Severe childhood anemia and emergency blood transfusion in Gadarif Hospital, eastern Sudan.

BACKGROUND: Anemia is a major cause of global morbidity and mortality, particularly among children. Management of anemia depends on causes and severity of anemia. However blood transfusion is a lifesaving intervention in severe and life-threatening anemia. There are no published data on blood transfusion for anemia in Sudan.
METHODS: A descriptive study was conducted in Gadarif Hospital in eastern Sudan during 1 August, 2017 to 31 March, 2018. Consecutive children who presented at the emergency room with an indication for blood transfusion were enrolled in the study. A detailed history was gathered from all patients. Physical examinations, including vital signs, were performed. The World Health Organization guidelines for blood transfusion were followed.
RESULTS: During the study period, a total of 1800 children were admitted to the emergency pediatric ward in Gadarif Hospital and were assessed for anemia, 513 (28.5%) were anemic and 141 (7.8%) had severe anemia. Three hundred anemic children received blood transfusion. The median (interquartile) of the age of the 300 children who received blood transfusion was 4.2 4.2(2.0-9.0) years. A total of 148 (49.3%) of the children were boys and 151 (50.3%) were younger than 5 years. The diagnoses associated with the order for blood transfusion were sickle cell disease (129, 43.0%), active bleeding (58, 19.3%), malaria (50, 16.7%), visceral leishmaniasis (25, 8.3%), severe acute malnutrition (16, 5.30%), snake bite (11, 3.7%), sepsis (5, 1.7%), and others. Two hundred eighty-five (95.0%) children improved, nine children were discharged against medical advice, and six (2.0%) children died.
CONCLUSION: There is a high burden of anemia in eastern Sudan. Sickle cell disease, malaria, and visceral leishmaniasis are the main causes of anemia in this region. Further research on blood transfusion is needed.

Introduction

Anemia in children is a large health problem and it is the main cause of global morbidity and mortality [1]. Severe anemia in sub-Saharan African children is a major cause of admission to the hospital, as well as a leading cause of mortality [2]. There are a variety of causes that lead to severe anemia, such as severe malaria, bacterial infection, sickle cell disease, and malnutrition [3-7]. Management of anemia depends on the causes and severity of anemia. However, blood transfusion is a lifesaving intervention in severe and life-threatening anemia [8].

Anemia is common in low and middle income countries where availability of blood is, sometimes, beyond reach with delays in acquisition or administration, a major factor of mortality in children with severe anemia [9-11]. The World Health Organization (WHO) has provided guidelines for informing about clinical decisions on transfusion associated with hemoglobin levels[12]. Unfortunately, there is poor adherence to current WHO transfusion guidelines in African countries [2].

Severe anemia secondary to infections, such as malaria, Leishmania species, and Shistosoma species, is a large health problem in Sudanese children [13-15]. While there are published data on blood transfusion in children in other African countries [10,11,16-18], there are no published data on blood transfusion in Sudan. Therefore, the current study was conducted to determine the rate of anemic children with WHO indications for blood transfusion, and to describe the indications for blood transfusion the time to blood transfusion and outcome of blood transfusion, in children in Gadatif Hospital in eastern Sudan.

Methods

We conducted a cross-sectional study in Gadarif Hospital in eastern Sudan during 1 August, 2017 to 31 March 2018. Gadarif is 400 km from the capital Khartoum on the Ethiopian and Eritrean borders. Gadarif city is located between latitudes 14° and 16° north and longitudes 33° and 36° east. This city is at an altitude of 496 m above sea level, with a population of 1,727,401 inhabitants. Gadarif Hospital is a 400-bed tertiary care facility that serves as a referral center for Gadarif State. The average patient turnover at this hospital is 150–200 patients per day. The emergency pediatric ward is staffed with three consultants, four specialists, and 14 medical doctors (registrars and residents).

Consecutive children (aged <18 years) who presented at the Outpatient Department and the Children’s Emergency Room with indication for blood transfusion were enrolled in the study. After the children’s parent(s) or guardians signed an informed consent form, a detailed history was gathered from all patients or their guardian. Physical examinations, including vital signs, were performed according to standardized procedures at the discretion of the treating doctor as part of standard care. Samples of urine and stool were collected, and they were investigated for schistosomal infection as described before [19,20]. Blood was withdrawn from the median antecubital vein and examined for malaria using thick and thin blood films which were stained with 10% Giemsa and read by expert microscopist. Hemoglobin estimation was done as part of the complete hemogram via automated blood-cell analyzer machine (Sysmex Hematology Analyzer; Sysmex, Kakogawa, Japan).

According to WHO, a child between 6 and 59 months is defined as “anemic” when the hemoglobin level is below 11.5 g/dl (“severely anemic” hemoglobin <7 g/dl). Between 5 and 11 years “anemia” is present with hemoglobin below 11.0 g/dl; between 12 and 14 years hemoglobin below 12.0 g/dl and from 15 years on hemoglobin below 13.0 g/dl. Except for the first age class, the definition of “severe anemia” is restricted to patients with hemoglobin level below 8.0 g/d [21].

Hemoglobin electrophoresis was performed on blood samples from patients who were clinically suspected to have sickle cell disease (after initial sickling test). Electrophoresis (electrophoretic equipment model MUPID-EXU, Japan) was done for those who were not diagnosed before; those who were already diagnosed were labeled as sickle cell disease.

The WHO guidelines for blood transfusion were followed [12,22] and these are as follows: hemoglobin levels <4 g/dl or hemoglobin levels of 4–7 g/dl plus shock, clinically detectable dehydration, impaired consciousness, respiratory acidosis as shown by deep breathing, heart failure, and/or more than 20% of red blood cells parasitized by malaria parasites; or hemoglobin levels >4 g/dl with continuing bleeding. Children were transfused with 20 mL/kg whole blood or 10 mL/kg packed cells, which were provided for no longer than 4 hours. Furosemide (1 mg/kg intravenously) was used at the beginning of blood transfusion for children with clinical signs of pulmonary edema. Pulmonary edema was clinically determined if the patient had shortness of breathing, increased respiratory rate with coarse crackles at the lung bases and radiologically as defined by the presence of Kerley B lines in the anteroposterior chest view. Severe acute malnutrition was diagnosed following the WHO guidelines for malnutrition. A child was considered as severe acute malnutrition if weight-for-height z score was <-2 SD for age and sex or presence of bilateral lower limb edema [23,24]. The diagnosis of visceral leishmaniasis was confirmed by the visualization of the amastigote form of the parasite by microscopic examination of aspirates from or bone marrow using Giemsa-stain.

The definition of sepsis was considered as “life threatening organ dysfunction caused by a dysregulated host response to infection [25]. Any severe adverse events were reviewed by the treating clinician. The time taken from order of blood to actual transfusion was calculated from the time when transfusion was prescribed to the time of actual transfusion. The outcome following blood transfusion was classified as survived (recovered), died, or left the hospital against medical advice. Other managements/treatments, such as antimalarials, antibiotics, and treatment for Leishmania species, were provided according to the diagnosis and the National guidelines [13,14].

