nelson Mandela Children’s Hospital (NMCH), and the Head of Department of Anaesthesiology at both hospitals. The study was registered with the National Health Research Database (GP202308062). Informed consent was obtained from parents or caregivers before surgery, including assent from participants where applicable. This report adheres to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines.
This was a prospective, cross-sectional study and included children aged 6 months to 11 years, with ASA physical status classification 1 and 2, and presenting for elective noncardiac surgical and diagnostic procedures performed under sedation or general anaesthesia at CMJAH and NMCH between January and May 2024. These procedures included general surgery, plastic surgery, orthopaedic surgery, ophthalmology, otorhinolaryngology, dental and maxillofacial surgery, audiology, and radiology. The age cutoffs for anaemia were based on the WHO classification for anaemia in children from 2001 (Supplementary Table 1), as these were the available guidelines at the time of data collection. Subsequently, new cutoffs were defined in 2024.12
Exclusion criteria were children under the age of 6 months and older than 11 years, ASA physical status classification ≥3, emergency surgery or surgery where the indication was owing to bleeding or anaemia, any history of blood transfusion within the preceding 4 months, known comorbid conditions that may affect the haemoglobin concentration (these include, but are not limited to haematological, oncological conditions, or both; congenital cardiac disease; chronic lung disease; chronic renal disease; obstructive sleep apnoea; and a history of extensive burns requiring blood transfusion), current or previous prolonged hospitalisation, patients who arrived in theatre or the radiology suite with established intravenous access; and refusal from the parent, caregiver, or child. Children aged 12–14 years were excluded as menarche in pubertal girls may be a confounding factor. Children with ASA physical status classification ≥3, and those presenting for urgent or emergency surgery were also excluded because of comorbidities that may be confounding factors.
CMJAH is a 1088-bed tertiary academic hospital where 900 elective paediatric surgical and diagnostic procedures are performed on average annually. NMCH is a 200-bed specialist quaternary paediatric hospital where 800 elective paediatric surgical and diagnostic procedures are performed on average annually. CMJAH and NMCH are in Johannesburg, an urban city in South Africa, which may be classified as a middle-income country (MIC).
In consultation with a biostatistician, a minimum sample size of 277 was calculated by using the modified Cochrane formula. This was based on an average of 1000 elective surgical and diagnostic procedures being performed on paediatric patients with ASA physical status classification 1 and 2 at both hospitals annually. A prevalence of anaemia of 46.2% in children was used based on the South African Paediatric Surgical Outcomes Study (SAPSOS).13 A confidence interval (CI) of 95% was used with a power of 80% and a 5% two-tailed margin of error. Non-probability sampling in the form of consecutive and convenience sampling was used.
All eligible patients for participation in the study were identified from elective booking lists the day before scheduled surgical or diagnostic procedures. The primary researcher (AdP) or anaesthesia provider taking care of the patient approached the parents or caregivers of patients to invite participation in the study on the morning of, or the day before the procedure. Upon agreement, they were provided with an information sheet detailing the study and written or telephonic (if parent or caregiver not present) informed consent and assent (where applicable) was obtained.
Children were typically accompanied by the parent/caregiver to theatre or the radiology suite. Standard ASA monitors were applied, after which an inhalational induction was performed. Once sedated or under general anaesthesia, an intravenous cannula was sited, and a blood sample was collected for analysis of haemoglobin concentrations. A drop of venous blood (minimum 10 μl) was placed on the microcuvette which was in turn placed in the HemoCue® device (Hb 201+ System; Ängelholm, Sweden). Results of the haemoglobin concentration (in g dl–1) that were displayed within 15–60 seconds were then recorded. As this study was designed to screen for anaemia, the haemoglobin concentration was not confirmed with a formal laboratory full blood count, and iron studies were not performed as this was not intended as part of the study. The surgical or diagnostic procedure continued at the discretion of the anaesthetist and the surgeon caring for the child.
Data collection was performed by the primary researcher (AdP) or the anaesthesia provider taking care of the patient. An anonymised data collection sheet was completed for each participant. The following data were collected: patient characteristics, ASA physical status classification, weight and height/length of child, history of deworming, planned procedure, surgical speciality, and haemoglobin concentration. Presence of anaemia was determined based on age-appropriate thresholds defined by the WHO from 2001 (Supplementary Table 1).
The weight and height/length were plotted on WHO growth charts to determine the nutritional status. Any form of malnutrition was regarded as an abnormal nutritional state and included stunting (length/height-for-age below third percentile), wasting (weight-for-height below third percentile), underweight (weight-for-age below third percentile), and overweight (BMI above 97th percentile).14,15
The primary responsible doctor of the patient and the parent/caregiver were informed regarding the presence and severity of anaemia.
