1. Blood Transfusion In NeonatesDr. Souhila Bait Laboratory Medicine Resident

2. Introduction Blood Transfusion is not without hazards You should weigh the risk against benefit Use of right products to the right patient at the right time 3. Consider: infants will live long enough to get a long term complication of blood transfusion. neonate has special need : small size O2 affinity of fetal hemoglobin Immature immune system Presence of maternal alloantibodies Shortened red cell survival Decreased erythropoiesis Cardiovascular adaptive capacity 4. Use of clinical guidelines may provide the following: improvements in outcomes. improvements in medical practice. decision support tools for practitioners. points of reference for medical orientation andeducation. criteria for self-evaluation. 5. Strategies to reduce donor exposure or RBC transfusions: Delayed clamping of the umbilical cord. Restricting blood sampling. Using recombinant human erythropoietin to stimulateerythropoiesis. Using iron supplementation or vitamins to minimize the severity of anemia. Using appropriately collected and stored multipack RBC units. Collecting and transfusing umbilical cord blood (autologousblood transfusion). 6. Blood and blood component Specification RBCs administered should be as fresh as possible: componentsfor transfusion in utero or to children under 1 year of age must be prepared from blood donated by donors who have given at least one previous donation within the past 2 years, which was negative for all mandatory microbiological marker. Leuco-depleted: All components other than granulocytes should be leucocyte depleted (not more than 5 x106 leucocytes per unit) at the time of manufacture. Leukocyte depletion is important in neonatal transfusion. It helps in preventing non-hemolytic febrile transfusion reactions (NHFTR), HLA allo-immunization, transmission of leukotropic viruses (CMV, EBV and HTLV-1), and replacement of CMV negative blood components. Methods of leuco-depletion include the following: a. Centrifugation and removal of buffy coat (pre-storage). b. Use of leukocyte filters (pre or post storage). c. Washing of RBCs with saline. d. Freezing and thawing of red cells 7. irradiated: inactivation of donor T cells to prevent the risk of transfusion related graft versus host disease(GVHD).It is essential to irradiate all red cell and platelet components(with the exception of frozen red cells) for: 1. 2. 3. 4. 5.Intrauterine transfusion (IUT). Exchange transfusion (ET) of red cells after IUT. Top-up transfusion after IUT. When the donation is from a first- or second-degree relative or a human leucocyte antigen (HLA)-selected donor. When the child has proven or suspected immunodeficiency.cytomegalovirus (CMV) seronegative: or leuco-depleted to 1.5 } and significant risk of bleeding (e.g. preterm and/or intubated, previous PVH) or who are about to undergo an invasive procedure should receive FFP at a dose of 15 ml/kg. 15. The only indications for FFP in neonates recommended in therecent BCSH guidelines are: DIC, vitamin-K-dependent bleeding and inherited deficiencies of coagulation factors. For neonatal transfusions AB Plasma is used (compatible to all bloodgroups) , or choose compatible FFP with neonates ABO red cell antigens (see Table ) 16. Platelets Transfusion Transfusion of plateletsPreterm or term neonate, with bleeding50 109/lSick preterm or term infant, not bleeding30 109/lStable preterm or term infant, not bleeding20 109/l Term infants are unlikely to bleed if the platelet count ismaintained above 20x109, but in small, preterm babies a higher threshold is generally recommended, particularly during the rst few days when the risk of PVH is highest or if there is a coexistent coagulopathy. 17. Platelets for neonatal transfusion should be ABO identical or compatible RhD identical or compatible. Be HPA compatible in infants with allo-immune thrombocytopenia Be irradiated if appropriate. For platelet and FFP transfusions, plasma compatibility should beensured whenever possible. Both products contain enough red cell stroma to stimulate Rh immunization Therefore, RhD- girls for whom only RhD+ products are available should receive anti-D Ig. The dose should be 50IU/per unit of FFP(200300 ml) or per 500 ml of platelets transfused, or 250 IU per adult therapeutic dose of platelets (c. 250350ml, whether from a single aphaeresis donation or from a pack derived from a buffy coat pool from four donations). Components must not contain other clinically signicant red cell antibodies. 