Transfusion of red blood cells and platelets are commonly performed on
neonates in the neonatal intensive care unit (NICU). Transfusions in the neonatal population are
associated with higher mortality and morbidity when compared to the adult
population. Known risks of transfusions
include alloimmunization, transfusion reactions and transmission of
infections. It has also been suggested
that necrotizing enterocolitis (NEC) or intraventricular hemorrhage (IVH) may
occur in neonates following a red blood cell transfusion. These risks must be balanced against clinical
need, especially in the neonatal population.
Unfortunately, few clinical trials have been performed to establish
guidelines for neonatal transfusions.
For this reason, transfusion practices and guidelines widely vary and
are sometimes controversial. This
article overviews the need for improving transfusion practices by establishing
NICU transfusion guidelines.
Current practices involve red cell transfusions that are guided by the
neonate’s hematocrit level. The authors
of this article suggest using more restrictive transfusion hemoglobin
thresholds when deciding if transfusion is necessary. The suggested transfusion hemoglobin at 1-7
days old is < 11 for ventilated neonates and < 10 for nonventilated neonates. At age 8-14 days, the suggested hemoglobin drops to < 9.5 for ventilated neonates and < 7.5 for neonates without oxygen support. By using these lower thresholds, it is hoped that the rate of unnecessary transfusions will decline. The article also proposes alternative procedures may reduce the need for red cell transfusions in the NICU. The use of erythropoietin and darbepoetin, which is a long-acting erythropoietin analog, has shown promise in stimulating erythropoiesis in infants and therefore reducing the need for red cell transfusions. In a study performed, one group of neonates were given darbepoetin once weekly and another group was given erythropoietin 3 times a week. Both groups were then compared to a placebo group and a much lower transfusion rate was noted. The article also suggests delayed cord clamping to reduce the need for neonatal transfusion. Delaying cord clamping by at least 1 minute can result in an increased hemoglobin after birth. Thrombocytopenia is common in neonates in the NICU with a prevalence of 73% in neonates that weigh less than 1,000 g and 85-90% in neonates that weigh less than 750 g. The article states that only 2% of all platelet transfusions in the NICU are appropriately performed due to thrombocytopenic bleeding while the remaining 98% are given for prophylactic measures. Studies have been conducted which compared bleeding outcomes in neonates who were transfused at platelet counts ranging from 40,000-60,000/uL and neonates transfused at more conservative range of 20,000-40,000/uL. Results from these studies showed no significant bleeding differences. The authors suggest that a more restrictive platelet transfusion trigger would decrease the number of platelet transfusions and therefore minimize risks involved. The authors of this article conclude that a more precise guideline for neonatal platelet and red cell transfusions should be developed to eliminate unnecessary transfusions. This will serve to reduce risks and complications involved with transfusion procedures. The authors also acknowledge that, although more restrictive transfusion practices should be implemented, further studies need to be performed to determine whether such procedures would have any adverse effect on long-term neurodevelopment.