Data were captured on a Microsoft Excel (version 16.103; Microsoft Corporation, Redmond, Washington, USA) spreadsheet and all analyses performed using R software (version 4.4.0; R Foundation for Statistical Computing, Vienna, Austria). Other than were stated, continuous data are summarised as median (second quartile, third quartile), whereas categorical data are summarised as frequency (percentage). Univariate statistical associations were performed using χ2 tests for categorical variables, and Wilcoxon rank sum tests for continuous variables. Multivariable logistic regression was used to assess associations between patient characteristics and presence of anaemia. In addition, Spearman’s correlation was performed as an exploratory test. P-values <0.05 were considered statistically significant.
Results
A total of 318 patients were recruited for the study, with 290 being enrolled from 22 January to 13 May 2024 (Fig. 1). The mean age of patients was 4.2 (2.2–7.10) years. The other patient characteristics are listed in Table 1.
Fig 1.
Consort flow diagram. CMJAH, Charlotte Maxeke Johannesburg Academic Hospital; NMCH, Nelson Mandela Children’s Hospital.
Table 1.
Patient characteristics for the sample, and by whether the child was anaemic. Data are presented as median (Q1–Q3) or n (%). ∗Determined by WHO growth charts. CI, confidence interval.
| Characteristic | Overall N=290 |
Had anaemia |
Difference in medians (95% CI) | |
|---|---|---|---|---|
| No N=199 |
Yes N=91 |
|||
| Age (years) | 4.15 (2.17–7.12) | 4.74 (2.46–8.06) | 3.32 (1.74–6.14) | –1.42 (–2.17 to –0.50) |
| Sex | ||||
| Female | 67 (23) | 46 (23) | 21 (23) | |
| Male | 223 (77) | 153 (77) | 70 (77) | |
| ASA physical status classification | ||||
| 1 | 179 (62) | 124 (62) | 55 (60) | |
| 2 | 111 (38) | 75 (38) | 36 (40) | |
| Nutritional status∗ | ||||
| Abnormal | 29 (10) | 20 (10) | 9 (9.9) | |
| Normal | 261 (90) | 179 (90) | 82 (90) | |
| Weight (kg) | 16 (12–22) | 16 (12–24) | 14 (11–19) | –2.6 (–5.3 to –0.5) |
| Height (cm) | 101 (85–122) | 103 (89–126) | 96 (80–112) | –7 (–19 to –1) |
| Dewormed in the last 6 months | 100 (34) | 66 (33) | 34 (37) | |
| Surgical discipline | ||||
| Audiology | 5 (1.7) | 5 (2.5) | 0 (0) | |
| Dental | 8 (2.8) | 5 (2.5) | 3 (3.3) | |
| Ear Nose and Throat | 15 (5.2) | 14 (7.0) | 1 (1.1) | |
| Maxillofacial | 3 (1.0) | 3 (1.5) | 0 (0) | |
| Ophthalmology | 9 (3.1) | 7 (3.5) | 2 (2.2) | |
| Orthopaedic | 33 (11) | 21 (11) | 12 (13) | |
| General | 147 (51) | 95 (48) | 52 (57) | |
| Plastic | 18 (6.2) | 13 (6.5) | 5 (5.5) | |
| Radiology | 52 (18) | 36 (18) | 16 (18) | |
| Haemoglobin, g dl–1 | 11.80 (10.90–12.60) | 12.30 (11.70–13.00) | 10.30 (9.70–10.80) | –2.00 (–2.30 to –1.65) |
Of 290 children, 91 were anaemic, giving an overall prevalence of anaemia of 31.4% (95% CI 26.1–37.1). Anaemia was classified as mild in 57.1% (95% CI 46.3–67.5), moderate in 40.7% (95% CI 30.5–51.5), and severe in 2.2% (95% CI 0.3–7.7) of children (Figs 2 and 3).
Fig 2.
Box-and-whisker plot of haemoglobin concentration by WHO disease severity classification.
Fig 3.
Bar graph comparing patient characteristics with severity of anaemia.
Children with anaemia tended to be younger than those without anaemia by >1 year on average. The exception was children with severe anaemia, who appeared to be substantially older than children in all other WHO classification groups, but as there were only two children in the group with severe anaemia, these data should be interpreted with caution.
The median (IQR, range) age of children who were anaemic was 3.32 (1.77–6.10) years. There was a statistically significant association with age and having anaemia (mean difference –1.42, 95% CI –2.17 to –0.50, P=0.003), with children having anaemia being younger. Additionally, a Spearman’s correlation was performed as an exploratory test and revealed a weak positive correlation between age and the severity of anaemia among the 91 affected children, with a correlation coefficient of 0.22 (95% CI 0.02–0.43).
