Factors associated with complications among children and adolescents with sickle cell disease in southwestern Nigeria

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Olasinde, Olayinka R. Ibrahim, Abimbola O. Odeyemi, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7321419/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 12 You are reading this latest preprint version Abstract Background Despite Nigeria having the largest burden of sickle cell disease (SCD) globally, the spectrum of complications and associated factors remains an understudied area, with most studies focused on acute complications of vaso-occlusive crisis. Hence, we determined the spectrum of complications (acute and chronic) of sickle cell disease and the associated factors among Nigerian children and adolescents residing in southwestern Nigeria. Methods This cross-sectional descriptive study was conducted among children and adolescents with SCD in southwestern Nigeria from January 2021 to June 2022. We obtained relevant information from the caregivers and verified this from the case record files and physical examinations to identify past or present evidence of complications. Results Among the 100 children and adolescents recruited, 34 (34.0%) had at least one complication of SCD, 21 (61.8%) of whom were males. Osteomyelitis was the most common complication [20 (50.0%)] of 40 patients. The variables associated with complications were age, hospital admissions, total white blood cell count, and liver size. After adjusting for confounders, the variables associated with complications were adolescent age [adjusted odds ratio (AOR) of 7.8, 95% confidence interval (CI)] of 1.806–33.225, hepatomegaly of 2.0–5.0 cm with an AOR of 4.8 (95% CI of 1.199–18.782), and hepatomegaly greater than 5.0 cm with an AOR of 8.8 (95% CI of 1.989–38.676). Conclusions This study revealed that one-third of SCD children and adolescents experienced at least one complication, and half experienced osteomyelitis. Being an adolescent and the presence of hepatomegaly increased the odds of complications of SCD. Sickle cell disease children adolescents complications Nigeria Figures Figure 1 Figure 2 Figure 3 Introduction Sickle cell disease (SCD) is the most common inherited blood disease afflicting humans and the most important structural abnormality of the haemoglobin chain. 1 It arises from mutations in the gene encoding the β-globin chain of haemoglobin. Consequently, it leads to pathogenetic processes resulting in repeated vascular occlusion, progressive ischemia, and tissue necrosis with variable and diverse clinical manifestations and complications. 2 The complications associated with SCD remain a leading cause of morbidity and may be associated with death, especially among children under five, where as many as 4.2% of underfive deaths are due to SCD-related complications. 3 Complications in SCD children affect multiple organ systems due to chronic haemolytic anaemia, repeated vaso-occlusion with ischemia‒reperfusion injuries, or a combination of both processes. 4 Some of the well-documented complications associated with SCD include chronic pain and intermittent painful episodes, musculoskeletal problems, renal complications such as enuresis, neurologic problems such as headaches and stroke, pulmonary complications such as acute chest syndrome and pulmonary hypertension, and recurrent infections, among others. 5 , 6 These complications often coexist, affecting the quality of life of patients, and if untreated, they may lead to untimely death. In addition to this morbidity, SCD negatively affects cognitive function, mental health, and educational achievement. 7 Effective management of various complications and improved outcomes associated with SCD will include understanding its spectrum and related factors, which can be leveraged to provide targeted intervention and strengthen preventive measures and resource allocation. Given the above, we aimed to describe the spectrum of complications and associated factors among children with SCD attending a haematology clinic at a tertiary health center in southwestern Nigeria. Methods Study design and setting This cross-sectional observational study was conducted at the Paediatric Haematology Clinic of Bowen University Teaching Hospital (BUTH), Ogbomoso, southwestern Nigeria, between January 2021 and June 2022. BUTH is a 350-bed Christian missionary tertiary health facility serving as a referral centre for Ogbomoso and the surrounding communities. The Paediatric Haematology Clinic operates weekly on Wednesdays at the Paediatric Outpatient Department, providing routine care to children with sickle cell disease (SCD), including laboratory investigations, medication (such as folic acid, proguanil, and vitamin C), health education, and counselling. The study evaluated the clinical characteristics and complications among children with SCD who attended the clinic during the study period. Ethical considerations Ethical approval was obtained from the Hospital Research Ethics Committee of BUTH. Informed consent was secured from parents or caregivers, and assent was obtained from children aged seven years and above after providing detailed information about the study. The confidentiality and anonymity of the participants were strictly maintained throughout the study. Study Population, Inclusion, and Exclusion Criteria The study population consisted of children and adolescents with a confirmed diagnosis of SCD (genotypes HBSS or HBSC) attending the Paediatric Haematology Clinic during the study period. The inclusion criteria were as follows: Confirmed SCD diagnosis (HBSS or HBSC) Attendance at the Paediatric Haematology Clinic within the study timeframe The exclusion criteria were as follows: Children with an unknown or unconfirmed SCD genotype Sample size determination and sampling technique We estimated the minimum sample using the Daniel equation for cross-sectional studies, N = Z 2 P(1-P) ÷ d 2 , where N is the calculated sample size, the Z value for 95% CI (1.96), P is the prevalence from another study and d is the margin of error taken as 0.05. Using a prevalence of chronic complications (leg ulcers) of 6.5% in a previous Nigerian study 8 , we obtained a minimum sample of 93, which was rounded to 100. A consecutive sample of eligible children attending the clinic was employed until the sample size was reached. Definitions Hepatic complications : Sickle cell-related liver disorders such as hepatic sequestration, hepato-biliary stones, and liver abscess. Renal complications : Pyelonephritis, chronic kidney disease, or nephrotic syndrome. Stroke : Acute neurological events due to cerebral vessel occlusion or hemorrhage confirmed by CT or MRI. Acute Chest Syndrome (ACS) : Acute illness with fever, respiratory symptoms, and new pulmonary infiltrates on chest X-ray. Avascular Necrosis (AVN) : Osteonecrosis of the femoral or humeral head confirmed radiographically. Priapism : Sustained, painful penile erection. Leg ulcer : Ulceration of the skin and underlying tissue on the lower extremities. Osteomyelitis : Clinical signs of bone infection with radiological evidence. Data collection methods Sociodemographic data and past medical history data were collected through interviews with parents, caregivers, or the child (if possible). The information collected included age at diagnosis, health events, and occurrence of complications related to SCD. Each participant underwent a thorough physical examination to identify evidence of past or present complications such as hemiplegia, stunting, digital clubbing, and leg ulcers, among others. Data Management and Statistical Analysis The data were entered and analysed via IBM SPSS version 25.0 for Windows. Continuous variables such as age are presented as medians and interquartile ranges, whereas categorical variables are presented as frequencies and percentages. Socioeconomic status was classified according to Oyedeji’s social classification into high (classes I & II), middle (class III), and low (classes IV & V) socioeconomic classes. The prevalence of SCD complications was expressed as the percentage of children who had developed complications at any point in their lifetime. Chi-square tests and Fisher’s exact tests were used to compare clinical and laboratory variables between children with and without complications. Variables significant in the bivariate analysis, along with age and sex, were included in a binary logistic regression model to identify factors independently associated with the development of complications. The results are reported as adjusted odds ratios with 95% confidence intervals. Statistical significance was set at a p value < 0.05. Results General characteristics of the study participants The median (interquartile range) age was 9 (6.0–13.0) years, and the majority were males (59%). Most mothers of the children had at least a primary level of education (86%). Additionally, most of the children were in the middle class (48%), as shown in Table 1 . Table 1 Sociodemographic characteristics of children and adolescents with sickle cell anaemia Variable Frequency Percent Age [years] Median (Interquartile range) 9.0 (6.0 to 13.0) Sex Female 41 41.0 Male 59 59.0 Mothers’ educational level No formal education 4 4.0 Primary 17 17.0 Secondary 40 40.0 Tertiary 39 39.0 Fathers’ educational level No formal education 6 6.0 Primary 7 7.0 Secondary 50 50.0 Tertiary 37 37.0 Socioeconomic class Lower class 26 26.0 Middle class 48 48.0 Tertiary 26 26.0 Prevalence of complications among the study participants. During the study period, 34 (34.0%) children and adolescents developed various complications of SCD (Fig. 1 ). Furthermore, six children and adolescents experienced two complications, while the remainder experienced a single complication. Cumulatively, osteomyelitis was the most common complication, occurring in 20 out of 40 patients, whereas the least common complication was hepatopathy (Fig. 3 ). Factors associated with complications among the study participants In the present study, the variables associated with the development of complications included age, hospital admissions, total white blood cell count, and liver size (Tables 2 a and 2 b). Table 2 a: Clinical and laboratory factors associated with complications among children and adolescents with SCA. Variables Total n = 100 (%) Complications (34) No complications (66) ꭓ2 p Age (year) 0 to 5 19 (19.0) 4 15 6.517 0.038 6-<10 34 (34.0) 8 26 10–18 47 (47.0) 22 34 Sex Male 59 (59.0) 21 38 0.163 0.687 Female 41 (41.0) 13 28 Maternal educ. No formal educ. 4 (4.0) 1 3 0.340 f 0.986 Primary 17 (17.0) 6 11 Secondary 40 (40.0) 13 27 Tertiary 39 (39.0) 14 25 Fathers’ educ No formal educ. 6 2 4 1.611 f 0.718 Primary 7 1 6 Secondary 50 19 31 Tertiary 37 12 25 SEC Upper 26 (26.0) 8 18 0.504 f 0.764 Middle 48 (48.0) 18 30 Lower 26 (26.0) 8 18 NHIS access Yes 13 (13.0) 4 9 0.070 f 0.792 No 87 (87.0) 30 57 Hb genotype SS 90 (90.0) 32 58 0.970 f 0.487 SC 10 (10.0) 2 8 Age at diagnosis* 5 24 (24.0) 6 18 Medications Hydroxyurea Yes 2 2 0 3.962 f 0.113 No 98 32 66 Routine drugs Yes 83 29 54 0.192 f 0.783 No 17 5 12 Educ.-education; SEC-Socioeconomic class; NHIS-National Health Insurance Scheme; Hb-haemoglobin; U-Mann‒Whitney U test; f-Fischer exact test Table 2 b: Clinical and laboratory factors associated with complications among children and adolescents with SCA. Variables Total n = 100 (%) Complications (34) No complications (66) ꭓ2 p No of hosp. admissions * 0 61 15 46 8.695 f 0.022 1 31 14 17 2–3 6 3 3 > 3 2 2 0 Clinic visits * 0 15 6 9 2.867 f 0.422 1 12 3 9 2–3 44 18 26 > 3 29 7 22 Malaria episodes * 0 18 5 13 0.878 f 0.380 1 33 13 20 2–3 41 13 28 > 3 8 3 5 WBC (per mm 3 ) ≤ 15,000 59 15 44 4.717 0.030 > 15,000 41 19 22 PCV (%) ≥ 24 60 21 39 0.550 f 1.000 18–23 39 13 26 < 18 1 0 1 Splenic size (cm) 10.0 4 0 4 Liver size (cm) 5.0 cm 28 15 13 Hosp.-hospital. *-number in the past year; PCV-Packed cell volume; WBC-white blood cell count; U-Mann‒Whitney U test, f-Fischer exact test, ꭓ2- Chi‒square test After adjusting for confounders, the variables that were associated with the occurrence of complications were age 10–18 years, with an adjusted odds ratio (AOR) of 7.8 (95% confidence interval [CI] of 1.806–33.225; liver size of 2.0–5.0 cm, with an AOR of 4.8 (95% CI of 1.199–18.782); and liver size of greater than 5.0 cm, with an AOR of 8.8, 95% CI of 1.989–38.676), as shown in Table 3 . Table 3 Binary logistic regression of factors associated with complications among children and adolescents with SCA Variable Subgroup n = 34(%) beta coefficient adjusted odds ratio 95% CI p Age (years) 0 to 5 4 (11.8) 1 6-<10 8 (23.5) 0.162 1.176 0.275, 5.040 0.827 10–18 22(64.7) 2.047 7.746 1.806, 33.225 0.006 Sex Female 13(38.2) Male 21(61.8) -0.102 0.903 0.321, 2.540 0.846 No of hosp. admissions * 0 to 1 29(85.3) 2 or more 5 (14.7) 1.580 4.855 0.906, 26.025 0.065 WBC (per mm 3 ) ≤ 15,000 15(44.1) > 15,000 19(55.9) 0.571 1.770 0.625, 5.012 0.283 Liver size (cm) 5.0 cm 15(44.1) 2.171 8.771 1.989, 38.676 0.004 *-Number in the past year; WBC-white blood cell count; CI-confidence interval Discussion SCD-related complications remain a significant burden among children living with this clinical condition. This study revealed that one in three children and adolescents in our cohort had at least one form of complication, with a spectrum similar to that reported in Nigeria. 8 , 9 Most of the children with complications in our cohort had osteomyelitis, which is an infectious bone complication observed in SCD. Bone complications have consistently been identified as common manifestations of sickle cell disease (SCD). 8 , 9 In contrast, research from Portugal reported a notably lower prevalence, with only 2.4% of patients experiencing osteomyelitis. 10 This variation may be explained by differences in genetic factors and environmental exposures that influence disease severity, as well as disparities in early diagnosis and preventive care strategies, which are more widely implemented in high-income countries, leading to a reduced incidence of complications. 11 , 12 Bone-related complications are well recognised features of people living with sickle cell disease and may include bone marrow necrosis, bone infarcts, osteomyelitis, septic arthritis, and aseptic necrosis. 13 , 14 The main mechanism of sickle cell bone disease is bone marrow hyperplasia from haemolytic anaemia, resulting in thinning of the cortex of bones and intravascular sickling, leading to stasis, hypoxia, and necrosis. 14 Children are particularly predisposed to osteomyelitis due to impaired immune function and functional asplenia, increasing the risk of bacterial sepsis and infection of the bone. 15 Chronic leg ulcers, septic arthritis, and avascular necrosis are other bone diseases associated with SCD, as reported in our study. Our study revealed that the incidence of acute chest syndrome (ACS) among children with sickle cell disease is similar to the prevalence reported in Nigeria 16 , 17 but lower than that reported in Tanzanian children. 18 This difference may be influenced by Tanzania’s increasing recognition of the public health significance of SCD and the recent introduction of targeted interventions and specialised SCD programs, which may have improved access to SCD care and contributed to higher reported incidence rates of acute chest syndrome than those reported in Nigeria. 19 Acute chest syndrome (ACS) is a potentially fatal pulmonary complication of sickle cell disease and has been reported by earlier authors. 8 , 10 , 16 The higher incidence observed in some settings, 20 particularly in high-income countries, likely reflects better access to advanced diagnostic facilities and comprehensive health insurance coverage, which facilitate timely diagnosis and treatment. For example, France reported a significant decline in paediatric ACS incidence following the introduction of the pneumococcal conjugate vaccine (PCV-13), which was specifically targeted at children with SCD, over two decades ago. 21 In contrast, limited healthcare access, financial constraints, and underdiagnosis in our environment may lead to underreporting of ACS cases, as many patients may not reach medical facilities before their eventual death, further contributing to the apparent lower incidence. The incidence of cerebrovascular accident (CVA) in this study, 11.7%, is considerably higher than that previously reported in a study among children in the same region. 16 Meta-analytic findings across sub-Saharan Africa report a pooled paediatric stroke incidence that ranges from 2.9–16.9%, with an average of approximately 4.2%. 22,23 A hospital-based study of Ugandan children with SCD also reported a stroke prevalence of 6.8%. 24 In high-income countries, paediatric stroke incidence is generally lower, ranging between 3% and 5%. 25,26 These discrepancies likely reflect differences in access to diagnostic modalities such as magnetic resonance imaging (MRI) and transcranial Doppler ultrasound (TCD), the availability of preventive strategies, including routine TCD screening, chronic transfusion programs, and the use of hydroxyurea. The absence of routine TCD screening at our center for children and adolescents with SCD may partly explain the higher stroke incidence observed in this study. TCD is widely recognised as the single most effective tool for primary stroke prevention in SCD, as it allows for early identification of children with elevated cerebral blood flow velocities who are at increased risk of stroke. 27 Stroke remains a fatal neurologic complication of SCD; other neurologic complications in children, including headaches, seizures, transient ischemic attack (TIA), posterior reversible encephalopathy (PRES), moyamoya syndrome, silent cerebral infarcts, cognitive impairment, and neuropathic pain, have been reported. 28 , 29 Priapism and hepatopathy were the least reported complications in our cohort, which aligns with previous reports that the incidences of both priapism and hepatopathy increase with age. 8 , 30 Dey et al 30 reported that hepatobiliary involvement, including hepatopathy, becomes more prominent in older children and adults with sickle cell disease, likely because of progressive organ damage over time. Similarly, Isa et al 8 reported that clinical manifestations such as priapism are more common in adolescents and adults, providing a plausible explanation for the low prevalence of these complications in our study. While hepatopathy was among the least frequently reported complications in our cohort, our analysis after adjusting for confounders revealed that both age and liver size (hepatomegaly) were significantly associated with SCD complications. Compared with children aged five years and younger, the adolescents (aged 10 to 18 years) in this study were 7.8 times more likely to experience complications. This probably reflects the fact that among our study population, adolescents have lived longer with the disease, thus experiencing a greater impact of the disease as well as the accumulation of its various complications. 