<ns4:p><ns4:bold>Background</ns4:bold>: Provision of adequate supplies of donor blood for paediatric transfusion remains a challenge. Guidelines recommend restrictive transfusion practices, based on expert opinion. We examined whether survival among children admitted to hospital varied by admission haemoglobin status and whether this was influenced by malaria infection and/or transfusion.</ns4:p><ns4:p> <ns4:bold>Methods</ns4:bold>: A retrospective analysis in an unselected population of children admitted to a rural district hospital in Kenya over an 8-year period. We describe baseline parameters with respect to categories of anaemia and outcome (in-hospital death) with respect to haemoglobin, malaria and transfusion status.</ns4:p><ns4:p> <ns4:bold>Results</ns4:bold>: Among 29,226 admitted children, 1,143 (3.9%) had profound anaemia (Hb &lt;4g/dl) and 3,469 (11.9%) had severe anaemia (Hb 4-6g/d). In-hospital mortality was; 97/1,143 (8.5%) in those with Hb&lt;4g/dl and 164/2,326 (7.1%) in those with severe anaemia (Hb ≥4.0-&lt;6g/dl). Admission Hb &lt;3g/dl was associated with higher risk of death versus those with higher Hbs (OR=2.41 (95%CI: 1.8 - 3.24; P&lt;0.001), increasing to OR=6.36, (95%CI: 4.21–9.62; P&lt;0.001) in malaria positive children. Conversely, mortality in non-malaria admissions was unrelated to Hb level. Transfusion was associated with a non-significant improvement in outcome if Hb&lt;3g/dl (malaria-only) OR 0.72 (95%CI 0.29 - 1.78), albeit the number of cases were too few to show a statistical difference. For those with Hb levels above 4g/dl, mortality was significantly higher in those receiving a transfusion compared to the non-transfused group. For non-malarial cases, transfusion did not affect survival-status, irrespective of baseline Hb level compared to children who were not transfused at higher Hb levels.</ns4:p><ns4:p> <ns4:bold>Conclusion</ns4:bold>: Although severe and complicated anaemia is common among children admitted to hospital in sSA (~16%), our data do not indicate that outcome is improved by transfusion irrespective of malaria status. Given the limitations of observational studies, clinical trials investigating the role of transfusion in outcomes in children with severe anaemia are warranted.</ns4:p>