Minimizing blood loss and the need for transfusions in very premature infants

Question 1

Does the timing of umbilical cord clamping at delivery influence the need for and frequency of PRBC transfusions?

Answer 1

1. Delay cord clamping (optimally for 30 s to180 s after birth) for preterm infants who are not in immediate need of resuscitation
2. While cord milking may be considered as an alternative to delayed cord clamping, because so few patients have been enrolled in randomized trials to date, the technique cannot be recommended as routine practice at the present time

Question 2

Does a low hemoglobin threshold for blood transfusion safely reduce the need for transfusions?

Answer 2

For infants in the first and second week of life, minimum hemoglobin levels of 100 g/L and 85 g/L, respectively, are recommended. Infants requiring respiratory support may require transfusions at a higher threshold. In view of the concerns regarding the increased risk for cognitive delay, clinicians should avoid using thresholds lower than those tested in published RCTs

Question 3

Does the volume of blood transfused reduce the need for further PRBC transfusions?

Answer 3

A higher volume of transfused blood (20 mL/kg) should be considered when transfusing a preterm baby, if the hemodynamic and respiratory status of the patient permits

Question 4

Does treatment with recombinant human erythropoietin safely reduce the need for PRBC transfusions?

Answer 4

Routine use of erythropoietin (SC, IV or PO) is not recommended. Dosage and delivery method should be individualized if parents withhold consent to transfuse blood

Question 5

Does enteral iron supplementation reduce the need for blood transfusions?

Answer 5

Supplemental iron does not appear to reduce the need for blood transfusion in preterm neonates. For treatment beyond two months of age, however, iron supplements may improve hematological values and help to avoid iron deficiency anemia. Supplementation with physiological doses (2 mg/kg/day to 3 mg/kg/day, or 4 mg/kg/day to 6 mg/kg/day in newborns who are iron deficient) should be considered

Question 6

Does the use of noninvasive monitoring in preterm infants reduce the need for transfusions?

Answer 6

1. Noninvasive CO2 monitoring should be considered when caring for ventilated preterm infants. Exercise caution in infants with significant pulmonary disease because of potential for greater inaccuracy
2. Using noninvasive bilirubin monitoring devices before phototherapy is recommended

Question 7

Is there evidence to support the use of point-of-care testing techniques for reducing PRBC transfusions?

Answer 7

Point-of-care testing should be considered in preterm infants. This strategy requires support from the institution’s biochemistry laboratory and compliance with accreditation standards

Question 8

Is there evidence to support the use of in-line or other continuous monitoring techniques for reducing PRBC transfusions?

Answer 8

Blood sampling is technically challenging in preterm infants. Venous and arterial sampling requires skill and experience. Capillary sampling requires less skill. However, no literature was available to determine whether one technique was superior to another in terms of minimizing blood loss or the need to repeat testing because of sampling difficulties.

Question 9

Is there evidence to support limiting routine blood sampling?

Answer 9

Caregivers should scrutinize and limit blood sampling to the minimum required for safe clinical care. Using marked tubes to indicate the minimum volume to collect, and clustering blood samples to reduce the number of skin breaks and painful procedures are recommended