A sample size of 300 participants was calculated as the sample size in a finite population using the formula N = Z2 P (1-P)/e2 (N = sample size, Z = level of confidence, P = baseline level of the selected indicator and e = margin of error. P was estimated at 0.50). This was determined by the prevalence (48.9%) of severe anemia in children who were previously admitted with visceral leishmaniasis in the same hospital [13]. The calculated sample size had 80% power and precision of 5% at α = 0.05. We assumed that 10% of the children might have incomplete data.

Ethics

Ethical approval was received from the Ethics Committee at the Faculty of Medicine, Gadarif University, Sudan (reference number: 2016/08). Written informed consent was collected from each participant’s parents (or guardian) before taking part in the research.

Statistical analysis

Data were entered into a computer using SPSS for Windows (version 20.0). Continuous data were checked for normality using Shapiro-Wilk test and they were presented as mean (Standard Deviation–SD) if they were normally distributed or median [interquartile range–IQR] if they were not normally distributed. Frequencies and proportions were calculated.

Results

During the study period between, a total of 1800 children were admitted to the emergency pediatric ward in Gadarif Hospital. Of the 1800 children, 513 (28.5%) were anemic and 141 (7.8%) had severe anemia.

Three hundred anemic children were admitted to the emergency pediatric ward and received blood transfusion.

The median (interquartile) of the age of the study population (300 children who received blood transfusion) was 4.2 4.2(2.0 –9.0) years and 148 (49.3%) of them were boys. A total of 151 (50.3%) were children aged younger than 5 years. The median (interquartile) of their hemoglobin was 5.0 (3.9–6.3)g/dl (Table 1).

Table 1

Patient’s characteristics and their outcomes.

	Number (%)	Age,	Hemoglobin,
		median (interquartile)	median (interquartile)
Admitted	1800(100.0)	5.2(2.0–10.5)	12.8(7.2–13.9)
Non anemic	1287 (71.5)	5.3(2.1–10.3)	12.9 (11.1–14.1)
Anemic	513 (28.5)	5.1(2.0–10.4)	9.8(9.5–10.6)
Mild–moderate	372 (20.6)	5.0(2.1–9.8)	8.1(6.8–9.8)
Severe	141 (7.8)	5.2(2.0–10.5)	3.2(2.8–3.6)
Received transfusion	300 (13.6)	4.2(2.0 –9.0)	5.0(3.9–6.3)
Age < 5 years	151 (50.3)	2.0(1.0–3.0)	5.0(4.0–6.2)
Hb < 4.0 g/dL	76 (25.3)	6.0(2.0–11.7)	3.1(2.6–3.7)
Hb ≥ 4–≤ 7 g/dL	204 (74.3)	4.0(2.0–8.7)	5.4(4.8–6.8)
Improved	285 (95.0)	4.0(2.0–9.0)	5.0(3.9–6.3)
Discharged against medical advice	9 (3.0)	10(7.0–11.0)	6.0(4.4–7.0)
Died	6 (2.0)	2.5(1.0–10.0)	5.0(3.3–7.5)

The distribution of hemoglobin level of the transfused children is shown in Fig 1.

Fig 1

Distribution of hemoglobin level of the transfused children.

While fever (≥37.5°C) (262, 87.3%) and difficulty in breathing (193, 64.3%) were the predominant symptoms, pallor (274, 91.3%), and hepatomegaly (215, 71.7%) were the main signs that were detected in children who received blood transfusion Table 2.

Table 2

Symptoms and signs in children who received blood transfusion in Gadarif Hospital, Sudan.

Variables	Frequency	Proportion (%)
Symptoms
Difficulty in breathing	193	64.3
Fever	262	87.3
Weakness	78	26.0
Vomiting	46	15.3
Cough	83	27.7
Diarrhea	30	10.0
Active bleeding	58	19.3
Signs
Pallor	274	91.3
Hepatomegaly	215	71.7
Splenomegaly	83	277
Jaundice	48	16.0
Pedal edema	23	7.7

The diagnosis associated with order of blood transfusion is shown in Fig 2.

Fig 2

The diagnoses associated with blood transfusion.

The vast majority (115/129, 89.1%) of the sickle cell disease were diagnosed before. Hemoglobin electrophoresis was performed to 14/129 children. Of the 14 children, eight (57.1%), five (35.7%) and one child (7.1%) had hemoglobin SS, hemoglobin AS and hemoglobin AC, respectively. There was no case of intestinal or urinary schistosomiasis.

Seventy-six (25.3%) children were transfused because had hemoglobin levels <4 g/dl and 204 (68.0%) children had hemoglobin levels of 4–7 g/dl. Of 204 children who had hemoglobin levels of 4–7 g/dl and were transfused; 110 (53.9%) had heart failure, 38 (18.6%) had > 20% of red blood cells parasitized by malaria parasites, 32 (15.7%) had continuing bleeding, 9(4.4%) had combined/ others reasons, 8(3.9%) had dehydration and 7(3.4%) had impaired level of consciousness.

The median (interquartile range) request-to-issue time for blood was 6 (3–12) hours.

Five (1.6%) children had a “probable” blood transfusion reaction in the form of fever (1°C above the baseline temperature) and all of them had an urticarial rash within 3 hours of starting blood transfusion. Thereafter, the transfusion was stopped and these children received intravenous hydrocortisone. All of the five children completely recovered.

A total of 285 (95.0%) children improved, nine (3.0%) children were discharged against medical advice, and six (2.0%) children died. Four of the children who died were girls, and two of them had severe malaria, two had malnutrition, and one had sickle cell disease. Two of the children who died had hemoglobin levels <4 g/dl. The mean (range) time taken for blood transfusion in the six children was 4.3 (2–6) hours.

Discussion

To the best of our knowledge, this is the first report on blood transfusion in Sudanese children. This paper is to provide information on the rate of anemic children who received blood transfusion and to describe the indications, outcome, time needed to transfuse and mortality following transfusion in eastern Sudan. The main findings of the current study were as follows. The prevalence of anemia in children who presented to the hospital was 28.5% and 7.8% had severe anemia. Sickle cell disease and malaria were the main diagnoses associated with anemia requiring blood transfusion.