9 , 18 The presence of hepatomegaly in patients with chronic complications of SCD is likely due to various pathological changes in the liver, most of which result in an enlarged liver. These complications include hepatic sequestration of red cells, intrahepatic cholestasis, sinusoidal dilation, obstruction caused by sickle cells, chronic liver disease, and iron overload. 30 Each of these conditions typically manifests as hepatomegaly. This observation highlights the importance of closely monitoring children and adolescents with hepatomegaly, especially those with other complications associated with SCD. Study Limitations While this study employed a cross-sectional approach with corroboration of information provided by the parents with case records, a few of the responses by the parents/caregivers may have some biased recall. Additionally, the children and adolescents were not followed, especially those without complications, which would have allowed us to evaluate various complications that may have developed. Conclusion Our study corroborates the fact that SCD is a complex disease associated with various complications, with one-third of children and adolescents experiencing complications. The findings from our study highlight the importance of a comprehensive approach to managing SCD in paediatric patients, including early detection, regular monitoring, and tailored interventions to address specific complications. Care should be taken via a multidisciplinary approach with the paediatrician as the coordinator to optimise the quality of life for children with SCD. Abbreviations ACS-Acute Chest Syndrome. AVN- vascular Necrosis BUTH: Bowen University Teaching Hospital HB-Hemoglobin SCD- Sickle cell disease SCA-Sickle cell anaemia TCD-transcranial Doppler ultrasound Declarations Ethics approval and consent to participate This study was approved by the Bowen University Teaching Hospital Human Ethical Research Committee. Informed consent was secured from parents or caregivers, and assent was obtained from children aged seven years and above after providing detailed information about the study. The confidentiality and anonymity of the participants were strictly maintained throughout the study, and the data were kept with absolute confidentiality. Clinical trial number Not applicable. Consent for publication Not applicable Availability of data and materials The dataset used and/or analysed during the current study is available from the corresponding author upon reasonable request. Competing interests ORI is an editor/editorial member of BMC Pediatrics. The other coauthors have none to declare. Funding This research has no external grants or financial support. It was self-sponsored by the authors Authors' contributions YTO contributed to conceptualisation, data curation, formal analysis, and manuscript drafting and approved the final version of the manuscript. ORI was involved in conceptualisation, data curation, formal analysis, and manuscript drafting and approved the final manuscript. AOO contributed to data curation, formal analysis, and manuscript drafting and approved the final manuscript. AO participated in the conceptualisation, data curation, formal analysis, and manuscript drafting and approved the final manuscript. ATA was involved in data curation, formal analysis, and manuscript drafting and approved the final manuscript. VOA contributed to data curation, formal analysis, and manuscript drafting and approved the final manuscript. JIO contributed to data curation, formal analysis, and manuscript drafting and approved the final manuscript. Acknowledgements Many thanks to the children (and their parents) who attended the paediatric SCD clinic of BUTH for participating in this study. References Kumar V, Abbas AK, Fausto N, Aster JC. The anaemias. In: Kumar V, Abbas AK, Fausto N, Aster JC, eds. Pathologic Basis of Diseases . 8th ed. Philadelphia: Saunders; 2010:619-661. Quinn CT. Minireview: Clinical severity in sickle cell disease: the challenges of definition and prognostication. Exp Biol Med . 2016;241(7):679-688. doi:10.1177/1535370216640385 Nnodu OE, Oron AP, Sopekan A, Akaba GO, Piel FB, Chao DL. Child mortality from sickle cell disease in Nigeria: a model-estimated, population-level analysis of data from the 2018 Demographic and Health Survey. Lancet Haematol . 2021;8(10):e723-e731. doi:10.1016/S2352-3026(21)00216-7 Beck CE, Trottier ED, Kirby-Allen M, Pastore Y. 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Neurosci Lett . 2019;706:201-206. doi:10.1016/j.neulet.2019.04.030 Dey A, Malpani P, Channa U. Study of spectrum of hepatobiliary involvement in children with sickle cell disease. Asian J Med Sci . 2023;14(10):221-226. Additional Declarations Competing interest reported. Olayinka Rasheed Ibrahim (ORI) is an editor/editorial member of BMC Pediatrics. The other coauthors have none to declare. 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Olasinde","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2UlEQVRIiWNgGAWjYLCChAobHn4GBjYStDw4kyYj2UCKFsaHbYdtDA4Qq8XgeI/hg8S2wzzGN5KfPfhQwSDPL3aAgJYzZ4wNEs6l85jdSDM3nHGGwXDm7AQCWm7kmEkklFkDtSSYSfO2MSQY3Cak5f4b8x8JbMw8xjPSvxGp5QaPGUNCmzOPgUQOkbZInkkrlkg4k8YjceZNmeSMMxKE/cJ3/PDGjz8qbOz529O3SXyosJHnlyagReEAhwGEJQBWKYFfOQjIN7A/gLD4DxBWPQpGwSgYBSMTAAAfNkV/JW+ZeAAAAABJRU5ErkJggg==","orcid":"","institution":"Bowen University Iwo/Bowen University Teaching Hospital","correspondingAuthor":true,"prefix":"","firstName":"Yetunde","middleName":"T.","lastName":"Olasinde","suffix":""},{"id":511259855,"identity":"35d571af-fb64-477e-8ffb-495d144e0539","order_by":1,"name":"Olayinka R. Ibrahim","email":"","orcid":"","institution":"University of Global Health Equity","correspondingAuthor":false,"prefix":"","firstName":"Olayinka","middleName":"R.","lastName":"Ibrahim","suffix":""},{"id":511259856,"identity":"ff75369f-edfd-421c-9689-1ea56d4ba666","order_by":2,"name":"Abimbola O. Odeyemi","email":"","orcid":"","institution":"Osun State University, Uniosun Teaching Hospital","correspondingAuthor":false,"prefix":"","firstName":"Abimbola","middleName":"O.","lastName":"Odeyemi","suffix":""},{"id":511259857,"identity":"2e0e97ae-310b-4135-b2de-2b39b811ca9c","order_by":3,"name":"Adeola Olasinde","email":"","orcid":"","institution":"Kwara State University Teaching Hospital","correspondingAuthor":false,"prefix":"","firstName":"Adeola","middleName":"","lastName":"Olasinde","suffix":""},{"id":511259858,"identity":"3dcb036c-f00e-4e74-a885-916d0c2be1ea","order_by":4,"name":"Ademola T. Abolarin","email":"","orcid":"","institution":"Bowen University Iwo/Bowen University Teaching Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ademola","middleName":"T.","lastName":"Abolarin","suffix":""},{"id":511259859,"identity":"0cd12958-af35-495e-97d9-35cf42ab765a","order_by":5,"name":"Victor O. Adeagbo","email":"","orcid":"","institution":"Bowen University","correspondingAuthor":false,"prefix":"","firstName":"Victor","middleName":"O.","lastName":"Adeagbo","suffix":""},{"id":511259860,"identity":"f3ebec46-02a8-4e7b-97b2-ffeb76d1c272","order_by":6,"name":"James I. Owolabi","email":"","orcid":"","institution":"Bowen University","correspondingAuthor":false,"prefix":"","firstName":"James","middleName":"I.","lastName":"Owolabi","suffix":""}],"badges":[],"createdAt":"2025-08-07 18:53:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7321419/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7321419/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":91076841,"identity":"1fb9c86f-f4ec-4afc-b068-bad9e3ae3f2f","added_by":"auto","created_at":"2025-09-11 11:12:36","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":201124,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePrevalence of complications among children and adolescents with SCA\u003c/strong\u003e Most of the 34 children and adolescents were in the 10- to 18-year age group, and most were males (21; 61.8%) (Figure 2).\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7321419/v1/f78d6cfbef046eb2c7d0ff1a.png"},{"id":91074840,"identity":"2723b86d-1501-4bf8-b4fd-bd0b69c28f21","added_by":"auto","created_at":"2025-09-11 11:04:36","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":189114,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eAge and sex distributions of complications among the study children and adolescents with SCA.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7321419/v1/e6a3dd27f8562adad2615eb6.png"},{"id":91074836,"identity":"c3a0cea6-2dce-4123-befc-76f0c0fdd6b5","added_by":"auto","created_at":"2025-09-11 11:04:36","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":100257,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eDistribution of various complications among children and adolescents with SCA.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7321419/v1/d843c5c10fd3bbe2f7201968.png"},{"id":91078644,"identity":"23f5bd92-2f02-4d30-bdc8-d401d2319ec8","added_by":"auto","created_at":"2025-09-11 11:20:37","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2210843,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7321419/v1/cd55f1d5-d9eb-4010-8a78-fe6877520e56.pdf"}],"financialInterests":"Competing interest reported. Olayinka Rasheed Ibrahim (ORI) is an editor/editorial member of BMC Pediatrics. The other coauthors have none to declare.","formattedTitle":"Factors associated with complications among children and adolescents with sickle cell disease in southwestern Nigeria","fulltext":[{"header":"Introduction","content":"\u003cp\u003eSickle cell disease (SCD) is the most common inherited blood disease afflicting humans and the most important structural abnormality of the haemoglobin chain.