South African Paediatric Surgical Outcomes Study-2 (SAPSOS-2): a prospective multi-centre pre–post study evaluating haemoglobin response to oral iron for iron-deficiency anaemia in children undergoing elective noncardiac surgery

Heidi M. Meyer; Alexandra Torborg; Bruce Biccard; Hyla Kluyts; Vernon J. Louw; Sharon Cox; Shazia Peer; Marion Arnold; Celeste Cilliers; Sameera Patel; Yael Benjamin; Aneesa Solwa; Lise Smuts; Ayesha Parak; Carmen Gerber; Steven J. Staffa; Susan M. Goobie

doi:10.1016/j.bja.2026.06.001

South African Paediatric Surgical Outcomes Study-2 (SAPSOS-2): a prospective multi-centre pre–post study evaluating haemoglobin response to oral iron for iron-deficiency anaemia in children undergoing elective noncardiac surgery

Heidi M. Meyer^*
, Alexandra Torborg
, Bruce Biccard
, Hyla Kluyts
, Vernon J. Louw
, Sharon Cox
, Shazia Peer
, Marion Arnold
, Celeste Cilliers
, Sameera Patel
, Yael Benjamin
, Aneesa Solwa
, Lise Smuts
, Ayesha Parak
, Carmen Gerber
, Steven J. Staffa
, Susan M. Goobie

^*Corresponding author for this work

Research output: Contribution to journal › Article › peer-review

Abstract

Background: Preoperative anaemia in children is associated with increased morbidity, mortality, and blood transfusion exposure. This study aimed to evaluate a pragmatic preoperative anaemia pathway and the haemoglobin (Hb) response (ΔHb) to oral iron in children with iron-deficiency anaemia (IDA) undergoing elective noncardiac surgery in South Africa. Methods: This prospective pragmatic study with a pre–post design was conducted at two academic hospitals in South Africa from February 2023 to March 2025. Children aged >6 months to <16 yr were first screened using point-of-care capillary HemoCue®. Children with laboratory-confirmed IDA received oral iron and selective deworming. The primary outcome was ΔHb. Secondary outcomes included anaemia prevalence detected by point-of-care screening with HemoCue®, proportion of IDA among children with laboratory-confirmed anaemia, improvement or resolution of anaemia, and feasibility measures. Results: On preoperative HemoCue® screening, 177/755 (23.4%; 95% confidence interval 20.4–26.6%) children had Hb concentrations below WHO age-specific thresholds. Among the 175 children who underwent confirmatory laboratory testing, 71/175 (40.6%) had anaemia. Of these, 39/71 (54.9%) had IDA, with 35/39 (89.7%) completing follow-up. Median ΔHb was 1.0 g dl⁻¹ (interquartile range 0.5–1.8; P=0.001). The WHO anaemia severity category (defined as mild, moderate or severe) improved in 23/35 (65.7%) children, and 17/35 (48.6%) were no longer anaemic. Adherence was high and side effects infrequent. Conclusions: This pragmatic preoperative anaemia-management pathway was feasible and produced a modest increase in Hb in children with IDA. These findings highlight the potential role of structured optimisation pathways and support further evaluation in resource-limited settings. Clinical trial registration: ClinicalTrials.gov (NCT05681871).

Original language	English
Pages (from-to)	773-781
Number of pages	9
Journal	British Journal of Anaesthesia
Volume	137
Issue number	3
DOIs	https://doi.org/10.1016/j.bja.2026.06.001
Publication status	Published - Sept 2026
Externally published	Yes

Bibliographical note

Publisher Copyright:
© 2026 The Authors. Published by Elsevier Ltd on behalf of British Journal of Anaesthesia. This is an open access article under the CC BY license. http://creativecommons.org/licenses/by/4.0/

Keywords

anaemia
haemoglobin
iron-deficiency anaemia
oral iron
paediatric anaesthesia
paediatric surgery
patient blood management

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Meyer, H. M., Torborg, A., Biccard, B., Kluyts, H., Louw, V. J., Cox, S., Peer, S., Arnold, M., Cilliers, C., Patel, S., Benjamin, Y., Solwa, A., Smuts, L., Parak, A., Gerber, C., Staffa, S. J., & Goobie, S. M. (2026). South African Paediatric Surgical Outcomes Study-2 (SAPSOS-2): a prospective multi-centre pre–post study evaluating haemoglobin response to oral iron for iron-deficiency anaemia in children undergoing elective noncardiac surgery. British Journal of Anaesthesia, 137(3), 773-781. https://doi.org/10.1016/j.bja.2026.06.001

