When is albumin (human albumin) transfusion recommended in neonates?

When to Transfuse Albumin in a Neonate

Albumin transfusion is NOT recommended for routine use in neonates, including for volume replacement, respiratory distress, or correction of low serum albumin levels.

Primary Recommendations Against Albumin Use

The most recent 2024 International Collaboration for Transfusion Medicine Guidelines explicitly advises against albumin in neonatal populations across multiple clinical scenarios 1:

Preterm Neonates with Respiratory Distress

• Do not use albumin in preterm neonates (≤36 weeks) with respiratory distress and low serum albumin levels to improve respiratory function 1
• This is a conditional recommendation with very low certainty of evidence 1
• No mortality benefit or improvement in clinically important outcomes has been demonstrated 2, 3

Volume Replacement in Preterm Neonates

• Do not use albumin for volume replacement in preterm neonates (≤32 weeks or ≤1,500g) with or without hypoperfusion 1, 4
• This applies regardless of whether the infant has signs of shock 1
• Eight studies comparing albumin to alternatives in the first 3 days of life showed no benefit 2

Hypotension Management

• Crystalloid solutions are first-line for volume expansion and resuscitation in hypotensive neonates 1, 2
• A single RCT of 63 hypotensive preterm neonates found no difference in mortality (RR 1.36; 95% CI 0.69-2.66), chronic lung disease, or intraventricular hemorrhage between albumin and saline 1
• The wide confidence intervals indicate insufficient power to detect meaningful differences 1

Critical Clinical Pitfalls

Low Albumin is NOT a Treatment Target

• Never administer albumin simply to "correct" a low albumin level 4, 5
• Hypoalbuminemia is a marker of illness severity, not a therapeutic target 4, 5
• Albumin infusion does not improve outcomes when given solely for low serum levels 4, 6

Safety Concerns

• The FEAST trial in 3,141 children demonstrated excess mortality with albumin bolus strategy (RR 1.45; 95% CI 1.10-1.92) compared to no bolus in febrile illness with hypoperfusion 2
• Potential adverse effects include fluid overload, pulmonary edema (especially if infused >2 mL/min), hypotension, hemodilution requiring RBC transfusion, and anaphylaxis 4
• In patients with increased capillary permeability, albumin supplementation often leads to greater albumin leakage, contributing to edema without outcome improvement 6

Rare Exceptions Where Albumin May Be Considered

After Crystalloid Failure

• Albumin may be indicated for hypovolemia only after crystalloid infusion has failed 6
• This should be a rare occurrence in neonatal practice 6

Acute Hemorrhagic Shock

• In acute hemorrhagic shock, albumin may be used with crystalloids when blood products are not immediately available 6
• This is a temporizing measure until appropriate blood products arrive 6

Ongoing Albumin Losses with Normal Capillary Permeability

• In patients with acute or continuing losses of albumin AND normal capillary permeability (such as persistent thoracostomy tube drainage), albumin supplementation may prevent hypoalbuminemia 6
• This has not been systematically studied in neonates 6

Practical Algorithm for Decision-Making

Step 1: Neonate requires volume resuscitation

• Use isotonic crystalloid (normal saline) as first-line 1, 2

Step 2: Inadequate response to crystalloid

• Reassess clinical status and consider blood products if hemorrhage 6
• Consider albumin only if crystalloid has definitively failed AND blood products unavailable 6

Step 3: Hypoalbuminemia identified on laboratory testing

• Do not treat the number 4, 5
• Focus on treating underlying disease process 5, 6
• Increase nutritional protein intake when appropriate 5

Step 4: Respiratory distress with low albumin

• Do not use albumin 1, 2
• Treat respiratory distress with evidence-based respiratory support 1

Cost and Resource Considerations

• Albumin 20% costs approximately $130 per 25g, substantially more expensive than crystalloids without proven superiority 2, 4
• Of 14 guideline recommendations, 12 recommend against albumin use in common clinical scenarios 4
• Albumin is a scarce resource that should be reserved for proven indications 3

Strength of Evidence

The evidence against routine albumin use in neonates is consistent across multiple high-quality guidelines 1, 2, 4. While the certainty of evidence is rated as "very low" due to limited neonatal-specific trials, the consistent lack of benefit combined with potential harms and high cost supports the strong recommendation against routine use 1, 3. The 2024 ICTMG guidelines represent the most current synthesis of available evidence and should guide clinical practice 1.