The prevalence of anemia in our study is slightly higher than the estimated prevalence of anemia globally(24.8%) [1]. In a recent meta-analysis the global anemia prevalence in 2010 was 32.9% [26]. However, our rate of anemia is much lower than that among children in other African countries (e.g., two thirds of Tanzanian children who are tested in the Emergency Department have anemia) [10]. The prevalence of severe anemia in our study is similar to the reported prevalence (9.7%) of severe anemia among children in Nigeria [27]. However, the prevalence of severe anemia in our study is much lower than that in other African countries (12% in Kenya, 41% in Uganda, and 42% in Tanzania) [2,10]. The difference in the prevalence of anemia in our study and other studies could be explained by a difference in the enrolled participants. Children of all age groups were enrolled in our study, while in most of the other studies, children aged younger than 5 years were enrolled. Furthermore, eastern Sudan is characterized by unstable transmission of malaria [28], while most of the other African countries have stable transmission of malaria. Previous reports have shown that severe malaria and severe anemia are the most common morbidities in eastern Sudan [6,29]. Severe anemia in Sudanese children is area/region-specific (e.g., Shistosomal infection). Shistosomal infection was reported as the main cause of severe anemia of children in irrigated areas in eastern Sudan [7]), and was not observed in this study.

Our study showed that the diagnoses associated with the order for blood transfusion were sickle cell disease (129, 43.0%), active bleeding (58, 19.3%), malaria (50, 16.7%), visceral leishmaniasis (25, 8.3%), and severe acute malnutrition (16, 5.30%). In Tanzania, severe malaria (20.1%), sickle cell disease (18.3%), septicemia (7.6%), and severe malnutrition (5.4%) are the major causes of admission to the emergency pediatric ward [10]. Similarly, fever (26%), vomiting (8.3%), cough (8.1%), general body malaise (7.6%), difficulty in breathing (6.5%), and diarrhea (5.7%) are the predominant complaints in children who are admitted to the Emergency Pediatric Department in Tanzania [10]. In neighboring Kenya, blood transfusion is mostly used to treat severe malaria-associated anemia and sickle cell disease, and to replace massive blood loss [8,11]. In Ghana, malaria was reported as the main factor for requirement for blood transfusions in children [18]. However, septicemia (19, 13.6%), sickle cell disease (13, 9.3%), and malnutrition (10, 7.1%) are the most common indications for blood transfusion in Nigerian children [27].

In the current study 91% of the children had pallor, 87% of them presented with fever and 64% presented with difficulty in breathing, yet only 141 (47%) were diagnosed as severe anemia. Perhaps the symptoms might not be a useful indicator for anemia in this setting.

Approximately two fifths of the transfused children in the current study had sickle cell disease. A recent report showed that one in every 123 children in eastern and western Sudan is at risk of having sickle cell disease [30]. The (Misseriya tribes) ethnicity and the consanguineous marriages were the main explanations of the high prevalence (24.9%) of carriers of HbS allele (HbAS) in certain areas of Sudan [31]. A much lower rate (9.3%) of sickle disease has been reported in transfused Nigerian children [27]. Notably, some African countries, such as Cameroon, Gabon, Ghana, and Nigeria, have a high incidence of sickle cell disease (20%–30%) and it is much higher in Uganda (45%) [32].

In the current study, the median (interquartile range) request-to-issue time for blood was 6 (11–28) hours, which is unacceptably prolonged for urgent requests. Nabwera et al. reported a median request-to-issue time of between 3.6 and 5.4 hours in a pediatric referral hospital in Kenya [17]. In Tanzania, the median time to transfusion was 7.8 hours in anemic children who were transfused in a urban tertiary hospital [10]. Therefore, our study showed a much longer time to transfusion than the recommended guidelines from optimum healthcare systems. These guidelines suggest availability of uncross-matched blood within 10 minutes and availability of group-specific blood within 30 minutes [33]. A delay in transfusing children is associated with adverse outcomes [2,11]. Interestingly, it has recently been shown that there was no significant difference in clinical outcomes between the children who received immediate transfusion and those who did not (no immediate transfusion, control group)[34].

The “probable” blood transfusion reaction in our study was higher than that reported by Kiguli et al. (6/1,387, 0.4%) in other African countries [2]. We found that 285 (95.0%) children improved, nine (3.0%) children were discharged against medical advice, and six (2.0%) children died. In Nigeria, 117 (83.6%) children with anemia recovered, while four (2.8%) left the hospital against medical advice and 19 died [27]. In our study, the overall mortality rate in transfused children was 6/300 (2.0%). This rate is lower than that reported among anemic children in Tanzania (12.1%) [10] and in Nigeria (13.6%) [27]. However, the mortality rate in our study is similar to that (4%) reported in in Uganda, Kenya, and Tanzania in children with severe febrile illness [2]. Mortality in children with severe anemia is high when hemoglobin levels are <4 g/dL or if there is associated respiratory distress [35]. This difference among studies could be explained by differences in participants (age of the enrolled children), as well as differences in the definition of severe anemia [2].

Limitations of the study

Some factors such HIV was not investigated. HIV has been reported as the leading cause of severe anemia in other African countries [4]. However, a recent meta-analysis showed a low (1.0%) prevalence of HIV in Sudan [36].

Conclusion

There is a high burden of anemia in eastern Sudan. Sickle cell disease, malaria, and visceral leishmaniasis are the main causes of anemia in this region. Future reach on blood transfusion is required.

Table of the raw data included in this paper.

(XLSX)

Click here for additional data file.

2 Sep 2019

PONE-D-19-15934

Severe childhood anemia and emergency blood transfusion in Gadarif Hospital, eastern Sudan

PLOS ONE

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The reviewers have raised some major concerns that need attention in a revision. The reviewers raise that the manuscript should provide a clear definition for anemia, as well as definitions for other conditions measured. The reviewers request additional details on methodological aspects of the study and note concerns about the possibility of selection bias in the population. The reviewers also note that further statistical analyses must be carried out and the presentations of the data improved.

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Reviewer #1: Reviewer’s report for manuscript # PONE-D-19-15934

Summary: This was a cross sectional study conducted at a tertiary hospital in Eastern Sudan, in which the investigators attempted to determine the clinical use of blood among children receiving urgent transfusion. They found that approximately 56.5% (300/531) of children with anemia presenting to the emergency unit were transfused. Sickle cell disease (43%), acute bleeding (19.3%) and malaria (16.7%) were the leading diagnostic categories for which urgent blood transfusions were given.

Overall impression

The authors conducted a descriptive study, but methods of which lack details. There is a major concern for selection bias, since hemoglobin electrophoresis was only done among some patients, and yet sickle cell disease turned out to be the leading diagnostic category for transfusion. The data analysis seems incomplete (for the type of study design), since they could not even establish the factors associated with the main outcome variables. Consequently, the claims/answers to the current study are not supported by credible results. The authors make several speculations, such as about HIV, Schistosomiasis, and Sickle cell disease with no supporting data. Similarly, the results of some stated objectives are either not available or cancelled; probably for tests that were never performed. Results presentation and discussion deserve major revisions.