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e It arises from mutations in the gene encoding the β-globin chain of haemoglobin. Consequently, it leads to pathogenetic processes resulting in repeated vascular occlusion, progressive ischemia, and tissue necrosis with variable and diverse clinical manifestations and complications.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e The complications associated with SCD remain a leading cause of morbidity and may be associated with death, especially among children under five, where as many as 4.2% of underfive deaths are due to SCD-related complications.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eComplications in SCD children affect multiple organ systems due to chronic haemolytic anaemia, repeated vaso-occlusion with ischemia‒reperfusion injuries, or a combination of both processes.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e Some of the well-documented complications associated with SCD include chronic pain and intermittent painful episodes, musculoskeletal problems, renal complications such as enuresis, neurologic problems such as headaches and stroke, pulmonary complications such as acute chest syndrome and pulmonary hypertension, and recurrent infections, among others.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e These complications often coexist, affecting the quality of life of patients, and if untreated, they may lead to untimely death. In addition to this morbidity, SCD negatively affects cognitive function, mental health, and educational achievement.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eEffective management of various complications and improved outcomes associated with SCD will include understanding its spectrum and related factors, which can be leveraged to provide targeted intervention and strengthen preventive measures and resource allocation. Given the above, we aimed to describe the spectrum of complications and associated factors among children with SCD attending a haematology clinic at a tertiary health center in southwestern Nigeria.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy design and setting\u003c/h2\u003e\u003cp\u003eThis cross-sectional observational study was conducted at the Paediatric Haematology Clinic of Bowen University Teaching Hospital (BUTH), Ogbomoso, southwestern Nigeria, between January 2021 and June 2022. BUTH is a 350-bed Christian missionary tertiary health facility serving as a referral centre for Ogbomoso and the surrounding communities. The Paediatric Haematology Clinic operates weekly on Wednesdays at the Paediatric Outpatient Department, providing routine care to children with sickle cell disease (SCD), including laboratory investigations, medication (such as folic acid, proguanil, and vitamin C), health education, and counselling.\u003c/p\u003e\u003cp\u003eThe study evaluated the clinical characteristics and complications among children with SCD who attended the clinic during the study period.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eEthical considerations\u003c/h3\u003e\n\u003cp\u003eEthical approval was obtained from the Hospital Research Ethics Committee of BUTH. Informed consent was secured from parents or caregivers, and assent was obtained from children aged seven years and above after providing detailed information about the study. The confidentiality and anonymity of the participants were strictly maintained throughout the study.\u003c/p\u003e\u003c/p\u003e\n\u003ch3\u003eStudy Population, Inclusion, and Exclusion Criteria\u003c/h3\u003e\n\u003cp\u003eThe study population consisted of children and adolescents with a confirmed diagnosis of SCD (genotypes HBSS or HBSC) attending the Paediatric Haematology Clinic during the study period. The inclusion criteria were as follows:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eConfirmed SCD diagnosis (HBSS or HBSC)\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eAttendance at the Paediatric Haematology Clinic within the study timeframe\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eThe exclusion criteria were as follows:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eChildren with an unknown or unconfirmed SCD genotype\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\n\u003ch3\u003eSample size determination and sampling technique\u003c/h3\u003e\n\u003cp\u003eWe estimated the minimum sample using the Daniel equation for cross-sectional studies, N\u0026thinsp;=\u0026thinsp;Z\u003csup\u003e2\u003c/sup\u003eP(1-P)\u0026thinsp;\u0026divide;\u0026thinsp;d\u003csup\u003e2\u003c/sup\u003e, where N is the calculated sample size, the Z value for 95% CI (1.96), P is the prevalence from another study and d is the margin of error taken as 0.05. Using a prevalence of chronic complications (leg ulcers) of 6.5% in a previous Nigerian study\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e, we obtained a minimum sample of 93, which was rounded to 100.\u003c/p\u003e\u003cp\u003eA consecutive sample of eligible children attending the clinic was employed until the sample size was reached.\u003c/p\u003e\n\u003ch3\u003eDefinitions\u003c/h3\u003e\n\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eHepatic complications\u003c/b\u003e: Sickle cell-related liver disorders such as hepatic sequestration, hepato-biliary stones, and liver abscess.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eRenal complications\u003c/b\u003e: Pyelonephritis, chronic kidney disease, or nephrotic syndrome.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eStroke\u003c/b\u003e: Acute neurological events due to cerebral vessel occlusion or hemorrhage confirmed by CT or MRI.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eAcute Chest Syndrome (ACS)\u003c/b\u003e: Acute illness with fever, respiratory symptoms, and new pulmonary infiltrates on chest X-ray.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eAvascular Necrosis (AVN)\u003c/b\u003e: Osteonecrosis of the femoral or humeral head confirmed radiographically.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003ePriapism\u003c/b\u003e: Sustained, painful penile erection.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eLeg ulcer\u003c/b\u003e: Ulceration of the skin and underlying tissue on the lower extremities.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eOsteomyelitis\u003c/b\u003e: Clinical signs of bone infection with radiological evidence.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eData collection methods\u003c/h2\u003e\u003cp\u003eSociodemographic data and past medical history data were collected through interviews with parents, caregivers, or the child (if possible). The information collected included age at diagnosis, health events, and occurrence of complications related to SCD. Each participant underwent a thorough physical examination to identify evidence of past or present complications such as hemiplegia, stunting, digital clubbing, and leg ulcers, among others.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eData Management and Statistical Analysis\u003c/h3\u003e\n\u003cp\u003eThe data were entered and analysed via IBM SPSS version 25.0 for Windows. Continuous variables such as age are presented as medians and interquartile ranges, whereas categorical variables are presented as frequencies and percentages. Socioeconomic status was classified according to Oyedeji\u0026rsquo;s social classification into high (classes I \u0026amp; II), middle (class III), and low (classes IV \u0026amp; V) socioeconomic classes. The prevalence of SCD complications was expressed as the percentage of children who had developed complications at any point in their lifetime. Chi-square tests and Fisher\u0026rsquo;s exact tests were used to compare clinical and laboratory variables between children with and without complications. Variables significant in the bivariate analysis, along with age and sex, were included in a binary logistic regression model to identify factors independently associated with the development of complications. The results are reported as adjusted odds ratios with 95% confidence intervals. Statistical significance was set at a p value\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eGeneral characteristics of the study participants\u003c/h2\u003e\u003cp\u003eThe median (interquartile range) age was 9 (6.0\u0026ndash;13.0) years, and the majority were males (59%). Most mothers of the children had at least a primary level of education (86%). Additionally, most of the children were in the middle class (48%), as shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eSociodemographic characteristics of children and adolescents with sickle cell anaemia\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFrequency\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePercent\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge [years]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMedian (Interquartile range)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9.0 (6.0 to 13.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSex\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e41\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e41.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e59\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e59.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMothers\u0026rsquo; educational level\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo formal education\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrimary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e17.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSecondary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e40.