Red blood cell transfusions in the newborn
- Robin Ohls, MD
Robin Ohls, MD
- Professor of Pediatrics
- University of New Mexico
- Section Editors
- Donald H Mahoney, Jr, MD
Donald H Mahoney, Jr, MD
- Section Editor — Pediatric Hematology
- Professor of Pediatrics
- Baylor College of Medicine
- Joseph A Garcia-Prats, MD
Joseph A Garcia-Prats, MD
- Section Editor — Neonatology
- Professor of Pediatrics
- Baylor College of Medicine
Red blood cell (RBC) transfusion provides an immediate increase in oxygen delivery to tissues and is an effective and rapid intervention to treat acute anemia. RBC transfusions may reduce the morbidity associated with chronic anemia, such as the anemia of prematurity, and can be lifesaving in neonates with severe blood loss.
The indications for neonatal RBC transfusions and the selection of the proper blood product will be reviewed here. Anemia of prematurity and indications for red cell transfusion in infants and children are discussed separately. (See "Anemia of prematurity" and "Red blood cell transfusion in infants and children: Indications".)
Overview — Symptomatic anemia occurs when the RBC mass does not adequately meet the oxygen demands of tissues. Signs include increased resting heart rate, acidosis, poor growth, decreased energy to nipple feed, apnea, and increased need for respiratory support.
Oxygen supply to tissues is defined as the product of cardiac output and arterial oxygen content. The arterial oxygen content is dependent upon the hemoglobin concentration, arterial oxygen saturation, oxygen carrying capacity of hemoglobin (1.34 mL/gm hemoglobin), and, to a minor extent, the solubility of oxygen. Oxygen supply is increased by increasing cardiac output, arterial oxygen saturation, or hemoglobin concentration.
The indications for neonatal RBC transfusions differ based upon the rate of fall in hemoglobin (acute versus chronic anemia). The need for transfusion in an infant with acute blood loss is generally dependent upon persistent clinical signs of inadequate oxygen delivery following intravascular volume restoration. In chronic anemia, the need for RBC transfusion is, likewise, based upon clinical signs of inadequate oxygen delivery (such as increased resting heart rate, acidosis, poor growth, and apnea) and the degree of respiratory support needed by the infant. Although target hemoglobin and hematocrit (HCT) (values below which a RBC transfusion is administered) have been used as clinical indicators for RBC transfusion, it remains uncertain what target HCT or hemoglobin will optimally balance the risk and benefits of this intervention.
- Rohde JM, Dimcheff DE, Blumberg N, et al. Health care-associated infection after red blood cell transfusion: a systematic review and meta-analysis. JAMA 2014; 311:1317.
- Patel RM, Knezevic A, Shenvi N, et al. Association of Red Blood Cell Transfusion, Anemia, and Necrotizing Enterocolitis in Very Low-Birth-Weight Infants. JAMA 2016; 315:889.
- dos Santos AM, Guinsburg R, de Almeida MF, et al. Red blood cell transfusions are independently associated with intra-hospital mortality in very low birth weight preterm infants. J Pediatr 2011; 159:371.
- Baer VL, Lambert DK, Henry E, et al. Red blood cell transfusion of preterm neonates with a Grade 1 intraventricular hemorrhage is associated with extension to a Grade 3 or 4 hemorrhage. Transfusion 2011; 51:1933.
- Rashid N, Al-Sufayan F, Seshia MM, Baier RJ. Post transfusion lung injury in the neonatal population. J Perinatol 2013; 33:292.
- Shannon KM, Keith JF 3rd, Mentzer WC, et al. Recombinant human erythropoietin stimulates erythropoiesis and reduces erythrocyte transfusions in very low birth weight preterm infants. Pediatrics 1995; 95:1.
- Bell EF, Strauss RG, Widness JA, et al. Randomized trial of liberal versus restrictive guidelines for red blood cell transfusion in preterm infants. Pediatrics 2005; 115:1685.
- Kirpalani H, Whyte RK, Andersen C, et al. The Premature Infants in Need of Transfusion (PINT) study: a randomized, controlled trial of a restrictive (low) versus liberal (high) transfusion threshold for extremely low birth weight infants. J Pediatr 2006; 149:301.
- Chen HL, Tseng HI, Lu CC, et al. Effect of blood transfusions on the outcome of very low body weight preterm infants under two different transfusion criteria. Pediatr Neonatol 2009; 50:110.
- Whyte R, Kirpalani H. Low versus high haemoglobin concentration threshold for blood transfusion for preventing morbidity and mortality in very low birth weight infants. Cochrane Database Syst Rev 2011; :CD000512.
- Whyte RK, Kirpalani H, Asztalos EV, et al. Neurodevelopmental outcome of extremely low birth weight infants randomly assigned to restrictive or liberal hemoglobin thresholds for blood transfusion. Pediatrics 2009; 123:207.
- Venkatesh V, Khan R, Curley A, et al. The safety and efficacy of red cell transfusions in neonates: a systematic review of randomized controlled trials. Br J Haematol 2012; 158:370.
- McCoy TE, Conrad AL, Richman LC, et al. Neurocognitive profiles of preterm infants randomly assigned to lower or higher hematocrit thresholds for transfusion. Child Neuropsychol 2011; 17:347.
- Nopoulos PC, Conrad AL, Bell EF, et al. Long-term outcome of brain structure in premature infants: effects of liberal vs restricted red blood cell transfusions. Arch Pediatr Adolesc Med 2011; 165:443.
- Widness JA, Seward VJ, Kromer IJ, et al. Changing patterns of red blood cell transfusion in very low birth weight infants. J Pediatr 1996; 129:680.