@article{0a219a24082b473bba677da79ea58d2f,

title = "South African Paediatric Surgical Outcomes Study-2 (SAPSOS-2): a prospective multi-centre pre{\textendash}post study evaluating haemoglobin response to oral iron for iron-deficiency anaemia in children undergoing elective noncardiac surgery",

abstract = "Background: Preoperative anaemia in children is associated with increased morbidity, mortality, and blood transfusion exposure. This study aimed to evaluate a pragmatic preoperative anaemia pathway and the haemoglobin (Hb) response (ΔHb) to oral iron in children with iron-deficiency anaemia (IDA) undergoing elective noncardiac surgery in South Africa. Methods: This prospective pragmatic study with a pre{\textendash}post design was conducted at two academic hospitals in South Africa from February 2023 to March 2025. Children aged >6 months to <16 yr were first screened using point-of-care capillary HemoCue{\textregistered}. Children with laboratory-confirmed IDA received oral iron and selective deworming. The primary outcome was ΔHb. Secondary outcomes included anaemia prevalence detected by point-of-care screening with HemoCue{\textregistered}, proportion of IDA among children with laboratory-confirmed anaemia, improvement or resolution of anaemia, and feasibility measures. Results: On preoperative HemoCue{\textregistered} screening, 177/755 (23.4\%; 95\% confidence interval 20.4{\textendash}26.6\%) children had Hb concentrations below WHO age-specific thresholds. Among the 175 children who underwent confirmatory laboratory testing, 71/175 (40.6\%) had anaemia. Of these, 39/71 (54.9\%) had IDA, with 35/39 (89.7\%) completing follow-up. Median ΔHb was 1.0 g dl−1 (interquartile range 0.5{\textendash}1.8; P=0.001). The WHO anaemia severity category (defined as mild, moderate or severe) improved in 23/35 (65.7\%) children, and 17/35 (48.6\%) were no longer anaemic. Adherence was high and side effects infrequent. Conclusions: This pragmatic preoperative anaemia-management pathway was feasible and produced a modest increase in Hb in children with IDA. These findings highlight the potential role of structured optimisation pathways and support further evaluation in resource-limited settings. Clinical trial registration: ClinicalTrials.gov (NCT05681871).",

keywords = "anaemia, haemoglobin, iron-deficiency anaemia, oral iron, paediatric anaesthesia, paediatric surgery, patient blood management",

author = "Meyer, \{Heidi M.\} and Alexandra Torborg and Bruce Biccard and Hyla Kluyts and Louw, \{Vernon J.\} and Sharon Cox and Shazia Peer and Marion Arnold and Celeste Cilliers and Sameera Patel and Yael Benjamin and Aneesa Solwa and Lise Smuts and Ayesha Parak and Carmen Gerber and Staffa, \{Steven J.\} and Goobie, \{Susan M.\}",

note = "Publisher Copyright: {\textcopyright} 2026 The Authors. Published by Elsevier Ltd on behalf of British Journal of Anaesthesia. This is an open access article under the CC BY license. http://creativecommons.org/licenses/by/4.0/",

year = "2026",

month = sep,

doi = "10.1016/j.bja.2026.06.001",

language = "English",

volume = "137",

pages = "773--781",

journal = "British Journal of Anaesthesia",

issn = "0007-0912",

number = "3",

}

Meyer, HM, Torborg, A, Biccard, B, Kluyts, H, Louw, VJ, Cox, S, Peer, S, Arnold, M, Cilliers, C, Patel, S, Benjamin, Y, Solwa, A, Smuts, L, Parak, A, Gerber, C, Staffa, SJ & Goobie, SM 2026, 'South African Paediatric Surgical Outcomes Study-2 (SAPSOS-2): a prospective multi-centre pre–post study evaluating haemoglobin response to oral iron for iron-deficiency anaemia in children undergoing elective noncardiac surgery', British Journal of Anaesthesia, vol. 137, no. 3, pp. 773-781. https://doi.org/10.1016/j.bja.2026.06.001

South African Paediatric Surgical Outcomes Study-2 (SAPSOS-2): a prospective multi-centre pre–post study evaluating haemoglobin response to oral iron for iron-deficiency anaemia in children undergoing elective noncardiac surgery. / Meyer, Heidi M.; Torborg, Alexandra; Biccard, Bruce et al.
In: British Journal of Anaesthesia, Vol. 137, No. 3, 09.2026, p. 773-781.

Research output: Contribution to journal › Article › peer-review

TY - JOUR

T1 - South African Paediatric Surgical Outcomes Study-2 (SAPSOS-2)

T2 - a prospective multi-centre pre–post study evaluating haemoglobin response to oral iron for iron-deficiency anaemia in children undergoing elective noncardiac surgery

AU - Meyer, Heidi M.

AU - Torborg, Alexandra

AU - Biccard, Bruce

AU - Kluyts, Hyla

AU - Louw, Vernon J.

AU - Cox, Sharon

AU - Peer, Shazia

AU - Arnold, Marion

AU - Cilliers, Celeste

AU - Patel, Sameera

AU - Benjamin, Yael

AU - Solwa, Aneesa

AU - Smuts, Lise

AU - Parak, Ayesha

AU - Gerber, Carmen

AU - Staffa, Steven J.

AU - Goobie, Susan M.