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTertiary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e39.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFathers\u0026rsquo; educational level\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo formal education\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e6.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrimary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e7.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSecondary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e50.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTertiary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e37\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e37.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSocioeconomic class\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLower class\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e26.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMiddle class\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e48\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e48.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTertiary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e26.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003ePrevalence of complications among the study participants.\u003c/b\u003e\u003c/p\u003e\u003cp\u003eDuring the study period, 34 (34.0%) children and adolescents developed various complications of SCD (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eFurthermore, six children and adolescents experienced two complications, while the remainder experienced a single complication. Cumulatively, osteomyelitis was the most common complication, occurring in 20 out of 40 patients, whereas the least common complication was hepatopathy (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eFactors associated with complications among the study participants\u003c/h2\u003e\u003cp\u003eIn the present study, the variables associated with the development of complications included age, hospital admissions, total white blood cell count, and liver size (Tables\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e2\u003c/span\u003ea and \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e2\u003c/span\u003eb).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ea: Clinical and laboratory factors associated with complications among children and adolescents with SCA.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariables\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003cp\u003en\u0026thinsp;=\u0026thinsp;100 (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eComplications\u003c/p\u003e\u003cp\u003e(34)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNo complications (66)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eꭓ2\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge (year)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e0 to 5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e19 (19.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e6.517\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e0.038\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6-\u0026lt;10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e34 (34.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e10\u0026ndash;18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e47 (47.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e59 (59.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.163\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.687\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e41 (41.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMaternal educ.\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo formal educ.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 (4.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.340\u003csup\u003ef\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.986\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrimary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e17 (17.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSecondary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e40 (40.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTertiary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e39 (39.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eFathers\u0026rsquo; educ\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo formal educ.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.611\u003csup\u003ef\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.718\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrimary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSecondary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTertiary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e37\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSEC\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUpper\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e26 (26.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.504\u003csup\u003ef\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.764\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMiddle\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e48 (48.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLower\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e26 (26.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eNHIS access\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e13 (13.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.070\u003csup\u003ef\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.792\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e87 (87.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e57\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eHb genotype\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e90 (90.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e58\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.970\u003csup\u003ef\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.487\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSC\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10 (10.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAge at diagnosis*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u003c/b\u003e\u0026thinsp;1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e29 (29.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.165\u003csup\u003ef\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.563\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003e1 to 5\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e47 (47.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003e\u0026gt;\u0026thinsp;5\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e24 (24.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMedications\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eHydroxyurea\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3.962\u003csup\u003ef\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e0.113\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e98\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e66\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eRoutine drugs\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e83\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.192\u003csup\u003ef\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.783\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eEduc.-education; SEC-Socioeconomic class; NHIS-National Health Insurance Scheme; Hb-haemoglobin; U-Mann‒Whitney U test; f-Fischer exact test\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eb: Clinical and laboratory factors associated with complications among children and adolescents with SCA.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariables\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTotal n\u0026thinsp;=\u0026thinsp;100 (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eComplications\u003c/p\u003e\u003cp\u003e(34)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNo complications (66)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eꭓ2\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eNo of hosp. admissions\u003c/b\u003e*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e61\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e46\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e8.695\u003csup\u003ef\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e0.022\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u0026ndash;3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eClinic visits\u003c/b\u003e*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2.867\u003csup\u003ef\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.422\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u0026ndash;3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMalaria episodes\u003c/b\u003e*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.878\u003csup\u003ef\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.380\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u0026ndash;3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e41\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eWBC (per mm\u003c/b\u003e\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026le;\u0026thinsp;15,000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e59\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4.717\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e0.030\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;15,000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e41\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePCV (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026ge;\u0026thinsp;24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e60\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.550\u003csup\u003ef\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1.000\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e18\u0026ndash;23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSplenic size (cm)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;5.