What are the requirements for a blood transfusion to a neonate?

Requirements for Blood Transfusion in Neonates

Blood transfusions in neonates should follow restrictive transfusion strategies with specific hemoglobin thresholds based on the infant's clinical status, particularly for preterm neonates born at less than 30 weeks' gestation. 1

Transfusion Volume and Dosing Requirements

• Blood should be prescribed in volume (mL) rather than units for all pediatric patients 1, 2
• Red blood cell transfusion dosing: 10 mL/kg (expected to increase hemoglobin by approximately 20 g/L) 1, 2
• Other blood components should be dosed as follows:
  • Fresh Frozen Plasma: 10-15 mL/kg
  • Platelets: 10-20 mL/kg
  • Cryoprecipitate: 5-10 mL/kg
  • Fibrinogen concentrate: 70 mg/kg (maximum 2g) 1

Hemoglobin Thresholds for Transfusion

For preterm neonates (<30 weeks' gestation), the following restrictive transfusion thresholds are recommended 1:

1. Higher level of illness severity (requiring mechanical ventilation, CPAP, non-invasive positive pressure ventilation, or nasal cannula flow ≥1 L/min):

   • Postnatal age 1-7 days: Hemoglobin <11 g/dL (110 g/L)
   • Postnatal age 8-14 days: Hemoglobin <10 g/dL (100 g/L)
   • Postnatal age >14 days: Hemoglobin <8.5 g/dL (85 g/L)

2. Lower level of illness severity (not requiring respiratory support as defined above):

   • Postnatal age 1-7 days: Hemoglobin <10 g/dL (100 g/L)
   • Postnatal age 8-14 days: Hemoglobin <8.5 g/dL (85 g/L)
   • Postnatal age >14 days: Hemoglobin <7 g/dL (70 g/L)

Product Specifications

• Neonates should receive blood components specifically designated for neonatal use 1, 2
• Cytomegalovirus (CMV)-negative blood components should be used for all neonates 1, 2
• Blood should be as fresh as possible for neonatal transfusions to minimize metabolic complications

Parental Consent Requirements

• Parents should be properly informed about the complexity of neonatal transfusion medicine, including known benefits and remaining uncertainties 1
• Parental views and preferences should be considered in the decision-making process 1
• Documented informed consent should be obtained before transfusion whenever possible (except in emergencies)

Monitoring Requirements

During transfusion:

• Continuous monitoring of vital signs (heart rate, respiratory rate, blood pressure, oxygen saturation)
• Temperature monitoring to prevent hypothermia
• Monitoring for signs of transfusion reactions
• Calcium levels should be monitored during massive transfusion 2

Special Considerations

• Blood draws should be minimized to prevent iatrogenic anemia, with recommended maximum withdrawal of 3-5 mL 2
• Consolidate laboratory tests whenever possible to reduce blood draws 2
• Use appropriate collection tubes (microvettes or pediatric tubes) for smaller children 2
• Consider closed-system blood sampling to eliminate discard volumes, particularly for central lines 2
• Calculate cumulative blood loss and monitor for iatrogenic anemia 2

Common Pitfalls and Caveats

1. Overestimating blood volume: Blood volume varies by age, with term neonates having 85-100 mL/kg compared to older children (70-75 mL/kg). Using adult values for neonates can lead to inadequate resuscitation 2.

2. Inappropriate transfusion thresholds: Historically, transfusion decisions were based on clinical signs like tachycardia, tachypnea, or poor feeding, which have been shown to be unreliable indicators of the need for transfusion 3.

3. Unnecessary transfusions: The most recent evidence supports restrictive transfusion strategies, as liberal strategies have not demonstrated improved outcomes 1.

4. Failure to consider long-term outcomes: While short-term outcomes have been well-studied, long-term neurodevelopmental outcomes of different transfusion strategies are still being investigated 1.

5. Inadequate product specifications: Product specifications were not reported in detail in many RCTs and may not be considered by clinicians prescribing transfusions 1.

The evidence for neonatal transfusion practices continues to evolve, and these recommendations may need to be updated as new data become available, particularly regarding long-term neurodevelopmental outcomes 1, 4.