Minimizing blood loss and transfusion need in premature infants

Question 1

What is the benefit of delayed cord clamping?

Answer 1

• Delayed cord clamping recommended for prem infants not in immediate need of resuscitation
• DCC decreases the risk for transfusion

Question 2

Is there any increased risk of IVH associated with cord milking?

Answer 2

• No harm or increased risk of IVH reported with cord milking
• Numbers are too small at present to make it a routine recommendation

Question 3

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

Answer 3

• SR by Whyte found that lower transfusion thresholds were associated with a modest reduction in the need for transfusion
• SR by Kirpalani reported no increased risk of death or NDI at 18-21 months with lower transfusion threshold
• Based on results of the Cochrane review and PINT study, using lower transfusion threshold is recommended

Question 4

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

Answer 4

• Transfusing a higher volume (20mL/kg instead of 15mL/kg) can decrease risk of exposure to more than one donor

Question 5

What is the relationship between ROP and EPO?

Answer 5

• EPO administered in the first week of life not associated with increased risk of ROP (all stages) but is associated with an increased risk of severe ROP
• Later use of EPO (8-28d) reduces need for transfusion with trend toward increased risk of ROP (not statistically significant)

Question 6

For which patients is EPO indicated?

Answer 6

• When parents refuse other types of blood products

- Not routinely indicated given higher risk of ROP and in light of the fact that it may not reduce donor exposure

Question 7

Does enteral Fe supplementation reduce the need for blood transfusions?

Answer 7

• No evidence of benefit for using enteral Fe to prevent or reduce need for transfusions in the neonatal period
• Supplemental Fe in physiologic doses once full PO feeds achieved improves Hb and ferritin and reduces risk of Fe deficiency anemia and poor cognitive outcomes

Question 8

Does noninvasive monitoring reduce need for transfusions?

Answer 8

• No direct evidence noninvasive monitoring reduces need for transfusion, but timely use of these devices can reduce phlebotomy which can subsequently reduce the need for transfusion

Question 9

Is there evidence to support point of care testing to reduce pRBC transfusions?

Answer 9

• Decreased number of transfusions and decreased phlebotomy losses with introduction of POC testing in one centre
• POC testing should be considered in prems if supported by the centre

Question 10

If there evidence to support in-line or other continuous monitoring?

Answer 10

• Reduces need for phlebotomy but not need for transfusion

- Requires presence of an arterial line

Question 11

Is there evidence to support limiting routine blood sampling?

Answer 11

• No standard definition of ‘routine’ bloodwork

Question 12

What are low threshold criteria for transfusion for infants in the first and second week of life?

Answer 12

• First week: Hb 100

- Second week: Hb 85

Question 13

What is the dose of iron supplementation for typical and iron deficient babies?

Answer 13

• Typical: 2-3mg/kg/day

- Iron deficient: 4-6mg/kg/day