Specific issues, in details

Major issues

a) Introduction:

1. The objective(s) of the study, as stated in line 92-96, are not clear. Please revise, and clarify on the following:

i) Was the aim to ‘assess the rate’ of anemic children who….or to the ‘determine the proportion’ of anemic children who receive transfusion….?

ii) Did the authors examine (the indication, patterns and outcomes…), or describe?

b) Methods:

1. The authors need to clarify on the type of study design (line 98). Was this a cross-sectional study?

2. Generally, the methods lack details. By providing details of the scientific methods used in a clinical study, the researcher assures the global community that – another person, using the same tools may reproduce similar findings. Please explain and clarify on the following:

i) Samples of urine and stool were taken off (line 113); Provide details of the specific tests that were performed, and the machines used.

ii) Line 114-115, mentions that blood was examined for malaria. Please provide details; which films: thick films, thin films, or both? Which stains were used? Who read them?

iii) The diagnosis of anemia is very crucial in this study (refer to line 116). How was hemoglobin determined? Please provide details (e.g which machine was used?)

iv) Hemoglobin electrophoresis (refer to line 116). Provide details of the machine and techniques used.

v) Hemoglobin electrophoresis (refer to line 116). The authors say this was done “if required in some cases”! This is a major concern for selection bias, if such a test that confirms sickle cell status was only performed among some patients. Remarkably sickle cell disease turned out to be the leading diagnostic category for transfusion, yet some children were NOT tested! Please explain.

vi) In line 123, the authors state that transfusions were given for longer than 4 hours. However, transfusions are generally given for a period 2-4hrs. The practice of transfusion for longer than 4hrs is not safe and increases the risk for bacterial contamination. Is this the standard practice at Gadarif hospital? Please Explain.

vii) Similarly, explain how the diagnosis /suspicion of pulmonary edema was made. There is a risk for irrational use of frusemide.

viii) The text in line 126 is confusing. Do you mean “the time taken from order, to actual transfusion”? This may not be referred to as ‘time of blood transfusion’. Please modify.

ix) There are many other details missing, that should be mentioned such as:

x) How was the diagnosis of acute malnutrition made? Provide details.

xi) How was the diagnosis of visceral leishmaniasis made? Provide details.

xii) How was the diagnosis of sepsis made?

3. Statistical analysis:

i) Generally, additional statistical analysis needs to be done, such as univariate and bivariable analysis - to establish factors associated with the main outcomes such as survival, etc.

ii) Line 145: were all the numerical data symmetrical, to justify the use of Mean (SD)? If not, use median for asymmetrical data. Please check and revise.

4. For this study, the authors need to specify their operational definitions. For example;

i) What defined malaria?

ii) What defined sickle cell disease?

iii) What defined acute malnutrition?

iv) What defined acute bleeding?..etc.

c) Results:

1. Generally when presenting results, Table 1; which is the table of baseline characteristics comes up-front. These characteristics may include; gender, age, duration of illness, relationship with primary caregiver, occupation of caregiver, ethnic group/tribe etc. This table is missing.

2. Present the results systematically; objective by objective.

3. Results of some stated objectives are missing, such as; ‘pattern’ and ‘time taken from order, to actual transfusion’. Provide them.

4. Samples of urine and stool were taken off. Provide the results of these tests.

5. Hemoglobin electrophoresis was done. Provide detailed results, including the proportion with SS, AS etc.

6. Figure 1(line 154-166): The flow chart:

Consider revising this flow chart, such as below (only a guide);

.....Chart is attached, separate file,

7. The authors should account for each study participant. For example, 141/300 transfused children were categorized as severe anemia. What was the diagnosis among the 159 with Hb>5 but got transfused? Please explain and modify.

8. These 159, deserve a thorough discussion (in the discussion section).

9. This account above is important, because the description offered in line, 170 -173; does not seem to tie-up with what we normally see clinically: That 91% had pallor, 87% with fever and 64% with breathlessness, yet only 141 (47%) were diagnosed as severe anemia. Please clarify.

10. Line 181: Figure 2: This is a duplication of presentation of findings. Generally it is not necessary to show both the text (177-180) and figure. You choose either.

If choose text, then one writes...’the diagnosis associated with order of blood transfusion is shown in figure 2, below:’

11. Line 189: For the five that developed adverse events, provide more details. E.g. After stopping, what happened to them? Full recovery? Where these 5 among the the 6 deaths? or the 9 that discharged self..

12. Fully account for each participant; such as in # c(11), and c(6) - c(8) above.

13. Line 190: The phrase; “A total of 285 children improved…” is left hanging. So what factors were associated with recovery? This entire paragraph (190-194) does not make sense, without additional statistical analysis, as pointed out in c(3) above. Please revise.

d) Discussion:

1. What is the burden of Sickle cell disease in Sudan? In line 236, they mention one in 123 children. Do the authors believe this figure/prevalence? ….especially in light of their current finding that show; 129/300 (43%) of transfused children in that same setting have sickle cell disease? Please explain, and discuss.

2. This section is generally poorly written (flow), with lots of repetitions. Suggested flow may include the following areas (paragraphs):

i) First paragraph – what was the aim of the study/ what was your question?

ii) What did you find (the answer to your question)

iii) A brief explanation of the findings, in comparison/contrast with other studies.

iv) What is new in the current study?

v) The strength of your study.

vi) Limitations

vii) Conclusions /or and recommendations.

e) Conclusion:

Generally, the conclusion shall need to be revised, once most of the above revisions are finalized, especially those related to additional statistical analysis.

Minor issues

a) Abstract:

1. Were all the 1,800 children evaluated for anemia? Please clarify.

2. The text in line, 46-47 is confusion. “The diagnoses associated with the order for anemia…” Do clinicians order for anemia? Consider revising text, such as; “The diagnoses associated with the order for blood transfusion were…..” Do the same elsewhere, such as line 177.

b) Introduction:

1. The text in line 72-73 lack clarity. Consider revising text, such as; ‘Childhood anemia is a major cause of morbidity and mortality globally.

c) Methods:

1. Line 99, add ‘city’ to ‘Gadarif’ so that text reads; Gadarif city is 400km…..

2. Sample size estimation: Specify the formula used; such as Kish, Leslie for cross-sectional studies.

d) Results,

1. Line 170: The authors need to use terminologies correctly and in context. By ‘breathlessness’ do the authors mean, respiratory distress or difficulty in breathing? Please clarify.

2. Similarly, Line 171: Palpitation is a rare symptom among children, especially in <5 years who often don't report symptoms. Remember 151 (50.3%) were <5 years! In addition, in table 1; palpitation is grouped as a sign! This is confusing. Please revise.

3. Line 184: revise the phrase, such as; Median time, from order to time of blood issue (or better start of transfusion) – as appropriate.

4. Line 186: For fever, generally we consider an increment of >1°C, from baseline. Was this the case? Please clarify.

5. Line 187 (Adverse events are very important): Better specify; of the 5, how many got fever, and how many got urticarial rash?

e) Discussion:

1. Line 201: The authors state that, “the prevalence of anemia in our study was slightly higher than…”. Why? Please discuss. But, first clarify on how the 531(diagnosed with anemia) were got from the 1,800...to exclude selection bias. In other words, were all the 1,800 admitted children evaluated for anemia? Please clarify.

