Indication of Blood Transfusion in Newborns Dr Bijan Keikhaei Full Professor of Pediatric Hematology and Oncology Research Center for Thalassemia and Hemoglobinopathy, Health Institute, Ahvaz Jundishapur University of Medical Sciences

Introduction Blood forms an important part of the therapeutic armamentarium of the neonatologist ( Very small premature neonates ). because of their immaturity, ongoing illness and the need for repeated sampling. it is essential that one considers the risk/benefit ratio and strive to develop treatment strategies that will result in the best patient outcomes. Since neonatal physiology varies with the maturity, age, weight and the presence of morbidities, it is difficult to formulate one parameter to guide all transfusion decisions. What specific pretransfusion processing is performed before transfusing blood products to neonates? • What are the indications for the use of various blood products?

Introduction

Introduction

Introduction

Blood Transfusion Benefit Risk

Hb Level Blood Transfusion Gestational age& weight Clinical Context

TRANSFUSION THRESHOLDS Transfusion threshold describes the lower limit of hemoglobin level at which a transfusion is considered. A balance has to be maintained between severe anemia and increasing the risk of morbidity and mortality by exposing a patient to donor blood unnecessarily

Potential benefits of transfusion Improved tissue oxygenation lower cardiac output to maintain the same level of oxygenation Effects of Transfusion Thresholds on Neurocognitive Outcome of extremely low birth weight infants

Potential Risks of transfusion Infectious Non-infectious I. Immunologic: Acute Immunologic Delayed II. Non-immunologic

Potential Risks of transfusion Transfusion-associated Graft versus host disease Cytomegalovirus infection CMV seronegative donations and leucodepleted products should be considered as equally ‘CMV safe’. PRBC transfusion in preterm neonates should be restricted to minimum to prevent complications which are unique to them such as increased incidence of retinopathy of prematurity (ROP), CMV infection and even necrotizing enterocolitis (NEC). Hypoglycaemia. Transfusion overload

Immune mediated hemolysis Acute hemolytic transfusion reactions are a common fatality in adult patients, but these are rare in neonates. Newborns do not form red blood cell (RBC) antibodies; all antibodies present are maternal in origin. Newborns must be screened for maternal RBC antibodies, including ABO antibodies if non-O RBCs are to be given as the first transfusion. If the initial results are negative, no further testing is needed for the initial 4 postnatal months.

Blood Transfusion Policies in Newborn Restrictive transfusion practice Liberal transfusion practice

Choosing the blood group for neonatal transfusions It is preferable to take samples from both, mother and the newborn. Mother’s sample should be tested for blood group and for any atypical red cell antibodies. ABO compatibility is essential while transfusing PRBCs. Though ABO antigens may be expressed only weakly on neonatal erythrocytes, neonate’s serum may contain transplacentally acquired maternal IgG anti-A and/or anti-B. Blood should be of newborn’s ABO and Rh group. It should be compatible with any ABO or atypical red cell antibody present in the maternal serum. In exchange transfusions for Rh hemolytic disease of newborn, blood transfused should be compatible with mother’s serum. Ideally Rh negative blood of the baby’s ABO group has to be used after cross matching with maternal serum. If compatible ABO group is not available then group O and Rh negative blood can be used.

Pre-transfusion Issues Donor selection a. Avoid blood donation from first and second degree relatives. b. In addition to routine screening tests, the donor should be negative of Hb S and seronegative for Cytomegalovirus (CMV). Pre-transfusion testing of donor blood a. Blood typing errors can result from i. Weak expression of red blood cell(RBC) antigens in neonates ii. Presence of maternal antibodies that can mask the corresponding antigens. iii. Umbilical cord samples contaminated by maternal blood/ Wharton’s jelly.

Irradiated blood i . Intrauterine transfusion of packed RBC and platelets ii. Transfusion of packed RBC and platelets (also in blood exchange transfusion) after intrauterine transfusion iii. Transfusion of RBC and platelets in neonates with birth weight < 1500 grams and/or gestation at birth < 30weeks iv. Donations from first or second degree relatives v. Neonates with congenital or acquired immunodeficiency.

CMV negative blood i. Intrauterine transfusion of packed RBC and platelets ii. Neonates with birth weight <1500 grams and/or gestation < 30weeks iii. Neonates with congenital or acquired immune deficiency;

T activation: T antigens (and the closely related Th, Tk and Tx antigens) are present on the neonate’s RBC surface and get activated in certain clinical situations (e.g. Necrotizing enterocolitis and Septicemia) when RBC get exposed to bacterial or viral enzymes (neuraminidase). This leads to poly agglutination of the RBCs (unexpected agglutination on testing with sera from ABO compatible donors) and thereby hemolysis. In high risk situations avoid all plasma or plasma products as most adults have anti T antibodies due to prior exposure to bacteria and vaccines. If unavoidable use plasma with low titres of anti T antibody to prevent hemolysis.

Recommendations on use of blood products in neonates Blood for transfusion should be less than 5 days old, Irradiated CMV negative warmed HCT of 50 to 60 Reconstituted blood: Reconstituted whole blood is obtained by combining packed RBC with fresh-frozen plasma (FFP). Ideally FFP should be from the same donor bag from which the packed RBC was produced. Otherwise AB group FFP from a different donor may be used. The final product should be used within 24h of reconstitution and has the same characteristics as whole blood except for reduced platelets.

IUT

IUT

Guidelines for packed red blood cells (PRBCs) transfusion thresholds for term neonates Condition Hb (g/dL) Severe pulmonary disease <13 Moderate pulmonary disease <10 Severe cardiac disease Major surgery Symptomatic anemia <8