Department of Paediatrics
GUIDELINES FOR THE USE OF BLOOD PRODUCTS IN
NEONATES
 Red blood cell transfusion
Background Maintaining adequate haemoglobin enhances oxygen carrying
capability which may help to avoid tissue hypoxia.
Maintaining adequate tissue oxygenation should help to promote optimum
growth and development.
However oxygen transport usually far exceeds need and is not usually limited
by haemoglobin concentration. In addition, transfusion needs vary with age
and as haemoglobin changes. Fetal haemoglobin has very high oxygen
affinity, but as HbA levels increase with age and following transfusion, oxygen
affinity decreases and the dissociation curve shifts to the right, thus allowing
the baby to tolerate lower haemoglobin levels.
There is very little data to support commonly used haemoglobin thresholds for
transfusion and increased recognition of the potential harm from transfusion
(blood borne infection especially from multiple donor exposure, transfusion
reactions and errors, iron overload).
Aims
 Maintain adequate oxygen delivery
 Minimize donor exposure
 Minimize infection risk
Minimize donor exposure and phlebotomy losses
 Avoid unnecessary blood sampling
 Use non-invasive monitoring when available
 Replace ‘dead space’ when sampling from arterial lines.
 Labs try to practise aliquotted donation (6 satellite bags from a single
donor made into pedipacks)
 Use blood <35 days old
 Keep blood taking log in intensive care babies
Type of donor blood to be transfused
 ABO compatible with baby and mother
 CMV negative for all infants< 1 year
 Leucocyte depleted ( issued as standard)
 Irradiated blood is required to prevent GVHD only if:
- Previous intra-uterine transfusion
- Suspected cellular immunodeficiency
- Suspected Di George syndrome
- Recommended for exchange transfusion provided it does not
lead to significant delay.
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Indications for Transfusion
Transfusion should be considered for the following babies but these are only
guidelines, the decision to transfuse should be taken depending on the
current clinical condition of the baby.
Thresholds may be higher in the neonates with hypovolaemia, septic shock,
or NEC or lower in the older, more stable babies.
1. Infants receiving intensive care or ventilated with O2 requirement.
 Acute blood loss 10% or cardiovascular compromise
 Cumulative loss of 10% in first week of life
 Hb <12g/dl
2. Oxygen dependent and/or continuous CPAP
 Symptomatic
 Hct < 35% (capillary)
 Hb <11g/dl (venous)
3. Weaning CPAP ( in air or low O₂ requirement <30%)
 Symptomatic
 Hct < 30% (capillary)
 Hb < 10g/dl (venous)
4. Stable infant & reticulocyte count <2.0% (100 x 10⁹/l)
 Symptomatic
 Hct < 20% (capillary)
 Hb< 7g/dl (venous)
5. Stable infant & reticulocyte count > 2.0% (100 x 10⁹/l)
 Avoid transfusion if possible
 Hct < 20% (capillary)
 Hb < 7 g/dl (venous)
AND symptomatic
Volume to be transfused
Evidence suggests that transfusion with larger volumes leads to better rises in
Hb and fewer overall transfusions.
Calculate volume by
Desired Hb (g/dl) – Actual Hb (g/dl) x weight (Kg) x 4
OR
20 mls/Kg
Desired Hb is generally 14g/dl.
For the extreme preterm or very unstable neonate especially in the first week
of life transfusion volumes should be accurately tailored using the formula to
avoid large fluid and blood pressure changes.
Thereafter unless there is good reason to avoid large volumes it is advisable
to use 20 mls/Kg, which is likely to be the higher volume.
Frusemide
The evidence to inform the use of frusemide is not strong, but it is our routine
policy to give frusemide at a dose of 1mg/Kg mid way through a transfusion in
order to minimize risk of fluid overload.
In some circumstances e.g. hypovolaemia or hypotension, frusemide should
be omitted. Discuss with SpR or consultant if unsure.
Feeds
There is concern that transfusion can be associated with the development of
NEC. There is no good evidence for this. There are highly anecdotal accounts
of well babies developing overwhelming NEC following ‘routine’ transfusion’
and there is some literature extrapolating from different situations (eg post in
utero transfusion).
Despite the lack of evidence we will continue to withhold feeds during
transfusion in babies who are thought to be at high risk of NEC.
Discuss with consultant or registrar.
Timing of transfusion
Intensive care, unwell or unstable babies should be transfused as soon as
possible after the need is identified.
In the stable baby who is having a more elective transfusion, it should be
timed so that it finishes before 22.00
Pre transfusion testing
Up to 4 months a sample from infant and mother for ABO and RhD group
determination.
0.5 mls EDTA microtainer labelled with microtainer labels.
The form must contain full clinical details, including gestation, previous
transfusion history and the likelihood of need for multiple transfusions.