2. The phrase in line 215 conveys no meaning, especially with regard to what is put in parenthesis or (....). Please revise.

3. Line 216-217, about schistosomiasis: Are you sure? Please provide results of stool and urine, showing how many did not have. These results are missing.

4. Line 218-219; how did you know? When HIV was not tested. No mention of HIV testing in the methods or results.

5. Line 252-253: This phrase is not accurate; 0.4% in Kiguli et al study is not comparable to 1.6%! Please revise or explain.

f) Other comments: None.

Reviewer #2: PLONE-D-19-15943

Title

Severe childhood anemia and emergency blood transfusion in Gadarif Hospital, eastern Sudan

GENERAL COMMENTS

In this study the Authors assessed the prevalence of anemia in children admitted to their hospital in Sudan with an indication for blood transfusion through an eight months period. We subsequently examined a series of pre- and post- transfusion parameters (underlying disease, symptoms, signs, patients’ outcome and others).

The study, as the first performed in Sudan in this field, appears original and useful to better understand the real prevalence of anemia, its causes, the indications to blood transfusion, the transfusion behavior in a pediatric emergency department and the patients’ outcome.

However, I have some remarks and suggestions for changes.

First of all, I think that a clear statement (with an appropriate reference) must be included with respect to the definition of anemia used by the Authors, because this can affect the results.

According to WHO, a child between 6 and 59 months is defined as “anemic” when the hemoglobin level is below 11.5 g/dl (“severely anemic” below 7 g/dl). Between 5 and 11 years “anemia” is present with Hb below 11.0 g/dl; between 12 and 14 years below 12.0 g/dl and from 15 years on below 13.0 g/dl. Except for the first age class, the definition of “severe anemia” is restricted to patients with hemoglobin level below 8.0 g/dl.

See: World Health Organization. Haemoglobin concentrations for the diagnosis of anaemia and assessment of severity. WHO; 2011.

In the Results section of the abstract (line 42) the sentence was: “…513 (28.5%) were anemic (hemoglobin < 11 g/dl) and 141 (7.8%) had severe anemia” (hemoglobin level < 5 g/dl).” Please adjust this point.

In the statistical section the Authors declare that data are presented as mean (with standard deviation), but in line 184-185 they cite a “median (interquartile range)”. In line 194 the haemoglobin level should be expressed as median [IQR], especially since the word in brackets is “range”. Median and IQR are also cited in lines 242 and 244.

In my opinion the sentence in statistical section should be “Data are presented as mean (± Standard Deviation – SD) or median [interquartile range – IQR]

In the same sections the Authors should be described the methodology used to calculate the sample size (see line 132 – 135)

OTHER SPECIFIC COMMENTS

Introduction, Line 72 – 88

I would suggest a complete revision of the text, to make it more concise. The contents are appropriate, but there is a series of repetitions and redundancies.

Line 85

The reference n.12 (“Guidelines for informing about clinical decisions on transfusion associated with hemoglobin levels” ) doesn’t correspond to the WHO’s guidelines. In my opinion it could be better the reference n.20.

Line 123

Furosemide instead of frusemide

Line 135

A difference of 5% of what? Please specify.

Line 148 (Patients’ characteristics)

It is the only subheading in the “Results” section: the Authors may choose to erase it, to add other subheadings, if deemed appropriate.

Line 151

The question is always the same: is the definition of severe anemia arbitrarily chosen or reference-based? It is sufficient to declare it.

Figure 1. and lines 167-169

I suggest a table instead of a flowchart with the subsequent descriptive text.

The table is in the attachment named as “Suggested Table”

I would appreciate a bar chart with hemoglobin level classes at admission (e.g. < 4 / 4 - <5 / 5 - < 6 and so on) in the x axis and the prevalence in the y axis.

Line 194

See “statistic section” in the General comments

Discussion

Line 202

I suggest to add the following reference: Kassebaum NJ, Jasrasaria R, Naghavi M, Wulf SK, Johns N, et al. A systematicanalysis of global anemia burden from 1990 to 2010. Blood 2014(123):615–24. https://doi.org/10.1182/blood-2013-06-508325

Line 251

I suggest to add also the following reference and include a short discussion on its different results respect to the articles in reference 2 and 11. Maitland K, Kiguli S, Olupot-Olupot P, Engoru C, Mallewa M, Saramago Goncalves P, et al. Immediate Transfusion in African Children with Uncomplicated Severe Anemia. New England Journal of Medicine. 2019 Aug 1;381(5):407–19.

Conclusion

“Future reach on anemia is required” The phrase is not clear: please reword.

Lastly, it could be interesting to know the level of blood transfusion appropriateness. Are the WHO guidelines always followed? Did the Authors document cases of undertransfusion or non-transfusion in patients in need for homologous blood supply?

**********

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Reviewer #1: No

Reviewer #2: No

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Submitted filename: Figure 1_PONE-D-19-15934.docx

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Submitted filename: Suggested table .docx

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20 Sep 2019

We would like to thank the editor and reviewers for their valuable comments on this manuscript. We greatly appreciate your time dealing with the manuscript and assessing the review comments, which enabled us to greatly improve the quality of our manuscript. Here is a point-by-point response to the reviewers’ comments and concerns

5. Review Comments to the Author

Summary: This was a cross sectional study conducted at a tertiary hospital in Eastern Sudan, in which the investigators attempted to determine the clinical use of blood among children receiving urgent transfusion. They found that approximately 56.5% (300/531) of children with anemia presenting to the emergency unit were transfused. Sickle cell disease (43%), acute bleeding (19.3%) and malaria (16.7%) were the leading diagnostic categories for which urgent blood transfusions were given.

Overall impression

The authors conducted a descriptive study, but methods of which lack details. There is a major concern for selection bias, since hemoglobin electrophoresis was only done among some patients, and yet sickle cell disease turned out to be the leading diagnostic category for transfusion. The data analysis seems incomplete (for the type of study design), since they could not even establish the factors associated with the main outcome variables. Consequently, the claims/answers to the current study are not supported by credible results. The authors make several speculations, such as about HIV, Schistosomiasis, and Sickle cell disease with no supporting data. Similarly, the results of some stated objectives are either not available or cancelled; probably for tests that were never performed. Results presentation and discussion deserve major revisions.

Specific issues, in details

Comment

Major issues

a) Introduction:

1. The objective(s) of the study, as stated in line 92-96, are not clear. Please revise, and clarify on the following:

i) Was the aim to ‘assess the rate’ of anemic children who….or to the ‘determine the proportion’ of anemic children who receive transfusion….?

ii) Did the authors examine (the indication, patterns and outcomes…), or describe?

Response

Objectives were revised, the word “assess” was replaced with “determine" and “describe” instead of “examine” in the specified lines as suggested. The word pattern was deleted from the objectives because it was not investigated. Please see lines 94- 97.

Comment

b) Methods:

1. The authors need to clarify on the type of study design (line 98). Was this a cross-sectional study?

Response

Cross-sectional study was added. Please see the method line 100.