N1 - Publisher Copyright: © 2026 The Authors. Published by Elsevier Ltd on behalf of British Journal of Anaesthesia. This is an open access article under the CC BY license. http://creativecommons.org/licenses/by/4.0/

PY - 2026/9

Y1 - 2026/9

N2 - Background: Preoperative anaemia in children is associated with increased morbidity, mortality, and blood transfusion exposure. This study aimed to evaluate a pragmatic preoperative anaemia pathway and the haemoglobin (Hb) response (ΔHb) to oral iron in children with iron-deficiency anaemia (IDA) undergoing elective noncardiac surgery in South Africa. Methods: This prospective pragmatic study with a pre–post design was conducted at two academic hospitals in South Africa from February 2023 to March 2025. Children aged >6 months to <16 yr were first screened using point-of-care capillary HemoCue®. Children with laboratory-confirmed IDA received oral iron and selective deworming. The primary outcome was ΔHb. Secondary outcomes included anaemia prevalence detected by point-of-care screening with HemoCue®, proportion of IDA among children with laboratory-confirmed anaemia, improvement or resolution of anaemia, and feasibility measures. Results: On preoperative HemoCue® screening, 177/755 (23.4%; 95% confidence interval 20.4–26.6%) children had Hb concentrations below WHO age-specific thresholds. Among the 175 children who underwent confirmatory laboratory testing, 71/175 (40.6%) had anaemia. Of these, 39/71 (54.9%) had IDA, with 35/39 (89.7%) completing follow-up. Median ΔHb was 1.0 g dl−1 (interquartile range 0.5–1.8; P=0.001). The WHO anaemia severity category (defined as mild, moderate or severe) improved in 23/35 (65.7%) children, and 17/35 (48.6%) were no longer anaemic. Adherence was high and side effects infrequent. Conclusions: This pragmatic preoperative anaemia-management pathway was feasible and produced a modest increase in Hb in children with IDA. These findings highlight the potential role of structured optimisation pathways and support further evaluation in resource-limited settings. Clinical trial registration: ClinicalTrials.gov (NCT05681871).

AB - Background: Preoperative anaemia in children is associated with increased morbidity, mortality, and blood transfusion exposure. This study aimed to evaluate a pragmatic preoperative anaemia pathway and the haemoglobin (Hb) response (ΔHb) to oral iron in children with iron-deficiency anaemia (IDA) undergoing elective noncardiac surgery in South Africa. Methods: This prospective pragmatic study with a pre–post design was conducted at two academic hospitals in South Africa from February 2023 to March 2025. Children aged >6 months to <16 yr were first screened using point-of-care capillary HemoCue®. Children with laboratory-confirmed IDA received oral iron and selective deworming. The primary outcome was ΔHb. Secondary outcomes included anaemia prevalence detected by point-of-care screening with HemoCue®, proportion of IDA among children with laboratory-confirmed anaemia, improvement or resolution of anaemia, and feasibility measures. Results: On preoperative HemoCue® screening, 177/755 (23.4%; 95% confidence interval 20.4–26.6%) children had Hb concentrations below WHO age-specific thresholds. Among the 175 children who underwent confirmatory laboratory testing, 71/175 (40.6%) had anaemia. Of these, 39/71 (54.9%) had IDA, with 35/39 (89.7%) completing follow-up. Median ΔHb was 1.0 g dl−1 (interquartile range 0.5–1.8; P=0.001). The WHO anaemia severity category (defined as mild, moderate or severe) improved in 23/35 (65.7%) children, and 17/35 (48.6%) were no longer anaemic. Adherence was high and side effects infrequent. Conclusions: This pragmatic preoperative anaemia-management pathway was feasible and produced a modest increase in Hb in children with IDA. These findings highlight the potential role of structured optimisation pathways and support further evaluation in resource-limited settings. Clinical trial registration: ClinicalTrials.gov (NCT05681871).

KW - anaemia

KW - haemoglobin

KW - iron-deficiency anaemia

KW - oral iron

KW - paediatric anaesthesia

KW - paediatric surgery

KW - patient blood management

UR - https://www.scopus.com/pages/publications/105043368750

U2 - 10.1016/j.bja.2026.06.001

DO - 10.1016/j.bja.2026.06.001

M3 - Article

AN - SCOPUS:105043368750

SN - 0007-0912

VL - 137

SP - 773

EP - 781

JO - British Journal of Anaesthesia

JF - British Journal of Anaesthesia

IS - 3

ER -

Meyer HM, Torborg A, Biccard B, Kluyts H, Louw VJ, Cox S et al. South African Paediatric Surgical Outcomes Study-2 (SAPSOS-2): a prospective multi-centre pre–post study evaluating haemoglobin response to oral iron for iron-deficiency anaemia in children undergoing elective noncardiac surgery. British Journal of Anaesthesia. 2026 Sept;137(3):773-781. doi: 10.1016/j.bja.2026.06.001

South African Paediatric Surgical Outcomes Study-2 (SAPSOS-2): a prospective multi-centre pre–post study evaluating haemoglobin response to oral iron for iron-deficiency anaemia in children undergoing elective noncardiac surgery

Abstract

Bibliographical note

Keywords

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