18. Cryoprecipitate Its prepared from FFP by thawing at 2-40C. Undissolved precipitate is collected by centrifugationand supernatant plasma is aseptically expressed into a satellite bag. Cryoprecipitate contains about 80 to 100 U of factor VIII in 10-25 ml of plasma, 300 mg of fibrinogen and varying amounts of factor XIII. it is stored at temperature of -200c. indications: Congenital factor VIII and XIII deficiency. von Willebrand disease. Afibrinogenemia & dysfibrinogenemia. 19. Component Volumes to be Transfused to Children and Neonates Red cell concentrates for exchange transfusion:Term Infant80-160mls/kgPreterm Infant100-200mls/kg For top-up transfusion10-20mls/kgvolume of packed cells(ml)=weight(kg)x desired rise in haemoglobin x 4 Platelet concentrates:Children weighing less than 15kg10-20mls/kgChildren weighing more than15kgsingle Apheresis unit/standart poolDose: 5-10 ml / kg raise platelet count 75 to 100109/ l Fresh Frozen Plasma10-20mls/kg Cryoprecipitate5-10mls/kg or 15-30kg= 5 units > 30 kg= 10 unitsIt is desirable to give cryoprecipitate only if the neonatal fibrinogen level remains low despite FFP transfusion. 20. Infusion flow rates : RBC: 3-5 ml/kg/hour FFP: within 30 minutes, provided the volume does not exceed 5-10 ml/kg. Platelets: within 30 minutes. It is seldom necessary to reduce the volume of the platelet concentrate if the dose does not exceed 5-10 ml/kg. It has been seen that transfusion with PRBC at a dose of 20ml/kg is well tolerated and results in an overall decrease in number of transfusions compared to transfusions done at 10ml/kg in preterm an VLBWinfants In infants and newborn, one unit of PRBC(10ml/kg) increases Hb by 3g/dl. 21. Choice of ABO group for blood products for administration to children. ABO group of blood product to be transfusedPatients ABO groupRed cellsPlateletsFFP*First choiceOOOSecond choiceAA or B or ABFirst choiceAAA or ABSecond choiceO**O**_First choiceBBB or ABSecond choiceO **A or O **_First choiceABABABSecond choiceA, BAAThird choiceO **OABABFor plasma and platelet transfusions, infants should receive ABO-specific components whenever possible, to avoid transfusing plasma antibody incompatible with the infant's red cell antigens. *GroupO fresh frozen plasma (FFP) should only be given to patients of group O. Although group AB FFP can be given to people of any ABO blood group, supplies are usually limited.**GroupO components which test negatively for high titre anti-A and anti-B should be selected. 22. Transfusion exchange The main indication for neonatal exchange transfusion is to preventneurological complications (kernicterus) caused by a rapidly-rising unconjugated bilirubin concentration If exchange transfusion is needed,must be: IAT-cross-match compatible with maternal plasma; group O or ABO compatible with maternal and neonatal plasma, RhDnegative or RhD identical with neonate. be irradiated and transfused within 24 h of irradiation If an ET is required in ABO HDN, this should be with group O red cellswith low titre plasma anti-A and anti-B, or with group O red cells suspended in AB plasma For HDN due to anti-D: use group O Rh D negative An exchange transfusion of about two times the neonates blood volume (about 170 ml/kg) is most effective to reduce bilirubin and restore the haemoglobin level; this can usually be carried out with one unit of whole blood. A unit of whole donor blood will normally have a haematocrit of 37-45%, which is more than adequate for neonatal needs. 23. Blood film in diagnosing HDN Blood film examination is usually diagnostic in DAT negative in cases of suspected HDN in ABO,RhD incompatibility: Blood film in ABO incompatibility: caracteristically shows large numbers of spherocytes with little or no increase in NRBCs. Blood film in RhD incompatibility:shows few spherocytes and large number of NRBCs For infants with ABO hemolytic disease of the newborn, only group O RBCs should be transfused until compatibility tests are nonreactive with ABO-specific units. For HDN due to anti-D ,use group O RhD negative blood. 24. Conclusions Policies, Procedures and Guidelines for BloodTransfusion in Pediatric age group should be in place and implemented. Training and Education for the hospital staff inpolicies, and guidelines in pediatric age group are important issues to be considered. The use of special products is a must for specificpatients in pediatric age group to ensure safety.