There was no statistical significance found when comparing anaemia with sex (Table 2). There were no significant associations between overall nutritional status and the presence of anaemia (Table 2). In both groups (anaemic and non-anaemic), 90% of children had a normal nutrition status (P>0.9). The remainder of the children (n=29, 10%) had an abnormal nutritional status, of which 20 (6.9%) were stunted, five (1.7%) were wasted, seven (2.4%) were underweight, and three (1.0%) were overweight. These three groups were all classified as abnormal nutrition for the analysis because of small numbers in each group.
Table 2.
Patient characteristics by whether the child was anaemic. Data are presented as n (%) or median (Q1–Q3). ∗Pearson's χ2 test. CI, confidence interval.
| Characteristic | Had anaemia |
P-value∗ | Odds ratio (unadjusted) (95% CI) |
Odds ratio (adjusted) (95% CI) |
|
|---|---|---|---|---|---|
| No N=199 |
Yes N=91 |
||||
| Age (years) | 4.7 (2.5–8.0) | 3.3 (1.8–6.1) | 0.002 | 0.87 (0.80–0.95) | |
| Age group | |||||
| <5 yr | 108 (54) | 60 (66) | Reference | Reference | |
| ≥5 yr | 91 (46) | 31 (34) | 0.063 | 0.61 (0.36–1.02) | 0.61 (0.35–1.05) |
| Sex | |||||
| Female | 46 (23) | 21 (23) | Reference | Reference | |
| Male | 153 (77) | 70 (77) | >0.9 | 1.00 (0.56–1.83) | 0.92 (0.51–1.69) |
| Nutritional status | |||||
| Abnormal | 20 (10) | 9 (9.9) | Reference | Reference | |
| Normal | 179 (90) | 82 (90) | >0.9 | 1.02 (0.46–2.44) | 1.10 (0.49–2.67) |
| Dewormed in the last 6 months | |||||
| Yes | 66 (33) | 34 (37) | Reference | Reference | |
| No | 133 (67) | 57 (63) | 0.500 | 1.2 (0.71–2.01) | 1.03 (0.59–1.77) |
| ASA physical status classification | |||||
| 1 | 124 (62) | 55 (60) | Reference | Reference | |
| 2 | 75 (38) | 36 (40) | 0.761 | 1.08 (0.65–1.80) | 1.11 (0.65–1.88) |
Overall, 100 (34%) children had been dewormed in the last 6 months. There was no significant association between deworming status and the presence of anaemia (P=0.5).
Most anaemic children were classified as ASA physical status 1 (n=55, 60%). There was no significant association between ASA physical status classification and the presence of anaemia (P=0.761; Table 2).
No children in this study required blood transfusion.
Discussion
The overall prevalence of preoperative anaemia in children presenting for elective noncardiac surgical or diagnostic procedures in this study from a middle income country was 31.4% based on a screening HemoCue® test. Most children had mild anaemia and only 2.2% had severe anaemia. In comparison, the incidence of preoperative anaemia has recently been reported as in high-income countries. McCormack and colleagues16 used data from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) paediatric databases from 2012 to 2023, and concluded that the incidence of preoperative anaemia (based on a labratory Complete Blood Count) in children undergoing noncardiac surgery was 25.7%.
The prevalence of paediatric anaemia is higher in younger pateints; children <5 years have an increased incidence of anaemia.17,18 In this study, we did not find a significant association between age and anaemia when using an age cut off of 5 years old.
Our report of anaemia incidence is lower than previous reports from a paediatric South African cohort. In a secondary analysis of the SAPSOS study, the prevalence of preoperative anaemia was found to be 46.2%. However, this included patients presenting for elective and emergency surgery of any ASA physical status classification, and there was no exclusion of patients who had presented with bleeding or required blood transfusion which may have contributed to the higher prevalence of anaemia.19 Of note is that the SAPSOS study was not designed to investigate preoperative anaemia.
Malnutrition has been linked to an increased risk of anaemia. In sub-Saharan Africa, stunted children had 1.29 times higher odds of having anaemia, wasted children 1.09 times, and underweight children 1.24 times.10,17,20 In our study, only 10% of children exhibited nutritional deficiencies, and no meaningful associations could be made.
Studies from sub-Saharan Africa concur that being dewormed decreases odds of having anaemia.20,21 Only about one-third (34%) of children in our study had been dewormed in the preceding 6 months. This may be attributable to the relatively young median age (4.2 years) of participants in this study. As deworming programmes are predominantly school-based, they primarily target school-aged children, thereby potentially excluding younger, pre-school children.21,22
Risk factors associated with anaemia was assessed as a secondary objective in this study. Consequently, the sample size was insufficiently powered to draw meaningful conclusions regarding associations between anaemia and sex, nutritional status, deworming status and ASA physical status. Larger studies are needed to investigate associations between these variables and anaemia.
