What are the guidelines for transfusing placental blood in neonates?

Transfusion of Placental Blood in Neonates

Placental blood transfusion through delayed umbilical cord clamping (DCC) or umbilical cord milking (UCM) should be the standard approach for providing neonates with their own blood at birth, as it increases blood volume by approximately 30%, improves hemodynamic stability, and reduces transfusion requirements without increasing complications. 1

Mechanisms and Benefits of Placental Transfusion

Placental transfusion delivers approximately 20 mL/kg of autologous blood to the neonate, enhancing arterial oxygen content, increasing cardiac output, and improving oxygen delivery during the critical transition period. 2

For Preterm Neonates (<30 weeks GA):

• Reduces intraventricular hemorrhage (IVH) risk 3
• Decreases gastrointestinal complications including necrotizing enterocolitis (NEC) 3
• Lowers allogeneic RBC transfusion requirements by up to 30% 3
• Reduces NICU mortality by 30% 3
• Improves initial hemodynamic stability with higher mean blood pressure at 1 and 6 hours of life 4

For Term Neonates:

• Higher hemoglobin levels and reduced iron deficiency in infancy 3
• Improved myelination and neurodevelopmental outcomes at 12 months 3
• Better motor and social development at 4 years, particularly in boys 3

Recommended Techniques by Clinical Scenario

Vigorous Neonates (Standard Care):

Delayed cord clamping for 60-120 seconds is the recommended standard of care for all vigorous neonates, both term and preterm. 1, 2

Non-Vigorous Neonates Requiring Resuscitation:

For non-vigorous preterm neonates (30-35 weeks), cut umbilical cord milking (C-UCM) is an effective and safe alternative that can be performed quickly while initiating resuscitation. 4

• C-UCM technique: After cutting the cord, milk the umbilical cord 3-4 times toward the infant over 2-3 seconds per stroke 4
• Results in significantly higher hematocrit at 48 hours (50.2% vs 46.2%, p<0.0001) 4
• Improves serum ferritin at 6 weeks and stabilizes initial blood pressure 4
• No increase in complications including polycythemia, hyperbilirubinemia, or respiratory distress 4

Resuscitation with intact umbilical cord is an emerging practice that allows ventilation before cord clamping, reducing cardiovascular instability and supporting optimal organ perfusion. 3

• Requires bringing resuscitation equipment to the mother's bedside 3
• Prevents hypovolemia-associated inflammatory cascade and ischemic injury 3
• Particularly important for neonates with nuchal cord or shoulder dystocia 3

Extremely Preterm Neonates (≤28 weeks):

Avoid routine cord milking in infants ≤28 weeks gestation due to insufficient evidence of benefit and unknown safety profile. 5

Autologous Placental Blood Collection and Storage

Collecting and storing placental blood for later autologous transfusion is feasible and can eliminate the need for allogeneic transfusions in select populations. 6, 1

Target Populations Most Likely to Benefit:

• Infants with birth weight 1,000-2,000g 6
• Neonates requiring immediate surgical intervention after birth 6
• Marginally premature and full-term neonates 1

Collection and Storage Parameters:

• Approximately 20 mL/kg of placental blood can be harvested regardless of birth weight 6
• Storage for up to 35 days without aerobic or anaerobic contamination 6
• In one study, 8 of 10 infants (1,000-2,000g) and 3 of 5 surgical neonates required no allogeneic transfusions when autologous placental blood was used 6

Limitations:

• Collection is technically difficult in extremely low gestational age neonates (ELGAN), the population with highest transfusion needs 1
• Transfusion is rare in term and near-term populations where collection is most feasible 1

Physiological Advantages of Fetal Blood

Fetal hemoglobin and erythrocytes have distinct advantages over adult donor blood for neonatal transfusions. 1

• Fetal hemoglobin provides appropriate oxygen release kinetics for developing tissues, while adult hemoglobin causes excessive oxygen delivery leading to inflammatory and oxidative damage to immature lungs, brain, intestines, and retina 1
• Fetal erythrocytes are more pliable than adult RBCs, reducing risk of microvascular congestion and improving peripheral perfusion 1
• Adult RBCs have pro-inflammatory tendencies that may be particularly problematic in ELGAN 1

Integration with Restrictive Transfusion Guidelines

When allogeneic transfusions are necessary, follow restrictive transfusion thresholds based on gestational age, postnatal age, and cardiorespiratory support requirements. 1

Transfusions should be administered at 4-5 mL/kg/hour (typical 15 mL/kg dose over 2-4 hours) to prevent hemodynamic instability, volume overload, and hyperkalemia. 7

Prevention Strategies to Minimize Transfusion Needs

Beyond placental transfusion, implement comprehensive blood conservation strategies: 1

• Use umbilical cord blood for admission laboratory tests in very low birth weight neonates 1
• Minimize iatrogenic blood losses by reducing phlebotomies and using point-of-care devices with micro-methods 1
• Early iron supplementation (2-3 mg/kg) starting at 2-4 weeks of life in enterally fed preterm neonates 1
• Strict adherence to evidence-based transfusion policies 1

Note on Erythropoietin:

Routine EPO administration is NOT recommended due to lack of clear benefit, high heterogeneity in studies, and potential increased risk of retinopathy of prematurity (ROP). 1

Critical Implementation Considerations

Successful implementation requires coordinated teamwork between obstetrics, pediatrics, midwifery, and nursing with clear protocols. 3

• Preheat delivery room to 26°C and have radiant warmer ready 5
• Position resuscitation equipment at mother's bedside when intact cord resuscitation is planned 3
• Cord blood gases can still be collected with optimal cord management 3
• Monitor for potential hypovolemia in cases of nuchal cord or shoulder dystocia where placental transfusion may be compromised 3

Common Pitfalls to Avoid

• Do not assume immediate cord clamping is necessary for resuscitation—ventilation with intact cord or rapid cord milking can provide both resuscitation and blood volume restoration 3
• Avoid cord milking in extremely preterm infants ≤28 weeks until more safety data are available 5
• Do not overlook the importance of preventing hypovolemia, which can trigger inflammatory cascades leading to ischemic injury and even sudden unexpected neonatal asystole 3
• Remember that autologous placental blood collection, while beneficial, is most challenging in the ELGAN population that needs it most 1