Products / Services

Paediatric Transfusion Products

The field of transfusion medicine for children shares most of the same principles as that of adults but it has distinctive features which need separate consideration. Those children who require blood products are also among the most intensively transfused of all patients. Because they are likely to have a long lifespan following transfusion, minimising adverse events is of great importance.

For the purpose of these guidelines, neonates are considered to be infants within 4 weeks of the normal gestational age (40 weeks) and infants are children within the first year of life.

1. Intra-uterine Transfusion (IUT)

This should only be done by specialised units. It is most commonly indicated for correction of foetal anaemia caused by red cell allo-immunisation. Intra-uterine platelet transfusions are rarely indicated and are essentially used only to correct foetal thrombocytopenia caused by platelet allo-immunisation. However, the use of intravenous immunoglobulin in mothers with allo-immunisation has largely replaced foetal platelet transfusions.

Red cell products for intra-uterine transfusions are specially prepared by the blood transfusion service on request by the clinician. They are usually group 0, Rh-D negative (preferably also Kell negative), crossmatch compatible with maternal serum, < 5 days old, leucocyte depleted and irradiated.

2. Neonatal Transfusion

a. Exchange Transfusion

Exchange transfusion may be used to manage severe anaemia at birth and to treat severe hyperbilirubinaemia, usually caused by haemolytic disease of the newborn (HDN). The aim in exchange transfusion is to remove Rh-D positive red cells, reduce bilirubin levels and remove maternally derived anti-D. The bilirubin level at which an exchange transfusion is indicated varies according to the weight and gestational age of the baby and the South African Neonatal Academic Hospitals' Consensus Guidelines should be followed. (S Afr Med J 2006;96: 819-¬824). The early administration of intravenous immunoglobulin (1 g/kg) to Coombs positive infants with neonatal jaundice significantly reduces the level of exchange transfusions for hyperbilirubinaemia.

The red cell component used for exchange transfusion varies nationally and internationally. Some centres use unmodified whole blood while others plasma reduce whole blood to a haematocrit of 0.5-0.6 l/l. Some centres, particularly in the USA, reconstitute red cell concentrates with fresh frozen plasma but it increases donor exposure and is not recommended. The unit should be group 0 (or ABO compatible with maternal and neonatal plasma), Rh-D negative, crossmatch compatible with maternal plasma, < 5 days old, irradiated (must be transfused within 24 hours of irradiation) and leucocyte-depleted. It should not be transfused directly from cold storage and should be warmed during the procedure with care taken to avoid overheating. In normal term infants the routine use of calcium gluconate is unnecessary. However, in sick, preterm neonates monitoring of ionized calcium is advisable.

b. Small volume red cell transfusions

Most neonatal transfusions are small volume (10-20 ml/kg). It should be noted that during the first 4 months of life, blood bank pre-transfusion testing differs from adults. If there are no clinically significant red cell antibodies in the infant or maternal plasma, and the direct antiglobulin test is negative, a full crossmatch is not necessary, although the ABO and Rh-D group should be re-confirmed prior to each transfusion.

Sugqested transfusion thresholds for infants < 4 months of age are listed below:

Anaemia in the first 24 hours	Hb < 12g/dl (Hct c 0.36 l/l)
Neonate receiving mechanical ventilation	Hb < 12g/dl
Acute blood loss	= 10% blood volume lost
Oxygen dependent (not ventilated)	< 8-11g/dl
Late anaemia, stable patient (off oxygen)	Hb < 7g/dl

The age of the unit does not matter for small volume top-up transfusions, but large volume transfusions (exchange transfusion or acute blood loss) should be < 5 days old in order to avoid hyperkalaemia and reduced 2,3 DPG levels with poorer oxygen release. Leucocyte depleted products are also recommended for infants < 1 year.

Neonatal units should arrange with their local blood banks that those neonates with extended transfusion needs are placed on a "limited donor exposure" programme where the transfusion requirements of one infant are met by reserving units bled from one donor for a specific infant. This ensures minimum infectious risk and red cell antigen exposure.

c. Specific paediatric products for neonates and infants

The use of an adult red cell concentrate unit, fresh frozen plasma (FFP) or platelet concentrate for infants and small children will result in significant wastage since the volumes required are generally small. The services therefore prepare special products for paediatric use in the following volumes.

• Red cell Concentrates:
  • Infant: 120-140ml
  • Neonate: 50-80ml
• FFP: 130ml
• Platelets: 50-60ml volume; usually aliquoted into 5-6 units obtained from a single apheresis unit

• Consider in all neonates: < 30 x 10⁹ /l
• Consider if increased bleeding risk: < 50 x 10⁹ /l
  • <1000g and < 1 week old
  • Clinically unstable (e.g. labile blood pressure)
  • Previous major bleeding
  • Current minor bleeding
  • Coagulopathy
  • Planned surgery or exchange transfusion
• Major bleedinq: < 100 x 10⁹ /l