The use of a HemoCue® device as a screening tool for anaemia in our setting has several advantages. It requires a small blood sample (10 μl) for analysis, it is relatively inexpensive, user friendly, portable, battery-operated, and does not require the blood sample to be stored or refrigerated. It is readily available and gives digitally displayed results within a few seconds. A recent systematic review and meta-analysis concluded that point-of-care diagnostic tests for anaemia, such as the HemoCue®, have acceptable sensitivity and specificity for screening of anaemia in healthy children.23, 24, 25 Once anaemia is identified, additional laboratory investigations including a full blood count and iron studies may be conducted.
HemoCue® does, however, have its limitations. It may overestimate or underestimate haemoglobin values compared with laboratory methods. Multiple studies show a difference of typically 0.2–0.5 g dl–1. Gwetu and Chhagan23 found that only 6% of samples differed by more than 1 g dl–1. Variation in haemoglobin concentrations between capillary and venous samples have been noted. Capillary samples show greater variability and on average slightly higher haemoglobin concentrations than venous samples. Evidence in neonates and critically ill paediatric patients is limited; therefore, this point-of-care device cannot substitute laboratory tests in this subgroup of patients.23, 24, 25
Perioperative patient blood management (PBM) guidelines are well established in adults, with successful implementation associated with improved overall patient outcomes, including reduced rates of perioperative blood transfusions and reduced healthcare costs.26 However, the application of these strategies in paediatric patients presents several challenges, such as paucity of robust evidence and age-specific physiological considerations regarding haemostasis and optimisation.27 Nevertheless, the potential benefits, coupled with an appeal from the WHO for PBM to be adopted as a global standard of care, underscore the importance of adapting and implementing these strategies in routine perioperative paediatric practice.28,29
Anaemia affects children globally and is seen as a moderate-to-severe public health problem.30 Although the prevalence observed in this study is lower than that reported in other research conducted in LMICs,2,31 it nonetheless highlights the magnitude of anaemia among otherwise healthy children during the perioperative period. In our context, routine preoperative haemoglobin testing is not typically performed for patients with ASA physical status classification 1–2 undergoing elective surgeries.32 Implementing this practice using a point-of-care test could be beneficial for identifying and optimising patients for surgery, forms part of one of the three pillars of PBM, while also serving as a valuable opportunity for health education and promotion. Preoperative anaemia should be diagnosed and treated at least 3–6 weeks before elective surgery, which may be achieved by implementation of anaemia clinics.
There are limitations to this study. The study was performed in an urban setting in Johannesburg, which is considered a MIC. The results may not be generalisable to other populations in South Africa, namely rural settings or other provinces. The study made use of WHO definitions for anaemia from 2001, which has subsequently been revised in 2024. In the updated definitions, a new category is defined; 6–23 months with haemoglobin concentration ≥10.5 g dl–1 as non-anaemic and 9.5–10.4, 7.0–9.4, and <7.0 g dl–1 as thresholds for mild, moderate, and severe anaemia.12 The incidence of anaemia may be higher when using the new cutoff values. Our study only described the prevalence of anaemia in ASA physical status classification 1 and 2 paediatric patients presenting for elective noncardiac surgical and diagnostic procedures and therefore did not include the entire paediatric surgical population. Our report was not sufficiently powered to draw conclusions regarding associations between anaemia and risk factors. The HemoCue® device was used to determine haemoglobin concentrations, which is not the gold standard for the diagnosis of anaemia. In addition, the haemoglobin concentrations were not confirmed with a formal laboratory full blood count.
Future studies should focus on diagnosis of anaemia using laboratory tests and identifying the aetiology of anaemia and to investigate interventions such as regular deworming and iron supplementation.
Conclusion
This study highlights the notable prevalence of preoperative anaemia among otherwise healthy paediatric patients undergoing elective procedures in two middle income South African tertiary hospitals. Most cases were mild, yet the findings underscore the importance of routine haemoglobin screening to support early identification and treatment of anaemia.
Authors' contributions
Conceptualisation of the study: AdP, CL, and ZJ
Development of the methodology: AdP, CL, and ZJ
Data acquisition: AdP
Data analysis: AdP, ZJ
Wrote the final manuscript: AdP
Reviewed and edited the final manuscript: CL, ZJ
Declaration of interests
The authors declare that they have no conflict of interest. This study was conducted as partial fulfilment of a Master’s of Medicine Research report for AdP at the University of the Witwatersrand.
Acknowledgements
We thank anaesthesia sisters and anaesthesia providers who assisted with data collection, and Professor Peter Kamerman for the statistical analysis.
Handling Editor: Susan M Goobie
Footnotes
Supplementary data to this article can be found online at https://doi.org/10.1016/j.bjao.2025.100524.
Appendix A. Supplementary data
The following is the Supplementary data to this article:
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