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e94\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e61\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2.340\u003csup\u003ef\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.384\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5.0 to 10.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;10.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eLiver size (cm)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;2.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e8.124\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e0.017\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2.0 to 5.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;5.0 cm\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eHosp.-hospital. *-number in the past year; PCV-Packed cell volume; WBC-white blood cell count; U-Mann‒Whitney U test, f-Fischer exact test, \u003cb\u003eꭓ2-\u003c/b\u003eChi‒square test\u003c/p\u003e\u003cp\u003eAfter adjusting for confounders, the variables that were associated with the occurrence of complications were age 10\u0026ndash;18 years, with an adjusted odds ratio (AOR) of 7.8 (95% confidence interval [CI] of 1.806\u0026ndash;33.225; liver size of 2.0\u0026ndash;5.0 cm, with an AOR of 4.8 (95% CI of 1.199\u0026ndash;18.782); and liver size of greater than 5.0 cm, with an AOR of 8.8, 95% CI of 1.989\u0026ndash;38.676), as shown in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eBinary logistic regression of factors associated with complications among children and adolescents with SCA\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSubgroup\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003en\u003c/p\u003e\u003cp\u003e=\u0026thinsp;34(%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ebeta coefficient\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eadjusted odds ratio\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e95% CI\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003eAge (years)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0 to 5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4 (11.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6-\u0026lt;10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e8 (23.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.162\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.176\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.275, 5.040\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.827\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10\u0026ndash;18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e22(64.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2.047\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e7.746\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1.806, 33.225\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e0.006\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e13(38.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e21(61.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-0.102\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.903\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.321, 2.540\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.846\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eNo of hosp. admissions\u003c/b\u003e*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0 to 1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e29(85.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 or more\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e5 (14.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1.580\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4.855\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.906, 26.025\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.065\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eWBC (per mm\u003c/b\u003e\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026le;\u0026thinsp;15,000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e15(44.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;15,000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e19(55.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.571\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.770\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.625, 5.012\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.283\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003eLiver size (cm)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;2.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e5 (14.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.0 to 5.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e14(41.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1.557\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4.746\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1.199, 18.782\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e0.026\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;5.0 cm\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e15(44.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2.171\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e8.771\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1.989, 38.676\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e0.004\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"7\"\u003e*-Number in the past year; WBC-white blood cell count; CI-confidence interval\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eSCD-related complications remain a significant burden among children living with this clinical condition. This study revealed that one in three children and adolescents in our cohort had at least one form of complication, with a spectrum similar to that reported in Nigeria.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e Most of the children with complications in our cohort had osteomyelitis, which is an infectious bone complication observed in SCD. Bone complications have consistently been identified as common manifestations of sickle cell disease (SCD).\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e In contrast, research from Portugal reported a notably lower prevalence, with only 2.4% of patients experiencing osteomyelitis.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e This variation may be explained by differences in genetic factors and environmental exposures that influence disease severity, as well as disparities in early diagnosis and preventive care strategies, which are more widely implemented in high-income countries, leading to a reduced incidence of complications.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e,\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e Bone-related complications are well recognised features of people living with sickle cell disease and may include bone marrow necrosis, bone infarcts, osteomyelitis, septic arthritis, and aseptic necrosis.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e The main mechanism of sickle cell bone disease is bone marrow hyperplasia from haemolytic anaemia, resulting in thinning of the cortex of bones and intravascular sickling, leading to stasis, hypoxia, and necrosis.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e Children are particularly predisposed to osteomyelitis due to impaired immune function and functional asplenia, increasing the risk of bacterial sepsis and infection of the bone.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e Chronic leg ulcers, septic arthritis, and avascular necrosis are other bone diseases associated with SCD, as reported in our study.\u003c/p\u003e\u003cp\u003eOur study revealed that the incidence of acute chest syndrome (ACS) among children with sickle cell disease is similar to the prevalence reported in Nigeria\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e but lower than that reported in Tanzanian children.\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e This difference may be influenced by Tanzania\u0026rsquo;s increasing recognition of the public health significance of SCD and the recent introduction of targeted interventions and specialised SCD programs, which may have improved access to SCD care and contributed to higher reported incidence rates of acute chest syndrome than those reported in Nigeria.\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e Acute chest syndrome (ACS) is a potentially fatal pulmonary complication of sickle cell disease and has been reported by earlier authors.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e The higher incidence observed in some settings,\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e particularly in high-income countries, likely reflects better access to advanced diagnostic facilities and comprehensive health insurance coverage, which facilitate timely diagnosis and treatment. For example, France reported a significant decline in paediatric ACS incidence following the introduction of the pneumococcal conjugate vaccine (PCV-13), which was specifically targeted at children with SCD, over two decades ago.