Beyond hemoglobin thresholds: identifying clinical predictors for red blood cell transfusion in pediatric severe anemia.
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BACKGROUND: We aimed to evaluate the etiological causes of severe anemia and identify clinical and laboratory predictors for red blood cell (RBC) transfusion in the pediatric emergency department (PED). METHODS: This retrospective study included 186 children (1 month-18 years) with severe anemia as per the WHO age criterion in a tertiary PED (2023-2025). LASSO and multivariable logistic regression identified independent predictors of transfusion, while quantile regression analyzed Hb increment. RESULTS: Median age was 8 years 2 months, and 57.5% were female. Impaired red cell formation was the primary mechanism (70.4%), predominantly nutritional anemia (53.2%). Transfusion was performed in 88 patients (47.3%). Multivariable analysis identified heart murmur (OR = 16.08, p = 0.004), hepatomegaly (OR = 8.25, p = 0.021), splenomegaly (OR = 5.33, p = 0.026), tachycardia (OR = 5.28, p < 0.001), lower Hb (OR = 0.26, p < 0.001), normocytosis (OR = 8.99, p = 0.002), and elevated RDW (OR = 0.04, p = 0.007) as independent predictors. Quantile regression predicted a median Hb increment of 1.80 g/dL per 10 mL/kg transfusion (p < 0.001). CONCLUSIONS: Our results demonstrate that symptomatic severe anemia is strongly associated with transfusion. The administration of RBC transfusion should not rely solely on absolute Hb thresholds; rather, bedside clinical indicators and laboratory findings are necessary to optimize pediatric emergency management. IMPACT: RBC transfusion administration is driven by a combination of absolute Hb levels, specific laboratory markers, and bedside clinical signs of hemodynamic instability, rather than strict Hb thresholds alone. This study identifies robust independent predictors for transfusion using a LASSO regression model and quantifies the expected median Hb increment (1.80 g/dL per 10 mL/kg) via quantile regression. These findings contextualize the management of severe pediatric anemia by highlighting the necessity of integrating bedside clinical assessments with Hb values to evaluate urgent transfusion needs. Emphasizing the evaluation of multi-lineage cytopenias facilitates the earlier identification of underlying malignancies.