Small volume transfusions can be given repeatedly over the first 4 months
without further serological testing, provided there are no atypical maternal
antibodies and the infant DAT is negative when first tested.
Over 4 months new sample required
Nb the heel prick screening now includes haemoglobinopathy testing. If a
baby is to be transfused before this time, please complete a neonatal
screening card before the baby is transfused.
Liasing with the Lab
Try to anticipate the need for transfusion early, especially in the intensive care
babies.
Try to notify the lab before midday if transfusion is needed OR is likely to be
needed later in the day so that units can be brought over on routine transport.
Documentation
The date, time and amount of blood transfused MUST be written in the notes
as well as the indication for transfusion.
The sticker form the blood product unit will be stuck in the notes and the pack
number should match the number on the request form.
Transfer
If a baby is being transferred and likely to need transfusion, check with the lab
to arrange to transfer any usable satellite packs, to minimise donor exposure.
Any blood products to be transferred with the baby must be packed by blood
bank who will also liase with the receiving hospital blood bank.
This applies to any blood products.

PLATELET TRANSFUSION
SEE PROTOCOL FOR INVESTIGATION AND MANAGEMENT OF
THROMBOCYTOPAENIA
Indications for Transfusion
1. Platelet count < 30 x 10⁹
 Consider in all patients
2. Platelet count < 50 x 10⁹
 < 1000 g and first week of life
 Clinically unstable ( eg fluctuating BP ,septic shock)
 Previous grade 3-4 IVH
 Minor bleeding ( petichiae or puncture site oozing)
 Concurrent coagulopathy
 Requires surgery or exchange transfusion
3. Platelet count < 100 x 10⁹
 Active, significant bleeding (GI or pulmonary haemorrhage)
Volume to be transfused
15mls /Kg over 30-60 minutes
If red cell transfusion is also required, give platelets first
Platelets to be transfused
ABO and RhD compatible
HPA compatible in suspected or proven alloimmune thrombocytopenia
(commonly HPA-1a negative platelets required)
In suspected cases of neonatal alloimmune thrombocytopenia (NAIT)
Discuss with consultant haematologist prior to transfusion
Platelets are not routinely kept on site and need to be brought over from
Oxford.
Try to anticipate the need for platelet transfusion and discuss with the
transfusion lab during daytime hours.
When the platelet count may fall quickly or the risk of bleeding high, e.g
worsening sepsis/ NEC or suspected alloimmune thrombocytopenia,
liaise with the haematology department at counts < 100 x 10⁹
 4.5% Human Albumin Solution
There is no evidence to support the use of HAS 4.5 % as a fluid bolus in
hypovolaemia, hypotension or acidosis.
In hyperbilirubinaemia, when exchange transfusion is being considered, 4.5%
HAS may be used for its ability to bind bilirubin and lower free levels.
 20% Human Albumin Solution
20% HAS can be used, with frusemide, to increase the oncotic pressure and
draw fluid back into the vascular space in the sick oedematous neonate.
This is a temporary effect and should be reserved for the very sick neonate
usually receiving full intensive care, in whom oedema is compromising the
ability to effectively ventilate.
The decision to use 20% HAS should be taken following discussion with the
consultant responsible for the unit.
20% HAS can cause dangerous fluid shifts, and haemodynamic instability and
should be transfused SLOWLY.
It increases the intravascular volume by up to 3 times the actual volume of
albumin infused and stays in the circulation for about 18hours.
Doses should probably not be repeated within 24 hours.
Volume to be transfused
5 mls/Kg over 2-3 hours with frusemide 1-2mg /Kg

Fresh Frozen Plasma
Indications for Use
 Clinical or laboratory evidence of DIC (consider use of cryoprecipitate)
 Vitamin K dependant bleeding
 Inherited deficiency of coagulation factors
 Sick neonate with sepsis and hypotension
 Not to be used for bleeding alone
Product to be used
Standard issue for children born since 1996 is methylene blue treated, US
sourced FFP
Volume to be transfused
10-15mls/ Kg over 30 mins
References
Blood transfusion task force. Transfusion guidelines for neonates and older children.
British journal of haematology 124 433-453
Murray N, Roberts IAG. Neonatal transfusion practice Arch Dis Child 2004:89F101F107
So K et al. Randomised controlled trial of colloid or crystalloid in hypotensive
preterm infants. Arch Dis Child 1997 76:F43-F46
Andersen C.Critical haemoglobin thresholds in premature infants Arch Dis Child
2001:84;F146-F148
John Radcliffe Infirmary Guidelines for the use of blood products in neonates.
CC/LAW September 2008 (Review 2 years)
Gosset guidelines/Blood products - guidelines for the use of blood products in neonates