\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e In contrast, limited healthcare access, financial constraints, and underdiagnosis in our environment may lead to underreporting of ACS cases, as many patients may not reach medical facilities before their eventual death, further contributing to the apparent lower incidence.\u003c/p\u003e\u003cp\u003eThe incidence of cerebrovascular accident (CVA) in this study, 11.7%, is considerably higher than that previously reported in a study among children in the same region.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e Meta-analytic findings across sub-Saharan Africa report a pooled paediatric stroke incidence that ranges from 2.9\u0026ndash;16.9%, with an average of approximately 4.2%.\u003csup\u003e22,23\u003c/sup\u003e A hospital-based study of Ugandan children with SCD also reported a stroke prevalence of 6.8%.\u003csup\u003e24\u003c/sup\u003e In high-income countries, paediatric stroke incidence is generally lower, ranging between 3% and 5%.\u003csup\u003e25,26\u003c/sup\u003e These discrepancies likely reflect differences in access to diagnostic modalities such as magnetic resonance imaging (MRI) and transcranial Doppler ultrasound (TCD), the availability of preventive strategies, including routine TCD screening, chronic transfusion programs, and the use of hydroxyurea.\u003c/p\u003e\u003cp\u003eThe absence of routine TCD screening at our center for children and adolescents with SCD may partly explain the higher stroke incidence observed in this study. TCD is widely recognised as the single most effective tool for primary stroke prevention in SCD, as it allows for early identification of children with elevated cerebral blood flow velocities who are at increased risk of stroke.\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e Stroke remains a fatal neurologic complication of SCD; other neurologic complications in children, including headaches, seizures, transient ischemic attack (TIA), posterior reversible encephalopathy (PRES), moyamoya syndrome, silent cerebral infarcts, cognitive impairment, and neuropathic pain, have been reported.\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e,\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003ePriapism and hepatopathy were the least reported complications in our cohort, which aligns with previous reports that the incidences of both priapism and hepatopathy increase with age.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e Dey et al\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e reported that hepatobiliary involvement, including hepatopathy, becomes more prominent in older children and adults with sickle cell disease, likely because of progressive organ damage over time. Similarly, Isa et al\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e reported that clinical manifestations such as priapism are more common in adolescents and adults, providing a plausible explanation for the low prevalence of these complications in our study.\u003c/p\u003e\u003cp\u003eWhile hepatopathy was among the least frequently reported complications in our cohort, our analysis after adjusting for confounders revealed that both age and liver size (hepatomegaly) were significantly associated with SCD complications. Compared with children aged five years and younger, the adolescents (aged 10 to 18 years) in this study were 7.8 times more likely to experience complications. This probably reflects the fact that among our study population, adolescents have lived longer with the disease, thus experiencing a greater impact of the disease as well as the accumulation of its various complications.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e The presence of hepatomegaly in patients with chronic complications of SCD is likely due to various pathological changes in the liver, most of which result in an enlarged liver. These complications include hepatic sequestration of red cells, intrahepatic cholestasis, sinusoidal dilation, obstruction caused by sickle cells, chronic liver disease, and iron overload.\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e Each of these conditions typically manifests as hepatomegaly. This observation highlights the importance of closely monitoring children and adolescents with hepatomegaly, especially those with other complications associated with SCD.\u003c/p\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eStudy Limitations\u003c/h2\u003e\u003cp\u003e While this study employed a cross-sectional approach with corroboration of information provided by the parents with case records, a few of the responses by the parents/caregivers may have some biased recall. Additionally, the children and adolescents were not followed, especially those without complications, which would have allowed us to evaluate various complications that may have developed.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eOur study corroborates the fact that SCD is a complex disease associated with various complications, with one-third of children and adolescents experiencing complications. The findings from our study highlight the importance of a comprehensive approach to managing SCD in paediatric patients, including early detection, regular monitoring, and tailored interventions to address specific complications. Care should be taken via a multidisciplinary approach with the paediatrician as the coordinator to optimise the quality of life for children with SCD.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eACS-Acute Chest Syndrome.\u003c/p\u003e\n\u003cp\u003eAVN- vascular Necrosis\u003c/p\u003e\n\u003cp\u003eBUTH: Bowen University Teaching Hospital\u003c/p\u003e\n\u003cp\u003eHB-Hemoglobin\u003c/p\u003e\n\u003cp\u003eSCD- Sickle cell disease\u003c/p\u003e\n\u003cp\u003eSCA-Sickle cell anaemia\u003c/p\u003e\n\u003cp\u003eTCD-transcranial Doppler ultrasound\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Bowen University Teaching Hospital Human Ethical Research Committee. Informed consent was secured from parents or caregivers, and assent was obtained from children aged seven years and above after providing detailed information about the study. The confidentiality and anonymity of the participants were strictly maintained throughout the study, and the data were kept with absolute confidentiality.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe dataset used and/or analysed during the current study is available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eORI is an editor/editorial member of BMC Pediatrics. The other coauthors have none to declare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research has no external grants or financial support. It was self-sponsored by the authors\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eYTO contributed to conceptualisation, data curation, formal analysis, and manuscript drafting and approved the final version of the manuscript. ORI was involved in conceptualisation, data curation, formal analysis, and manuscript drafting and approved the final manuscript. AOO contributed to data curation, formal analysis, and manuscript drafting and approved the final manuscript. AO participated in the conceptualisation, data curation, formal analysis, and manuscript drafting and approved the final manuscript. ATA was involved in data curation, formal analysis, and manuscript drafting and approved the final manuscript. VOA contributed to data curation, formal analysis, and manuscript drafting and approved the final manuscript. JIO contributed to data curation, formal analysis, and manuscript drafting and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMany thanks to the children (and their parents) who attended the paediatric SCD clinic of BUTH for participating in this study.\u003cbr\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eKumar V, Abbas AK, Fausto N, Aster JC. The anaemias. In: Kumar V, Abbas AK, Fausto N, Aster JC, eds. \u003cem\u003ePathologic Basis of Diseases\u003c/em\u003e. 8th ed. Philadelphia: Saunders; 2010:619-661.\u003c/li\u003e\n\u003cli\u003eQuinn CT. Minireview: Clinical severity in sickle cell disease: the challenges of definition and prognostication. \u003cem\u003eExp Biol Med\u003c/em\u003e. 2016;241(7):679-688. doi:10.1177/1535370216640385\u003c/li\u003e\n\u003cli\u003eNnodu OE, Oron AP, Sopekan A, Akaba GO, Piel FB, Chao DL. Child mortality from sickle cell disease in Nigeria: a model-estimated, population-level analysis of data from the 2018 Demographic and Health Survey. \u003cem\u003eLancet Haematol\u003c/em\u003e. 2021;8(10):e723-e731. doi:10.1016/S2352-3026(21)00216-7\u003c/li\u003e\n\u003cli\u003eBeck CE, Trottier ED, Kirby-Allen M, Pastore Y. Acute complications in children with sickle cell disease: Prevention and management - a position statement by the Canadian Paediatric Society. \u003cem\u003ePaediatr Child Health\u003c/em\u003e. 2022;27(1):50-55.\u003c/li\u003e\n\u003cli\u003eKehinde MO, Temiye EO, Danesi MA. Neurological Complications of Sickle Cell Anemia in Nigerian Africans -A Case-Control Study. \u003cem\u003eJ Natl Med Assoc\u003c/em\u003e. 2008;100(4):394-400. doi:10.1016/S0027-9684(15)31271-2\u003c/li\u003e\n\u003cli\u003eOni OO, Odeyemi AO, Olasinde YT, et al. Pulmonary hypertension and left ventricular geometric types in sickle cell anemia. \u003cem\u003eAm J Cardiol\u003c/em\u003e. 2023;203:175-183. doi:10.1016/J.AMJCARD.2023.06.100\u003c/li\u003e\n\u003cli\u003eLee S, Lucas S, Proudman D, Nellesen D, Paulose J, Sheehan VA. Burden of central nervous system complications in sickle cell disease : A systematic review and meta-analysis. \u003cem\u003ePaediatr Blood Cancer\u003c/em\u003e. 2022;69:e29493.