Chapter 13

Question 1

What are some key differences in the transfusion of blood products to neonatal and pediatric patients compared to adults?

Answer 1

Hemoglobin Concentration at Birth:

Newborns have higher hemoglobin levels (approx. 165 g/L) which increases to 184 g/L within 24 hours after birth.
Over the first three months, hemoglobin decreases to around 115 g/L.

Preterm Infants:
Preterm infants experience a more significant decrease in hemoglobin compared to term infants.
Their hemoglobin values at 2 weeks, 1 month, and 2 months are lower compared to term infants.

Question 2

Question: How does hemoglobin concentration change in neonates after birth?

Answer 2

• Newborns have a hemoglobin concentration of approximately 165 g/L, which increases to 184 g/L within 24 hours after birth.
  Over the first three months, hemoglobin decreases to around 115 g/L.
  Hemoglobin levels in children normalize to match adult levels by age 12.

Question 3

Question: How do hemoglobin levels differ between preterm and term infants?

Answer 3

• Preterm infants experience a more significant decrease in hemoglobin compared to term infants.
• Hemoglobin values at 2 weeks, 1 month, and 2 months are lower in preterm infants compared to term infants.
• At 2 weeks: Preterm infants (1.0–1.5 kg) have a mean hemoglobin level of 163 g/L, while term infants have a mean of 165 g/L.
• By 3 months, hemoglobin decreases to around 115 g/L in term infants.

Question 4

What are the difference in ranges for coagulation factor assays and screening tests in neonates compared to older children?

Answer 4

also Pr S is lower in infant

Question 6

What pre-transfusion testing is required for neonates (infants under 4 months)?

Answer 6

ABO and Rh(D) typing, antibody screen
Only red blood cell typing is performed for ABO group; reverse typing not done
ABO antibodies present after birth are maternal in origin
For non-Type O neonates with Type O mothers, test neonate’s plasma for maternal anti-A or anti-B antibodies
Blood units must be compatible with both neonate and maternal ABO and Rh(D) type

Question 7

Is the crossmatch necessary in neonates?

Answer 7

If antibody screen is negative, crossmatch may be omitted to minimize blood loss

Question 8

How often should antibody screening be repeated for neonates?

Answer 8

If the initial screen is negative, repeat screening is not required during the same hospitalization up to 4 months

Question 9

What are the unique factors that make red blood cell transfusion in neonates different from children and adults?

Answer 9

• Small blood volume
• Physiologic anemia of infancy
• Decreased endogenous erythropoietin production
• Inability to tolerate minimal physiological stress

Question 10

What are the challenges in determining when a neonate may benefit from a red blood cell transfusion?

Answer 10

• Varying hemoglobin levels and hemoglobin type (HbF vs. HbA)
• Difficulty assessing clinical indications for transfusion
• Lack of consensus on how to define significant symptoms
• Hemoglobin or hematocrit may not reflect true RBC mass in preterm/ill newborns.

Question 11

What are the general guidelines for red blood cell transfusion in neonates?

Answer 11

Acute blood loss of >10% blood volume
Hemoglobin < 80 g/L in stable newborns with symptoms of anemia (apnea, bradycardia, tachycardia, etc.)
Hemoglobin < 120 g/L in infants with respiratory distress syndrome or congenital heart disease

Question 12

What were the findings of the Premature Infants in Need of Transfusion (PINT) study regarding restrictive transfusion in preterm neonates?

Answer 12

No adverse effect on short-term mortality or morbidity in infants <1 kg
Long-term effects on neurodevelopment and cognitive delay are not yet clear

Question 13

What are the suggested transfusion thresholds for neonates with anemia of prematurity as per the Canadian Paediatric Society?

Answer 13

• 0-7 days: With respiratory support: Hb 115 g/L (Hct 35%), No respiratory support: Hb 100 g/L (Hct 30%)
• ## 8-14 days:** With respiratory support: **Hb 100 g/L (Hct 30%),
• No respiratory support: Hb 85 g/L (Hct 25%)
• 14 days: With respiratory support: Hb 85 g/L (Hct 25%),
• No respiratory support: Hb 75 g/L (Hct 23%)

Question 14

What is the usual dose of red blood cells for neonatal transfusion and its expected effect?

Answer 14

Dose: 10-20 ml/kg of body weight
Expected increase: A 15 ml/kg dose raises Hb concentration by ~20 g/L

Question 15

Why was it common practice to transfuse neonates with fresh red blood cells in the past?

Answer 15

Concerns about high plasma potassium in stored red blood cells.
Decreased levels of 2,3-DPG in stored red blood cells affecting oxygen delivery.

Question 16

Are fresh red blood cells still required for all neonatal transfusions?

Answer 16

• No, smaller volume transfusions (<20 ml/kg) over 3-4 hours do not typically require fresh blood.
• Use of aliquots from the same unit up to its normal expiry date is safe for small-volume transfusions

Question 17

How can the potassium content in stored red blood cells be managed during rapid or massive transfusions?

Answer 17

Supernatant reduction or washing of red blood cells.
Potassium filters are available if washing or reduction is not feasible.

Question 18

What strategies can limit donor exposure in neonates receiving red blood cell transfusions?