Comment

2. Generally, the methods lack details. By providing details of the scientific methods used in a clinical study, the researcher assures the global community that – another person, using the same tools may reproduce similar findings. Please explain and clarify on the following:

i) Samples of urine and stool were taken off (line 113); Provide details of the specific tests that were performed, and the machines used.

Response

Urine and stool analysis was conducted for schistosomal infection as described before. This has been inserted in the method. Please see the methods line 116.

Comment

ii) Line 114-115, mentions that blood was examined for malaria. Please provide details; which films: thick films, thin films, or both? Which stains were used? Who read them?

Response

Blood was examined for malaria using thick and thin blood films which were stained with 10% Giemsa and read by expert microscopist. This point has been inserted in the method. Please see it in lines 117-118.

Comment

iii) The diagnosis of anemia is very crucial in this study (refer to line 116). How was hemoglobin determined? Please provide details (e.g which machine was used?)

Response

Hemoglobin estimation was done as part of the complete hemogram via automated blood-cell analyzer machine (Sysmex Hematology Analyzer; Sysmex, Kakogawa, Japan). This point has been inserted in the method as suggested. Please see lines 118-120.

Comment

iv) Hemoglobin electrophoresis (refer to line 116). Provide details of the machine and techniques used.

v) Hemoglobin electrophoresis (refer to line 116). The authors say this was done “if required in some cases”! This is a major concern for selection bias, if such a test that confirms sickle cell status was only performed among some patients. Remarkably sickle cell disease turned out to be the leading diagnostic category for transfusion, yet some children were NOT tested! Please explain.

Response

The test was performed for those who were suspected clinically to have sickle cell disease; the test was not done to already diagnosed patients, we depended on the recorded results from past tests. Haemoglobin genotype using the usual electrophoretic method (electrophoretic equipment model MUPID-EXU, Japan). Please see lines 127-131.

Comment

vi) In line 123, the authors state that transfusions were given for longer than 4 hours. However, transfusions are generally given for a period 2-4hrs. The practice of transfusion for longer than 4hrs is not safe and increases the risk for bacterial contamination. Is this the standard practice at Gadarif hospital? Please Explain.

Response

Yes it is correct that , transfusions are generally given for a period 2-4hrs. It was typo error (we mean for not longer than) it has been corrected. Please see the text line 138

Comment

vii) Similarly, explain how the diagnosis /suspicion of pulmonary edema was made. There is a risk for irrational use of frusemide.

Response

Pulmonary edema was clinically determined if the patient had shortness of breathing, increased respiratory rate with coarse crackles at the lung bases and radiologically as defined by the presence of Kerley B lines in the anteroposterior chest viewwas explained in the text. This point has been inserted in the method lines 140-143.

Comment

viii) The text in line 126 is confusing. Do you mean “the time taken from order, to actual transfusion”? This may not be referred to as ‘time of blood transfusion’. Please modify.

Response

The sentence was modified to “The time taken from order of blood to actual transfusion” Please see it now line 151.

Comment

ix) There are many other details missing, that should be mentioned such as:

x) How was the diagnosis of acute malnutrition made? Provide details.

Response

Details of diagnosis of malnutrition were added in the methods “Severe acute malnutrition was diagnosed following the WHO guidelines for malnutrition. A child was considered as severe acute malnutrition if weight-for-height z score was <-2 SD for age and sex or presence of bilateral lower limb edema”. Please see it lines 143-146.

Comment

xi) How was the diagnosis of visceral leishmaniasis made? Provide details.

Response

Details of diagnosis of leishmaniasis were added “The diagnosis of visceral leishmaniasis was confirmed by the visualization of the amastigote form of the parasite by microscopic examination of aspirates from or bone marrow using Giemsa-stain”. Lines 146-148.

Comment

xii) How was the diagnosis of sepsis made?

Response

Diagnosis of sepsis was explained in the text” The definition of sepsis is considered as “life threatening organ dysfunction caused by a dysregulated host response to infection[25]. Lines 149-150.

Comment

3. Statistical analysis:

i) Generally, additional statistical analysis needs to be done, such as univariate and bivariable analysis - to establish factors associated with the main outcomes such as survival, etc.

Response

We agreed that univariate and bivariable analysis is needed. However, there are few numbers “ 9 children discharged against medical advice and 6 children died” in the outcome. If we tried to conduct bivariable analysis in this case the model will be distorted with a wide range of confidence intervals. Hence this is the reason behind that we did not conduct it.

Comment

ii) Line 145: were all the numerical data symmetrical, to justify the use of Mean (SD)? If not, use median for asymmetrical data. Please check and revise.

Response

Yes Continuous data were checked for normality using Shapiro-Wilk test and they were presented as mean (Standard Deviation – SD) if they were normally distributed or median [interquartile range – IQR] if they were not normally distributed. This point has been inserted in the statistics. Please see lines 173-175.

Comment

4. For this study, the authors need to specify their operational definitions. For example;

i) What defined malaria?

ii) What defined sickle cell disease?

iii) What defined acute malnutrition?

iv) What defined acute bleeding?..etc.

to add the other definitions

Response

All these have been defined as suggested. Please see the methods and mentioned above.

Comment

c) Results:

1. Generally when presenting results, Table 1; which is the table of baseline characteristics comes up-front. These characteristics may include; gender, age, duration of illness, relationship with primary caregiver, occupation of caregiver, ethnic group/tribe etc. This table is missing.

Response

The suggested table has been inserted. Thank you very much indeed as you draw its outlines.

Comment

2. Present the results systematically; objective by objective.

Systematic presentations of the results

3. Results of some stated objectives are missing, such as; ‘pattern’ and ‘time taken from order, to actual transfusion’. Provide them.

Results of pattern, time taken from order to actual transfusion.

Response

The pattern was not investigated and it has been deleted from the objectives. The others have been put in order as suggested.

Comment

4. Samples of urine and stool were taken off. Provide the results of these tests.

Response

It has been added” There was no case of intestinal or urinary schistosomiasis” Please see line 237

Comment

5. Hemoglobin electrophoresis was done. Provide detailed results, including the proportion with SS, AS etc.

Response

The details have been inserted in the results. Please see lines 236.

Comment

6. Figure 1(line 154-166): The flow chart:

Consider revising this flow chart, such as below (only a guide);…Chart is attached, separate file,

Response

The suggested revised chart has been added. Thank very much indeed for this suggestion.

Comment

7. The authors should account for each study participant. For example, 141/300 transfused children were categorized as severe anemia. What was the diagnosis among the 159 with Hb>5 but got transfused? Please explain and modify.

Response

Yes the details of blood transfusion in this group as” Of 204 children who had hemoglobin levels of 4–7 g/dl and were transfused; 110 (53.9%) had heart failure, 38 (18.6%) had < 20% of red blood cells parasitized by malaria parasites, 32 (15.7%) had continuing bleeding, 9(4.4%) had combined/ others reasons, 8(3.9%) had dehydration and 7(3.4%) had impaired level of consciousness” Please see lines 240-244.

