Antibiotic prophylaxis and multi-vitamin multi-mineral supplements provide no benefit for children with severe anaemia

17 Sep 2019

Results from the TRACT trial show that children with severe anaemia do not benefit from receiving either antibiotic prophylaxis or Multi-vitamin Multi-mineral supplements for three months after they are discharged from hospital. These results were published today in The Lancet Global Health journal.

Severe anaemia is common and life-threatening for children in sub-Saharan Africa. Around one in ten children in hospital because of severe anaemia die while in hospital, and one in eight die within six months of being discharged from hospital. One in six children end up back in hospital within six months of being discharged.

Previous research had found that several micronutrient deficiencies might be important causes of severe anaemia. This suggested that Multi-vitamin Multi-mineral supplements could be an attractive and low risk strategy for correcting underlying nutritional-related anaemia. Until now, no Multi-vitamin Multi-mineral supplements have been tested against WHO recommended treatments in children hospitalised with severe anaemia for meaningful outcomes such as prevention of severe anaemia relapse, readmission or re-transfusion, and longer-term mortality.

Cotrimoxazole is a cheap, widely available antibiotic. It has been shown to reduce deaths among children with HIV, and can help prevent malaria and bacterial infections. It is plausible that using cotrimoxazole for prevention (prophylaxis) rather than just to treat infections may improve outcomes in children through reducing bacterial infections following severe anaemia.

The TRACT trial tested whether giving children Multi-vitamin Multi-mineral supplements and/or cotrimoxazole prophylaxis for three months following discharge from hospital could help improve outcomes for these children. 3983 children took part in the trial. Children with severe anaemia were randomised to receive:

Multi-vitamin Multi-mineral sprinkles or standard iron/folate supplements
Cotrimoxazole prophylaxis or no prophylaxis

By day 180, 8% of children in the Multi-vitamin Multi-mineral arm and 9% of children in the iron/folate arm had died. This difference was compatible with chance. Children in the MVMM group were no more or less likely to be readmitted to hospital than children in the iron/folate group. No differences in other outcomes were seen.

By day 180, 9% of children in the cotrimoxazole arm, and 8% of children in the no cotrimoxazole arm had died. This difference is compatible with chance. No differences in other outcomes were seen, with the exception of less malaria in children receiving cotrimoxazole, which was expected given what is known about this drug already.

These results suggest that neither Multi-vitamin Multi-mineral supplements nor cotrimoxazole prophylaxis should become standard practice for children being discharged from hospital having received treatment for severe anaemia.

A substantial proportion (17%) of children in TRACT were readmitted to hospital within 180 days. This suggests that future trials should focus on strategies to prevent the need for readmission.

Previous results from the TRACT trial looking at blood transfusion strategies did identify approaches that could reduce deaths among children with severe anaemia.

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