- Maier RF, Sonntag J, Walka MM, et al. Changing practices of red blood cell transfusions in infants with birth weights less than 1000 g. J Pediatr 2000; 136:220.
- New HV, Berryman J, Bolton-Maggs PH, et al. Guidelines on transfusion for fetuses, neonates and older children. Br J Haematol 2016; 175:784.
- Keir A, Pal S, Trivella M, et al. Adverse effects of red blood cell transfusions in neonates: a systematic review and meta-analysis. Transfusion 2016.
- Goobie SM, Faraoni D, Zurakowski D, DiNardo JA. Association of Preoperative Anemia With Postoperative Mortality in Neonates. JAMA Pediatr 2016; 170:855.
- Aher SM, Ohlsson A. Late erythropoietin for preventing red blood cell transfusion in preterm and/or low birth weight infants. Cochrane Database Syst Rev 2014; :CD004868.
- Ohls RK, Christensen RD, Kamath-Rayne BD, et al. A randomized, masked, placebo-controlled study of darbepoetin alfa in preterm infants. Pediatrics 2013; 132:e119.
- Ohlsson A, Aher SM. Early erythropoietin for preventing red blood cell transfusion in preterm and/or low birth weight infants. Cochrane Database Syst Rev 2014; :CD004863.
- Alverson DC. The physiologic impact of anemia in the neonate. Clin Perinatol 1995; 22:609.
- Wardle SP, Garr R, Yoxall CW, Weindling AM. A pilot randomised controlled trial of peripheral fractional oxygen extraction to guide blood transfusions in preterm infants. Arch Dis Child Fetal Neonatal Ed 2002; 86:F22.
- Bifano EM, Smith F, Borer J. Relationship between determinants of oxygen delivery and respiratory abnormalities in preterm infants with anemia. J Pediatr 1992; 120:292.
- Bard H, Fouron JC, Chessex P, Widness JA. Myocardial, erythropoietic, and metabolic adaptations to anemia of prematurity in infants with bronchopulmonary dysplasia. J Pediatr 1998; 132:630.
- Böhler T, Janecke A, Linderkamp O. Blood transfusion in late anemia of prematurity: effect on oxygen consumption, heart rate, and weight gain in otherwise healthy infants. Infusionsther Transfusionsmed 1994; 21:376.
- Alkalay AL, Galvis S, Ferry DA, et al. Hemodynamic changes in anemic premature infants: are we allowing the hematocrits to fall too low? Pediatrics 2003; 112:838.
- Izraeli S, Ben-Sira L, Harell D, et al. Lactic acid as a predictor for erythrocyte transfusion in healthy preterm infants with anemia of prematurity. J Pediatr 1993; 122:629.
- Tschirch E, Weber B, Koehne P, et al. Vascular endothelial growth factor as marker for tissue hypoxia and transfusion need in anemic infants: a prospective clinical study. Pediatrics 2009; 123:784.
- Whyte RK, Jefferies AL, Canadian Paediatric Society, Fetus and Newborn Committee. Red blood cell transfusion in newborn infants. Paediatr Child Health 2014; 19:213.
- Bell EF. When to transfuse preterm babies. Arch Dis Child Fetal Neonatal Ed 2008; 93:F469.
- Strauss RG. How I transfuse red blood cells and platelets to infants with the anemia and thrombocytopenia of prematurity. Transfusion 2008; 48:209.
- Venkatesh V, Khan R, Curley A, et al. How we decide when a neonate needs a transfusion. Br J Haematol 2013; 160:421.
- Menitove JE. Standards for blood banks and transfusion services, 21st ed, American Association of Blood Banks, Bethesda 2002.
- Strauss RG, Burmeister LF, Johnson K, et al. Feasibility and safety of AS-3 red blood cells for neonatal transfusions. J Pediatr 2000; 136:215.
- Fernandes da Cunha DH, Nunes Dos Santos AM, Kopelman BI, et al. Transfusions of CPDA-1 red blood cells stored for up to 28 days decrease donor exposures in very low-birth-weight premature infants. Transfus Med 2005; 15:467.
- Fergusson DA, Hébert P, Hogan DL, et al. Effect of fresh red blood cell transfusions on clinical outcomes in premature, very low-birth-weight infants: the ARIPI randomized trial. JAMA 2012; 308:1443.
- Khodabux CM, von Lindern JS, van Hilten JA, et al. A clinical study on the feasibility of autologous cord blood transfusion for anemia of prematurity. Transfusion 2008; 48:1634.
- Baer VL, Lambert DK, Carroll PD, et al. Using umbilical cord blood for the initial blood tests of VLBW neonates results in higher hemoglobin and fewer RBC transfusions. J Perinatol 2013; 33:363.
- Chambers LA. Evaluation of a filter-syringe set for preparation of packed cell aliquots for neonatal transfusion. Am J Clin Pathol 1995; 104:253.
- Strauss RG, Burmeister LF, Johnson K, et al. AS-1 red cells for neonatal transfusions: a randomized trial assessing donor exposure and safety. Transfusion 1996; 36:873.
- Acute blood loss
- Chronic anemia
- - Target hemoglobin or hematocrit
- Preoperative target
- - Erythropoietin
- - Search for other transfusion markers
- Our approach
- SELECTION OF RED BLOOD CELL PRODUCTS
- Products for acute life-threatening blood loss
- Hemolytic disease of the newborn
- Red blood cells
- - Leukoreduced and irradiated red cells
- - CMV-safe red cells
- Cord blood
- SUMMARY AND RECOMMENDATIONS