\u003c/li\u003e\n\u003cli\u003eIsa H, Adegoke S, Madu A, et al. Sickle Cell Disease Clinical Phenotypes in Nigeria: A Preliminary Analysis of the Sickle Pan Africa Research Consortium Nigeria Database HHS Public Access. \u003cem\u003eBlood Cells Mol Dis\u003c/em\u003e. 2020;84:102438. doi:10.1016/j.bcmd.2020.102438\u003c/li\u003e\n\u003cli\u003eAkaba K, Nwogoh B, Obanife H, Essien O, Epoke E. Prevalence of chronic complications in adult sickle cell anemia Patients in a tertiary hospital in South-South Nigeria. \u003cem\u003eNiger J Med\u003c/em\u003e. 2020;29:665-669.\u003c/li\u003e\n\u003cli\u003eLage J, Monteiro B, Costa A, Mendes IF, Ferreira T, Loureiro HC. Acute Complications of Sickle Cell Disease in Children Under 5 Years at a Level II Hospital. \u003cem\u003eGlob Pediatr Heal\u003c/em\u003e. 2022;9. doi:10.1177/2333794X221141356\u003c/li\u003e\n\u003cli\u003eTebbi CK. Sickle Cell Disease, a Review. \u003cem\u003eHemato\u003c/em\u003e. 2022;3(2):341-366. doi:10.3390/HEMATO3020024\u003c/li\u003e\n\u003cli\u003eScourfield LEA, Nardo-Marino A, Williams TN, Rees DC. Infections in sickle cell disease. \u003cem\u003eHaematologica\u003c/em\u003e. 2025;110(3):546-561. doi:10.3324/HAEMATOL.2024.285066\u003c/li\u003e\n\u003cli\u003eSmith JA. Bone disorders in sickle cell disease. \u003cem\u003eHematol Oncol Clin North Am\u003c/em\u003e. 1996;10(6):1345-1356. doi:10.1016/S0889-8588(05)70405-6\u003c/li\u003e\n\u003cli\u003eGiordano P, Urbano F, Lassandro G, Faienza MF. Mechanisms of bone impairment in sickle bone disease. \u003cem\u003eInt J Environ Res Public Health\u003c/em\u003e. 2021;18(4):1832. doi:10.3390/ijerph18041832\u003c/li\u003e\n\u003cli\u003eAcute and chronic bone complications of sickle cell disease - UpToDate. https://www.uptodate.com/contents/acute-and-chronic-bone-complications-of-sickle-cell-disease. Accessed March 20, 2024.\u003c/li\u003e\n\u003cli\u003eAdegoke S, Adeodu O, Adekile A. Sickle cell disease clinical phenotypes in children from South‑Western, Nigeria. \u003cem\u003eNiger J Clin Pract\u003c/em\u003e. 2015;18(1):95-101.\u003c/li\u003e\n\u003cli\u003eIragbogie IA, Maimuna YO, Hayatu A, Dalhat AS, Musa IK. Clinical profile of paediatric sickle cell disease at a reference hospital in North\u0026ndash;eastern Nigeria. \u003cem\u003eNiger J Paediatr\u003c/em\u003e. 2021;48(2):74-81.\u003c/li\u003e\n\u003cli\u003eSaidi H, Smart LR, Kamugisha E, et al. Complications of sickle cell anaemia in children in Northwestern Tanzania. \u003cem\u003eHematology\u003c/em\u003e. 2016;21(4):247-256. doi:10.1080/10245332.2015.1101976\u003c/li\u003e\n\u003cli\u003eBukini D, Rifai A, Kanza C, et al. Strengthening advanced therapy for sickle cell disease in Africa: experience from sickle cell disease centre in Dar es Salaam, Tanzania. \u003cem\u003eBMJ Glob Heal\u003c/em\u003e. 2025;10(1):e017878. doi:10.1136/BMJGH-2024-017878\u003c/li\u003e\n\u003cli\u003eHonsel V, Khimoud D, Ranque B, et al. Comparison between adult patients with sickle cell disease of Sub-Saharan African origin born in metropolitan France and in Sub-Saharan Africa. \u003cem\u003eJ Clin Med\u003c/em\u003e. 2019;8(12):2173.\u003c/li\u003e\n\u003cli\u003eAssad Z, Michel M, Valtuille Z, et al. Incidence of Acute Chest Syndrome in Children With Sickle Cell Disease Following Implementation of the 13-Valent Pneumococcal Conjugate Vaccine in France. \u003cem\u003eJAMA Netw Open\u003c/em\u003e. 2022;5(8):e2225141. doi:10.1001/JAMANETWORKOPEN.2022.25141\u003c/li\u003e\n\u003cli\u003eNoubiap JJ, Mengnjo MK, Nicastro N, Kamtchum-Tatuene J. Neurologic complications of sickle cell disease in Africa A systematic review and meta-analysis. \u003cem\u003eNeurology\u003c/em\u003e. 2017;8(14):1516-1524.\u003c/li\u003e\n\u003cli\u003eMarks LJ, Munube D, Kasirye P, et al. Stroke Prevalence in Children With Sickle Cell Disease in Sub-Saharan Africa: A Systematic Review and Meta-Analysis. \u003cem\u003eGlob Pediatr Heal\u003c/em\u003e. 2018;5. doi:10.1177/2333794X18774970,\u003c/li\u003e\n\u003cli\u003eMunube D, Katabira E, Ndeezi G, et al. Prevalence of stroke in children admitted with sickle cell anaemia to Mulago Hospital. \u003cem\u003eBMC Neurol\u003c/em\u003e. 2016;16(1). doi:10.1186/S12883-016-0704-2,\u003c/li\u003e\n\u003cli\u003eGargot J, Parriault MC, Adenis A, et al. Low Stroke Risk in Children With Sickle Cell Disease in French Guiana: A Retrospective Cohort Study. \u003cem\u003eFront Med\u003c/em\u003e. 2022;9:851918. doi:10.3389/FMED.2022.851918\u003c/li\u003e\n\u003cli\u003eKunz JB, Lobitz S, Grosse R, et al. Sickle cell disease in Germany: Results from a national registry. \u003cem\u003ePediatr Blood Cancer\u003c/em\u003e. 2020;67(4). doi:10.1002/PBC.28130,\u003c/li\u003e\n\u003cli\u003eDeBaun MR, Kirkham FJ. Central nervous system complications and management in sickle cell disease. \u003cem\u003eBlood\u003c/em\u003e. 2016;127(7):829-838.\u003c/li\u003e\n\u003cli\u003eBasuni ZT, Monagel DA, Taha A, Ahmed N, Ahmed A. Neurological abnormalities among pediatric patients with sickle cell disease in Saudi Arabia: a single center retrospective study. \u003cem\u003eFront Paediatr\u003c/em\u003e. 2024;11:1290314.\u003c/li\u003e\n\u003cli\u003eGaladanci AA, Debaun MR, Galadanci NA. Neurologic complications in children under five years with sickle cell disease. \u003cem\u003eNeurosci Lett\u003c/em\u003e. 2019;706:201-206. doi:10.1016/j.neulet.2019.04.030\u003c/li\u003e\n\u003cli\u003eDey A, Malpani P, Channa U. Study of spectrum of hepatobiliary involvement in children with sickle cell disease. \u003cem\u003eAsian J Med Sci\u003c/em\u003e. 2023;14(10):221-226.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Sickle cell disease, children, adolescents, complications, Nigeria","lastPublishedDoi":"10.21203/rs.3.rs-7321419/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7321419/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eDespite Nigeria having the largest burden of sickle cell disease (SCD) globally, the spectrum of complications and associated factors remains an understudied area, with most studies focused on acute complications of vaso-occlusive crisis. Hence, we determined the spectrum of complications (acute and chronic) of sickle cell disease and the associated factors among Nigerian children and adolescents residing in southwestern Nigeria.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eThis cross-sectional descriptive study was conducted among children and adolescents with SCD in southwestern Nigeria from January 2021 to June 2022. We obtained relevant information from the caregivers and verified this from the case record files and physical examinations to identify past or present evidence of complications.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eAmong the 100 children and adolescents recruited, 34 (34.0%) had at least one complication of SCD, 21 (61.8%) of whom were males. Osteomyelitis was the most common complication [20 (50.0%)] of 40 patients. The variables associated with complications were age, hospital admissions, total white blood cell count, and liver size. After adjusting for confounders, the variables associated with complications were adolescent age [adjusted odds ratio (AOR) of 7.8, 95% confidence interval (CI)] of 1.806\u0026ndash;33.225, hepatomegaly of 2.0\u0026ndash;5.0 cm with an AOR of 4.8 (95% CI of 1.199\u0026ndash;18.782), and hepatomegaly greater than 5.0 cm with an AOR of 8.8 (95% CI of 1.989\u0026ndash;38.676).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eThis study revealed that one-third of SCD children and adolescents experienced at least one complication, and half experienced osteomyelitis. Being an adolescent and the presence of hepatomegaly increased the odds of complications of SCD.\u003c/p\u003e","manuscriptTitle":"Factors associated with complications among children and adolescents with sickle cell disease in southwestern Nigeria","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-11 11:04:31","doi":"10.21203/rs.3.rs-7321419/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-22T04:05:00+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-05T14:57:42+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-15T14:59:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"273558567332812304618299346611163409330","date":"2025-09-12T12:16:21+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"274703978529135807875125487800900993996","date":"2025-09-11T08:11:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"123350729519811302705454358082495616752","date":"2025-09-10T14:55:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"150430720081423723297552900321178649009","date":"2025-09-06T09:20:54+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-04T06:53:06+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-08-13T17:35:32+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-13T06:09:47+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-13T06:08:04+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pediatrics","date":"2025-08-07T18:40:27+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"258cb6e1-4e26-463f-8d33-ef8aa1a37b5d","owner":[],"postedDate":"September 11th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-05T21:08:05+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-11 11:04:31","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7321419","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7321419","identity":"rs-7321419","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}