Comment

8. These 159, deserve a thorough discussion (in the discussion section).

Add to discussion Hb>5 and transfused

Response

Please see above

Comment

9. This account above is important, because the description offered in line, 170 -173; does not seem to tie-up with what we normally see clinically: That 91% had pallor, 87% with fever and 64% with breathlessness, yet only 141 (47%) were diagnosed as severe anemia. Please clarify.

To explain why only 47% had severe anemia where 91% had pallor & 87% had fever

Response

Yes we agreed it is a valid point. The explanation for this point is that symptoms might not be a useful indicator for anemia. This point has been inserted in the discussion. Please see line 302-305.

Comment

10. Line 181: Figure 2: This is a duplication of presentation of findings. Generally it is not necessary to show both the text (177-180) and figure. You choose either.

Figure 2 to be deleted or otherwise choose the figure and sentence below

If choose text, then one writes...’the diagnosis associated with order of blood transfusion is shown in figure 2, below:’

Response

Oaky the text was removed and the figure is retained.

Comment

11. Line 189: For the five that developed adverse events, provide more details. E.g. After stopping, what happened to them? Full recovery? Where these 5 among the the 6 deaths? or the 9 that discharged self..

Response

The details have been inserted. Please see 248-250.

12. Fully account for each participant; such as in # c(11), and c(6) - c(8) above.

Response

Please see above

Comment

13. Line 190: The phrase; “A total of 285 children improved…” is left hanging. So what factors were associated with recovery? This entire paragraph (190-194) does not make sense, without additional statistical analysis, as pointed out in c(3) above. Please revise.

factors associated with recovery needed?????

Response

We agreed that there should be more analysis on the factors and their outcomes. As we mentioned above 285 out three hundreds improved. This left only 15 (died and discharged against medical advice) which is small number to perform bivariate analysis

Comment

d) Discussion:

1. What is the burden of Sickle cell disease in Sudan? In line 236, they mention one in 123 children. Do the authors believe this figure/prevalence? ….especially in light of their current finding that show; 129/300 (43%) of transfused children in that same setting have sickle cell disease? Please explain, and discuss.

Response

The (Misseriya tribes) ethnicity and the consanguineous marriages were the main explanations of the high prevalence (24.9%) of carriers of HbS allele (HbAS) in certain areas of Sudan. This point has been added to the discussion as suggested. Please see lines 308-310.

Comment

2. This section is generally poorly written (flow), with lots of repetitions. Suggested flow may include the following areas (paragraphs):

i) First paragraph – what was the aim of the study/ what was your question?

ii) What did you find (the answer to your question)

iii) A brief explanation of the findings, in comparison/contrast with other studies.

iv) What is new in the current study?

v) The strength of your study.

vi) Limitations

vii) Conclusions /or and recommendations.

Response

All these points have been addressed.

e) Conclusion:

Generally, the conclusion shall need to be revised, once most of the above revisions are finalized, especially those related to additional statistical analysis.

Response

All these have been addressed in the discussion as suggested.

Minor issues

Comment

a) Abstract:

1. Were all the 1,800 children evaluated for anemia? Please clarify.

Response

Yes were assessed for anemia. This point has been inserted in the abstract as suggested.

Comment

2. The text in line, 46-47 is confusion. “The diagnoses associated with the order for anemia…” Do clinicians order for anemia? Consider revising text, such as; “The diagnoses associated with the order for blood transfusion were…..” Do the same elsewhere, such as line 177.

Response

The sentence now read (diagnoses associated with the “severity” instead of “order” of anemia). It has been corrected throughout the paper as suggested

Comment

b) Introduction:

1. The text in line 72-73 lack clarity. Consider revising text, such as; ‘Childhood anemia is a major cause of morbidity and mortality globally.

Response

The sentence was rephrased

Comment

c) Methods:

1. Line 99, add ‘city’ to ‘Gadarif’ so that text reads; Gadarif city is 400km…..

Response

The word city is added now

Comment

2. Sample size estimation: Specify the formula used; such as Kish, Leslie for cross-sectional studies.

Response

Formula specification has been inserted as suggested.

Comment

d) Results,

1. Line 170: The authors need to use terminologies correctly and in context. By ‘breathlessness’ do the authors mean, respiratory distress or difficulty in breathing? Please clarify.

Response

Breathlessness explained as difficulty in breathing.

Comment

2. Similarly, Line 171: Palpitation is a rare symptom among children, especially in <5 years who often don't report symptoms. Remember 151 (50.3%) were <5 years! In addition, in table 1; palpitation is grouped as a sign! This is confusing. Please revise.

Response

I agreed it is confusing “ palpitation” has been deleted from the text and the table.

Commet

3. Line 184: revise the phrase, such as; Median time, from order to time of blood issue (or better start of transfusion) – as appropriate.

Response

The sentence was rephrased as: The median (interquartile range) request-to-issue time for blood was 6 (3−12) hours.

Comment

4. Line 186: For fever, generally we consider an increment of >1°C, from baseline. Was this the case? Please clarify.

Response

The fever was defined.

Comment

5. Line 187 (Adverse events are very important): Better specify; of the 5, how many got fever, and how many got urticarial rash?

Response

The details have been inserted as all of them had fever and urticarial rash. Please see lines 247-250.

Comment

e) Discussion:

1. Line 201: The authors state that, “the prevalence of anemia in our study was slightly higher than…”. Why? Please discuss. But, first clarify on how the 531(diagnosed with anemia) were got from the 1,800...to exclude selection bias. In other words, were all the 1,800 admitted children evaluated for anemia? Please clarify.

Response

This was clarified in the results section, please see above.

Comment

2. The phrase in line 215 conveys no meaning, especially with regard to what is put in parenthesis or (....). Please revise.

Response

Sentence rephrased

Comment

3. Line 216-217, about schistosomiasis: Are you sure? Please provide results of stool and urine, showing how many did not have. These results are missing.

Response

The sentence is rephrased as “Shistosomal infection was reported as the main cause of severe anemia of children….” This fact was cited from a previous study and not as a finding of this study.

Comment

4. Line 218-219; how did you know? When HIV was not tested. No mention of HIV testing in the methods or results. This should be one of the limitation of the study

Response

This part was deleted as you can see. The HIV was not tested, this has been inserted in the limitation of the study. Please see lines 341.

Comment

5. Line 252-253: This phrase is not accurate; 0.4% in Kiguli et al study is not comparable to 1.6%! Please revise or explain.

Response

The sentence was rephrased as follows: The “probable” blood transfusion reaction in our study was higher than that reported by Kiguli et al

f) Other comments: None.

Reviewer #2: PLONE-D-19-15943

Title

Severe childhood anemia and emergency blood transfusion in Gadarif Hospital, eastern Sudan

GENERAL COMMENTS

In this study the Authors assessed the prevalence of anemia in children admitted to their hospital in Sudan with an indication for blood transfusion through an eight months period. We subsequently examined a series of pre- and post- transfusion parameters (underlying disease, symptoms, signs, patients’ outcome and others).

