Transfusion Guidelines for Preterm and Term Infants
John A. Widness, MD
Peer Review Status: Internally Peer Reviewed
Diagnosis of Anemia:
Well established, scientifically founded criteria for the diagnosis of anemia in the neonate are not available at present. This void is in part due to the difficulty in studying patients who are unable to communicate how they feel ("symptoms") and the fact that objective clinical "signs" of neonatal anemia are non-specific and thus frequently are indicators of problems other than anemia, e.g., sepsis, apnea, seizures, growth failure ("failure to thrive"), etc. Defining when clinically significant anemia is present is an area of active research.
See UI NICU Guidelines for Administering 15mL/kg Erythrocyte Transfusions to Neonates for our NICU's transfusion guidelines for preterm infants. Infants should not be treated to replace phlebotomy losses alone. Instead, as shown in the Table, a combination of the patient's clinical condition (primarily his/her respiratory status) and the presence of peripherial hematocrit values below levels specified for the various degrees of illness are used.
Treatment and Prevention of Anemia:
Mimimize phlebotomy losses:
Keep laboratory testing to only those tests which are needed. This is especially true in the first weeks of life when sick infants have the greatest amount of blood drawn due to their often tenuous condition.
Transfusion with packed red blood cells (PRBCs):
Good clinical practice dictates and regulatory agencies advise that chart documentation of the reason that the transfusion is being administered should be recorded. Transfuse to achieve a calculated hematocrit of approximately 45%, or give a maximum volume of 15 mL/kg. As a "rule of thumb," for each 1 mL of PRBC’s transfused (Hct of ≈ 85%)/kg, anticipate a 1% increase in the patient’s hematocrit. Hence for 15 mL of PRBC/kg, a pre-transfusion hct of 32% should rise to approximately 47% when checked several hours after transfusing.
Transfuse using irradiated (only infants with birth weights <1.5 kg) filtered to reduce CMV risk, packed red blood cells (Hct ≈ 85%). The blood bank routinely screens all blood for other viral pathogens including HIV, hepatitis B, hepatitis C, and HTLV I/II. Assuming a packed cell hematocrit of 80-90% and a blood volume of 80 mL/kg:
Multicenter U.S. and European VLBW clinical trial results indicate that EPO therapy is of marginal clinical benefit as it is currently being administered. Thus, if EPO therapy is considered this needs to be discussed with the staff attending. If EPO is to be used, the dose is 200-300 U s.q./kg/d every other day. Enteral iron intake should be increased to 6 mg/kg/d during EPO treatment.