Latest CPS Position on Reducing Neonatal Transfusions
I cannot provide the latest Canadian Paediatric Society (CPS) position statement on reducing transfusions in neonates because no CPS guideline is included in the evidence provided. The available evidence consists of international guidelines from JAMA Network Open (2024) and Blood Reviews (2025), but these are not CPS publications 1.
What the Most Recent International Guidelines Recommend
Restrictive Transfusion Strategy for Very Preterm Neonates
The 2024 JAMA Network Open international consensus guideline recommends a restrictive RBC transfusion strategy for preterm neonates <30 weeks' gestation, with moderate certainty of evidence 1.
Specific Hemoglobin Thresholds
The recommended hemoglobin thresholds are stratified by postnatal age and respiratory support needs 1:
For neonates on respiratory support:
For neonates on no or minimal respiratory support:
Evidence Supporting Restrictive Approach
The guideline development process incorporated data from the two largest randomized controlled trials (TOP and ETTNO trials, published 2020) comparing high versus low transfusion thresholds 1. These trials demonstrated that restrictive transfusion thresholds likely had little to no difference in important short-term and long-term outcomes, including mortality and neurodevelopmental impairment 1.
Clinical Implementation Considerations
The steering committee acknowledges that clinical status, comorbid conditions, and parental values and preferences should be considered in decision-making 1. However, the recommendation remains conditional based on moderate certainty of evidence, meaning the restrictive approach should be the default strategy 1.
Blood Conservation Strategies Beyond Transfusion Thresholds
Patient Blood Management Approaches
Minimize iatrogenic blood loss by limiting unnecessary blood sampling, which is a major contributor to anemia in preterm neonates 1.
Delayed cord clamping should be implemented as a blood conservation strategy to prevent iatrogenic anemia 1.
Iron supplementation is recognized as an important component of patient blood management in neonates 1.
Transfusion Administration Standards
When transfusions are necessary, the recommended initial rate for infants and neonates is 4-5 mL/kg/hour, with slower rates for patients with reduced cardiac output 2. Standard transfusion volumes range between 10-20 mL/kg, typically given over 2-4 hours 2.
Important Caveats
Uncertainty Regarding Long-Term Outcomes
Long-term follow-up data at school age are not yet available from the major trials, and iron-deficiency anemia in infancy is associated with subtle cognitive, behavioral, and processing deficits that may become more evident later in life 1. The recommendations will need updating when these long-term outcome data are published 1.
Transfusion-Related Risks in Neonates
Neonates face higher transfusion complication rates compared to older populations, with adverse reaction rates of 37/100,000 RBC units in infants <12 months versus 13/100,000 in adults 1. Specific concerns include associations with intraventricular hemorrhage, bronchopulmonary dysplasia, retinopathy of prematurity, and necrotizing enterocolitis 1.
Product Specifications
All cellular blood products for neonates should be leukoreduced and irradiated to reduce risks of transfusion-transmitted cytomegalovirus infection and transfusion-associated graft-versus-host disease 3.
Emerging Research Areas
Autologous and allogeneic umbilical cord blood transfusions are being investigated as alternatives to adult RBC transfusions, with the hypothesis that preserving fetal hemoglobin may reduce inflammatory and oxidative damage to developing organs 1. However, these approaches remain investigational and are not yet standard practice 1.