The study, as the first performed in Sudan in this field, appears original and useful to better understand the real prevalence of anemia, its causes, the indications to blood transfusion, the transfusion behavior in a pediatric emergency department and the patients’ outcome.

However, I have some remarks and suggestions for changes.

Comment

First of all, I think that a clear statement (with an appropriate reference) must be included with respect to the definition of anemia used by the Authors, because this can affect the results.

According to WHO, a child between 6 and 59 months is defined as “anemic” when the hemoglobin level is below 11.5 g/dl (“severely anemic” below 7 g/dl). Between 5 and 11 years “anemia” is present with Hb below 11.0 g/dl; between 12 and 14 years below 12.0 g/dl and from 15 years on below 13.0 g/dl. Except for the first age class, the definition of “severe anemia” is restricted to patients with hemoglobin level below 8.0 g/dl.

See: World Health Organization. Haemoglobin concentrations for the diagnosis of anaemia and assessment of severity. WHO; 2011.

Has to define all conditions in a paragraph titled operational definitions

Response

Yes thank you very much. The provided definition for anemia has been inserted as well the reference provided. Please see lines 121-126.

Comment

In the Results section of the abstract (line 42) the sentence was: “…513 (28.5%) were anemic (hemoglobin < 11 g/dl) and 141 (7.8%) had severe anemia” (hemoglobin level < 5 g/dl).” Please adjust this point.

Response

Okay thank you very much for your suggestion. The point has been adjusted.

Comment

In the statistical section the Authors declare that data are presented as mean (with standard deviation), but in line 184-185 they cite a “median (interquartile range)”. In line 194 the haemoglobin level should be expressed as median [IQR], especially since the word in brackets is “range”. Median and IQR are also cited in lines 242 and 244.

Clarification of mean interquartile usage in an expression of mean SD

In my opinion the sentence in statistical section should be “Data are presented as mean (± Standard Deviation – SD) or median [interquartile range – IQR]

Response

Yes we agreed and this has been adjusted all over the paper.

Comment

In the same sections the Authors should be described the methodology used to calculate the sample size (see line 132 – 135)

Response

Yes the sample size has been clarified. Please see lines 159-160

OTHER SPECIFIC COMMENTS

Introduction, Line 72 – 88

I would suggest a complete revision of the text, to make it more concise. The contents are appropriate, but there is a series of repetitions and redundancies.

Response

Repetitions and redundancies removed

Comment

Line 85

The reference n.12 (“Guidelines for informing about clinical decisions on transfusion associated with hemoglobin levels” ) doesn’t correspond to the WHO’s guidelines. In my opinion it could be better the reference n.20.

Response

Yes we agreed and it has been replaced by the suggested reference.

Reference 20 considered to replace reference 12

Line 123

Furosemide instead of frusemide

Response

Yes corrected as suggested

Comment

Line 135

A difference of 5% of what? Please specify.

Response

It is the precision (statistical term), it has been corrected.

Comment

Line 148 (Patients’ characteristics)

It is the only subheading in the “Results” section: the Authors may choose to erase it, to add other subheadings, if deemed appropriate.

Response

The subheading was deleted as suggested.

Comment

Line 151

The question is always the same: is the definition of severe anemia arbitrarily chosen or reference-based? It is sufficient to declare it.

Response

The definition of anemia is included as suggested

Comment

Figure 1. and lines 167-169

I suggest a table instead of a flowchart with the subsequent descriptive text.

The table is in the attachment named as “Suggested Table”

Response

The suggested table added

Comment

I would appreciate a bar chart with hemoglobin level classes at admission (e.g. < 4 / 4 - <5 / 5 - < 6 and so on) in the x axis and the prevalence in the y axis.

A bar chart to be added

Response

Oaky the requested figure has been inserted, please see figure 2.

Comment

Line 194

See “statistic section” in the General comments

Response

Statistics revised

Comment

Discussion

Line 202

I suggest to add the following reference: Kassebaum NJ, Jasrasaria R, Naghavi M, Wulf SK, Johns N, et al. A systematic analysis of global anemia burden from 1990 to 2010. Blood 2014(123):615–24. https://doi.org/10.1182/blood-2013-06-508325

Response

The reference is added

Comment

Line 251

I suggest to add also the following reference and include a short discussion on its different results respect to the articles in reference 2 and 11. Maitland K, Kiguli S, Olupot-Olupot P, Engoru C, Mallewa M, Saramago Goncalves P, et al. Immediate Transfusion in African Children with Uncomplicated Severe Anemia. New England Journal of Medicine. 2019 Aug 1;381(5):407–19.

Response

The reference is added, please see line

Comment

Conclusion

“Future reach on anemia is required” The phrase is not clear: please reword.

Response

It has been changed

Comment

Lastly, it could be interesting to know the level of blood transfusion appropriateness. Are the WHO guidelines always followed? Did the Authors document cases of undertransfusion or non-transfusion in patients in need for homologous blood supply?

To add the information of adherence to WHO guidelines on blood transfusion.

Response

It is a valid point and thank you very much. However we did not think of it in our objectives. Perhaps we will include it in our future research.

Regards

________________________________________

Submitted filename: renamed_bb956.docx

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30 Oct 2019

PONE-D-19-15934R1

Severe childhood anemia and emergency blood transfusion in Gadarif Hospital, eastern Sudan

PLOS ONE

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Reviewer #2: (No Response)

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Reviewer #2: All the remarks are amended, except the redundancies in the Introduction section.

When I said "redundancies", I meant: "children" two times in the first line and "mortality in children with severe anemia" two times in line 81 and 82. Please, arrange the text in a different fashion.

Figure 1 can be totally replaced by the new Table 1.

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31 Oct 2019

We would like to thank the editor and reviewers for their valuable comments on this manuscript. We greatly appreciate your time dealing with the manuscript and assessing the review comments, which enabled us to greatly improve the quality of our manuscript. Here is a point-by-point response to the reviewers’ comments and concerns

Comment

reviewer #2: All the remarks are amended, except the redundancies in the Introduction section.

When I said "redundancies", I meant: "children" two times in the first line and "mortality in children with severe anemia" two times in line 81 and 82. Please, arrange the text in a different fashion.

Figure 1 can be totally replaced by the new Table 1

Response

The redundancies in the Introduction section have been removed as suggested.

Please see the introduction now.

Figure 1 has been deleted as suggested.

Regards

Submitted filename: point to point 31 october.docx

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12 Nov 2019

Severe childhood anemia and emergency blood transfusion in Gadarif Hospital, eastern Sudan

PONE-D-19-15934R2

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19 Nov 2019

PONE-D-19-15934R2

Severe childhood anemia and emergency blood transfusion in Gadarif Hospital, eastern Sudan

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