Answer 18

Transfuse only when absolutely necessary.
Use a dedicated donor unit with satellite packs or sterile docking devices for repeated transfusions.
Assign multiple transfusions to the same patient from a single unit.

Question 19

What are the components of SAGM, the additive solution used in Canada for red blood cell storage?

Answer 19

NaCl: 877 mg/100 ml
Dextrose: 900 mg/100 ml
Adenine: 16.9 mg/100 ml
Mannitol: 525 mg/100 ml

Question 20

Are small-volume transfusions (<20 ml/kg) of red blood cells stored in additive solutions safe for neonates?

Answer 20

Yes, studies and years of experience confirm that small-volume transfusions in additive solutions are safe.

Question 21

What should be done for neonates requiring massive transfusions or those with renal insufficiency?

Answer 21

It is recommended to remove the additive solution in these cases.

Question 22

What is the conclusion regarding the use of recombinant human erythropoietin (rHuEPO) in neonates with anemia of prematurity?

Answer 22

Results are controversial, and it is premature to make firm recommendations.
Erythropoietin might reduce the number of transfusions, but donor exposure can also be minimized by using a dedicated donor unit.

Question 23

How does hemoglobin concentration change in neonates after birth?

Answer 23

Newborns have a hemoglobin concentration of approximately 165 g/L, which increases to 184 g/L within 24 hours after birth.
Over the first three months, hemoglobin decreases to around 115 g/L.
Hemoglobin levels in children normalize to match adult levels by age 12.

Question 24

How do hemoglobin levels differ between preterm and term infants?

Answer 24

Preterm infants experience a more significant decrease in hemoglobin compared to term infants.
Hemoglobin values at 2 weeks, 1 month, and 2 months are lower in preterm infants compared to term infants.
At 2 weeks: Preterm infants (1.0–1.5 kg) have a mean hemoglobin level of 163 g/L, while term infants have a mean of 165 g/L.
By 3 months, hemoglobin decreases to around 115 g/L in term infants.

Question 25

PEDIATRIC recipients

What are the general guidelines for red blood cell transfusion in pediatric patients more than four months of age?

Answer 25

• Acute blood loss >15% total blood volume.
• Hemoglobin <70 g/l with symptoms of anemia.
• Significant preoperative anemia when other corrective therapy is not available.
• Hemoglobin <130 g/l on extracorporeal membrane oxygenation (ECMO).
• Chronic transfusion programs for disorders of red blood cell production (e.g., β-thalassemia major, Diamond-Blackfan syndrome).

Question 26

What are the indications for platelet transfusions in neonatal recipients?

Answer 26

Platelet transfusions are indicated to prevent or decrease bleeding associated with quantitative or qualitative platelet disorders.
A transfusion trigger of 20 x 10^9/l is used for stable term infants.
A higher trigger (30–50 x 10^9/l) is used for preterm infants or those with comorbidities.
Neonates with active bleeding or consumptive coagulopathy may require a higher platelet transfusion threshold.

Question 27

What are the general guidelines for platelet transfusions in neonates?

Answer 27

Stable patient: Platelet count < 20 x 10^9/l.
Unstable patient: Platelet count 30–50 x 10^9/l.
Infant with active bleeding or undergoing invasive procedure: Platelet count < 50 x 10^9/l.
Platelets are given in doses of 5–10 ml/kg.
Ideally, type-compatible platelets should be given.
Plasma-reduced platelet products should be used if incompatible with neonate’s red blood cells.

Question 28

What are the general guidelines for plasma transfusion in neonates and young children?

Answer 28

Replacement therapy in a bleeding patient or before invasive procedure.
When specific factor concentrates are not available (e.g., Factors II, V, X, XI, protein C or S).
PT/INR >1.5x mid-range of age-related normal value and/or PTT >1.5x top of age-related normal value in a bleeding patient or before invasive procedure.
During therapeutic plasma exchange when plasma is indicated.
Emergency reversal of warfarin (prothrombin complex concentrate preferred if available).
Plasma is given at a dose of 10–15 ml/kg, increasing factor activity by 20%.

Question 29

What are the main situations where massive transfusion is required in neonates?

Answer 29

Cardiopulmonary bypass (CPB)
Blood volume passed through circuit is 2-3 times the patient’s blood volume.
Priming with red blood cells and plasma for infants, and albumin for children.
Heparinization and activation of platelets/neutrophils and coagulation factors occur.
Extra-corporeal membrane oxygenation (ECMO)
Used for respiratory or cardiac failure.
Heparinization required, with platelet transfusions to maintain >100 x 10^9/L.
Average use: 5 days, with higher hemorrhagic complication risk.
Exchange transfusion

Question 30

What are the precautions when using gamma-irradiated and CMV-seronegative blood products in neonates?

Answer 30

Gamma-irradiated blood products:
Used to prevent transfusion-associated graft vs. host disease (TA-GVHD).
Red blood cells can be irradiated up to 28 days after collection.
Irradiated blood must be transfused no later than 14 days after irradiation.
Irradiation increases potassium accumulation, potentially problematic for neonates.
CMV-seronegative blood products:
Only necessary for intrauterine transfusions.
Leukoreduced blood products are sufficient for most neonatal transfusions.
Not needed for low birth weight neonates due to high maternal CMV seroprevalence.