Low-Titer Group O Whole Blood in Pediatric Severe Bleeding
Low-titer group O whole blood (LTOWB) is safe and effective in pediatric patients with severe traumatic bleeding and should be used as part of initial hemostatic resuscitation, not reserved solely as rescue therapy.
Evidence Supporting Use in Pediatric Trauma
The most compelling recent evidence demonstrates significant survival benefit in injured children:
A 2023 prospective observational study of 80 pediatric trauma patients requiring massive transfusion (>40 mL/kg in 24 hours) showed that LTOWB administration was independently associated with improved 72-hour survival (AOR 0.23, P=0.009) and 28-day survival (AOR 0.41, P=0.02) after adjusting for age, injury severity, and physiologic derangement 1.
Survivors who received LTOWB had reduced hospital length of stay, ICU length of stay, and ventilator days compared to conventional component therapy 1.
Safety Profile in Pediatric Populations
Multiple studies confirm the safety of LTOWB in children:
A 2021 propensity-matched cohort study of 72 pediatric trauma patients found no increase in adverse events including transfusion reactions, thromboembolism, acute kidney injury, sepsis, or organ failure when comparing LTOWB to conventional components 2.
A 2024 retrospective study of 244 children <2 years undergoing cardiac surgery with cardiopulmonary bypass demonstrated that LTOWB use resulted in statistically fewer re-explorations for bleeding (p<0.001) with no differences in mortality or renal failure 3.
The safety profile extends across age groups, including infants and young children, with no clinically significant differences in adverse outcomes 3, 2.
Current Guideline Framework for Emergency Transfusion
While specific pediatric LTOWB guidelines are evolving, established transfusion principles apply:
Group O RhD negative blood should be immediately available and transfused when hemorrhage is life-threatening, with Group O RhD negative prioritized for children and women of childbearing potential 4.
Major hemorrhage protocols should result in immediate release and protocolized administration of blood components without prior approval from a hematologist 4.
In massive bleeding situations, patients have minimal circulating antibodies and will usually accept group-specific blood without reaction 4.
Clinical Application in This Case
For this 7-year-old with hemorrhagic shock (BP 67/40, HR 160, GCS 10, positive FAST):
LTOWB should be initiated immediately as part of the initial hemostatic resuscitation, not withheld as rescue therapy 1.
The child meets criteria for massive transfusion protocol activation given hemodynamic instability and positive FAST examination 4.
Group O RhD negative LTOWB is preferred for this pediatric patient 4.
Important Caveats
Common pitfall: Waiting to use LTOWB until conventional component therapy fails delays the survival benefit demonstrated in the literature. The 2023 study showed improved outcomes when LTOWB was incorporated early in resuscitation 1.
RhD considerations: While 80% of transfusion medicine directors would transfuse RhD+ LTOWB to male children, only 20% would do so for females due to future alloimmunization concerns 5. For a 7-year-old of unknown sex, RhD negative should be prioritized 4.
Ongoing research: While survey data shows 86.7% of transfusion medicine directors and 90.6% of trauma directors support randomized controlled trials of LTOWB in pediatric trauma, current observational evidence strongly supports its use 5.
Answer to Question
The correct answer is B: safe and effective. LTOWB is not contraindicated (option C is incorrect), has been studied in pediatric populations including trauma and cardiac surgery (option D is incorrect), and should not be reserved only as rescue therapy (option A is incorrect) given the survival benefit when used as part of initial resuscitation 1, 2, 3.